periodically monitor for gastric cancer ---
Vit B12 deficiency is common after total or partial
gastrectomy or chronic gastritis
o 2/2 loss of intrinsic factor
Vit B12 is a cofactor in purines & DNA synthesis
ineffective erythropoiesis megaloblastic anemia
total RBC count & reticulocyte count are low shiny tongue (glossitis) & pale palmar creases ---
ineffective erythropoiesis is a hallmark of both
Vit B12 & folate deficiency
delayed nuclear maturation # of megaloblasts ineffective erythropoiesis due to transition to mature RBC & death of immature precursors total RBC count & reticulocyte count are low ---
antiviral Rx for influenza: oseltamivir o must be started within 48 hrs for efficacy confirm Dx: nasal swab for influenza antigens --- fever, leukocytosis, LUQ pain: splenic abscess left pleuritic chest pain, left pleural effusion,
splenomegaly
MCC: Staph, Strep, Salmonella
MC risk factors: infective endocarditis with
hematogenous spread
Rx: ABX + splenectomy
percutaneous drainage for poor surgical candidate DDx: malaria, Hodgkin’s, infectious mono, TB --- anorexia, constipation, thirst, easy fatigue,
hypercalcemia, smoking Hx: SCC of lung o sCa++mous cell carcinoma
PTHrP Ca++ resorption from bone & renal Ca+
+ resorption from distal tubule CXR: hilar mass
DDx: small cell carcinoma (a/w ACTH or SIADH), adenocarcinoma (a/w hypertrophic osteoarthropathy) --- OTC cold meds containing acetaminophen &
phenylephrine can provoke warfarin-associated IC hemorrhage
acetaminophen potentiates warfarin effects phenylephrine elevates BP
Rx: prothrombin-complex concentrate (rapid & short-term warfarin reversal) & IV Vit K
(promotes clotting factor synthesis; 12 – 24 hr) alt Rx: FFP if PCC not available; FFP takes longer
to prepare/administer & more volume infusion ---
VIPoma
feature
s watery diarrhea, weight loss, lethargy,facial flushing, N/V, muscle weakness
labs hypokalemia ( intestinal K+ secretion),
acholrhydria ( gastric acid secretion),
hypercalcemia ( bone resorption), hyperglycemia ( glycogenolysis), secretory diarrhea: Na+, osmolal gap
Dx watery diarrhea, VIP > 75 pg/mL
abdominal CT (usually pancreatic tail)
Rx IV fluids, octreotide to decrease diarrhea
VIP binds intestinal epithelial cells to increase fluid & electrolyte secretion into intestinal lumen maybe a/w MEN Type I
--- steatorrhea, hepatomegaly, PUD: systemic
mastocystosis
o pruritus, facial flushing, urticaria
--- striatal neuro-degeneration: Huntington’s spongiform encephalopathy: CJD
loss of nigrostriatal DA neurons: Parkinson’s selective loss of cholinergic neurons: Alzheimer’s neurodegeneration of frontal/temporal lobes: Pick’s ---
rationalization: excusing an unacceptable
behavior/emotion in a false, but logically rational way to avoid the true reason for a behavior, to prevent anxiety & protect self-esteem
can result in a delay in care or difficult Rx course ---
repression: blocking upsetting ideas/impulses
from entering consciousness; blocking inner states
denial: blocking external sensory data
--- acute dyspnea, pleuritic chest pain, tachycardia,
follwed by hypotension, syncope: acute massive PE accompanied by RV dilation & hypokinesis 2/2
occlusion of the pulmonary artery, which RA, RV, & pulmonary artery pressure
can cause RBBB & right axis deviation septal deviation toward LV results in LV preload
& cardiac output
PCWP & SVR are not affected
---
hypovolemic shock: RA, RV, pulmonary artery,
& PCWP; SVR to maintain organ perfusion
cardiogenic shock: PCWP & SVR, C.O.
o cardiac index, RA pressure
septic shock: peripheral vasodilation & SVR,
RA, pulmonary artery, & PCWP, C.O. o mixed venous O2 saturation
---
acute mitral regurgitation as a complication of
o flash pulmonary edema & crackles
--- MCC of 20 HTN in children, to-&-fro bruit @ CVA:
fibromuscular dysplasia
angiogram: “sting of beads”
---
viral meningitis: self-limited inflammation of
leptomeninges cause by viral infection MCC: echovirus or coxsackie virus MC in infants; incidence decreases with age prodrome constitutional & URI symptoms; next
36 – 48 hrs high fever, headache, irritability, &
nuchal rigidity
WBC (lymphocyte predominance), normal
glucose, mildly elevated protein
Rx: supportive; resolves in 7 – 10 days
DDx: bacterial (neutrophils, protein, glucose), TB meningitis (lymphocytes, protein, glucose) --- hemolytic anemia, cytopenias, hypercoagulability:
PND
Dx: RBC CD55 & CD59 testing
--- oral corticosteroids: Rx acute asthma exacerbation ---
Management of GERD
no cancer risk factors or alarm symptoms PPI o if refractory, try another PPI or to 2x daily male, age > 50, symptoms for > 5 yrs, or cancer risk
factors or alarm symptoms upper endoscopy o if no evidence of esophagitis manometry
GI alarm symptoms
hematemesis, persistent vomiting, anemia, melena, weight loss, dysphagia/odynophagia ---
intrauterine fetal demise: in utero fetal death
after 20 wks gestation, before labor onset o Dx: USS
next: coagulation profile to detect incipient DIC o retention of dead fetus can cause chronic
consumptive coagulopathy due to gradual release of thromboplastin from the placenta
low/normal fibrinogen may indicate early signs of
consumptive coagulopathy if a/w PLT count, PT, PTT, or fibrin split products
o fibrinogen is usually higher in pregos
if any coagulation derangements prompt delivery if normal coagulation parameters…
o watchful expectancy or labor induction o expectant management complications:
chorioamnionitis & DIC
---
Congenital hypothyroidism
etiology thyroid dysgenesis (MCC) features most are asymptomatic,
jaundice, lethargy, hoarse cry, dry skin,
poor feeding, constipation, large tongue Dx TSH, free T4, via newborn screening Rx levothyroxine
---
maternal Graves’: transplacental passage of
TSH receptor antibodies congenital Grave’s: poor feeding, jitteriness, tachycardia, weight loss ---
synchronized cardioversion: Rx a-fib, a-flutter,
stable monomorphic v-tach
temporary transvenous pacemaker: sick sinus
syndrome, 2nd or 3rd degree heart block
---
duodenal hematoma: MCC direct blunt abdominal
trauma; MC in children Dx: CT with oral contrast
#1 Rx: NG suction & parenteral nutrition; spontaneous resolution in 1 – 2 wks
#2 Rx: surgical removal if conservative Rx fails ---
Vaccines for pregos
all pregos Tdap & inactivated influenza
special
circumstances Hep A & B (high risk)Pneumococcus (2nd & 3rd trimester if high risk),
H. influenza (if asplenic), Meningococcus (if high risk), Anti-D Ig (if Rh-negative mother) not
recommended
HPV, MMR, Varicella, smallpox, intranasal influenza
**avoid conception for 4 wks
unvaccinated pregos with confirmed rubella
exposure are offered termination of pregnancy
or Rx prego with IV Ig
serology not needed if documentation of vaccine ---
Evaluation of nipple discharge
unilateral likely malignant
Dx: mammogram +/- USS, surgical evaluation bilateral color of discharge??
o bloody or serous mammogram o milky, non-bloody…
palpable mass or skin changes??
yes mammogram
no likely physiologic discharge
physiologic galactorrhea
o painless, B/L milky-brown-gray-green o MCC: hyperprolactinemia
Dx: pregnancy test, TSH & prolactin o Dx: pituitary MRI if prolactin is elevated --- frequent exposure to ototoxic agents
(aminoglycosides for P. aeruginosa) for CF Rx can cause sensorineural deafness
--- back pain, constipation, anemia, renal dysfunction,
ESR: MM
o hypercalcemia causes polyuria,
constipation, confusion, or acute pancreatitis --- acute onset polyarticular & symmetric arthritis
that resolves within 2 wks: viral arthritis 2/2
Parvovirus B19
o adults in frequent contact with children morning stiffness < 30 min, no joint swelling
o MCP, PIP, wrist, knees, ankles
transient aplastic anemia
Dx: anti-B19 IgM antibodies
Rx: resolves spontaneous in 2 – 3 wks, no Rx DDx: RA (arthritis > 6 wks), SLE, rheumatic fever --- progressive dyspnea, tricuspid regurgitation,
peripheral edema: pulmonary HTN due to LV
mean pulmonary arterial pressure ≥ 25 mmHg @ rest (normal ≤ 20 mmHg)
#1 initial Rx: furosemide & ACE-I
---
Impetigo
Non-bullous Bullous-type
MCC S. aureus or
Group A Strep S. aureus
feature s localized painful, non-itchy pustules & honey-crusted lesions; lymphadenopathy rapidly enlarging
flaccid bullae with
yellow fluid,
“collarette” of scale @ periphery of lesion
Rx topical mupirocin oral ABX (cephalexin,
dicloxacillin, clinda) predisposing factors: warm, humid climates,
poverty, crowding, pre-existing skin trauma,
atopic dermatitis
prevention: hand-washing
complications: post-strep GN, rheumatic fever --- melena, episodic gnawing, nocturnal abdominal
pain relieved by eating: duodenal ulcer unopposed acid enters duodenum causing pain high a/w H. pylori infection
Rx H. pylori-associated PUD: triple therapy with
PPI + amoxicillin + clarithromycin
Rx PUD only: PPI or H2 blocker
DDx: gastric ulcer (pain worse with eating) --- CHF 2/2 restrictive cardiomyopathy, bibasilar rales,
right-sided pleural effusion: hemochromatosis LV volume is normal with symmetric thickening Rx of hemochromatosis (phlebotomy) can
reverse the cardiac dysfunction
DDx: amyloidosis, sarcoidosis, & scleroderma all cause non-reversible cardiac dysfunction ---
Stages of syphilis
primary painless chancre
Dx: spirochetes on darkfield microscopy Rx: IM benzathine PCN G 1x
PCN-allergic: oral doxycycline x14 days
secondar y
diffuse rash (+ palms/soles), hepatitis,
condyloma lata, lymphadenopathy
Rx: IM PCN G 1x
PCN-allergic: oral doxycycline x 14 days latent asymptomatic
Rx: IM PCN G 3x doses
PCN-allergic: doxycycline x 28 days tertiary Tabes dorsalis, Argyll-Robertson pupil,
dementia, aortic insufficiency, gummas Rx: IV PCN G x14 days
PCN-allergic: ceftriaxone x 14 days pregos intrapartum transmission
Rx: PCN G
PCN-allergic: desensitize to PCN congenital syphilis: failure to thrive, meningitis,
seizures, congenital defects
--- MCC of complicated influenza pneumonia: S. aureus MC in hospitalized, nursing homes, IVDA, CF Gram+ cocci in clusters
Rx: anti-staphylococcal ABX
---
TNM staging is most important prognostic factor
in breast cancer
--- depressed patients must be closely monitored for
suicidality within the first few weeks of initiating
pharmacotherapy; more likely to act on impulses as motivation & initiative improve before a depressed outlook
--- tachypnea, retractions, grunting, nasal flaring, & cyanosis @ birth: respiratory distress syndrome MCC are immature lungs & surfactant deficiency risk factors: prematurity, maternal diabetes,
cesarean without labor
maternal diabetes delays surfactant maturation
due to fetal hyperinsulinemia, which antagonizes cortisol, thus blocks sphingomyelin maturation CXR: “ground glass” opacities, air bronchograms ---
Cholesterol embolism (atheroembolism)
risk
factors cardiac catheterization or angiography; with comorbid hypercholesterolemia,
DM Type II, HTN feature
s
livedo reticularis, blue toe syndrome,
acute kidney injury, amaurosis fugax,
Hollenhorst plaques, intestinal ischemia
Dx Cr, eosinophilia, hypocomplementemia,
eosinophiluria
confirm Dx: skin or renal Bx (biconcave, needle-shaped clefts within occluded vessel) --- patient undergoing coronary angiography are at
risk for contrast-induced nephropathy U/A: muddy-brown granular & epithelial casts Rx: benign, resolves in 3 – 5 days
---
pseudocyesis is a form of conversion disorder
normal endometrial stipe, pregnancy test negative Rx: psych evaluation
DDx: missed abortion (intrauterine collapsed gestational sac, +pregnancy test), ectopic (adnexal mass & empty uterus, +pregnancy test) ---
neoadjuvant therapy: given before standard Rx
adjuvant therapy: given in addition to standard Rx
induction therapy: initial dose of treatment to
rapidly kill tumor cells & induce remission
consolidation therapy: given after induction Rx
with multi-drug regimen to further reduce tumor
maintenance therapy: given after consolidation Rx
to kill residual tumor cells; keep patient in remission
salvage therapy: Rx for a disease when standard
Rx fails (radiation for PSA recurrence after radical prostatectomy)
---
cirrhosis increases risk for HCC, but HCC does
not risk of cirrhosis
Management of cirrhosis
periodic surveillance of LFTs, INR, albumin, etc compensated: asymptomatic or vague symptoms
USS for HCC +/- AFP; every 6 months decompensated: jaundice, pruritus, upper GI bleed;
assess complications
o varices: start non-selective β-blockers,
repeat EGD annually**
o ascites: dietary Na+ restriction, diuretics,
o hepatic encephalopathy: lactulose, Rx
underlying cause
--- childhood Hx of recurrent renal stones, +family Hx,
+urinary cyanide nitroprusside screening test, & hexagonal crystals on U/A: cystinuria
defective transport of dibasic amino acids (Lys, Arg) poor solubility of cysteine leads to renal stones --- persistent abdo pain or dyspepsia post-op or years
after cholecystectomy: post-cholecystectomy
syndrome
due to biliary or extra-biliary causes
elevated ALP, mildly abnormal ALT/AST, & dilated common bile duct on USS
MCC: common bile duct stones or sphincter dysFx Dx: endoscopic USS, then ERCP or MRCP ---
Management of Cushing’s
#1 test: ACTH levels & urinary cortisol low ACTH adrenal CT
o MCC: exogenous glucocorticoids o exclude adrenal adenoma & hyperplasia normal/high ACTH pituitary MRI
o mass > 6 mm dexamethasone supp test no mass or < 6 mm inferior petrosal
sinus sampling (invasive)
MCC: ACTH-producing pituitary adenoma, ectopic ACTH, or ectopic CRH
ectopic ACTH: rapid onset HTN, hypokalemia,
proximal muscle weakness, metabolic alkalosis, hyperglycemia; less likely to have central obesity, moon facies
---
Prevention of recurrent nephrolithiasis
dietar
y fluids (produce > 2 L urine/day)reduce Na+, reduce protein, reduce oxalate,
normal Ca++ intake, increase citrate
Rx thiazides (passive Ca++ reabsorption),
potassium citrate (urine alkalization),
allopurinol (for uric acid stones) reduced dietary Ca++ leads to oxalate
absorption in the gut excreted into urine & binds urinary Ca++ Ca++ oxalate stones ---
fever, odynophagia, dysphagia, drooling, stiff neck, muffled voice, inability to extend neck & widened prevertebral space: retropharyngeal abscess MC in age 6 months – 6 yrs
prodrome URI direct spread of infection
polymicrobial (Group A Strep, S. aureus, anaerobes) Dx: CT with contrast
complications: airway compromise, bacteremia, carotid artery rupture, jugular venous thrombosis --- young adult with cirrhosis, neuropsych symptoms,
& Kayser-Fleischer rings: Wilson’s (aka hepatolenticular degeneration)
AR inheritance
resting tremor, muscle rigidity, slurred speech, depression, paranoia, catatonia
impaired ceruloplasmin secretion, thus decreased secretion of copper in biliary system
Cu++ deposition in liver, basal banglia, cornea also a/w Fanconi’s, hemolytic anemia, neuropathy Dx: liver biopsy, low ceruloplasmin, slit lamp,
urinary Cu++ excretion
#1 Rx: D-penicillamine or trientine
o oral zinc prevents copper absorption
#2 Rx: liver transplant
--- liver disease, hyperpigmentation, arthropathy,
diabetes, impotence, dilated cardiomyopathy:
hemochromatosis
--- productive cough, hemoptysis, recurrent fevers,
recent travel: pulmonary TB
chest CT: upper lobe cavitary lesions with surrounding alveolar infiltrates
--- MC benign cutaneous vascular tumor in adults:
cherry angioma (aka senile hemangioma)
age 3rd – 4th decade, increases with age
sharply circumscribed areas of congested capillaries & post-capillary venules in papillary dermis
benign, no Rx required
--- MC benign vascular tumor in children:
superficial infantile (strawberry) hemangioma
red, demarcated plaques that blanch grows rapidly in first 1 – 2 yrs of life, then
spontaneously regress in childhood
Rx: propranolol if at risk for complications ---
spider angiomas are estrogen dependent
MC in pregos, OCP use, cirrhosis (hyperestrogen) dilated cutaneous arterioles with a central papule
& radiating blanching capillaries
--- recurrent sinopulmonary & GI bacterial infections
in adults may indicate humoral immunity defect o a/w food allergies & autoimmune disease Dx: quantitative serum Ig levels
---
NSAIDs can cause SIADH
o NSAIDs potentiate the action of ADH hypotonic hyponatremia with euvolemia Dx: r/o hypothyroidism & adrenal insufficiency Dx: urine & plasma osmolality
low plasma osmolality with high urine osmolality serum uric acid is low due to urinary excretion
& hemodilution
---
mineralocorticoid deficiency: hypotonic
hyponatremia with hypovolemia; elevated K+ ---
nephrotic syndrome & advanced renal failure:
hypotonic hyponatremia with hypervolemia --- incidence of carpal tunnel syndrome in pregos
2/2 estrogen-mediated depolymerization of ground substance, causing interstitial edema
initial Rx: wrist splinting
#2 Rx: NSAIDS (risk of miscarriage), local corticosteroid injection, surgical decompression ---
Urinary incontinence
Stress loss of urethral support, intraabdominal pressure exceeds urethral sphincter leaking with cough, sneeze, laugh, lifting Urge detrusor overactivity
sudden, overwhelming, frequent need Overflow impaired detrusor contractility,
constant involuntary dribbling & incomplete emptying
epidural anesthesia: block afferent & efferent
nerves from the bladder; can cause overdistension post-partum urinary retention: indwelling catheter
for 24 hr to decompress the bladder
--- ankylosing spondylitis & IBD (UC) are a/w
HLA-B27; may occur together
both are +p-ANCA, despite absence of vasculitis ---
infantile colic: crying ≥ 3 hr/day, ≥ 3 days/wk,
for ≥ 3 wks; typically evenings
o resolves spontaneously by age 4 months Rx: calming techniques, reassurance
---
misoprostol: synthetic prostaglandin, used with
mifepristone to terminate pregnancies ≤ 49 days
--- cyanosis & respiratory distress immediately after
birth, scaphoid-abdomen: congenital
diaphragmatic hernia
XR: displaced cardiac silhouette, gasless abdomen --- acute gout Rx: NSAIDs (indomethacin),
colchicine, corticosteroids prophylactic Rx: allopurinol
---
male pubertal gynecomastia resolves within a few
months – 2 yrs without intervention; reassurance ---
antiphospholipid antibody syndrome promotes
arterial/venous thromboses & recurrent spontaneous abortions
o thrombocytopenia & prolonged PTT prophylactic Rx: LMWH & low-dose ASA --- leukopenia & thrombocytopenia in SLE is due to
peripheral immune-mediated destruction
o pancytopenia is common with SLE
---
alcoholic hepatitis: AST:ALT > 2; < 300 IU/L
o also GGT & ferritin (acute phase reactant) ---
dermatomyositis is an idiopathic inflammatory
myopathy with immune-mediated muscle injury that can be due to a paraneoplastic syndrome from malignancy (lung cancer)
Dx: muscle biopsy
---
Achilles tendon reflex can be decreased or
absent with age
lower extremity weakness, rectal tone, bowel/bladder incontinence, & brisk LE DTRs: possible spinal cord compression
---
ovulatory phase: cervical mucus is profuse,
clear & thin, stretches 6 cm, exhibits “ferning”, & pH > 6.5 (more basic than usual)
o ideal for spermatozoa entering uterus
pre- & post-ovulatory: scant, opaque, & thick mucus --- Hx of pelvic surgery or irradiation can develop a
urinary fistula
Dx: intravenous pyelography
--- young male with lower abdominal pain, tenesmus,
bloody diarrhea with acutely worsening fever, leukocytosis, hypotension, & tachycardia:
ulcerative colitis complicated by toxic megacolon
may be the first presentation of UC
Dx: abdominal XR with colonic distension > 6 cm + 3 signs…
o fever > 380C, HR > 120, leukocytosis, anemia Rx: bowel rest, NG tube, steroids (if UC), ABX
o sigmoidoscopy is used to confirm UC, but risk of perforation in toxic megacolon severe cases: subtotal colectomy & end-ileostomy ---
sulfasalazine: Rx Crohn’s, UC, RA
--- fever, malaise, productive cough, eosinophilia,
hemoptysis: allergic bronchopulmonary
aspergillosis (ABPA)
hypersensitivity reaction to Aspergillus MC a/w asthma & CF
---
academia alone does not lead to CNS depression,
but the underlying cause results in lethargy & altered mental status
CO2 retention due to underlying COPD can lead to CO2 narcosis (PaCO2 > 60 mmHg)
--- DIC depletes clotting factors & 20 fibrinolysis thrombocytopenia, prolonged PT & PTT,
decreased fibrinogen, schistocytes
--- predominant unconjugated hyperbilirubinemia
o bilirubin production (hemolysis) o bilirubin uptake (portosystemic shunt) o abnormal conjugation (Gilbert’s) predominant conjugated hyperbilirubinemia
o hepatocellular injury
o bilirubin excretion in bile canaliculi (Dubin-Johnson)
o intrahepatic cholestasis (10 biliary cirrhosis) o extrahepatic cholestasis (biliary obstruction) normal transaminases & ALP suggest inherited
bilirubin metabolism disorders
elevated transaminases & normal ALP suggest intrinsic liver disease (viral, hemochromatosis) elevated ALP suggest intrahepatic cholestasis or
biliary obstruction
--- painless jaundice, fatigue, weight loss, pruritus,
acholic stools with dark urine, ALP, GGT:
malignant biliary obstruction
MCC: adenocarcinoma, cholangiocarcinoma Dx: USS or CT; ERCP if non-diagnostic
DDx: acute choledocholithiasis (acute RUQ pain), chronic autoimmune hepatitis, chronic pancreatitis --- elderly patient with hip fracture should undergo
definitive surgical correction
surgery can be delayed up to 72 hrs to evaluate surgical risk & address unstable comorbidities ---
Ovarian & adnexal torsion
risk factors ovarian mass ≥ 5 cm, reproductive age, infertility Rx with ovulation induction features sudden onset unilateral pelvic pain,
vaginal bleeding is uncommon
Dx β-hCG to exclude ectopic pregnancy,
USS with color Doppler
Rx laparoscopy with detorsion rotation of ovary around infundibulopelvic
(suspensory ligament) & utero-ovarian ligaments
adnexal torsion: includes fallopian tube
MC right-side: longer ligament
DDx: appendicitis, ruptured ovarian cyst, endometriosis, tubo-ovarian abscess
--- gradual onset fever, chills, lower abdominal pain,
vaginal discharge: tubo-ovarian abscess
risk factors: multiple partners, young age, Hx of PID ---
ovarian hyperstimulation syndrome: ovarian
enlargement from multiple cysts with fluid shifts out of the intravascular space
o results in ascites & hypovolemia
complication of gonadotrophin Rx for infertility ---
major depressive disorder (MDD): persistent &
pervasive sadness, self-critical ruminations, & suicidality a/w feeling worthlessness & hopeless ≥ 2 wks
can be diagnosed anytime during acute grief; bereavement period is not an exception Rx: SSRI & psychotherapy
---
electroconvulsive Rx: refractory to antidepressants
o #1 Rx if not eating/drinking; acutely suicidal, catatonic, or psychotic
---
first-time DVT with a reversible inciting incident
(surgery)
Rx: unfractionated or LMWH within 48 – 72 hrs if hemodynamically stable
o prevents extension of the clot & future clots rather than lysis of the present clot
o streptokinase & tPA: only Rx STEMI --- low bone mass with normal mineralization:
osteoporosis
normal serum Ca++, phosphorus, PTH, & ALP
--- defective mineralization of organic bone matrix:
osteomalacia 2/2 Vit D deficiency
defective mineralization of growth plates in kids:
rickets --- Rickets risk factors skin pigmentation, exclusive breastfeeding, inadequate sun exposure, maternal Vit D deficiency feature
s craniotabes (“ping-pong ball” skull),delayed fontanelle closure, frontal bossing, costochondral hypertrophy (rachitic rosary)
genu varum
XR metaphyseal cupping & fraying, epiphyseal widening, osteopenia labs Ca++ & phosphorus, ALP & PTH Rx Vit D fortified baby food or formula; or
supplementation
---
Vit D deficiency causes marked hypophosphatemia,
ALP, normal Ca++, secondary hyperPTH XR: bone density with thin cortex, “codfish”
vertebral bodies, & pseudofractures (Looser zones) --- large anterior fontanelle, lethargy, poor feeding,
macroglossia: congenital hypothyroidism frontal bossing, anterior shin bowing, saddle-nose,
notched/gap teeth: congenital syphilis
“bucket-handle” fx = classic metaphyseal lesion:
child abuse
--- large tender, soft-tissue mass with localized pain MC primary malignant bone tumor in children,
MC @ metaphysis of long bones: osteosarcoma