• Bence Jones Protein

• • multiple myeloma free light chains (either kappa or lambda) ,

• • Waldenstrom’s macroglobinemia

• Bilateral breast cancer • Lobular carcinoma

• Bilateral renal cell carcinoma • Von Hippel-Lindau

• Birbeck Granules • • histiocytosis X (eosinophilic granuloma)

• Bladder trabeculation • BPH

• Bloody nipple discharge • Intraductal papilloma

• Blueberry muffin baby • Rubella

• Blue Bloater • • Chronic Bronchitis

• Blue Sclera • Osteogenesis imperfecta

• Boot-Shaped Heart • • Tetralogy of Fallot

• Bouchard’s Nodes • • osteoarthritis (PIP)

• Boutonniere’s Deformity • • rheumatoid arthritis

• Bronze Diabetes • Hemochromatosis

• Brown Tumor • • hyperparathyroidism

• Brudzinski sign • meningitis

• Brushfield Spots • • Down’s, on iris

• Call-Exner Bodies • • granulosa cell tumor

• Carbon monoxide poisoning • Hyperemia, edema and necrosis of globus

• Cardiomegaly with Apical Atrophy • • Chagas’ Disease

• Central Nuclei in Muscle • Muscular dystrophies

• Chancre • • 1° Syphilis, painless firm ulcers

• Chancroid • • Haemophilus ducreyi, painful soft ulcers

• Charcot Triad • • multiple sclerosis (nystagmus, intention tremor, scanning speech)

• Charcot-Leyden Crystals • • bronchial asthma

• Cherry-red spot on macula • Tay-Sachs, 50% of Niemann-Pick

• Cheyne-Stokes Breathing • • cerebral lesion

• Chocolate Cysts • • endometriosis

• Cholesterol clefts • atherosclerosis

• Chordae tendinae short and fused • Rheumatic heart disease

• Chronic staph infections • Chronic granulomatous disease, a deficiency of NADPH oxidase, can’t kill catalase positive bugs

• Chvostek’s Sign • • Hypocalcemia facial spasm in tetany

• Clear nuclei • Thyroid papillary carcinoma (Orphan Annie’s eyes)

• Clue Cells • • Gardnerella vaginitis

• Codman’s Triangle • • osteosarcoma

• Coin Lesions in Lung • Pulmonary Hamartoma

• Cold Agglutinins • • Mycoplasma pneumoniae • • infectious mononucleosis

• Cold thyroid nodules • Colloid cyst or thyroid adenoma

• Concentric laminar intimal fibrosis of small arteries of lung • Primary pulmonary hypertension

• pernicious anemia (antibodies to intrinsic factor or parietal cells ® ¯IF ® ¯Vit B12 ® megaloblastic anemia)

• Albright’s Syndrome • • polyostotic fibrous dysplasia, precocious puberty, café au lait spots, short stature, young girls

• Alport’s Syndrome • • hereditary nephritis with nerve deafness, Type 4 collagen defect (basement membranes)

• Alzheimer’s • • progressive dementia; tau proteins, neurofibrillary tangles, apolipoprotein E4 allele, narrow gyri and wide sulci (atrophy), occipital sparing, hydrocephalus ex vacuo, plaques in hippocampus and cortex, ¯ Acetylcholine, Hiramo bodies (inrtacellular inclusion bodies in hippocampal cells)

• Argyll-Robertson Pupil • • loss of light reflex constriction (contralateral or bilateral) • • “Prostitute’s Eye” - accommodates but does not react • • Pathognomonic for 3°Syphilis

• Arnold-Chiari Malformation • • cerebellar tonsil herniation

• Barrett’s • • columnar metaplasia of lower esophagus ( risk of adenocarcinoma)

• Bartter’s Syndrome • • hyperreninemia

• Becker’s Muscular Dystrophy • • similar to Duchenne, but less severe (deficiency in dystrophin protein)

• Bell’s Palsy • • CNVII palsy (entire face; recall that UMN lesion only affects lower face)

• Berger’s Disease • • IgA nephropathy

• Bernard-Soulier Disease • • defect in platelet adhesion (abnormally large platelets & lack of platelet-surface glycoprotein)

• Berry Aneurysm • • circle of Willis (subarachnoid bleed) • • often associated with ADPKD

• Bowen’s Disease • • carcinoma in situ on shaft of penis ( risk of visceral ca)

• Briquet’s Syndrome • • somatization disorder • • psychological: multiple physical complaints without physical pathology

• Broca’s Aphasia • • Motor Aphasia intact comprehension

• Bronchiolitis • RSV

• Brown-Sequard • • hemisection of cord (contralateral loss of pain & temp / ipsilateral loss of fine touch, UMN)

• Bruton’s Disease • • X-linked agammaglobinemia

• Budd-Chiari • • post-hepatic venous thrombosis

• Buerger’s Disease • • acute inflammation of small, medium arteries ® painful ischemia ® gangrene

• Burkitt’s Lymphoma • • small noncleaved cell lymphoma EBV • • 8:14 translocation

• Caisson Disease • • gas emboli

• Carpal Tunnel Syndrome • Median nerve entrapment

• Chagas’ Disease • • Trypansoma infection sleeping disease, cardiomegaly with apical atrophy, achlasia

• Chediak-Higashi Disease • • Phagocyte Deficiency: neutropenia, albinism, cranial & peripheral neuropathy • • repeated infections

• Congenital adrenal hyperplasia • 21-hydroxylase deficiency: virilism, no cortisol, salt loss, hypotension • 11-hydroxylase deficiency: virilism, no cortisol, salt retention, hypertension

• Conn’s Syndrome • • primary aldosteronism

• Cori’s Disease • • glycogen storage disease (debranching enzyme deficiency)

• Creutzfeldt-Jakob • • prion infection ® cerebellar & cerebral degeneration

• Crigler-Najjar Syndrome • • congenital hyperbilirubinemia (unconjugated) • • glucuronyl transferase deficiency

• Crohn’s • • IBD; ileocecum, transmural, skip lesions, lymphocytic infiltrate, granulomas • (contrast to UC: limited to colon, mucosa & submucosa, crypt abscesses, pseudopolyps, colon cancer risk)

• Croup • Parainfluenza

• Curling’s Ulcer • • acute gastric ulcer associated with severe burns

• Cushing’s • • Disease: hypercorticism 2° to ACTH from pituitary (basophilic adenoma) • • Syndrome: hypercorticism of all other causes (1° adrenal or ectopic)

• Cushing’s Ulcer • • acute gastric ulcer associated with CNS trauma

• de Quervain’s Thyroiditis • • self-limiting focal destruction (subacute thyroiditis)

• DiGeorge’s Syndrome • • thymic hypoplasia ® T-cell deficiency • • hypoparathyroidism

• Down’s Syndrome • • trisomy 21 or translocation

• Dressler’s Syndrome • • Post-MI Fibrinous Pericarditis autoimmune

• Dubin-Johnson Syndrome • • congenital hyperbilirubinemia (conjugated) • • striking brown-to-black discoloration of the liver

• Duchenne Muscular Dystrophy • • deficiency of dystrophin protein ® MD X-linked recessive

• Edwards’ Syndrome • • trisomy 18 • • rocker-bottom feet, low ears, heart disease

• Ehler’s-Danlos • • defective collagen

• Eisenmenger’s Complex • • late cyanotic shunt (R®L) pulmonary HTN & RVH 2° to long-standing VSD, ASD, or PDA

• Erb-Duchenne Palsy • • trauma to superior trunk of brachial plexus Waiter’s Tip

• Ewing Sarcoma • • undifferentiated round cell tumor of bone

• Eyrthroplasia of Queyrat • • carcinoma in situ on glans penis

• Fanconi’s Syndrome • • impaired proximal tubular reabsorption 2° to lead poisoning or Tetracycline (glycosuria, hyperphosphaturia, aminoaciduria, systemic acidosis)

• Felty’s Syndrome • • rheumatoid arthritis, neutropenia, splenomegaly

• Gardner’s Syndrome • • adenomatous polyps of colon plus osteomas & soft tissue tumors

• Gaucher’s Disease • • Lysosomal Storage Disease glucocerebrosidase deficiency • • hepatosplenomegaly, femoral head & long bone erosion, anemia • Crinkled tissue paper cells in marrow

• Gilbert’s Syndrome • • benign congenital hyperbilirubinemia (unconjugated

GIST • Tumor arising in cells of Cajal (pacemakers of gut)

• Glanzmann\\\\\\\'s Thrombasthenia • • defective glycoproteins on platelets

• Goodpasture’s • • autoimmune: ab’s to glomerular & alveolar basement membranes; linear immunofluorescence

• Grave’s Disease • • autoimmune hyperthyroidism (TSI)

• Guillain-Barre • • idiopathic polyneuritis (ascending muscle weakness & paralysis; usually self-limiting)

• Hamman-Rich Syndrome • • idiopathic pulmonary fibrosis

• Hand-Schuller-Christian • • chronic progressive histiocytosis

• Hashimoto’s Thyroiditis • • autoimmune hypothyroidism (antimicrosomal or antithyroglobulin); Hurthle cells, thyroid germinal centers,

• Ha****oxicosis • • initial hyperthyroidism in Hashimoto’s Thyroiditis that precedes hypothyroidism

• Henoch-Schonlein purpura • • hypersensivity vasculitis • • hemmorhagic urticaria (with fever, arthralgias, GI & renal involvement) • • associated with upper respiratory infections

• Hereditary Spherocytosis • RBC cytoskeletin defect, most commonly spectrin

• Hirschprung’s Disease • • aganglionic megacolon

• Horner’s Syndrome • • ptosis, miosis, anhidrosis (lesion of cervical sympathetic nerves often 2° to a Pancoast tumor)

• Huntington’s • • progressive degeneration of caudate nucleus, putamen & frontal cortex; AD

• Hunter’s • Decreased iduronosulfate sulfatase

• Hurler’s • Decreased alpha-L-iduronidase

• Jacksonian Seizures • • epileptic events originating in the primary motor cortex (area 4)

• Job’s Syndrome • • immune deficiency: neutrophils fail to respond to chemotactic stimuli

• Kaposi Sarcoma • • malignant vascular tumor (HHV8 in homosexual men)

• Kartagener’s Syndrome • • immotile cilia 2° to defective dynein arms infection, situs inversus, sterility

• Kawasaki Disease • • mucocutaneous lymph node syndrome (lips, oral mucosa)

• Keratoconjunctivitis • adenovirus

• Klinefelter’s Syndrome • • 47, XXY

• Kluver-Bucy • • bilateral lesions of amygdala (hypersexuality; oral behavior)

• Krabbe Disease • Beta-galactosidase deficiency

• Krukenberg Tumor • • adenocarcinoma with signet-ring cells (typically originating from the stomach) metastases to the ovaries

• Laennec’s Cirrhosis • • alcoholic cirrhosis

• Lesch-Nyhan • • HGPRT deficiency • • gout, retardation, self-mutilation

• Letterer-Siwe • • acute disseminated Langerhans’ cell histiocytosis

• Libman-Sacks • • endocarditis with small vegetations on valve leaflets • • associated with SLE

• Lou Gehrig’s • • Amyotrophic Lateral Sclerosis degeneration of upper & lower motor neurons

• Mallory-Weis Syndrome • • bleeding from esophagogastric lacerations 2° to wretching (alcoholics)

• Marfan’s • • elastin defect, floppy mitral valve, arachnodactyly, cystic medial necrosis, subluxed lens

• McArdle’s Disease • • glycogen storage disease (muscle phosphorylase deficiency)

• Meckel’s Diverticulum • • rule of 2’s: 2 inches long, 2 feet from the ileocecum, in 2% of the population • • embryonic duct origin; may contain ectopic tissue (gastric, pancreatic, etc.)

• Meig’s Syndrome • • Triad: ovarian fibroma, ascites, hydrothorax

• Menetrier’s Disease • • giant hypertrophic gastritis (enlarged rugae; plasma protein loss)

• Monckeberg’s Arteriosclerosis • • calcification of the media (usually radial & ulnar aa.), pipestem arteries

• Munchausen Syndrome • • factitious disorder (consciously creates symptoms, but doesn’t know why)

• Meningioma • Arachnoid cap cells, whorls of cells

• Mesothelioma • Asbestos exposure

• Nelson’s Syndrome • • 1° Adrenal Cushings ® surgical removal of adrenals ® loss of negative feedback to pituitary ® Pituitary Adenoma

• Niemann-Pick • • Lysosomal Storage Disease sphingomyelinase deficiency • • “foamy histiocytes”

• Osler-Weber-Rendu Syndrome • • Hereditary Hemorrhagic Telangiectasia

• Osteogenesis imperfecta • Type I collagen defect

• Paget’s Disease • • abnormal bone architecture (thickened, numerous fractures ® pain) , woven and lamellar bone mosaic

• Pancoast Tumor • • bronchogenic tumor with superior sulcus involvement ® Horner’s Syndrome

• Parkinson’s • • dopamine depletion in nigrostriatal tracts; Cogwheel rigidity

• Peutz-Jegher’s Syndrome • • melanin pigmentation of lips, mouth, hand, genitalia plus hamartomatous polyps of small intestine

• Peyronie’s Disease • • subcutaneous fibrosis of dorsum of penis

• Pick’s Disease • • progressive dementia similar to Alzheimer’s, knife-edged gyri

• Plummer’s Syndrome • • hyperthyroidism, nodular goiter, absence of eye signs (Plummer’s = Grave’s - eye signs)

• Plummer-Vinson • • esophageal webs & iron-deficiency anemia, SCCA of esophagus

• Pompe’s Disease • • glycogen storage disease (acid maltase deficiency) ® cardiomegaly

• Pott’s Disease • • tuberculous osteomyelitis of the vertebrae

• Potter’s Complex • • renal agenesis ® oligohydramnios ® hypoplastic lungs, defects in extremities

• Raynaud’s • • Disease: recurrent vasospasm in extremities • • Phenomenon: 2° to underlying disease (SLE or scleroderma)

• Reiter’s Syndrome • • urethritis, conjunctivitis, arthritis non-infectious (but often follows infections), HLA-B27, polyarticular

• Reye’s Syndrome • • microvesicular fatty liver change & encephalopathy • • 2° to aspirin ingestion in children following viral illness

• Riedel’s Thyroiditis • • idiopathic fibrous replacement of thyroid

Rotor Syndrome • • congenital hyperbilirubinemia (conjugated) • • similar to Dubin-Johnson, but no discoloration of the liver

• Sezary Syndrome • • leukemic form of cutaneous T-cell lymphoma (mycosis fungoides)

• Shaver’s Disease • • aluminum inhalation ® lung fibrosis

• Sheehan’s Syndrome • • postpartum pituitary necrosis

• Shy-Drager • • parkinsonism with autonomic dysfunction & orthostatic hypotension

• Simmond’s Disease • • pituitary cachexia

• Sipple’s Syndrome • • MEN type IIa (pheochromocytoma, thyroid medulla, parathyroid)

• Sjogren’s Syndrome • • triad: dry eyes, dry mouth, arthritis risk of B-cell lymphoma

• Spitz Nevus • • juvenile melanoma (always benign)

• Stein-Leventhal • • polycystic ovary

• Stevens-Johnson Syndrome • • erythema multiforme, fever, malaise, mucosal ulceration (often 2° to infection or sulfa drugs)

• Struma Ovarii • Thyroid teratoma of ovary

• Still’s Disease • • juvenile rheumatoid arthritis (absence of rheumatoid factor)

• Takayasu’s arteritis • • aortic arch syndrome • • loss of carotid, radial or ulnar pulses

• Tay-Sachs • • gangliosidosis (hexosaminidase A deficiency ® GM2 ganglioside)

• Tetralogy of Fallot • • ?VSD, ?overriding aorta, ?pulmonary artery stenosis, ?right ventricular hypertrophy

• Tourette’s Syndrome • • involuntary actions, both motor and vocal

• Turcot’s Syndrome • • adenomatous polyps of colon plus CNS tumors

• Turner’s Syndrome • • 45, XO

• Typhoid Fever • Bradycardia and in white people rose spots on abdomen

• Vincent’s Infection • • “trench mouth” - acute necrotizing ulcerative gingivitis

• von Gierke’s Disease • • glycogen storage disease (G6Pase deficiency)

• von Hippel-Lindau • • hemangioma (or hemangioblastoma) • • adenomas of the viscera, especially renal cell carcinoma • defect in VHL tumor suppressor

• von Recklinghausen’s • • neurofibromatosis & café au lait spots & Lisch nodule (iris hamartomas)

• von Recklinghausen’s Disease of Bone • • osteitis fibrosa cystica (“brown tumor”) 2° to hyperparathyroidism

• von Willebrand’s Disease • • defect in platelet adhesion 2° to deficiency in vWF; increased bleeding time and PTT

• Waldenstrom’s macroglobinemia • • proliferation of IgM-producing lymphoid cells

• Wallenberg’s Syndrome • • Posterior Inferior Cerebellar Artery (PICA) thrombosis “Medullary Syndrome” • • Ipsilateral: ataxia, facial pain & temp; Contralateral: body pain & temp

• Waterhouse-Friderichsen • • catastrophic adrenal insufficiency 2° to hemorrhagic necrosis (eg, DIC) • • often 2° to meningiococcemia

• Weber’s Syndrome • • Paramedian Infarct of Midbrain • • Ipsilateral: mydriasis; Contralateral: UMN paralysis (lower face & body)

• Wegener’s Granulomatosis • • necrotizing granulomatous vasculitis of paranasal sinuses, lungs, kidneys, etc.

• Weil’s Disease • • leptospirosis

• Wermer’s Syndrome • • MEN type I (thyroid, parathyroid, adrenal cortex, pancreatic islets, pituitary)

• Wernicke’s Aphasia • • Sensory Aphasia impaired comprehension

• Wernicke-Korsakoff Syndrome • • thiamine deficiency in alcoholics; bilateral mamillary bodies (confusion, ataxia, ophthalmoplegia)

• Whipple’s Disease • • malabsorption syndrome (with bacteria-laden macrophages) & polyarthritis

• Wilson’s Disease • • hepatolenticular degeneration (copper accumulation & decrease in ceruloplasmin)

• Wiskott-Aldrich Syndrome • • immunodeficiency: combined B- &T-cell deficiency (thrombocytopenia & eczema)

• Wolff-Chaikoff Effect • • high iodine level (-)’s thyroid hormone synthesis

• Zenker’s Diverticulum • • esophageal; cricopharyngeal muscles above UES

• Zollinger-Ellison • • gastrin-secreting tumor of pancreas (or intestine) ® acid ® intractable ulcers



Bloody Mary



Adhesive arachnoiditis • Caused by bacterial meningitis, leads to obstructive hydrocephalus

• Albumino-Cytologic Dissociation • • Guillain-Barre (markedly increased protein in CSF with only modest increase in cell count)

• AFP increase • Neural tube defects, hepatocellular carcinoma, yolk sac and embryonal carcinoma

• AFP decrease • Down’s

• Amnion nodosum • Renal agenesis

• Amyloid in thyroid • Thyroid medullary carcinoma (calcitonin)

• Analgesic abuse • Papillary necrosis, esp. in diabetics

• Anasarca • Minimal change disease

• Aneurysmal nodules • Polyarteritis nodosa

• Angiomyolipoma • Tuberous sclerosis

• Anosmia • Kallman’s syndrome

• Anterior vermian atrophy • alcoholism

• Anti-centromere antibody • Limited scleroderma (CREST)

• Anti-DNA topoisomerase antibody • Diffuse scleroderma

• Anti-endomysial antibody • Celiac sprue

• Anti-jo antibody • polymositis

• Anti-mitochondrial antibody • Primary biliary cirrhosis

• Antiplatelet Antibodies • • idiopathic thrombocytopenic purpura

• Anti-sacharommyces cervisiae antibody • Crohn’s

• Anti-Smith antibodies • Specific for SLE, anti-ribonulceoprotein

• Anti-smooth muscle antibody • Autoimmune hepatitis type I

• Arachnodactyly • • Marfan’s

• Aschoff Bodies • • rheumatic fever

• Ashleaf spots (skin) • Tuberous sclerosis

• Atypical lymphocytes • EBV

• Auer Rods • • acute promyelocytic leukemia (AML type M3)

• Autosplenectomy • • sickle cell anemia

• Babinski • • UMN lesion

• Bacterial conjuntivitis • S. aureus, strep. pneumo, Hemophilus aegyptius

• Basophilic Stippling of RBCs • • lead poisoning

• Condyloma Lata • • 2° Syphilis • • new coffee flavor at Bagel & Bagel

• Congenital Hepatic Fibrosis • Polycystic Kidney Disease, juvenile autosomal recessive form

• Contraction Band Necrosis • MI

• Cotton Wool Spots • • HTN

• Councilman Bodies • • dying hepatocytes

• Crescents In Bowman’s Capsule • • rapidly progressive (crescentic glomerulonephritis)

• Crushed ping pong balls • • Pneumocystis carinii

• Crypt abscesses • Ulcerative colitis

• Currant-Jelly Sputum • • Klebsiella

• Curschmann’s Spirals • • bronchial asthma

• Cystathioine synthase deficieny • homocystinuria

D-dimers • DIC

• Depigmentation Of Substantia Nigra • • Parkinson’s

• Dew drop on rose petal • Chicken pox

• Diaphragmatic pleural plaques • Asbestosis

• Donovan Bodies • • granuloma inguinale (STD)

• Double bubble sign on ultrasound • Down’s syndorme - duodenal atresia

• Duret Hemorrhages • Uncal herniation

• Eburnation • • osteoarthritis (polished, ivory-like appearance of bone)

• Eccentric intimal fibrosis with medial hypertrophy • Chronic transplant rejection

• Ectopia Lentis • • Marfan’s

• Embolizing endocarditis • Infectious, marantic (fibrin deposits in hypercoagulable states)

• Erythema Chronicum Migrans • • Lyme Disease

• Excavation of Optic Cup • Glaucoma

• Exopthalmos • hyperthyroid

• FAT RN • TTP (fever, anemia, thrombocytopenia, renal failure, neuro problems)

• Fatty Liver • • Alcoholism

• Fecalith • Acute appendicitis

• False positive VDRL • SLE, Treponema pertenue (non-STD tropical infection)

• Ferruginous Bodies • • asbestosis

• Fish-mouthed mitral valve • Rheumatic heart disease

• Flea-bitten Kidney • Malignant Hypertension

• Frontal bossing • Sickle cell anemia

• Fungus ball in lung • Apergillus

• galactosemia • Galactose-1-phosphate uridyl transferase deficiency or galactokinase deficiency

• Garlic odor on breath • Arsenic (or lasagna)

• Ghon Complex • • Tuberculosis, primary

• Gold Pneumonia • Lipid pneumonia, exogenous (aspiration) or endogenous (obstruction

• Gower’s Maneuver • • Duchenne’s MD use of arms to stand

• Gray discoloration of skin • Argyria (silver poisoning)

• Hat size increase • Paget’s disease of bone

• Heart Failure Cells • CHF; hemosiderin-laden macrophages in lungs

• Heberden’s Nodes • • Osteoarthritis (DIP)

• Heinz Bodies • • G6PDH Deficiency

• Hemarthrosis • Coagulation factor deficiency

• Hemorrhagic Temporal Lobe Lesion • HSV

• Hemorrhagic Urticaria • • Henoch-Schonlein

• Heterophil Antibodies • • infectious mononucleosis (EBV)

• Hirano Bodies • • Alzheimer’s

• HLA B27 • Ankylosing spondylitis

• ochronosis (dark pigment of fibrous tissue) • Alkaptonuria -homogentisic acid oxidase deficiency

• Honeycomb lung • Pulmonary fibrosis

• Howell Jolley Bodies • Splenectomy, remnant of nuclear DNA

• H shaped vertebrae • Sickle cell anemia

• Human placental lactogen increase • Placental site trophoblastic tumor

• Hyaline thrombi • TTP

• Hydrosalpinx • Chronic pelvic inflammatory disease

• Hypersegmented PMNs • • Megaloblastic anemia

• Hypochromic Microcytic RBCs • • iron-deficiency anemia

• IgM against IgG • Rheumatoid arthritis (rheumatoid factor)

• ¯ Immunoglobulins • X-linked Brutons agammaglobulinemia, and common variable immunodeficiency

• Index finger overlapping 3rd and 4th • Edward’s (Trisomy 18)

• Jarisch-Herxheimer Reaction • • Syphilis over-aggressive treatment of an asymptomatic pt. that causes symptoms 2° to rapid lysis

• Joint Mice • • osteoarthritis (fractured osteophytes)

• Kaussmaul Breathing • • acidosis

• Keratin Pearls • • SCCA

• Kernig’s sign • meningitis

• Keyser-Fleischer Ring • • Wilson’s

• Kimmelstiel-Wilson Nodules • • diabetic nephropathy

• Koilocytes • • HPV

• Koplik Spots • • measles

• Lacunar cells • Variant of Reed-Sternberg cell seen in nodular sclerosing Hodgkin’s Disease

• Lacunar infarct • Chronic hypertension

Lamellar bodies • Contain surfactant in Type II pneumocytes

• Langhans giant cells • Tuberculosis, other including coccidioides

• Lemon yellow skin color • Pernicious anemia

• Lemon sign • Ultrasonographic finding in Neural Tube Defects

• Leukocoria • Retinoblastoma

• Lewy Bodies • • Parkinson’s (eosinophilic inclusions in damaged substantia nigra cells)

• Leukocyte alk. Phos. Positive • Leukemoid rxn.

• Lines of Zahn • • arterial thrombus

• Lisch Nodules • • neurofibromatosis (von Recklinhausen’s disease)

• Loss of grey-white junction • Tuberous sclerosis

• Low set ears • Downs, DiGeorge, Trisomy 18 (Edwards)

• Lumpy-Bumpy IF Glomeruli • • poststreptococcal glomerulonephritis

• Machine-like murmur • Patent ductus arteriosus

• Macronodular cirrhosis • Wilson’s, viral hepatitis, alpha-1-antitrypsin

• Malignant pustule • Anthrax (black skin lesion)

• Mallory Bodies • Alcoholic liver disease: intermediate filaments of hepatocyte cytoskeleton

• Maple syrup/burnt sugar urine • Alpha-ketoacid dehydrogenase deficiency; valine, leucine and isoleucine build up (branched)

• McBurney’s Sign • • appendicitis (McBurney’s Point is 2/3 of the way from the umbilicus to anterior superior iliac spine)

• Meconium ileus • Cystic Fibrosis

• Mees lines • Arsenic (parallel lines on fingernails)

• Melanosis coli • Laxative abuse

• Mental probs. with heart defect • Mitral prolapse

• Michealis-Gutmann Bodies • • Malakoplakia, an abnormal tissue response to kidney infection

• Microglial nodules • HIV

• Micrognathia • DiGeorge

• Micronodular cirrhosis • Wilsons, alcoholic, hemochromatosis, primary biliary cirrhosis

• Microsatellite instability • HNPCC (right-sided colon cancer), but also possible in other cancers

• Mid-systolic click • Mitral prolapse

• Monoclonal Antibody Spike • • multiple myeloma this is called the M protein (usually IgG or IgA) • • MGUS

• Mousy / musty odor • PKU

• Mucosal bleeding • Platelet problem (qualitative or quantitative)

• Myxedema • • hypothyroidism

• Necrolytic migratory erythema dermatitis • a-cell islet tumor

• Negri Bodies and hydrophobia • • rabies

• Neuritic Plaques • • Alzheimer’s

• Neurofibrillary Tangles • • Alzheimer’s

• Night pain relieved by aspirin • Osteoid osteoma

• Non-embolizing endocarditis • Rheumatic, Libman-Sacks (with SLE)

• Non-pitting Edema • • Myxedema • • Anthrax Toxin

• Notching of Ribs • • Coarctation of Aorta

• Nutmeg Liver • • CHF, right heart

• Onion skin kidney arterioles • Malignant nephrosclerosis (malignant hypertension)

• Oligoclonal band • Multiple sclerosis

• Osteoid production • osteosarcoma

• Painless Jaundice • • pancreatic CA (head)

• Palatal Petechaie • Strep pharyngitis

• Palpable purpura • Hypersensitivity vasculitis (Henoch-Schonlein, serum sickness)

• Pancarditis • Rheumatic fever

• Pannus • • rheumatoid arthritis

• PAS positive macrophages • Whipple’s disease

• Patent ductus arteriosus • Maternal rubella and prematurity

• Pautrier’s Microabscesses • • mycosis fungoides (cutaneous T-cell lymphoma)

• Periductal edema • Gynecomastia

• Periventricular Calcifications • Congenital CMV (brain ventricles, that is)

• Phenylalanine hydroxylase deficiency • PKU

• Philadelphia Chromosome • • CML

• Pick Bodies • • Pick’s Disease

• Piecemeal Necrosis • Chronic active hepatitis (periportal hepatocytes)

• Plexiform lesions • Pulmonary HTN (aneurysmal expansion of vessel wall)

• Pink, foamy lung exudate • Pneumocystis carinii pneumonia

• Pink Puffer • • Emphysema Centroacinar - smoking Panacinar - a1-antitrypsin deficiency

• Podagra • • gout (MP joint of hallux)

Porcelain gallbladder • Chronic cholecystitis (scarring)

• Porcelain gallstones • Associated with gallbladder adenocarcinoma

• Port-Wine Stain • • Hemangioma

• Posterior Anterior Drawer Sign • • tearing of the ACL

• Proliferating bile ducts • Obstructive jaundice

• Psammoma Bodies • • Papillary adenocarcinoma of the thyroid • • Serous papillary cystadenocarcinoma of the ovary • • Meningioma • • Mesothelioma

• Pseudohypertrophy • • Duchenne muscular dystrophy

• Pseudopoyps • Ulcerative colitis

• Pulmonary atherosclerosis • Cor pulmonale

• Punched-Out Bone Lesions • • multiple myeloma

• Punched-out esophageal lesions • herpes

• Rash on Palms & Soles • • 2° Syphilis • • RMSF

• RBC poikilocytosis • Beta-thalassemia

• Rectangular RBC’s • Hemoglobin SC

• Red hyalin globules • Alpha-1-antitrypsin deficiency (in liver)

• Red Morning Urine • • paroxysmal nocturnal hemoglobinuria

• Reed-Sternberg Cells • • Hodgkin’s Disease

• Reid Index Increased • • chronic bronchitis

• Reinke Crystals • • Leydig cell tumor

• Rhomboid crystals • Pseudogout

• Rim pattern • SLE, staining pattern with anti-double stranded DNA antibodies

• Rockerbottom feet • Patau (Trisomy 13), Edward’s (Trisomy 18)

• Rose thorns • Sporotrichosis

• Rouleaux Formation • • multiple myeloma RBC’s stacked as poker chips

• Rugae loss • Pernicious anemia (atrophic gastritis)

• S3 Heart Sound • • L®R Shunt (VSD, PDA) • • Mitral Regurg • • LV Failure

• S4 Heart Sound • • Pulmonary Stenosis • • Pulmonary HTN

• Scalloped colloid • Grave’s disease

• Schwartzman Reaction • • Neisseria meningitidis impressive rash with bugs

• Shagreen patches • Tuberous sclerosis

• Simian Crease • • Down’s

• Smith Antigen • • SLE (also anti-dsDNA)

• Smudge cells • CLL (delicate cells easily destroyed on peripheral smear)

• Soap Bubble on X-Ray • • giant cell tumor of bone

• Soldiers plaque • Clinically insignificant remnant of healed pericarditis

• Spider telangiectasia • Hyperestrinism: liver faillure, pregnancy

• Spike & Dome Glomeruli • • membranous glomerulonephritis

• Splinter hemorrhages • Infective endocarditis

• Strawberry tongue • Scarlet fever, Kawasaki’s

• Strawberry cervix • Trichomonas vaginalis

• Strawberry gallbladder • cholesterolosis

• String Sign on X-ray • • Crohn’s bowel wall thickening

• Sugar icing on spleen • Portal hypertension

• Sulfer granules • Collection of actinomyces or nocardia organisms in chronic abscessing bronchopneumonia

• Swiss cheese brain • Clostridia (gas forming)

• Syncitia • RSV, measles

• Tamm-Horsfall protein • Hyaline casts (non-specific)

• Target Cells • • Thalassemia

• Teardrop RBCs • Myelofibrosis

• Temporal lobe encephalitis • Herpes

• Tendinous Xanthomas • • Familial Hypercholesterolemia

• Tethered cord • Arnold-Chiari malformation (tonsilar herniation)

• Tetrahydrobiopterin cofactor def. • PKU

• Thymidine dimers • Xeroderma pigmentosum

• Thymus, parathyroid agenesis • Digeorge (3rd and 4th pharyngeal pouch)

• Thyroidization of Kidney • • chronic pyelonephritis

• TIBC increase • Anemia of chronic disease

• Tingible Bodies • Macrophage in lymph node germinal centers

• Tophi • • gout

• Tram-Track Glomeruli • • membranoproliferative glomerulonephritis

• Tree bark aorta • Syphilis

Precocious puberty: It is very important to distinguish between the two most common presentations and causes of precocious pubarche in order to facilitate the proper treatment.



Precocious puberty is caused by premature activation of the hypothalamus-pituitary-gonad (HPG) axis.



precocious pseudo-puberty is caused by a gonadotropin-independent process, typically an excess of sex steroids (severe cystic acne, significant growth acceleration). It can be caused by late-onset congenital adrenal hyperplasia.



Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation. Sequential development of the following is typically present: testicular enlargement, penis enlargement, pubic hair growth, and lastly, a growth spurt.







Benign premature thelarche: is characterized by bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty. These other signs of precocious puberty include rapid increase in height, increase in bone maturity, appearance of axillary and pubic hair, and menstrual bleeding. The treatment for benign premature thelarche is expectant because majority of the patients remain stable or have reversal of the breast enlargement in a few months. Patients with benign premature thelarche have a normal hormone profile. Their final height is generally not compromised.



DD: 1. Hypothalamic hamartomas secrete GnRH and cause central isosexual precocious puberty in both males and females. Central precocious puberty is characterized by rapid acceleration of height, increase in bone age, thelarche, adrenarche, pubarche, and menarche. Lab investigations in patients with hypothalamic hamartoma reveal gonadotropin levels in the pubertal range and elevated estrogen levels. Majority of these patients will require treatment with a GnRH analog.



2. Estrogen production from an ovarian tumor can lead to peripheral precocious puberty. This syndrome has similar clinical features as hypothalamic hamartoma, and is characterized by accelerated height and bone age, and menstrual bleeding. Hormonal profile reveals elevated estradiol in the presence suppressed LH and FSH. Treatment is usually surgical.



3. McCune-Albright syndrome consists of \\\\\\\"café au-lait\\\\\\\" spots, fibrous dysplasia of the bone, and precocious puberty. This patient does not have any features to suggest McCune-Albright syndrome. The cause of precocious puberty in McCune-Albright syndrome is excessive production of estrogen from ovarian cysts.







Nocturnal enuresis can be categorized as primary or secondary, with secondary enuresis accounting for roughly ¼ of all cases. If the child was continent for at least 6 months prior to the onset of bed-wetting, then the enuresis is considered secondary. While psychological problems are very rarely the cause of primary nocturnal enuresis, they are quite frequently the cause of secondary nocturnal enuresis. Nocturnal enuresis is more common in boys. Prevalence declines slowly throughout childhood; almost ¼ of 5-year-old children (such as the boy in this case) continue to have nocturnal enuresis. Typically, the condition resolves of its own accord between the ages of 5 and 7. By age 10, prevalence of nocturnal enuresis has dropped to under 5% of all children.



To increase the likelihood of success, parents should maintain a caring, patient approach, and may wish to try behavioral modification with positive reinforcement. If the child’s nocturnal enuresis persists for some time, alarm therapy or a prescription for desmopressin may be worth trying.



**First line management for primary nocturnal enuresis for children less than seven years of age is to reassure the patient’s parents that the child usually outgrows this phase and spontaneously recovers. Other options for treatment, however, are the use of alarms, along with behavioral therapy, such as limiting the child’s fluid intake before bedtime. In the alarm method, a sensor is placed in the child’s underwear or in the bed padding. Once the child voids and moisture is detected, the alarm is activated, waking up the child so that he could go to the toilet before he continues to empty his bladder. Although alarms have been shown to be less immediately effective than desmopressin use, the former is still more effective in preventing relapses. Alarms are more effective than treatment with tricyclics during and after treatment.







When giving an opinion about a patient’s diagnosis, the physician must be cautious and try to avoid giving false reassurance or a premature diagnosis that cannot be supported by adequate clinical evidence. In cases wherein the patients’ history or physical findings do not point to a specific diagnosis, the physician can correctly state that it is \\\\\\\"probably a medical condition\\\\\\\", and then begin the work up in order to arrive at a more specific diagnosis.







Chronic adrenal insufficiency: It must be suspected in patients with the corresponding signs and symptoms: fatigue, weight loss, myalgias, increased pigmentation, and a decreased amount of axillary and pubic hair. Hyponatremia, hyperkalemia and hyperchloremic metabolic acidosis are characteristic laboratory findings. The most common etiology of this condition is primary adrenal insufficiency (Addison’s disease). Diagnosis can be made through the ACTH stimulation test, or by the measurement of early morning serum cortisol level (A level less than 10 mg/dl indicates a high probability of the disease). DD: Hyperthyroidism shares some similar clinical manifestations with Addison’s disease (weight loss, asthenia,); however, the presence of other findings, such as fatigue, androgen deficit signs, hyponatremia and hyperkalemia, cannot be explained by hyperthyroidism alone. Hypothyroidism, not hyperthyroidism, is usually related to fatigue and hyponatremia (although the other symptoms still cannot be explained by hy

pothyroidism).







Sickle cell disease: In children, the most common initial symptom of sickle cell disease is dactylitis, which develops in 40% of patients. Splenic sequestration is the second most common, and occurs in about 20% of patients. Other complications, such as ischemic events, are not as frequent, and are seen mainly in the adult population.



Salmonella is an uncommon cause of hematogenous osteomyelitis in the general population; however, it is the most common cause of osteomyelitis in patients with sickle cell disease. Long bones are usually affected, and multiple foci are often present. Sickle cell anemia should be strongly suspected in child who has a history of anemia and an episode of Salmonella osteomyelitis. Interestingly, only about 30% of cases of sickle cell anemia are diagnosed at the age of 1 year. Hemoglobin electrophoresis will confirm the diagnosis.







Acute otitis media: The most common complication after an episode of acute otitis media is another episode of otitis media. Approximately 75% of early recurrences are due to different bacteria, while other recurrent episodes are caused by the same agents (usually Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). Children who have had more than two episodes are especially at risk. Some authors recommend prophylactic antibiotic therapy in such cases.



Contrary to popular belief, pneumonia is not a complication of acute otitis media. Both conditions can coexist, but one is not a risk factor for the other.



** While adults have wide, steeply angled Eustachian tubes, infants have shorter, almost horizontal Eustachian tubes. This fact makes fluid accumulation and infection quite common in young children; however, not all children develop acute otitis media (AOM). Recurrent episodes require further exploration by the clinician.



Exposure to cigarette smoke has been shown to alter mucosa, cilia, and adenoid structures, in addition to increasing the risk of developing AOM and upper respiratory tract infections. An increase in the level of smoke exposure is paralleled by an increase in the number of AOM episodes. Exposure to cigarette smoke is one of the most important risk factors for developing acute otitis media. Parents should be urged to quit smoking.



Current recommendations for AOM patients with an initial clinical treatment failure (failure of acute otitis media to respond clinically to amoxicillin by day 3 of treatment) and who has not received antibiotics in the month prior to the initiation of treatment are high doses of amoxicillin/clavulanate or certain second or third generation cephalosporins. The rationale is to enhance activity against penicillin-resistant S. pneumoniae (drug resistant S. pneumoniae or DRSP) found in an increasing percentage (30-60%) of cases of pneumococcal AOM in the US.



Discontinue amoxicillin, begin IM ceftriaxone, and refer the boy to an otolaryngologist for urgent tympanocentesis. This would be an appropriate choice if the patient has an initial clinical treatment failure and has received antibiotics in the month prior to beginning the current treatment. (Prior antibiotics in the month preceding AOM increases the likelihood that AOM is due to DRSP.) Under these conditions, the patient would also have been initially treated with high dose amoxicillin, high dose amoxicillin/clavulanate, or certain second or third generation cephalosporins. These regimens are reported to be more effective against DRSP than the usual dose of amoxicillin. IM ceftriaxone is even more effective against DRSP. Moreover, immediate tympanocentesis allows culture and sensitivity testing which can provide invaluable guidance in selected difficult cases not responding to empiric treatment.



Tympanostomy and tubing is generally reserved for chronic otitis media (COM) with effusion persisting for more than 3 months, or recurrent AOM (greater than six episodes in 6 months) which is not prevented by prophylactic antibiotics (half of normal dose amoxicillin or sulfisoxazole). It might be considered in AOM if the TM bulging, earache, fever, vomiting, and/or diarrhea were unusually severe or persistent.



**Post OM management: A normal appearing tympanic membrane with decreased mobility on pneumatic otoscopy is suggestive of an effusion in the middle ear. An effusion commonly persists up to three months after an acute episode of otitis media (OM) has been treated. If no other symptoms are present in such cases, watchful waiting is all that is necessary. If other symptoms are present, the effusion is bilateral, or has persisted for more than three months, further therapy should be considered.



Switching to a second-line antibiotic should be considered if there is inadequate improvement of symptoms or appearance of the tympanic membrane, or when there is persistence of a purulent nasal discharge. According to the CDC, three drugs can be used as alternatives. These are amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone.



Tympanocentesis or myringotomy with culture are indicated in children in whom the clinical response to a second-line treatment has been unsatisfactory.



Hearing should be assessed if effusion has persisted for more than three months.



Myringotomy and insertion of tympanostomy tubes should be considered for patients with otitis media and effusion after antibiotic therapy and an ample period of watchful waiting.







Gynecomastia is very common (up to 70%) in pubertal males. Its occurrence during puberty is associated with the relative excess production of estrogens from the testes. In majority of subjects, gynecomastia regresses in about 18-24 months; however, this may persist in some patients, and although rare, it could be cosmetically disfiguring.



Surgical resection is required in very large, cosmetically disfiguring gynecomastia which has not responded to medical therapy.



Liver cirrhosis is associated with gynecomastia. This is mainly due to an increased aromatization of circulating androgens.







Methamphetamine (MF): therapy is associated with decreased weight and height. Sadness and irritability can be seen in up to 22% of children at therapeutic doses. MF overdose has similar effects as dextroamphetamine, that is: anorexia, nausea, vomiting, tachycardia, increased blood pressure, palpitations, dizziness, headache, nervousness, euphoria, agitation, and aggressive or violent behavior.



It is very important to remember that MF cannot be stopped abruptly because of the high prevalence of psychological dependence to the drug. MF must therefore be slowly tapered.



DD: MF use in childhood has been associated with an increased probability of drug abuse problems in adulthood. Illicit drug overdose, especially cocaine, may be difficult to differentiate from MF or amphetamine overdose. A urine toxicology test may be useful in most cases.







Exercise-induced bronchoconstriction is usually seen after strenuous activities or exercises. Bronchodilation initially occurs during exercise, followed by bronchoconstriction, which begins after 3 to 5 minutes, and rapidly peaks within 10 to 15 minutes of cessation of exercise. This is extremely common in patients with a history of symptomatic asthma, and the patient\\\\\\\"s response correlates with the degree of airway hyperresponsiveness.



The first step in the management of patients with exercise-induced bronchoconstriction is to control the underlying asthma effectively.



Patients with well-controlled asthma and a history of exercise-induced bronchoconstriction should have prophylactic treatment with inhaled beta-2 agonists (e.g., albuterol) approximately 5 to 10 minutes before the initiation of exercise. Patients with less severe or less frequent attacks, along with their close contacts, must be taught how to recognize and treat the acute attack with inhaled beta-2 agonists.



It is important to realize that exercise is not the cause of asthma, but it induces bronchoconstriction in patients with underlying asthma. The patient should not be instructed to avoid exercise. In contrast, exercise should be encouraged to reduce the minute ventilation for any given level of exercise, and to prevent the recurrence of exercise-induced bronchoconstriction.







Capillary (strawberry) hemangioma: superficial, bright, red, strawberry-like round lesion is a benign vascular lesion. Most capillary hemangiomas are evident at birth. They may undergo subsequent growth for a period of several months (proliferation phase). Spontaneous regression usually follows (involution phase). It is estimated that 70% of superficial lesions will disappear by seven years of age, although residual skin changes may be left.



For lesions that are small, do not affect normal functioning, and do not constitute a significant cosmetic problem, observation is the best approach.



Laser treatment should be considered in patients with lesions on the face, and at sites of potential functional impairment (orbital area).



Imaging studies are usually indicated in infants with multiple superficial lesions to exclude visceral involvement.



Oral corticosteroids, and sometimes subcutaneous interferon, are indicated for the treatment of rapidly growing lesions.







Anorexia nervosa : Anorexia nervosa is a complex medical condition, which is difficult to treat. There are some indications to admit a patient with anorexia nervosa to the hospital. The Society for Adolescent Medicine (SAM) has developed some guidelines. The indications for admission are: dehydration, electrolyte abnormalities (hypokalemia, hyponatremia), bradycardia (less than 50 beats per minute), hypotension (BP < 80/50 mmHg), hypothermia (under 96ºF), orthostatism, acute food refusal, severe malnutrition (weight < 75% of the average for her age, height and sex), acute medical or psychiatric emergencies (pancreatitis, seizures, syncope, suicidal ideation, psychosis), and cardiac arrhythmia. If the patient meets any of these criteria, she must be admitted immediately. All other medical and psychiatric evaluations may be done after the patient is admitted to the hospital.



Hypocalcemia is common in patients with anorexia nervosa because of the presence of hypoalbuminemia.



Refeeding syndrome can develop during the second or third week of nutritional therapy of patients with anorexia nervosa. It is characterized by edema and heart failure, and can lead to delirium and cardiac arrest. Phosphate must be replaced immediately, and the patient should be managed in the intensive care unit.







Neonatal sepsis: The diagnosis of neonatal sepsis is suspected when an infant has poor appetite, decreased reactivity to external stimuli, diminished oral intake, and lassitude or depressed sensorium. The most common etiologic agents are Group B Streptococcus, Escherichia coli, Klebsiella and Enterobacter species. Although Listeria infections are rare in the United States, ampicillin is recommended as part of the antibiotic regimen. Cefotaxime, ceftriaxone or antipseudomonal penicillins are used in combination with the aforementioned drug. The type of bilirubinemia involved also affects the approach in management of septic infants. Indirect hyperbilirubinemia is usually physiologic in nature and persists, while direct hyperbilirubinemia is probably induced by sepsis-related cholestasis.



Ceftriaxone should not be used if there is hyperbilirubinemia, because it will increase both types of bilirubin. Moxalactam and sulfonamides are not recommended due to their capability of increasing indirect bilirubin levels.







Sydenham’s chorea (SC; also known as Saint Vitus dance), one of the classic manifestations of rheumatic fever. SC is more common in girls, especially between 5 and 13 years of age. SC is usually preceded by a period of emotional lability, manifested by a tendency to cry or laugh, as well as deterioration of school performance. SC starts with distal hand movements, later progressing to facial jerking and grimacing, as well as abnormal feet movement. Chorea usually develops several (one to eight) months after the onset of acute rheumatic fever, whereas carditis and arthritis typically develop within 21 days. The presence of carditis is diagnostic. Approximately one third of the patients have carditis; mitral regurgitation is the most common cardiac finding. Patients may not remember a prior sore throat, and cultures are also usually negative. Patients usually have hypotonia, and the relaxation phase of the patellar reflex is usually delayed. When the patient is examined with the arms stretched out, the arms mo

ve from the prone to the supine position (positive pronator sign).



DD: 1. Gilles de la Tourette syndrome starts between 2 and 15 years of age, and is four times more frequent in boys. Pronator sign, carditis and hypotonia are not present.



2. Attention deficit disorder is a chronic condition with no abnormal findings on physical examination.



Sydenham’s chorea (SC) should be treated immediately with oral penicillin for ten days. If patient adherence is an issue, an alternative is a single dose of intramuscular Benzathine penicillin. In patients who are allergic to penicillin, weight based erythromycin, divided in 2-4 doses, should be given. SC usually resolves within 12 to 15 weeks; however, prophylaxis should be continued into adulthood.



If the motor function is severely compromised, valproic acid, phenobarbital or haloperidol can be started, and the patient must be referred to a neurologist.







Atopic dermatitis: The characteristic (red, oozing) rash may involve the face and the scalp in children. Scaly, dry cheeks, especially in the winter, are also typical. Atopic dermatitis is believed to have a strong allergic/immunologic component because many patients demonstrate allergies to food and inhalant allergens. 80-85% of patients have elevated IgE levels, and there is a strong family predisposition to the disease. The condition promptly responds to topical steroids and calcineurin inhibitors such as topical tacrolimus and pimecrolimus.







Diarrhea diet: In a child with diarrhea and no clinical signs of dehydration, preferred intake includes fluids low in sugar and the resumption of a normal, age-appropriate diet with plenty of complex carbohydrates with limited fats and sugars. Foods containing excessive sugar can increase the osmolarity of the stool in the intestinal lumen, and fatty foods are known to delay gastric emptying. Both can worsen diarrhea.



The previously popular BRAT diet is no longer recommended for refeeding children with diarrhea because it is quite low in calories and protein. Moreover, the bananas and applesauce in the BRAT diet add excessive sugar.



Of greater concern is loperamide’s linkage with paralytic ileus, toxic megacolon, CNS depression, coma, and death in children.







Rabie prophylaxis: In a case of exposure to bats, immediate vaccination is recommended if the person was not aware of the presence of the animal. Postexposure prophylaxis consists of the administration of one dose of anti-rabies immunoglobulin and five doses of anti-rabies vaccine. If treatment is postponed for no more than five days (if the patient did not immediately report the exposure), effectiveness will be the same, although there have been reports of rabies in persons not vaccinated in the first 72 hours when the bite was in the head or the neck.







Ethics: Permission to treat a child can only be granted by the parent or legal guardian. As an exception to this rule, adolescents are typically allowed to give consent for their own care in regards to pregnancy, contraception, sexually transmitted diseases, substance use, and emotional illness.



When providing medical care, clinicians must seek to balance the autonomy of the family with the welfare of the child. In true emergency situations requiring imminent treatment of a child, most medical teams choose to proceed with treatment despite the parental refusal of care. Very rarely do courts uphold charges against physicians in such cases.







Homosexual parents: Homosexuality was classified as a sexual disorder in the DSM I and II, but was removed from the revised DSM III.



Multiple studies of both biological and adopted children of homosexual parents have been performed, and the general consensus is that these children experience normal childhood development. Among children of homosexual parents, adolescent concerns about identity and peer approval are becoming less intense as variance in the American family unit grows more common and socially accepted.



The majority of children adopted by homosexuals consider themselves to be heterosexual, though some do describe themselves as homosexual or bisexual.



Homosexual parents have not been proven to be more passive than heterosexual parents, and there is no documentation of increased violence or antisocial behavior in their children. Studies of domestic violence suggest it is similarly prevalent in homosexual and heterosexual relationships.



Although at least one study has suggested that certain learning disabilities (e.g., dyslexia, stuttering) are more common in homosexuals than in heterosexuals, there is no evidence that this tendency translates to increased learning disabilities in the children of homosexual parents.







Bacterial conjunctivitis: Characterized by redness and copious, purulent discharge. No fever or blurred vision. Examination shows conjunctival erythema and yellow exudates. It is usually a self-limited disease; however, it must be treated because there is a small, but real risk of keratitis, which can lead to visual impairment.



Erythromycin ointment or sulfa drops are the first line of therapy for uncomplicated bacterial conjunctivitis, as they cover most organisms.



Fluoroquinolone eye drops are preferred for contact lens wearers and cornel ulcers because of the activity against pseudomonas. They should not be used in uncomplicated bacterial conjunctivitis as first line therapy because of the risk of the emergence of resistance.



Primary care physicians should not prescribe corticosteroids, as they can cause sight-threatening complications in patients with bacterial conjunctivitis and herpes keratitis.



Bacterial conjunctivitis is very contagious. The best thing to do is to keep the child at home until the discharge is cleared. However, in many patients who work outside, this may not be feasible. In those patients, at least 24-hours of topical antibiotic therapy should be applied before returning to work.







Delayed puberty: The earliest sign of puberty is nocturnal increase in the LH surge. This is followed by a daytime increase in the levels of gonadotrophins, and increase in testosterone levels. On physical examination, enlargement of testes is one of the earliest signs of onset of puberty.



A patient is diagnosed with delayed puberty if he does not have testicular enlargement by 14 years of age, or if his testicles are 2.5 cm or less in diameter. Another criterion is a delay in the development for 5 years or more from the onset of genitalia enlargement. The most common cause of delayed puberty is constitutional delay. The initial evaluation involves the use of an imaging test to determine bone age. Bone age that is older or equal to the chronological age warrants further testing to rule out chromosomal abnormality and endocrine causes.



DD: Constitutional pubertal delay is characterized by delayed puberty, retarded bone age, and a positive family history without any evidence of systemic disorder. These patients develop puberty without any intervention. The development of secondary sexual characteristics can be enhanced in patients with constitutional pubertal delay by using small doses of testosterone for a short time. The use of testosterone for a short period of time does not compromise the final adult height.



Kallman’s syndrome consists of anosmia with hypogonadotropic hypogonadism, and sometimes there are associated midline facial defects. This syndrome is due to a genetic defect which leads to the defective migration of GnRH-secreting and olfactory neurons to their final adult positions.







Neurofibromatosis: To meet the diagnostic criteria NF 1, two or more of the following are required: a first degree relative with NF 1, the development of more than six CALS of 5 mm in greatest diameter (if children) or 15 mm (if adult), or the presence of more than two neurofibromas, Lisch nodules, optic glioma, bone dysplasia, or axillary freckling. If the patient is a child, there is a 15% possibility of development of optic nerve gliomas. Current recommendations include having a detailed ophthalmologic evaluation for early detection of this problem and for search of Lisch nodules (iris hamartoma). As primary care physicians have a lack of expertise in such an evaluation, immediate ophthalmologic referral is advised.



If there are any ophthalmologic or neurologic abnormalities, other tests such as MRI, head CT scan, EMG, or neurosurgery evaluation may be needed.



DD: Hypopigmented spots, in combination with a family history of bilateral deafness, strongly suggest neurofibromatosis type 2 (NF-2), an autosomal-dominant disorder. The spots described actually represent café-au-lait spots that are usually hypopigmented (unlike the hyperpigmented café-au-lait spots found in NF-1). Deafness is caused by bilateral acoustic neuromas, a characteristic neurologic manifestation of the syndrome.







Herpes zoster or varicella: The diagnosis of herpes zoster or varicella is made clinically. No further laboratory tests are needed.



In immunosuppressed patients (e.g., HIV), the rash can be atypical and can be confused with herpes simplex. If the patient is critical and antiviral therapy needs to be started, lesions can be scraped for PCR or immunofluorescence studies.







Vaccination: There are two true contraindications for DTaP vaccination: 1) anaphylaxis within seven days of administration of a previous DTP or DTaP vaccine, and 2) encephalopathy within seven days of administration of a previous DTP or DTaP vaccine. If high fever (>104.8F), shock, inconsolable crying for three or more hours, or seizure occur within 24 hours of receiving a dose of DTaP vaccine, then subsequent doses should be given with caution. Temporary contraindications to receipt of the DTaP vaccine include moderate or severe illness, with the vaccine administered as soon as the illness resolves. Mild acute illness with or without fever is not a contraindication to vaccine administration. There are no significant contraindications to receipt of vaccinations against Hib, poliovirus, and pneumococcus; therefore, a four-month-old child with otitis media should be vaccinated against DTaP, Hib, IPV, and PCV.



**Varicella vaccination of household contacts of transplant recipients is relatively safe and is currently recommended by the American Association of Pediatrics (AAP). It is advisable for all patients to receive pre-transplantation immunization, although this is not always possible and durable protection is reached in less than 50% of patients. Transmission of vaccine-associated VZV is not typical, except for some cases when post-vaccination rash appears; therefore, this child should be monitored for the appearance of a rash and isolated if a rash appears







TB:



All patients with sputum-positive pulmonary or laryngeal tuberculosis can transmit the infection to other household contacts or healthcare workers via infectious aerosols containing Mycobacterium tuberculosis bacilli. The acts of coughing, sneezing, singing, and even speaking can all produce microscopic aerosols containing the organism. All such patients should be placed in respiratory isolation until they are confirmed to be non-infectious. Patients are rendered non-infectious if they are receiving effective antituberculous therapy and have had three consecutive negative results on sputum acid-fast smears performed on different occasions. Non-infectivity should be documented by serial negative acid-fast smears, and not by the duration of therapy. A patient can still be infectious after prolonged drug therapy if he has a drug-resistant infection. Resolution of chest x- ray findings in patients with pulmonary tuberculosis typically lag behind the clinical response. Chest radiograph changes can persist for lon

ger periods of time after the patient has been rendered non-infectious, and may even become permanent.



**Multi-drug resistant TB: is an emerging problem in the USA. If the organisms are resistant to both rifampin and INH, we call it a multi-drug resistant TB (MDR-TB). In case of exposure to MDR-TB, chemoprophylaxis with pyrazinamide and ethambutol or quinolone with anti-mycobacterial activity, like ofloxacin or levofloxacin is recommended. But, if it is resistant to INH only, then the standard recommendations are to give the chemoprophylaxis with Rifampicin alone for four months or Rifampicin plus PZA for two months. The problem with the rifampin plus PZA combination in an immunocompetent host is liver toxicity. The patient needs careful monitoring.



**Tuberculous meningitis: is one of the forms of extrapulmonary tuberculosis. It is associated with high morbidity and mortality rates. Patients usually present with an insidious onset of symptoms such as malaise, headache, and low-grade fever. If left untreated, these symptoms can rapidly progress to persistent headaches, vomiting, cranial nerve involvement, confusion, seizures, coma, and eventually, death within six to eight weeks of the onset of illness. All patients with suspected tuberculous meningitis (based on initial history and CSF examination) should be immediately started on empiric antituberculous therapy, pending the results of confirmatory tests. The prognosis of the patient with tuberculous meningitis greatly depends on the stage in which the treatment is initiated. Early diagnosis and treatment of the patients is critical to prevent adverse clinical outcomes.



All patients with tuberculous meningitis should be initially treated with a combination of isoniazid, rifampin, and pyrazinamide (bactericidal agents) for the first two months, followed by treatment with INH and rifampin for the succeeding months. These three agents have good CSF penetration, and can achieve adequate therapeutic levels in the cerebrospinal fluid. Based on the current guidelines, all infants and children with drug-sensitive tuberculous meningitis should be treated for at least 12 months. In a patient with drug-resistant infection, the therapy may be extended to 18-24 months, depending on the clinical response and severity of the illness.



Summary: 1. Specific antituberculous therapy should be initiated early in all patients with clinically suspected tuberculous meningitis.



2. Infants and children with tuberculous meningitis, miliary TB, and tuberculous osteomyelitis should receive 12 months of antituberculous therapy.







kyphosis:



a) Flexible:



Scenario: Physical examination shows a postural round back that is corrected by voluntary hyperextension. Forward bending reveals no lateral deformity and no angulation. Neurological examination of the lower extremities is normal. You order x-ray of the spine that shows a convex alignment of the thoracic spine at 35 degrees.



It is typically noticed by parents or teachers who observe adolescents sitting or standing in a slouched position. On lateral radiographs, the angle of thoracic kyphosis is normal or slightly increased (normal 20-40 degree). Interestingly, contrary to common belief, there is no evidence that flexible kyphosis leads to adverse physical effects or permanent deformity.



b) Scheuermann disease (structural kyphosis )



Scenario: Physical examination reveals thoracic curving of the spine that is not corrected with voluntary hyperextension of the spine. On forward bending, sharp angularity is observed in the thoracic region, but no lateral deformity is present. Neurological examination of the lower extremities is normal. X-ray of the spine shows a convex alignment of the thoracic spine at 55 degrees.



Unlike flexible kyphosis, structural kyFphosis is not corrected with voluntary efforts, and a sharp angulation is commonly seen on forward bending. The typical treatment for structural kyphosis that is not severe (less than 70-80 degrees) includes the use of a Milwaukee brace. In more severe cases (significant angulation, intractable pain, neurological abnormalities), surgical correction is used.







Turner syndrome (45,XO): dorsal feet and hands edema, short webbed neck, and a cardiac murmur) is typical for Turner syndrome. It represents monosomy for the X chromosome (45, X), that is why no Barr body is revealed on the buccal smear. Less common chromosomal abnormalities that can be present in patients with Turner syndrome include X chromosome mosaicism and Xp deletion. Interestingly, the risk of having an infant with monosomy for the X chromosome does not increase with advance maternal age, unlike Down’s syndrome and Klinefelter’s syndrome (47, XXY). Moreover, no increased recurrence risk is present after having an infant with Turner syndrome.



All patients who are initially diagnosed must be screened for the presence of other associated somatic abnormalities. The most important of these are the cardiac defects, which include coarctation of the aorta, bicuspid aortic valve, mitral valve prolapse, and hypoplastic heart. Since some of these defects cannot be picked up by clinical examination, an echocardiogram is necessary. The other associated defects are: visual and hearing deficits, kidney malformation (including horseshoe shaped kidney), and an increased predisposition for autoimmune endocrinopathy (especially primary hypothyroidism); therefore, in addition to an echocardiogram, all patients initially diagnosed with Turner syndrome require visual and hearing assessment, renal ultrasound, and TSH level measurement.



Patients with Turner syndrome develop moderate to severe insulin resistance and diabetes when they are older. Blood sugar screening is performed based on the patient\\\\\\\"s clinical manifestations.



Patients with Turner syndrome have hypogonadism, and eventually require estrogen replacement; however, if estrogen therapy is given at an early age, there may be premature fusion of the epiphysis, which will potentially decrease the patient\\\\\\\"s final height. Most physicians begin prescribing hormone replacement therapy when the patient reaches 14 years of age. Growth hormone is approved for use in patients with Turner’s syndrome to improve their final height.







Imaging studies in UTI:



Imaging studies are recommended in the following patients:



1. children under the age of five years with a febrile UTI



2. males of any age with a first UTI



3. females under the age of three years with a first UTI



4. children with UTI who do not promptly respond to antibiotic therapy



5. children with recurrent UTI



Voiding cystourethrogram is routinely recommended, and is considered by most authors as an important imaging study to demonstrate vesico-ureteral reflux (VUR).



Infantile hypertrophic pyloric stenosis (IHPS): usually presents in infants who are three to six weeks old. 83% of affected patients are boys. Postprandial, non-bilious vomiting is characteristic. Peristaltic waves can sometimes be detected just before vomiting. These occur as wavy movements traveling from left to right across the upper abdomen. A palpable \\\\\\\"olive-like\\\\\\\" mass in the right upper quadrant is pathognomonic of the disease, but is actually detected by only 49% of physicians, since most cases are diagnosed at an early stage (usually between the third and fourth week).



Historically, laboratory evaluation will show hypokalemia and a hypochloremic, metabolic alkalosis secondary to the loss of gastric hydrochloric acid, although electrolyte imbalances are seen less often now that the diagnosis is made earlier. The imaging modality used most commonly to diagnose IHPS is ultrasound, though an upper gastrointestinal (UGI) contrast study is preferred in some medical centers.



Electrolyte derangements and dehydration must be corrected before proceeding with surgical correction of infantile hypertrophic pyloric stenosis. Studies have shown that children who undergo surgery without first correcting the electrolyte imbalances are at increased risk for postoperative apnea.



Rx: pyloromyotomy



Endoscopically guided balloon dilation has been studied, but is not often used because of inconsistent success in opening the muscular ring of the pylorus. This approach is typically reserved for patients who are not otherwise good surgical candidates.



Studies have documented an association between the development of infantile hypertrophic pyloric stenosis and the usage of oral erythromycin, which is typically given as postexposure prophylaxis for pertussis. In addition, there is some indication that the usage of macrolides in breastfeeding women is linked to the development of infantile hypertrophic pyloric stenosis, especially in infant girls.







Constipation: The normal frequency of passage of stools in the infant is around six to eight times daily. This approximates to one stool passage per episode of breastfeeding. On the fourth week of life, the pattern changes. The stool frequency decreases to one or two episodes daily or even less, such as three episodes per week. This has to be differentiated from true constipation in order to avoid exaggerated concern.



DD: Hirschsprung’s disease usually presents earlier in life (failure to pass meconium in first 48 hours) as intestinal obstruction or enterocolitis. Notwithstanding, some patients will be diagnosed later, but will have a history of chronic constipation and failure to thrive. For this reason, observation is required to determine if the constipation persists.



**While constipation can signify a serious disorder (e.g., Hirschsprung’s disease, cystic fibrosis, hypothyroidism) in select circumstances, most children who are constipated are normal. Children with a history of resisting toilet training are at increased risk for developing constipation, as are those children whose dietary intake is high in dairy products and low in fiber. If dietary modification fails to relieve constipation, usage of a laxative is the next best step. Once the child’s bowel begins to operate properly on its own, the laxatives should be discontinued gradually.



Magnesium hydroxide, also known as milk of magnesia, is a mild saline laxative that causes the osmotic retention of fluid in the gut lumen. It can be titrated to produce soft, but non-liquid stool, and is safe for use in young children. In a child experiencing moderate constipation and no encopresis, magnesium hydroxide is an excellent treatment choice.



Bisacodyl suppositories are powerful stimulant laxatives that cause increased peristalsis. Usage of these suppositories commonly results in abdominal cramping, diarrhea, and nausea, and is best reserved for short-term \\\\\\\"rescue therapy\\\\\\\" in children with severe constipation.



Phosphate enemas are highly effective at relieving impaction, and act by distending the rectum and stimulating the muscles of the colon; however, frequent use of these enemas can cause electrolyte imbalances, and is therefore discouraged. This form of treatment is best reserved for relieving impaction. or for bowel preparation prior to medical procedures.







Tick bite: The risk of acquiring Lyme disease after being bitten by a tick is less than 1.5%. The most common complication of tick bites is local inflammation or infection.



In order to be infected with Lyme disease, the patient must have been exposed to the tick for more than 36 hours, because the transmission of the infectious agent - Borrelia burgdorferi - takes place only after the tick is firmly attached to the skin and has suctioned a certain amount of blood which gives it an engorged appearance. If a tick is found and it is not engorged with blood, there is no risk of Lyme disease, as ticks take at least 24 hours to firmly attach to their victims.



The majority of patients have a transitory skin reaction in the first 24-72 hours on the site of contact with the tick; this lesion must not be confounded with erythema chronicus migrans, which develops later.



The tick that transmits Lyme disease is brown, while the one that transmits RMSF is black







Epiglottitis: With the introduction of the Haemophilus influenzae type b vaccine in 1985, epiglottitis has become much less common in recent years. When it does occur, it causes an inflammatory edema of the epiglottis that impinges upon the airway. Respiratory arrest is easily provoked at this stage, and treatment should be focused on relieving any airway obstruction and treating the infection. The threshold for performing intubation should be very low. Since the outpatient setting is inadequate for such procedures, it is imperative that an ambulance be called so the child’s condition can be properly addressed by emergency personnel.



Frequently, epiglottitis is diagnosed solely by the clinical presentation. However, if a lateral neck radiograph is deemed necessary, it will reveal a swollen epiglottis (the \\\\\\\"thumbprint sign\\\\\\\") in classic epiglottitis. Endotracheal intubation should be performed before the radiograph is obtained, because patient is at great risk for respiratory arrest.







Lead intoxication: Lead intoxication remains a common preventable environmental hazard, although its prevalence is declining in developed countries. Early recognition of lead poisoning helps to prevent the development of long-term irreversible neurological sequelae. The two main factors contributing to lead poisoning in industrialized countries are exposure to old, lead-based paints which are usually found in old houses, and non-nutritive hand-to-mouth activities of young children.



Children with a blood lead level greater than 10 ìg/dL should be comprehensively evaluated by obtaining a CBC, serum electrolyte levels, and urinalysis. Environmental/behavioral interventions are crucial in the management of patients with lead intoxication. Ideally, these include identifying the source of exposure, removing the family from the lead-containing dwelling, cleansing of the environment, and educating the family in an effort to reduce hand-to-mouth activitiesof the children.



High-risk populations must be screened for lead intoxication. This includes children who live in or frequently visit old houses, and children whose sibling was diagnosed with lead poisoning. Measurement of the blood lead level is the gold standard in lead intoxication screening. A blood lead level greater than 10 ìg/dL is diagnostic. Venous sampling is always preferred to capillary sampling because the former is more accurate.



**Mild lead poisoning (blood lead level < 45 µg/dL) can be treated by DMSA or d-penicillamine, although this approach is not evidence-based. Moderate lead poisoning (blood lead level between 45 and 70 µg/dL) requires the treatment with EDTA IV or oral DMSA. Continuous IV infusion of EDTA is preferred to IM injection



Severe lead intoxication (blood lead level > 70 µg/dL and/or acute encephalopathy) is a medical emergency and prompt chelation therapy with dimercaprol and EDTA is necessary.







Afebrile pneumonia syndrome (APS): Causative organisms of APS include Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma, CMV, RSV, Parainfluenza virus, Adenovirus, and Pneumocystis carinii. The fever may either be absent or low grade. Other symptoms include cough, tachypnea, irritability, and poor feeding. Because of the lack of specificity of symptoms and radiologic findings, the causative organism cannot be determined solely by the clinical presentation. However, some organisms have characteristic features which may aid in the differential diagnosis and direct the necessary work-up of the patient.



The age of onset (between 2 and 19 weeks) and the presence of staccato cough are suggestive of Chlamydia pneumonia. This diagnosis can further be supported if there is a history of conjunctivitis in the neonatal period. Conjunctivitis is present in half of cases and may present either in the neonatal period or be concurrent with the pulmonary infection. Additional characteristics include auscultatory and radiologic findings that are out of proportion to the overall healthy appearance of the infant. Chest-x ray shows hyperinflation, peribronchial thickening, and bilateral, symmetrical, interstitial infiltrates. The WBC count is usually normal, but the eosinophil count is elevated. The diagnosis can be confirmed by tissue culture isolation of the organism from nasopharyngeal specimens, direct fluorescent antibody tests, enzyme-linked immunoassays, or polymerase chain reaction.







Delayed speech development: may indicate an underlying hearing impairment and should prompt referral of the patient for audiologic assessment. Other candidates for hearing evaluation include children with a family history of hereditary childhood hearing loss, history of meningitis, history of recurrent or persistent otitis media with effusion for more than three months, documented intrauterine infections, craniofacial anomalies, and use of ototoxic medications such as aminoglycoside.



Hearing loss early in life, even mild or unilateral, may affect speech and language development, social and emotional development, and academic achievements. Early identification is thus mandatory for a better prognosis; hence, screening programs have been widely and strongly advocated. Although the American Academy of Pediatrics endorses universal screening, at present, systematic screening is implemented in 32 states only.



The etiology of hearing impairment depends on whether the hearing loss is conductive or sensorineural. The most common cause of conductive hearing loss in children is presence of fluid in the middle ear. Other causes include tympanic membrane perforation (trauma or infection), ossicular discontinuity (infection, cholesteatoma, and trauma), tympanosclerosis, and congenital anomalies of the external ear canal or middle ear components. As for sensorineural hearing loss (SNHL), it may be congenital or acquired. The most common infectious cause of congenital SNHL is CMV. Other less common congenital infectious causes include toxoplasmosis, syphilis, and rubella. Postnatal infectious causes include group B streptococcus and bacterial meningitis. Hearing loss can also be genetically determined; it may be autosomal dominant or recessive, isolated or in a syndromic association with other anomalies.







Downs syndrome: Endocardial cushion defect is the most common congenital heart lesion in patients with Down’s syndrome. Other malformations that are frequent in Down’s syndrome include duodenal atresia, Hirschsprung’s disease, atlanto-axial instability, and hypothyroidism. Echocardiography is the most useful test for diagnostic evaluation of this condition. Cardiac catheterization is evidently more accurate than echocardiography for diagnostic evaluation, but this modality is reserved for cases in which the size of the shunt is uncertain, laboratory data and clinical findings are equivocal, or when pulmonary vascular disease is suspected.



Patients with Down’s syndrome are at increased risk of developing acute leukemia later in life. Other conditions which occur with a higher frequency in Down\\\\\\\"s syndrome include Alzheimer-like dementia, autism, ADHD, depressive disorder, and seizure disorder.







Infectious mononucleosis: Suspect IM in any adolescent who presents with fever, pharyngitis, tonsillitis, lymphadenopathy, splenomegaly, and rash. The recognition of \\\\\\\"atypical lymphocytes\\\\\\\" in the peripheral smear can be a clue to its identification, but these can also be seen in toxoplasmosis, CMV infection, or lymphocytic leukemia.



**It is infrequent to find posterior cervical adenopathy in a case of common bacterial pharyngitis. The development of rash after administration of amoxicillin is also one of the characteristics of the disease. Even though the spleen and liver are not always palpable, the former is constantly increased in size and friable. Since there is an increased risk of splenic rupture, especially if the patient is actively involved in sports, a patient who is highly suspicious for IM must be recommended to avoid practicing sports while waiting for the test results. Despite this fact, almost 50% of the cases of splenic rupture associated with IM can occur spontaneously, without evidence of previous trauma or excessive exercise.







Smoking cessation: Nicotine is a highly addictive drug. It is extremely difficult for even the highly motivated to stop smoking. Numerous factors may elicit the urge to smoke. Studies have shown that smokers who attempt to quit while working or living with people who continue to smoke are much more likely to relapse.



Smoking cessation is difficult to accomplish if the smoker remains subject to environmental triggers, including friends and family who continue to smoke.



Parents who want their children to stop smoking should quit themselves.



Prescriptions for nicotine replacement (e.g., nicotine patch, nicotine gum) should be offered to those smokers interested in quitting.







Rash: Due to the success of immunization campaigns, infection with the rubella virus (Choice B) is now very rarely seen in the United States; cases today typically arise in non-immunized foreign born populations. Infection with rubella is most often asymptomatic, but can cause German measles, a mild illness classically characterized by low-grade fever, lymphadenopathy involving the posterior cervical and occipital lymph nodes, and a maculopapular rash that begins on the face and spreads caudally. The rash is similar in appearance to that caused by measles, but patients are usually much less sick upon presentation with rubella. Supportive treatment is sufficient when the illness is self-limited. Of primary concern is the congenital rubella syndrome, which has devastating effects on the unborn child, especially when a non-immune pregnant woman is exposed to the virus in the first trimester.



Varicella, commonly known as chickenpox, is an illness characterized by a low-grade fever, malaise, and a macular rash that appears in crops which progress through several stages, including papules, vesicles, pustules, and crusts. The rash is considered distinctive because it includes a variety of lesions at different stages.



Rubeola, commonly known as measles, is an illness characterized by the three C’s: cough, conjunctivitis, and coryza. Fever and photophobia are also common. The blue-white Koplik spots found on the buccal mucosa precede the appearance of the maculopapular rash, which starts on the face and spreads caudally to the trunk and extremities.



Roseola is a mild illness characterized by a high fever that rapidly resolves. The fever is followed by the eruption of a characteristic rosy nonpruritic rash originating on the trunk and spreading to involve the extremities.



Rocky Mountain Spotted Fever is a rickettsial disease transmitted by tick bite. It is characterized by fever, myalgias, headache, and a petechial rash. Classically, the rash first involves the distal extremities (especially the palms and soles) and subsequently spreads to involve the trunk.







Henoch-Schönlein purpura Classical clinical manifestations of Henoch-Schönlein purpura include abdominal pain, arthralgias, skin lesions, and renal involvement. An antecedent upper respiratory infection is present in 50% of patients. Abdominal pain is a presenting symptom in 10-15% of patients. The skin lesions are symmetric, involve dependent parts of the body, and classically progress from an erythematous, macular rash to papular purpura. The joints and kidneys are also commonly involved.



Thrombotic thrombocytopenic purpura (TTP) is a serious disorder characterized by the following classical pentad:



1. Severe thrombocytopenia



2. Microangiopathic hemolytic anemia (RBC fragments)



3. Fluctuating neurological signs



4. Renal failure



5. Fever



Patients with TTP generally present with fever, pallor, petechiae, and confusion. The peripheral smear shows RBC fragments. PT and PTT are usually normal. The LDH is elevated due to hemolysis. Hemolytic uremic syndrome (HUS) and TTP comes under a spectrum of diseases. If a patient has more neurologic symptoms and less renal failure, the disease is considered TTP. On the other hand, if a patient has significant renal failure and less neurologic symptoms, the disease is considered HUS. Both TTP and HUS are very serious conditions, and require emergent plasmapheresis.







Idiopathic thrombocytopenic purpura Platelet-specific autoantibodies are the presumed pathogenesis of idiopathic thrombocytopenic purpura. In children, the condition is typically characterized by a sudden onset of bleeding, manifested as petechiae, purpura, epistaxis, and gingival bleeding. More severe bleeding is rare. Commonly, there is a history of infection in the several weeks prior to presentation. Symptomatic patients with moderate to severe thrombocytopenia

Diaper rash (diaper dermatitis): is a type of irritant contact dermatitis that is caused by a combination of factors: overhydration, friction, maceration and prolonged contact with excretions. The appearance of the rash after an episode of diarrhea is very characteristic. Management includes keeping the diaper area of the skin as dry as possible. This involves: frequent changing of diapers, avoiding tight-fitting diapers, exposing the skin to air, using diapers with super absorbent surfaces, and applying barrier creams such as zinc oxide or petrolatum. An uncomplicated diaper rash resolves quickly if the abovementioned measures are performed. Otherwise, a low-potency corticosteroid ointment may be prescribed.

DD: Candidal diaper rash: Tomato-red plaques and satellite papules are characteristic of candidal intertrigo and perineal infection. This infection is common in infants who have recently received antibiotic therapy because the decrease in the normal bacterial flora favors yeast proliferation. The condition can be confounded with diaper dermatitis, which affects the same area but usually spares the crural folds. Treatment of candidal diaper rash involves the application of an antimycotic cream such as clotrimazole or nystatin, while zinc oxide is the preferred treatment for diaper dermatitis.



Intestinal parasitosis: due to Helminths (hookworms, roundworms, pinworms, or whipworms) is the most frequent cause of chronic diarrhea, iron-deficiency anemia, and eosinophilia in patients coming from endemic countries. The prognosis is excellent with adequate therapy. Since the disease is easily transmitted, prophylactic treatment should be given to the rest of the household members.



Hemophilia: is an X-linked recessive disorder that occurs almost exclusively in males. Females are usually the carriers of the disease. A female may acquire hemophilia, an extremely rare possibility, only when her father is a hemophiliac, and her mother is a carrier who transmits the abnormal allele to her.

When a father is a hemophiliac, he will transmit his abnormal X gene to all his daughters, and consequently, they will all be carriers of the disease. When the mother is a carrier, her daughters have 50% chances of being carriers and her sons have 50% chances of getting the disease.



Childhood absence epilepsy (CAE): age of onset (4-8 years), no neurologic signs, typical EEG pattern, and no myoclonic activity. This condition is usually responsive to ethosuximide or valproate, although high doses may be required to control it effectively. Interestingly, many traditional anti-epileptic drugs are not effective in absence epilepsy, and can even exacerbate the condition (e.g. gabapentin). The prognosis in patients with CAE, especially if generalized tonic-clonic seizures are absent, is good. Staring spells will disappear in the teenage years. The risk of persistence of the condition is higher in patients who develop generalized tonic-clonic seizures. Unlike CAE, juvenile myoclonic epilepsy (JME) is characterized by a late onset of absence seizures with myoclonic activity, and is associated with life-long seizures.



Candidiasis: The first-line therapy for oral candidiasis is a topical antifungal - nystatin suspension or clotrimazole troches. Oral fluconazole can be used in resistant cases.



Child abuse: Always maintain a high index of suspicion for physical/sexual abuse in children (especially females) with sudden behavioral problems, especially if the family has an unstable economic background or if the child\\\\\\\"s parents have a history of drug/alcohol abuse.

**Whenever you suspect child abuse, it is strongly recommended that you inform the social services of your hospital or to call the child protection agency. Even if you are proved wrong later on, you do not owe any liability legally and, perhaps, it is the most important step in the management of suspected child abuse.



Allergic rhinitis: Dog or cat dander is one of the most common identifiable allergen in patients with allergic rhinitis. Allergen avoidance is traditionally considered the first step in the management. If the allergen is not identified or the symptoms persist after the avoidance measures, nasal corticosteroids should be the first-line therapy. Second-generation antihistamines and cromolyn are less effective than topical steroids. Nasal decongestive sprays are not recommended because tachyphylaxis usually develops and rebound phenomena may result.



Thalassemia major: Patients with this disorder usually die early in life due to relentless anemia and catastrophic expansion of erythroid precursors. Hypertransfusion therapy has a great role in treated patients (i.e. the child may survive several years after the diagnosis). Hypertransfusion regimen can suppress the effects of chronic severe anemia and extramedullary hematopoiesis, but result in significant iron overload and resultant organ damage.



Failure to thrive (FTT): is not a diagnosis in itself; rather, it is a term used to describe failure to gain weight in children younger than two years old. Children categorized as FTT weigh less than the 5th percentile for their age; more severe cases involve a slowing of linear growth and head circumference as well. The three causes of FTT are inadequate calorie intake, inadequate calorie absorption, and increased calorie requirements. Newborn infants need 110 kcal/kg/day, while children up to twelve months need 100 kcal/kg/day to grow at a normal pace. Psychosocial factors are very commonly involved in cases of FTT; this is why the clinician must explore whether there are stressors in the home environment. Organic causes of FTT, while less common, may include feeding problems, milk-protein intolerance, inborn errors of metabolism, infection, cystic fibrosis, gastroesophageal reflux, or renal tubular acidosis.

Dietary modification is the first-line of treatment in an otherwise well-appearing child with FTT.

The anxiety caused to the family by admitting the child to the hospital should not be underestimated. Although admitting a child with FTT for hyperalimentation was a common practice in the past, it is now considered unnecessary unless the child is severely malnourished, or if the child is at risk for neglect or abuse. If oral feedings do not result in appropriate weight gain within four to six weeks, supplemental feeding by nasogastric tube is preferred to the intravenous route.

If the history and physical examination are suggestive of an organic cause for the child’s FTT, then laboratory evaluation is warranted. Appropriate tests include urinalysis and culture, hematocrit, blood urea nitrogen, calcium, electrolyte levels, HIV ELISA test, and Mantoux tuberculin skin testing. Note that unless there is clinical evidence suggestive of thyroid disturbance, thyroid hormone levels are not typically tested.



Cat bites: get infected most of the time. Furthermore, the lesion is usually deeper than when produced by a dog, because the cat’s teeth are smaller and sharper. Pasteurella multocida, the major causative organism, is transmitted by the cat’s bite. However, this is often a polymicrobial infection. Adequate prophylaxis can be obtained by using amoxicillin and clavulanic acid. In adults, especially those allergic to penicillin, the second alternative is doxycycline. More ill patients can be treated with intravenous ampicillin-sulbactam combination.

** The incidence of infection complicating a cat bite is close to 50%; therefore, antibiotic prophylaxis is usually recommended, especially in high-risk situations (a hand bite is considered a high-risk situation) wherein the potential infection could extend to the bone and joint. The first dose of antibiotics (e.g. ampicillin/sulbactam) is usually given parenterally, and covers a broad spectrum of cat mouth flora, including Pasteurella multocida. An oral antibiotic (e.g. amoxicillin/clavulanate) is administered subsequently for 3-5 days.



Cat-scratch disease: is an infection that usually affects the young immunocompetent population. It is produced by Bartonella henselae. Around 10% of the patients with cat-scratch disease can develop suppuration of the lymph nodes. Other complications are: visual loss due to neuroretinitis, encephalopathy, fever of unknown origin, and hepatosplenomegaly.



Gastroesophageal reflux (GER) is a clinical diagnosis. Reassurance should be offered to the mother that the \\\\\\\"spitting up\\\\\\\" is a normal occurrence in infants up to 24 months old. It typically requires no intervention if the child is otherwise healthy and developing appropriately (the \\\\\\\"happy spitter\\\\\\\"). Children with mild GER symptoms, should be initially addressed with reassurance and thickening of formula with cereal, which usually results in decreased emesis, decreased cry, and better weight gain.

Prone positioning is another conservative treatment that may alleviate symptoms; however, this treatment method is of some concern, because of the correlation between prone positioning and SIDS. Formula thickening should be attempted first.

H2 receptor antagonists such as ranitidine are appropriate in those infants with a more severe GER presentation and who have failed conservative treatment.

Surgery is reserved for cases of GER that do not respond to medical management.



Pneumonia: It can be difficult to distinguish between bacterial and viral pneumonia, and indeed viral pneumonia is very common in previously healthy children and adults.

Classically, bacterial pneumonias are sudden in onset, associated with high fevers, and cause the child to look very ill if not toxic. Auscultatory findings are typically focal and distinctive. Chest radiographs may demonstrate a lobar consolidation. In contrast, viral pneumonias are gradual in onset and cause the child to look mildly ill. Auscultatory findings are more diffuse and bilateral. Chest radiographs may also demonstrate a more diffuse, bilateral infiltrate. Both forms of pneumonia are frequently preceded by an upper respiratory tract infection.

Community-acquired bacterial pneumonia in children is most commonly caused by S. pneumoniae. Amoxicillin is the drug of choice for the outpatient treatment of patients younger than five years of age.

Group B streptococcus pneumonia occurs most often in neonates.

Mycoplasma causes respiratory infection most often in school-aged children and young adults. The clinical presentation is usually gradual (although it may be abrupt) and is characterized by malaise, headache, fever, rhinorrhea, and sore throat with progression to lower respiratory symptoms.

Pneumocystis carinii pneumonia (PCP) is seen in patients with defects in cell-mediated immunity, especially in HIV-infected patients. It is usually seen in HIV patients when the CD4 cell count decreases to less than 200 cells/cubic mm. It has an insidious onset, and usually presents with low-grade fever, cough, dyspnea, and tachypnea. Chest x-ray results of patients with PCP reveal diffuse, bilateral ground-glass opacity.

Trimethoprim-sulfamethoxazole is the initial drug of choice for treatment in patients with suspected or proven Pneumocystis carinii pneumonia.

Respiratory syncytial virus is the most important respiratory pathogen of early childhood, and the major cause of bronchiolitis and pneumonia in children < 1 year. The illness manifests in annual outbreaks, appearing in winter with peaks in January, February, or March. Although this disease affects all age groups, lower respiratory symptoms appear mainly in children. Apnea is an important clue for this condition, as up to 25% of infants presenting with RSV infection will have this. How it causes significant apnea is not clearly known. The illness tends to be more severe, with a higher frequency of complications in preterms and infants with chronic medical conditions such as congenital heart disease, chronic lung disease, and immune deficiencies.

Diagnosis of RSV is quickly made by detection of RSV antigen in nasal or pulmonary secretions by ELISA.

**In healthy infants and young children, bronchiolitis is usually a self-limited disease; however, patients who are hypoxic or cannot feed because of distress should be hospitalized. These children should be kept in respiratory isolation. Therapy in most cases consists of supportive measures. Humidified oxygen and tube or intravenous feedings are indicated. Although there is no strong evidence that inhaled bronchodilators are effective in patients with bronchiolitis, it is a routine practice to administer these (nebulized albuterol or epinephrine) and observe the patient for any effect. If no prompt clinical response is seen, most clinicians discontinue these drugs.

Although ribavirin is a nucleoside analogue with good in vitro activity against RSV, studies examining its effect in children have been conflicting, and the cost for a course of therapy is substantial. It is usually reserved for patients with severe disease.

A secondary bacterial infection of the middle ear and future risk of bronchial hyperreactivity are the most common complications of RSV bronchiolitis.



Congenital toxoplasmosis: The consumption of undercooked meat during pregnancy may be associated with congenital toxoplasmosis, which can manifest as microcephaly or other abnormalities, such as chorioretinitis, mental retardation, deafness, and seizures. Domestic cats are definite hosts for T. gondii. Humans can acquire the infection by: (1) the consumption of raw or undercooked meat of infected animals (including lamb, beef, or game), or (2) contact with cat feces. Other congenital infections of the TORCH group can also result in microcephaly.



Rehumatic disease prophylaxis: The benefits of antibiotic therapy in a child with acute pharyngitis include: (1) reduction of the severity and duration of the symptoms, (2) prevention of rheumatic fever, and (3) prevention of local suppurative complications.

Interestingly, antibiotic therapy does not decrease the risk of acute glomerulonephritis because cutaneous (not pharyngeal) infection is typically implicated as its cause.



Disease associations: Meconium ileus is usually the earliest manifestation of cystic fibrosis (CF), and is almost pathognomonic for the disease. Uncomplicated meconium ileus is characterized by distal intestinal obstruction, wherein the terminal ileum is dilated and filled with thick, tar-like, inspissated meconium. Plain abdominal x-ray findings (dilated, gas-filled loops of small bowel, absent air-fluid levels, and a meconium mass within the right side of the abdomen) are usually suggestive of the diagnosis. Since CF is inherited in an autosomal recessive pattern, a family history of recurrent respiratory infections (or other manifestations of CF) is an important clue to the diagnosis of this patient.

Duodenal atresia is associated with Down’s syndrome and polyhydramnios.

A family history of severe constipation is sometimes present in patients with Hirschsprung’s disease.

Patients with pyloric stenosis are typically firstborn males.



Even though most cases of muscular dystrophy such as Duchenne’s, Becker’s, or myotonic dystrophy present around 10-12 years of age, some cases can be diagnosed when the child is 2-3 years old. Limb-girdle or facioscapulohumeral muscular dystrophies can be detected at this age; while congenital dystrophies and glycogen-storage diseases are evident soon after birth, and have early mortality.

Muscular dystrophy can be a cause of inability to walk or limping in the infant or toddler, even though the more common cause of this problem is spasticity, a condition amenable to rehabilitation therapy. Hypothyroidism, MSUP and phenylketonuria must be screened for at birth, and are almost always accompanied by mental retardation and global delays in development.



Neonatal screening for hypothyroidism is performed by obtaining a small sample (few drops) of blood from the heel pad and using a piece of filter paper to absorb the blood sample. This test may be done within two to five days following delivery. It is performed after the first 24 hours of life because there is a normal physiologic TSH surge following delivery. After 24 hours, the TSH levels gradually drop to normal levels or may remain slightly elevated for the next few days. It is very important to avoid any delays in the diagnosis and treatment to avoid permanent neurological deficits.

Most centers in the United States use total T4 measurement as a primary tool for screening for neonatal hypothyroidism. If the total T4 levels are low, TSH levels of the same sample is measured, and if the TSH levels are over 20 U/L, repeat testing (measurement of both Free T4 and TSH levels) is performed from a regular blood draw to confirm the diagnosis. Some programs use TSH as a primary screening tool.

Once the diagnosis of neonatal hypothyroidism is confirmed by measuring the Free T4 and TSH levels from a regular blood draw, other ancillary procedures such as thyroid ultrasonography, radioactive iodine scanning and urinary iodide levels are performed to investigate the etiology of the hypothyroid state. Radioactive iodine uptake and scanning are useful to determine the location, size and function of the thyroid gland.

Levothyroxine is the treatment of choice for hypothyroidism, and the dose in the neonate is higher than the adult dose; however, levothyroxine therapy should be started once the diagnosis is confirmed with a regular blood draw. The clinical features of hypothyroidism in neonates can be subtle and unreliable. Levothyroxine therapy in neonates is therefore started once the biochemical confirmation is obtained, even if the clinical features of hypothyroidism are not present.



Febrile seizures

The generally accepted criteria for febrile seizures are:

1. Age less than six years

2. No past history of afebrile seizures

3. Temperature greater than 38 C

4. No evidence of CNS infection / inflammation

5. No metabolic disturbances present which may produce seizures

Febrile seizures may be subdivided into 2 forms: simple and complex.

A simple febrile seizure is characterized by the absence of focal features, a duration of less than 15 minutes for an isolated event, and for seizures occurring in series, a cumulative duration of less than 30 minutes. This form of seizures is more common, and is associated with only a mild elevation of the risk for subsequent epilepsy (i.e. afebrile seizures) in latter life, compared to the general population,contrary to previous thinking.

It is important to note that the question specifically asks about prognosis, and not recurrence. If the question particularly asks about the recurrence of febrile seizures during childhood, then the answer would be “significantly elevated risk”, regardless if this case was a simple or complex febrile seizure for the first time.

Febrile seizures often occur on the first day of a mild illness as the child’s temperature is rising, and may be the first manifestation of illness. Generally, studies are not necessary for the evaluation of the simple febrile seizure, although it may be appropriate to explore the cause of the fever in children with other symptoms (e.g., severe diarrhea). Parents should be reassured that it is not an indication of future neurologic dysfunction or disease.

Complex febrile seizures, on the other hand, are characterized by focal features (i.e. postictal paresis), a duration of more than 15 minutes, and if occurring in series, a cumulative duration of greater than 30 minutes.



Congenital adrenal hyperplasia (CAH) is a group of disorders characterized by a deficiency in one of the enzymes involved in steroid synthesis. In 90% of cases, the deficiency concerns 21-hydroxylase, which is necessary in mineralocorticoid and glucocorticoid synthesis. In addition to a low production of mineralocorticoids and glucocorticoids, the deficiency of 21-hydroxylase results in an excess of its substrates. These excess substrates are shunted towards androgen synthesis, resulting in ambiguous genitalia and virilization in females, and precocious puberty in males. ACTH levels are also evidently elevated, and lead to hyperplasia of the adrenal glands, further contributing to the increased production of androgens.

Salt wasting syndrome occurs in severe deficiencies. It presents in the first 2-4 weeks of life with emesis, dehydration, and shock. Laboratory work-up reveals hyponatremia and hyperkalemia (from lack of aldosterone), and hypoglycemia (from lack of cortisol).

Diagnosis confirmation of 21-hydroxylase deficiency is carried out by documenting the elevation of 17 alpha-hydroxyprogesterone, a substrate of 21-hydroxylase. Other biologic disturbances occuring in 21-hydroxylase deficiency include elevated corticotropin and renin levels, and a serum aldosterone level that is inappropriately low for the renin level.

The treatment principle for 21-hydroxylase deficiency is based on supplementation of deficient hormones (mineralocorticoids and glucocorticoids). This supplementation will decrease corticotropin (ACTH) production, and consequently correct androgen levels.

11-hydroxylase deficiency is a far less frequent cause of CAH than 21-hydroxylase deficiency. It is characterized by: (1) decreased aldosterone and cortisol, and (2) increased androgens and deoxycorticosterone. A deficiency in 11-hydroxylase results in an excess in its substrate, 11-deoxycorticosterone. This substrate has mineralocorticoid activity. Patients with this condition present with hypertension, hypernatremia, and hypokalemia.

3-beta-hydroxysteroid dehydrogenase is a rare cause of CAH. It involves: (1) a decrease in testosterone, mineralocorticoids and glucocorticoids, and (2) an increase in DHEA-S. Consequently, males fail to acquire normal external genitalia because of a lack of testosterone, and females are slightly masculinized because of DHEA-S excess.



Marfan syndrome (MFS): a disease characterized by arachnodactyly, increased arm span relative to height, and valvular (mitral or aortic) insufficiency. Dural ectasia is the most common finding, although frequently overlooked (present in more than 90% of patients), and usually requires an MRI of the lumbar spine for the confirmation of the diagnosis. Other characteristics that can affect up to 80% of the patients with MFS are ectopia lentis, aortic dilatation (more frequent in adults), and mitral valve prolapse.

The risk of aortic dissection is high in patients with MFS. For this reason, corrective surgery is recommended when the aortic root reaches 45 mm. About 80% of the patients will have mitral insufficiency, which can lead to CHF. These patients will benefit from mitral valve replacement.



Diaphragmatic paralysis in a newborn usually results from phrenic nerve injury. The two most common causes of phrenic nerve injury are birth injury and cardiothoracic injury . It is typically accompanied by the signs of brachial plexus injury, like Erb’s palsy. Other causes of diaphragmatic paralysis, (e.g., diaphragmatic hypoplasia, neural and neuromuscular disorders) are very rare.



Myelomeningocele: In 80% of myelomeningocele cases, the lumbar region is involved. Almost all these patients will have bladder dysfunction, which can ultimately lead to upper urinary tract involvement and renal dysfunction. Children with S2-S3 involvement can have external anal sphincter dysfunction that can lead to fecal incontinence. This is a much less common complication than bladder involvement, and is specifically associated with S2-S3 involvement.



Giardiasis has several routes of transmission: person-to-person, food-borne and waterborne. Person-to-person transmission occurs in two settings: (1) in institutions where there is fecal incontinence and poor hygiene (e.g., some daycare centers), and (2) in male homosexuals. Symptomatic patients with giardiasis should receive appropriate treatment.

Asymptomatic carriers of Giardia lamblia are not usually treated, except in specific instances such as in outbreak control and for prevention of household transmission by toddlers to pregnant women and patients with hypogammaglobulinemia or cystic fibrosis.



Severe malnutrition: remains as one of the major health problems in developing countries.

The initial treatment of patients with severe malnutrition should address the following issues: temperature control (warming), possible infection, dehydration and malnutrition (feeding). Dehydration should be treated with oral rehydration whenever possible.



Posterior urethral valves are predominantly found in males and are the most common cause of severe obstructive uropathy in children. The abnormal development of the valves in utero can obstruct urinary flow, leading to detrusor hypertrophy and, eventually, vesicoureteral reflux and hydronephrosis. Hallmarks of PUV include a distended bladder and a weak urine stream.

Voiding cystourethrogram (VCUG) is a radiographic examination of the bladder and lower urinary tract. The bladder is filled with contrast material by catheter and multiple radiographic images of the bladder and urethra are obtained as the patient empties the bladder. VCUG is especially helpful in evaluating young children for vesicoureteral reflux and posterior urethral valves.



Foreign body aspiration:

Never forget your ABCs of resuscitation no matter what the nature of emergency is.

The Heimlich maneuver is recommended in kids older than one year. Below that age, give blows on the back with chest thrusts.

If the child is unconscious, do it while the patient is lying down. After the abdominal thrusts, examine the airway for a foreign body. If visualized, it should be removed.



Transient synovitis (also known as toxic synovitis) is a common condition that causes pain in the hip, thigh, or knee in boys aged 3-10 years old. Up to 25% of children with transient synovitis will have bilateral effusions. The disorder may be preceded by a respiratory infection, although the erythrocyte sedimentation rate (ESR) and white blood count (WBC) are typically normal. If the clinical presentation suggests transient synovitis and plain radiographs are unremarkable, an ultrasound should be performed. Ultrasonography is the preferred technique for identifying small joint effusions, and may demonstrate widening of the joint space of the hip. This modality is also useful in guiding aspiration of the joint, a procedure that is warranted in a febrile child with hip effusion.



Breastfeeding: Every primary care physician should encourage breastfeeding. It is recommended that the infant be fed at least every four hours. The mother should be able to identify early signs of hunger, like suckling of the hand or fingers or arm movements towards the mouth, as preterm or debilitated infants may not be able to cry vigorously or show agitation.

It is a good practice to feed the newborn using both breasts, as complete emptying of the breast will increase the milk’s nutritional qualities. Unfortunately, sometimes there may be a decreased production of milk, and the baby has to be fed using artificial formula. Feeding the baby using both breasts will therefore not guarantee the infant’s satiety.



Neonatal jaundice appearing in the first 24 hours of birth is always pathologic. Immune or non-immune hemolysis is frequently present in such patients.

G-6-PD deficiency is the most common red cell enzymopathy that can lead to hemolysis. It is an X-linked disorder, and should be suspected in a male infant of African, Mediterranean, or Asian descent. No triggering agent is usually present, although those infants who develop severe jaundice with G6PD deficiency usually have Gilbert\\\\\\\"s syndrome as well.

Physiologic jaundice manifests 24 hours after birth.



Enterovirus and Arbovirus infections are the most common cause of viral meningitis or encephalitis in the pediatric population. These infections are more frequent during summer, late spring, and early fall. Most arbovirus infections are zoonosis (transmitted through animal vectors); for this reason, these infections are more common in the rural areas. Herpes simplex virus is the most common cause of viral meningitis in the adult population, not in children.



Sickle cell disease is an inherited disorder that results from the presence of hemoglobin S. The most severe and common form is sickle cell anemia, in which only hemoglobin S is present (HbSS). Clinical manifestations rarely present prior to 6 months of age, when fetal hemoglobin levels decline and functional asplenia typically develops. Dactylitis (pain in the hands and feet) is common in the first 18 months of life. The best diagnostic test is hemoglobin electrophoresis because it precisely determines which form of sickle cell disease is present.

Acute severe anemia may be superimposed on chronic anemia in patients with sickle cell disease. When this occurs, it is a life-threatening condition. Clinical manifestations include weakness, pallor and lethargy. The three typical causes of acute anemia are splenic sequestration crisis, aplastic crisis, and hyperhemolytic crisis.

Aplastic crisis represents a transient failure of erythropoiesis with an abrupt reduction in the blood hemoglobin and the number of erythroid precursors in the bone marrow. A very important finding during a crisis is the virtual absence of reticulocytes. The typical cause is an infection; parvovirus B19 infection is the most common cause in children.



Intussusception occurs when a part of the small bowel is telescoped into itself. The most frequent vicinity is the ileocecal region. Almost 60% of the cases occur in children younger than 1 year of age, while 80% present before 2 years of age. The classic presentation is a sudden onset of colicky abdominal pain followed by vomiting, and the vomitus rapidly changes from alimentary to bilious. The child usually draws up his legs towards the abdomen because of the pain. Hematochezia is present in 70% of the cases; 15% of the patients have the characteristic \\\\\\\"currant jelly\\\\\\\" stools. Initially, the child is irritable, but he may eventually become apathetic when he is no longer able to eat, and he gets dehydrated. Palpation of a sausage-shaped abdominal mass on the right side is characteristic. Abdominal x-ray reveals generalized distension of the bowel loops or another evidence of obstruction. An enhanced density that projects into the air level of the large bowel can be identified in 25% of the case

s. This density represents the invaginated bowel loop, and is known as the \\\\\\\"crescent sign.\\\\\\\"

DD: Acute gastroenteritis (AGE) presents with fever that precedes abdominal pain and diarrhea. AGE will not explain the presence of the abdominal mass and the massive bowel distention seen in the abdominal x-ray of this patient.

Meckel’s diverticulum usually presents in toddlers and older children, generally between five and ten years of age, and in young adults. The most common location of pain is in the right lower quadrant. Hematochezia is also present, but the stool is non-mucoid, and there is no palpable abdominal mass.



Erb’s palsy: The classical scenario of Erb’s palsy is described. It is the most common form of obstetrical brachial plexus injury and involves the upper roots (C5, C6, and sometimes C7) of the plexus resulting in an adducted and internally rotated right arm with forearm pronation and flexed wrist. A serious complication is diaphragmatic paralysis due to phrenic nerve involvement. Symmetric palmar grasp reflex indicates that lower roots of the brachial plexus are intact and is a good prognostic sign. The prognosis of Erb’s palsy is typically good with an 80% chance of full or near-full recovery. Horner’s syndrome may be associated with the injury of lower roots of the brachial plexus.



Gastrointestinal foreign bodies occur typically in toddlers, because exploring objects by putting them into the mouth is a characteristic behavior pattern in that age group. Coins are the most common GI foreign bodies. Foreign bodies can become lodged in any of the areas of esophageal physiologic narrowing. They require attention and frequently removal in that case. Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty. Pyloric obstruction is rare and manifests as persistent vomiting.

Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty; therefore, no intervention is usually necessary.



Cellulitis: is characterized by its irregular and elevated borders, as well as increased local temperature, tenderness, and erythema. It is an infection located between the subcutaneous tissue and the fat, therefore local anesthesia will not be useful in this situation. Pain can be treated by oral analgesics.



Cleft lip with or without cleft palate is typically a multifactorial disorder but can have autosomal dominant, autosomal recessive, and X-linked inheritance, as well as be associated with teratogenic agents. Reconstruction of a cleft lip is generally performed at approximately three months of age according to the rule of ‘10:’ 10 lbs of weight, 10 weeks of age, and 10 g of hemoglobin.



The reticulocyte count is an index of RBC production by the bone marrow. Increased destruction of RBCs (hemolytic anemia) prompts the normal bone marrow to compensate for the loss by increasing the rate of erythropoiesis, which results in an increased reticulocyte count. On the other hand, nonhemolytic anemias, due to a decreased production of RBCs, will result in a low reticulocyte count. The reticulocyte count is therefore increased in hemolytic anemia, and decreased in nonhemolytic anemia.



Diabetic ketoacidosis (DKA) must be suspected in any child with dehydration, metabolic acidosis, nausea, vomiting, tachypnea without oxygenation problems, abdominal pain, and hyperglycemia. Patients must be immediately admitted to the Intensive Care Unit for correction of the metabolic acidosis and dehydration. Treatment involves intravenous fluids and insulin administration, as well as adequate potassium supplementation (to avoid hypokalemia).



Botulism: Giving honey to the child is the main clue to the diagnosis. Constipation is typically the first manifestation of the disease, and is followed by lethargy, poor sucking and weak crying. Gag reflex is frequently impaired. This may result in aspiration if airways are not protected.



Chlamydial infection This newborn most likely has conjunctival and pulmonary chlamydial infection. Chlamydia may have been transmitted from the mother during the neonate\\\\\\\"s passage through the birth canal. Cervical carriage in the mother has been associated with a higher incidence of preterm labor, PROM, and late post-term endometritis.

Chlamydia is the most common causative agent of infectious neonatal conjunctivitis. Infected infants have a 25-50% risk of developing conjunctivitis and a 5-20% risk of developing pneumonia. Chlamydial conjunctivitis develops a few days to several weeks after birth and manifests with conjunctival congestion, edema, and mucoid or frank purulent discharge. Pneumonia usually appears 3-19 weeks after birth, and symptoms include cough, tachypnea, rales, and absence of fever. Wheezing is rare. The latter two features differentiate chlamydial pneumonia from RSV bronchiolitis.

Neonatal disease is best prevented by early detection and treatment in pregnant women. Screening is recommended in high-risk individuals such as single mothers, adolescents, patients with low socioeconomic status, and promiscuous patients. Erythromycin is the drug of choice in pregnancy and should be given to both the patient and her sexual partner. Another test should be performed later in pregnancy, and a positive result warrants a second course of antibiotics. Infants should also be treated with oral erythromycin for 14 days, as topical agents are ineffective. Colonization takes place during delivery, when the newborn comes in contact with the vaginal secretions of the mother.



Here comes the OBG

Preconception: All women who wish to get pregnant should take 400 micrograms of folic acid daily at least one month before the projected date of conception. Oral contraceptive pills (OCPs) can be stopped at any time; however, conception may be delayed because the patient may continue to have anovulatory cycles immediately after discontinuation.



Screening: Alpha-Feto-Protein (AFP) is produced by the yolk sac and fetal liver and a certain amount of it crosses the placenta to the maternal circulation. AFP production is altered in the presence of fetal anomalies, and its measurement in maternal serum can be used to screen for these anomalies.

Increased levels are seen in the presence of neural tube defects, abdominal wall defects (Gastroschisis, Omphalocele), as well as “false positive” causes such as fetal demise, multiple gestation, and inaccurate gestational age. In the case of an increase in MSAFP levels, the physician should first perform an ultrasonography to rule out the false positive causes, and to detect the presence of any anomaly that may be seen by ultrasound. Amniocentesis has to be ordered afterwards for confirmation by measuring amniotic levels of AFP and Acetylcholinesterase (AChE). AChE is a protein that is increased only in neural tube defects.

Low levels of MSAFP are frequently associated with chromosomal anomalies, especially Down’s syndrome. The screening can be rendered more accurate when MSAFP is coupled with beta-hCG and Unconjugated Estriol (UE3) levels; it is then called triple test. A combination of a decreased MSAFP, increased beta-hCG and decreased UE3 levels is typical of Down’s syndrome, whereas in trisomy 18, all three parameters are decreased. Likewise, Ultrasonography has to be performed to rule out inaccurate dates and fetal demise, then amniocentesis to confirm the diagnosis. MSAFP and triple test should be performed between the 16th and 18th week of gestation, and it must be noted that their reliability in screening depends greatly on the accuracy of the gestational age.

Amniocentesis is indicated in cases of abnormal levels of MSAFP or triple screen, but after ultrasonography has ascertained gestational age accuracy, and ruled out fetal demise and multiple gestation. It is best performed between 16 and 20 weeks’ gestation.

Chorionic villous sampling (CVS): Chorionic villus sampling is indicated in women with known genetic diseases, or previously affected children. It is performed between 10 and 12 weeks’ gestation, and therefore offers the advantage of a first trimester termination of pregnancy in case the fetus is affected.Transverse limb abnormality is one of the complications of chorionic villous sampling (CVS). The risk of this complication depends upon the age of gestation; the risk is greatest when the age of gestation is less than 9 weeks, and is lowest when it is greater than 11 weeks.

Cordocentesis or Percutaneous Umbilical Blood Sampling (PUBS) is used for rapid karyotype analysis, or when fetal blood dyscrasias, such as fetal anemia and Rhesus isoimmunization, are suspected. In the present case, ultrasound has to be performed first to rule out the other causes of MSAFP elevation beside genetic anomalies.

Serum estriol levels can be measured in pregnancy along with MSAFP and beta-hCG (Triple test) as a screening tool for chromosomal anomalies in the fetus.



Down syndrome: is the most common autosomal abnormality among live births and the most common cause of mental retardation in children. Most cases are caused by total trisomy 21, which typically arises from maternal meiotic nondisjunction. Since advanced maternal age (defined as 35 years of age or older) is associated with an increased risk of having offspring with Down syndrome, accurate prenatal screening for the condition is in high demand. At this time, the integrated test is considered the best overall screening test for Down syndrome, with a detection rate of 85% and a false positive rate of 1.2%. The integrated test is comprised of ultrasound measurement of nuchal translucency thickness at 10 weeks in combination with measurement of serum markers from the first trimester (PAPP-A) and the second trimester (alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol, and dimeric inhibin-A); however, the actual diagnosis of Down syndrome can only be made by examining the fetal karyotype, which r

equires chorionic villus sampling or, more commonly, amniocentesis.



BioPhysical Profile: BPP is a scoring system to evaluate baby\\\\\\\'s well being. Its indicated when there is Decreased movement or a non-reactive NST. It includes NST in addition to 4 things, 1-Fetal tone, 2-Movment, 3-Breathing(30/10min), 4-Amniotic fluid inxed(5-20). Each has a score of 2, when present and 0 when absent. 8-10 is normal, and should be repeated once or twice weekly, until term.In presence of OlygoHydramnions (AFI<5) delivery is considerd. If score is 6 w/o OH, Contraction stress test is ordered. If it gives non-reassuring results then Deliver, if it gives suspicious results then repeat the next day. If its 4 w/o OH and fetal lung are mature, Delivery is considered. If lungs are not mature, steriods is gven and BPP accessed w/i 24 hrs. If score is <4, deliver now.



Genetics: If the father is affected by an X-linked recessive disease and the mother is not a carrier, none of their children will be affected by the disease, although all their female children will be silent carriers.

For autosomal-dominant diseases, the probability of the disease for the child is close to 50% if one of the parents is affected.

For autosomal recessive diseases, the probability of the disease for the child is close to 25% if both parents are silent carriers.



Fetal hydantoin syndrome presents with a small body size with microcephaly, hypoplasia of the distal phalanx of the fingers and toes, nail hypoplasia, low nasal bridge, hirsutism, cleft palate and rib anomalies.



Fetal Alcohol Synd: Irritability, mild to moderate mental retardation, hpoplastic maxilla, lng philtrum, thin upper lip border and microcephaly, and epicanthal folds.



Pseudocyesis: Pseudocyesis is an imaginary pregnancy that usually occurs in women having a strong desire to become pregnant or in need for motherhood. It was suggested that the depression caused by this need was behind the occurrence of some hormonal changes similar to those of pregnancy, and thus resulting in nearly all its symptoms and signs. Patients may present with amenorrhea, enlargement of the breasts and abdomen, morning sickness, weight gain, changes of the uterus and cervix, sensation of fetal movements, and even a positive urine pregnancy test. Ultrasound, however, reveals a vacant uterus with normal endometrial stripe and the pregnancy test is negative. The woman may show an acute depression when no baby is born.

Abortions: Abortion is a spontaneous loss of pregnancy that occurs before 20 weeks gestation. It is also defined as the expulsion of a fetus, or an embryo, weighing 500g, or less. Preterm birth is a spontaneous termination of pregnancy that occurs between 20 and 37 weeks gestation.

In complete abortion, the whole conceptus passed through the cervix. The cervix then closes, and pain and uterine contractions subside. Ultrasonography shows an empty uterus. Incomplete abortion implies the evacuation of some of the fetal tissue while the rest is still retained in the uterine cavity.

Threatened abortion is any hemorrhage occurring before the 20th week gestation, with a live fetus. The cervix is closed and there is no passage of fetal tissue. Mild lower abdominal pain may be noted. The fetal heart is active on Ultrasound. 25% of pregnancies have vaginal bleeding, to some extent, in the first trimester. In half of these cases, the abortion will actually occur.

Inevitable abortion manifests with vaginal bleeding, lower abdominal cramps that may radiate to the back and perineum, and a dilated cervix. Ultrasonography demonstrates a ruptured or collapsed gestational sac with absence of fetal cardiac motion. Incomplete abortion has the same presentation except that there is an incomplete evacuation of the conceptus. Ultrasonography reveals endometrial debris.

Septic Abortion Is to be suspected in ALL abortions outside hospital who come bcack with pain and vaginal discharge. Its managed with cervical and blood sampling, IV antibiotics and gentle suction cuertage.

Abruptio Placenta: Pt presents with vaginal bleeding, ABDOMINAL PAIN, and uterine tenderness. The absence of hemorrhage DOES NOT rule out this Dx.

DDX:Placenta Previa, absence of bleeding RULES OUT this dx.

Risk factors are:1-HT and preecclampsia, 2-Placental abruption in previous pregnancy, 3-trauma, 4-short umbilical cord, 6-COCAINE abuse.

AP is the mcc of DIC in pregnancy, which results from a release of activated thromboplastin from the decidual hematoma in to maternal circulation.

It can progress rapidly so careful monitoring is mandatory. Once dx is made, large-bore IV , as well as Foley cathater is inserted. Pts with AP in LABOR should be managed aggressively to insure rapid vaginal delivery, since this will remove the inciting cause of DIC and hemorrhage. Now if pt is stable tocolysis with MgSO4 is considered, but remmeber Ritordin is CI in pt with HT. Again, once we dx the next step is Vaginal delivery with augmentation of labor if necessary. Now if mother and baby are not stable or if there is CI, then Emergency C-section is indicated. Now if there is Dystocia ( narrowing of the birth passage) then Forcepts can be used.

Placenta Previa: presents with painless vaginal bleeding in the 3rd trimester. Dx is with US, accuracy of 90% transabdominally and 100% transvaginally. Pelvic exam is CI. Risk factors are: multi parity, advanced age, multiple gestation. If the bleeding continues, C-section has to be done ASAP. Even if pregnancy is not term yet. In cases of extended bleeding surgeon might discover A Placenta Acerta. Now if the mother is stable and fetus is at term, scheduled C is choice. However, until then pt has to be monitored closely. If both mother and fetus are stable IM steriod are used to mature the lungs. Forcepts are not used in complete PP.

In any case Vaginal delivery is not an option for any kind of PP. If both mothe and fetus are OK and there is no more bleeding and mother has access to close hospital then she can be sent home and monitored at home until 36week, then schedule c-section is done.

Pt with complete PP, after bleedng is controlled and both baby and mohter are fine, Schedule Elective C-section.

Vasa Previa: Hemorrhage w fetal heart rate changes, progresing from tachycardia to bradycardia to a sinusoidal pattern. \\\\\\\"Apt\\\\\\\" test distinguishes maternal from fetal blood. Mortality risk is 75%. Dx w transvaginal US in combination w Doppler. VP necessitates emergency C section.



Preeclampisa/Eclampsia: A history of preeclampsia in the past increases the risk of developing this complication during a subsequent pregnancy. The risk is higher if the preeclampsia presented earlier (age of delivery was less than 32-33 weeks), or if the patient has renal disease or chronic hypertension.

Patients at term and with severe preeclampsia should be promptly managed with hydralazine (or labetalol) to lower the blood pressure, and MgSO4 to prevent progression to eclampsia. Once initial stabilization has been obtained, delivery should be carried out. For patients with mild preeclampsia, vaginal delivery is the preferred mode of delivery. For patients with severe preeclampsia, the preferred mode of delivery has not been evaluated. Cesarean section should be decided on an individual basis.

Patients with severe preeclampsia and who are remote from term are best managed in a tertiary care center or by referring them to obstetricians who specialize in the management of high-risk pregnancies.

Patients with severe preeclampsia are at greater risk of developing eclampsia. The first priority in patients with eclampsia or postictal coma is respiratory and cardiovascular resuscitation. Anticonvulsant medications can be administered after placing two large-bore needles in the patient. The most effective agent used in these cases is magnesium sulfate; however, the most effective treatment to prevent further complications is to accelerate delivery. Eclampsia can cause several other complications besides seizures, such as disseminated intravascular coagulopathy, acute renal failure, hepatocellular injury, liver rupture, intracerebral hemorrhage, etc. Magnesium sulfate prevents seizures, but it will not stop the pathologic process.

So if Qs asks Which of the following is the most effective strategy to decrease this patient\\\\\\\"s risk for developing further complications?

Ans: Speed vaginal delivery or termination of pregnancy

if the question asks about the next step in the management?

Magnesium sulfate, because the hemodynamic stability and seizure control are important before attempting delivery.

So the bottom line is If the patient is in the third trimester, especially in the last six weeks, termination of pregnancy is advised in order to stop the pathologic process. There is no pharmacologic therapy more effective than this intervention.

Anti-seizure prophylaxis in a patient with eclampsia has been a topic of prolonged debate. Recently, some studies have confirmed that magnesium sulfate is not only the best anticonvulsant medication for patients with eclampsia, but it is also the more effective agent to prevent further seizures. Diazepam or phenytoin can be added to the therapy if seizures persist, even though the use of diazepam is limited because of depressant effects on the fetus.

In pregnant patients with a hypertensive crisis, either hydralazine or labetalol are the antihypertensive drugs of choice. Methyldopa is preferred for oral therapy in mild to moderate hypertension in a pregnancy.

Retinal hemorrhage is considered to be an extremely ominous sign of preeclampsia/eclampsia.

Eclampsia is diagnosed when unexplained convuslions occur in the setting of preeclampsia.

HELLP syndrome is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and abnormal liver function tests. Magnesium sulfate is the standard of care for patients with severe preeclampsia and HELLP syndrome, because it significantly reduces the risk of seizure and is relatively safe. Although 50% of all cases of eclampsia occur prior to term, the risk is significant within the first 24-48 hours after delivery. Magnesium sulfate infusion should cover this period. Antihypertensive agents may be indicated to control elevated blood pressure if it exceeds 160/105 mmHg. Plasma exchange transfusion is useful in patients with persistent HELLP syndrome.



Preterm pregnancy: Respiratory distress syndrome (RDS) is a common complication in preterm infants. It occurs when fetal lung maturity has not been reached yet. Other complications of preterm birth include intraventricular hemorrhage, sepsis, necrotizing enterocolitis and kernicterus. The mortality rate in preterm infants is greatly influenced by the gestational age. For instance, it is similar to that of full-term infants when birth occurs at 36 weeks and attaining 50% when it occurs at 24 weeks.

The patient in advanced stage of labor should be managed more aggressively and tocolysis has to be instituted at once. Magnesium sulfate is now the drug of choice for tocolytic therapy because of its fewer side effects such as feeling of warmth and flushing. However, it is not FDA approved for this use. It is particularly useful in the presence of contraindications to beta 2 agonists, such as diabetes and heart disease. It acts by competing with calcium ions for entry into the cell.

Among tocolytic agents, Ritodrine (beta 2 agonist) is the only agent approved by FDA for management of preterm labor. Terbutaline is also widely used in the US and exists in the oral, subcutaneous and intramuscular forms. Most side effects of beta-agonist result from their concurrent b1 activity, and include increase in heart rate, rise in systolic pressure, decrease in diastolic pressure, chest pain secondary to MI, and arrhythmia. Beta agonists may also cause fluid retention secondary to decrease in water clearance, which when added to the tachycardia and increased myocardial work, may result in cardiac failure. In addition, they increase gluconeogenesis in the liver and muscle, resulting in hyperglycemia, which increases insulin requirements in diabetic patients. The passage of beta-agonists through the placenta does occur and may be responsible for fetal tachycardia, as well as hypoglycemia or hyperglycemia at birth.

Other tocolytic gents include prostaglandin synthetase inhibitors, such as indomethacin, and calcium channel blockers. Indomethacin is quite effective but it can result in oligohydramnios and premature closure of ductus arteriosus. It also decreases fetal renal function and increases the risk of necrotizing enterocolitis and intracranial hemorrhage. Calcium channel blockers are promising agents and nifedipine may gradually replace I.V. b-agonists. Its only side effects are headache, hypotension, tachycardia and cutaneous flushing. Tocolytic therapy does not decrease the incidence of preterm births but prolong gestation, increasing thus, birth weight and decreasing complications related to prematurity. Contraindications include chorioamnionitis, pre-eclampsia, placenta abruptio, severe placenta previa bleeding, fetal demise and fetal anomalies incompatible with life.

Cervical cultures should also be performed to detect urinary or genital infections, as well as the presence of group B streptococcus. It is reasonable to administer prophylactic antibiotic therapy since it has been proven to prolong pregnancy even in the absence of ruptured membranes. Steroids are also necessary at this stage of pregnancy. When administered between 24 and 34 weeks’ gestation, they accelerate fetal lung maturity and thus decrease the incidence of RDS. They also reduce mortality and the incidence of intraventricular hemorrhage.



Post-term pregnancy: Post-term pregnancy is defined as a pregnancy age more than 42-weeks gestation. Perinatal mortality is 2-3 times higher in post-term pregnancies and it is related most commonly to post-maturity syndrome, which occurs consequently to aging and infarction of the placenta. Post-mature infants typically have a loss of subcutaneous fat, long fingernails, dry and peeling skin, and abundant hair. In 70-80% of cases, fetuses are not affected by placental insufficiency and continue to grow past 42-weeks gestation, resulting in macrosomia. The cause of post-term pregnancy is unknown; however, some associated syndromes have been noted such as anencephaly and trisomy 18.

In terms of diagnosis of post-term pregnancy, the importance of accurate dating cannot be stressed enough. In fact 20-30% of pregnancies have uncertain dates, which may mislead to another diagnosis or cause it to be overlooked.

The management of post term pregnancy is principally based on the well being of the fetus. The non-stress test and biophysical profile should be performed twice weekly and if there is oligohydramnios or if spontaneous decelerations are noted, delivery has to be accomplished. If on the contrary, those parameters are reassuring, as in this case, labor should not be induced unless the cervix is favorable, the infant is macrosomic or in the presence of obstetrical indications for delivery. If the pregnancy is more than 43 weeks, delivery is mandated. If the pregnancy is more than 42 weeks, the cervix is favorable and fetal head is into the pelvis labor should be induced. Patients with uncertain dates should be managed expectantly as long as fetal assessment is reassuring, and the possibility of preterm pregnancy should be considered as much as that of post-term pregnancy.

Expectant management is more appropriate since fetal heart tracing is reassuring and there is no oligohydramnios. Moreover, the cervix is not favorable for induction of labor.

The patient does not have oligohydramnios (AFI of 5 or more), so amnioinfusion is not necessary.

C. Section is indicated in the presence of signs of fetal distress. The fetal heart activity of this fetus is normal.

Fetal lung maturity is not a concern here since it occurs in preterm not post-term infants. The respiratory condition most frequent in post term fetuses is meconium aspiration.



Premature rupture of membranes (PROM): Premature rupture of membranes (PROM) is a rupture that occurs before labor at any time of gestation. Preterm PROM (PPROM) is the rupture of membranes that occurs before term, whether there are uterine contractions or not. The origin of PROM or PPROM is not clear yet. Several etiologic factors, however, have been supposed to contribute to its occurrence. Such factors include infection, abnormal membrane physiology, incompetent cervix and nutritional deficiencies of copper and ascorbic acid. The diagnosis of rupture of membranes is mainly clinical. The patient usually complains of either a gush or continual leakage of clear fluid from the vagina. Differential diagnoses include urinary incontinence, vesicovaginal fistula and leukorrhea. On examination, amniotic fluid may be noted in the vagina or leaking through the cervix when Valsalva maneuver or slight fundal pressure is applied. When the patient is not in labor, and whether the pregnancy is at term or not, the hand of

the examiner should not be inserted into the vagina because of the increased risk of infection, and the examination should be performed with a sterile speculum. The amniotic origin of the fluid is confirmed by Nitrazine paper, which turns blue when in contact with amniotic fluid. It can be confirmed by demonstration of arborization, or “ferning” when the fluid is air-dried on a slide and examined at low magnification. In the case of PPROM, amniotic fluid sampling to measure fetal lung indices is mandatory. Also, ultrasound examination should be performed to detect fetal anomalies, determine gestational age and measure amniotic volume, which will all influence the management decision. In the case fetus with a severe congenital anomaly incompatible with life labor should be allowed to proceed.

Intra Uterine Fetal Demise (IUFD): Intra Uterine Fetal Demise (IUFD) is the death of a fetus in utero that occurs after 20 weeks gestation and before the onset of labor. It can be caused by a multitude of conditions such as hypertensive disorders, diabetes mellitus, placental and cord complications, antiphospholipid syndrome, congenital anomalies, and fetal infections (TORCH, Listeria). The cause remains, however, unknown in 50% of cases. A search should be undertaken to determine the cause after the first episode of IUFD. The work up should include: serology testing and cultures of TORCH, Listeria and Parvovirus infections, an autopsy, complete body radiographs and chromosomal studies of the fetus, testing for anticardiolipin antibodies and Kleihauer-Betke test to detect a fetomaternal hemorrhage. It is very important to try to diagnose the cause of the demise after the first episode and to correct it, in order to prevent recurrence in the following pregnancy. IUFD is suspected when the patient reports the

disappearance of fetal movements, a decrease or stagnation in uterine size, and/or when fetal heart sounds are no longer heard. The most appropriate test to confirm this diagnosis is Real Time Ultrasonography, which will demonstrate a lack of fetal movement and absence of fetal heart activity. Beta-hCG serum levels are not useful because they remain usually elevated because of an ongoing placental production. After the diagnosis is confirmed, the coagulation profile has to be determined to detect an eventual disseminated intravascular coagulation, which is a serious complication of IUFD, early in its course.



IUGR: IUGR is defined as birth weight below the 10th percentile for a given gestational age, and refers to fetuses and neonates whose growth potential has been restricted by pathologic processes in utero. These fetuses are particularly prone to problems such as meconium aspiration, asphyxia, polycythemia, hypoglycemia, and mental retardation.

Once IUGR diagnosed, fetal well-being has to be closely monitored with NST and BPP twice weekly. The mother can also contribute to this monitoring by assessment of a kick count.

Decision to deliver depends on fetal well-being and lung maturity. Delivery is usually indicated at 34-weeks or later, or at any gestational age when fetal lung maturity is reached. If there is an associated oligohydramnios, delivery should be strongly considered. In addition, IUGR fetuses are more susceptible to asphyxia, and the threshold to perform a C. section should be lower than that of normal fetuses. In fact, some signs on fetal heart tracing that may be considered reassuring in a normal fetus, are ominous in a fetus with IUGR and may indicate distress.

At birth, neonates with IUGR are very prone to hypothermia, and hypoglycemia. Respiratory distress syndrome also frequently occurs because of reduced surfactant synthesis and release caused by asphyxia and resultant acidosis.



Labor: Labor is defined as the progressive cervical effacement, dilatation, or both resulting from uterine contractions, which occur at least every 5 minutes and last 30 to 60 seconds.

Labor progresses through four stages:

The first stage extends from the onset of labor until full dilation of the cervix, and includes two phases: a latent phase, during which dilation progresses at a slow rate until reaching 2-3cm, followed by an active phase, during which the dilation is more rapid. The length of the latent phase is highly variable but is considered prolonged when it exceeds 20 hours in the primiparous and 14 hours in the multiparous. The progression of the active phase is evaluated by the rate of cervical dilation. At this phase, the cervix normally dilates at a rate of at least 1cm/hr in the primiparous and 1.2cm/hr in the multiparous.

The second stage of labor extends from complete dilation of the cervix to delivery of the baby. It usually lasts 30 min to 3 hours in the primiparous, and 5 to 30 minutes in the multiparous. The third stage of labor starts with the delivery of the baby, and ends with the delivery of the placenta. The fourth stage extends from delivery of the placenta until 6 hours postpartum. The mother should be closely observed during this stage because of the risk of postpartum hemorrhage.

Prolonged latent phase can be caused by hypertonic uterine contractions, hypotonic contractions, or premature or excessive use of anesthesia or sedation. Hypertonic contractions, although intense, are ineffective. They are more painful and are associated with increased uterine tone. Hypertonic activity of the uterus usually responds to therapeutic rest with morphine sulphate or an equivalent drug. Hypotonic contractions are less painful and are characterized by an easily indentable uterus during the contraction. Sometimes, patients diagnosed with prolonged latent phase may actually be still in false labor. Contractions of false labor are usually painless and sporadic, but can be rhythmic, occurring every 10 to 20 minutes. Their main characteristic, however, is that they are not accompanied with cervical changes. Patients with hypocontractile dysfunction are best treated with a diluted infusion of oxytocin.

Anesthesia may reduce uterine activity if administered in the latent phase (such as in this case). In the active phase, it has either the opposite effect, or no significant effect. The only treatment when it is the cause of a prolonged latent phase is to allow the responsible drug to be evacuated; the uterus usually resumes its normal activity afterwards.

Twin pregnancy: Recent studies have indicated that if the fetal heart rate is reassuring, the second twin does not have to be delivered within a fixed time frame after the first twin. Expectant management suffices for the spontaneous deliveries of most twins, but electronic fetal monitoring and ultrasound are of significant help in promptly recognizing fetal distress when it does occur.

Once the first twin is delivered, the positioning and heart rate of the second twin must be assessed with ultrasound. If labor has halted, oxytocin should be administered.



Arrest disorders: Hypotonic uterine contractions is the most common cause of arrest disorders in the active phase of labor. Patients with such conditions should undergo an augmentation of labor using amniotomy and/or oxytocin infusion.



False Labor: Characterized by painless and irregular contractions for 5hrs or more. In the last month these contractino may become rhythmic occuring every 10-20 minutes mimicking contraction of real labor. The main characteristic is however they are not accompanied with progressive cervical changes, so cervix is closed shut. All the pt needs is reassurance.



Deccelereaions: Early decelerations defined as decrease in fetal heart rate by 15 beats/sec from baseline for at least 15 seconds, occuring at the same time as the uterine contraction.

Fetal sleep presents with decreased long-term variability.

Fetal cord compression presents with variable decelerations. Such decelerations are not related to uterine contractions, are variable in form and may be non-repetitive. The first step in the presence of variable deceleration is oxygen administration and change in maternal position to the left or right side. Placing the patient in the Trendelenburg position and elevating the presenting part may be tried thereafter, if the anomaly is persistent. Amnioinfusion can be used when variable decelerations occur after the membranes have ruptured, in order to relieve cord compression. However, regardless of membranes’ status, it is not a first-line measure and the change in position plus mask oxygen is more appropriate.

Uteroplacental insufficiency presents with late decelerations.

Intrauterine infection presents with tachycardia, which may be associated with other signs of fetal distress.

Scalp pH is performed if the abnormal fetal heart pattern persists after all initial measures (i.e.; position change, mask oxygen and discontinuation of oxytocin) have been tried.

Cesarean section is indicated when fetal distress is confirmed.



Preterm labor: Antenatal corticosteroid therapy has been proved to be effective in reducing perinatal morbidity and mortality associated with preterm labor. It reduces the risk of infant respiratory distress syndrome by stimulating phospholipids synthesis (surfactant!) and accelerating morphologic development of the lungs. Besides that, antenatal corticosteroid therapy appears to reduce the risk of intraventricular hemorrhage in infants. It should be given to any pregnant woman from 24 to 34 weeks of gestation with intact membranes at high risk for preterm delivery. Two regimens of therapy are available: betamethasone and dexamethasone (some authors believe that betamethasone is preferred over dexamethasone). Intramuscular administration of steroids provides stable and predictable concentration of the drug in the blood that is required to achieve desired fetal effects. Intravenous administration results in peaks and troughs in the blood concentration of the drug and, therefore, is not recommended. One study

that compared an oral regimen to intramuscular administration of dexamethasone found increased risk of intraventricular hemorrhage and sepsis in the oral dexamethasone group.

Shoulder dystocia: Shoulder dystocia is commonly defined as a failure of the fetal shoulders to pass through the maternal pelvis once the fetal head has been delivered. It is diagnosed when the anterior shoulder cannot be delivered with mild, downward pressure. Risk factors for the development of shoulder dystocia include macrosomia, maternal diabetes mellitus, operative vaginal delivery, shoulder dystocias in previous deliveries, postdate pregnancies, male fetal gender, advanced maternal age, obesity and excessive weight gain, and disproportion between the fetal shoulders and maternal pelvis. However, more than 50% of cases of shoulder dystocia are not associated with any known risk factors. When shoulder dystocia occurs, appropriate support staff (eg, nursing, anesthesia, obstetrics, pediatrics) should be summoned. The mother should be told not to push while attempts are made to reposition the fetus. Suprapubic pressure directed downward and laterally should then be applied by an assistant. If that fails t

o deliver the anterior shoulder, then typically the McRoberts maneuver is attempted, though many other techniques work as well (eg, Rubin maneuver, Woods screw maneuver, delivery of posterior arm).

The McRoberts maneuver requires that two assistants grasp both of the mother’s legs and flex the thighs back against her abdomen. This maneuver has been shown to relieve the shoulder dystocia in 42% of patients. Before the maneuver is implemented, however, the mother should be told to stop pushing until everything is in place.

The Zavanelli maneuver replaces the fetal head in the pelvis before performing a cesarean section. It is generally accepted that the physician has up to seven minutes to deliver a previously well-oxygenated infant before there is an increase in the risk of damage due to asphyxia. Therefore, the Zavanelli maneuver is normally employed when other methods have failed and the \\\\\\\"safe\\\\\\\" period of seven minutes is dwindling.



Breech presentation: If prior to 37 must be left alone. After that External cephalic version may be attempted PRIOR TO onset of labor, given no CI (Hypertension).



Post partum hemorrhage (PPH): The most common cause of post partum hemorrhage (PPH) is uterine atony, and the first step in the management of all patients with PPH is to do a pelvic examination to identify retained placental fragments. If the retained placental products are not identified, manual uterine massage should be started. Uterine massage stimulates the uterus, uterine contractions start, and bleeding stops.

If bimanual uterine massage fails to control bleeding, uterotonic drugs (like IV oxytocin) are used to control bleeding.

If bleeding does not stop with the medical measures, surgical measures are taken. Uterine artery ligation is one of the surgical measures for the treatment of PPH.



Uterine Rupture: Presents with intense abdominal pain asso w vaginal bleeding, ranging from spotting to massive hemorrhage.

Risk in transverse line is 0.5% and in Vertical its 5.0%. If pt does not want any more children, total hysterectomy is the Tx of choice. If she wants more kids then Debridment and closure is indicated. Difficult to ddx from abrupta placenta. UR is preceeded by agitation, rapid breathing, tachycardia.



Postpartum endometritis: It is a polymicrobial infection of the decidua (the pregnancy endometrium) characterized by fever, uterine tenderness, foul-smelling vaginal discharge, and leukocytosis. As the infection is often produced by both aerobes and anaerobes from the genital tract, any treatment regimen must include broad-spectrum antibiotics that also cover beta-lactamase producing anaerobes. At this time, the gold standard of treatment for endometritis is clindamycin and gentamicin.

Metronidazole is contraindicated in breastfeeding mothers.

Endometritis occurs after 3% of vaginal births, but after 15-30% of cesarean deliveries (especially those performed after labor commences or after the rupture of membranes). Studies show that the most important risk factor in the development of endometritis is the route of delivery. Several causes contribute to this finding, including contamination of the uterine cavity, prolonged rupture of membranes, and presence of sutures or other foreign objects.



Chorioamnionitis: Chorioamnionitis is the infection of the amniotic fluid surrounding the fetus. It is frequently associated with preterm or prolonged rupture of membranes but can also occur with intact membranes. Patients with chorioamnionitis exhibit fever greater than 38°C(98.7F), uterine tenderness and irritability, elevated WBC count and fetal tachycardia. Maternal infection of any origin can cause fever, elevated WBC count as well as fetal tachycardia. So, a careful examination to detect any other foci of infection is necessary. Fetal tachycardia may also be congenital or consequent to beta 2-agonist administration to the mother, for example for tocolysis. Elevation of maternal WBC also occurs at the onset of labor or can be caused by corticosteroid administration. Amniotic fluid cultures are the gold standard for diagnosis if any doubt remains.

Once chorioamnionitis is diagnosed, broad-spectrum antibiotic therapy should be instituted, but not before samples for culture are taken. Ampicillin and gentamicin are the drugs of choice. Labor should thereafter be induced or augmented if contractions have already begun. If the cervix is unfavorable and fetal heart tracing is alarming, a C- section may be necessary.



Diabetes: All pregnant patients are generally screened for gestational diabetes between the 24th and 28th weeks of pregnancy using the 50 gm glucose tolerance test. This test does not require fasting. Blood glucose levels are checked one hour after the ingestion of 50 gm of glucose. Patients with blood glucose values of 140 mg/dL or higher should be subjected to a 3-hour glucose tolerance test after the ingestion of 100 gm of glucose on a fasting state. Two or more blood glucose values greater than 105, 190, 165 and 145 mg/dL at 0, 1, 2 and 3 hours, respectively, are diagnostic of gestational diabetes. Some workers have proposed lower cutoff values for the diagnosis of gestational diabetes. The American Diabetes Association is recommending the use of a 75-gm glucose tolerance test, with different cut-off values, for use in non-pregnant women and for diagnosing gestational diabetes.

The recommended fasting blood glucose values in pregnant diabetic patients should range between 60-90 mg/dL, and postprandial blood glucose values should be less than 120 mg/dL. NPH in combination with regular or lispro insulin is generally recommended if diet and exercise are not able to adequately control the blood sugar. Oral hypoglycemics are not indicated in pregnant patients. The use of glargine insulin is not considered safe during pregnancy.



UTI: In pregnant patients with signs and symptoms suggestive of urinary tract infection, begin empiric antibiotic therapy immediately with cephalexin, amoxicillin, or nitrofurantoin for a period of 3-7 days. Some experts also advocate obtaining a urine culture to allow for later modification of the treatment regimen based upon pathogen sensitivity and patient response to pharmacotherapy. Trimethoprim-sulfamethoxazole is not advised in the first or third trimester of pregnancy.

Acute pyelonephritis is usually characterized by costovertebral angle tenderness, fever, chills, dysuria, nausea, vomiting, and respiratory discomfort. Pregnant women are particularly susceptible to experiencing adverse outcomes secondary to pyelonephritis (eg, septic shock syndrome, preterm birth, low birth weight). Traditionally, pyelonephritis in the pregnant woman is treated with hospitalization and intravenous antibiotics such as ceftriaxone or ampicillin and gentamicin until she is afebrile for 24-28 hours and experiencing an improvement in symptoms. Some providers will consider outpatient treatment if the pyelonephritis is otherwise uncomplicated. Whether the treatment is provided on an inpatient or outpatient basis, the treatment course should last for 10-14 days. For the remainder of the pregnancy, low-dose antibiotic prophylaxis with nitrofurantoin or cephalexin should be accompanied by occasional urinary evaluation for infection.

If the symptoms of pyelonephritis do not respond to antibiotic therapy within 48 hours, then a renal ultrasound to assess for perinephric abscess or renal calculi should be performed.

Repeat: Traditionally, pyelonephritis in the pregnant woman is treated with hospitalization and intravenous antibiotics such as ceftriaxone or ampicillin and gentamicin until she is afebrile for 24-28 hours and experiencing an improvement in symptoms. She should then be discharged on oral antibiotics, with the entire treatment course lasting for 10-14 days.

Ultrasound is the test of choice for suspected nephrolithiasis in a pregnant patient.

Helical CT scan is the test of choice for suspected nephrolithiasis; however, a CT scan is associated with radiation exposure, and is not the best test in pregnant patients.

Asymptomatic bacteriuria must be treated promptly in the pregnant female as it can quickly progress to cystitis and pyelonephritis. Although Streptococcus agalactiae (Group B Streptococcus) is a less common cause of cystitis and pyelonephritis in pregnancy than Escherichia coli, its presence is indicative of significant genital colonization with Group B Streptococcus, which is associated with an increased risk of preterm labor and premature birth.

positive urine culture for Group B Streptococcus in a pregnant female should be treated immediately with a 10-day course of antibiotics. The antibiotic may either be penicillin G or cephalexin; both antibiotics are considered safe for the fetus. After the treatment course is completed, it is important to document that the patient’s urine is sterile.



Thyroid disease: As soon as pregnancy is confirmed in hypothyroid patients who are receiving hormone replacement therapy, the dose of L-thyroxine should be increased. During pregnancy, the requirement in levothyroxine increases by 25 to 50%. The causes of the increased requirement for L-thyroxine during pregnancy include increases in thyroxine-binding globulin (TBG) and the volume of distribution of T4, and an increase in body mass. The serum TSH level is a sensitive marker of the hypothyroid state, and should be checked each trimester. The dose of L-thyroxine should be adjusted accordingly.

Due to an increase in serum concentrations of TBG, pregnant women have high levels of T3 and T4. In order to determine if a patient has true hyperthyroidism, free T4, total T4 and TSH levels need to be determined.

In order to diagnose a pregnant woman with hyperthyroidism, she must meet the following criteria:

1. high serum free T4

2. serum TSH value < 0.01 mU/L

On the other hand, gestational transient thyrotoxicosis (GTT) is diagnosed if the woman meets the following criteria:

1. mildly increased free T4

2. slightly decreased TSH levels at the end of the first trimester

GTT is a medical condition that occurs approximately in 10% of women. It usually presents between 8 to 11 weeks of gestation, and does not occur after 14 weeks. It is due to the elevated levels of human chorionic gonadotropin (hCG), which has thyroid-stimulating properties.



Sickle-cell disease: Patients with sickle-cell disease are at a very high risk for complications during pregnancy. The possible complications include acute crisis, endometrial infection, pyelonephritis, and thromboembolic events. Up to 46% of sickle-cell patients have complications during pregnancy. Such patients therefore need a safe and very effective method to prevent undesirable pregnancies. Therefore, patients with sickle-cell disease need a safe and reliable method for contraception to prevent undesired pregnancies. The use of oral contraceptive pills in patients with sickle-cell disease is controversial despite the fact that no studies show any associated increased side effects with OCP use. Depot medroxyprogesterone appears to be safe and effective in preventing pregnancies in patients with sickle-cell disease.

Syphilis: Any pregnant woman that has positive treponemal tests should be considered infected until proven otherwise. Untreated syphilis is associated with a very high prevalence of adverse fetal outcomes (up to 80%), including stillbirth, neonatal death, and mental retardation. Appropriate therapy should be promptly instituted. Penicillin remains the drug of choice (gold standard) for the treatment of syphilis. In patients with a penicillin allergy, penicillin desensitization is recommended. It is typically accomplished using incremental doses of oral penicillin V.



Cardiology in pregnancy: Women who have congenital heart disease and become pregnant are at risk for significant maternal and fetal deterioration. Pregnancy is associated with a number of physiologic changes, including expansion of intravascular volume, changes in the cardiac output, and systemic vascular resistance. The risk of complications in such patients is even higher if the patient has Eisenmenger syndrome (i.e., severe pulmonary hypertension and shunt reversal). Pregnancy in these patients is associated with a 30-50% risk of mortality. Majority of the maternal deaths occur during the first week after delivery; however, death can also occur during gestation, labor, or delivery since the sudden drop in systemic vascular resistance after delivery increases the right-to-left shunt, which may precipitate maternal cyanosis. Unfortunately, a sudden increase in systemic vascular resistance can also lead to adverse effects due to the decreased cardiac output, which can cause syncope. Furthermore, there is an

associated higher incidence of spontaneous abortions, pre-term delivery, and fetal mortality in these patients. Due to these reasons, all pregnant patients with Eisenmenger syndrome should be advised to have an elective termination of pregnancy.



Anticoagulation: The goal is to prevent thrombotic or embolic complications in the pregnant patient, while avoiding fetal or maternal harm due to anti-thrombotic agents. The most common indications are the presence of mechanical prosthetic heart valves or the history of venous thromboembolism. Because warfarin is teratogenic and can freely cross the placental barrier, a patient on anticoagulation therapy who plans to get pregnant should replace warfarin with subcutaneous unfractionated heparin or low-molecular-weight heparin in the first trimester.



Pruritus: Pruritus is a very common complaint during pregnancy. It is reported to affect up to 20% of pregnant women. The symptom may be a manifestation of pregnancy-associated dermatosis, although there is usually no pathologic process present in most cases. Common pruritic locations are the scalp, anus, vulva, and abdomen (during the third trimester). Pregnancy-induced pruritus may be related to dermographism or urticaria, which are common in the last half of pregnancy. Topical steroids, antihistamines, oatmeal baths, emollients, and UVB are used to treat the condition.

Herpes gestationis (also called pemphigoid gestationis) is an uncommon blistering dermatosis that is associated with pregnancy. It typically starts during the second or third trimester, or postpartum period. It may first manifest as abdominal pruritis, a relatively common benign condition during pregnancy, with later development of a rash. The rash is localized around the umbilicus, and is characterized by papules, urticarial plaques, and vesicles, although bullae may also form. Contrary to its name, herpes gestationalis is not caused by a viral infection, and is believed to be an autoimmune disorder.

Herpes gestationis is an autoimmune disease of pregnancy. Autoantibodies are detected in the skin as well as in the circulation. Corticosteroids are the mainstay of therapy. In early and mild cases, topical mid-potency steroids (e.g., triamcinolone) are used. In more advanced cases or if topical steroids are not effective, systemic steroids are employed.

Note: Topical steroids and antihistamines are widely used to treat many pregnancy-associated dermatoses, including papular urticarial papules and plaques of pregnancy (PUPPP); therefore, these are typically the correct choices for questions asking about the treatment of pregnancy-associated dermatoses!



Rh – incompatibility: Hemolytic disease of the newborn due to Rh-incompatibility is possible only when the mother is Rh-negative and the father is Rh-positive.

Hemolytic disease is very unlikely in the first pregnancy, as the mother is not sensitized. The mother becomes sensitized as a result of fetomaternal hemorrhage at or near the end of pregnancy. This risk of sensitization can be reduced by a RhoGAM injection within 72 hours of the delivery.

Anti-D immune globulin should be administered intramuscularly at 28 weeks’ gestation to all Rh (D) negative women if no anti-D isoimmunization is detected by antibody screening. Antenatal prophylaxis is not necessary only if the father of the child is known with certainty to be Rh (D) negative . Antenatal prophylaxis helps to reduce significantly the risk of Rh (D) isoimmunization during pregnancy. Peripartum anti-D immune globulin is also indicated to reduce the risk of isoimmunization due to fetomaternal transfusion during the delivery. Early antenatal anti-D immune globulin prophylaxis is indicated in case of the events and procedures that can increase the risk of isoimmunization (e.g., spontaneous abortion, ectopic pregnancy, and amniocentesis). Otherwise, the risk of isoimmunization before the 28th week of pregnancy is very low.

Failure to adjust the dose of anti-D immune globulin after events that are associated with excessive feto-maternal hemorrhage (e.g., placental abruption) may result in maternal alloimmunization.

Events that are associated with feto-maternal hemorrhage (such as placental abruption) may require adjustments in the dosage of anti-D immune globulin; therefore, the presence and the amount of feto-maternal transfusion should have been determined in this patient during her first pregnancy.

The rosette test is a qualitative test that helps determine the presence of feto-maternal hemorrhage. If negative, the standard dose of anti-D immune globulin should be administered. If positive, the amount of hemorrhage can be evaluated using Kleihauer-Betke stain or fetal red cell stain using flow cytometry, and the dose of anti-D immune globulin should be corrected accordingly.



Pregnancy Facts:

Screening for gourpB strep should be done 36-37 week gestation and positive cases should be tx with Penicilline G during labor, even in the absence of risks.

Low back pain is very common in thrid trimester. Its caused by lumbar lordosis and relaxation of ligament to the joints.

Both Graves dis and Migrain will improve in Pregnancy.

Excessive use of oxytocin may cause water retention (acts like ADH), hyponatremia and seizures (water intoxication).

ACE inhibitors and Oral hypoglycemic agents (Glibenclamide) are CI in pregnancy. Stop them and give Insulin for DM, and Methyldopa(most comonly used), Hydralazine and Labetalol for HT control in pregnancy.

Pregnancy hasa protective efect on both MS and PUD.

In pregnancy both BUN and Creatinin are decreased to half of prepregnancy levels. Amoxicilin has no effect on them.

Asymptomatic Bacteriuria of Pregnancy, increases risk of developing cystitis and pyelonephritis. E coli is the cause 70% of the times. tx is 7-10 days of Nitrofurantoin, Ampicillin or first gen Cephalos.

Neonates of pts with graves dis treated with with surgery are at risk for Thyrotoxoicosis.because of the passage of throid stimulating immunoglobin across the placenta.

Hypotension is a comon se of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling.

In pregnancy its recommended to CONTINUE excercise as you were doing before, like an aerobic instructor.

Edema of lower extremities (Bilateral) in pregnancy is most commonly a benign problem. Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria, no need to do ECG or DVT (presents unilateral and fever).

Oxytocin is like ADH so it causes water retention and Water toxicity due to decrease in Na concentration ( 123 ). So it could cause seizure post partum.

Screening cultures should be performed at week 36-37 and positive cases should be treared with IV penicillin therapy during labor to prevent the new born from getting infected.

If hypertension sets in before 20 weeks, its either Mole or CHRONIC hypertension. If it sets in after 20 weeks, its either Preeclampsia (Proteinuria, >300mg) or TRANSIENT hypertension (not accompanied by proteinuria, <300mg).

Antibodies to ABO antigens belong to IgM antibody class so they don’t cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies that are responsible for Rh alloimmunization belongto IgG class and do cross placenta.

All pregnant drivers should wear seatbelts while driving. Seat belts have been shown to improve both fetal and maternal outcomes in automobile accidents. Pregnant drivers who do not wear seat belts while driving are more likely to have excessive internal bleeding and fetal death if they are involved in a car accident. The current recommendation is that both lap and shoulder straps should be used. The lap strap should be placed under the abdomen, and the shoulder strap should be placed diagonally across the chest and abdomen.



Adolescents pregnancy: Adolescents are at increased risk of adverse pregnancy outcomes. These adverse outcomes include increased perinatal mortality, preterm delivery and premature and low birth weight infants. It is unclear whether these outcomes are due to socioeconomic factors (e.g., low education and low income) or biologic immaturity. A recent study demonstrated unfavorable prognosis in the adolescent pregnant women compared to the pregnant women aged 20-24, even after adjusting for socioeconomic risk-factors; therefore, biologic immaturity may be an important contributor to the increased risk of teenage pregnancies. Moreover, the children of adolescent mothers may be at increased risk of severe socioeconomic outcomes, including future cognitive disorders. Unlike late pregnancies, adolescent pregnancy does not increase the risk of congenital malformations.



Exposure to the low-energy electromagnetic fields that are generated by video displays, power lines, and electronic devices has not been demonstrated to be dangerous to a fetus.

Ethics: Expectant teenage mothers are legally entitled to give consent for procedures related to the management of their pregnancies, including the performing of cesarean sections.

Adolescents do not need consent from their parents for contraceptive services. Barrier methods should be used by all sexually active adolescents even if an additional method of contraception is being used.

Most states have implemented laws that allow for a physician to provide certain types of medical care to adolescents without parental consent. Elective abortions are typically protected under these laws. Therefore, a teenaged girl would have the authority to provide legal consent for an abortion.

When deciding ethical issues such as this, it is important to focus on the principles of patient autonomy and beneficence. Patients have the right to seek, accept, or refuse care. With the mentally disabled, it may be impossible to obtain informed consent, but at the least simple assent should be strenuously pursued. If sterilization is not wanted, it should not be performed against the patient’s will. Involuntary sterilization violates a woman’s right to privacy, her reproductive rights, and her bodily integrity.

Lesbian women often conceal their sexual orientation from their primary care physicians. Recent developments and legislations regarding same sex marriages have encouraged more homosexual couples to \\\\\\\"come forward\\\\\\\" or reveal their sexual orientation. It is important for primary care physicians to be sensitive and knowledgeable to their special needs and concerns.



Epilespsy: Although anti-epileptic drug use during pregnancy is associated with an increased risk of congenital abnormalities, over 90% of women with epilepsy have normal pregnancy. There is currently no agreement about which anti-epileptic drug is most or least teratogenic; therefore, the drug that works best for the patient should be used. Early detection of neural tube defects by serum alpha-fetoprotein screening, amniocentesis or ultrasonography is important. If major abnormalities are present, the pregnancy can be terminated or an optimal management strategy can be planned.

Switching to another drug is not usually recommended for the patient taking anti-epileptic drugs during pregnancy.

According to the American Academy of Pediatrics (AAP) and American Academy of Neurology (AAN), breastfeeding should be encouraged in women with epilepsy. This is due to the belief that the benefits of breastfeeding outweigh the risk of exposure of the infant to antiepileptic drugs.



Ethics: Expectant teenage mothers are legally entitled to give consent for procedures related to the management of their pregnancies, including the performing of cesarean sections.

Adolescents do not need consent from their parents for contraceptive services. Barrier methods should be used by all sexually active adolescents even if an additional method of contraception is being used.

Most states have implemented laws that allow for a physician to provide certain types of medical care to adolescents without parental consent. Elective abortions are typically protected under these laws. Therefore, a teenaged girl would have the authority to provide legal consent for an abortion.

When deciding ethical issues such as this, it is important to focus on the principles of patient autonomy and beneficence. Patients have the right to seek, accept, or refuse care. With the mentally disabled, it may be impossible to obtain informed consent, but at the least simple assent should be strenuously pursued. If sterilization is not wanted, it should not be performed against the patient’s will. Involuntary sterilization violates a woman’s right to privacy, her reproductive rights, and her bodily integrity.

Lesbian women often conceal their sexual orientation from their primary care physicians. Recent developments and legislations regarding same sex marriages have encouraged more homosexual couples to \\\\\\\"come forward\\\\\\\" or reveal their sexual orientation. It is important for primary care physicians to be sensitive and knowledgeable to their special needs and concerns.



Contraception: Levonorgestrel is the recommended method of emergency contraception if used soon enough after an unprotected sexual intercourse. It has maximal efficacy when used within the first 12 hours after intercourse, good efficacy within 48 hours, and appears to work up to 120 hours after intercourse.

One controlled trial showed that levonorgestrel prevents 85% of expected pregnancies (compared to 57% prevented by estrogen/progesterone combination).

The copper intrauterine device is an effective emergency contraception tool that can be used if a patient presents more than 120 hours after unprotected intercourse.

The most effective reversible contraceptive methods are injectable contraceptives (97 to 98% in 1 year) and oral contraceptives (92%). Oral contraceptives (OC) are contraindicated in patients with a history of thrombosis, estrogen-dependant tumors, or liver disease, as well as those who are heavy smokers or older than 35 years. They are also not recommended for patients who are younger, on anticonvulsant medication, have a heavy smoking history, have migraines, or uncontrolled hypertension. Depot medroxyprogesterone is ideal for women with heavy menstrual loss, fibroids, a history of PID, or heavy smoking.

Implantable and injectable contraceptives, including implantable levonorgestrel and depot medroxyprogesterone acetate, have the lowest rate of pregnancy (does not exceed 2-3%) among nonpermanent methods of contraception.

\\\\\\\"Norplant\\\\\\\" consists of six capsules of levonorgestrel which are placed subdermally, generally in the upper arm. It offers contraceptive protection for about five years. The most common complication is menorrhagia (prolonged vaginal bleeding during each period), which occurs in about 28% of the cases.

The absolute contraindications to the use of oral contraceptives are the following:

1. history of thromboembolic event or stroke

2. active liver disease

3. history of estrogen dependent tumor

4. pregnancy

5. abnormal uterine bleeding

6. heavy smokers who are older than 35

7. hypertriglyceridemia

Relative contraindications are the following:

1. migraine headaches

2. poorly controlled hypertension

3. anticonvulsant drug therapy

Numerous commonly used antiseizure medications (e.g., phenytoin, carbamazepine, ethosuximide, phenobarbital, topiramate) are known to decrease the efficacy of oral contraceptives.

Alternative antiseizure medications that do not decrease oral contraceptive efficacy include gabapentin and valproate.

Combination oral contraceptive pills (OCPs) are the most reliable form of reversible contraception; however, the use of these hormonal drugs may affect a person\\\\\\\"s TBG, total T4, and free T4 levels. The estrogen component of the combination pill increases Thyroxine Binding Globulin (TBG) levels, which may result in an increase in the total T4 levels and decrease in free T4 levels. A person with an intact and normal thyroid gland may compensate for these changes by increasing thyroid hormone production, which normalizes the free T4 levels. On the other hand, a hypothyroid patient cannot compensate for these possible physiologic changes since she is unable to produce sufficient amounts of thyroid hormone and is dependent on levothyroxine therapy. The dosage of levothyroxine may therefore be increased in hypothyroid patients who are taking OCPs to compensate for the mentioned physiologic responses. After starting combination OCPs in well-controlled patients with hypothyroidism, TSH levels should be checke

d in 12 weeks, and the dose of levothyroxine should be adjusted accordingly.

Studies have shown that adolescents in a private practice setting are very concerned about the prospect of gaining weight secondary to oral contraceptive (OCP) use. However, available data has demonstrated that OCPs do not cause an increase in body weight or percent body fat. Occasionally adolescents voice other concerns about OCP use, including fears of developing blood clots, birth defects, and infertility, but these concerns are more common in the lower socioeconomic groups.

Chronic OCP can cause hypertension, discontinue it and problem goes away.

SLE pts with increased risk of thrombosis (antiphospholipid and nephritic synd) and pts with active renal involvemnt should avoid OCP.

Pt with Migrain should avoid OCP due to increased risk for Stroke. Breast cancer has NO asso with COP. Endometrial and Ovarian cancers risk is decreased with use if OCP.

When you 1st start taking it it could cause irregular bleeding and that is the mcc of incompliance. Tell the pt to keep taking it and it will be OK.

The accidental usage of oral contraceptives during the first trimester of pregnancy is not associated with an increased risk of fetal malformation.



Human papilloma virus (HPV): infection is a sexually transmitted infection strongly linked with the development of cervical intraepithelial neoplasia (CIN) and cervical cancer. Early initiation of sexual activity, multiple new sexual partners, and high-risk partners (partners with HPV infection), are the main risk factors for the acquisition of HPV infection and cervical cancer. Screening for cervical cancer by cytologic examination/Pap smear is an effective way of detecting early pre-invasive and invasive carcinoma.

According to the guidelines, screening for cervical intraepithelial neoplasia (CIN) or cancer should be started three years after the onset of sexual intercourse, or at the age of 18 years (recently changed to 21 years) whichever is earlier. This is due to the fact that high-grade cervical cytologic abnormalities due to HPV usually do not occur until three to five years after HPV exposure.

There are different approaches for the evaluation of ASCUS. HPV DNA testing is the best way to evaluate atypical squamous cells of unknown significance. In this method, samples are collected both for cytology and HPV DNA, and if cytology results are negative, the sample for HPV DNA is discarded. If cytology results are positive, HPV DNA testing is performed, and if this test is positive for high-risk HPV type, an immediate colposcopy is performed. If the test is negative for high-risk HPV type, the Pap smear is repeated after one year.

High-grade squamous intraepithelial lesions include CIN II, CIN III, moderate and severe dysplasia, and carcinoma in situ. High-grade squamous intraepithelial lesions are more likely to be progressive than low-grade lesions, and these should always be treated with ablation or excision. Ablation can be done using cryosurgery or laser, and excision can be done using knife conization, laser conization or Loop Electrosurgical Excision Procedure (LEEP). Loop Electrosurgical Excision Procedure (LEEP) is the treatment of choice for high-grade squamous intraepithelial lesion. LEEP is preferred because of its low cost, accuracy, and easiness to perform. It is a very successful procedure and can be performed in an office setting.

Most of the low-grade squamous intraepithelial lesions (LSIL) or low-grade cervical intraepithelial neoplasia (CIN I) regress spontaneously; therefore, expectant management is preferred for biopsy proven CIN 1 with satisfactory colposcopic examination. A colposcopic examination is satisfactory when an entire lesion and a transformation zone are visualized. Expectant management includes repeat cytology at 6 and 12 months, or HPV DNA testing at 12 months. If there is progression during the follow-up, or lesions are persistent after one year, treatment is indicated.

When the colposcopic exam is unsatisfactory, the next step is always excision as this allows for histological examination. Even if colposcopic examination is satisfactory, treatment may be indicated if the patient is anxious about her disease, or if she seems to be non-compliant with follow-up. If the patient opts for treatment, available modalities are either ablation or excision. Ablation can be done with cryosurgery or laser, and excision can be done with knife conization, laser conization, or Loop Electrosurgical Excision Procedure (LEEP).

A HGSIL revealed on Pap smear indicates a 1-2% probability of already having invasive cervical cancer and a 20% probability of acquiring invasive cervical cancer if left untreated. Immediate referral to colposcopy and endocervical curettage is indicated. If colposcopy suggests HGSIL, a diagnostic excisional procedure should be performed.

Human papilloma virus (HPV) infection has been strongly linked with the development of cervical intraepithelial neoplasia (CIN) and cervical cancer. Sexual intercourse, especially with multiple new partners, is the main risk factor for the acquisition of HPV infection. The risk of acquiring HPV infection (and, hence, CIN/cervical cancer) is much lower in lesbian women if they do not engage in sexual intercourse with men. Lesbian women still need to undergo routine screening for cervical cancer. Annual screening by Papanicolaou smear is recommended for all women approximately three years after the onset of vaginal intercourse, or at the age of 21, whichever is earlier. The risk of acquiring HPV infection (and CIN/cervical cancer) is lower in lesbian women if they do not engage in sexual intercourse with men. The risk of cervical neoplasia is highest in lesbian women who have had sex with more than one male sexual partner, have an early age at first coitus with men, have been infected with HPV, and have been t

reated for an abnormal cervical cytology test in the past. The risk is also increased with cigarette smoking.

Bleeding is the most common short-term complication after cervical conization (cone biopsy), both cold knife conization and LEEP. The causes of bleeding include inadequate intraoperative hemostasis and vasodilatation after the effect of the local vasoconstrictor wears off. Usually, the bleeding can be easily controlled by conservative measures. Surgical hemostasis is rarely required.

All women at high risk of HPV infection and a normal Pap smear should have annual Pap smear tests.



Cervical stenosis: Surgical treatment of cervical intraepithelial neoplasia before conception increases the incidence of cervical incompetence and preterm birth 200-300%. It is thought that the risk is proportional to the amount of tissue removed during the procedure. Frequent cervical examinations in the second trimester will aid in determining if either cerclage is necessary in the short term or cesarean section is necessary in the long term.





HIV: All HIV-positive adults are normally counseled to receive HAART (highly active antiretroviral therapy), which is a combination of two nucleoside analogue reverse transcriptase inhibitors and one protease inhibitor or one non-nucleoside reverse transcriptase inhibitor. An HIV-positive woman who is already receiving HAART should be counseled to continue her treatment regimen if her pregnancy is identified after the first trimester. (Zidovudine in particular is considered an essential component of the treatment regimen as it has been demonstrated to significantly decrease the vertical transmission of HIV.) For those HIV-positive women whose pregnancies are identified early on in the first trimester, an acceptable alternative is to discontinue HAART for the remainder of the first trimester and then resume it thereafter. Ultimately, the preferred mode of delivery in all HIV-positive women is elective cesarean section.

Efavirenz and delavirdine are thought to have some teratogenic qualities and are best avoided during pregnancy if other options are available.

Studies have shown that HIV can be transmitted through breast milk. Worldwide, it is estimated that one of every eight babies born to HIV-positive women will acquire the virus through breastfeeding. For this reason, HIV-positive women in the United States and other industrialized countries who have ready access to commercially prepared formula are advised to feed their infants with formula instead of breast milk.

Most antiretroviral drugs are passed through breast milk in significant quantities, which is thought to decrease HIV transmission by indirectly providing the drugs to the infant. This understanding – accompanied by the concern that formula is often too difficult or expensive to obtain in developing countries – is the justification for suggesting that HIV-positive women in developing countries be given HAART while breastfeeding their children. However, the recommendation in the United States remains that HIV-positive women feed their infants with formula instead of breast milk, regardless of therapy given to the mother or infant.



Condyloma acuminate: This is the dermatologic manifestation of an infection with the human papilloma virus, with over 90% of such condylomas arising from HPV subtypes 6 and 11 specifically. HPV is primarily transmitted through sexual contact, and the areas affected include the penis, vulva, vagina, cervix, perineum, and perianal region. Less frequently, HPV may be found in the oropharynx, larynx, or trachea secondary to oral-genital contact or secondary to vertical transmission from mother to infant during childbirth. One relatively common benign laryngeal tumor in children, recurrent respiratory papillomatosis, is caused by the acquisition of HPV during passage through the vaginal canal. However, since HPV is thought to be contracted by the infant in less than 1% of all childbirths to women who have condylomas, no intervention is usually undertaken



Pelvic inflammatory disease (PID): The risk factors for PID include the following:

1. Oral contraception

2. No barrier contraception

3. Multiple sexual partners

4. Age < 35 years

5. History of previous episodes

6. African-American ethnicity

Studies have shown that among all the PID risk factors, having multiple sexual partners is the one associated with the highest increase in risk for occurrence of PID (4.6 to 20 fold increase in risk).

The presence of fever, chills, bandemia, leukocytosis, as well as nausea and vomiting, indicates that the infection is severe. PID can be a serious condition that needs to be treated immediately. Treatment of severe PID is aimed at obtaining high blood concentrations of the antibiotics as soon as possible. For this reason, all therapy should be intravenous. Combinations that can be used are: cefoxitin + doxycycline or ceftriaxone + doxycycline. If a tubo-ovarian abscess is diagnosed, surgical evaluation is immediately needed.

Tubo-varian abscess Is seen in 10% of pt w PID. Admit the pt, Broad spectrum antibiotics should be started immediately AFTER taking cultures. Gentamycin+Clindamycin+Ampicillin. In absence of obvious response w/i 48 hours , drainage should be considered. If there is doubt re Dx we do Laparoscopy. If rupture we need to do exploratory Laparotomy.



Vaginitis, Candida Its not an STD. It may appear in presence of risk factors like DM, OCP, pregnancy and immunosupresive therapy. It can also trigger by Alkaline pH of the vagina during menses that is favorable for growth of Candida. Symptoms are vaginal and vulvar pruritis, burning and dysparunia. Discharge has cottage cheese appearance. Its NOT malodorous and pH is 4-4.5. Dx is by KOH wet mount preparation and visualization os pseudohypha and spores. Tx is Imidazole cream or 10 day oral Ketoconazole (especially if recurrent). Fluconazole is the new drug with fewer SE. Give 2 doses, a week apart. Most recurrences are due to non-compliance. If that is OK, then suspect anoterh oraganism and culture on Sabourausd. 50% of reccurence is due to other organism like like T.Glabrata and Candida tropicalis. In addition, 35% of pt with recurrent yeast infection and who have negative cultures, have HPV on biopsy.

DD: Trichomonas (Metro)

Gardenella Vaginitis (Metro).



Mittelschmerz: It’s a mid-cycle (LMP was 2 weeks ago) abdominal pain that typically presents in young females. If there is no fever its not PID.

Vaginismus: Involuntary spasm of the perineal musculature that interferes with sextual intercourse.

Unlike Dysparunia, Vaginismus is not due to any medical cause. In ALL cases its due to ignorant of women\\\\\\\'s anatomy, ahuge apprehention about penetration, and an uncontrolable fear of pain. Tx includes relaxation, Kegel excercise (to relax vaginal muscle), and graduation dialation (penetration).



Chlamydia trachomatis: Genitourinary infection caused by Chlamydia trachomatis is extremely common, and results in insidious and often chronic unrecognized disease. The large majority of women (up to 70 percent) are asymptomatic. It is a major cause of infertility, pelvic inflammatory disease (PID), and ectopic pregnancy in women. Some of the risk factors associated with the development of Chlamydia trachomatis infection include younger age with multiple sexual partners, inconsistent use of barrier contraceptives, and a history of prior sexually transmitted disease (STD). The Centers for Disease Control recommend that all pregnant women be screened for Chlamydia at the first prenatal visit. Women under age 25 and those at increased risk for chlamydial infection should have repeat testing in the third trimester. Chlamydia endometritis during pregnancy can lead to chorioamnionitis and premature delivery of the fetus. Untreated infection during pregnancy can also lead to conjunctivitis (ophthalmia neonatorum) a

nd pneumonia in the newborn baby. Chlamydia infection is a sexually transmitted disease. Pregnant women under age 25 and those at increased risk for chlamydial infection should have repeat testing in the third trimester.

Chlamydia infections are susceptible to tetracyclines, macrolides, and fluoroquinolones. Azithromycin (1 g PO as a single dose) and doxycycline (100 mg PO BID for 7 days) are the two most commonly used and recommended treatment regimens in the general population. Some of the other less frequently used alternative regimens include seven days of an erythromycin base (500 mg PO QID), erythromycin ethylsuccinate (800 mg PO), ofloxacin (300 mg PO BID), or levofloxacin (500 mg PO QD). Presumptive treatment of the partners is crucial in the management of these patients to prevent recurrence/reinfection. Doxycycline, the fluoroquinolones, and erythromycin estolate are contraindicated for use in pregnant women. The recommended regimens during pregnancy include erythromycin base (500 mg PO QID for 7 days) and amoxicillin (500 mg PO TID for 7 days). Azithromycin (1 gm as a single dose) is an alternative, though it has not been well tested in pregnancy.



Lymphoganuloma Venereum It’s a STD caused by C.Trochomatis. Serotype L1L2L3. Initially there is headache and fever, then a papul apears that turns in to an ulcer typicaly in vulvovaginal region. Ulcer is painless and disease may go un noticed unti inguinal adenitis develops a month after. If untreated at this stage LGV becomes chronic causing ulceration, PROCTATITIS, rectal stricture rectovaginal fistulas and elephantiasis. Tx is Doxycycline or erythromycin .

DD:Granuloma Inguinale is caused by Donovania granulomatis, Unlike LGV the ulcer and lymphadenopahty present simultaneously. Also the ulcer here has irregular borders and beefy red granular base. Recommended Tx include azithromycin, doxycycline, erythromycin.



Trichomoniasis: Trichomoniasis is a sexually transmitted infection caused by the protozoa Trichomonas vaginalis. The infection may be entirely asymptomatic or may be characterized by a copious frothy gray-green vaginal discharge, fishy odor, vulvar and vaginal pruritus, or dysuria. Treatment is indicated for all women diagnosed with trichomoniasis and their sexual partners, and metronidazole is considered the treatment of choice. Metronidazole is known to enter breast milk in significant concentrations, but few adverse effects have been reported in infants. Therefore most physicians recommend that lactating women be treated with metronidazole 2g PO for 1 dose, and that breastfeeding be discontinued for 12-24 hours only.



Vulvovaginitis: is an extremely common condition in the sexually active age group. The etiology of symptoms includes infection of the vulva, vagina, and cervix, and the noninfectious causes are chemicals and irritants, hormonal disorders, and, rarely, some systemic disorders. Common infectious causes are vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis. Most of the symptoms of vaginitis are nonspecific, and self-diagnosis and treatment by the patient is unreliable. Even diagnosis by history and physical examination by a physician is not reliable and should always be confirmed in the office by microscopy. This is important to avoid frequent misdiagnosis and inappropriate treatment. Most common techniques used are saline and KOH preparation for microscopy. The vaginal secretions have characteristic pseudohyphae in candidiasis. Bacterial vaginosis is confirmed by the presence of clue cells in the smear. Motile trichomonads and an abundance of polymorphonuclear cells are found in patients with t

richomoniasis.



Pelvic cystic mass: A pregnant woman with a pelvic cystic mass needs to be observed carefully. If the mass is larger than 5 cm in size and persists beyond the first trimester or shows no regression in subsequent visits, surgical intervention is indicated. Removal of the cyst is recommended during the second trimester to avoid acute complications that lead to preterm delivery or abnormal labor.



Ascites: Abdominal paracentesis and ascitic fluid analysis is the most reliable way to differentiate between the different causes of ascites. The most common cause of ascites in the United States is hepatic cirrhosis. Some of the other causes are cancer, congestive heart failure, peritoneal tuberculosis, nephrotic syndrome, and pancreatic disease.

The differential diagnosis of ascites can be narrowed down by calculating the serum to ascitic fluid albumin gradient (SAAG). This is done by subtracting the ascitic fluid albumin value from the serum albumin value. SAAG value is useful in identifying the presence or absence of portal hypertension. SAAG value of > or = 1.1 g/dL indicates the presence of portal hypertension. Clinical conditions associated with high SAAG (> 1.1 g/dL), include cirrhosis, congestive heart failure and alcoholic hepatitis. Conditions associated with low (< 1.1 g/dL) albumin gradient; include peritoneal carcinomatosis, peritoneal tuberculosis, nephrotic syndrome, pancreatitis, and serositis.



Premenstrual syndrome (PMS): Abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido 7 to 10-days before the start of each menstrual cycle. The presence of symptoms such as this patient is presenting, after menstrual cycle begins or after ovulation, points out to the diagnosis of premenstrual syndrome (PMS). Symptoms usually disappear near menses and

the patient is symptom free until her next ovulation. Psychological symptoms may include anxiety, mood swings, difficulty concentrating, decreased libido and irritability.

PMS has to be differentiated primarily from major depression because there is an association between puerperal depression, menopausal depression and PMS. A menstrual diary for at least 3 cycles is a useful aid for confirming the diagnosis in suspected cases; PMS is confirmed when one or several particular symptoms occur repeatedly at the same time of the several cycles.



Once the diagnosis is confirmed, treatment depends on the patient\\\\\\\'s complaints. There is no universally accepted treatment. Reduction of caffeine intake may reduce breast symptoms. Exercise program may be effective in improving the general well being. Recently, selective serotonin reuptake inhibitors have been shown to be beneficial in double blind controlled trials and now the drug of choice for mood decline.







Amenorrhea: Amenorrhea is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended. Women athletes with this condition have been shown to have decreased levels of luteinizing hormone (LH) and gonadotropin-releasing hormone (GnRH), resulting in an estrogen deficiency. These amenorrheic women are therefore at increased risk for all conditions associated with estrogen deficiency, including infertility, vaginal atrophy, breast atrophy, and osteopenia.

Females who maintain a lower weight or body mass index (BMI) due to the sport or activity that they regularly engage in (e.g. ballet dancers, gymnasts, and runners) may become hypoestrogenic and present with exercise-induced amenorrhea. They are at special risk of developing osteopenia, and even osteoporosis. Spontaneous fractures have been reported in these types of patients, with osteoporosis or osteopenia confirmed through bone densitometry. Treatment consists of improving caloric intake; if this is not possible, patients are started on hormonal replacement with oral contraceptives and supplementation with calcium and vitamin D.

The most common cause of secondary amenorrhea is pregnancy. Drugs that inhibit or induce the cytochrome P450 system can reduce oral contraceptive efficacy.



Infertility: The first step in WOMEN is to check Basal Body Temperature and mid luteal PROGESTERONE. The ovulatory factor involves defects in the hypo-thalamic pituitary ovarian axis, and related infertility maybe due to impairment of follicular maturation ovulation or endometrial development. BBT assess the DURATION luteal finction and MLP asseses LEVEL of lutal function. Endometrial biposy is done to confirm luteal phase defect. rather than initial evaluation.

MALES: According to the recent studies, male factors account for 20-30% of the infertility causes. Semen analysis is therefore performed early in the evaluation of the infertile couple. It is usually the initial screening test, and it evaluates sperm concentration, motility, and morphology. Identification of azoospermia and severe oligospermia are likely causes of infertility. Although cutoff values for semen analysis exist, there is a broad overlap in the values of the semen measurements in fertile and infertile samples; therefore, borderline results should be interpreted with caution. If sperm analysis is normal then an endocrine hormonal evaluation is carried out. It includes: 1-TFT (since increaed TSH inhibits GnRH and then decrease FSH. 2-Testosterone levels to indicate the presene or not of Gonadism. 3-Gonadotropin to determine whether hypogonadism is central or testicular and 4-Prolactin lelevs.

Causes of infertility in femlaes falls in 4 factors: 1-Peritoneal factor. 2-Ovulatory. 3-Cervical. 4-tubo-uterine. Peritoneal is the mc type and includes Endometriosis and peritoneal adhesions. Laparoscopy is the procedure of choice. for dx and tx. Mild forms of endometriosis usually respond to meds like GnRH agonists, Danazol and Medroxyprogesterone. 2-Ovulatory factor involves hypothalamus-pit-ovary axis. and infertility might be due to impairment of follicular maturation, ovulation,or endometrial development. ovulatory abnormality may initially be screened by Basal body temp and midluteal phase level of progesterone, the former asseses DURAtion and later LEVEL of luteal function. If luteal phase shows low progesterone, hence infertility, then tx is suppository progesterone deposition. 3-Tubo0uterine is seldom a cause. It onvolves Fibroids, endometrial polyps, tubal occlusion(2ary to IUD or endometriosis). Investigation is ainlt hysterosalpingography or laparoscopy. 4-Cervial involves cervial structure abn

ormalities and abnormal mucus production. In 5-10% infertility remains unidentified. Intrauterine insemination is the tx.

Clomiphene Citrate is an antiesterogen that acts by competitively inhibiting esterogen receptors at hypo-thalamus, thus inhibiting the negative feed back esterogen has on GnRH production and consequesntly increasing LH & FSH secretion and improving ovulation. Along with HCG and HMC its indicated for chronic anovulaation. Side effects include large ovaries, hot flashes, abdominal bloating, breast discomfort and abnormal uterine bleeding.

A retroverted uterus is a common condition found in 11% of the female population. If this condition is secondary to chronic PID or endometriosis, it can be associated with infertility. It is also related to dyspareunia, low back pain, and dysmenorrhea. If it is not spontaneously corrected during pregnancy before the second trimester, it can lead to uterus incarceration and be life-threatening. It is not an etiologic cause of abortion.

Chances of infertility in a female with cystic fibrosis are 20% percent. This increased risk is due to secondary amenorrhea caused by malnutrition, and is also due to thick, tenacious cervical mucus. Chances of infertility in a male with cystic fibrosis are 95%. Spermatogenesis is normal in a patient with cystic fibrosis, but sperm transport is impaired because of impaired development of the Wolffian duct.



A defect in the luteal phase: A defect in the luteal phase refers to a relatively low progesterone secretion by the corpus luteum. Progesterone is important for embryo implantation and maintenance of pregnancy, so a defect in its secretion may cause infertility even if ovulation takes place. The defect may affect the level or duration of production of progesterone. Luteal phase defect is suggested by short cycles, history of spontaneous abortion, abnormal basal body temperature (BBT) or low levels of midluteal progesterone. The diagnosis is confirmed by endometrial biopsy, which demonstrates a lag in endometrial maturation of 2 days or more as compared with normal states.

Luteal phase defect is treated with progesterone vaginal suppositories. Clomiphene citrate or human menopausal gonadotropin (hMG) may be used if progesterone suppositories give no results; they increase serum FSH level and thus correct follicular maturation and oocyte expulsion

As mentioned above, luteal phase defect refers to a deficiency in progesterone production; therefore, combined oral contraceptive pills are not appropriate.

Danazol is an androgen derivative that has a gonadotropin inhibitory effect. It is indicated in endometriosis, fibroids and fibrocystic breast disease.



Polycystic ovarian syndrome (Stein-Leventhal syndrome): infertility, menstrual irregularity, obesity, hirsutism, and increased ovarian volume measured by ultrasonography. Anovulation is the principal cause of infertility in patients with polycystic ovarian syndrome. Interestingly, several studies have demonstrated that weight reduction in overweight or obese patients with this syndrome is associated with restoration of ovulation, decrease in androgen production, and pregnancy. Furthermore, the data from these studies indicate that even a moderate reduction in weight may restore fertility.

Insulin-resistant hyperinsulinemia is a common finding in patients with PCOD.

PCOD is an important risk factor for development of DM-2 in women. About 10% of diabetes in premenstural women is POS related. Thus a glucose tolerance test is needed in all POS pts. A two hour test with > 140 is Dx and needs furthur action. Life style modification and Metformin is then indicated. Metformin helps in following ways: 1-prevents DM, 2-Causes anorexia and prevents obesity, 3-corrects hirsutism mildly, 4-menstural irregularity and infertility

The treatment of PCOS is directed primarily at the problems of hirsutism, menstrual irregularity, and infertility. Treatment modalities for hirsutism include ovarian and adrenal suppression, antiandrogen therapy, and local depilatory measures. Oral contraceptives are a simple and relatively safe method of ovarian suppression and will often normalize the menstrual cycle. The estrogen component in oral contraceptives increases the sex hormone binding globulin with a resultant decrease in free testosterone. This reduces the symptoms of excessive hair growth and acne.

Clomiphene citrate is the drug most commonly used to induce ovulation in patients with polycystic ovary syndrome (PCOS).

This condition should be suspected in any pt who has mentrural irregularities, and evidence of Hyperandrogenism(facial hair). Presence f these establishes the dx.50% of pts are obeseand are at risk of DM-II. The next step is to do Oral glulcose tolerance test

Characterized by unbalanced Estrogen secretion resulting in Endometrial Hyperplasia.



Ovarian HyperStimulation Synd Major complications of ovulation induction are multiple gestation and OHSS. OHSS occurs in 1-3% of pts. It develops 5-7 days after administrationof hMG or hcg and refers to acute increase in vascular permeability of enlarged ovaries. Symptoms include abdominal pain, distension, nasea, vomiting diarrhea, weight gain,hypotension and pleural effusion. Ovaries are large in US. OHSS maybe complicated with oravian torsion, ovarian rupture, renal insufficiency. Symptoms resolve in 1-2 weeks, but may persist longer is pregnancy is successful. Tx is supportive.



Androgen insensitivity syndrome:The combination of primary amenorrhea, bilateral inguinal masses (one removed earlier and one palpable in this case), and breast development without pubic or axillary hair is strongly suggestive of androgen insensitivity syndrome. This condition is related to a mutation of the androgen receptor (AR) gene, making peripheral tissues unresponsive to androgens that are typically available in normal concentrations in these patients. Although the genotype is 46, XY, a female phenotype develops. Breast development is present, because testosterone is converted to estrogen; however, there is no pubic or axillary hair. No mullerian structure is present (uterus, fallopian tube), and the vagina ends with a blind pouch.

Primary amenorrhea is usually due to chromosomal abnormalities and physiologic delay of puberty (45% and 20% of causes, respectively). In both cases, development of secondary sexual characteristics is delayed. Imperforate hymen presents as cyclic, pelvic or abdominal pain with primary amenorrhea. Sometimes, a small suprapubic mass (the uterus containing retained menstrual blood) can be palpated. Perineal exam will reveal a bulging, bluish membrane between the labia. This bluish or violaceous discoloration is due to blood sequestration behind the imperforate hymen, and is also known as hematocolpos.



Tetsticular feminization defect or absence of androgen receptor results in feminine phenotype with 46XY genotype. MIF is produced by gonads, so urtus and vagina are absent. Breat develop because peripheral production of estrogen , whereas axillary hair and pubic hair does not. Tx is testicular resection at puberty and creation of aneo vagina. Pt prestns with amenorrhea, developed breasts, absent pubic and axllary hair , absent internal reproductive organs and a 46XY karyotype.



Turner syndrome: Ovarian function and morphology is highly variable in patients with Turner syndrome. Most patients do not undergo puberty, and present with primary amenorrhea. Some patients may develop normally and undergo spontaneous menarche, but secondary amenorrhea may occur after some time. Such patients may become pregnant without medical assistance before developing secondary amenorrhea; however, most women are infertile. In one retrospective study of 522 patients, three women became pregnant spontaneously.

Summary: Pregnancy is almost impossible, but there still remains a very small chance, in patients with Turner syndrome.





Endometriosis: is a progressive disease typically diagnosed in women aged 25 to 29 years, and is thought to affect 5-10% of all women. It is characterized by the presence of endometrial tissue in the ovaries, fallopian tubes, or other abnormal sites, and commonly causes significant pelvic pain and infertility. Typically pt prestns with Dysmenorrhea, Dysparunea(when endometriomas is in cule-de-sac), Dyschezia(Pain on defecation), hematochezia, hematuira, and pre post menstrual spotting.

Endometriosis should be considered a strong likelihood in women who experience dysmenorrhea after years of painless menstruation. Diagnosis is difficult and is best done with direct visualization of the implants by laparoscopy or, less commonly, laparotomy. Laparoscopy is GOLD standard which shows powder burns. The hemorrhage of endometriomas into the ovaries results in formation of cystic cavity filled with blood with dark color, hence the name \\\\\\\'Chocolate cyst\\\\\\\'. To complicate matters, there may be little correlation between the clinical manifestations and the actual extent of endometrial implants.

The most frequent sites of involvement are the ovaries, cul-de-sac, broad ligaments, uterosacral ligaments, uterus, fallopian tubes, and sigmoid colon. Endometriosis may also involve the appendix, cecum, and colon, which may lead to intestinal obstruction.

Endometriosis can be treated medically or surgically. The first line of tx is OCP. They cause a state of pseudopregnancy and causing an \\\\\\\"exhaustion atrohpy\\\\\\\" of the endometriomas. If OCP fails or not tolerated then we give Danazole, its an androgen deivative that causes Pseudomenopause state. SE are acne,hirsutism deep voice.GnRh agonists have an inhibitory action of LH & FSHwhen given continuslywhich produces temporary castration. Its also a 2nd line of choice.

Surgical treatment involves removal of lesions through bipolar coagulation or laser vaporization, while severe cases may require hysterectomy and bilateral salpingo-oophorectomy.

In patients with severe or unresponsive symptoms (including infertility), the standard of care requires that confirmatory laparoscopy be performed to definitively establish the diagnosis of endometriosis before instituting treatment.

DDX:Vaginismus, use Vaginal dialators.

Pain disorder, pain in one or more anatomical sitetxis pain managment training.

Somatization disorder, tx is follow up visitsregularly scheduled.

Endometriosis is the location of tissue outside uterine cavity so hysterosalpingogram cant see it.



Dysfunctional uterine bleeding (DUB): Heavy unremitting endometrial hemorrhage through the menarche and perimenopuase requires high dose conjugated estrogens to suppress bleeding, and to ensure cardiovascular stability. Once cardiovascular stability is achieved, D&C should be performed.

The most common cause of dysfunctional uterine bleeding (DUB) in adolescent women is anovulation. So, endometrial biopsy is not required in these patients. Once the bleeding is stopped, advise the patient to: take 25 mg of oral conjugated estrogen daily for 25 days; add 10 mg of medroxypreogesterone for the last 10 to 15 days of treatment; then allow 5-7 days for withdrawal bleeding. All this in order is to mimic the menstrual cycle.

In which pts with DUB do you perform endometrail biopsy to rule out endometrial carcinoma? When a pt is >35, obese, DM or has chronic HT.

Menopause: Most females rapidly lose considerable bone mass following menopause. Lifestyle modification, including weightbearing exercises and optimum calcium and vitamin D supplementation, prevents postmenopausal bone mass loss and possibly reduces the risk of fragility fractures. The National Academy of Science recommends daily supplementation of elemental calcium (1200 mg) and vitamin D (400 to 800 international units) in women after 50 years of age. This can be easily achieved by taking one multivitamin tablet (which contains 400 international units of vitamin D) with two tablets of calcium/vitamin D (containing 600 mg of elemental calcium and 200 international units of vitamin D) everyday.

Short-term use of low-dose estrogen for menopausal symptoms does not appear to be harmful; however, hormone replacement therapy fell out of favor following a recently published study of the women’s health initiative because of increased, undesirable cardiovascular and other side effects.

Exercise with weightbearing leads to improvement in bone mass, owever, exercise should be individualized in patients with significant osteoporosis, since they have a higher risk of fracture. In such patients, stressful exercises should be avoided as much as possible.

Recently published women’s health initiative studies show that older postmenopausal women on hormone replacement therapy are at an increased risk for myocardial infarction, deep venous thrombosis, strokes, and breast cancer. The findings of this study do not apply to younger patients with premature ovarian failure, such as the patient described in this vignette. Hormone replacement therapy in the form of conjugated equine estrogen and medroxyprogesterone with careful monitoring can be safely used in younger patients without any excessive cardiovascular risk.

The use of bisphosphonates in older, postmenopausal women has been extensively studied, and has been shown to be very useful in the treatment of low bone density. On the other hand, bisphosphonates are not very well studied in younger patients with low bone density. The long-term effects of bisphosphonates such as alendronate or etidronate are unknown in younger patients. Furthermore, although risedronate (bisphosphonates) may improve bone mineral density in this patient, it will not improve her hypoestrogenic symptoms; therefore, it is not the preferred drug regimen.



Premature ovarian failure: Premature ovarian failure refers to a failure of estrogen production by the ovaries that occur in women less than 35 years. It may be secondary to an increased atresia or a reduced number of primordial follicles. It is most commonly idiopathic but may also be due to mumps, oophoritis, irradiation or chemotherapy. It can be associated with disorders such as Hashimoto\\\\\\\'s thyroiditis, Addison\\\\\\\'s disease, type I diabetes mellitus and pernicious anemia, which supports the hypothesis of an autoimmune origin. Diagnosis is confirmed by increased FSH serum levels and in patients less than 30 years. A chromosomal analysis becomes necessary in order to rule out the presence of a Y chromosome.

Since patients with premature ovarian failure lack viable oocytes, measures of ovulation induction, such as clomiphene citrate, hCG and hMG, will be useless, and the only option such patients have to restore fertility is egg or embryo donation.

Ovarian failure, chemo induced chemotherapy causes failure of follicular cells of the ovary resulting in decreased production of estrogen and inhibin. This result in loss of feedback inhibition of estrogen on FSH and LH , causing their high levels. Inhibin causes feedback inhibition of FSH only, so in the absence of inhibin, FSH levels are higher than LH which is pathognomonic of ovarian failure. Clinically, pts have Amenorrhea, hot flashes. They might develop anxiety, depression and irritability. Loss of estrogen results in atrophy of breast, vagina, myometrium.



Postmenopausal bleeding: The most common cause of postmenopausal bleeding is atrophic vaginitis (50-60%). However, one should always rule out the most serious conditions, such as endometrial carcinoma (less than 10%) by obtaining endometrial biopsy.

Atrophic vaginitis is characterized by vaginal dryness, burning, dyspareunia, reduced vaginal secretions, and vulvar pruritus. Occasionally, urinary symptoms such as dysuria, hematuria, and discomfort are also seen. Pelvic examination typically reveals loss of labial fullness, pallor of the vaginal epithelium, and decreased vaginal secretions. The condition commonly occurs secondary to declining estrogen levels in postmenopausal women. In nonmenopausal women, estrogen production can be countered by radiation therapy, chemotherapy, immunologic disorders, oophorectomy, and lactation. Atrophic vaginitis is treated with hormonal replacement therapy, transvaginal estrogen replacement (e.g., creams, hormone-releasing rings), or lubricants.

DD: Vulvar cancer most often occurs in women aged 65-75 and is characterized by a long history of pruritus. Vulvar bleeding, discharge, dysuria, and pain are reported less often. A raised vulvar lump or mass is apparent on pelvic examination, and may be fleshy, ulcerated, leukoplakic, or warty in appearance.

Cervical cancer most often occurs in women aged 40-60. Women at increased risk for developing cervical cancer include smokers and those with a history of sexually transmitted diseases, human papillomavirus infection, low socioeconomic status, two or more lifetime sexual partners, or immunosuppression (e.g., AIDS). Cervical cancer is responsible for less than 1% cases of postmenopausal bleeding.



Breast mass: Most of the palpable breast masses in young patients (less than 35 years of age) are due to benign etiology, most commonly benign fibrocystic disease or fibroadenoma of the breast. The symptoms of fibrocystic disease may get worse during pregnancy due to the hormonal changes in the body. Despite these facts, any complaints of a dominant mass in the breast should be thoroughly evaluated to exclude malignancy. A dominant breast mass characterized by a hard, single, and immobile mass with irregular borders should raise the suspicion for malignancy. A cystic breast mass should be evaluated with fine needle aspiration biopsy to obtain tissue or fluid for a more specific diagnosis.The goal of aspiration is complete drainage of the cyst and collapse of the cyst wall. Clear cyst fluid may be discarded, with a follow up exam in 4-6 weeks. If the mass persists at that time it may be re-aspirated and further workup may be warranted. Any blood-tinged fluid obtained should be sent for cytologic analysis. If

the fluid is non-bloody, the patient should be reassured and reexamined in four to six weeks to check for any signs of recurrence.

Excisional biopsy is invasive and does not need to be the first step in a breast cyst evaluation. If the mass persists, definitive evaluation with a biopsy would be an appropriate next step.



Fibroadenoma: 1x1 cm firm rubbery freely mobile round mass in a 35 yo women w/o axillary nodes palpable. Best initial step is Mamogram.



Breast Carcinoma: Inflamatory beast cancer: Erythema and edema of non lactating breast could be due to locally advanced cancer, biopsy should be done first to rule out that dx. Tx is 2-3 weeks of combination chemotherapy to shrink the tumor allowing sybsequent extended resection.

Metastatic Breast Cancer has a poor prognosis. with little chance of cure. Its importnat to choose Local (Surgery) vs Systemic (Systemic Chemotherapy) tx in pt with metastatic breast cancer. Tumor burden, based on TNM staging, is considered the single most important prognostic consideration in treating pts with breast cancer. ER+ and PR+ are good prognostic factors. Over expression of Her2/Neu oncogene is worst progosis.

Breast cancer is the leading cause of metastatic skin disease in women. These lesions are erythematous that present as erosions covered by necrotic skin. Tx is palliative radiation therapy with aggressive wound care.

Two proibitions when having breast cancer in pregnants: No chemo in 1st trimester, and no Radiotherapy anytime in pregnancy. Also Lumpectomy is not a good choice for 1st trimester cuase it needs Radiation afterwards. So the only Tx for 1st trimester is Modified Radical Mastectomy.



Nipple discharge: Nipple discharge is a relatively common problem, and is due to a benign cause in most cases. A detailed history and physical examination can essentially determine the differential diagnoses and necessary diagnostic work-up. It is important to determine whether the discharge is spontaneous or provoked, and whether it is unilateral or bilateral. In general, patients with a malignant cause have a spontaneous, unilateral and guaiac positive

or grossly bloody discharge. In contrast, patients with an endocrine, medication-induced or other physiologic causes tend to have a bilateral nipple discharge.

All patients with a unilateral spontaneous nipple discharge should be screened for breast cancer with a mammogram. Patients with evidence of a mass or suspicious finding on mammogram should have further evaluation such as fine needle aspiration biopsy or open breast biopsy. The discharge should also be examined for the presence of occult or gross blood; positive results are then sent for cytologic analysis.



Intraductal Papiloma: A benign tumor of lactiferous ducts. Clinically manifest as serous bloody discharge. Mamo wont show it, too small. Resection has to be done to relief pain guided by galactogram.



Lactation suppression: Tight fitting bra and ice packs. Bromocriptine is no longer used.



Mastitis Infection of breast with S. Aureus. It must be ddx with Breast Engorgement (heavy,tender,firm and warm breasts bilaterallyin women who not nursing. Its manged with tight fiting bras, anagesics and ice pack, breast feeding should be resumed). Mastitis is tx with oral Dicloxacillin. Breast feeding should be suspended but milk has to be pumped until infection clears. If it onvolves abscess, incision and drainge is required.



Raloxifene Is a Selective Estrogen Receptor Modulator (SERM) used for prevention of osteoporosis. Unlike Estrogen, it doesn’t increase risk of Endometrial cancer. It decreases risk of Breast cancer. It has noeffect on Ovarian cancer. Ts most important SE is it increases the risk of Pulmonary Thromboembolism and is CI in pt with a hx of DVT. It may also worsen hot flashes and vaginal dryness.



Tamoxifen: An antiestrogen drug used for breast cancer. When used as adjuvent therapy for early stage disease it reduces the risk of recurrence of original cancer and new cancer in other breast. However it increases the risk of 2 types of cancer, 1-endometrial (lining of Uterus) and Uterine Sarcoma.

It reduces the risk of breast cancer in those who are at increased risk for developing breast cancer, ITS PROVEN. SEE RALOXIFEN.

It increased the risk for endometrial cancer by 1% and ONLY in postmenopasusal women. It decreased risk of breast cancer, so overall it reduces mortality rate. It also decreases risk facto in the opposite breast. It protects against osteoporosis. However it does cause hot flashes and vaginal dryness due to its antiesterogenic effect. Remember its mixed agonist-antagonist on estrogen receptors.





Maternal substance abuse 1-Herion abuse: Newborn will show tremors, increasd weakness, frequent loose stool, high pich cry, fist sucking, poor feeding and tachypnea, Hyperirritability. Symptoms manifest w/I 24/48 after birth, Exclude hypocalcemia and hypoglycemia. 2-Mthadone withdrawl resents at the 2nd to6th wek of life with seizure. 3-Cocaine: asso w IUGR, intracranial hemorrhages, and premature labor or abrupta placenta. Its not common. 4-Alcohol withdrawl: presents with tremors, agitation, lethargy and seizures .Its rare.



Urinary incontinence: Urinary incontinence is a common problem in the elderly population which causes significant functional and psychological morbidity. It frequently leads to a decline in self-confidence and a diminished quality of life in the elderly population.

It is important to distinguish between the three main types of urinary incontinence to devise a proper treatment plan. A detailed history and physical examination is the most important step to differentiate between the various types of urinary incontinence. A thorough history is also useful to identify various reversible causes of urinary continence, such as excessive fluid intake, urinary tract infection, atrophic vaginitis, stool impaction, and the use of various drugs causing or contributing to urinary incontinence.

The three major types of urinary incontinence are stress incontinence, urge incontinence, and overflow urinary incontinence. Stress incontinence is the most common cause of urinary incontinence in younger females and occurs due to inadequate urethral support from the fascia and muscles. An increase in the intraabdominal pressure leads to urethral sphincter opening, which causes urinary leakage in the absence of bladder contraction. A detailed history, physical examination, and clinical stress test can provide the diagnosis of stress urinary incontinence in almost all the patients. In a clinical stress test, the patient is asked to relax and give a single vigorous cough. Leakage that occurs instantaneously with coughing is virtually diagnostic of stress urinary incontinence. Aggrevating factors are Obesity, pregnancy, COPD and Smoking. Postvoid cystometry is normal. Tx include Kegel excercise, esterogen in post menopasusal women. Surgical tx is Burch and Sling procedures.

It is important to differentiate stress urinary incontinence (urethral hypermobility) from urge incontinence (detrusor overactivity). Pelvic floor exercises should always be the first line of treatment in patients with stress urinary incontinence.

URGE Incontinence etruser instability, blader irritation form neoplasm, and interestitial cyctitis result in UI, which causes sudden and frequesnt loss of moderate to large amount of urine. Often accomodated with Nocturia.

OVERFLOW: Diabetic Nephropathy causes OI. Characterized by loss of small amount of urine from an over extended bladder and a markedly increased residual volume. There is hx of DM which is not controlled. CC are certain medications (Ibuprofen), Diabetic nephropathy, MS and spinal cord injury. NSAIDs have an inhibitory action on the detruser, so the first step is to stop NSAID. Then cholinergic drug (Bethanechol) should be added afterwards to improve detruser action . Intermittent self catheterization can be used.

One of effects of epidural anesthesia is urinary retension due to denervation of bladder. When bladder presure is > sphingter pt urianates until balace is achieved again. This incontinence is transient. PE may show distended blader. Postvoidal vol is high. Tx is by Intermittant cathaterization until control is regained. Oxybutyrin is used for Urge incontinence. Urethroplexy is for stress incontinence.



Uterine prolapse: Uterine prolapse is typically seen in multiparous, postmenopausal woman with a history of multiple vaginal deliveries. The injury to the pelvic ligaments and loss of estrogen weakens the endopelvic fascia. The uterus and cervix descend down the vaginal canal towards the vaginal orifice (introitus). Patients usually complain of a sensation of pressure or heaviness in the pelvic area, which is relieved by lying down and aggravated by prolonged standing or exertion. Some patients may complain of low back pain, dyspareunia, or a visible mass at the introitus. In chronic cases, patients may have bleeding or discharge from ulcerative, superficial epithelium. All symptomatic patients (constant sensation of heaviness, pain, or bleeding) should have surgical correction of the defect in the pelvic support. The aim of surgical treatment is to completely relieve the symptoms and prevent any future relapse.

Conservative treatment with the insertion of a pessary to hold the pelvic organs in place should be only used in patients who are poor candidates for surgical intervention. It does not correct the underlying defect, and there is a higher chance of relapse in active patients.















Alkaline phosphatase: Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women, provided there is no associated symptoms or signs. Hence, reassuring the patient and explaining this observation is adequate and no further investigation is necessary.



Cervical cancer : Risk factors: Young age at first coitus (<20). Young age at marriage and first pregnany. High parity, multiple sex partners, smoking, and low socioeconomic status.

If pap is dysplasia, perform colposcopy. If it shows inflamatory Atypia then repeat after 4-6 weeks. If pt comes in with spotting, and you see the cervix having a gross lesion that bleeds by touching, dont even bother for PAP, go straight to Punch biopsy to rule out cancer. **** Once pt had the cancer check for cytology every year not every 2 year for normal people.

Adenomyosis Is defined as presence of Endometrial glands in the uterine muscle. MF in women above 49, , presents with severe dysmenorrhea, and menorrhagia. The typica lexam reveals enlarged sysmetrical uterus. If Adenomyosis is in one side of uterus then enlargment is asymetrical.

DD: Myomatous Uterus , Leomyoma, Endometrial carcioma.

For women above 35, its mandatory to perform an Endometrial curetage or even hysterectomyto rule out endometrial cancer.Leomyomas, are difficult to ddx from Adenomyosis, except that consistency of Uterus is softer in Adenomyosis. Endometrial Carcinoma, occurs in women after menopause . Endometritis manifest with fever, and enlarged and tender uterus, asso with vaginal discharge . It usually occurs after a septic abortion, and the mc oranism responsible is Strep.

Fibroid uterus: Presents with Dysmenorrhea, heavy menses, and enlarge uterus is almost dx of either Adenomyosis or FU. Submucosal fibroids often imterefre with rmbryonal implantation and infertility. Fibroids are the mc benign uterin tmors in women and the mc indication for hysterectmy. Tey are estrogen-dependent tumors, therefore they increase in csize with OCP and pregnancy. and often regress after menopause.

DD: Endometriosis which presents with Amenorrhea. Make sure you can DDx the above conditions with Adenomyosis.



Granulosa Cell Tumor: SOLID tumors. Bimodal distribution. If occur before puberty , Precociouspuberty is presented. It produces excess estrogen and causes pubic hair, hpertrophy of brest and hyperplasia of uterus. Usually removal of tumor reverses the problem. If its in postmenopausal women it causes bleedingand uterus shows myohyperplasia. DDX1 ysgerminoma, in young women and children, unilateral and go under torsion. It doesnt produce any hormones. DDX2:Sertoli-Leydig,produces androgen and DEFEMINIZATION, followed by masculinization in childbearing years. DDX3:Mature teratoma or Dermoid cysts, benign and dont produce any hormones. DDX4;Serous cystadenomas, are the mc CYSTIC ovarian neoplasm. 25% are malignant,half cases are bilateral. They dont produce any hormones. Ovarian mass and abdominla pain are presenting features.



Hirsutism Women produce androgens. DHEA-s and Testosterone in adrenals and ovaries. DHEA-S is only in adrenals by adrenal tumors. ACTH increase in pts w hirsutism is seen with ectopic or pituitary dependant Cushings dis. ACTH increases the production of cortisol as well as angrogens from the adrenal glands, however, the adrenal glands show diffuse hyperplasia rather than a discrete adenoma.



Clomiphene Citrate: Is an antiestrogen acts by competitive blocking of receptors of hypothalamous, inhibiting the negative feedback that estrogenhas on GnRH and consequently insreasing Lh & FSH and improving ovulation. Along with hMg and hCG itsindicated for chronic ovulation. SE are hot flashes, breast discomfort, spotting. DANAZOL is an androgen derivative that has gonadotropin inhibitory effect . Its indicated in Endometriosis, Fibroids and Fibrocystic breast disease.



DES toxicity If given to pregnant women causesClear cell ADENOCARCINOMA of vagina in their duaghters. In the old days it was the best tx for threatened abortion. With erly dx and tx survival is 80%.





Ovarian Cancer Screening for CA125 and vaginal US are good eough for pt at risk of OC. Althout there is no evidence that US of abdomen can help decrease mortality from OC.



Primary Dysmenorrhea Pt present with hx of lower abdominal pain, that radiated to upper thighs and back. The pain is colicky and starts a few hours prior to menses, lasting 3-4 days. It usually appears 6-12 months after menarche. Tx is NSAID, so are OCPs. The pathology here is that menstural fluid has higher levels of prostaglandins.



Vulvar Hypertrophic Dystrophy Thick and hyperkeratotic due to long term scratching. Mostly seen in PM women.

Vulvar Papillomatosis or Condylomata acuminata. Caused by HPV 6,11. Present as exophytic lesionswith araised papilloatous or spiked surfacemay grow into a calliflowerlike formation.

treatment of b-blocker induced bradycardia is GLUCAGON

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cirrhosis pt. of the following, which one predicts the worst prognosis ?

1.PT increased

2.albumin decreased

3¡



answer is PT first then albumin

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preeclampsia.with -HTN -give hydralazine or .b blocker labetalol

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cardiac contusion do cxray and EKG

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HIV + pt. syphilis positive, no active lesions and the time of syphilis status is unknown.

Answer is PCN x 3 q wkly



Pt comes with hot flashes past history of pulmonary embolism, smoker and takes sertraline for depression. treatment?



give . Clonidine

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how do u assess severity of sarcoidoses



ans-ACE level

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rapid strep test- HIGH specifity and low sensitivity…..

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Hydralzine ...s/e



Answer is given below read all the s/e

*Lupus like syndrom : +ve ANA and AHA

*Reflex techycardia and increase myocardial 02 demand

*headach and flushing

*nausia, dizziness, diaphoreisis

*salt and water retention

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// Mother had cocaine during pregnancy, chilg at risk for antisocial.also….. learning disorder…ADHD. And conduct d/o can happen commonly.

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carbamazepine toxicity,--.Toxicity u monitor CARDIAC…. If in treatment follow CBC and LFT’s, Agranulocytosis

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The best predictor of good HTN control?

Answer is end organ damage.

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vegeterian . should take .zinc, b12 or folic/a

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who makes the decision of competency or who decides someone incompetent

JUDGE makes the decision in the court.. not psychiatrist or other physicians

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turner\'s syndrome.

It happen by chance

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Broca\'s area is inferior frontal gyrus

Wernick\'s area is sup temp gyrus

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breast ca in pregnancy remains same

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How do you manage rectal prolepse?

Manual reduction… if incarcerated immediate surgical consult or send pt to ER.

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28 yrs old fell form second floor .with calcaneal fracture & back pain. How to treat his back pain ---corcet= orthosis

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foreign body in the eye .The best way to Dx?

……. First test is ophthalmoscope, best test is fluorescent

sarcoidosis pulmonary cavity…. Always treat with antibiotic

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birth mark in half of his face . Tx---. laser

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China Berry…Neurological symptoms

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On exam you did not find any foreign body but there are diposition of corneal endothelial cell and acrcular gao in cornea, Dx

1. corneal ulceratin

2. karatitis

3. conjunctivitis



Answer is keratitis

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Optic Photalgia (Flash Burns, \"Welder\'s Burns\"). Occurs as a result of exposure to ultraviolet radiation (welders, sun exposure, snow blindness) and generally presents several hours after the insult. Fluorecin will

show a epithelial keratitis with diffuse uptake in the cornea. Patch both eyes, bed rest, strong oral analgesia, and sedation if necessary. If no reduction of symptoms is noted after 24 hours, refer. Topical analgesics produce

slow healing and may lead to additional injury.

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lightening victim with cardiac arrest. Rx-- epinephrine

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chicken pox --. different stages ( rash,vesicular macule,papule )

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23 yrs old guy with cocaine toxicity . Rx except ?

a. diazepam

b. lorazepam

c. phentolamine

d. propranolol

e. nifedipine



Answer is propranolol >>U/A > IVP > CT..



Q)Painful gross or microscopic hematuira (s/s -> kidney stone):these are the steps >>>> U/A > KUB > IVP > CT ??

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thyroid disorders,

early menopause

or somethign else???



answer is osteoprosis and early menopause AND STRESS FRACTURES

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paNIC DISORDER---DEPRESSION

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Atropine should not be used to treat Mobitz type II block associated with BBB

Hemodynamically unstable pts should be treated initially temporary transvenous pacemaker insertion followed by permanent pacemaker implantation.

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Infection of which valve is most likely to be associated with the development of heartblock.

Mitral valve

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Q1) how do u check the progression of multiple sclerosis?

Q2) how to u follow Multiple sclerosis?

Q3) Diagnostic test of Multiple sclerosis

Q4) Effect of pregnancy on multiple sclerosis?

Answers to above question

1) Progression based on clinic

2) F/U depend on clinical course

3) Dx MRI

4) Pregnancy? Pregnancy exacerbate MS symptom.

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person with symptoms of Obstructive sleep apnea...what is the first/next step?

a) sleep study

b)medical workup

c)CPAP treatment

Answer is Medical w/u as below

1.r/o hypothyrid.ent exam

2.polysomnogram

3.treat-weight reduction(doenot work) >>>cpap

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A mother is concern about obese child 3 y. what is the reason child is obese

mother behaviour problem

child neglect

genetic

eating disorder

ANSWER IS MOTHERS behavioral problems excessive eating may lead to childs excessive eating

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Methyldopa (Aldomet) -- Centrally acting antihypertensive agent widely considered the first-line agent for treatment of hypertension during pregnancy.

Studies have revealed no adverse effects on cognitive development up to the age of 7.5 y among children with in utero exposure to methyldopa.



Hydralazine (Apresoline) -- Intravenous form is useful when treating severe hypertension due to preeclampsia/eclampsia.

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Lead poisoning case

I. complete physical exam

II. cbc,sma7 blood lead level, lft, glucose,

peripherial blood smear, serrum ferritin

III. 70 IM or IV dimercaprol

IV. Plan to admit or d/c home

V. console: Inspect home for lead paint

remove child from lead hazard



//////////////Meniere¡¯s disease. Triad. ---1-Vertigo 2.Hearing loss 3.Tinnitus



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Sarcoidosis patient gets affection of eye.---uveitis and. Glaucoma

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This case clearly indicated the PD pt presented psychiatic s/s, not depression.. So, the management step by step is (MKSAP, in Neurology, parkinson\'s dis, Table, 39):

Hallucinations, delusions TX: (step by step):

1). Discontinue non-levodopa drugs, if failed..

2)/. Reduce dose of carbidopa/levodopa (to the minimum theraputic dose), if failed...

3). Clozapine, quetiapine, donepezil, respiridone, olanzapine



For the depression in PD pt:

MKSAP: SSRIs.

Swanson: TCAs

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HIV is a major no no for breast feeding, pretty much anything else, except meds like (antipsychotics, lithium), drug abuse, etc, you can encourage breast feeding. even with jaundice, you can usually keep breast feeding. The AAP does not recommed very much not to breast feed.

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PMR : --No muscle tenderness, but muscle ache..

-- Weakness: yes, it is main s/s of PMR



polymyositis -- weakness and muscle pain and tenderness..

FM is almost always dx in a 55yrs

ldh>350 units

glucose>200mg/dl

AST>250units/lt.

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AVOID DIGOXIN AND VERAPAMIL in WPW syndrome

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Polyarteritis nodosa

Fever, abd pain, weight loss, renal disturbances.

Labs: elevated ESR, leukocytosis, anemia, hematuria, proteinuria.

Dx: Biopsy

DO NOT MISS HEPATITIS B!!!!!

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Tourette\'s associations:



Attention-Deficit/Hyperactivity Disorder (ADHD)



Difficulties with Impulse Control (disinhibition)



Obsessive-Compulsive Disorder (OCD)highest prevalance



Various Learning Disabilities (such as dyslexia)



Various Sleep Disorders



Remember, Tourette\'s is an Axis I disorder in DSM IV.

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purigo gravidarum

it says that 3rd trimester pruritic rash after jaundice for a couple of weeks...i dunno how jaundice occurs...resolves after delivery.....recurs in future pregnancies...may also recur with OCP use if happened once/////////////////////



cerebellar ataxia

25% after 1to2 months of varicella inf

5% after vaccination

resolves over weeks to months

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prostate ca with bony mets and pain

this is acute conditioin

we have to stop testosterone

bilateral orchiectomy...castrate testo levels achieved in 3 hrs

ketoconazole...in pts who cannot undergo surgery...it blocks cytochrome 450 system and thus stops adrenal and gonadal tetsto..castrate levels achieved in 8 hrs

LHRH...its increases the FSH and LH in the begining by the flare phenomenon and thus is not good for acute setting..castrate levels in 30 days



if there is spinal cord compression due to bone metastasis...give steroids also...it will decrease edema and testosterone

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In an unconscious pt with an intact brain stem, the fast component of the nystagmus disappears ,so that the eyes deviate toward the irrigated side for 2-3 minutes before returning to their original position.

With impairment of brain stem function,the response becomes peverted and finally disappears.

Ref CMDT

I think if the pt. is UNCONCIOUS the nystagmus disappears and eyes are tonically deviated to the side of applied irrigation for 2/3 min. If in this case nystagmus is present, that means pt. is concious.

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long acting biphosphnates,pamidronate or zolendronate r the drug ofchoice for the treatment of hypercalcemia

//////////////////GIVE testosterone TO MAINTAIN ERRECTION.



STARRING INTO THE SKY=GENERALISED COMPLEX SZ.TEMP. LOBE EPILEPSY= DEPAKOTE

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aida /needle stick/GIVE POST EXPO PROPX FOR 28DAYS

3 DRUGS

DDI+AZT +ANY NRTI

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CMDT says renal osteodystrophy confirms the diagnosis of CRF

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both DI and polydipsia has low urin osmolarity; however; when you do water deprivation test, the urin osmolarity does not change in DI, but increases in polydipsia.

so for discussion to differentiat causes of DI;

what is the best initial diagnostic test? water deprivation test. it will differentiate btw polydipsia and the other two.



what is the most accurate test:--- vassopressing stimulation test. it wii differentiate btw central vs nephrogenic DI

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Mohs surgery for skin cancer.

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No I/m laoding dose of phenoytin-- erratic absorption/SLOW ABSORPTION

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NSAID/ methotrexate: parenteral steroid is not used for psoriasis,

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viral pericarditis---pericardial tamponade, ---Pulsus Paradoxsus,

///////// LEGS FOR ERYTHEMA NODOSUM, it\'s associated with Chrohn\'s disease



//////////////Ceftriaxone displaces bilirubin in albumin thus affecting conjugation.



It is generally avoided in neonates less than 1 month old for fear of exacerbating jaundice!



After 1 month of age, it is safe to use Ceftriaxone already!

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PID---IV Cefotetan or IV Cefoxitin plus IV Doxycycline is generally use for inpatient treatment of PID.



IM Ceftriaxone x 1 plus oral Doxycyline x 14 days is the outpatient treatment of PID.



You will shift IV antibiotics to PO antibiotics after patient has been AFEBRILE for at least 24 hours and there are clinical signs of improvement!



order wet mount + Koh ( associated STD infection ), RPR , HIV Eliza, HBAgn, vaccination ( HB vaccine if she does not have the infection)

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Cause of increased erythropoiten - the renal cell carcinoma.



////pt on penicilin and developed autoimmune hemol--do direct coomb test



////SBP_

cefotaxime,if sever

ceftriaxon also we ,treating E-coli, gram +\'s,,polys>250 absolute neutrophil count.



//////////Tourette\'s disorder is a neuropsychiatric disorder characterised clinically by motor and vocal tics, which may be associated to conductual disorders such as obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD). Although the neurochemistry of Tourette\'s disorder is not well known, there are some effective therapies for tics, OCD and ADHD. However, these are not devoid of adverse effects. Tics only require treatment when they interfere with the functioning of the patient. If therapy is needed, monotherapy at the minimal effective dose is desirable, but some patients may require two or more drugs. The most frequently used drugs for tics are antipsychotics (mainly pimozide and haloperidol) and clonidine ..The drugs of choice for OCD in patients with Tourette\'s disorder are the selective serotonin reuptake inhibitors (SSRIs), although the tricyclic antidepressant clomiplamine, which inhibits both serotonin and noradrenaline uptake, has also been found to be useful.

ADHD can be treated with some psychostimulants, mainly methylphenidate, although these drugs must be used with caution. Other potentially useful drugs for the treatment of ADHD in patients with Tourette\'s disorder are clonidine, guanfacine, selegiline, some tricyclic antidepressants, sertraline, pimozide and clonazepam. Finally, the potential value of some nonpharmacological therapies (hypnotherapy, biofeedback, conductual therapies, electroconvulsive therapy, acupuncture and surgery) is briefly reviewed.

///////



Saw palmetto is utilized throughout the world mainly for its effects on BPH. (B9 prostatic hyper) saw palmetto led to an increase in flow rate in men with BPH....It will increase your urine stream.

///////////////////////



Ipecac, an over-the-counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated with serious cardiac toxicity.

/////////////





///toddlers, under the age of 5, are treated differently from children 5 years and older.

According to www.eMedicine.com, infants and toddlers are susceptible to Streptococcus pneumoniae, H. influenzae type B, and Staphylococcus aureus, so they should be treated with cephalosporins, such as ceftriaxone, cefotaxime, or cefuroxime, or a penicillin such as ampicillin.

Children of 5 years, ready to start school, are susceptible to Mycoplasma pneumoniae, so they should be treated with macrolides, such as azythromycin, clarithromycin, or erythromycin



///DM is the most important risk factor for CAD.



///Q 1) Rx of DHB after Premarine > I will choose Low and low ( because her endometrium is stable by premarine)so try low/low , if pt. have spotting with it then high esro or med estro with low progesterone.



If was not treated with premarine try high estro and low progesterone.



Q2) In turner - before fusion > Conjugate estrogen 0.3 q.d 21 days. Add DMPA 5mg q.d from 15 - 25th day of cycle to induce period.

Can use OCP also ( not my choice) should be low and low.



After fusion - estrogen 0.625mg ( can use higher according to tolerance )add progestreone as above

OCP try high estro and med progesterone.

///False elevation of PSA.. March 26 2003, 1:23 AM





1)* PSA levels have been demonstrated to be elevated in acute prostatitis, subclinical or chronic prostatitis, and urinary retention.



2)* An increase in PSA levels has been reported following ejaculation. In 67% of the men older than 50 years who were tested, a 41% mean increase (0.8 ng/mL) in PSA occurred 1 hour after ejaculation.



3)* Performing a prostate needle biopsy increases PSA by a median of 7.9 ng/mL or 6.5 times baseline values within 5 minutes following the biopsy, and this level persists for 24 hours



4) * vigorous prostate massage



***No significant change occurs in the PSA level following a DRE . Cystoscopy, urethral catheterization, and transrectal prostate ultrasonography do not tend to elevate the PSA.

///Only nocardia is weakly acid fast other than Mycobacteria.

In nocardia thre will be mainly pulmonary involvment, begins with malaise, weight loss, fever night sweats and cough, dont know about hepatoslenomegaly.

Choice of Abx is TMP/SMZ



///Legionnaire\'s disease is caused by L.Pneumophilia followed by L micdadie

Sputum examination on Gram stain show..

Typically, many leukocytes and a paucity of organisms are observed.

If visible, the organisms are small, faintly staining, gram-negative bacillii. Erythromycin was considered the drug of choice for L pneumophila, but the newer macrolides and quinolones have begun to replace erythromycin.Fluoroquinolones, primarily levofloxacin, sparfloxacin, and trovafloxacin, as well as newer macrolides (eg, azithromycin)are now used for treating it.



///Sturge Weber Syndrome?

Laser for capillary angioma...

opthalmology referal

anti convulcent med when needed



///ASCUS and LGSIL - atypia /mild dysplasia - CIN 1

HGSIL -moderate CIN II

severe dysplasia - CIN III



* If your Pap test is normal, you will continue routine screening.

* If your Pap test is atypical ( ASCUS, not able to be categorized as normal or abnormal), you will repeat the test in 4 months.( if Pt is compliant otherwise do colpo )

* If the repeat test is abnormal, your doctor will do a colposcopy.

.

If there are abnormal cells on the cervix, the doctor will perform a biopsy.

* If your test is abnormal and suggestive of cancer, you will have a colposcopy, ECC and biopsy.

In a biopsy your doctor will take a small sample of the tissue of your cervix to see if cancer cells are present.

A biopsy is the only way to tell for certain if you have precancer, true cancer, or neither.

.



Sometimes, the biopsy itself is used to treat a precancer or a very early cancer.



If the biopsy is normal and you have a normal Pap test, the Pap test will be performed again in 4 months.



If the biopsy is normal but a Pap test is abnormal, your doctor will repeat the colposcopy and biopsy.



If the biopsy is abnormal and suggestive of cervical intraepithelial neoplasia (CIN) or cancer, you will be treated for cervical cancer.



///\"Is there any benefit to giving varicella vaccine to a child who\'s been exposed to the disease and who hasn\'t been previously immunized?\"



IVIG is not generally recommended for everybody whoever exposed to chickenpox(large quantity of imunoglobuline is needed to modify the disease)



IT is only recommended in :

1. pregnent women after exposure

2. newborne whose mother developed chickenpox 5 days before or 2-5 days after delivery.

3 Exposed leukemic pt. any imunodeficient state, svere debilitating illness(after exposure)



Varivax can be offered within 3 days of exposure who is more than 12 month old in epidemics.



Because of benign nature of disease in healthy children vaccine is not rutine after exposure.

Yes, you immunize exposed child if prev unimmunized. March 25 2003, 2:01 AM



Will post-exposure use of the vaccine prevent or modify varicella?



Yes, the vaccine may prevent or modify illness when administered within 3 to 5 days after exposure. The ACIP now recommends vaccination of susceptible persons who are eligible for vaccination as soon as possible after exposure--ideally within 3 days but possibly up to 5 days of an exposure--to prevent illness or modify disease severity. If a person has already been infected, and the vaccine is given soon enough, disease may be modified or prevented. If the person was infected >5 days prior to vaccination, there is unlikely to be any benefit from vaccination but vaccination is not known to be harmful. Finally, exposure even in a household setting does not result in transmission 100% of the time. So, if the exposed person has not been infected, vaccination will confer protection against subsequent exposures.



///Bronchoscopy and bronchoalveolar lavage for direct identification of organism is specific diagonostic test.



But if this pt.is HIV +iv, chest X-ray show bilateral infiltret and has +iv S/S , low CD4 count

then Rx of PCP can be started before confirmation of DX,

Admit Pt >>I/V abx.

Steriod is indicated in severe case when PO2is 35.



///Use of ACE inhibitors as tolerated, with close monitoring for renal deterioration and for hyperkalemia (avoid in advanced renal failure, bilateral renal artery stenosis [RAS], RAS in a solitary kidney)

///TMP-SMX is considered to be the initial drug of choice for mild, moderate, or severe PCP infection. Alternative therapies for mild-to-moderate PCP include oral therapy with dapsone/trimethoprim, clindamycin/primaquine, and atovaquone. Alternative therapies for patients with moderate-to-severe PCP include intravenous (IV) trimetrexate, IV pentamidine, and IV clindamycin with oral primaquine. In addition, corticosteroids are indicated for patients infected with HIV who have severe PCP and hypoxemia.



///if someone is on carbamezapine with measure CBC periodically. serum conc. to be done for monitoring.

In the event of toxicity..do EKG

beccause in acute toxicity it can cause bradycardia and cardiovascular collapse,Also has cns symtom (Ataxia, nystagmus, stupor convulsion and coma)in acute toxicity.

* can cause aplastic anemia and agrnulocytosis, should f/u CBC

* cause liver damage and seriuos hepatotoxicty f/u liver funtion.



///Coronary artery disease and hypertension are the leading causes of heart failure



/// heart block is most likely associated with mitral valve infections



///Ticlopidine can be used in patients intolerant to Aspirin but they should be monitored for the development of neutropenia or agranulocytosis That\'s why clopidogrel is preferred over ticlopidine



///DOWN SYNDROME

Affected individuals rarely reproduce. Between 15-30% of females with trisomy 21 are fertile and they have 50% risk of having an affected child. There is no evidence of an affected male fathering a child.



So far there is no known case of a \"MALE\" down syndrome patient fathering a child

In female\'s About 70% are infertile, and the risk to child getting down is 50% if the mother has down syndrome,



Few facts about down syndrome,,,,

most common disease associated with down

mental retardation ,congenital heart disease,(endocardial cushion defect most common then VSD and asd, tof, pda)

leukemia, GI defect, hearing loss, cataract.

single best test to perform on a down patient,, is ECHOcardiogram,,, even the patient is asymptomatic,

most death\'s in down are related to heart diease



///In pregnancy and with OCP there will be increase thyriod binding globuline, that will bind with thyroxine and will decrease free thyroxine available for work, but total T4 will be normal so in hypothyroid pt ,u have to increase the thyroxine dose



///DMII in case with hepatic failure give Insulin -all other anidiabetics are cotraindicated

/// Child asthma/maintenance therapy if symp>2times a wk and nighttime symp>2/mth

You can start inhaled steroids or montelukast



///For insomnia in alzheimer\'s

For long term use - it is trazodone

short term use is ativan (lorazepam)



///CF /A.Recessive

.( in hetero + hetero) 25% affected (1 in 4), 50% carrier ( should be 1in 2 ) and 25% (1 in 4) normal



Thus two- thirds (3 in 4 ) of all clinically unaffected offspring are carriers.

A healthy older brother of cystic fibrosis ask what is the chance that he could be carrier- it\'s - 3 in 4



///Diuretics use should be carefully monitor to avoid

volume deplation. Loop diurectics e.g furosemide is the drug of choce. (Effective even when renal function is markedly reduced)



////Diuretics use should be carefully monitor to avoid

volume deplation. Loop diurectics e.g furosemide is the drug of choce. (Effective even when renal function is markedly reduced)



///As s3 indicate impaird ventricular compliance, so I peak s3. Though s3 is very signufican in CHF, s4 is happen to be significant in angina and MI.

this is from Merck manual.



The fourth heart sound (S4) is produced by the augmented diastolic ventricular filling near the end of diastole caused by atrial contraction

It is absent in atrial fibrillation but almost always present during active myocardial ischemia or early after MI.



The third heart sound (S3), or pericardial knock, occurs in early diastole, when the ventricle is dilated and noncompliant (hear Audio 197-. It occurs during passive diastolic ventricular filling and indicates serious ventricular dysfunction, except in children, in whom it can be normal



http://www.merck.com/pubs/mmanual/section16/chapter197/197c.htm



Fourth heart sound is common in Angina



http://www.merck.com/pubs/mmanual/section16/chapter202/202c.htm



///Hypotension and tachycardia are often late findings of shock in young athletes.



///A diabetic with poor glucose control on maximum dose of glyburide?

add metformin



///.AAM teen ager boy with snycope come with mother and Ekg classic for wpw asked for imediate management(procainamide) and next q how do u treat permanently(radio ablation)



/// Campylobactor -common bloody diorrhea in neonate



///E coli and shigella-positive systemic symptoms.



/// Genetics of following disorder.( tansmission in off spring, if one sibling has this chances for the next one, if parent is diseased etc etc )



Turner syndrome

down syndrome

cystic fibrosis

sickle cell disease





questions like....ABOve mentioned patients wants to become pregnant.... what advice. chances of prganacy , complications of pregnancy.. et cetc

///



Down syndrom can be confirm by amnio- by Kariotype and culture of fetal cell.



///PCP -Vivid hallucination

Insects crawling on body common in cocaine.



///aspirin. displace thyroxine from biding site so in Hyperthyroid crisis or thyroid storm Like hyperthermia, atrial fibrillation, confusion the easpirin is ABSOLUTELY contraindicated.



/// Heparin induced thrombocytopenia.

Warfarin should be avoided in acute HIT unless it is used in combination with therapeutic-dose danaparoid, lepirudin, or argatroban. Warfarin has been associated with worsening venous thrombosis, venous limb gangrene, and/or skin necrosis when used alone or in combination with ancrod in acute HIT. However, warfarin is appropriate for longer term anticoagulation in patients with HIT and thrombosis. Warfarin should be delayed until therapeutic anticoagulation with danaparoid, lepirudin or argatroban is achieved, and ideally, until there is substantial resolution of the thrombocytopenia. Warfarin-induced thrombotic complications have been described in patients in whom the alternative anticoagulant was stopped prior to resolution of thrombocytopenia



///A 75-year-old man , metastatic prostate ,,no spinal cord compression or impending bone fractures, but he has diffuse skeletal metastases.

What course of therapy would you recommend?

(A) Single-agent diethylstilbestrol

(B) A single luteinizing hormone–releasing hormone (LHRH) analogue

(C) A single nonsteroidal antiandrogen such as flutamide

(D) An LHRH analogue plus flutamide (complete androgen blockade)

(E) An LHRH analogue plus chemotherapy (mitoxantrone



/// ENDOCARDITIS prophylaxis,,,,,, ONLY ASD with ostium secundum type defect and MITRAL VALUE PROLAPSE wihout murmur requires NO PROPHYLAXIS every thing else requires prophylaxis..i.e VALVULAR disease///congenetial diseases///prosthethic valve disease.



///In an adult pt with dehydration and volume contraction, some of the signs/symptoms are hypotension and tachycardia, and the management is to expand the intravascular volume, regardless of [Na+] level, with normal saline solution. We\'ve all seen nursing home pt\'s with [Na+] > 150, hypotensive, tachycardic, dry mucosa, skin tenting, etc., and the first thing we do is infuse normal saline for volume expansion, and correct hypernatremia after the pt is hemodynamically stable.



///1/4 NS or 1/2 NS March 21 2003, 9:43 PM



depends on the weight of the infant. It could be 1/2 NS or 1/4 NS



Saline guide (Rough):

Weight 28 kg: D5 1/2NS (77 meq/L)





Summary: 35 kg Child with isotonic dehydration

First 8 hours: D5 1/2NS with 20 KCl at 250 cc/hour

Next 16 hours: D5 1/2NS with 20 KCl at 163 cc/hour



///NG losses usually replaced with D5 1/2NS with 20 mEq/L of KCl.

Diarrhea usually replaced with D5 1/4NS with 40 mEq/L of KCl.

General principles in treating dehydration.



///COMPLICATION OF TURP

IMMEDIATE COMPLICATION.

* Most immediate and serious complication is hyponatremia >>nausia, vomiting, confusion , hypertension,bradycardia, visual disturbance, skin changes, coma.(TUR syndrom)

*Hemorrhage

*perforation of prostate capsule with extravesion.

LATE COMPLICATION

*Tertrograde Ejaculation and Impotence

* Urethral stricture and bladder neck contacture

*Urinery incontinence >> Urge. stress,Total



///Using reference ranges of 0-2.5 for men aged 40-49 years, 0-3.5 for men aged 50-59 years, 0-4.5 for men aged 60-69 years, and 0-6.5 for men aged 70-79 years, they reported an overall specificity of 95%.



/// postpartum female, develops oliguria, dark urine,and petechiae on lower limb.Labs: normal INR, decreased platelet count, decreased Hemoglobin, normal U/A.The most likely dg is HUS



///The risk of a diagnosis of breast cancer is slightly increased during OC use but diminishes after discontinuance and is not increased among former OC users who have discontinued OCs for >= 10 yr.

Several epidemiologic studies show that the incidence of cervical neoplasia, particularly adenocarcinoma of the cervix, is increased in OC users, particularly those who have used OCs for > 5 yr. A causal relationship has not been established, but OC users should have a Papanicolaou test at least annually.

A number of studies have shown that OC use decreases the risk of lethal endometrial and ovarian cancers by about 50%; this reduced risk persists for at least 10 to 15 yr after discontinuance. Other documented benefits of OC use include decreased incidence of abnormal uterine bleeding (including menorrhagia), dysmenorrhea, premenstrual tension, iron-deficiency anemia, benign breast disease, and functional ovarian cysts; the reduced incidence of ectopic pregnancy and of salpingitis associated with OC use should decrease infertility

If breakthrough bleeding persists, the woman should be given a combination with a higher dose of estrogen (ie, a more estrogenic formulation).

**If amenorrhea develops, the progestin component should be decreased.