Long Goljan Notes

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CHAPTER 1: CELLULAR REACTION TO INJURY
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5+4!'66#+6!7!849(:'/;!<4/2'&+!9('6(2'2=;!)0++!0/&'</*6;!/9(9$(6'6;!=0(>$8!/*$+02/$'(26!?'@+@!
849+0$0(984;!/$0(984;!849+09*/6'/;!+$<AB!
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I.!!Hypoxia C!'2/&+D#/$+!(:4=+2/$'(2!()!$'66#+!?6/E+!&+)'2'$'(2!()!/6!68(<FB@!"++&!GH!)(0!
(:'&/$'(2!98(698(04*/$'(2!9/$8>/4!7!>8+0+!4(#!=+$!%IJ!)0(E!'22+0!K'$(!E+EL0/2+!?+*+<$0(2!
$0/269(0$!646$+E;!</**+&!(:'&/$'M+!98(698(04*/$'(2B@!I8+!*/6$!0:2!'6!GH!$(!0+<+'M+!$8+!+*+<$0(26@!
J0($(26!/0+!L+'2=!F'<F+&!());!=(!L/<F!'2$(!$8+!E+EL0/2+;!/2&!)(0E!%IJ;!/2&!%IJ!'2!)(0E+&!'2!$8+!
E'$(<8(2&0'/!
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A. Terms:
1. Oxygen content!C!NL!:!GH!6/$2!O!9/0$'/*!90+66#0+!()!/0$+0'/*!(:4=+2!
?$8+6+!/0+!$8+!P!E/'2!$8'2=6!$8/$!</004!GH!'2!(#0!L*((&B!
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12!NL;!$8+!GH!/$$/<8+6!$(!8+E+!=0(#9!?GH!6/$Q2B!
J/0$'/*!90+66#0+!()!/0$+0'/*!GH!'6!GH!&'66(*M+&!'2!9*/6E/!
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12!RS.;!)(#0!8+E+!=0(#96!?T+!E#6$!L+!OHU!')!T+O!'6!OP;!'$!</22($!</004!GHB!
I8+0+)(0+;!>8+2!/**!)(#0!8+E+!=0(#96!8/M+!/2!GH!(2!'$;!$8+!GH!6/$Q2!'6!,VVW@!
2. O2 satn '6!$8+!GH!1"!$8+!RS.!'6!/$$/<8+&!IG!$8+!8+E+!=0(#9!C!?E+/6#0+&!L4!/!9#*6+!
(:'E+$+0B!
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3.!!Partial pressure of O2!'6!GH!&'66(*M+&!'2!JX%YK%!
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GH!)*(>-!)0(E!/*M+(*'!$80(#=8!$8+!'2$+098/6+;!$8+2!&'66(*M+6!'2!9*/6E/;!/2&!'2<0+/6+6!$8+!
9/0$'/*!90+66#0+!()!GH;!&'))#6+6!$80(#=8!$8+!RS.!E+EL0/2+!/2&!/$$/<8+6!$(!$8+!8+E+!=0(#96!
(2!$8+!RS.!(2!$8+!NL;!>8'<8!'6!$8+!GH!6/$Q2!
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I8+0+)(0+!7!')!9/0$'/*!90+66#0+!()!GH!'6!&+<0+/6+&;!GH!6/$Q2!N%Y!$(!L+!&+<0+/6+&!?SZ<!GH!</E+!
)0(E!/E(#2$!$8/$!>/6!&'66(*M+&!'2!9*/6E/B!
B. Causes of tissue hypoxia:
1. Ischemia!?&+<0+/6+!'2!%RI[R1%X!L*((&!)*(>!AA"GI!M+2(#6B!
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K..!16<8+E'/!'6!$80(EL#6!'2!E#6<#*/0!/0$+04!?LZ<!$8'6!'6!$8+!E<<!&+/$8!'2!\Y%!C!K1;!
$8+0+)(0+!K1!'6!=((&!+:/E9*+!()!'6<8+E'/!LZ<!$80(EL#6!'6!L*(<F'2=!/0$+0'/*!L*((&!)*(>;!
90(&#<'2=!$'66#+!849(:'/B!
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G$8+0!</#6+6!()!$'66#+!'6<8+E'/-!&+<0+/6+!'2!./0&'/<!G#$9#$!?*+/&6!$(!849(M(*+E'/!/2&!
</0&'(=+2'<!68(<FB!LZ<!$8+0+!'6!/!&+<0+/6+!'2!/0$+0'/*!L*((&!)*(>@!
2. 2nd MCC of tissue hypoxia = hypoxemia
Hypoxia!C!]L'=Q!$+0E!
Hypoxemia!C!</#6+!()!849(:'/!?$8+4!/0+!2($!$8+!6/E+BU!&+/*6!>'$8!$8+!9/0$'/*!90+66#0+!()!

/0$+0'/*!GH!?GH!&'66(*M+&!'2!/0$+0'/*!9*/6E/;!$8+0+)(0+;!>8+2!$8+!9/0$'<*+!90+66#0+!()!GH!'6!
&+<0+/6+&;!$8'6!'6!</**+&!849(:+E'/B@!!
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N+0+!/0+!^!</#6+6!()!849(:+E'/-!
a. Resp acidosis!?'2!$+0E6!()!849(:+E'/B!7!'2!$+0E6!()!_/*$(2Q6!*/>;!$8+!6#E!()!$8+!
9/0$'/*!90+66#0+!()!=/6!E#6$!C!àV!/$!/$E(698+0'<!90+66#0+!?8/M+!GH;!.GH;!/2&!2'$0(=+2U!
2'$0(=+2!0+E/'26!<(26$/2$!7!$8+0+)(0+;!>8+2!4(#!0+$/'2!.GH;!$8'6!'6!0+69!/<'&(6'6U!>8+2!
.GH!=(+6!#9;!9GH!N%Y!$(!=(!&(>2!LZ<!E#6$!8/M+!$(!+D#/*!àVU!
I8+0+)(0+;!+M+04!$'E+!4(#!8/M+!0+69!/<'&(6'6;!)0(E!%"b!</#6+;!4(#!8/M+!849(:+E'/!LZ<!
*(>!/0$+0'/*!9GHU!'2<0+/6+!.GHC!&+<0+/6+!9GH;!/2&!M'<+!M+06/!'2!0+69!/*F/*(6'6B@!
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b. Ventilation defects!7!L+6$!+:/E9*+!'6!0+69!&'6$0+66!642&0(E+!?/F/!84/*'2+!
E+EL0/2+!&c!'2!<8'*&0+2B@!!12!/&#*$6;!$8'6!'6!</**+&!%&#*$!R_Y;!/2&!8/6!/!M+2$'*/$'(2!
&+)+<$@!!X(6$!M+2$'*/$'(2!$(!$8+!/*M+(*';!L#$!6$'**!8/M+!9+0)#6'(2U!$8+0+)(0+!8/M+!<0+/$+&!/2!
'2$0/9#*E(2/04!68#2$@!![:/E!D#+6$'(2-!9$!>'$8!849(:+E'/;!='M+2!,VVW!()!GH!)(0!HV!
E'2#$+6;!/2&!9GH!&'&!2($!'2<0+/6+;!$8+0+)(0+!'2&'</$+6!/!YN\"I;!E/66'M+!M+2$'*/$'(2!
&+)+<$@!
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c. Perfusion defects 7!F2(<F!())!L*((&!)*(>!
K..!9+0)#6'(2!&+)+<$!C!9#*E(2/04!+EL(*#6;!+69+<'/**4!'2!90(*(2=+&!)*'=8$6;!>'$8!6'$$'2=!
&(>2!/2&!2($!=+$$'2=!#9@!!Y$/6'6!'2!M+'26!()!$8+!&++9!M+'26;!*+/&6!$(!90(9/=/$'(2!()!/!
<*($!/2&!Pde!&/46!*/$+0!/2!+EL(*#6!&+M+*(96!/2&!+EL(*'c+6@!!12!$8'6!</6+;!4(#!8/M+!
M+2$'*/$'(2;!L#$!2(!9+0)#6'(2U!$8+0+)(0+!$8+0+!'6!/2!'2<0+/6+!'2!&+/&!69/<+@!!1)!4(#!='M+!
,VVW!GH!)(0!/!9+0)#6'(2!&+)+<$;!9GH!>'**!=(!\J!?>/4!$(!&'6$'2=#'68!M+2$!)0(E!9+0)#6'(2!
&+)+<$B;!LZ<!2($!+M+04!6'2=*+!M+66+*!'2!$8+!*#2=!'6!2($!9+0)#6+&@!!
!
I8+0+)(0+;!9+0)#6'(2!&+)+<$6!L+</#6+!/2!'2<0+/6+!'2!&+/&!69/<+;!>8'*+!M+2$'*/$'(2!&+)+<$6!
</#6+!'2$0/9#*E(2/04!68#2$6@!!I(!$+**!$8+!&'))+0+2<+;!='M+!,VVW!GH!/2&!6++!>8+$8+0!$8+!
9GH!6$/46!$8+!6/E+;!'+!&(+6!2($!=(!#9!?68#2$B!(0!'2<0+/6+6!?'2<0+/6+!'2!&+/&!69/<+B@!!
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d. Diffusion defect!7!6(E+$8'2=!'2!$8+!'2$+098/6+!$8/$!GH!</22($!=+$!$80(#=8A'+!
)'L0(6'6@!!S+6$!+:/E9*+7Y/0<('&(6'6!?/!0+6$0'<$'M+!*#2=!&'6+/6+BU!GH!/*0+/&4!8/M+!$0(#L*+!
=+$$'2=!$80(#=8!$8+!E+EL0/2+U!>'$8!)'L0(6'6!'$!'6!>(06+@!!%2($8+0!+:/E9*+7J#*E(2/04!
+&+E/U!GH!</22($!<0(66U!$8+0+)(0+!$8+0+!'6!/!&'))#6'(2!&+)+<$@!!%2($8+0!+:/E9*+!'6!9*/'2!
(*&!)*#'&!)0(E!8+/0$!)/'*#0+!*+/&6!$(!&4692+/;!LZ<!/<$'M/$+&!$8+!f!0+)*+:!'6!'2'$'/$+&!
?'22+0M/$+&!L4!.",VBU!/<$'M/$'(2!()!.",V;!*+/&6!$(!&4692+/!?</2Q$!$/F+!/!)#**!L0+/$8B!LZ<!
)*#'&!'2!'2$+06$'#E!()!$8+!*#2=;!/2&!$8+!f!0+<+9$(0!'6!'00'$/$+&@!!!
I8+6+!/0+!$8+!)(#0!$8'2=6!$8/$!</#6+!849(:+E'/!?0+69!/<'&(6'6;!M+2$'*/$'(2!&+)+<$6;!
9+0)#6'(2!&+)+<$6;!/2&!&'))#6'(2!&+)+<$6B@!
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3. Hemoglobin related hypoxia
12!$8+!</6+!()!/2+E'/;!$8+!<*/66'<!E'6<(2<+9$'(2!'6!/!849(:+E'/!?&+<0+/6+!'2!9GHB@!!
I8+0+!'6!"G!849(:+E'/!'2!/2+E'/;!$8+0+!'6!2(0E/*!=/6!+:<8/2=+!?2(0E/*!0+69'0/$'(2B;!
$8+0+)(0+!2(0E/*!9GH!/2&!GH!6/$#0/$'(2;!L#$!$8+0+!'6!/!&+<0+/6+!'2!NL@!!I8/$!'6!>8/$!
/2+E'/!'6-!&+<0+/6+!'2!NL@!1)!4(#!8/M+!e!=E!()!NL;!$8+0+!'6!2($!/!>8(*+!*($!()!GH!$8/$!
=+$6!$(!$'66#+;!$8+0+)(0+!=+$!$'66#+!849(:'/!/2&!$8+!9/$'+2$!8/6!+:+0$'(2/*!&4692+/!>'$8!
/2+E'/;!+:+0<'6+!'2$(*+0/2<+@!
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a. Carbon monoxide (CO)-!<*/66'<!7!8+/$+0!'2!>'2$+0U!'2!/!<*(6+&!69/<+!>'$8!/!8+/$+0!
?8+/$+0!8/M+!E/24!<(EL#6$/L*+!E/$+0'/*6U!/#$(E(L'*+!+:8/#6$!/2&!8(#6+!)'0+@!!12!$8+!
8(#6+!)'0+!6<+2/0'(;!$>(!$8'2=6!</#6+!$'66#+!849(:'/-!,B!.G!9('6(2'2=!/2&!HB!.4/2'&+!
9('6(2'2=!LZ<!#98(*6$+04!'6!E/&+!()!9(*4#0+$80/2+!90(&#<$6@!g8+2!$8+0+6!8+/$;!<4/2'&+!
=/6!'6!='M+2!())U!$8+0+)(0+!9$6!)0(E!8(#6+!)'0+6!<(EE(2*4!8/M+!.G!/2&!<4/2'&+!
9('6(2'2=@!
!
.G!'6!M+04!&'))#6'L*+!/2&!8/6!/!8'=8!/))'2'$4!)(0!NL;!$8+0+)(0+!$8+!GH!Y%IQ"!>'**!L+!
&+<0+/6+&!LZ<!'$6!6'$$'2=!(2!$8+!8+E+!=0(#9;!'26$+/&!()!GH!?0+E+EL+0!$8/$!.G!8/6!/!
HVVh!/))'2'$4!)(0!NLB@!!
!
?NL!'6!2(0E/*!7!'$6!"GI!/2+E'/;!9GH!?GH!&'66(*M+&!'2!9*/6E/B!'6!2(0E/*;!$((BU!>8+2!GH!
&'))#6+6!'2$(!$8+!RS.;!.G!/*0+/&4!6'$$'2=!$8+0+;!/2&!.G!8/6!/!8'=8+0!/))'2'$4!)(0!8+E+@!!
I(!$0+/$;!='M+!,VVW!GH@!!_+<0+/6+!()!GH!6/$Q2!C!<*'2'</*!+M'&+2<+!'6!<4/2(6'6!
"($!6++2!'2!.G!9('6(2'2=!LZ<!<8+004!0+&!9'=E+2$!K%Y5Y!'$;!$8+0+)(0+!E/F+6!$8+!
&'/=2(6'6!8/0&!$(!E/F+@!!K.!64E9$(E!()!.G!9('6(2'2=!C!8+/&/<8+!
!
b. Methemoglobin: !
K+$8+E(=*(L'2!'6!T+PO!(2!8+E+!=0(#9;!$8+0+)(0+!GH!.%""GI!L'2&@!!I8+0+)(0+;!'2!
E+$8+E(=*(L'2!9('6(2'2=;!$8+!(2*4!$8'2=!6<0+>+&!#9!'6!GH!6/$#0/$'(2!?LZ<!$8+!'0(2!'6!OP;!
'26$+/&!()!OHB@!![:/E9*+-!9$!$8/$!8/6!&0/>2!L*((&;!>8'<8!'6!<8(<(*/$+!<(*(0+&!LZ<!$8+0+!
'6!2(!GH!(2!8+E+!=0(#96!?2(0E/*!9GH;!NL!<(2<+2$0/$'(2!'6!2(0E/*;!L#$!$8+!GH!6/$#0/$'(2!
'6!2($!2(0E/*BU!i6+/$!'6!+E9$4;!L#$!</22($!6'$!'2!'$;!LZ<!'$Q6!OPj@!!RS.Q6!8/M+!/!
E+$8+E(=*(L'2!0+&#<$/6+!646$+E!'2!=*4<(*4$'<!<4<*+!?0+&#<$'(2!</2!0+&#<+!OP!$(!OHB@!
!
[:/E9*+-!!J$!)0(E!0(<F4!E(#2$/'26!>/6!<4/2($'<U!$8+4!=/M+!8'E!,VVW!GH;!/2&!8+!>/6!
6$'**!<4/2($'<!?>/6!&0'2F'2=!>/$+0!'2!E$26!7!>/$+0!8/6!2'$0'$+6!/2&!2'$0/$+6;!>8'<8!/0+!
(:'&'c'2=!/=+2$6!$8/$!(:'&'c+!NL!6(!$8+!'0(2!L+<(E+!OP!'26$+/&!()!OHB@!.*#+!>/6!$8/$!GH!
&'&!2($!<(00+<$!$8+!<4/2(6'6@!!R:-!1k!E+$8/*'2+!L*#+!?_G.BU!/2<'**/04!R:!C!M'$/E'2!.!?/!
0+&#<'2=!/=+2$B@!!K(6$!0+<+2$!&0#=;!_/96(2+!?#6+&!$(!R:!*+90(64B!'6!/!6#*)/!/2&!2'$04*!
&0#=@!I8+0+)(0+!&(+6!$>(!$8'2=6-!,B!90(&#<+!E+$8+E(=*(L'2!/2&!HB!8/M+!9($+2$'/*!'2!
90(&#<'2=!8+E(*4$'<!/2+E'/!'2!=*#<(6+!a!98(698/$+!&+84&0(=+2/6+!&+)'<'+2<'+6@!!
I8+0+)(0+;!8+E(*46'6!'2!laJ_!&+)!'6!0+)+00'2=!$(!(:'&'c'2=!/=+2$6;!</#6'2=!/2!'2<0+/6+!'2!
9+0(:'&+;!>8'<8!&+6$0(46!$8+!RS.U!$8+!6/E+!&0#=6!$8/$!90(&#<+!8+E(*46'6!'2!laJ_!&+)!
/0+!6#*)/!/2&!2'$04*!&0#=6@!!I8+6+!&0#=6!/*6(!90(&#<+!E+$8+E(=*(L'2@!!I8+0+)(0+;!
+:9(6#0+!$(!&/96(2+;!90'E/D#'2+;!/2&!IKJdYKh;!(0!2'$04*!&0#=6!
?2'$0(=*4<+0'2Z2'$0(90#66'&+B;!$8+0+!</2!L+!/!<(EL(!()!8+E(*4$'<!/2+E'/;!laJ_!&+);!/2&!
E+$8+E(=*(L'2+E'/!LZ<!$8+4!/0+!(:'&'c'2=!/=+2$6@!.(EE(2!$(!6++!E+$8+E(=*(L'2+E'/!
'2!N1k!LZ<!9$!'6!(2!IKJdYKh!)(0!R:!()!J.J@!!I8+0+)(0+;!9($+2$'/*!<(E9*'</$'(2!()!$8/$!
$8+0/94!'6!E+$8+E(=*(L'2+E'/@!
!
c. Curves: left and right shifts
g/2$!/!0'=8$!68')$+&!<#0M+!7!>/2$!NL!>'$8!/!&+<0+/6+&!/))'2'$4!)(0!GH;!6(!'$!</2!0+*+/6+!GH!
$(!$'66#+6@!!./#6+6-!H;P!L'698(698(=*4<+0/$+!?SJlB;!)+M+0;!*(>!9N!?/<'&(6'6B;!8'=8!
/*$'$#&+!?8/M+!/!0+69!/*F/*(6'6;!$8+0+)(0+!8/M+!$(!849+0M+2$'*/$+!LZ<!4(#!>'**!&+<0+/6+!$8+!
.GH;!*+/&'2=!$(!/2!'2<0+/6+!'2!9GH;!*+/&'2=!$(!/!0'=8$!68')$!LZ<!$8+0+!'6!/2!'2<0+/6+!'2!
642$8+6'6!()!H;P!SJlB@!
!
X+)$!68')$!7!.G;!E+$8+E(=*(L'2;!NLT!?)+$/*!NLB;!&+<0+/6+!'2!H;PdSJl;!/*F/*(6'6!

I8+0+)(0+;!>'$8!.G;!$8+0+!'6!/!&+<0+/6+!'2!GH!6/$Q2!?849(:'/B!/2&!*+)$!68')$@!
!
4. Problems related to problems related to oxidative pathway
!
a. Most imp: cytochrome oxidase!?*/6$!+2c4E+!L+)(0+!'$!$0/26)+06!$8+!+*+<$0(26!$(!GH@!
R+E+EL+0!$8+!P!.Q6!7!<4$(<80(E+!(:'&/6+;!<4/2'&+;!.G!/**!'28'L'$!<4$(<80(E+!(:'&/6+@!!
I8+0+)(0+!P!$8'2=6!)(0!.G!7!?,B!&+<0+/6+!'2!GH!6/$!?849(:'/B;!?HB!*+)$!68')$6!?6(;!>8/$!*'$$*+!
4(#!</004;!4(#!</2Q$!0+*+/6+B;!/2&!?PB!')!4(#!>+0+!/L*+!$(!0+*+/6+!'$;!'$!L*(<F6!<4$(<80(E+!
(:'&/6+;!6(!$8+!+2$'0+!646$+E!68#$6!&(>2!
!
b. Uncoupling!7!/L'*'$4!)(0!'22+0!E'$(!E+EL0/2+!$(!642$8+6'c+!%IJ@!!122+0!E'$(!
E+EL0/2+!'6!9+0E+/L*+!$(!90($(26@!!b(#!(2*4!>/2$!90($(26!$(!=(!$80(#=8!/!<+0$/'2!9(0+;!
>8+0+!%IJ!642$8/6+!'6!$8+!L/6+;!*+/&'2=!$(!90(&#<$'(2!()!%IJU!4(#!&(2Q$!>/2$!0/2&(E!
'2)*#:!()!90($(26!7!/2&!$8/$!'6!>8/$!#2<(#9*'2=!/=+2$6!&(@!![:/E9*+6-!&'2'$04*98+2(*!
?<8+E'</*!)(0!90+6+0M'2=!>((&B;!/*<(8(*;!6/*'<4*/$+6@!!\2<(#9*'2=!/=+2$6!</#6+6!90($(26!
$(!=(!0'=8$!$80(#=8!$8+!E+EL0/2+U!$8+0+)(0+!4(#!/0+!&0/'2'2=!/**!$8+!90($(26;!/2&!M+04!
*'$$*+!%IJ!L+'2=!E/&+@!!SZ<!(#0!L(&4!'6!'2!$($/*!+D#'*'L0'#E!>'$8!+/<8!($8+0;!0:26!$8/$!
90(&#<+!90($(26!'2<0+/6+!?0:26!$8/$!E/F+!"%_N!/2&!T%_N;!$8+6+!>+0+!$8+!90($(26!$8/$!
>+0+!&+*'M+0+&!$(!$8+!+*+<$0(2!$0/269(0$!646$+EB@!!I8+0+)(0+!/24!0:2!$8/$!E/F+6!"%_N!
/2&!T%_N!$8/$!*+/&6!$(!90($(2!90(&#<$'(2!>'**!0+M!#9!0:26!E/F'2=!"%_N!/2&!T%_N!$(!
E/F+!E(0+!90($(26@!g'$8!'2<0+/6+&!0/$+!()!0:26;!*+/&6!$(!/2!'2<0+/6+!'2!$+E9+0/$#0+U!
$8+0+)(0+;!>'**!/*6(!6++!NbJ[RIN[RK1%@!!.(E9*'</$'(2!()!6/*'<4*/$+!$(:'<!C!849+0$8+0E'/!
?LZ<!'$!'6!/2!#2<(#9*'2=!/=+2$B@!!%2($8+0!+:/E9*+-!/*<(8(*'<!(2!8($!&/4!>'**!*+/&!$(!8+/$!
6$0(F+!LZ<!/*0+/&4!8/M+!#2<(#9*'2=!()!(:'&/$'M+!98(698(04*/$'(2!?LZ<!E'$(!/0+!/*0+/&4!
E+66+&!#9B@!
!
I8+6+!/0+!/**!$8+!</#6+6!()!$'66#+!849(:'/!?'6<8+E'/;!NL!0+*/$+&;!<4$(!(:'&/6+!L*(<F;!
#2<(#9*'2=!/=+2$6B@!!%L6(*#$+!F+4!$8'2=6m!
!
5. What happens when there is:
/@!0+69!/<'&(6'6!7!NL!6$/46!6/E+;!GH!6/$Q2!&+<0+/6+&;!9/0$'/*!90+66#0+!()!GH!&+<0+/6+&!?GH!
6/$!&+<0+/6+&!LZ<!9GH!'6!&+<0+/6+&B!
L@!/2+E'/!7!(2*4!NL!'6!/))+<$+&!?2(0E/*!GH!6/$Q2!/2&!9GHB!
<@!.GZE+$8+E(=*(L'2!7!NL!2(0E/*;!GH!6/$Q2!&+<0+/6+&;!9GH!2(0E/*!
R:!.G!7!,VVW!GHU!E+$8+E(!7!1k!E+$8/*'2+!L*#+!?_G.B!(0!M'$!.!?/6<(0L'<!/<'&B!
!
C. Decreased of ATP (as a result of tissue hypoxia)!
!
1. Most imp: have to go into anaerobic glycolysisU!+2&!90(&#<$!'6!*/<$'<!/<'&!?940#M/$+!
'6!<(2M+0$+&!$(!*/<$/$+!LZ<!()!'2<0+/6+&!"%_NBU!2++&!$(!E/F+!"%_;!6(!$8/$!$8+!"%_!</2!
)++&L/<F!'2$(!$8+!=*4<(*4$'<!<4<*+!$(!E/F+!H!E(0+!%IJ@!!g84!&(!>+!8/M+!$(!#6+!/2/+0(L'<!
=*4<(*46'6!>'$8!$'66#+!849(:'/n!K'$(<8(2&0'/!/0+!$8+!(2+!$8/$!E/F+6!%IJU!8(>+M+0;!>'$8!
/2/+0(L'<!=*4<(*46'6;!4(#!E/F+!H!%IJ!>'$8(#$!=('2=!'2$(!$8+!E'$(<8(2&0'/@!![M+04!<+**!
?'2<*#&'2=!RS.Q6B!'2!$8+!L(&4!'6!</9/L*+!()!9+0)(0E'2=!/2/+0(L'<!=*4<(*46'6;!$8+0+)(0+!
6#0M'M'2=!(2!H!%IJ!9+0!=*#<(6+!')!4(#!8/M+!$'66#+!849(:'/@!!K'$(<8(2&0'/*!646$+E!'6!$($/**4!
68#$!&(>2!?2(!GH!/$!$8+!+2&!()!$8+!+*+<$0(2!$0/269(0$!646$+E!7!</2!(2*4!=+$!H!%IJ!>'$8!
/2/+0(L'<!=*4<(*46'6B@!!!
!
l((&!2+>6!7!=+$!H!%IJ!

S/&!2+>6!7!L#'*&!#9!()!*/<$'<!/<'&!'2!$8+!<+**!/2&!(#$6'&+!$8+!<+**!?'2<0+/6+&!/2'(2d=/9!
E+$/L(*'<!/<'&(6'6!>'$8!$'66#+!849(:'/B!&#+!$(!*/<$'<!/<'&(6'6!)0(E!/2/+0(L'<!=*4<(*46'6@!!!
!
N(>+M+0;!</#6+6!8/M(<!'26'&+!$8+!<+**!LZ<!'2<0+/6+!()!/<'&!>'$8'2!/!<+**!>'**!&+2/$#0+!90($+'26!
?>'$8!6$0#<$#0/*!90($+'26!E+66+&!#9;!$8+!<(2)'=#0/$'(2!>'**!L+!/*$+0+&BU!+2c4E+6!>'**!L+!
&+2/$#0+&;!$((@!!%6!/!0+6#*$;!<+**6!</22($!/#$(&'=+6$!/24E(0+!LZ<!+2c4E+6!/0+!&+6$0(4+&!LZ<!
L#'*&#9!()!/<'&@!!I'66#+!849(:'/!>'**!$8+0+)(0+!*+/&!$(!.G%l\X%I1G"!2+<0(6'6!?/F/!
'2)/0<$'(2B@!!I8+0+)(0+;!L#'*&#9!()!*/<$'<!/<'&!>'$8'2!$8+!<+**!>'**!*+/&!$(!.(/=#*/$'(2!2+<0(6'6@!
!
2. 2nd problem of lacking ATP: all ATP pumps are screwed up!LZ<!$8+4!0#2!(2!%IJ@!!
%IJ!'6!$8+!9(>+0;!#6+&!L4!E#6<*+6;!$8+!9#E9;!/24$8'2=!$8/$!2++&6!+2+0=4!2++&6!%IJ@!!
Na/K pump!7!L*(<F+&!L4!&'='$/*'6!$(!/**(>!"/!$(!=(!'2$(!</0&'/<!E#6<*+;!6(!./!<8/22+*6!
(9+2!$(!'2<0+/6+!)(0<+!()!<(2$0/<$'(2!?$8+0+)(0+;!6(E+$'E+6!4(#!>/2$!$8+!9#E9!L*(<F+&B;!
/2&!6(E+$'E+6!4(#!>/2$!$(!+28/2<+!'$@!
!
g'$8!2(!%IJ;!"/!'2$(!$8+!<+**!/2&!'$!L0'2=6!NHV;!>8'<8!*+/&6!$(!<+**#*/0!6>+**'2=!?>8'<8!'6!
0+M+06'L*+B@!!I8+0+)(0+;!>'$8!$'66#+!849(:'/!$8+0+!>'**!L+!6>+**'2=!()!$8+!<+**!&#+!$(!&+<0+/6+&!
%IJ!?$8+0+)(0+!>'**!=+$!GH!L/<F;!/2&!>'**!9#E9!'$!(#$!7!$8+0+)(0+!'$!'6!R[k[RY%SX[B@!
!
12!$0#+!RS.;!/2/+0(L'<!=*4<(*46'6!'6!$8+!E/'2!+2+0=4!6(#0<+!LZ<!$8+4!&(!2($!8/M+!
E'$(<8(2&0'/U!2($!2(0E/*!'2!($8+0!$'66#+6!?>/2$!$(!#$'*'c+!T%Q6;!I.%;!+$<B@!
!
3. Cell without O2 leads to irreversible changes@!
!
Ca changes with irreversible damage!7!./Z%IJ/6+!9#E9@!!g'$8!&+<0+/6+!'2!%IJ;!./!
8/6!+/64!/<<+66!'2$(!$8+!<+**@!!g'$8'2!$8+!<+**;!'$!/<$'M/$+6!E/24!+2c4E+6!?'+!98(698(*'9/6+6!
'2!$8+!<+**!E+EL0/2+6;!+2c4E+6!'2!$8+!2#<*+#6;!*+/&'2=!$(!2#<*+/0!94F2(6'6!?6(!$8+!
<80(E/$'2!&'6/99+/06B;!'2$(!=(+6!'2$(!$8+!E'$(!/2&!&+6$0(46!'$B@!
!
./!/<$'M/$+6!+2c4E+6U!849+0</*<+E'/!*+/&6!$(!/<#$+!9/2<0+/$'$'6!LZ<!+2c4E+6!'2!$8+!
9/2<0+/6!8/M+!L++2!/<$'M/$+&@!I8+0+)(0+;!>'$8!'00+M+06'L*+!<8/2=+6;!./!8/6!/!E/3(0!0(*+@!G)!
$8+!$>(!$8/$!=+$!&/E/=+&!?E'$(!/2&!<+**!E+EL0/2+B;!<+**!E+EL0/2+!'6!&/E/=+&!/!*($!
>(06+;!0+6#*$'2=!'2!L/&!$8'2=6!)0(E!$8+!(#$6'&+!$(!=+$!'2$(!$8+!<+**@!!N(>+M+0;!$(!/&&!'26#*$!$(!
'23#04;!F2(<F!())!E'$(<8(2&0'/!?+2+0=4!90(&#<'2=!)/<$(04B;!'$!'6!/!M+04!L/&!6'$#/$'(2!?<+**!
&'+6BA.5dKS!)(0!K1;!$0/26/E'2/6+6!)(0!8+9/$'$'6!?YlGI!/2&!%YIZ%XIB;!/E4*/6+!'2!
9/2<0+/$'$'6@!
!
II. Free Radicals
X'M+0!>'$8!L0(>2'68!9'=E+2$!7!*'9()#6<'2!?6++2!(2!=0(66!9'<U!</2!/*6(!L+!8+E(6'&+0'2;!L'*'0#L'2;!
+$<U!$8+0+)(0+!2++&!$(!8/M+!/!</6+!>'$8!$8+!=0(66!9'<BU!+2&!90(&#<$6!()!)0++!0/&'</*!&/E/=+!/0+!
*'9()#6<'2!LZ<!<+0$/'2!$8'2=6!/0+!2($!&'=+6$'L*+!?'2<*#&+!*'9'&6B@!
!
A. Definition of free radical!7!<(E9(#2&!>'$8!#29/'0+&!+*+<$0(2!$8/$!'6!(#$!()!(0L'$;!$8+0+)(0+!
'$Q6!M+04!#26$/L*+!/2&!'$!>'**!&/E/=+!$8'2=6@!
!
B. Types of Free Radicals:
,@!!G:4=+2-!!g+!/0+!L0+/$8'2=!GH;!/2&!GH!</2!='M+!)0++!0/&'</*6@!!1)!='M+!/!9+06(2!eVW!GH!)(0!
/!9+0'(&!()!$'E+;!>'**!=+$!6#9+0(:'&+!)0++!0/&'</*6;!>8'<8!*+/&!$(!0+9+0)#6'(2!'23#04;!+69!/)$+0!
='M'2=!$J%!>8+2!$04'2=!$(!0'&!/!&/E/=+&!$80(EL#6@!!G:4=+2$/$+&!L*((&!=(+6!L/<F!'2$(!$8+!

&/E/=+&!</0&'/<!E#6<*+C0+9+0)#6'(2!'23#04@!!5'&6!>'$8!0+69!&'6$0+66!642&0(E+!</2!=+$!)0++!
0/&'</*!'23#04!/2&!=(!L*'2&!LZ<!$8+4!&+6$0(4!$8+!0+$'2/!7!</**+&!0+$'2(9/$84!90+E/$#0'$4U!/*6(!
*+/&6!$(!L0(2<8(9#*E(2/04!&469*/6'/;!>8'<8!*+/&6!$(!&/E/=+!'2!$8+!*#2=6!/2&!/!<0'99*'2=!
*#2=!&'6+/6+@!!!
!
H@!!g/$+0!'2!$'66#+6!<(2M+0$+&!$(!84&0(:4*!)0++!0/&'</*6;!*+/&'2=!$(!E#$/$'(26!'2!$'66#+6@!!
.(E9*'</$'(2!()!0/&'/$'(2!$8+0/94!'6!.%".[R!?K.!</2<+0!)0(E!0/&'/$'(2!'6!*+#F+E'/;!&#+!$(!
84&0(:4*!)0++!0/&'</*6B@!!T+HO!90(&#<+6!84&0(:4*!)0++!0/&'</*6!LZ<!()!$8+!)+2$(2!0:2@!I8'6!'6!
>8/$!E/F+6!T+!(M+0*(/&!&'6+/6+6!6(!&/2=+0(#6;!LZ<!>8+0+M+0!T+!'6!(M+0*(/&+&;!*+/&6!$(!
84&0(:4*!)0++!0/&'</*6!>8'<8!>'**!&/E/=+!$8/$!$'66#+!?$8+0+)(0+;!'2!*'M+0!*+/&6!$(!<'008(6'6;!'2!
8+/0$!*+/&6!$(!0+6$0'<$'M+!</0&'(E4(9/$84;!'2!9/2<0+/6!*+/&6!$(!)/'*#0+;!/2&!E/*/L6(09$'(2;!
/*(2=!>'$8!&'/L+$+6B@!!!
%#&'(!)'*+!H-!.+**!123#04!H!
P@!!I4*+2(*!?/F/!/<+$/E'2(98+2B-!
K..!&0#=!'2&#<+&!)#*E'2/2$!8+9/$'$'6!LZ<!)0++!0/&'</*6!?+69!$/0=+$6!$8+!*'M+0;!L#$!/*6(!$/0=+$6!
$8+!F'&2+46B@!!.4$(<80(E+!JêV!'2!*'M+0!E+$/L(*'c+6!&0#=6;!/2&!</2!<8/2=+!&0#=6!'2$(!)0++!
0/&'</*6@!!_0#=6!/0+!()$+2!<8/2=+&!'2!$8+!*'M+0!$(!$8+!/<$'M+!E+$/L(*'$+!7!'+!98+24$('2@!!
g8+0+!'2!$8+!*'M+0!&(+6!/<+$/E'2(98+2!$(:'<'$4!E/2')+6$!'$6+*)n!7!0'=8$!/0(#2&!<+2$0/*!M+'2@!!
I0+/$E+2$-!2d/<+$4*<46$+'2+U!8(>n!g+**;!$8+!)0++!0/&'</*6!</2!L+!2+#$0/*'c+&@!Y#9+0(:'&+!
)0++!0/&'</*6!</2!L+!2+#$0/*'c+&!>'$8!6#90/(:'&+!&'6E#$/6+!?YG_B@!!l*#$/$8'(2+!'6!$8+!+2&!
90(&#<$!()!$8+!8+:(6+Z9+2$(6+!98(698/$+!68#2$!/2&!$8'6!68#2$!/*6(!=+2+0/$+6!"%_JN@!!K/'2!
)#2<$'(2!'6!$(!2+#$0/*'c+!)0++!0/&'</*6!?+69!&0#=!)0++!0/&'</*6;!/2&!)0++!0/&'</*6!&+0'M+&!)0(E!
9+0(:'&+B@!!l*#$/$8'(2+!=+$6!#6+&!#9!'2!2+#$0/*'c'2=!$8+!/<+$/E'2(98+2!)0++!0/&'</*6@!!
I8+0+)(0+;!>8+2!='M+!2d/<+$4*<46$+'2+!?/F/!E#</E'6$BU!4(#!/0+!0+9*+2'68'2=!=*#$/$8'(2+;!
$8+0+)(0+!='M'2=!6#L6$0/$+!$(!E/F+!E(0+!=*#$/$8'(2+;!6(!4(#!</2!F++9!#9!>'$8!2+#$0/*'c'2=!
/<+$/E'2(98+2!)0++!0/&'</*6@!!?*'F+!E+$8($0+:/$+;!/2&!*+#F(M+0'2!0+6<#+!7!#6'2=!#9!$((!E#<8!
)(*/$+;!*+#F(M+0'2!6#99*'+6!$8+!6#L6$0/$+!$(!E/F+!_"%;!)(*/$+!0+&#<$/6+B@!
!
^@!!./0L(2!$+$0/<8*(0'&+-!..*^!</2!L+!<(2M+0$+&!$(!/!)0++!0/&'</*!'2!$8+!*'M+0!?..*PB!'2!$8+!
*'M+0;!/2&!/!)0++!0/&'</*!</2!L+!)(0E+&!(#$!()!$8/$!?6++2!'2!&04!<*+/2'2=!'2&#6$04B@!
!
e@!!%69'0'2!O!I4*+2(*!C!M+04!L/&!)(0!F'&2+4!?$/F+6!/!*(2=!$'E+!)(0!&/E/=+!$(!L+!6++2B@!!T0++!
0/&'</*6!)0(E!/<+$/E'2(98+2!/0+!&+6$0(4'2=!$8+!0+2/*!E+&#**/!o(2*4!0+<+'M+6!,VW!()!$8+!
L*((&!6#99*4d0+*/$'M+*4!849(:'<B!/2&!0+2/*!$#L#*+6@!!%69'0'2!'6!F2(<F'2=!())!$8+!M/6(&'*/$(0!
Jl[H;!>8'<8!'6!E/&+!'2!$8+!/))+0+2$!/0$+0'(*+@!!I8+0+)(0+!%l!11!?/!M/6(<(26$0'<$(0B!'6!*+)$!'2!
<8/0=+!()!0+2/*!L*((&!)*(>!/$!$8+!+))+0+2$!/0$+0'(*+@!!['$8+0!6*(#=8'2=!()!E+&#**/!(0!&+6$0(4+&!
/L'*'$4!$(!<(2<+2$0/$+Z&'*#$+!4(#0!#0'2+;!>8'<8!'6!</**+&!/2/*=+6'<!2+980(9/$84!?&#+!E/'2*4!$(!
/<+$/E'2(98+2B@!
III. Apoptosis
!
J0(=0/EE+&!<+**!&+/$8@!!%9(9$($'<!=+2+6!7!i90(=0/EE+&!$(!&'+j!?$8+(04B@!!"(0E/*!)#2<$'(26-!
?,B!+EL04(!7!6E/**!L(>+*!=($!*#E+26!)0(E!/9(9$(6'6@!?HB!5'2=!()!$8+!L(&4!7!b!<Q6(E+!?)(0!
E+2BU!!K1T!M+04!'E9!LZ<!/**!E#**/0'/2!6$0#<$#0+6!?#$+0#6;!<+0M':;!#99+0!,ZP!()!M/='2/B!/0+!=(2+;!
$8+0+)(0+;!2(!E#**/0'/2!6$0#<$#0+6@!!K1T!'6!/!6'=2/*!>(0F'2=!>'$8!/9(9$(6'6;!M'/!</69/6/6+6@!!I8+4!
&+6$0(4!+M+04$8'2=;!$8+2!>0/9!+M+04$8'2=!'2!/9(9$($'<!L(&'+6!$(!L+!&+6$0(4+&;!/2&!*'9()#6<'2!'6!
*+)$!(M+0@!!?PBT(0!>(E/2!7!h!<Q6(E+U!(2*4!8/M+!(2+!)#2<$'(2'2=!(2+!LZ<!$8+!($8+0!'6!/!L/00!L(&4@!!
%L6+2<+!()!4!<Q6(E+!</#6+&!=+0E'2/*!0'&=+!$(!=(!$8+!(M/0'/2!0(#$+;!$8+0+)(0+!/9(9$(6'6!F2(<F+&!
())!$8+!>(*)'/2!6$0#<$#0+6!?+9'&4&4E'6;!6+E'2/*!M+6'<*+6;!/2&!M/6!&+)+0+26B@!!?^B!I84E#6!'2!

/2$+0'(0!E+&'/6$'2#E!7!*/0=+!'2!F'&6U!')!/L6+2$;!'$!'6!_'l+(0=+!642&0(E+!?/L6+2$!$84E'<!68/&(>B;!
/2&!>(#*&!/*6(!8/M+!$+$/24U!</#6+!()!$84E#6!$(!'2M(*#$+!'6!/9(9$(6'6@!?eB!%9(9$(6'6!'6!$8+!E/3(0!
</2<+0!F'**'2=!E+<8/2'6E@!!?aB!J0(<+66!()!/$0(984!/2&!0+&#<+&!<+**!(0!$'66#+!E/66!'6!&#+!$(!
/9(9$(6'6@!![:@!N+9/$'$'6!7!<(#2<'*E/2!L(&4!?*((F6!*'F+!+(6'2(98'*'<!<+**!>'$8(#$!/9(9$(6'6B!()!
/9(9$(6'6!?'2&'M'&#/*!<+**!&+/$8!>'$8!'2)*/EE/$'(2!/0(#2&!'$B@!!f#6$!2++&6!/!6'=2/*!?8(0E(2+!(0!
<8+E'</*B!>8'<8!/<$'M/$+!$8+!</69/6+6;!/2&!2(!'2)*/EE/$'(2!'6!/0(#2&!'$@!%9(9$(6'6!()!2+#0(26!7!
*(66!L0/'2!E/66!/2&!L0/'2!/$0(984;!/2&!*+/&6!$(!'6<8+E'/@!R+&!<4$(9*/6E;!/2&!942($'<!2#<*+/6@!!
%$8+0(6<*+0($'<!9*/D#+@!!I8+0+)(0+;!/9(9$(6'6!'6!'2M(*M+&!'2!+EL04(;!9/$8(*(=4;!/2&!F2(<F'2=!())!
</2<+0!<+**6@!
IV. Types of necrosis!7!E/2')+6$/$'(26!()!$'66#+!&/E/=+@!!
!
A. Coagulation Necrosis-!R+6#*$6!()$+2!)0(E!/!6#&&+2!<#$())!()!L*((&!6#99*4!$(!/2!(0=/2!'@+@!
16<8+E'/!?&+)'2'$'(2!()!'6<8+E'/!C!&+<0+/6+!'2!/0$+0'/*!L*((&!)*(>B@!!12!'6<8+E'/;!$8+0+!'6!2(!
(:4=+2!$8+0+)(0+!*/<$'<!/<'&!L#'*&6!#9;!/2&!*+/&6!$(!<(/=#*/$'(2!2+<0(6'6@!!l0(66!E/2')+6$/$'(2!()!
<(/=#*/$'(2!2+<0(6'6!'6!'2)/0<$'(2@!!\2&+0!E'<0(6<(9+;!*((F6!*'F+!</0&'/<!E#6<*+!L#$!$8+0+!/0+!2(!
6$0'/$'(26;!2(!2#<*+';!L0'=8$!0+&;!2(!'2)*/EE/$(04!'2)'*$0/$+;!/**!&#+!$(!*/<$'<!/<'&!$8/$!8/6!
&+2/$#0+&!/2&!&+6$0(4+&!/**!$8+!+2c4E+6!?</22($!L+!L0(F+2!&(>2!7!2+#$0(98'*6!2++&!$(!<(E+!
'2!)0(E!$8+!(#$6'&+!$(!L0+/F&(>2B@!!I8+0+)(0+;!M/=#+!(#$*'2+6!C!<(/=#*/$'(2!2+<0(6'6!?6++!<(*(0!
<8/2=+!'2!8+/0$B@!!!
!
,@!!J/*+!M6!8+E(008/='<!'2)/0<$'(26-!*((F!/$!<(26'6$+2<4!()!$'66#+@!!!
!
?/B!l((&!<(26'6$+2<4!C!=0(66*4!*((F!9/*+-!'2)/0<$-!8+/0$;!F'&2+4;!69*++2;!*'M+0!?0/0+6$!()!$8+!
(0=/2!$(!'2)/0<$!LZ<!&#/*!L*((&!6#99*4BU!'+!<(/=#*/$'(2!2+<0(6'6@!![:/E9*+!()!/!9/*+!'2)/0<$'(2!
()!$8+!69*++2;!E(6$!*'F+*4!&#+!$(!+EL(*'!)0(E!*+)$!6'&+!()!8+/0$U!</#6+6!()!+EL(*'-!M+=+$/$'(26!
?0/0+*4!+EL(*'c+!'2!/<#$+!08+#E/$'<!+2&(</0&'$'6BU!'2)+<$'M+!+2&(</0&'$'6U!E'$0/*!6$+2(6'6!
?8+/0$!'6!0+9+/$+&*4!/$$/<F+&!L4!=0(#9!%!L+$/!8+E(*4$'<!6$0+9$(<(<<#6BU!/2&!<*($6Z$80(EL'@!!
I8+!>(06$!/0084$8E'/!/66(<'/$+&!>'$8!+EL(*'c/$'(2!'2!$8+!646$+E'<!<'0<#*/$'(2!'6!/$0'/*!)'L!LZ<!
$8+0+!'6!6$/6'6!'2!$8+!/$0'/;!<*($!)(0E/$'(2;!$8+2!'$!M'L0/$+6!?*'*!9'+<+6!()!<*($!+EL(*'c+B@!!!
!
Gangrenous Necrosis: dry and wet gangrene: J'<$#0+!()!/!&04!=/2=0+2+!7!2($!>+$!
=/2=0+2+!LZ<!$8+0+Q6!2(!9#6@!!G<<#06!'2!&'/L+$'<Q6!>'$8!/$8+0(6<*+0(6'6!()!9(9*'$+/*!/0$+04!/2&!
9(66'L*+!$80(EL(6'6U!?&04!=/2=0+2+!0+*/$+&!$(!<(/=#*/$'(2!2+<0(6'6!0+*/$+&!>'$8!'6<8+E'/!
?&+)'2'$'(2!()!'6<8+E'/!C!&+<0+/6+!'2!/0$+0'/*!L*((&!)*(>B;!>8'<8!'6!&#+!$(!/$8+0(6<*+0(6'6!()!
$8+!9(9*'$+/*!/0$+04@!!J/$8(=+2+6'6!()!K1-!<(0(2/04!$80(EL(6'6!(M+0*4'2=!$8+!/$8+0(E/$(#6!
9*/D#+;!*+/&'2=!$(!'6<8+E'/;!/2&!*#E+2!'6!L*(<F+&!&#+!$(!$80(EL(6'6@!!K..!2(2$0/#E/$'<!
/E9#$/$'(2!C!&'/L+$+6!LZ<!+28/2<+&!/$8+0(6<*+0(6'6!?9(9*'$+/*!/0$+04!C!&/2=+0(#6!/0$+04B@!!
.(0(2/04!'6!/*6(!&/2=+0(#6!LZ<!6E/**!*#E+2@!!12!>+$!=/2=0+2+;!'$Q6!<(E9*'</$+&!L4!'2)+<$'M+!
8+$+0(*46'6!/2&!<(26+D#+2$!*'D#+)/<$'M+!2+<0(6'6@!
?LB!X((6+!<(26'6$+2<4!()!$'66#+C!8+E(008/='<!'2)/0<$-!L(>+*;!$+6$+6!?$(06'(2!()!$8+!$+6$+6B;!
+69+<'/**4!$8+!*#2=6!LZ<!'6!8/6!/!*((6+!<(26'6$+2<4!/2&!>8+2!$8+!L*((&!M+66+*6!0#9$#0+;!$8+!
RS.Q6!>'**!$0'<F*+!(#$;!*+/&'2=!$(!/!8+E(008/='<!/99+/0/2<+@!!
!
[:/E9*+-!!8+E(008/='<!'2)/0<$'(2!()!6E/**!L(>+*!&#+!$(!'2&'0+<$!8+02'/@!!H2&!K..!()!L(>+*!
'2)/0<$'(2!'6!=+$$'2=!/!9'+<+!()!6E/**!L(>+*!$0/99+&!'2!'2&'0+<$!8+02'/*!6/<@!!K..!()!L(>+*!
'2)/0<$'(2!'6!/&8+6'(26!)0(E!90+M'(#6!6#0=+04@!
!

[:/E9*+-!!12!$8+!X#2=!7!8+E(008/='<!'2)/0<$'(2;!>+&=+!68/9+&;!>+2$!$(!9*+#0/*!6#0)/<+;!
$8+0+)(0+!8/M+!+))#6'(2!/2&!+:#&/$+6U!2+#$0(98'*6!'2!'$U!8/M+!9*+#0'$'<!<8+6$!9/'2!?F2')+d*'F+!
9/'2!(2!'269'0/$'(2B@!!J#*E(2/04!+EL(*#6!*+/&6!$(!8+E(008/='<!'2)/0<$'(2@!!!
!
B. Liquefactive Necrosis-!
[:<+9$'(2!$(!0#*+!()!.(/=#*/$'(2!2+<0(6'6!6++2!>'$8!'2)/0<$'(26-!L0/'2@!
K.!6'$+!()!'2)/0<$'(2!)0(E!</0($'&!/0$+04!7!>84!>+!*'6$+2!)(0!/!L0#'$!?8+/0'2=!)(0!/!2('6+!$8/$!
'6!=('2=!$80#!/!M+66+*!$8/$!8/6!/!2/00(>!*#E+2!7!9*/<+!>'$8!$80(EL#6!&+M+*(96!(M+0!
/$8+0(6<*+0($'<!9*/D#+!/2&!*+/&6!$(!6$0(F+BU!*+/&6!$(!$0/26'+2$!'6<8+E'<!/$$/<F6!'6!*'$$*+!
/$8+0(6<*+0($'<!9*/D#+6!=('2=!$(!*'$$*+!M+66+*6!()!$8+!L0/'2;!90(&#<'2=!E($(0!/2&!6+26(04!
/L2(0E/*'$'+6;!$8/$!=(!/>/4!'2!H^!806@!!S0/'2!>'$8!]E+68>(0FQ!7!'2!L0/'2;!/6$0(<4$+6!'6!
/2/*(=(#6!$(!$8+!)'L0(L*/6$6!LZ<!()!90($(9*/6E'<!90(<+66+6@!!I8+0+)(0+;!/<$'2=!*'F+!)'L0(L*/6$!
?</2Q$!E/F+!<(**/=+2B;!L#$!'$6!90($(9*/6E'<!90(<+66+6!='M+6!6(E+!6$0#<$#0+!$(!$8+!L0/'2@!!
I8+0+)(0+;!'2)/0<$'(2!()!$8+!L0/'2!L/6'</**4!*'D#+)'+6!'$!?8/6!2(!6$0#<$B;!/2&!4(#!6++!/!<46$!
69/<+!7!liquefactive necrosis@!!I8+0+)(0+;!+:<+9$'(2!$(!$8+!0#*+!()!'2)/0<$'(26!2($!L+'2=!
<(/=#*/$'M+!2+<0(6'6!'6!$8+!L0/'2!/2&!'$!#2&+0=(+6!*'D#+)/<$'M+!2+<0(6'6!?2(!6$0#<;!$8+0+)(0+!
*+/M+6!/!8(*+B@!!.+0+L0/*!/L6<+66!/2&!(*&!/$8+0(6<*+0($'<!6$0(F+!dL($8!/0+!*'D#+)/<$'M+!
2+<0(6'6@!
!
X'D#+)/<$'M+!7!*'D#+)'+6U!$8'2F!2+#$0(98'*;!LZ<!$8+'0!3(L!'6!$(!98/=(<4$(6'6!>'$8!$8+'0!+2c4E+6!
?$(!]*'D#+)4QBU!*'D#+)/<$'M+!2+<0(6'6!0+*/$+6!$(!/2!'2)+<$'(2!>'$8!2+#$0(98'*6!'2M(*M+&!?#6#/**4!
/<#$+!'2)+<$'(2!7!90(&#<'2=!/2!/L6<+66!(0!/2!'2)*/EE/$(04!<(2&'$'(2;!>8'<8!*'D#+)'+6!$'66#+B@!!
I8+0+)(0+;!*'D#+)/<$'M+!2+<0(6'6!#6#/**4!/99*'+6!$(!/<#$+!'2)*/EE/$'(2;!0+*/$+&!$(!2+#$0(98'*6!
&/E/='2=!$8+!$'66#+@!![:<+9$'(2!$(!$8+!0#*+-!*'D#+)/<$'M+!2+<0(6'6!0+*/$+&!$(!'2)/0<$!?2($!/2!
'2)*/EE/$(04!<(2&'$'(2;!'$!3#6$!*'D#+)'+6B!?6*'&+!68(>6!*'D#+)/<$'M+!2+<0(6'6!&#+!$(!'2)+<$'(2!'2!
$8+!L0/'2B@!!Y(;!')!4(#!'2)/0<$!$8+!L0/'2;!(0!8/M+!/2!'2)+<$'(2;!(0!8/M+!/2!/L6<+66!'$!'6!$8+!
6/E+!90(<+66!7!*'D#+)/<$'M+!2+<0(6'6@!
!
[:/E9*+-!!%L6<+66!7!=0/E!iOj!<(<<'!'2!<*#6$+06@!!g84!/0+!$8+4!'2!<*#6$+06n!.(/=#*/6+;!>8'<8!
*+/&6!$(!/L6<+66+6!>'$8!6$/98!/#0@!!.(/=#*/6+!<(2M+0$6!)'L0'2(=+2!'2$(!)'L0'2;!6(!'$!*(</*'c+6!
$8+!'2)+<$'(2;!)'L0'2!6$0/2&6!=+$!(#$;!0+6#*$'2=!'2!/2!/L6<+66@!!Y$0+9-!0+*+/6+6!84/*#0(2'&/6+;!
>8'<8!L0+/F6!&(>2!l%lQ6!'2!$'66#+;!/2&!'2)+<$'(2!690+/&6!$80(#=8!$8+!$'66#+!?<+**#*'$'6B@!!
T0(E!9('2$!()!M'+>!()!2+<0(6'6;!2+#$0(98'*6!/0+!'2M(*M+&;!$8+0+)(0+!'$!'6!*'D#+)/<$'M+!2+<0(6'6@!
[:/E9*+-!!%SY.[YY-!X#2=!7!4+**(>'68!/0+/6;!8'=8!)+M+0!/2&!90(&#<$'M+!<(#=8U!=0/E!6$/'2!
68(>+&!=0/E!iOj!&'9*(<(<<#6;!>8'<8!'6!6$0+9!92+#E(2'/+@!?K..!()!L0(2<8(92+#E(2'/@B@!!
"($!8+E(008/='<!LZ<!'$6!9/*+;!/2&!>+&=+&!68/9+&!2+<0(6'6!/$!$8+!9+0'98+04;!>8'<8!*+/&6!$(!
9*+#0'$'<!<8+6$!9/'2@!
!
[:/E9*+-!9$!>'$8!)+M+0;!2'=8$!6>+/$6;!>$!*(66!7!K!$L;!>8'<8!8/6!=0/2#*(E/$(#6!?</6+(#6B!
2+<0(6'6@!!J/$8(=+2+6'6!()!=0/2#*(E/!?'2M(*M+6!1Xd,H!/2&!6#L6+$!()!8+*9+0!I!<+**6!/2&!iOj!
JJ_B@!!!
!
C. Caseous (cheesy consistency) Necrosis-!7!+'$8+0!8/M+!E4<(L/<$+0'/*!'2)+<$'(2!?/24!
'2)+<$'(26;!'2<*#&'2=!/$49'</*6;!(0!646$+E'<!)#2=/*!'2)+<$'(2BU!$8+6+!/0+!$8+!G"Xb!$8'2=6!$8/$!>'**!
90(&#<+!</6+/$'(2!'2!/!=0/2#*(E/@!!1$!'6!$8+!*'9'&!'2!$8+!<+**!>/**!()!$8+!(0=/2'6EQ6!*+/&6!$(!
<8++64!/99+/0/2<+@!
!
Y/0<('&(6'6!7!=+$!=0/2#*(E/6;!L#$!$8+4!/0+!2($!</6+(#6!LZ<!$8+4!/0+!2($!E4L/<$+0'#E!(0!
646$+E'<!)#2='!?8+2<+!]2(2</6+/$'2=Q!=0/2#*(E/6B!

.0(82Q6!&c!7!=+$!=0/2#*(E/6;!L#$!2($!</6+(#6!LZ<!2($!0+*/$+&!$(!E4<(L/<$+0'#E!(0!646$+E'<!
)#2='@!
!
D. Fat Necrosis-!
!
,@!![2c4E/$'<!T/$!"+<0(6'6-!#2'D#+!$(!9/2<0+/6!
[:/E9*+-!9$!>'$8!+9'=/6$0'<!&'6$0+66!>'$8!9/'2!0/&'/$'2=!$(!$8+!L/<F!7!9/2<0+/$'$'6!?</22($!L+!
J+9$'<!\*<+0!_c!LZ<!9/2<0+/6!'6!0+$0(9+0'$(2+/*B;!$8+0+)(0+!3#6$!8/M+!+9'=/6$0'<!9/'2!0/&'/$'2=!
$(!$8+!L/<F@!%!$49+!()!+2c4E/$'<!T%I!2+<0(6'6!?$8+0+)(0+!2+<0(6'6!0+*/$+&!$(!+2c4E+6B@!!
[2c4E/$'<!)/$!2+<0(6'6!'6!#2'D#+!$(!$8+!9/2<0+/6!LZ<!+2c4E+6!/0+!L0+/F'2=!&(>2!)/$6!'2$(!
T%Q6;!>8'<8!<(EL'2+!>'$8!./!6/*$6;!)(0E'2=!<8/*F4!>8'$+!/0+/6!()!+2c4E/$'<!)/$!2+<0(6'6!
?<8/*F4!>8'$+!/0+/6!&#+!$(!</*<'#E!L(#2&!$(!T%Q6!7!6/9(2')'</$'(2!?6(/9Z*'F+!6/*$!)(0E/$'(2BBU!
$8+6+!</2!L+!6++2!(2!:0/46!LZ<!8/M+!</*<'#E!'2!$8+E@!![:/E9*+-!%!9$!>'$8!9/'2!<(26$+2$*4!
9+2+$0/$'2=!'2$(!$8+!L/<F;!68(>!:d0/4!()!R\p@!!_:!'6!9/2<0+/$'$'6!/2&!+69!6++2!'2!/*<(8(*'<6@!!
N'6$(!6*'&+!(2!+2c4E/$'<!)/$!2+<0(6'6!7!L*#'68!&'6<(*(0/$'(2;!>8'<8!'6!</*<')'</$'(2!?/!$49+!()!
&46$0(98'<!</*<')'</$'(2d</*<')'</$'(2!()!&/E/=+&!$'66#+B@!!g8/$!+2c4E+!>(#*&!L+!+*+M/$+&n!
%E4*/6+!/2&!*'9/6+!?*'9/6+!'6!E(0+!69+<')'<!LZ<!/E4*/6+!'6!/*6(!'2!$8+!9/0($'&!=*/2&;!6E/**!
L(>+*;!/2&!)/**(9'/2!$#L+6B@!!g8/$!$49+!()!2+<0(6'6n!%2($8+0!+:/E9*+-![2c4E/$'<!)/$!
2+<0(6'6@!!\2&+0*4'2=!</#6+n!%*<(8(*!90(&#<+6!/!$8'<F!6+<0+$'(2!$8/$!>'**!*+/&!$(!/<$'M/$'(2!()!
+2c4E+6U!>8'<8!*+/&6!$(!9/2<0+/$'$'6@!!I8+0+)(0+;!>8+2+M+0!4(#!6++!L*#+!&'6<(*(0/$'(2!/2&!
/$8+0(6<*+0($'<!9*/D#+!'2!/!9/2<0+/6;!'$!>'**!L+!</*<'#E@!
!
H@!!I0/#E/$'<!T/$!"+<0(6'6-!![:/E9*+-!>(E/2!>'$8!&/E/=+!$(!L0+/6$6!'6!IR%\K%I1.!T%I!
2+<0(6'6!?2($!+2c4E/$'<BU!'$!</2!</*<')4;!</2!*((F!*'F+!</2<+0!(2!E/EE(=0/E@!!_'))!L$>2!$8/$!
/2&!</*<')'</$'(2!'2!L0+/6$!</2<+0!'6!$8/$!'$!'6!9/'2T\X@!?</2<+0!C!9/'2*+66B@!!I0/#E/$'<!)/$!
$'66#+!#6#/**4!(<<#06!'2!L0+/6$!$'66#+!(0!($8+0!/&'9(6+!$'66#+!
!
E. Fibrinoid necrosis:!?$8+!d('&!E+/26-!*((F6!*'F+;!L#$!'62Q$B!
I8+0+)(0+;!*((F6!*'F+!)'L0'2;!L#$!'6!2($!)'L0'2A@'$!'6!$8+!2+<0(6'6!()!'EE#2(*(='<!&c-!
[:/E9*+6!()!'EE#2(*(='<!&c-!
J/*9/L*+!9#09#0/!C!6E/**!M+66+*!M/6<#*'$'6!?'EE#2+!<(E9*+:!$49+!111B@!
T'L0'2('&!2+<0(6'6!8/6!'EE#2+!<(E9*+:!&+9(6'$'(2!()!6E/**!M+66+*@!
J/$8(=+2+6'6!()!'EE#2+!<(E9*+:-!&/E/=+!()!$49+!111!NJb!?/2!'EE#2+!<(E9*+:!'6!/2!%=d%L!
<'0<#*/$'2=!'2!$8+!<'0<#*/$'(2U!'$!&+9(6'$6!>8+0+M+0!<'0<#*/$'(2!$/F+6!'$!7!'+!=*(E+0#*#6;!6E/**!
M+66+*;!>8+0+M+0B@!!1$!/<$'M/$+6!$8+!<(E9*+E+2$!646$+E!?$8+!/*$!646$+EB;!>8'<8!90(&#<+6!
.e/;!>8'<8!'6!<8+E($/<$'<!$(!2+#$0(98'*6@!!I8+0+)(0+;!&/E/=+!&(2+!/6!/!0+6#*$!()!$49+!111!
NJb!'6!&(2+!L4!2+#$0(98'*6@!!%2&!$8+4!/0+!$8+0+!LZ<!$8+!'EE#2+!<(E9*+:!/<$'M/$+&!$8+!
/*$+02/$'M+!<(E9*+E+2$!646$+E@!!I8+!<(E9*+:!8/6!*'$$*+!$(!&(!>'$8!$8+!&/E/=+;!'$Q6!$8+!
2+#$0(98'*6!&(!+M+2$#/*!&/E/=+B!
!
N+2(<8dY<8(*+'2!9#09#0/!7!)++*!9+06(2Q6!*+=6;!/2&!6++!9/*9/L*+!9#09#0/!?&#+!$(!$49+!111!
NJbB@!!R8+E/$'<!)+M+0!?M+=+$/$'(26!())!$8+!E'$0/*!M/*M+B!7!8/M+!)'L0'2!*'F+!?)'L0'2('&!2+<0(6'6B!
E/$+0'/*6!?2+<0(6'6!()!'EE#2(*(='<!&cB@!!K(02'2=!6$'))2+66!C!08+#E/$('&!/0$80'$'6;!6++!
)'L02('&!2+<0(6'6!LZ<!'EE#2(*(='<!&/E/=+@!!I8+0+)(0+;!)'L0'2('&!2+<0(6'6!'6!2+<0(6'6!()!
'EE#2(*(='<!&/E/=+!?'2!M+66+*!'$Q6!/!M/6<#*'$'6;!'2!F'&2+4!'$Q6!/!=*(E+0#*(2+980'$'6;!/2&!'2!
*#9#6!=*(E+0#*(2+980'$'6!'2M(*M'2=!'EE#2+!<(E9*+:+6B@!
!
F. Liver-!!I0'/&!/0+/-!9(0$/*!M+'2;!8+9/$'<!/0$+04;!L'*+!&#<$@!X'M+0!'6!#2'D#+!LZ<!'$!8/6!&#/*!L*((&!
6#99*4!/2&!6(!8+9/$'<!/0$+04!/2&!/2&!9(0$/*!M+'2!>'**!&#E9!L*((&!'2$(!6'2#6('&6@!!G$8+0!
10

+:/E9*+6!()!6'2#6('&!(0=/26!/0+!SK!/2&!69*++2@!!.8/0/<$+0'6$'<!()!6'2#6('&6-!=/96!L+$>++2!
+2&($8+*'/*!<+**6;!>'$8!2($8'2=!$8+0+!6(!$8'2=6!</2!)'$!$80(#=8!?$8'2=6!*'F+!RS.Q6!/2&!
'2)*/EE/$(04!<+**6B@!!lSK!'6!)+2+6$0/$+&;!8/M+!*'$$*+!$'24!9(0+6!>'$8'2!$8+!<+**6;!)(0!)'*$0/$'(2@!!
Y'2#6('&6!8/M+!=/96!6(!*/0=+!<+**6!</2!=+$!$80(#=8!$8+E!?2($!$0#+!>'$8!lSK!LZ<!'$!'6!'2$/<$;!/2&!
*'*!9(0+6!/**(>!)'*$0/$'(2B@!!J(0$/*!M+'2!L*((&!/2&!8+9/$'<!/0$+04!L*((&!=(!$80(#=8!6'2#6('&6;!/2&!
+M+2$#/**4!$/F+2!#9!L4!<+2$0/*!M+'2;!>8'<8!L+<(E+6!$8+!8+9/$'<!M+'2@!!I8+!8+9/$'<!M+'2!&#E96!
'2$(!$8+!'2)!M+2/!</M/;!>8'<8!=(+6!$(!$8+!0'=8$!6'&+!()!$8+!8+/0$@!!I8+0+)(0+;!$8+0+!'6!/!
<(EE#2'</$'(2!L+$>++2!0'=8$!8+/0$!/2&!*'M+0@!!R'=8$!NT!?L*((&!)'**6!L+8'2&!)/'*+&!8+/0$B;!
$8+0+)(0+!$8+!*'M+0!L+<(E+6!<(2=+6$+&!>'$8!L*((&;!*+/&'2=!$(!2#$E+=!*'M+0!?/F/!<(2=+6$'M+!
8+9/$(E+=/*4B@!!1)!4(#!L*(<F!$8+!9(0$/*!M+'2;!2($8'2=!8/99+26!$(!$8+!*'M+0;!LZ<!'$!'6!S[TGR[!$8+!
*'M+0@!!S*(<F/=+!()!8+9/$'<!M+'2!*+/&6!$(!L#&&!<8'/0'!/2&!*'M+0!L+<(E+6!<(2=+6$+&@!g8'<8!9/0$!()!
*'M+0!'6!E(6$!6#6<+9$'L*+!$(!'23#04!2(0E/**4n!%0(#2&!<+2$0/*!M+'2;!LZ<!'$!=+$6!)'06$!&'LL'+6!(2!GH!
<(E'2=!(#$!()!$8+!6'2#6('&6!?c(2+!,B@!!q(2+!H!'6!>8+0+!4+**(>!)+M+0!>'**!8'$!?E'&c(2+!2+<0(6'6B!
&#+!$(!'&+6!+=49$'@!!q(2+!P;!/0(#2&!9(0$/*!M+'2;!>8'<8!>'**!8/M+!*+/6$!GH!?/2/*(=(#6!$(!0+2/*!
E+&#**/;!>8'<8!(2*4!0+<+'M+6!,VW!()!$8+!L*((&!6#99*4;!/2&!$8+!<(0$+:!0+<+'M+6!rVWB@!!T/$$4!
<8/2=+!'6!/0(#2&!c(2+!P!?9/0$!/0(#2&!<+2$0/*!M+'2B@!!I8+0+)(0+;!>8+2!/6F'2=!/L(#$!
/<+$/E'2(98+2!$(:'<'$4;!>8'<8!9/0$!'6!E(6$!6#6<+9$'L*+n!%0(#2&!$8+!<+2$0/*!M+'2!LZ<!'$!=+$6!$8+!
*+/6$!/E(#2$!GH;!/2&!$8+0+)(0+!</22($!<(EL/$!)0++!0/&'</*!'23#04@!
,@!!%*<(8(*!0+*/$+&!*'M+0!&/E/=+-!!!
?/B!K..!)/$$4!<8/2=+-!/*<(8(*@!
?LB!K+$/L(*'6E!()!/*<(8(*-!"%_N!/2&!/<+$4*!.(%!?/<+$/$+!'6!/!T%;!/2&!/<+$4*!.(%!</2!L+!
<(2M+0$+&!$(!T%Q6!'2!$8+!<4$(6(*B@!!"%_N!'6!9/0$!()!$8+!E+$/L(*'6E!()!/*<(8(*;!$8+0+)(0+;!
)(0!L'(<8+E'</*!0:26-!g8/$!</#6+6!940#M/$+!$(!)(0E!*/<$/$+!'2!/2/+0(L'<!=*4<(*46'6n!
"%_N!&0(M+!'$!'2!$8/$!&'0+<$'(2;!$8+0+)(0+!/*>/46!6++!*/<$'<!/<'&(6'6!?/!)(0E!()!E+$/L(*'<!
/<'&(6'6B!'2!/*<(8(*'<Q6!LZ<!'2<0+/6+&!"%_N!&0'M+6!'$!'2!$8/$!&'0+<$'(2@!!%*6(;!'2!)/6$'2=!
6$/$+;!/*<(8(*'<!>'**!8/M+!$0(#L*+!E/F'2=!=*#<(6+!L4!=*#<(2+(=+2+6'6!LZ<!2++&!940#M/$+!
$(!6$/0$!'$!())@!!N(>+M+0;!4(#!8/M+!*/<$/$+!?/2&!2($!940#M/$+B!$8+0+)(0+!/*<(8(*'<6!>'**!
8/M+!)/6$'2=!849(=*4<+E'/@!!%<+$4*!.(%!</2!/*6(!E/F+!F+$(2+!L(&'+6!?/<+$(/<+$4*!.(%;!
NKl!.(%;!/2&!L+$/!84&0(:4L#$40'<!/<'&B@!!Y++!L+$/!84&0(:4L#$40'<!F+$(2+!L(&'+6!'2!
/*<(8(*'<Q6!LZ<!'$Q6!/!"%_N!&0'M+2!0+/<$'(2@!I8+0+)(0+;!$>(!$49+6!()!E+$/L(*'<!/<'&(6'6!
6++2!'2!/*<(8(*'<6!/0+!*/<$'<!/<'&(6'6!?LZ<!&0'M'2=!940#M/$+!'2$(!*/<$/$+B!/2&!'2<0+/6+&!
642$8+6'6!()!F+$(2+!L(&'+6!LZ<!+:<+66!/<+$4*!.(%U!E/'2!F+$(/<'&!C!L+$/!84&0(:4L#$40'<!
/<'&@!!g84!&(+6!'$!90(&#<+!)/$$4!<8/2=+n!12!=*4<(*46'6;!/0(#2&!0:2!^;!=+$!'2$+0E+&'/$+6!
&'84&0(:4/<+$(2+!98(6898/$+!?"%_N!0:2B!/2&!'6!)(0<+&!$(!L+<(E+!=*4<+0(*!Pd98(698/$+@!!
S'=!$'E+!L(/0&!D#+6$'(2m!g'$8!=*4<+0(*!P!98(698/$+!68#$$*+;!=+$!%IJ@!!%*6(!'E9!$(!
</0L(84&0/$+!L/<FL(2+!)(0!E/F'2=!$04=*4<+0'&+6!?/&&!P!T%Q6!$(!=*4<+0(*!P!7!98(698/$+;!
/2&!4(#!=+$!IlQ6B@!!12!*'M+0;!$8+!*'9'&!)0/<$'(2!')!kX_X!?+2&(=+2(#6!Il!'6!642$8+6'c+&!'2!
$8+!*'M+0!)0(E!=*4<+0(*!P!98(698/$+!&+0'M+&!)0(E!=*4<(*46'6B@!!R+6$0'<$'2=!)/$!>'**!"GI!
&+<0+/6+!$8+!642$8+6'6!()!kX_X@!!R+6$0'<$'2=!</0L6!g1XX!&+<0+/6+!$8+!kX_X!642$8+6'6!LZ<!
'$!'6!=*#<(6+!'2$+0E+&'/$+!'$!'6!E/&+!)0(E@!!l*4<+0(*!P!98(698/$+!'6!/!90(&#<$!()!=*4<(*46'6!
>8'<8!'6!>84!)/$$4!*'M+0!'6!K.Q*4!&#+!$(!/*<(8(*'6E!?$8'6!0:2Bm!
%#&'(!)'*+!P-!12)*/EE/$'(2!,!
H@!!5>/68'(0F+0!7!F'&!>'$8!)/$$4!<8/2=+@!!I8+!E+<8/2'6E-!>8+2!4(#!E/F+!kX_X;!/2&!$(!L+!
/L*+!$(!=+$!'$!(#$!()!$8+!*'M+0;!$8+!kX_X!E#6$!L+!6#00(#2&+&!L4!/9(90($+'26@!!12!F>/68'(0F(0;!
$8+0+!'6!&+<0+/6+&!90($+'2!'2$/F+U!$8+4!8/M+!/&+D#/$+!2#EL+0!()!</*(0'+6;!L#$!'$6!/**!</0L6@!!
I8+0+)(0+;!$8+4!</22($!=+$!kX_X!$8/$!$8+4!E/&+!'2!$8+!*'M+0!(#$!LZ<!$8+0+!/0+!2(!
/9(*'9(90($+'26!$(!<(M+0!'$!/2&!9#$!'$!(#$!'2!$8+!L*((&6$0+/E!/2&!6(*#L'*'c+!'$!'2!>/$+0@!X'9'&!
/2&!>/$+0!&(!2($!E':U!$8+0+)(0+!'$!'6!2+<+66/04!$(!9#$!90($+'26!/0(#2&!$8+!*'9'&!$(!&'66(*M+!'$!
'2!>/$+0@!I8+0+)(0+;!$8+!90($#L+0/2$!/L&(E+2!'2!$8+6+!9$6!'6!$8+0+!)(0!$>(!0+/6(26-!,B!
11

&+<0+/6+&!90($+'2!'2$/F+!>8'<8!&+<0+/6+6!(2<($'<!90+66#0+;!*+/&'2=!$(!/6<'$+6@!!HB!I8+!
L'==+6$!0+/6(2!'6!$8/$!$8+4!8/M+!8#=+!*'M+06!0+*/$+&!$(!)/$$4!<8/2=+@!!I8+!E+<8/2'6E!)(0!
)/$$4!<8/2=+!'6!&'))+0+2$!)0(E!/*<(8(*!LZ<!'2!/*<(8(*U!$8+!E+<8!'6!&#+!$(!'2<0+/6+&!642$8+6'6!
()!kX_X@!!12!$8'6!</6+;!$8+0+!'6!/!*/<F!()!90($+'2!$(!9#$!/0(#2&!$8+!kX_X!/2&!+:9(0$!'$!(#$!()!
$8+!*'M+0@!
!
P@!!N+E(6'&+0'2!/2&!T+00$'2-!L0'+)!&'6<#66'(2-!!T+00'$'2!C!6(*#L*+!)(0E!()!<'0<#*/$'2=!T+;!/2&!'6!
/!=((&!E/0F+0!)(0!T+!'2!SK@!!1$!'6!$8+!$+6$!()!<8('<+!'2!&:Q'2=!/24!T+!0+*/$+&!90(L*+E!7!T+!&+)!
/2+E'/;!(0!%2+E'/!()!.80(2'<!_c!(0!T+!(M+0*(/&!&cQ6!6#<8!/6!8+E(<80(E/$(6'6!/2&!
8+E(6'&+0(6'6!?>(#*&!L+!+*+M/$+&B@!!T+00'$'2!'6!/!6(*#L*+!)(0E!()!T+;!>8'*+!8+E(6'&+0'2!'6!/2!
'26(*#L*+!)(0E!()!T+!6$(0/=+;!/2&!'6!6$(0+&!'2!E/<0(98/=+6!/2&!SK@!!Y$/'2!'$!>'$8!J0#66'/2!
L*#+@!
!
V. Types of calcification-!&46$0(98'<!/2&!E+$/6$/$'<!
A. Dystrophic calcification-!E+/26!/L2(0E/*!</*<')'</$'(2@!!I8+!&/E/=+&!$'66#+!=+$6!
</*<')'+&@!!!
,@!![:/E9*+-!Y++2!'2!+2c4E/$'<!)/$!2+<0(6'6!?<8/*F4!>8'$+!/0+/6!(2!:d0/4!/0+!/!0+6#*$!()!
&46$0(98'<!</*<')'</$'(2B@!!!
H@![:/E9*+-!)(($L/**!9*/4+0!>'$8!8+E/$(E/!'2!)(($;!$8/$!L+<(E+6!</*<')'+&!&646$0(98'</**4!?./!
L'2&6!/2&!<(d90(&#<+6!&46$0(98'<!./!&+9(6'$6B@!!Y+0#E!./!'6!2(0E/*;!L#$!&/E/=+&!$'66#+!
L+<(E+6!</*<')'+&@!G<<#06!'2!/$8+0(E/$(#6!9*/D#+6!?</#6+6!6+0'(#6!$'66#+!&/E/=+B;!
$8+0+)(0+!$8+4!/0+!&'))'<#*$!$(!&'66(*M+!?2++&!$(!L+!(2!$8+!(02'68!&'+$!7!/!M+=/2!&'+$B@!!!
P@!K..!/(0$'<!6$+2(6'6!?K..-!<(2=+2'$/*!L'<#69'&!/(0$'<!M/*M+B!C!&46$0(98'<!</*<')'</$'(2!?/*6(!
*+/&6!$(!/!8+E(*4$'<!/2+E'/B@!!Y*'&+-!$8+!/(0$/!8/6!(2*4!H!M/*M+6!&('2=!$8+!3(L!()!$80++;!/2&!
=+$6!&/E/=+&;!*+/&'2=!$(!&46$0(98'<!</*<')'</$'(2!>8'<8!2/00(>6!(0')'<+!()!M/*M+;!*+/&'2=!$(!
/(0$'<!6$+2(6'6@!
!
B. Metastatic calcification-!12!</6+6!()!N49+0</*<+E'/!(0!849+098(698/$+E'/;!./*<'#E!'6!
/<$#/**4!E/&+!$(!&+9(6'$!'2!2(0E/*!$'66#+6;!2(2d&/E/=+&!$'66#+6@!!!
K..!849+0</*<+E'/!?(#$6'&+!()!8(69'$/*B!C!90'E/04!849+09/0/$840('&'6E!
K..!849+0</*<+E'/!?'26'&+!$8+!8(69'$/*B!C!E/*'=2/2<4!'2&#<+&!849+0</*<+E'/@!
g'$8!849+0</*<+E'/;!</2!9#$!./!'2!"GRK%X!$'66#+6U!$8'6!'6!</**+&!E+$/6$/$'<!</*<')'</$'(2@!!12!
&46$0(98'<!</*<')'</$'(2!$8+0+!'6!&/E/=+&!$'66#+!>'$8!2(0E/*!6+0#E!./!*+M+*6@!!K+$/6$/$'<!
</*<')'</$'(2!'6!>8+2!$8+0+!'6!8'=8!./!(0!98(698(0#6!6+0#E!*+M+*6!?/<$#/**4!>8+2!./!'6!&+9(6'$+&!
'2$(!L(2+;!'$!'6!$8+!98(698(0#6!9/0$!()!6(*#L'*'$4!90(&#<$!$8/$!&0'M+6!./!'2$(!L(2+B@!N'=8!
98(698/$+!*+M+*6!?M+04!&/2=+0(#6B!>'**!$/F+!./!/2&!&0'M+!'$!'2$(!2(0E/*!$'66#+@!I8'6!'6!>84!8/M+!
$(!9#$!/!9$!>'$8!0+2/*!)/'*#0+!(2!&'/*46'6!?8/M+!8'=8!98(698(0#6!6+0#E!*+M+*6B!$8+0+)(0+!2++&!$(!
&'/*4c+!$8+!98(698/$+!LZ<!$8+!98(698/$+!>'**!&0'M+!./!'2$(!2(0E/*!$'66#+!7!'+!8+/0$;!<(2&#<$'(2!
646$+E;!0+2/*!$#L#*+6;!L/6+E+2$!E+EL0/2+!?2+980(</*<'2(6'6B!7!/**!*+/&!$(!&/E/=+@!
!
VI. Cell Membrane Defects
A. RBC membrane defect-!!Y98+0(<4$(6'6!'6!/!&+)+<$!'2!69+<$0'2!>'$8'2!RS.!<+**!E+EL0/2+U!')!
4(#!</2Q$!6++!/!<+2$0/*!/0+/!()!9/**(0!?')!4(#!&(2Q$!6++!/!&(2#$B!$8+2!'$Q6!/!698+0(<4$+@!!%L6+2<+!
()!69+<$0'2!>'$8!'2!$8+!RS.!&(+6!2($!/**(>!$8+!RS.!$(!)(0E!/!L'<(2</M+!&'6FU!'$!'6!&+)+<$'M+;!/2&!
$8+0+)(0+!)(0E6!/!698+0+@!!!
!
12

B. Ubiquitin!7!6$0+66!90($+'2@!!N'=8!#L'D#'$'2!*+M+*6!/0+!/66(<'/$+&!>'$8!8'=8!*+M+*6!()!6$0+66@!!
Y(E+!()!$8+!'2$+0E+&'/$+!)'*/E+2$6!?F+0/$'2;!&+6E'2;!M'E+2$'2B!/0+!9/0$!()!$8+!6#9+06$0#<$#0+!()!
(#0!<+**6!?i)0/E+!()!$8+!<+**j;!#9(2!>8'<8!$8'2=6!/0+!L#'*$B@!g8+2!$8+6+!'2$+0E+&'/$+!)'*/E+2$6!
=+$!&/E/=+&;!$8+!#L'D#'$'2!E/0F6!$8+2!)(0!&+6$0#<$'(2@!!I8+!'2$+0E+&'/$+!)'*/E+2$6!8/M+!L++2!
$/==+&!?#L'D#'2/$+&B!/2&!E/0F+&!)(0!&+6$0#<$'(2@!!Y(E+!()!$8+6+!90(&#<$6!8/M+!2/E+6;!)(0!
+:/E9*+-!$8+0+!/0+!(9+2!69/<+6!>'$8'2!$8+!*'M+0!$'66+;!$8+6+!69/<+6!/0+!)/$!/2&!$8+4!/0+!90(L/L*4!
&#+!$(!/*<(8(*@!!I8+!#L'D#'2'$+&!90(&#<$6!()!$8+!*'M+0!/0+!</**+&!K/**(04!L(&'+6@!!I8+6+!/0+!$8+!
0+6#*$!()!#L'D#'2/$+&!)'*/E+2$6!</**+&!F+0/$'2!/2&!$8+6+!/0+!6++2!'2!/*<(8(*'<!8+9/$'$'6@!!%2($8+0!
+:/E9*+-!Y'*M+0!6$/'2!()!2+#0()'L'*/04!$/2=*+6!7!f/<(L!<0#$c)+*$!/2&!/*c8+'E+06!&c@!!I/#!90($+'2!'6!
/66(<'/$+&!>'$8!2+#0()'L!$/2=*+6U!$8'6!'6!/2!+:/E9*+!()!/!#L'D#'2/$+&!2+#0()'*/E+2$@!![:/E9*+-!
Y#L6$/2$'/!2'=0/!'2!J/0F'26(2Q6!_c!7!'2<*#&+!'2<*#6'(26!</**+&!X+>4!L(&'+6;!2+#0($0/26E'$$+0!
&+)'<'+2<4!'6!&(9/E'2+@!!X+>4!L(&'+6!/0+!#L'D#'2/$+&!2+#0()'*/E+2$6@!I8+0+)(0+;!K/**(04!L(&'+6;!
X+>4!L(&'+6;!/2&!2+#0()'L!$/2=*+6!/0+!/**!+:/E9*+6!()!#L'D#'2$/$'(2@!
!
VII. Cell Cycled!M+04!M+04!'E9(0$/2$-!L'=!L'=!L'=!$'E+!
!
A. Different types of cells-!
,@!X/L'*+!<+**6!7!<+**!>8+0+!$8+!&'M'6'(2!'6!M'/!/!6$+E!<+**@!!I80++!$'66#+6!$8/$!8/6!6$+E!<+**6-!
L(2+!E/00(>;!L/6+E+2$!E+EL0/2+!()!6F'2;!/2&!$8+!L/6+!()!<049$6!'2!$8+!'2$+6$'2+@!!I8+6+!
<+**6!8/M+!$8+!$+2&+2<4!()!L+'2=!'2!$8+!<+**!<4<*+!/!*($@!!12!98/0E-!$8+0+!/0+!<+**!<4<*+!69+<')'<!
/2&!<+**!<4<*+!2(269+<')'<!&0#=6@!!I8+!<+**6!$8/$!/0+!E(6$!/))+<$+&!L4!$8+6+!&0#=6!/0+!$8+!
*/L'*+!<+**6!LZ<!$8+4!/0+!'2!$8+!<+**!<4<*+@!!.(E9*'</$'(26!()!$8+6+!&0#=6!/0+!SK!6#990+66'(2;!
&'/008+/;!E#<(<'&'6;!/2&!0/68+6!(2!$8+!6F'2!?$8+0+!/0+!6$+E!<+**6!'2!/**!$8+6+!$'66#+6mB@!
!
H@!Y$/L*+!<+**6!7!'2!0+6$'2=!98/6+;!l(!98/6+@!!K(6$!()!9+0+2<84E/*!(0=/26!?*'M+0;!69*++2;!/2&!
F'&2+4B!/2&!6E(($8!E#6<*+!/0+!6$/L*+!<+**6@!!Y$/L*+!<+**6!</2!#2=(!&'M'6'(2;!L#$!E(6$!()!$8+!
$'E+!$8+4!/0+!0+6$'2=;!/2&!6(E+$8'2=!E#6$!6$'E#*/$+!$8+E!$(!=+$!'2$(!$8+!<+**!<4<*+!/2&!
&'M'&+!7!'+!/!8(0E(2+!(0!/!=0(>$8!)/<$(0@!!T(0!+:/E9*+-!+6$0(=+2!'2!>(E/2!>'**!8+*9!'2!$8+!
90(*')+0/$'M+!98/6+!()!$8+!E+26$0#/*!<4<*+@!!I8+!+2&(E+$0'/*!<+**6!/0+!'2'$'/**4!'2!$8+!l(!98/6+!
/2&!$8+2!$8+!+6$0(=+2!6$'E#*/$+&!$8+!<+**6!$(!=(!'2$(!$8+!$8+!<+**!<4<*+@!I8+0+)(0+;!$8+4!</2!
&'M'&+;!L#$!$8+4!8/M+!$(!L+!'2M'$+&!L4!/!8(0E(2+!(0!/!=0(>$8!)/<$(0@!
!
P@!J+0E/2+2$!<+**6!7!</2!2(!*(2=+0!=+$!'2$(!$8+!<+**!<4<*+;!/2&!8/M+!L++2!9+0E/2+2$*4!
&'))+0+2$'/$+&@!!I8+!($8+0!$49+6!()!E#6<*+!<+**6-!6$0'/$+&;!</0&'/<!/2&!2+#0(2/*!<+**6@!!G2*4!
E#6<*+!$8/$!'6!"GI!/!9+0E/2+2$!$'66#+!C!6E(($8!E#6<*+U!849+09*/6'/!C!'2<0+/6+!'2!s;!>8'*+!
849+0$0(984!C!'2<0+/6+!'2!6'c+@!g(#*&!/!9+0E/2+2$!<+**!L+!/L*+!$(!#2&+0!849+09*/6'/n!"G;!
LZ<!$8/$!E+/26!E(0+!<(9'+6!()!'$@!!./2!'$!=(!#2&+0!849+0$0(984n!b+6@!!%!6E(($8!E#6<*+!<+**!
</2!#2&+0=(!849+09*/6'/!%"_!849+0$0(984@!!!
!
B. Different phases of cell cycle:
,@!!l,!98/6+-!I8+!E(6$!M/0'/L*+!98/6+!()!<+**!<4<*+!'6!$8+!l,!98/6+@!!.(E9/0+!>'$8!E+26$0#/*!
<4<*+-!I8+!E(6$!M/0'/L*+!98/6+!'6!$8+!90(*')+0/$'M+!98/6+!?2($!$8+!6+<0+$(04!98/6+B@!!I8+!
90(*')+0$'M+!98/6+!M/0'+6!>'$8!6$0+66U!8(>+M+0;!(2<+!(M#*/$'(2!8/6!(<<#00+&;!'$!'6!,^!&/46@!!
I8+0+)(0+;!90(*')+0/$'M+!98/6+!'6!/2/*(=(#6!$(!l,!98/6+!()!$8+!<+**!<4<*+!LZ<!'$!</2!L+!68(0$+0!
(0!*+2=$8+2+&U!2(2+!()!$8+!($8+0!98/6+6!?Y;!lH;!/2&!K!98/6+B!<8/2=+6;!$8+4!6$/4!$8+!6/E+@!!
I8+0+)(0+;!'2!</2<+0!<+**6;!(2+6!>'$8!/!*(2=+0!<+**!<4<*+!>'**!8/M+!/!*(2=+0!l,!98/6+;!/2&!
</2<+0!<+**6!>'$8!/!68(0$+0!<+**!<4<*+!>'**!8/M+!/!68(0$+0!l,!98/6+@!!!
!
13

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98(698(04*/$'(2!C!/<$'M/$'(2B@!!J8(698(04*/$'(2!#6#/**4!'2M(*M+6!6+2&'2=!/!E+66/=+!$(!
/<$'M/$+!6(E+$8'2=@!!l*#</=(2!'6!/!98(698(04*/$(0;!>8'*+!'26#*'2!'6!/!&+98(698(04*/$(0@!!
l*#</=(2!>'**!98(698(04*/$+!90($+'2!F'2/6+!/2&!/<$'M/$+!'$;!>8'*+!126#*'2!>(#*&!
&+98(698(04*/$+!90($+'2!F'2/6+!/2&!'2/<$'M/$+!'$@!!!
!
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&+9@!F'2/6+!?$8+0+)(0+!'$!'6!2(>!/<$'M+B@!!5+4!/0+/!$(!<(2$0(*!'2!<+**!<4<*+-!$0/26'$'(2!)0(E!l,!
$(!Y!98/6+@!!S+</#6+!')!4(#!8/M+!/!E#$/$'(2!/2&!'$!=(+6!'2$(!Y!98/6+;!'$!$8+2!L+<(E+6!
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90($+'2;!>8'<8!90+M+2$6!$8+!<+**!)0(E!=('2=!)0(E!$8+!l,!$(!$8+!Y!98/6+@!!12!=+2+0/*;!$(!=(!
)0(E!l,!$(!Y;!$8+!/<$'M+!<4<*'2!&+9!F'2/6+!98(698(04*/$+6!$8+!RL!90($+'2U!>8+2!'$!'6!
98(698(04*/$+&C/<$'M/$'(2;!'$!</2!=(!)0(E!$8+!l,!98/6+!$(!$8+!Y!98/6+@!!%!90(L*+E!(<<#06!')!
$8+0+!'6!/!E#$/$'(2@!!I8+0+)(0+!$8+!+2c4E+!'6!<8+<F+&!L4!?HB!9eP!6#990+66(0!=+2+-!*(</$+&!
(2!<80(E(6(E+!,`;!>8'<8!E/F+6!/!90($+'2!90(&#<$!$8/$!'28'L'$6!$8+!<4<*'2!&!&+9!F'2/6+@!!
I8+0+)(0+;!'$!</22($!=(!'2$(!$8+!Y!98/6+U!9eP!'6!$8+!2#EL+0!,;!E(6$!'E9!=+2+!$8/$!0+=#*/$+6!
8#E/2!</2<+0@!
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=+2+6!90(&#<$6!7![a!?>8'<8!F2(<F6!())!$8+!9ePB!/2&![`!?>8'<8!F2(<F6!()!$8+!RL!6#990+66(0!
=+2+B@!!!
!
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());!$8+0+!>'**!L+!2(!RL!90($+'2;!/2&!$8+!<+**!>'**!90(=0+66!$(!$8+!Y!98/6+!LZ<!'$!'6!
#2<(2$0(**+&@!!I8'6!E#$/$'(2!'2!$8+!RL!6#990+66(0!=+2+!90+&'69(6'2=!$(!E/24!</2<+06;!6#<8!
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6#2L#06$!/99+/0/2<+!(2!:d0/46B;!/2&!L0+/6$!</2<+0!?RL!6#990+66(0!</2!L+!'2M(*M+&B@!!
_+9+2&'2=!(2!$8+!/=+!L0/<F+$;!'$!8'$6!'2!&'))+0+2$!/0+/6@!1)!4(#!F2(<F!()!9eP!6#990+66(0!
=+2+-!$8+!F'2/6+!>'**!L+!/*>/46!/<$'M+;!'$!>'**!/*>/46!98(698(04*/$+!$8+!RL!90($+'2;!/2&!$8/$!
E+/26!$8/$!'$!>'**!/*>/46!=(!'2$(!$8+!Y!98/6+;!/2&!$8'6!'6!L/&@!!1)!4(#!F2(<F!())!/24!()!$8(6+!
=+2+6;!$8+!<+**!>'**!=(!'2$(!$8+!Y!98/6+@!!I8+!9eP!6#990+66(0!=+2+!'6!$8+!=#/0&'/2!()!$8+!
=+2(E+;!LZ<!'$!='M+6!$8+!<+**!$'E+!$(!&+$+<$!')!$8+0+!/0+!/24!&+)+<$6Z/L2(0E/*'$'+6!'2!$8+!_"%!
?69*'<'2=!&+)+<$6;!<(&(2!$8'2=;!>8/$+M+0;!+$<B@!!_"%!0+9/'0!+2c4E+6!</2!69*'<+!(#$!$8+!
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&/E/=+&!_"%;!$8+2!'$!'6!0+E(M+&!L4!/9(9$(6'6@!I8+0+)(0+!$8'6!=+2+!'6!'E9!LZ<!'$!='M+6!$8+!
<+**!/2!(99(0$#2'$4!$(!<*+/2!'$6!_"%!L+)(0+!=('2=!'2$(!$8+!Y!98/6+@!!!
!
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?)0(E!H"!$(!^"B@!T(0!+:/E9*+-!')!'$Q6!'2!E#6<*+;!'$!>'**!8/M+!&(#L*+!$8+!2#EL+0!()!<(2$0/<$'*+!
+*+E+2$6@!
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L*(<F+&!L4!+$(9(6'&+!/2&!L*+(E4<'2@!
^@!!K!98/6+!C!E'$(6'6U!>8+0+!$8+!<+**!&'M'&+6!'2$(!$>(!H"!<+**6@!!I8+!<+**!</2!+'$8+0!=(!'2$(!
$8+!l(!0+6$'2=!98/6+;!(0!</2!<(2$'2#+!&'M'&'2=!'2!$8+!<4<*+;!(0!</2!L+!9+0E/2+2$*4!
&'))+0+2$'/$+&@!!9eP!=+2+!E/F+6!/!90($+'2!$(!'28'L'$!$8+!F'2/6+;!$8+0+)(0+!90+M+2$6!$8+!RL!
14

90($+'2!)0(E!L+'2=!98(698(04*/$+&;!$8+0+)(0+!6$/46!'2!$8+!l,!98/6+@!I8+0+)(0+;!>8+2!4(#!
F2(<F!'$!());!2(!(2+!'6!'2/<$'M/$'2=!$8+!F'2/6+;!/2&!$8+!<+**!'6!<(26$/2$*4!98(698(04*/$+&!/2&!
$8/$!F++96!$8+!<+**!&'M'&'2=;!/2&!$8+2!8/6!$8+!9($+2$'/*!$(!*+/&!$(!</2<+0@!
!
C. Drugs that act on the cell cycle-!
!
,@!!_0#=6!/<$'2=!(2!Y!98/6+-!!
/B![0=($!/*F/*('&6!>(0F!(2!$8+!E'$($'<!69'2&*+!'2!Y!98/6+!
LB!K+$8($0+:/$+!>(0F6!'2!Y!98/6+-!![:/E9*+-!9$!>'$8!08+#E/$('&!/0$8'0'$'6!8/6!E/<0(<4$'<!
/2+E'/@!_0#=!0+69(26'L*+!)(0!$8'6!'6!'2!>8/$!98/6+!()!$8+!<+**!<4<*+n!Y!98/6+!LZ<!'$!'6!
E+$8($0+:/$+!L*(<F'2=!&'84&0()(*/$+!0+&#<$/6+!
!
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<8+E($8+0/94!/=+2$!E/&+!)0(E!/!4+>!$0++n!J/<*'$/:+*!?E!98/6+B!
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6'&+!+))+<$6!'6!2(!*(2=+0!#6+&@!!g8/$!&0#=!/2&!>8+0+!&(+6!'$!/<$n!.(*<8'<'2+!?E!98/6+B!
!
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>8'$+!(#$!()!$8+!*#2=;!(2!/!&0#=U!+2&6!#9!>'$8!<4/2(6'6U!>8'<8!&0#=n!_/96(2+!
15

VII. Adaptations to environmental stress: Growth alterations
A. Atrophy-!_'/=2(6'6-!$8+!&+<0+/6+!'2!$'66#+!E/66!/2&!$8+!<+**!&+<0+/6+6!'2!6'c+@!!I8+!<+**!8/6!
3#6$!+2(#=8!(0=/2+**+6!$(!6#0M'M+;!'+!*+66!E'$(<8(2&0'/!$8+2!2(0E/*!<+**6;!$8+0+)(0+;!3#6$!$04'2=!
$(!]++FQ!'$!(#$!#2$'*!>8/$+M+0!'$!2++&6!$(!6$'E#*/$+!</2!<(E+!L/<F@!!!
,@!![:/E9*+-!!!84&0(2+980(6'6;!$8+!<(E90+66'(2!/$0(984!'6!</#6'2=!$8'22'2=!()!<(0$+:!/2&!
E+&#**/;!K..!84&0(2+980(6'6!'6!6$(2+!'2!$8+!#0+$+0!?$8+!9+*M'6!'6!&'*/$+&B@!!p#+6$'(2!</2!L+!
/6F+&!>8/$!F'2&!()!=0(>$8!/*$+0/$'(2!</2!(<<#0!8+0+@!!%26>+0!'6!/$0(984!LZ<!()!$8+!'2<0+/6+&!
90+66#0+!(2!$8+!<(0$+:!/2&!$8+!E+&#**/!/2&!90(&#<+6!$(!'6<8+E'/;!L*((&!)*(>!&+<0+/6+6!/2&!
</2!90(&#<+!/$0(984!()!0+2/*!$#L#*+6@!
!
H@!![:/E9*+-!!%$0(98'+&!L0/'2!&#+!$(!/$8+0(6<*+0(6'6!?K.B!(0!&+=+2+0/$'(2!()!2+#0(26!
?/*c8+'E+06;!0+*/$+&!$(!L+$/!/E4*('&!90($+'2;!>8'<8!'6!$(:'<!$(!2+#0(26B@!!!
!
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F2(<F!())!2+#0(26!$(!$8+!E#6<*+;!6(!'$!'6!2($!6$'E#*/$+&;!*+/&'2=!$(!/$0(984@!!
!
^@!![:/E9*+-!![2&(<0'2+!0+*/$+&-!!
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0+$'#<#*/0'6!*/4+06!()!$8+!/&0+2/*!<(0$+:U!"GI!$8+!=*(E+0#*(6/!LZ<!%.IN!8/6!2($8'2=!$(!
>'$8!6$'E#*/$'2=!/*&(6$+0(2+!0+*+/6+@!!I8+!)/6'<#*/$/!'6!>8+0+!=*#<(<(0$'<('&6!?<(0$'6(*B!
/0+!E/&+;!>8'*+!0+$'<#*/0'6!'6!>8+0+!6+:!8(0E(2+6!/0+!E/&+!?,`!F+$(6$+0('&6!/2&!
$+6$(6$+0(2+B@!!%.IN!'6!0+69(26'L*+!)(0!6$'E#*/$'2=!$8+6+;!$8+0+)(0+!c(2/!)/6'<#*/$/!/2&!
c(2/!0+$'<#*/0'6!/0+!/$0(98'+&@!!
!
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&+<0+/6+!()!IYN!/2&!$8+0+)(0+!2($8'2=!'6!6$'E#*/$'2=!$8+!$840('&!=*/2&!>8'<8!*+/&6!$(!
/$0(984@!
!
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=0(>$8!/*$+0/$'(2n!%$0(984;!LZ<!$8+!.TIR!0+=#*/$(0!(2!<Q6(E+!`!'6!&+)+<$'M+!/2&!8/6!
90(L*+E6!>'$8!6+<0+$'(26@!!I8+!6+<0+$'(26!L+<(E+!$8'<F+0!/2&!/6!/!0+6#*$;!'$!L*(<F6!$8+!&#<$6!
/2&!6(!$8/$!E+/26!$8/$!$8+!=*/2&6!$8/$!>+0+!E/F'2=!$8+!)*#'&6!?$8+!+:(<0'2+!9/0$!()!$8+!
=*/2&B!</22($!E/F+!)*#'&6!LZ<!()!$8+!L/<F!90+66#0+!L*(<F'2=!$8+!*#E+2!()!$8+!&#<$;!>8'<8!
*+/&6!$(!/$0(984!()!$8+!=*/2&6;!>8'<8!$8+2!*+/&6!$(!E/*/L6(09$'(2!'2!/**!<8'*&0+2!>'$8!<46$'<!
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!
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F'&2+4!/2&!6+<(2&/04!NI"!?0+2(M/6#<*/0!NJ;!*+/&'2=!$(!8'=8!0+2'2!*+M+*!<(E'2=!(#$!()!$8+!
F'&2+4B@!!12!$8+!($8+0!F'&2+4;!'$!'6!(M+0>(0F+&;!$8+0+)(0+!$8+0+!'6!849+0$0(984!?0+2'2!*+M+*!
<(E'2=!(#$!()!$8'6!M+'2!'6!&+<0+/6+&!/2&!6#990+66+&B@!!
!
B. Hypertrophy '2<0+/6+!()!$8+!Y1q[!()!<+**;!2($!2#EL+0
Y<+2/0'(-!!%!<+**!L'(*(=4!D#+6$'(2-!!>8/$!'6!$8+!"!()!$8'6n!
N49+0$0(984!()!/!</0&'/<!E#6<*+!?9+0E/2+2$!E#6<*+B;!6#99(6+!$8+0+!'6!/!L*(<F!3#6$!
L+)(0+!$8+!lH!98/6+@!!g8/$!'6!$8+!2#EL+0!()!<80(E(6(E+6n!%26>+0-!s!()!<Q6(E+6!'6!^";!
LZ<!'$!/*0+/&4!#2&+0>+2$!642$8+6'6-!/*0+/&4!&(#L*+&@!!
,!"!C!69+0E!?HP!<Q6(E+6B!
H!"!C!2(0E/*!?&'9*('&!<+**B!
16

P!"!C!$0'6(E4!
^!"!C!&(#L*+!$8+!2#EL+0!
!
C. Hyperplasia!7!'2<0+/6+!'2!$8+!s!()!<+**6!
12!2(0E/*!90(*')+0/$'M+!=*/2&;!$8+0+!/0+!$8(#6/2&6!()!E'$(6+6;!$8+0+)(0+!6++!E(0+!=*/2&6!
>'$8!849+09*/6'/@!!!
!
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')!4(#!&'&2Q$!8/M+!90(=+6$+0(2+!?#2&(+6!>8/$!+6$0(=+2!&'&d<(#2$+0/<$6!$8+!+6$0(=+2B;!4(#!
>'**!=+$!</2<+0@!!I8+!<+**6!>'**!=(!)0(E!849+09*/6'/;!$(!/$49'</*!849+09*/6'/!$(!+2&(E+$0'/*!
</2<+0@!!I8+0+)(0+!849+09*/6'/!*+)$!#2<8+<F+&!$8+0+!'6!/2!'2<0+/6+&!0'6F!()!</2<+0@!!G2+!
+:<+9$'(2-!L+2'=2!90(6$/$'<!849+09*/6'/U!849+09*/6'/!()!$8+!90(6$/$+!&(+6!"GI!*+/&!$(!
</2<+0U!3#6$!#0'2/04!'2<(2$'2+2<+@!
!
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849+09*/6'/@!!!
!
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)+>!gS.Q6;!/2&!'2<0+/6+&!RS.Q6@!!I8+0+)(0+;!8/M+!RS.!849+09*/6'/@!!I8'6!'6!2($!+:9+<$+&!$(!
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!
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!
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17

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!
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!
18

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19

CHAPTER TWO: INFLAMMATION
!
I. Acute Inflammation
A. Cardinal signs of inflammation
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!
B. Steps involved in Acute inflammation ?$8'6!$8+!2(0E/*!6+D#+2<+!'2!/<#$+!'2)*/EE/$'(2B:!!

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!
20

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?HB.8*/E4&'/!</2!=+$!(#$!()!98/=(*46(6(E+;!E+<8/2'6E!#2F2(>2;!L#$!6(E+$'E+6!
$8+4!8/M+!E#<(#6!/2&!/**!F'2&6!()!$8'2=6!/0(#2&!$8+E@!!
LB!O2 dependent myeloperoxidase system!'6!$8+!L(/0&6mm!
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2+#$0(98'*6!/2&!E(2(<4$+6;!L#$!2($!E/<0(98/=+6@!!I8+!E(6$!'E9(0$/2$!<()/<$(0!'6!
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'6!=*#<(6+!a!98(698/$+!&+84&0(=+2/6+;!>8'<8!<(2M+0$6!laJ!'2$(!ad98(698(=*#<(2/$+;!
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='M'2=!())!+2+0=4;!>8'<8!'6!</**+&!/!0+69!L#06$;!>8'<8!</2!L+!E+/6#0+&!L4!0/&'/$'(2!
&+$+<$(06U!/2&!L4!/!2+=/$'M+!"SI!&4+!$+6$@!!12!$8+!"SI!$+6$;!4(#!8/M+!/!$+6$!$#L+;!/&&!
$8+!<(*(0*+66!"SI!&4+U!/2&!')!2+#$0(98'*6!/2&!E(2(<4$+6!/0+!>(0F'2=!2(0E/**4;!$8+4!>'**!
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$8+0+!'6!2($!/!0+69!L#06$;!$8+0+)(0+!$8+!9$!8/6!<80(2'<!=0/2#*(E/$(#6!&c!()!<8'*&8((&@!!!
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F'**!L#=6;!L#$!'$!'6!#6+&!)(0!/2($8+0!0+/6(2@!!g'$8'2!$8+!2+#$0(98'*6!/2&!E(2(<4$+6!/0+!
0+&&'68!=0/2#*+6!>8'<8!/0+!*46(6(E+6;!/2&!/0+!6++2!'2!$8+!9+0'98+0/*!L*((&@!!
K4+*(9+0(:'&/6+!?(2+!()!$8+!E/24!+2c4E+6!'2!$8+!=0/2#*+6B!>'**!</$/*4c+!$8+!0:2@!!1$!>'**!
<(EL'2+!9+0(:'&+!>'$8!<8*(0'&+!$(!)0(E!L*+/<8@!!I8'6!is the most potent bactericidal
mechanism O2 dep myeloperoxidase system;!>8'<8!'6!'2!"[\IRGJN1XY!/2&!
KG"G.bI[Y!L#$!"GI!'2!E/<0(98/=+6;!LZ<!E/<0(98/=+6!*(6+!$8+!646$+E!>8+2!$8+4!
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()!$8+!."Y!/0+!E'<0(=*'/*!<+**6;!6(!$8+!0+6+0M('0!<+**!)(0!."YZ%1_Y!'6!$8+!E'<0(L'/*!<+**@!!
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!
21

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!
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$8+!&c!$(!$8+!L(4;!/2&!'6!/2!/64E9$(E/$'<!</00'+0;!/2&!$8+4!>'**!$0/26E'$!$8+!&c!$(!eVW!
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$8'6!'6!>8/$!$8+!F'&!>(#*&!2++&!$(!F'**!$8+!L/<$+0'/@!!I8+6+!F'&6!/0+!E'66'2=!J[RGh1_[!
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6$'<F!'2!(0&+0!$(!=+$!(#$@!!!I8+0+)(0+;!')!$8+!2+#$0(98'*6!</2Q$!6$'<F;!$8+4!</2Q$!=+$!(#$;!/2&!
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!
C. Chemical mediators:
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22

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!
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23

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eVW!()!2+#$0(98'*6!$8/$!>+0+!6$#<F!/0+!2(>!<'0<#*/$'2=B@!!.(0$'<(6$+0('&6!&+6$0(4!Sd<+**6!
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K+<8/2'6E-!![9'2+980'2+!&+<0+/6+6!/&8+6'(2!E(*+<#*+!64$8+6'6!/2&!2+#$0(98'*!<(#2$!
=(+6!#9@!!!
!
D. Electron microscopy of inflammatory cells:
,@!!12!*#2=;!$49+!11!92+(E(<4$+!?L*/<F!&($6!/0+!*46(6(E+6B@!
X/E+**/0!L(&'+6!7!6$0#<$#0+6!>8+0+!*+<'$8'2!/2&!98(698($'&4*!<8(*'2+!'6!*(</$+&U!')!/6F!>8+0+!
E/<0(98/=+;!'6;!>'**!/6F!>8'<8!E/F+6!6#0)/<$/2$@!
!
H@!!K(2(<4$+-!!6'2=*+!2#<*+#6!>'$8!/!=0/4'68!<4$(9*/6E!7!8/6!6</M/=+&U!</2!)(0E!)(/E!<+**!
'2!/$8+0(6<*+0($'<!9*/D#+!LZ<!'$!8/6!98/=(<4$'c+&!(:'&'c+&!X_XQ6!?>8'<8!'6!/!)0++!0/&'</*BU!k'$!
[!2+#$0/*'c+6!(:'&'c+&!X_X@!!!
!
P@!!X4E98(<4$+!7!/**!2#<*+#6!/2&!6</2$!<49$(9*/6E;!90(L!/!I!<+**!?aVW!()!9+0'98+0/*!L*((&!
*4E98(<4$+6!/0+!I!<+**6BU!0/$'(!()!8+*9+0!$(!6#990+66(0-!._^-._t!'6!?H-,B;!$8+0+)(0+;!E(0+!
*'F+*4!$(!L+!/!N+*9+0!I!<+**;!$8+2!/!6#990+66(0!Id<+**;!/2&!S!<+**6!?HVWB!/0+!*+/6$!*'F+*4@!
!
^@!!R[R!*((F6!*'F+!/!$8#EL90'2$;!8/M+!0'L(Q6!(2!'$;!/2&!*'F+6!$(!E/F+!90($+'26;!*'F+!1=Q6!
?$8+0+)(0+!'$!'6!/!9*/6E/!<+**B@!!K#*$'9*+!E4+*(E/!7!8/6!+<<+2$0'</**4!*(</$+&!2#<*+#6;!
<4$(9*/6E!'6!/*>/46!6F4!L*#+;!E/F'2=!9*/6E/!<+**6!+c!$(!0+<(=2'c+@!!J*/6E/!<+**6!/0+!&+0'M+&!
)0(E!S!<+**6;!/2&!*(</$+&!'2!$8+!=+0E'2/*!)(**'<*+@!
!
e@!!l0/2#*+6!7!+(6'2(98'*!?8/M+!/!0+&!<(*(0!6'E'*/0!$(!<(*(0!()!RS.Q6B!7!8/M+!<046$/*6!'2!$8+!
=0/2#*+6@!!![(6'2(98'*6!/0+!$8+!(2*4!'2)*/EE/$(04!<+**!$8/$!8/6!<046$/*6!'2!$8+!=0/2#*+6@!!I8+4!
/0+!</**+&!.8/0<($dX+'&+2!<046$/*6!>8+2!'$Q6!6++2!'2!$8+!69#$#E!()!/6$8E/$'<!9/$'+2$@!!I8+4!
/0+!&+=+2+0/$+&!+(6'2(98'*6!'2!69#$#E!()!/6$8E/$'<;!/2&!8/M+!)(0E+&!<046$/*6!$8/$!*((F!*'F+!
69+/0!8+/&6@!S/6(98'*6!8/M+!=0/2#*+6!$8/$!/0+!E(0+!9#09*'68!/2&!&/0F+0;!>8'*+!L/6(98'*6!
8/M+!&/0F+0!<(*(06@!
!
a@!!K+<8!)(0!F'**'2=!'2M/6'M+!8+*E'2$8+67I49+!11!NJb7E/3(0!L/6'<!90($+'2!'6!'2M(*M+&@!!
R+E+EL+0!$8/$!68'6$($(6(E+!+==6!/0+!<(/$+&!L4!1=[!%LQ6@!![(6'2(98'*6!8/M+!1=[!0+<+9$(06U!
$8+0+)(0+;!+(6'2(98'*6!8((F!'2$(!$8+!1=[!0+<+9$(0!/2&!0+*+/6+!<8+E'</*6U!$8+!E/'2!(2+!
0+*+/6+&!'6!E/3(0!!L/6'<!90($+'2;!>8'<8!&+6$0(46!$8+!8+*E'2$8;!>8'<8!'6!$49+!11!NJb;!LZ<!'$!'6!/!
<+**!8((F'2=!'2$(!/2!%L!(2!$8+!$/0=+$!<+**@!!I8+!+))+<$(0!<+**!'6!I49+!11!NJb!0:2!'6!$8+!
+(6'2(98'*6U!&(2Q$!=+$!<(2)#6+&!>'$8!I49+!1!NJb!0:2!>8+0+!$8+!+))+<$(0!<+**!'6!$8+!K%YI!
.[XX;!/2&!$8+4!0+*+/6+!8'6$/E'2+!?/2!+(6'2(98'*!<8+E($/<$'<!)/<$(0B;!$8+0+)(0+!$8+4!/0+!
'2M'$+&!$(!/0+/!()!$49+!1!NJb!LZ<!$8+4!8/M+!8'6$/E'2/6+!/2&!/04*6#*)/$/6+;!>8'<8!2+#$0/*'c+6!
*+#F($0'+2+6@!!I8+!9#09(6+!()!+(6'2(98'*6!'2!$49+!1!NJb!'6!$(!F2(<F!())!<8+E'</*!E+&'/$(06!
90(&#<+&!'2!0:2U!8(>+M+0;!>8+2!/2!+(6'2(98'*!F'**6!/2!'2M/6'M+!8+*E'2$8;!'$!&(+6!6(!M'/!$49+!
11!NJb@!!!
24

E. Cluster designations:
N+*9+0!$!<+**!C!._^!
.4$($(:'<!I!<+**!C!._t!
K/0F+0!)(0!%=!0+<(=2'$'(2!6'$+!!)(0!/**!I!<+**6!'6!._P!
K/0F+0!)(0!8'6$'(<4$+6!?'2<*#&'2=!*/2=+08/2Q6!<+**6B!'6!._,!
K/0F+0!)(0!K.!*+#F+E'/!'2!<8'*&0+2!C!._,V!?</**/!%=BU!9(6'$'M+!Sd<+**!*4E98(E/!
._,e!/2&!PV!C!RY!<+**!
._H,;!G2*4!(2!S!<+**6!7![96$+'2!L/00!M'0#6U!8((F6!'2$(!._H,!(2!S!<+**6;!/2&!/<$#/**4!$8+!
/$49'</*!*4E98(<4$+6!/0+!2($!Sd<+**6!L#$!Id<+**6!0+/<$'2=!$(!$8+!'2)+<$+&!Sd<+**6@!
S#0F'$$6!'6!/!S!<+**!*4E98(E/!!
._ê!'6!)(#2&!(2!/**!*+#F(<4$+6;!'6!/!<(EE(2!/2$'=+2!(2!+M+04$8'2=!
!
F. Fever!7!1Xd,!'6!0+69(26'L*+!/2&!Jl[H!?$8'6!'6!>8/$!$8+!849($8/*/E#6!'6!E/F'2=B!>8'<8!
6$'E#*/$+6!$8+!$8+0E(0+=#*/$(04!<+2$+0@!T+M+0!'6!=((&m!1$!0'=8$!68')$6!$8+!GH!&'66(<!<#0M+@!!g84!
&(!>+!>/2$!E(0+!GH!'2!$8+!$'66#+6!>'$8!/2!'2)+<$'(2n!SZ<!()!GH!&+9+2&+2$!E4+*(9+0(:'&/6+!
646$+E@!!I8+0+)(0+;!>'$8!/2$'940+$'<6!'$Q6!L/&!LZ<!$8>/0$'2=!$8+!E+<8/2'6E!()!=+$$'2=!GH!$(!
2+#$0(98'*6!/2&!E(2(<4$+6!$(!&(!>8/$!$8+4!&(!L+6$@!!%*6(;!8($!$+E96!'2!$8+!L(&4!/0+!2($!=((&!
)(0!0+90(&#<$'(2!()!L/<$+0'/ZM'0#6+6@!
!
II. Types of inflammation (scenarios)
%@!9(6$!9/0$#E!>(E/2;!>'$8!9#6!<(E'2=!(#$!()!*/<$')+0(#6!&#<$!7!$8'6!'6!6$/98!/#0+#6!7!
6#99*+0/$'M+!'2)*/EE/$'(2!
!
S@!S(2+!()!<8'*&!>'$8!6+96'6;!(2!$(9!()!$8+!L(2+;!>/6!/!4+**(>'68!/0+/;!/2&!'$!>/6!/2!/L6<+66!7!
(6$+(E4+*'$'6!7!6$/98@!/#0+#6U!')!$8+!F'&!8/&!6'<F*+!<+**;!'$!'6!6/*E(2+**/U!>84!/$!E+$/9846'6!()!
L(2+n!SZ<!E(6$!()!L*((&!6#99*4!=(+6!8+0+;!$8+0+)(0+;!E+<8/2'6E!()!690+/&!'6!8+E/$(=+2(#6!
?$8+0+)(0+!<(E+6!)0(E!/2($8+0!6(#0<+;!/2&!$8+2!'$!=+$6!$(!L(2+B@!!
!
.@!N($;!690+/&!(M+0!)/<+!7!<+**#*'$'6!&#+!$(!6$0+9!?9*/4!(&&6mB!=0(#9!%!94(=+2+6!
?</**+&!+046'9'*'6;!/2($8+0!2/E+!)(0!<+**#*'$'6B!
!
_@!!_'98$8+0'/!C!96#+&(E+EL0/2+!?<(042+L/<$+0'#E!&'98$8+0'/B;!/!=0/E!O!0(&;!$8/$!E/F+6!/2!
+:($(:'2;!E+66'2=!#9!0'L(64*/$'(2!()!90($'+26!M'/!+*(2=/$'(2!)/<$(0!H;!$8+!$(:'2!&/E/=+6!
E#<(6/Z6#LE#<(6/;!90(&#<'2=!/!96+#&(E+EL0/2+U!>8+2!L/<$+0'/!&(+62Q$!'2M/&+;!90(&#<+6!/!
$(:'2!$8/$!&/E/=+6!$8+!E+EL0/2+U!<*(6$0'&'#E!&'))'<'*+!/*6(!&(+6!$8'6@!!1$!/*6(!90(&#+<+6!/!
96+#&(E+EL0/2+!/2&!/!$(:'2;!>8'<8!>+!E+/6#0+!'2!6$((*!$(!E/F+!$8+!&:@!!I8+0+)(0+;!$8+!
/26>+0!'6!.@!&'))'<*+@!
!
[@!T'L0'2(#'6!9+0'</0&'$'6;!#6#/**4!>'$8!'2<0+/6+&!M+66+*!9+0E+/L'*'$4U!6++2!'2!?,B*#9#6;!*+/&'2=!$(!
)0'<$'(2!0#LU!/*6(!6++2!'2!?HB!$8+!)'06$!>++F!()!K1;!/2&!$8+2!/=/'2!a!>++F6!*/$+0!'2!&0+66*+06Q6!
642&0(E+;!?PB!6++2!'2!.(:6/<F'+!
!
T@!!K.!(0=/2'6E!90(&#<'2=!'2)+<$'(2!'2!$8'0&!&+=0++!L#026!C!96+#&(E(2/6!/#0'='2(6/@!.(*(0!()!
9#6-!=0++2!&#+!$(!94(<4/2'2@!
!
l@!!S/6/*!<+**!*/4+0!(2!L($8!6'&+6!()!<*($;!90(*')+0/$+;!/2&!=(!#2&+02+/$8!'$!$(!<*($@!!12!/!90'E/04!
>(#2&!'$Q6!#6#/**4!6+/*+&!())!'2!^t!806!?'+!/99+2&+<$(E4B@!!!5+4!$(!>(#2&!8+/*'2=!'6!90+6<+2<+!
25

()!=0/2#*/$'(2!$'66#+@!!T'L0(2+<$'2!'6!/!M+04!'E9(0$/2$!90($+(=*4</2!/2&!'6!'2M(*M+&!'2!$8+!8+/*'2=!
()!$8+!>(#2&@!!T'L0(2+<$'2!'6!/2!'E9(0$/2$!/&8+6'(2!/=+2$!/2&!<8+E($/<$'<!/=+2$;!'2M'$'2=!
)'L0(L*/6$!'2!8+*9'2=!8+/*'2=!90(<+66@!!I8+!=0/2#*/$'(2!$'66#+!6$/0$6!/$!&/4!P!/2&!'6!(2!'$6!90'E+!
L4!&/4!e@!!1)!4(#!+M+0!9'<F+&!/$!/!6</0!/2&!'$!L*++&!*'F+!E/&!/2&!4(#!$04!$(!6$(9!'$!L#$!'$!6$'**!
L*++&!*'F+!E/&;!$8/$Q6!=0/2#*/$'(2!$'66#+@!!"(!=0/2#*/$'(2!$'66#+!E+/26!2(!8+/*'2=!()!/!>(#2&@!!
I49+!()!<(**/=+2!'2!'2'$'/*!6$/=+!()!>(#2&!0+9/'0!C!$49+!PU!$49+!^!<(**/=+2!6++2!'2!SKU!$49+!,!7!
M+04!6$0(2=!$+26'*+!6$0+2=$8U!6++2!'2!L(2+;!6F'2;!$+2&(26;!*'=/E+2$6@!
!
%)$+0!/!)+>!E(2$86;!/)$+0!E(2$86;!$8+!<(**/=+2!$49+!P!'6!L0(F+2!&(>2!L4!<(**/=+2/6+6;!/2&!/!
E+$/**'<!+2c4E+!<(2M+0$6!$49+!P!'2$(!$49+!,@!!q'2<!'6!9/0$!()!$8+!E+$/**'<!+2c4E+;!$8'6!'6!>84!'2!/!
9$!>'$8!c'2<!&+)'<'+2<4!8/6!9((0!>(#2&!8+/*'2=!LZ<!'$!6<0+>6!#9!$8+!<(**/=+2/6+!?E#6$!0+9*/<+!
$49+!P!>'$8!$49+!,B@!K/:!$+26'*+!6$0+2=$8!/)$+0!P!E(2$86!C!tVW@!!K..!9((0!>(#2&!8+/*'2=!C!
'2)+<$'(2!
!
N@![8*+06!_/2*(6!7!&+)+<$!'2!<(**/=+2!&#+!$(!642ZL0+/F'2=!&(>2U!8/M+!9((0!>(#2&!8+/*'2=@!!
!
1@!E/0)/2!7!&+)+<$!'2!)'L0'*'2U!/*6(!8/M+!9((0!>(#2&!8+/*'2=!
!
f@!!J$!>'$8!6<#0M4!7!&+)+<$!'2!84&0(:4*/$'(2!()!$>(!//Q6!7!90(*'2+!/2&!*46'2+!M'/!/6<(0L'<!/<'&@!!!
R+E+EL+0!'$Q6!/!$0'9*+!8+*':U!>8/$!E/F+6!$8+!$0'9*+!8+*':!6$'<F!$(=+$8+0!/2&!'2<0+/6+!$+26'*+!
6$0+2=$8n!.0(66L0'&=+6@!!g8+2!4(#!<0(66L0'&=+!$8'2=6;!$8+4!/2<8(0!'2$(!/0+/6!>8+0+!4(#!8/M+!
84&0(:4*/$+&!90(*'2+!/2&!*46'2+@!I8+0+)(0+!8/M+!>+/F!/L2(0E/*!<(**/=+2!'2!6<#0M4!LZ<!$8+0+!/0+!
2(!<0(66L0'&=+6!$(!/$$/<8;!*+/&'2=!$(!2($!L+'2=!/L*+!$(!8+/*!>(#2&6;!8+E(008/='2=;!
8+E/0$80(6+6A@<(**/=+2!8/6!>+/F!$+26'*+!6$0+2=$8!LZ<!</22($!<0(66L0'&=+@@!
!
%#&'(!)'*+!e-!T*#'&!/2&!8+E(&42,!
!
5@!!l0/2#*/$'(2!$'66#+!>'$8!/!*($!()!L*((&!M+66+*6!&#+!$(!*($!()!)'L0(L*/6$!l;!>'$8!'2)*/EE/$(04!
<+**6!)0(E!9*/6E/!<+**6!/2&!*4E98(<4$+6;!2+<+66/04!)(0!>(#2&!8+/*'2=!?0'<8!M/6<#*/0!$'66#+;!
>8'<8!'6!/L6(*#$+*4!+66+2$'/*!)(0!2(0E/*!>(#2&!8+/*'2=B@!
!
X@!!5+*('&!?849+0$0(98'<!6</0B!C!+:<+66!'2!$49+!P!<(**/=+2!&+9(6'$'(2U!>8'<8!</#6+6!/!$#E(0!
*((F'2=!*+6'(26;!+69!'2!L*/<F6@!!12!/!>8'$+!F'&!7!F+*('&!$(!&#+!$(!$8'0&!&+=0++!L#026@!!12!/2($8+0!
+:/E9*+-!'2!/!<80(2'</**4!&0/'2'2=!6'2#6!$0/<$!()!$8+!6F'2;!$8+4!$0'+&!$(!9#$!/2$'L'($'<6!(2!'$!?&'&2Q$!
>(0FB;!$8+0+!>/6!/2!#*<+0/$'(2!*+6'(2!/$!$8+!(0')'<+!()!$8'6!<80(2'</**4!&0/'2'2=!$0/<$;!/2&!2($8'2=!
>(0F+&@!!g8/$!'6!'$n!I8+!/26>+0!'6!6D#/E(#6!<+**!</0<'2(E/!&#+!$(!/!*($!()!$#02(M+0U!$49+!P!
<(2M+0$+&!$(!$49+!,;!/2&!)'L0(L*/6$6!/0+!'2M(*M+&@!!%!*($!()!<+**!&'M'6'(2!(<<#00'2=;!>8'<8!</2!
90+6&'69(6+!$(!E#$/$'(26!/2&!</2<+0;!+69!6D#/E(#6!<+**!</2<+0@!!YD#/E(#6!</2<+0!'6!'E9!LZ<!
<80(2'</**4!&0/'2'2=!6'2#6!$0/<$6;!/2&!90+&'69(6+6!$(!6D/E(#6!<+**!</0<'2(E/@!N49+09*/6'/!
90+&'69(6+6!$(!6D#/E(#6!<+**!</0<'2(E/@!
!
III. Chronic inflammation
!
%@!!_'))+0+2<+!'2!1EE#2(=*(L#*'26-!
,@!!%<#$+!12)*/EE/$'(2-!1=K!C!E/'2!1=!)'06$;!/2&!$8+2!1=l!
1=K!C!E/'2!1=U!2++&!/!*($!()!<(E9*+E+2$!<(E9(2+2$6!'2!8+/*'2=!90(<+66U!1=K!'6!$8+!
E(6$!9($+2$!/<$'M/$(0;!/2&!8/M+!/<$'M/$'(2!()!<(E9*+E+2$!9/$8>/4!?/**!$8+!>/4!)(0!,drBU!
1=K!8/6!,V!/<$'M/$'2=!6'$+6!?9+2$/E+0B@!
!
26

1=l!</2!/<$'M/$+!$8+!<*/66'</*!646$+E;!L#$!&(+6!"GI!=(!9/66+&!.P!/2&!6$(96!/2&!&(+6!
2($!=(!(2$(!.edr@!
%)$+0!,V!&/46;!$8+0+!'6!'6($49+!6>'$<8'2=;!/2&!$8+!E#!8+/M4!<8/'2!'6!69*'<+&!(#$!?E#!
<8/'2!&+)'+6!69+<')'<'$4!()!/2!1=BU!'$!69*'<+6!'2!/!=/EE/!8+/M4!<8/'2;!/2&!1=l!'6!E/&+!M'/!
'6($49+!6>'$<8'2=!
H@!!.80(2'<!'2)*/EE/$'(2-!1=l!?/6!E/'2!1=!7!1=K!'6!<(M+0$+&!$(!1=l!'EE+&'/$+*4B!
!
S@!!_'))+0+2<+!'2!.+**!I49+6-!
,@!%<#$+!'2)*/EE$'(26!C!2+#$0(98'*!
H@!%<#$+!/**+0='<!0+/<$'(26C!+(6'2(98'*6!?E/6$!<+**6!/0+!'2!$'66#+6B!
P@!k'0/*!'2)+<$'(26!C!*4E98(<4$+6!/0+!$8+!E/'2!'2)*/EE/$(04!<+**6!
^@!.80(2'<!'2)*/EE/$'(26!C!E(2(<4$+6ZE/<0(98/=+6!/0+!'E9@!%2&!6++!/!*($!()!9*/6E/!<+**6!
/2&!*4E98(<4$+6U!&(!2($!6++!9#6d+:#&/$'M+!?$8'6!'6!'2!/<#$+!'2)*/EE!7!'2<0+/6+&!M+66+*!
9+0E+/L'*'$4;!/2&!'2<0+/6+&!+E'=0/$'(2!()!2+#$0(98'*6!'2$(!'2$+06$'$'/*!$'66#+;!/!90($+'2!0'<8!
)*#'&!>'$8!uP!=0/E6Z&X;!>'$8!/!90($+'2!0'<8!)*#'&!C!9#6B@![:/E9*+-!.8(*+<46$'6@!!!
!
.@!!I49+!1k!N49+06+26'$'M'$4!R+/<$'(2-!
%2($8+0!+:/E9*+-!!l0/2#*(E/!C!<80(2'<!'2)*/EE/$'(2!?2+M+0!/<#$+BU!'+!</6+'(#6!2+<0(6'6!'2!
6(E+(2+!>'$8!ISU!0(#2&'68;!9'2F;!E#*$'2#<*+/$+&!='/2$!<+**6!C!=0/2#*(E/6U!9/$8(=+2+6'6!C!
$49+!1k!849+06+2$'6$'M'$4!0+/<$'(2!7!&+*/4+&!NJb@!!I8+!E/'2!/<$(06!/0+!<4$(:'<!I!<+**6U!>8+2!
$8+4!F'**!2+(9*/6$'<;!M'0/**4!'2)+<$+&!<+**6;!$8+6+!/0+!/*6(!$49+!1k!NJb!?2(!%LQ6!'2M(*M+&B@!
J('6(2!'M4!C!$49+!1k!NJb@!!S/<F!$(!IS!'2)+<$'(2;!/*+(M*/0!E/<0(98/=+!98/=(<4$(6+6!'$;!/2&!
$8+0+!'6!*4E98(8+E($(=+2(#6!690+/&U!E+/2>8'*+!$8+!E/<0(98/=+!'6!90(<+66'2=!$8+!%=@!!
I8+2!/)$+0!>++F6;!'$!90+6+2$6!'$!$(!8+*9+0!I!<+**6@!!I8+0+)(0+;!$8+!F+4!9*/4+06!'2!I49+!1k!
849+06+26'$'M'$4!0:2!/0+!E/<0(98/=+6!>8'<8!90(<+66!$8/$!%=!/2&!90+6+2$6!$8/$!%=!M'/!<*/66!11!
KN.!6'$+6!$(!$8+!8+*9+0!I!<+**6@!I8+6+!8+*9+0!Id<+**6!0+*+/6+!<4$(F'2+6-!=/EE/!1T"!/2&!
E/<0(98/=+!'28'L'$(04!)/<$(0@!!l/EE/!1T"!>'**!/<$'M/$+!$8+!E/<0(98/=+!$(!F'**!$8+!IS;!
.049$(<(<<#6;!8'6$(9*/6E(6'6;!+$<@!!I8+0+)(0+!$8+!=/EE/!1T"!'6!$8+!$0'==+0!$(!/<$'M+!$8+!
E/<0(98/=+U!E/<0(98/=+!</22($!F'**!>'$8(#$!$8+!/<$'M/$'(2!)0(E!=/EE/!1T"U!LZ<!646$E+E'<!
)#2='!/2&!IS!8/M+!*'9'&!'2!$8+!<+**!>/**;!$8'6!*+/&6!$(!</6+(#6!2+<0(6'6@!!%**!$8+!9'2F!6$/'2'2=!
<+**6!/0+!]+9$8'*('&Q;!>8'<8!/0+!/<$'M/$+&!E/<0(98/=+6!?>8'<8!8/M+!L++2!/<$'M/$+&!L4!=/EE/!
1T"BU!>8+2!$8+4!&'+;!$8+4!&'+!'2!6$4*+!7!$8+4!)#6+!$(=+$8+0!/2&!)(0E!E#*$'2#<*+/$+&!='/2$!
<+**6!?*'F+!$8+'0!]=0/M+6$(2+QB@!!I8+0+)(0+;!+9'$8+*('&!<+**6!/0+!)#6+&!E/<0(98/=+6U!L*/<F!&($6!
/0+!8+*9+0!I!<+**6@!
I8+0+!/0+!$>(!$49+6!()!8+*9+0!Id<+**-!!
/@!Y#L6+$!,-!!'2M(*M+&!'2!I49+!1k!?&+*/4+&!$49+B!NJbU!E/<0(98/=+6!8/M+!1Xd,HU!
>8+2!'$!'6!6+<0+$+&;!$8+!6#L6+$!,!8+*9+0!I!<+**6!/0+!90+6+2$+&!>'$8!$8+!/2$'=+2U!$8+2;!
6#L6+$!,!L+<(E+!K[KGRb!I!<+**6@!!1Xd,H!'6!'2M(*M+&!'2!/<$'M/$'2=!$8+!E+E(04!()!
6#L6+$!,!8+*9+0!$!<+**6@!!K(6$!9+(9*+!'2!$8+'0!90'E/04!&c!#6#/**4!0+<(M+0!>'$8!2(!
90(L*+E6;!L#$!$8+!=0/2#*(E/6!</2!</*<')4;!/6!6++2!(2!:d0/4@!%!</*<')'+&!=0/2#*(E/!'6!
2($!&+/&!LZ<!$8+4!/0+!0+6'6$/2$!$(!&4'2=@!!I8+0+)(0+;!E(6$!</6+6!()!6+<(2&/04!IS!/0+!
&#+!$(!0+/<$'M/$'(2!IS@!!l0/2#*(E/6!2+<0(6'6!'6!&#+!$(!0+/<$'M/$'(2@!
!
iOj!JJ_!?9#0')'+&!90($+'2!&+0'M/$'M+B!7!'23+<$+&!'2$(!$8+!6F'2U!$8+!E/<0(98/=+!()!$8+!
6F'2!'6!/!*/2=+08/2Q6!<+**!?8'6$'(<4$+B!?E/0F+0-!._!,B!7!>8'<8!8/M+!L'0L+<F!=0/2#*+6d
*((F!*'F+!$+22'6!0/<F+$6!(2![K@!!I8+4!98/=(<4($(6+!$8+!%=!?$8+!JJ_B;!/2&!90(<+66!'$!
M+04!D#'<F*4U!$8+4!90+6+2$!'$!$(!8+*9+0!6#L6+$!,;!>8'<8!8/6!E+E(04!()!90+M'(#6!
+:9(6#0+@!I8+0+)(0+;!'$!8((F6!'2!$8+!KN.!<*/66!11!%=!6'$+6!?/6!/**!'EE#2+!<+**6!&(B;!
/2&!(2<+!$8+!%=!?JJ_!90(<+66+&!L4!$8+!*/2=+08/2Q6!<+**B!'6!90+6+2$+&;!$8+!8+*9+0!I!
27

<+**!0+*+/6+6!$8+!<4$(F'2+6!90(&#<'2=!$8+!'2)*/EE/$(04!0:2!>'$8!'2&#0/$'(2!</**+&!$8+!
iOj!JJ_@!
!
.(00+*/$'(2-!(*&+0!9+(9*+!#6#/**4!&(2Q$!8(6$!/!M+04!=((&!I49+!1k!849+06+26'$'$4!0:2-!!
$8+4!8/M+!/!*+66!0+69(26+!$(!iOj!JJ_U!$8+0+)(0+!8/M+!$(!&(!/!&(#L*+!$+6$!(2!$8+E@!!
12!9$!>'$8!%1_6;!E/4!2($!=+$!/24!0:2@!!I8+4!&(2Q$!8/M+!+2(#=8!8+*9+0!Id<+**6!
$8+0+)(0+!&(2Q$!8/M+!=0/2#*(E/!)(0E/$'(2@!!K/<0(98/=+!'28'L'$(04!)/<$(0!F++96!
E/<0(98/=+6!'2!$8/$!/0+/U!$8+0+)(0+;!>'$8!N1k;!LZ<!$8+!8+*9+0!$!<+**!<$!'6!&+<0+/6+&;!
4(#!&(2Q$!)(0E!=0/2#*(E/6!/$!/**@!!I8+0+)(0+;!$8+4!>'**!8/M+!K%1!?(0=/2'6E6B!/**!(M+0!
$8+!L(&4!>'$8(#$!=0/2#*(E/6!LZ<!8+*9+0!I!<+**6!/0+!&+<0+/6+&@!!g8+2!4(#!&(!iOj!
JJ_;!e!EE!'2&#0/$'(2!'6!+2(#=8!$(!6/4!'$Q6!9(6'$'M+@!@!
!
IV. Tissue Repair
Y</0!$'66#+ ?LZ<!'$6!9+0E/2+2$!$'66#+BU!6</0!$'66#+!?)'L0(#6!$'66#+B!&(+6!2($!<(2$0/<$U!$8+0+)(0+;!')!
4(#!8/M+!E(0+!6</0!$'66#+!$(!)0++!>/**!()!*+)$!M+$0'<*+!>'**!*+/&!$(!&+<0+/6+&!+3+<$'(2!)0/<$'(2!?>8'<8!
'6!6$0(F+!M(*#E+!&'M'&+&!L4![_kB@!!!
!
%@!!R+69(26+!()!5'&2+46!$(!123#04-!5'&2+4!>'**!)(0E!6</0!$'66#+U!E+&#**/!'6!E(6$!6#6<+9$'L*+!$(!
'6<8+E'/!?LZ<!*+/6$!/E(#2$!()!L*((&!6#99*4B@!!g8/$!9/0$!()!2+980(2!E(6$!6#6<+9$'L*+!$(!$'66#+!
849(:'/n!H!9*/<+6-!
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L0#68!L(0&+06!7!$8'6!'6!>8+0+!E(6$!()!0+/L6(09$'(2!()!"/;!/2&!0+<*/'E'2=!()!L'</0L!'6!$8+0+@!!!
!
H@!K+&#**/04!6+=E+2$!()!$8'<F!/6<+2&'2=!*'EL!7!>8+0+!$8+!"/Z5dH.*!9#E9!'6!7!>8'<8!'6!
>8+0+!*((9!&'#0+$'<6!L*(<F@!!I8+!"/Z5dH.*!9#E9!=+2+0/$+6!)0++!>/$+0@!!I8+!$>(!$49+!()!
>/$+0!'2!#0'2+-!(L*'=/$+&!/2&!)0++@!!1)!$8+!>/$+0!'6!(L*'=/$+&;!$8+2!$8+!>/$+0!'6!(L*'=/$+&!$(!
=(!(#$!>'$8!+M+04!"/;!5;!/2&!.*!?<(2<+2$0/$+&!#0+/B@!S/6'</**4!HV!E*Q6!()!(L*'=/$+&!>/$+0!)(0!
+M+04!"/;!5;!.*!?'$Q6!(L*'=/$+&B!M'/!"/Z5ZH.*!9#E9@!!I8+!%_N!8(0E(2+!/L6(0L6!)0++!>/$+0!
LZ<!$8+!9#E9!=+2+0/$+6!)0++!>/$+0@!!!
!
X+$Q6!6/4!4(#!/L6(0L!(2+!"/;!8(>!E#<8!)0++!>/$+0!'6!*+)$!L+8'2&!'2!$8+!#0'2+n!7!HV!E*6U!$8+2!
0+/L6(0L+&!/2($8+0!5;!$8/$!'6!/2($8+0!HV;!6(!'$6!#9!$(!^VU!/2($8+0!H!.*Q6!/0+!0+/L6(0L+&!
>8'<8!'6!/2($8+0!^VU!$8+0+)(0+;!)(0!/L6(0L'2=!(2+!"/;!(2+!5;!/2&!H!.*Q6;!4(#!8/M+!$/F+2!tV!
E*6!()!)0++!>/$+0!)0(E!$8+!#0'2+!7!$8'6!'6!)0++!>/$+0!$8/$!'6!=+2+0/$+&U!'$6!'6!$8'6!9#E9!$8/$!
*((9!&'#0+$'<6!L*(<F;!>8'<8!'6!'2!$8+!$8'<F!/6<+2&'2=!*'EL!()!$8+!E+&#**/04!6+=E+2$@!!
!
S@!!X#2=!0+9/'0!<+**!'6!$49+!11!92+#E(<4$+!?</2!/*6(!0+9/'0!$49+!1!92+#E(<4$+6BU!'$!/*6(!
642$8+6'c+6!6#0)/<$/2$@!!!
!
.@!!."Y!7!0+9/'0!<+**!'6!$8+!/6$0(<4$+U!$8+!/6$0(<4$+!90(*')+0/$+6!?LZ<!'$Q6!/!6$/L*+!<+**;!2($!/!
2+#0(2B;!$8/$!</2!90(*')+0/$+!/2&!90(&#<+6!90($(9*/6E'<!90(<+66+6!7!</**+&!=*'(6'6!?0:2!$(!'23#04!
'2!$8+!L0/'2;!>8'<8!'6!&#+!$(!/6$0(<4$+!90(*')+0/$'(2BU!$8'6!'6!/2/*(=(#6!$(!)'L0(L*/6$6!*/4'2=!
<(**/=+2!$49+!P!'2!$8+!>(#2&@!
!
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12!J"Y;!8/M+!Y<8>/22!<+**6;!>8'*+!'2!$8+!."Y;!8/M+!(*'=(&+2&0(<4$+6!
?L($8!E/F+!E4+*'2B@!!I#E(0!Y<8>/22!<+**!C!6<8>/22(E/U!')!'$!'2M(*M+6!."!k111!'$!'6!</**+&!
/<(#6$'<!2+#0(E/@!!g8/$!=+2+$'<!&c!$8/$!'6!/#$(!&(E'2/2$!8/6!/66(<'/$'(2n!"+#0()'L0(E/$(#6@!!
28

!
?Y'&+!2($+-!E4/6$8+2'/!=0/M'6!7!$+26'*(2!'23+<$'(2!>'**!'2<0+/6+!%<8!'2!642/96+6!'2!+4+*'&6;!/2&!
E4/6$8+2'<!<0'6'6!>'**!+2&B!
!
!
V. Extra Side notes and Review of Inflammation:
!
%@!![YR!7!9#$$'2=!>8(*+!L*((&!'2$(!<4*'2&+0!/2&!6++!>8+2!'$!6+$$*+6@!!I8+!8'=8+0!$8+!&+26'$4;!(0!
>+'=8$;!$8+0+)(0+!6+$$*+!90+$$4!D#'<F!/2&!$8+0+)(0+!8/M+!/!'2<0+/6+!6+&'E+2$/$'(2!0/$+@!!g8+2!
6$#<F!$(=+$8+0!/2&!*((F6!*'F+!<('26!C!0(#*(#+:@!!g8+2!/==0+=/$+&!$(=+$8+0!C!'2<0+/6+&!6+&!
0/$+;!>8'<8!'6!'2<0+/6+&!1=l!/2&!)'L0'2(=+2!?'2<*#&+6!+M+04!/<#$+!/2&!<80(2'<!'2)*/EE/$'(2!$8+0+!
'6@!!g8/$!</#6+6!RS.Q6!$(!<*#E9!7!1=K;!LZ<!$8+!2+=!<8/0=+!2(0E/**4!F++96!RS.Q6!)0(E!6$'<F!$(!
+Z(@!!1=K!'6!/!*($!L'==+0U!<(*&!/==*#$'2'26!/0+!/66(<'/$+&!>'$8!1=K!/L;!*+/&'2=!$(!/==*#$'2'2@!!I8'6!
'6!>84!'2!<(*&!>8+$8+0;!4(#!=+$!R/42/#&Q6!98+2(E+2(2!?*'96;!2(6+;!+/06;!$(+6;!)'2=+06!$#02!
L*#+B@!!I8+!1=K!/L!</2!</#6+!<(*&!/==*#$'2'26;!*+/&'2=!$(!'6<8+E'/@!%2($8+0!$49+!()!<*#E9'2=!()!
1=K!/0+!.04(=*(L#*'26!7!1=Q6!<(2=+/*!'2!<(*&!>+/$8+0U!1=K!/LQ6!&(!$8+!6/E+!$8'2=@!!N'=8!/66(<!()!
8+9!.!>'$8!<04(=*(L#*'26@!!K#*$!E4*+(E/!C!'2<0+/6+&!+60!LZ<!'2<0+/6+&!1=lU!>'$8!>/*&+26$0(E6;!
>'**!6++!'2<0+/6+&!1=K!?g/*&+26$0(EQ6!K/<0(=*(L+E'/B@!!
!
S@!!%<#$+!/99+2&'<'$'6!7!=+$!.S.;!/2&!>/2$!$(!6++!/L6(*#$+!2+#$0(98'*'<!*+#F(<4$(6'6;!E+/2'2=!
$8/$!4(#!8/M+!/2!'2<0+/6+!()!2+#$0(98'*6!'2!$8+!9+0'98+0/*!L*((&U!/*6(!*((F'2=!)(0!$(:'<!
=0/2#*/$'(2;!/2&!/!X[TI!YN1TI@!!%66#E'2=!4(#!6$/0$!)0(E!E4+*(L*/6$!(2!$8+!*+)$;!/2&!+M+2$#/**4!
)(0E!/!6+=E+2$+&!2+#$0(98'*!(2!$8+!0'=8$U!2(0E/**4!=(!*+)$!$(!0'=8$!(2!E/$#0/$'(2U!$8+0+)(0+;!
>'$8!/!*+)$!68')$;!'$6!E+/26!$8/$!>+!=(!L/<F!$(!'EE/$#0+!2+#$0(98'*6U!$8+!&+)'2'$'(26!'6!=0+/$+0!
$8/2!,VW!L/2&!2+#$0(98'*6!'6!<(26'&+0+&!/!X[TI!YN1TI!?/**!$8+!2+#$0(98'*6!/0+!L/2&6BU!')!4(#!
8/M+!3#6$!(2+!E+$/E4+*(<4$+!(0!(2+!E4+*(<4$+;!'$6!'6!/#$(E/$'</**4!<(26'&+0+&!/!X[TI!YN1TI@!!
12!/<#$+!/99+2&'<'$'6;!$8+0+!'6!/2!/L6(*#$+!'2<0+/6+!'2!2+#$0(98'*6;!>'$8!$(:'<!=0/2#*/$'(2!/2&!/!
*+)$!68')$@!!!
!
.@!!K(6$!9($+2$!646$+E!)(0!F'**'2=!L#=6!C!GH!&+9+2&+2$!E4+*(9+0(:'&/6+!646$+EU!
K4+*(9+0(:'&/6+!'6!*(</$+&!'2!/c#0(98'*'<!=0/2#*+6;!>8'<8!/0+!*46(6(E+6@!
g/2$!/!*($!()!*46(6(E+!'2!/2!/<#$+!'2)*/EE/$(04!0:2;!LZ<!$8+0+)(0+!$8+0+!'6!E(0+!
E4+*(9+0(:'&/6+!/0(#2&!)(0!F'**'2=!L#=6!7!$8'6!'6!>8/$!$(:'<!=0/2#*/$'(2@!
I8+0+)(0+;!$(:'<!=0/2#*/$'(2!+26#0+6!$8/$!$8+0+!'6!+2(#=8!E4+*(9+0(:'&/6+!$(!>(0F!$8/$!9($+2$!
646$+E!$(!F'**!L#=6!?GH!&+9!E4+*(9+0(:'&/6+!646$+EB@!
CHAPTER 3: FLUID AND HEMODYNAMICS
!
I. Edema 7!+:<+66!)*#'&!'2!$8+!'2$+06$'$'/*!69/<+;!>8'<8!'6!+:$0/<+**#*/0!)*#'&!?[.TBU!$8'6!'6!(#$6'&+!$8+!
M+66+*!
A. Types of Edema
!
,@!!"(2dJ'$$'2=!+&+E/!7!'2<0+/6+&!M+66+*!9+0E+/L'*'$4!>'$8!9#6!'2!$8+!'2$+06$'/*!69/<+!
?9#6C+:#&/$+6B@!!X4E98/$'<!)*#'&!'6!/2($8+0!$49+!()!2(2d9'$$'2=!+&+E/@!!S*(<F/=+!()!
*4E98/$'<6!*+/&6!$(!*4E98/$'<!)*#'&!'2!$8+!'2$+06$'/*!69/<+@!!J'$6!+/0*4;!L#$!+M+2$#/**4!L+<(E+6!
2(29'$$'2=@!![:#&/$+6!/2&!*4E98/$'<!)*#'&!&(+6!2($!9'$@!
!
H@!!J'$$'2=!+&+E/!7!$0/26#&/$+!>'$8!0'=8$!8+/0$!)/'*#0+;!6>+**'2=!()!$8+!*(>+0!+:$0+E'$'+6;!)*#'&!
'2!$8+!'2$+06$'/*!69/<+@!I0/26#&/$+!&(+6!9'$@!
29

!
P@!!Y(!$8+0+!/0+!$80++!$8'2=6!$8/$!</#6+!+&+E/-!+:#&/$+6;!*4E98+&+E/;!/2&!$0/26#&/$+;!/2&!
$0/26#&/$+6!/0+!$8+!(2*4!(2+!$8/$!8/6!9'$$'2=!+&+E/@!
!
B. Transudate/Pitting Edema
I0/26#&/$+!&+/*6!>'$8!6$/0*'2=!)(0<+6-!!
!
,@!!g8/$!F++96!)*#'&!'2!(#0!L*((&!M+66+*6n!%*L#E'2;!/2&!$8'6!'6!</**+&!(2<($'<!90+66#0+@!!tVW!
()!(#0!(2<($'<!90+66#0+!'6!0+*/$+&!$(!$8+!6+0#E!/*L#E'2!*+M+*6@!!%24$'E+!$8+0+!'6!
849(/*L#E'2+E'/!$8+2!>+!>'**!8/M+!/!*+/F'2=!()!/!$0/26#&/$+!?90($+'2!()!*+66!$8/2!P!=Z&XB!
*+/F'2=!'2$(!'2$+06$'/*!69/<+!M'/!</9'**/0'+6!/2&!M+2#*+6!?9'$$'2=!+&+E/BU!!
!
H@!!"(0E/**4;!84&0(6$/$'<!90+66#0+!'6!$04'2=!$(!9#68!)*#'&!(#$@!I8+0+)(0+;!'2!/!2(0E/*!9+06(2;!
(2<($'<!90+66#0+!'6!>'22'2=@!!I8+0+)(0+;!/!&+<0+/6+!'2!(2<($'<!90+66#0+!/2&!/2!'2<0+/6+!'2!
84&0(6$/$'<!90+66#0+!>'**!*+/&!$(!$0/26#&/$+!?9'$$'2=!+&+E/B@!!!
!
P@!!%*L#E'2!'6!E/&+!'2!$8+!*'M+0@!!g'$8!<80(2'<!*'M+0!&c!?<'008(6'6B;!8/M+!/!&+<0+/6+&!/*L#E'2!
*+M+*@!!./2!4(#!M(E'$!'$!(#$n!"(@!!./2!<0/9!'$!(#$!?E/*/L6(09$'(2!642&0(E+B;!(0!</2!9++!'$!
(#$!?2+980($'<!642&0(E+B;!</2!<(E+!())!(#0!6F'2!?P0&!&+=0++!L#02!LZ<!*(6'2=!9*/6E/B;!
/2($8+0!9(66'L'*'$4!()!*(>!90($+'2!<$!?*(>d'2$/F+B!'6!6++2!'2!F'&6!7!5>/68'(0F(0!7!F'&!8/6!)/$$4!
*'M+0!/2&!&+<0+/6+&!90($+'2!'2$/F+;!*+/&'2=!$(!*(>!/*L#E'2!*+M+*@!!
!
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30

$0/<8(E/$/7!6</00'2=!$'66#0+!/2&!*4E98/$'<6;!*+/&'2=!$(!*4E98+&+E/!()!6<0($#E!
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!
II. Renal Physio
A. ECF/ICF
[.T!?,ZPB!C!+:$0/<+**#*/0!)*#'&!()!$>(!<(E9/0$E+2$6!7!M/6<#*/0!?,ZPB!/2&!'2$+06$'$'/*!?HZPB!
1.T!?HZPB!C!'2$0/<+**#*/0!)*#'&!<(E9/0$E+2$!
!
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P!X'$+06!?HZP-,ZP!0+*/$'(268'9BU!H!*'$+06!'2!'2$+06$'/*!69/<+;!/2&!,!X!>(#*&!=(!$(!$8+!M/6<#*/0!
69/<+U!'$!+D#'*'L0/$+6!>'$8!'2$+06$'/*ZM/6<#*/0!<(E9/0$E+2$6@!
!
B. Osmolality!C!E+/6#0+!()!6(*#$+6!'2!/!)*#'&U!&#+!$(!$80++!$8'2=6-!"/;!=*#<(6+;!/2&!L*((&!
#0+/!2'$0(=+2!?S\"B!7!#0+/!<4<*+!'6!*(</$+&!'2!$8+!*'M+0;!9/0$*4!'2!$8+!<4$(6(*!/2&!9/0$*4!'2!$8+!
E'$(<8(2&0'/U!#6#/**4!E#*$'9*4!"/!$'E+6!H!?LZ<!(2+!"/!/2&!(2+!.*B@!!
!
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!
C. Osmosis!
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31

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!
D. Tonicity!7!'6($(2'<!6$/$+;!849($(2'<!6$/$+;!/2&!849+0$(2'<!6$/$+!
g+!8/M+!/**!&'))+0+2$!$49+6!()!6/*'2+-!16($(2'<!6/*'2+;!849($(2'<!6/*'2+!?,ZH!2(0E/*!6/*'2+;!v!
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!
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!
1)!>+!8/M+!/2!isotonic gain;!>+!8/M+!'2!+D#/*!'2<0+/6+!'2!6/*$!/2&!>/$+0U!'+!6(E+(2+!
=+$$'2=!$((!E#<8!'6($(2'<!6/*'2+U!2(0E/*!6+0#E!"/;!+:<+66!'6($(2'<!"/!>(#*&!L+!'2!$8+![.T;!
/2&!$8+0+!>(#*&!L+!2(!(6E($'<!=0/&'+2$!)(0!>/$+0!E(M+E+2$@!
!
H@!!Hypotonic solutions!7!L4!&+)'2'$'(2;!'$!E+/26!849(2/$0+E'/@!!N49(=*4<+E'/!>'**!2($!
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X(6+!E(0+!6/*$!$8/2!>/$+0;!$8+0+)(0+;!6+0#E!"/!>(#*&!L+!&+<0+/6+&@!!1)!*(6'2=!E(0+!6/*$!
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32
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!
[:/E9*+-!l/'2!L($8!>/$+0!/2&!6/*$;!L#$!E(0+!>/$+0!$8/2!6/*$;!*+/&'2=!$(!849(2/$0+E'/!7!
$8+6+!/0+!$8+!9'$$'2=!+&+E/!6$/$+6!7!'+!RNT;!<'008(6'6!()!$8+!*'M+0@!!g8+2!$($/*!L(&4!"/!'6!
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[.T!!g8/$!'6!$8+!L'==+6$![.T!<(E9/0$E+2$n!12$+06$'/*!<(E9/0$E+2$@!!I8+0+)(0+;!'2<0+/6+!
'2!$($/*!L(&4!"/!>'**!*+/&!$(!+:9/26'(2!()!'2$+06$'/*!<(E9/0$E+2$!()!$8+![.T;!>/$+0!>'**!
)(**(>!$8+!"/;!$8+0+)(0+!4(#!=+$!+:9/26'(2!M'/!$0/26#&/$+!/2&!9'$$'2=!+&+E/U!6++2!'2!
0'=8$!NT!/2&!<'008(6'6@!!!!
!
[:/E9*+-!849+0$(2'<!*(66!()!6/*$!?)0(E!&'#0+$'<B!*+/&6!$(!849(2/$0+E'/!
!
[:/E9*+-!Y1%_N!?=/'2'2=!/!*($!()!>/$+0B!*+/&6!$(!849(2/$0+E'/!
!
[:/E9*+-!=/'2'2=!E(0+!>/$+0!$8/2!6/*$!>'**!*+/&!$(!849(2/$0+E'/-!9'$$'2=!+&+E/!
P@!!Hypertonic state!7!L4!&+)'2'$'(2;!8/M+!$((!E#<8!"/!?849+02/$0+E'/B!(0!8/M+!
849+0=*4<+E'/!?'+!9$!>'$8!_5%!8/6!/!849+0$(2'<!<(2&'$'(2;!>8'<8!'6!E(0+!<(EE(2!$8/2!
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(0!680#2F+2@!!!
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!
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>/$+0!$8/2!6/*$!'2!$8+!#0'2+;!4(#!8/M+!(6E($'<!&'#0+6'6!7!E':$#0+@!!g8+2!$8+0+!'6!=*#<(6+!/2&!
E/22'$(*!'2!$8+!#0'2+;!4(#Q0+!*(6'2=!849($(2'<!6/*$!6(*#$'(2!'2!#0'2+@!!!
!
[:/E9*+-!!S/L4!&'/008+/!C!849($(2'<!6/*$!6(*#$'(2!?/&#*$!&'/008+/!'6!'6($(2'<B;!$8+0+)(0+;!')!
L/L4!8/6!2(!/<<+66!$(!>/$+0!/2&!8/6!/!0($/M'0#6!'2)+<$'(2;!6+0#E!6(&'#E!68(#*&!L+!8'=8!
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$8+!L/L4!>/$+0!$(!<(00+<$!$8+!&'/008+/U!$8+0+)(0+!$8+!L/L4!>'**!<(E+!'2!>'$8!2(0E/*!6+0#E!
"/!(0!+M+2!849(2/$0+E'/!LZ<!$8+!&+2(E'2/$(0!?NHGB!'6!'2<0+/6+&@!!I0+/$E+2$!'6!9+&'/*4$+!
/2&!l/$(0/&+!7!$8+6+!/0+!849($(2'<!6/*$!6(*#$'(2!?3#6$!='M+!$8+E!L/<F!>8/$!$8+4!*(6$B@!!g8/$!
8/6!$(!L+!'2!9+&'/*4$+!/2&!>8/$!8/6!$(!L+!'2!l/$(0/&+!$(!(0&+0!$(!0+/L6(0L!$8+!"/!'2!$8+!l1!
$0/<$n!!l*#<(6+!LZ<!()!$8+!<(d$0/269(0$@!!g'$8!$8+!<(d$0/269(0$;!$8+!"/!N%Y!$(!L+!0+/L6(0L+&!
>'$8!=*#<(6+!(0!=/*/<$(6+@!![:/E9*+-!<8(*+0/;!'2!(0/*!0+9*/<+E+2$;!2++&!=*#<(6+!$(!0+/L6(0L!
"/!LZ<!<(d$0/269(0$!9#E9!*(</$+&!'2!$8+!6E/**!'2$+6$'2+@!!l/$(0/&+!8/6!=*#<(6+!/2&!6#<0(6+!
?>8'<8!'6!<(2M+0$+&!$(!)0#<$(6+!/2&!=*#<(6+B@!
33

!
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849+02/$0+E'/!
!
E. Volume Compartments
%0$+0'/*!L*((&!M(*#E+!'6!6/E+!/6!6$0(F+!M(*#E+!/2&!.G!?</0&'/<!(#$9#$B@!!g8+2!.G!
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+66+2$'/*!$(!(#0!L(&'+6@!!!
!
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M+2(#6!6'&+;!>8'*+!$8+!8'=8!90+66#0+!(2+6!/0+!(2!$8+!/0$+0'/*!6'&+!?'+!$8+!</0($'&6!/2&!/0<8!()!
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$'66#+6!?L/&!2+>6BU!=((&!2+>6-!F++9!#9!&'/6$(*'<!90+66#0+!7!$8'6!'6!'E9(0$/2$!LZ<!$8+!
<(0(2/04!/0$+0'+6!)'**!'2!&'/6$(*+6@!I8'6!'6!/**!&(2+!>'$8!</$+<8(*/E'2+6@!!R+2'2!646$+E!'6!
/<$'M/$+&!L4!</$+<8(*/E'2+6;!$((U!/2='($+26'2!11!</2!M/6(<(26$0'<$(0!$8+!9+0'98+0/*!/0$+0'(*+6!
?$8+0+)(0+!'$!8+*96!$8+!</$+<8(*/E'2+6B@!!%l!11!6$'E#*/$+6!,t!84&0(:4*/6+;!>8'<8!<(2M+0$6!
<(0$'<(6$+0(2+!'2$(!/*&(6$+0(2+;!/2&!6$'E#*/$+6!/*&(6$+0(2+!0+*+/6+;!>8'<8!*+/&6!$(!
0+/L6(09$'(2!()!6/*$!/2&!>/$+0!$(!=+$!</0&'/<!(#$9#$!#9@!!!
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/99/0/$#6n!%))+0+2$!/0$+0'(*+@!I8+0+!/0+!6+26(06;!>8'<8!/0+!E(&')'+&!6E(($8!E#6<*+!<+**6!
$8/$!6+26+!L*((&!)*(>@!!%_N!>'**!L+!0+*+/6+&!)0(E!/!2+0M+!0+69(26+;!/2&!9#0+!>/$+0!>'**!
'2<0+/6+!L#$!$8/$!&(+6!2($!8+*9!>'$8!'2<0+/6'2=!$8+!</0&'/<!(#$9#$@!!"++&!6/*$!$(!'2<0+/6+!.G@!!!
!
[:/E9*+-!L*++&'2=!$(!&+/$8!/2&!$8+0+!'6!/!*(66!()!P!XQ6!()!)*#'&!7!8(>!</2!4(#!F++9!SJ!#9n!
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$(2'<'$4!()!9*/6E/@!"(0E/*!6/*'2+!'6!V@rW@!!!
!
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tVWB@!!g8+0+!'6!$8+!0+6$!/L6(0L+&nU!'2!$8+!&'6$/*!/2&!<(**+<$'2=!$#L#*+!L4!/*&(6$+0(2+@!!I8+!
"/!'6!0+/L6(0L+&!'2$(!$8+!9+0'$#L#*/0!</9'**/0'+6@!!Y$/0*'2=!)(0<+6!'2!$8+!</9'**/0'+6!E#6$!L+!
/E+2/L*+!$(!'$@!!I>(!6$/0*'2=!)(0<+6-!(2<($'<!90+66#0+!?F++96!)*#'&6!'2!$8+!M+66+*B!/2&!
84&0(6$/$'<!?9#68+6!)*#'&6!(#$!()!M+66+*B@!!!
34

!
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$(!$8+!9+0'$#L#*/0!</9'**/04!84&0(6$/$'<!90+66#0+n!1$!&+<0+/6+6@!!I8+0+)(0+;!$8+!9+0'$#L#*/0!
(2<($'<!90+66#0+!'6!'2<0+/6'2=!?'+!$8+!)(0<+!$8/$!F++96!)*#'&6!'2!$8+!M+66+*B;!/2&!$8/$!'6!
0+69(26'L*+!)(0!0+/L6(09$'(2!()!/24$8'2=!'2$(!$8+!L*((&!6$0+/E!)0(E!$8+!F'&2+4@!!I8'6!'6!>84!
JG!?9+0'$#L#*/0!(2<($'<!90+66#0+B!u!JN!?84&0(6$/$'<!90+66#0+!()!9+0'$#L#*/0!</9'**/04B;!/**(>6!
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!
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$8+!%_N!+))+<$!/2&!$8+!9$!L+<(E+6!6*'=8$*4!849(2/$0+E'<!/2&!849($(2'<;!$8+0+)(0+!/L6(0L6!
'2$(!$8+![.T!<(E9/0$E+2$!>8+2!$8+0+!'6!/!&+<0+/6+&!.G@!
!
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'2<0+/6+!'2!$8+!)(0<+!()!<(2$0/<$'(2!()!$8+!8+/0$@!!I8'6!'6!)*#'&!(M+0*(/&U!$8+0+)(0+!>+!2++&!$(!
=+$!0'&!()!/**!$8+!M(*#E+@!!I8+0+!'6!'2<0+/6+&!0+2/*!L*((&!)*(>;!6(!$8+!R%%!>'**!2($!L+!
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/2&!'$!>(#*&!L+!9++Q&!(#$@!I8+0+)(0+!9$!'6!*(6'2=!849($(2'<!6/*$!6(*#$'(2!>'$8!'2<0+/6+&!'2!
/0$+0'/*!L*((&!M(*#E+@!!!
!
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)0(E!$8+!/$0'/;!/2&!='M+!())!&'#0+$'<!+))+<$U!'$!>/2$6!$(!=+$!0'&!6/*$@!!%"J!'6!(2*4!0+*+/6+&!'2!
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!
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>'**!$8/$!&(!$(!6+0#E!%_Nn!12<0+/6+!7!'2<0+/6+!()!(6E(*/*'$4!</#6+6!/!0+*+/6+!()!%_N@!!!
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!
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!
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!
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!
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>'$8!/!&+<0+/6+&!.G!?*'$$*+!E(0+!>/$+0!$8/2!6/*$B;!$8+0+)(0+!6+0#E!"/!>'**!*(>@!!"#E+0/$(0!'6!
'2<0+/6+&!)(0!$($/*!L(&4!6(&'#E;!L#$!&+2(E'2/$(0!8/6!*/0=+0!'2<0+/6+!>'$8!>/$+0@!
!
35

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!
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!
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III. Shock
!
A. Causes of hypovolemic shock 7!&'/008+/;!L*((&!*(66;!<8(*+0/;!6>+/$'2=;!2($!_1!?LZ<!*(6'2=!
9#0+!>/$+0;!/2&!2($!*(6'2=!"/;!$($/*!L(&4!"/!'6!"GRK%Xm!X(6'2=!>/$+0!)0(E!1.TU!2(!6'=26!()!
&+84&0/$'(2U!>8+2!4(#!*(6+!6/*$;!68(>!6'=26!()!&+84&0/$'(2B@!
!
[:/E9*+-!!!*/&4!>'$8!849(M(*+E'<!68(<F!7!>8+2!68+!>/6!*4'2=!&(>2;!8+0!SJ!/2&!9#*6+!>+0+!
2(0E/*U!>8+2!$8+4!6/$!8+0!#9;!$8+!SJ!&+<0+/6+&!/2&!9#*6+!>+2$!#9@!!g8/$!&(+6!$8'6!
'2&'</$+n!I8/$!68+!'6!M(*#E+!&+9*+$+&@!I8'6!'6!</**+&!$8+!I1XI!$+6$@!!"(0E/*!SJ!>8+2!*4'2=!
&(>2!LZ<!$8+0+!'6!2(!+))+<$'M+!=0/M'$4;!$8+0+)(0+!2(0E/*!L*((&!0+$#02'2=!$(!$8+!0'=8$!6'&+!()!
$8+!8+/0$;!/2&!2(0E/*!.G@!!N(>+M+0;!>8+2!4(#!6'$!$8+!9/$'+2$!#9;!/2&!'E9(6+!=0/M'$4;!4(#!
&+<0+/6+!$8+!M+2(#6!0+$#02!$(!0'=8$!8+/0$@!!Y(;!')!4(#!/0+!849(M(*+E'<;!'$!>'**!68(>!#9!L4!/!
&+<0+/6+!'2!SJ!/2&!/2!'2<0+/6+!'2!9#*6+@!
./0&'/<!(#$9#$!'6!&+<0+/6+&;!/2&!$8+!</$+<8(*/E'2+!+))+<$!</#6+6!$8'6!6<+2/0'(@!!N(>!>(#*&!
4(#!R:n!"(0E/*!6/*'2+@!
!
%#&'(!)'*+!`-!T*#'&!/2&!8+E(&42!P!
[:/E9*+-!!9$!<(**/96+6;!/2&!4(#!&(!/!$'*$!$+6$-!,VVZtV!/2&!9#*6+!()!,HV!>8'*+!*4'2=!&(>2@!
Y'$$'2=!#9;!'$!>/6!`VZaV!/2&!9#*6+!()!,eV@!!I8+!9$!'6!6+M+0+*4!849(M(*+E'<;!$8+0+)(0+!R:!'6!
2(0E/*!6/*'2+@!!I0+/$E+2$-!G2+!*'$+0!'2;!68(>+&!2(!6'=26;!9#$!/2($8+0!*'$+0!/2&!$8+!SJ!
L+<(E+6!2(0E/*;!/2&!'6!)++*'2=!L+$$+0;!L#$!6$'**!6'=26!()!M(*#E+!&+9*+$'(2!?&04!E(#$8B@!!g+!
8/M+!$8+!SJ!6$/L'*'c+&;!L#$!$8+!9$!*(6$!849($(2'<!6/*$!6(*#$'(2;!$8+0+)(0+!>+!2++&!$(!0+9*/<+!
$8'6@!!Y(!(2!1k;!='M+!849($(2'<!6/*$!6(*Q2!?LZ<!>/6!*(6'2=!849($(2'<!6/*$!6(*#$'(2B@!!g+!&(!2($!
='M+!eW!&+:$0(6+!/2&!>/$+0!LZ<!$8+0+Q6!2($!/24!6/*$!'2!'$@!!I8+0+)(0+;!>+!>'**!='M+!w!2(0E/*!
6/*'2+@!!I8+!$0+/$E+2$!90($(<(*!'6-!>8+2!/!9$!*(6+6!6(E+$8'2=;!4(#!0+9*/<+!>8/$!$8+4!*(6$@!!
%2&!>8+2!9$!'6!849(M(*+E'<;!/*>/46!='M+!'6($(2'<!6/*'2+@!
!
[:/E9*+-!_5%;!8/M+!(6E($'<!&'#0+6'6U!$(2'<'$4!()!)*#'&!'2!$8+!#0'2+!$8/$!8/6!+:<+66!=*#<(6+!'6!
849($(2'<@!N49($(2'<!)*#'&!8/6!/!*'$$*+!E(0+!)*#'&!$8/2!6/*$@!Y(!$8+!9$!'6!6+M+0+*4!849(M(*+E'<U!
$8+0+)(0+!$8+!)'06$!6$+9!'2!E/2/=+E+2$!'6!<(00+<$'(2!()!M(*#E+!&+9*+$'(2@!!Y(E+!9+(9*+!/0+!
'2!849(M(*+E'<!68(<F!)0(E!/**!$8/$!6/*$!/2&!>/$+0!*(66@!!!I8+0+)(0+!2++&!$(!<(00+<$!
849(M(*+E'/!/2&!$8+2!<(00+<$!$8+!L*((&!6#=/0!*+M+*6!?_5%!9$6!*(6+!849($(2'<!6(*#$'(2B@!!
I8+0+)(0+;!)'06$!6$+9!)(0!_5%!9$!'6!$(!='M+!2(0E/*!6/*'2+!LZ<!4(#!>/2$!$(!E/F+!$8+E!2(0E(d
$+26'M+@!!_(!2($!9#$!$8+!9$!(2!'26#*'2!LZ<!'$Q6!>(0$8*+66!#2*+66!4(#!<(00+<$!$8+!849(M(*+E'/@!!
1$!</2!$/F+!adt!*'$+06!()!'6($(2'<!6/*'2+!L+)(0+!$8+!L*((&!90+66#0+!6$/0$6!$(!6$/L'*'c+@!!%)$+0!9$!
'6!)++*'2=!L+$$+0!/2&!$8+!9$!'6!)'2+!M(*#E+!>'6+@!!"(>!>8/$!/0+!>+!=('2=!$(!&(n!!I8+!9$!'6!6$'**!
*(6'2=!E(0+!>/$+0!$8/2!6/*$!'2!#0'2+;!$8+0+)(0+!6$'**!*(6'2=!/!849($(2'<!6/*$!6(*#$'(2;!$8+0+)(0+!
2++&!$(!8/2=!#9!/2!1k!>'$8!w!2(0E/*!6/*'2+!?'+!$8+!0/$'(!()!6(*#$+6!$(!>/$+0B!/2&!'26#*'2!
?LZ<!$8+!9$!'6!*((6'2=!=*#<(6+B@!
!
Y(;!)'06$!$8'2=!$(!&(!/*>/46!'2!/!9$!>'$8!849(M(*+E'<!68(<F!'6!2(0E/*!6/*'2+;!$(!=+$!$8+!SJ!
2(0E/*@!!I8+2!$(!<(00+<$!$8+!90(L*+E!$8/$!</#6+&!$8+!849(M(*+E'/@!!1$!&+9+2&6!(2!>8/$!'6!
36

</#6'2=!$8+!849(M(*+E'/!?'+!')!9$!'6!6>+/$'2=;!='M+!849($(2'<!6/*$!6(*#$'(2;!')!&'/008+/!'2!/2!
/&#*$!='M+!'6($(2'<!6/*$!6(*Q2!?'+!2(0E/*!6/*'2+B;!')!9$!>'$8!_1!?'+!6$/L*+!SJ;!9$!'6!*#<'&B!='M+!
>/$+0!?$8+4!/0+!*(6'2=!>/$+0;!$8+0+)(0+!='M+!eW!&+:$0(6+!?'+!eVW!=*#<(6+B!/2&!>/$+0B@!
!
B. Four kinds of shock-!!

,@!N49(M(*+E'<!68(<F-!L*((&!*(66;!&'/008+/!?/&#*$!(0!<8'*&B;!L/6'</**4!>8+2+M+0!4(#!/0+!*(6+!
6/*$;!4(#!<(#*&!+2&!#9!>'$8!849(M(*+E'<!68(<F!
H@!./0&'(=+2'<!68(<F-!K.!&#+!$(!K1!
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^@!Y+9$'<!68(<F-!K.!&#+!$(![@!<(*'U!/*6(!K..!6+96'6!'2!8(69'$/*!/2&!'6!&#+!$(!/2!'2&>+**'2=!()!
$8+!#0'2/04!</$8+$+0@!!Y$/98!/#0+#6!'6!2($!$8+!K.!</#6+!()!1k!0+*/$+&!6+9$'<+E'/!'2!$8+!
8(69'$/*;![@.(*'!>'26!8/2&6!&(>2@!![2&($(:'2!'2!<+**!>/**!'6!/!*'9(9(*46/<8/0'&+;!>8'<8!/0+!
6++2!'2!=0/E!2+=/$'M+!L/<$+0'/@!!I8+!*'9'&6!/0+!+2&($(:'26@!!I8+0+)(0+;!=0/E!2+=/$'M+6!8/M+!
*'9'&6!?+2&($(:'26B!'2!$8+'0!<+**!>/**;!=0/E!9(6'$'M+!&(!2($@!!YG!')!4(#!8/M+![@.(*'!6+96'6;!4(#!
>'**!8/M+!L'=!$'E+!90(L*+E6;!/2&!'6!</**+&!6+9$'<!68(<F@!!
!
e@!!.*/66'</*!<*'2'</*!90+6+2$/$'(26-!
!
/B!N49(M(*+E'<!/2&!</0&'(=+2'<!68(<F-!4(#!>(#*&!6++!<(*&!/2&!<*/EE4!6F'2;!LZ<!()!
M/6(<(26$0'<$'(2!()!$8+!9+0'98+0/*!M+66+*6!L4!</$+<8(*/E'2+6!?0+*+/6+!'6!&#+!$(!$8+!
&+<0+/6+!'2!Yk!/2&!.GB!/2&!%l!11@!!I8+6+!>'**!M/6(<(26$0'<$!$8+!6F'2!/2&!0+&'0+<$!$8+!
L*((&!)*(>!$(!($8+0!'E9(0$/2$!(0=/26!'2!$8+!L(&4!*'F+!L0/'2!/2&!F'&2+46;!*+/&'2=!$(!/!<(*&!
<*/EE4!6F'2@!!SJ!'6!&+<0+/6+&;!9#*6+!'6!'2<0+/6+&@!
!
LB!J(#6+/#Q6!*/>6-!'6!/!<(2<+9$!$8/$!$+/<8+6!4(#!/L(#$!9+0'98+0/*!0+6'6$/2<+!()!/0$+0'(*+6!
>8'<8!<(2$0(*!$8+!&'/6$(*'<!L*((&!90+66#0+@!
TPR = V/r4
!
IJR!C!I($/*!9+0'98+0/*!0+6'6$/2<+!()!$8+!/0$+0'(*+6!
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!
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g8/$!<(2$0(*6!$8+!M'6<(6'$4!'2!$8+!L*((&n!NL@!!Y(!')!4(#!/0+!/2+E'<;!M'6<(6'$4!()!L*((&!'6!
&+<0+/6+&!?'+!*(>!8+E(=*(L'2B;!/2&!')!4(#!8/M+!9(*4<4$8+E'/!?8'=8!8+E(=*(L'2B;!
M'6<(6'$4!>'**!L+!'2<0+/6+&@!!I8+0+)(0+;!IJR!'2!/2+E'/!>'**!&+<0+/6+;!/2&!'2!9(*4<4$8+E'/!
>'**!'2<0+/6+@!
!
<B!Y+9$'<!68(<F!7!I8+0+!'6!/!0+*+/6+!()!+2&($(:'26!>8'<8!/<$'M/$+6!$8+!/*$+02/$'M+!
<(E9*+E+2$!646$+E@!!I8+!<(E9*+E+2$!>'**!+M+2$#/**4!0+*+/6+!.P/!/2&!.e/!>8'<8!/0+!
/2/984*/$(:'26;!>8'<8!>'**!6$'E#*/$+!$8+!E/6$!<+**6!$(!0+*+/6+!8'6$/E'2+@!!!I8+!8'6$/E'2+!
</#6+6!M/6(&'*/$'(2!()!/0$+0'(*+6!?$8+!6/E+!(2+6!()!$8+!9+0'98+0/*!0+6'6$/2<+!/0$+0'(*+6B@!!
I8+0+)(0+!L*((&!)*(>!'6!'2<0+/6+&!$80(#=8(#$!$8+!9+0'98+0/*!0+6'6$/2<+!/0$+0'(*+6!/2&!$8+!
6F'2!)++*6!>/0E@!!I8+!+2&($(:'26!/*6(!&/E/=+!$8+!+2&($8+*'/*!<+**6U!/6!/!0+6#*$;!$>(!
9($+2$!M/6(&'*/$(06!?"G!/2&!Jl1HB!/0+!0+*+/6+&@!!I8+0+)(0+;!H!(0!P!M/6(&'*/$(06!/0+!
0+*+/6+&;!/2&!/))+<$!$8+!IJR!$(!$8+!)(#0$8!9(>+0@!I8+0+)(0+;!$8+!IJR!>'**!&+<0+/6+!?&#+!
$(!M/6(&'*/$'(2B@!
!
37

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/E(#2$!()!L*((&!$8/$!0+E/'26!'2!$8+!/0$+0'/*!646$+E!>8'*+!4(#0!8+/0$!'6!)'**'2=!#9!'2!
&'/6$(*+@!!I8+0+)(0+;!>8+2!$8+!IJR!/0$+0'(*+6!/0+!&'*/$+&;!$8+!&'/6$(*'<!SJ!>'**!9/2!(#$@!
I8'2F!()!/!&/E!?>'$8!=/$+6B-!')!/**!$8+!=/$+6!/0+!>'&+!(9+2!/**!$8/$!>/$+0!>'**!<(E+!
=#68'2=!$80(#=8@!!I8'6!'6!>8/$!8/99+26!$(!$8+!/0$+0'(*+6!>8+2!$8+4!/0+!&'*/$+&@!!I8+!
L*((&!=#68+6!(#$!/2&!=(+6!$(!$8+!</9'**/04!$'66#+6;!6#99(6+&*4!)++&'2=!/**!$8+!$'66#+6!
>'$8!GH@!!I8'2F!'2!$8+!<(2$+:$!()!)'68'2=-!!>8+2!$8+!&/E!>/**!(9+26;!/**!$8+!>/$+0!0#68+6!
$80#!</#6'2=!$#0L#*+2$!>/$+06;!$8+0+)(0+!$8'6!>(#*&!L+!/!L/&!$'E+!$(!=(!)'68'2=@!!I8+!
)'68+6!>(#*&!L+!$04'2=!$(!6/M+!$8+E6+*M+6@!!I8/$!'6!>8/$!$8+!GH!'6!&('2=@!!I8+0+)(0+;!>'$8!
/**!$8'6!L*((&!=('2=!L4;!$8+!$'66#+6!</22($!+:$0/<$!GH!LZ<!'$!'6!=('2=!$((!)/6$!/2&!LZ<!'$!
'62Q$!/!<(2$0(**+&!0+*+/6+!()!L*((&@!!!I8+0+)(0+;!$8+!L*((&!'6!<(E'2=!L/<F!$(!$8+!0'=8$!6'&+!
()!$8+!8+/0$!)/6$+0!$8/2!#6#/*;!LZ<!/**!$8+!/0$+0'(*+6!/0+!>'&+*4!&'*/$+&@!!_#+!$(!$8+!L*((&!
=('2=!L/<F!$(!$8+!8+/0$!)/6$+0;!$8+!</0&'/<!(#$9#$!'6!'2<0+/6+&@!!I8'6!'6!6++2!'2!6+9$'<!
68(<F!/2&!$8+!6F'2!)++*6!>/0E!LZ<!$8+!M+66+*6!/0+!&'*/$+&@!!I8+0+)(0+;!>'$8!6+9$'<!68(<F;!
$8+0+!'6!/!N1lN!(#$9#$!)/'*#0+;!>'$8!>/0E!6F'2@!!!
!
N(>+M+0;!'2!849(M(*+E'<!/2&!</0&'(=+2'<!68(<F;!$8+!</0&'/<!(#$9#$!'6!&+<0+/6+&!?LZ<!$8+!
M+66+*6!/0+!<(26$0'<$+&!L4!</$+<8(*/E'2+6!/2&!/2='($+26'2!11B;!/2&!$8+!6F'2!)++*6!<(*&!
/2&!<*/EE4@!!
!
C. Swan ganz catheter!'6!'26+0$+&!'2!$8+!0'=8$!6'&+!()!$8+!8+/0$!/2&!'$!E+/6#0+6!/**!9/0/E+$+0!
$8/$!'6!$/#=8$!'2!9846'(*(=4@!!%**!()!$8+6+!$8'2=6!/0+!E+/6#0+&!'2!/!6>/2!=/2c!</$8+$+0@!
,@!!./0&'/<!G#$9#$-!E+/6#0+&!L4!6>/2!=/2c!!
!
H@!!Y46$+E'<!M/6<#*/0!0+6'6$/2<+-!!$8'6!'6!/!</*<#*/$'(2@!!I8+!L/6'</**4!E+/6#0+6!$8+!IJR;!'+!
E+/6#0+6!>8/$!/0$+0'(*+6!/0+!&('2=!
!
P@!!K':+&!M+2(#6!GH!<(2$+2$@!!b(#!F2(>!2(0E/**4!$8/$!$8+!GH!<(2$+2$!'6!+D#/*!$(!C!,@P^!:!NL!
:!GH!6/$Q2!O!9GH@!!K+/6#0+&!'2!R%!>'$8!6>/2!=/2c!</$8+$+0U!$8'6!'6!$8+!S[YI!I[YI!)(0!
+M/*#/$'2=!$'66#+!849(:'/@!!!
!
./0&'/<!(#$9#$!'2!</0&'(=+2'<!/2&!849(M(*+E'<!68(<F!'6!*(>;!$8+0+)(0+;!L*((&!2($!L+'2=!
9#68+&!/8+/&!>'$8!/!=0+/$!&+/*!()!)(0<+@!!Y(;!$'66#+!>'**!8/M+!/!*($!()!$'E+!$(!+:$0/<$!GH!)0(E!
>8/$!*'$$*+!L*((&!$8/$!'6!L+'2=!&+*'M+0+&@!!%6!/!0+6#*$;!E':+&!M+2(#6!GH!<(2$+2$!'2!
849(M(*+E'<!/2&!</0&'(=+2'<!68(<F!>'**!L+!&+<0+/6+&!'+!M+04!*(>!LZ<!$8+!L*((&!=('2=!
$80(#=8!$8+!M+66+*6!'6!M+04!6*(>!?2(!)(0<+!'6!8+*9'2=!$(!9#68!'$!$80(#=8B@!!I8+0+)(0+;!'$!
+:$0/<$6!E(0+!GH!$8/2!2(0E/*@!!K':+&!M+2(#6!GH!<(2$+2$!'2!6+9$'<!68(<F!?>8+2!L*((&!'6!
9/66'2=!$80(#=8!M+66+*6!/$!/!M+04!)/6$!0/$+B!>'**!*+/&!$(!/!N1lN!E':+&!M+2(#6!<(2$+2$!?LZ<!
$'66#+6!#2/L*+!$(!+:$0/<$!GHB@!!!
!
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90+66#0+!?[_k!/2&![_JB@!!./$8+$+0!'2!0'=8$!8+/0$!>'**!$+**!4(#!>8/$!$8+!90+66#0+!'6!'2!$8+!*+)$!
M+2$0'<*+@!!!
!
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</$8+$+0-!!!
!
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38

!
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g8/$!'6!IJR!'2!849(M(*+E'<!/2&!</0&'(=+2'<!68(<Fn!12<0+/6+&!&#+!$(!M/6(<(26$0'<$'(2!
IJR!'2!6+9$'<!68(<Fn!_+<0+/6+&!&#+!$(!M/6(&'*/$'(2@!
!
K':+&!M+2(#6!'2!849(M(*+E'<!/2&!</0&'(=+2'<n!X(>@!
K':+&!M+2(#6!'2!6+9$'<!68(<Fn!N'=8@!
!
N(>!&(!>+!6+9/0/$+!849(M(*+E'<!/2&!</0&'(=+2'<n!
J#*E(2/04!</9'**/04!>+&=+!90+66#0+!?E+/6#0+6!*+)$!M+2$0'<#*/0![_kB!
12!N49(M(*+E'<;!>8/$!'6!Xk[_kn!X(>@!
12!./0&'(=+2'<;!>8/$!'6!Xk[_kn!N'=8@!
12![2&($(:'2!68(<F!'$Q6!&+<0+/6+&@!
!
D. Examples:!
!
,@!![:/E9*+-!!G)!/**!(0=/26!'2!$8+!L(&4;!>8'<8!6#))+06!$8+!=0+/$+6$!&#+!$(!&+<0+/6+&!SJn!
5'&2+46@!!g8/$!9/0$n!K+&#**/@!!"($!$8+!L0/'2!LZ<!>'$8!&+<0+/6+&!.G;!$8+!<'0<*+!()!>'**'6!>'**!
&'6$0'L#$+!L*((&!)*(>!$(!<+0$/'2!/0+/6!'2!$8+!L0/'2;!+69+<'/**4!$8+!/0+/6!>8+0+!$8+0+!/0+!
2+#0(26@!!Y(E+(2+!>'$8!849(M(*+E'<;!(0!</0&'(=+2'<;!(0!6+9$'<!68(<F-!(*'=#0'/;!/2&!/2!
'2<0+/6+&!'2!S\"Z.0+/$'2+!</#6+6!6#=/06!'2!$8+!L(&4@!!I8'6!(<<#06!LZ<!$8+!9/$'+2$!'6!=('2=!
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!
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!
IV. Acid-base and Blood Gas
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!
pH = [HCO3-] / pCO2
A. New equation!)(0!/<'&ZL/6+!9846'(!L4!l(*3/2-!
!
Increase in bicarb = increase pH = metabolic alkalosis

Decrease in bicarb = decrease pH = metabolic acidosis
Increase pCO2 = decrease pH = respiratory acidosis

!
Decrease pCO2 = increase pH = respiratory alkalosis
39

!
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!
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!
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!
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!
C. Respiratory conditions: acidosis and alkalosis
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!
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40

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!
41

Day 2
!
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42

CHAPTER 4: NUTRITION
!
I. Eating disorders includes obesity, anorexia, bulimia
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A. Anorexia
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!
B. Bulimia Nervosa
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/*6(!M(E'$!(#$!L*((&!7!K/**(04!g+'66!Y42&0(E+!7!$+/0!'2!&'6$/*!+6(98/=#6!(0!90(:'E/*!
6$(E/<8@!!!
!
H@!!S(08/M+!642&0(E+;!>8'<8!'6!>(06+@!12!$8+!642&0(E+;!$8+0+!'6!/!0#9$#0+!/2&!/'0!/2&!
6+<0+$'(26!)0(E!$8+!+6(98/=#6!=+$!'2$(!$8+!9*+#0/*!</M'$4U!$8+!/'0!>'**!&'66+<$!$80(#=8!
6#L<#$/2+(#6!$'66#+;!<(E+!/0(#2&!$8+!/2$+0'(0!E+&'/6$'2#E;!>8'<8!*+/&6!$(!N+E'E/26!
<0#2<8!7!(L6+0M+&!>8+2!&0!*((F6!/$!9$Q6!<8+6$;!9#$6!/!6$+$8(6<(9+!&(>2;!/2&!4(#!8+/0!/!
]<0#2<8Q@!!I8+!i<0#2<8j!'6!/'0!$8/$!8/6!&'66+<$+&!$80(#=8!'2$+06$'/*!$'66#+!#9!'2$(!$8+!
E+&'/6$'2#E;!'2&'</$'2=!$8/$!/!0#9$#0+!(<<#00+&!'2!$8+!+6(98/=#6U!$8'6!'6!/2($8+0!<(EE(2!
$8'2=!'2!L#*'E'<6@!!!
Y(;!$8+0+!/0+!H!$8'2=6!'E9!'2!L#*'E'<6-!,B!K+$/L(*'<!/*F/*(6'6!)0(E!M(E'$'2=!?>8'<8!</2!
'2&#<+!/00$84E'/6!HB!S(08/M+Q6!642&0(E+!
!
C. Obesity-!!g'$8!(L+6'$4;!#6'2=!/!&'))!E+$8(&-!SK1-!F=Q6!'2!L(&4!>$ZE+$+06!'2!L(&4!!
8$QH@!!1)!4(#0!SK1!'6!PV!(0!=0+/$+0;!4(#!/0+!(L+6+U!')!4(#0!LE'!'6!^V!(0!=0+/$+0;!4(#!/0+!
E(0L'&*4!(L+6+@!!K/'2!<(E9*'</$'(2!()!(L+6'$4!C!NI"U!>'$8!NI";!*+/&6!$(!XkN;!/2&!
9($+2$'/**4!8+/0$!)/'*#0+@!!K..!&+/$8!'2!NI"!C!</0&'/<!&c@!!G$8+0!<(E9*'</$'(26!()!(L+6'$4!
'2<*#&+-!!=/**L*/&&+0!&c;!</2<+06!>'$8!/!*($!()!/&'9(6+;!4(#!/0(E/$'c+!E/24!,`dF+$(6$+0('&6!
*'F+!/2&0(6$+2+&'(2+!'2$(!+6$0(=+26@!!I8+0+)(0+;!>'**!849+0+6$0'2'6E!?/**!(L+6+!>(E+2!8/M+!
849+0+6$0'2'6EB;!4(#!/0+!/$!0'6F!)(0!+6$0(=+2!0+*/$+&!</2<+06!7!'+!L0+/6$!</2<+0;!+2&(E+$0'/*!
</0<'2(E/;!<(*(2!</2<+0@!!!
!
II. Malnutrition
!
43

J0($+'2d</*(0'+!E/*2#$0'$'(2-!
,@!!K/0/6E#6!7!$($/*!</*(0'+!&+9(6'$'(2;!/2&!>/6$'2=!/>/4!()!E#6<*+U!8(>+M+0;!8'=8!<8/2<+!
()!6#0M'M/*!')!$8+4!=+$!)((&!
H@!!5>/68'(0F(0!7!90(L!=(22/!&'+U!8/M+!</0L6;!L#$!2(!90($+'2U!/*6(!8/M+!/2+E'/6;!<+**#*/0!
'EE#2'$4!90(L6!?'+!2(!0:2!$(!/=6B;!*(>!/*L#E'2!*+M+*6;!/6<'$+6;!)/$$4!*'M+06@!
I8+6+!F'&6!/0+!/9/$8+$'<!/2&!2++&!$(!L+!)(0<+d)+&U!$8+0+)(0+;!F'&!>'$8!F>/68'(0F(0!'6!E(0+!
*'F+*4!$(!&'+!$8/2!<8'*&!>'$8!K/0/6E#6@!![:/E9*+-!F'&!>'$8!+&+E/;!)*/F4!&+0E/$'$'6;!0+&&'68!
8/'0!?.#!&+)B!7!F>/68'(0F(0!
!
III. Vitamins
A. Difference between fat and water soluble vitamins:
,@!!T/$!6(*#L*+!M'$/E'26!&'66(*M+!'2!)/$6;!'2&'</$'2=!$8/$!$8+4!/0+!$/F+2!#9!L4!<84E*(E'<0(26@!!
I8+!<84E*(E'<0(2!>'**!8/M+!%;!_;![;!/2&;!5!LZ<!$8+6+!/0+!$8+!)/$!6(*#L*+!M'$/E'26@!T/$!
6(*#L*+!/0+!E(0+!*'F+*4!$(!L+!6$(0+&!'2!)/$;!6(!$8+!$(:'<'$4!'6!E#<8!=0+/$+0;!LZ<!')!'$!'6!>/$+0!
6(*#L*+;!>+!3#6$!9++!'$!(#$@!!!
K..!L0'=8$!4+**(>!#0'2+!C!M'$/E'26!
H@!!g/$+0!6(*#L*+!M'$/E'26!/0+!/**!<()/<$(06!)(0!L'(<8+E'</*!0:2Q6@!!
!
B. Fat soluble vitamins:
1. Vitamin A!
/@!T#2<$'(2-!16!M+04!'E9!'2!<8'*&0+2!)(0!=0(>$8!/2&!</2!8/M+!)/'*#0+!$(!$80'M+!'2!M'$!!
%!&+)@!!k+04!'E9(0$/2$!'2!'(&(96'2Z08(&(96'2!>'$8'2!$8+!+4+!/2&!$8+!)'06$!6'=2!()!M'$!%!&+)!
'6!2'=8$!L*'2&2+66!>8'<8!'6!</**+&!2'<$(*(9'/@!!k'$!%!/*6(!90+M+2$6!6D!E+$/9*/6'/@!!!
!
L@![:/E9*+!()!k'$!%!&+)-!+4+!>'$8!6D!E+$/9*/6'/;!=((6+!L#E96!(2!L/<F!()!/0E!</**+&!
)(**'<#*/0!849+0F+0/$('6@!![4+!'6!*'2+&!>'$8!<#L('&/*!+9'$8+*'#EU!>8+2!4(#!=+$!6D!
E+$/9*/6'/;!>'**!=+$!>8'$+!69($6!(2!$8+!+4+@!!1)!L+<(E+!+:$+26'M+;!=0(>!(M+0!+4+;!/2&!
</2!*+/&!$(!6()$+2'2=!()!$8+!<(02+/!?F+0/$(E/*/<'/B;!/2&!*+/&6!$(!L*'2&2+66@!!H2&!K..!
L*'2&2+66!=*(L/**4!C!M'$!%!&+)@!!K..!L*'2&2+66!=*(L/**4!C!$0/<8(E/U!K..!L*'2&2+66!'2!\Y%!
C!&'/L+$+6@!!I8+0+)(0+;!M'$!%!>'**!90+M+2$!6D!E+$/9*/6'/;!')!4(#!/0+!k'$!%!&+)'<'+2$!/2&!/!
2(26E(F+0;!/!9+06(2!</2!+2&!#9!>'$8!6D!E+$/9*/6'/!'2!E/'26$+E!L0(2<8#6!/2&!
L0(2<8(=+2'<!</0<'2(E/@!!!
!
<@!I(:'<'$4-!N49+0M'$/E'2(6'6!%!7!+:@!L'=!=/E+!8#2$+0!$8/$!+/$6!L+/0!*'M+0!/2&!8/6!
8+/&/<8+6@!!12<0+/6+&!M'$!%!</#6+6!<+0+L0/*!+&+E/;!/*6(!=+$!9/9'**(+&+E/!?>8'<8!</#6+6!
$8+!8+/&/<8+B;!</2!/*69!*+/&!$(!8+02'/$'(2!/2&!&+/$8@!!I8+0+!'6!/*6(!/2!'2<0+/6+!()!
0+$'2('<!/<'&!?#6+&!)0(E!$0+/$'2=!/<2+!/2&!/<#$+!90(=0/2#*(<4$'<!/2+E'/B@!!I8+!0+$'2('<!
/<'&!$(:'<'$4!</2!*+/&!$(!6+M+0+!*'M+0!$(:'<'$4@!!I8+0+)(0+;!849+0M'$/E'2(6'6!()!M'$!%!/))+<$6!
H!/0+/6-!,B!<+0+L0/*!+&+E/!?L0/'2B!HB!*'M+0@!![:/E9*+-!')!8/M+!4(#2=!*/&4!9$!(2!0+$'2('<!
/<'&!)(0!/<2+;!2++&!$(!<8+<F!*'M+0!+2c4E+6!/2&!/6F!)(0!8+/&/<8+6!?</2!L+!&+M+*(9'2=!
9/9'**(+&+E/!(0!<+0+L0/*!+&+E/!0+*/$+&!$(!M'$!%!$(:'<'$4B@!!K/66'M+!/E(#2$!()!M'$!%!'2!
L+/0!*'M+06;!/2&!8#2$+0!&'+6!>'$8!E/66'M+!8+/&/<8+6!(0!*'M+0!)/'*#0+!
!
2. Vitamin D!C!k[Rb!'E9!(2!$8+!L(/0&6U!K.!6(#0<+!()!M'$!_!'6!)0(E!6#2*'=8$@!!!
/@!.8(*+6$+0(*!'6!$8+!!
,@!K/'2!<(E9(2+2$!()!(#0!<+**!E+EL0/2+6!!
H@!Y$/0$'2=!9('2$!)(0!E/F'2=!L'*+!6/*$6!/2&!L'*+!/<'&6!
P@!T'06$!<(E9(#2&!$8/$!6$/0$6!$8+!642$8+6'6!()!6$+0('&!8(0E(2+6!'2!$8+!/&0+2/*!<(0$+:!
44

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I8+0+)(0+!>+!2++&!<8(*+6$+0(*m!?E/F+6!L'*+!6/*$6;!8(0E(2+6;!<+**!E+EL0/2+6;!/2&!M'$!_B@!!!
!
L@!!Y(#0<+-!Y#2!'6!$8+!E(6$!'E9!6(#0<+!()!M'$!_@!$/F+!L/L4!(#$!$(!+:9(6+!$(!6#2*'=8$!?2(!
M'$!_!(0!M'$!5!'2!L0+/6$!E'*F;!$8+0+)(0+!E#6$!!L+!6#99*+E+2$+&!7!+:9(6+!$(!6#2!)(0!M'$!_B@!!!
!
<@!Y42$8+6'6!()!k'$/E'2!_-!!R+/L6(0L+&!'2!$8+!3+3#2#E@!!\2&+0=(+6!H!84&0(:4*/$'(2!
6$+96U!)'06$!'6!'2!$8+!*'M+0;!>8+0+!'$!'6!He!84&0(:4*/$+&!/2&!$8+!H2&!'6!'2!$8+!F'&2+4!/2&!'$6!
,!/*98/!84&0(:4*/6+@!!g8/$!8(0E(2+!9#$6!,d/*98/!84&0(:4*/6+!'2!$8+!90(:'E/*!$#L#*+n!
JIN@!!JIN!'6!0+69(26'L*+!)(0!642$8+6'6!()!,d/d84&0(:4*/6+!/2&!'6!642$8+6'c+&!'2!$8+!
90(:'E/*!$#L#*+@!?%.[!'6!)0(E!$8+!+2&($8+*'/*!<+**6!()!$8+!9#*E(2/04!</9'**/04;![JG!'6!
)0(E!$8+!+2&($8+*'/*!<+**6!()!$8+!9+0'$#L#*/0!</9'**/04B@!!,d/d84&0(:4*/6+!'6!$8+!H2&!
84&0(:4*/$'(2!6$+9;!/2&!2(>!'$!'6!/<$'M+!?$8+!)'06$!>/6!'2!$8+!F'&2+4B@!!!
!
&@!k'$!_!)#2<$'(2-!0+/L6(0L!./!/2&!98(698(0#6!)0(E!$8+!3+3#2#E@!!1$!N%Y!$(!0+/L6(0L!
L($8!()!$8+6+;!LZ<!'$6!E/'2!3(L!'6!E'2+0/*'c'2=!L(2+!/2&!</0$'*/=+@!!N/M+!$(!8/M+!
/990(90'/$+!6(*#L'*'$4!90(&#<$!$(!L+!/L*+!$(!&(!$8/$U!./!/2&!98(698(0#6!/0+!2+<+66/04!$(!
E'2+0/*'c+!</0$'*/=+!/2&!L(2+!?*'F+!$8+!(6$+('&!E/F'2=!L(2+B@!!I8+0+)(0+;!'$!E/F+6!6+26+!
$(!0+/L6(0L!./!/2&!98(698(0#6!LZ<!'$!2++&6!$(!E/F+!6#0+!$8/$!L($8!()!$8+E!/0+!90+6+2$!
'2!/&+D#/$+!/E(#2$6!$(!8/M+!/2!/&+D#/$+!6(*#L'*'$4!90(&#<$!$(!E'2+0/*'c+!L(2+@!!!
+@!J/0/$840('&!N(0E(2+!?JINB!7!T#2<$'(26-!!?,B'6!6(E+>8/$!0+*/$+&!$(!k'$/E'2!_!
E+$/L(*'6E;!'$!8+*96!*/6$!6$+9!)(0!84&0(:4*/$'(2!()!M'$!_!642@!!?HB!JIN!>'**!*+/&!$(!
0+/L6(09$'(2!()!./!'2!$8+!+/0*4!&'6$/*!$#L#*+!?$8'6!'6!/*6(!>8+0+!"/!'6!0+/L6(0L+&;!/2&!
$8'/c'&+6!L*(<F!$8'6!<8/22+*B@!!%$!$8/$!*(</$'(2;!$8+0+!'6!/!./!<8/22+*U!JIN!8+*96!
0+/L6(09$'(2!()!$8+!./!'2!$8'6!*(</$'(2@!./!8/6!$(!]$/F+!$#026Q!>'$8!"/;!#6#/**4!E(0+!"/;!
0+/L6(0L+&U!$8+0+)(0+!./!8/6!$(!62+/F!$80(#=8!<8/22+*;!>'$8!8+*9!()!JIN@!!I8+0+)(0+;!
>'$8!$8'/c'&+6;!"/!'6!L*(<F+&;!*+/M'2=!$8+!./!<8/22+*!<(E9*+$+*4!(9+2;!/2&!$8+!$8'/c'&+6!
>'**!*+/&!$(!849+0</*<+E'/@!!I8+0+)(0+;!#6+!'2!./!!6$(2+!)(0E+06!7!E(6$!()!6$(2+!)(0E+06!
8/M+!849+0</*<'#0+/U!$8+6+!9$6!8/M+!$((!E#<8!./!'2!$8+'0!#0'2+U!>8+2!$8+4!/0+!(2!
$8'/c'&+6;!$8+!&0#=!$/F+6!./!G\I!()!$8+!#0'2+;!6(!$8+4!&(!2($!)(0E!6$(2+6@!!?PB!JIN!>'**!
&+<0+/6+!0+/L6(09$'(2!()!98(698(0#6!'2!$8+!90(:!$#L#*+;!/2&!?^B!&+<0+/6+!$8+!
0+/<<#E#*/$'(2!()!L'</0L;!$((@!
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Vit Ds!E/'2!)#2<$'(2!'6!E'2+0/*'c'2=!L(2+;!/2&!(6$+(L*/6$6!?L(2+!L#'*&+06B!/0+!'2M(*M+&!
>'$8!$8'6!90(<+66;!$8+0+)(0+!$8+!0+<+9$(0!)(0!k'$!_!'6!*(</$+&!(2!$8+!(6$+(L*/6$@!g8+2!M'$!
_!8((F6!'2$(!$8+!0+<+9$(0;!'$!</#6+6!$8+!0+*+/6+!()!/*F/*'2+!98(698/$/6+@!Y(;!>8+2!4(#!
/0+!=0(>'2=!L(2+!(0!0+8+/*'2=!()!/!)0/<$#0+;!4(#!+:9+<$!$(!6++!/2!'2<0+/6+!'2!/*F/*'2+!
98(698/$/6+;!>8'<8!E/F+6!$8+!/990(90'/$+!6(*#L'*'$4!90(&#<$!$(!E'2+0/*'c+&!</0$'*/=+!/2&!
L(2+@!!52(>'2=!$8/$!PTH!L0+/F6!&(>2!L(2+!?E/'2$/'26!./!*+M+*6!'2!$8+!L*((&!6$0+/EB!
4(#!>(#*&!$8'2F!$8/$!'$6!0+<+9$(0!>(#*&!L+!(2!$8+!(6$+(<*/6$!?<+**!2(0E/**4!L0+/F6!L(2+!
&(>2B@!!N(>+M+0;!(2*4!(2+!8(0E(2+!8/6!/!0+<+9$(0!(2!(6$(+<*/6$6!/2&!$8/$!'6!
calcitonin@!!g8+2!</*<'$(2'2!8((F6!'2$(!$8+!(6$+(<*/6$!0+<+9$(0;!'$!'28'L'$6!$8+!(6$+(<*/6$;!
/2&!$8+0+)(0+!'6!#6+&!$(!$0+/$!849+0</*<+E'/@!!./*<'$(2'2!/*6(!#6+&!'2!$0+/$'2=!
(6$+(9(0(6'6@!!I8+!0+<+9$(0!)(0!JIN!'6!(2!$8+!(6$+(L*/6$;!L#$!2($!68/0'2=!$8+!6/E+!(2+!
/6!M'$!_@!!g8+2!JIN!8((F6!(2!$8+!(6$+(L*/6$;!'$!0+*+/6+6!1Xd,@!!%2($8+0!2/E+!)(0!1Xd,!'6!
(6$+(<*/6$!/<$'M/$'2=!)/<$(0!?($8+0!)#2<$'(26!()!1Xd,!/0+!/*6(!'2M(*M+&!'2!)+M+0;!6$'E#*/$+6!
%L!642$8+6'6;!/2&!S!<+**!6$'E#*/$'(2B@!!Y(;!1Xd,!?0+*+/6+&!)0(E!$8+!(6$+(L*/6$B!/<$'M/$+6!
45

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>(E+2;!+6$0(=+2!*+M+*6!F++9!/!<8+<F!(2!1Xd,!?&(!2($!>/2$!$((!E#<8!(6$+(<*/6$!
/<$'M/$'(2BU!'2!E+2;!'$!'6!$+6$(6$+0(2+!$8/$!F++96!1Xd,!'2!<8+<F!?9#$6!'28'L'$(04!+))+<$!(2!
1Xd,!0+*+/6+!)0(E!$8+!(6$+(L*/6$!/)$+0!JIN!8((F6!'2B@!!I8+0+)(0+;!'2!>(E+2;!</2!6++!>84!
$8+4!=+$!(6$+(9(0(6'6!7!*/<F!()!+6$0(=+2!C!1Xd,!2($!'2!<8+<F!/2&!L0+/F'2=!E(0+!L(2+!
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JIN!'6!E(0+!'2M(*M+&!'2!E/'2$/'2'2=!./!*+M+*6!'2!(#0!L*((&;!>8'*+!k'$!_!'6!E(0+!'2M(*M+&!
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!
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!
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0')/E9'2!/**!'2&#<+!$8+!<4$!9êV!646$+E!*(</$+&!'2!$8+!Y[R@!!I8+0+)(0+;!=+$!Y[R!
849+09*/6'/U!$8+0+)(0+;!4(#!E+$/L(*'c+!&0#=6!/2&!($8+0!$8'2=6!E/&+!'2!$8+!*'M+0;!
'2<*#&'2=!Hed84&0(:4M'$/E'2!_@!!I8+0+)(0+;!/24$8'2=!$8/$!0+MQ6!#9!$8+!9êV!+2c4E+6!>'**!
</#6+!/!&+<0+/6+!'2!M'$!_;!/2&!/24!($8+0!&0#=6!L+'2=!$/F+2@!
!
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I8+!98+24$('2!0+MQ+&!#9!$8+!9êV!646$+E;!>8'<8!'2<0+/6+&!$8+!E+$/L(*'6E!()!+6$0(=+2!
/2&!90(=+6$+0(2+!'2!$8+!L'0$8!<(2$0(*!9'**6;!$8+0+)(0+!2($!+2(#=8!*+M+*6!$(!90+M+2$!
90+=2/2<4@!!!
[:/E9*+-!!>8/$!'6!$8+!+2c4E+!'2!$8+!Y[R!$8/$!'2<0+/6+6!>8+2!$8+!9êV!'6!0+MQ&!#9n!!
l/EE/!=*#$/E4*!$0/26)+0/6+!?llIB!7!+2c4E+!()!Y[Rm!?*((F!/$!'2!/*<(8(*'<6B!
!
[:/E9*+-!K..!<80(2'<!0+2/*!&c!'2!\Y%-!&'/L+$+6!E+**'$#6!7!$#L#*/0!&/E/=+;!6(!2(!,d/d
84&0(:4*/6+;!$8+0+)(0+!'2/<$'M+!M'$!_@!!I8+0+)(0+;!9$6!>'$8!<80(2'<!0+2/*!)/'*#0+!/0+!9#$!(2!
,dHedM'$!_@!!!
!
[:/E9*+-!!')!6(E+(2+!=+$6!GI.!M'$!_;!>8/$!6$+96!&(+6!'$!=(!$80(#=8!$(!L+<(E+!
E+$/L(*'</**4!/<$'M+n!He!84&0(:4*/$+&!'2!*'M+0;!/2&!,d/d84&0(:4*/$+&!'2!4(#0!F'&2+4!?'$!'6!
"GI!,;!He!M'$!_!7!$8'6!'6!/!90+6<0'9$'(2!&0#=;!/2&!+:$0+E+*4!&/2=+0(#6B@!!K/24!9+(9*+!
8/M+!$8+!E'6<(2<+9$'(2!$8/$!$8+!M'$/E'2!_!'6!/*0+/&4!>(0F'2=@!!I8'6!'6!2($!$8+!</6+U!9$!
E#6$!8/M+!/!)#2<$'(2'2=!*'M+0!/2&!F'&2+4@!
!
g'$8!M'$!_!&+)!'2!F'&6!C!0'<F+$6U!M'$!_!&+)!'2!/&#*$6!C!(6$+(E/*/<'/!?6()$!L(2+6B@!
1)!4(#!</2Q$!E'2+0/*'c+!L(2+;!4(#!</22($!E'2+0/*'c+!</0$'*/=+;!/2&!$8+4!>'**!L($8!L+!6()$;!
$8+0+)(0+!9/$8(*(='<!)0/<$#0+6!/0+!<(EE(2@!!!
!
5'&6!8/M+!&'))+0+2$!/!)+>!$8'2=6!$8/$!/0+!&'))+0+2$!'2!0'<F+$6!7!'+!<0/2'($(9'+6;!6()$!6F#**6!
?</2!/<$#/**4!90+66!'2!/2&!'$!>'**!0+<('*B@!I8+4!</2!/*6(!=+$!0'<F+$'<!0(6/0'+6;!LZ<!$8+!
(6$+('&!'6!*(</$+&!'2!$8+!<(6$(<8(2&0/*!3#2<;!/2&!LZ<!$8+4!/0+!M'$!_!&+);!$8+0+!'6!/!*($!()!
2(0E/*!(6$+('&!>/'$'2=!$(!L+!E'2+0/*'c+&;!L#$!2($!/2!/990(90'/$+!./*<'#EZ98(698(0#6!
6(*#L'*'$4!90(&#<$U!>'**!8/M+!+:<+66!(6$+('&!>'$8!*'$$*+!L#E96;!>8'<8!'6!</**+&!0'<F+$'<!
0(6/04@!!"($!6++2!'2!/&#*$6Q!LZ<!$8+4!/0+!=+$$'2=!)#6+&@!
!
Y(;!H!$8'2=6!4(#!6++!'2!F'&6!/2&!2($!/&#*$6-!,B!<0/2'($(9'+6!HB!0'<F+$'<!0(6/0'+6U!08+!0+6$!'6!
$8+!6/E+;!>'$8!9/$8(*(='<!)0/<$#0+6!L+'2=!$8+!E/'2!90(L*+E@!!
!
46
8@!I(:'<'$4ZN49+0M'$/E'2(6'6!()!M'$!_-!849+0</*<+E'/;!$8+0+)(0+!0'6F!()!8/M'2=!$((!E/24!
6$(2+6!'2!$8+!#0'2+;!/2&!6$(2+6!'6!/!K..!<(E9*'</$'(2@!
I49+!,!0'<F+$6!7!E'66'2=!$8+!,d/d84&0(:4*/6+!
I49+!H!0'<F+$6!7!E'66'2=!$8+!0+<+9$(0!)(0!M'$!_!
3. Vitamin E
/@!K/'2!)#2<$'(2-!E/'2$/'2!<+**!E+EL0/2+6!/2&!90+M+2$!*'9'&!9+0(:'&/$'(2!()!$8+!<+**!
E+EL0/2+6U!'2!($8+0!>(0&6;!'$!90($+<$6!$8+!<+**!E+EL0/2+6!)0(E!L+'2=!L0(F+2!&(>2!L4!
98(698(*'9/6+!%!?*'9'&!9+0(:'&/$'(2;!>8'<8!'6!)0++!0/&'</*!&/E/=+!(2!$8+!<+**!E+EL0/2+;!
/2&!'6!90+M+2$+&!>'$8!M'$![B@!!G$8+0!)#2<$'(2-!2+#$0/*'c+&!(:'&'c+&!X_X;!>8'<8!'6!)/0!E(0+!
/$8+0(=+2'<!$8/2!X_X!L4!'$6+*)@!!g8+2!X_X!'6!(:'&'c+&;!'$!'6!>/4!E(0+!'23#0'(#6!$(!$8+!<+**!
$8+2!>8+2!'$!'6!2($!(:'&'c+&@!!k'$![!>'**!2+#$0/*'c+!(:'&'c+&!X_X;!$8+0+)(0+!'6!/!
</0&'(90($+<$/2$!?M'$![!/2&!.!L($8!2+#$0/*'c+!(:'&'c+&!X_XB@!!12!6#EE/04-!M'$![!)#2<!C!,B!
90($+<$6!<+**!E+E!)0(E!)0++!0/&'</*!&/E/=+@!HB!G:'&'c+6!)0++!X_X!?$8'6!'6!$8+!X_X!$8/$!
E/<0(98/=+6!98/=(<4$(6+!$(!90(&#<+!)(/E!<+**6;!/2&!*+/&6!$(!/$8+0(6<*+0($'<!9*/D#+6B@!
!
L@!_+)'<'+2<4!()!M'$/E'2![-!16!6++2!L#$!'6!M+04!#2<(EE(2;!/2&!')!6++2!')!>(#*&!L+!'2!F'&6!
>'$8!<46$'<!)'L0(6'6U!)0(E!L'0$8;!F'&6!8/M+!0+69!90(L6!/2&!9/2<0+/6!90(L*+E6@!!?*((F!/$!'2!
0(LL'26;!$((B@!%!F'&!$8/$!8/6!<46$'<!)'L0(6'6!>'**!8/M+!E/*/L6(09$'(2!90(L*+E6U!$8+0+)(0+!
>8/$!)(#0!M'$/E'26!68(#*&!4(#!='M+!8'En!.46$'<!)'L0(6'6!9$!8/6!/!E/*/L6(09$'(2!()!)/$U!
$8+0+)(0+!$8+4!>'**!8/M+!E/*/L6(09$'(2!()!)/$!6(*#L*+!M'$/E'26!7!%;!_;![;!/2&!5@!!k'$![!&+)!
'2!\Y%!'6!#6#/**4!6++2!'2!<46$'<!)'L0(6'6!9/$'+2$6@!!!
!
<@!.*'2'</*!90+6+2$/$'(26-!!G2+!()!$8+!)+/$#0+6!()!M'$![!&+)!'6!8+E(*4$'<!/2+E'/!?M'$![!
2(0E/**4!E/'2$/'26!$8+!'2$+=0'$4!()!$8+!E+EL0/2+BU!$8'6!9$!'6!2(>!6#6<+9$'L*+!$(!)0++!
0/&'</*!&/E/=+;!&/E/=+&!E+E!()!RS.!*+/&6!$(!8+E(*46'6!()!RS.!/2&!8+E(*4$'<!/2+E'/@!!
%2($8+0!)+/$#0+!()!M'$![!/0+!$8'2=6!0+*/$+&!$(!E4+*'2-!9(6$+0'(0!<(*#E2!&c;!69'2/*!
<+0+L+**/0!90(L6@!!I8+0+)(0+;!>'$8!M'$![!&+);!8/M+!2+#0(*(='</*!90(L*+E6!/2&!8+E(*4$'<!
/2+E'/@!
!
&@!k'$/E'2![!$(:'<'$4-!/24$8'2=!E(0+!$8/2!,,VV!#2'$6!?/M+0/=+!</96#*+!'6!^VV!#2'$6;!
$8+0+)(0+;!')!$/F+!P!9'**6;!/*0+/&4!$(:'<B@!!k'$/E'2![!$(:'<'$4!>'**!'28'L'$!642$8+6'6!()!!
k'$!5!&+9+2&+2$!.(/=#*/$'(2!)/<$(06!?H;!`;!r;!,V;!90($+'2!.;!90($+'2!YBU!'2!($8+0!>(0&6;!
4(#!/0+!/2$'.(/=#*/$+&@!![:/E9*+-!9$!>'$8!K1!7!$/F+!/2$'(:'&/2$6;!/2&!/69'0'2U!>'$8!
/2$+0'(0!K1;!$8+4!/2$'.(/=#*/$+!$8+!9$;!/2&!9$!=(+6!8(E+!(2!$80++!E(2$86!()!>/0)/0'2@!
"(0E/*!1"R!0/$'(;!/2&!$/F+6!*($6!/2&!*($6!()!M'$![!/2&!($8+0!M'$/E'26@!!I/F+!/!*($!()!M'$![!
/2&!>'**!8+*9!>/0)/0'2;!*+/&'2=!$(!(M+0!/2$'.(/=#*/$+&!6$/$+;!?0+E+EL+0!$8/$!>/0)/0'2!
L*(<F6!=/EE/!</0L(:4*/$'(2!()!M'$/E'2!5!&+9!)/<$(06B@!!k'$![!>'**!90+M+2$!$8+!Yb"IN[Y1Y!
()!$8+6+!)/<$(06@!!I8+0+)(0+;!M'$![!$(:'<'$4!'6!642+0='6$'<!'2!/<$'M'$4!>'$8!>/0)/0'2@![:/E9*+-!
9$!(2!>/0)/0'2;!</E+!8(E+!)0(E!K1;!1"R!0/$'(!'6!8#=+U!>84n!I/F'2=!M'$![@!
!
4. Vitamin K
/@!Y(#0<+6-!!./2!<(E+!)0(E!>8/$!>+!+/$;!L#$!E(6$!'6!642$8+6'c+&!L4!(#0!<(*(2'<!L/<$+0'/!
?(#0!/2/+0(L+6!'2!(#0!=#$B!7!$8'6!'6!>84!>+!='M+!M'$!5!'23+<$'(26!$(!(#0!L/L4!>8+2!$8+4!
/0+!L(02U!$8+4!(2*4!8/M+!P!&/46!>(0$8!()!M'$!5!)0(E!E(E;!L#$!/)$+0!$8/$;!$8+4!>(2Q$!8/M+!
/24!LZ<!'$6!2($!'2!L0+/6$!E'*FU!$8+0+)(0+;!/!M+04!*(>!*+M+*!()!M'$!5!L+$>++2!&/46!PdeU!/*6(;!
$8+4!&(2Q$!8/M+!L/<$+0'/!$(!E/F+!$8+!M'$!5@!!I8+0+)(0+;!</2!=+$!8+E(008/='<!&c!()!$8+!
2+>L(02!?$8'6!'6!>84!>+!='M+!M'$!F!>8+2!$8+4!/0+!L(02BU!/)$+0!e!&/46;!$8+!L/<$+0'/!
<(*(2'c+;!/2&!M'$!'6!E/&+!L4!$8+!L/L4@!!!
47

!
L@!K+$/L(*'6E-!!S/<$+0'/!E/F+!M'$!5!'2!/2!'2/<$'M+!)(0E!7!5H@!!5H!?'2/<$'M+!)(0E!E#6$!L+!
<(2M+0$+&!L4!+9(:'&+!0+&#<$/6+!$(!5,!?5,!'6!$8+!/<$'M+!)(0E!()!M'$/E'2!5B@!!5,!>'**!
=/EE/!</0L(:4*/$+6!$8+!M'$!5!&+9+2&+2$!)/<$(06!?H;!`;!r;!,V;!90($+'2!.!/2&!YB@!!l/EE/!
</0L(:4*/$+6!0+D#'0+6!$8+!6/E+!#2&+06$/2&'2=!/6!k'$/E'2!.;!'2!M'$!.!1)!4(#!&(2Q$!
84&0(:4*/$+!90(!/2&!*46!$8+2!$8+!<0(66*'2F6!/0+!>+/F+0!?/2<8(0!9$B@!!l/EE/!
</0L(:4*/$'(2!()!M'$!5!&+9!)/<$(06!/<$#/**4!/<$'M/$+6!$8+E!$(!L+<(E+!)#2<$'(2/*@!!k'$!5!&+9!
)/<$(06!/**!8/M+!6(E+$8'2=!'2!<(EE(2-!?,B8/M+!$(!L+!/<$'M/$+&!L4!M'$!5,!/2&!?HB!$8+4!/0+!
$8+!(2*4!.(/=#*/$'(2!)/<$(06!$8/$!/0+!L(#2&!$(!/!<*($!L4!./*<'#E!?./BU!6(!$8+4!8/M+!$(!L+!
L(#2&!L4!./!'2!(0&+0!$(!>(0F!/2&!)(0E!/!<*($U!')!4(#!</2Q$!L'2&;!$8+2!4(#!/0+!
/2$'.(/=#*/$+&@!!I8/$!'6!>8/$!=/EE/!</0L(:4*/$'(2-!=*#$/E'<!/<'&!0+6'&#+6!/0+!=/EE/!
</0L(:4*/$+&!(2!$8+!M'$!5!&+9!)/<$(06!?>8'<8!'6!&(2+!>'$8!5,B;!/2&!/**(>6!./!$(!L'2&!$8+!
)/<$(06U!!$8+0+)(0+;!'$!F++96!$8+E!$(=+$8+0!/2&!4(#!/0+!/L*+!$(!)(0E!/!<*($U!$8+0+)(0+;!')!
$8+4!/0+!2($!=/EE/</0L(:4*/$+&;!$8+4!/0+!#6+*+66!LZ<!./!</2Q$!=0/L!$8+E!$(!)(0E!!/!<*($!
?6(;!=/EE/</0L(:4*/$'(2!'6!$8+!/2<8(0!9$;!6(!./!</2!L'2&!$(!)(0E!/!<*($;!6'E'*/0!$(!
84&0(:4*/$'(2!()!90(*'2+!/2&!*46'2+!'2!<(**/=+2!642$8+6'6B@!
!
g/0)/0'2!L*(<F6!+9(:'&+!0+&#<$/6+;!6(!/**!$8+!M'$!5!9$!8/6!'6!5H!/2&!2(!
=/EE/</0L(:4*/$'(2!>'**!(<<#0@!!I8+0+)(0+;!$8+!9/$'+2$!'6!/2$'<(/=#*/$+&@!
!
<@!k'$/E'2!5!&+)'<'+2<4-!!K..!M'$!5!&+)!?'2!8(69'$/*B!C!L0(/&!69+<$0#E!%LQ6@!!H2&!K..!C!
9((0!&'+$;!L+'2=!/!2+>L(02;!E/*/L6(09$'(2@!!_+)!M'$!5!C!8+E(008/='<!&'/$8+6'6!?L*++&'2=!
'2$(!6F'2!(0!L0/'2B@!!52(>!>84!2+>L(02!8/6!M'$!5!&+)-!![:/E9*+-!F'&!>'$8!0/$!9('6(2!70/$!
9('6(2!'6!>/0)/0'2U!>8+2!0/$6!+/$!'$;!$8+4!=+$!/2$'.(/=#*/$+&!/2&!&'+@!!I0+/$!>'$8!
'2$0/E#6<#*/0!k'$/E'2!5@![:/E9*+-!F'&!*'M+&!>'$8!=0/2&9/0+2$6!/2&!&+M+*(9+&!
8+E(008/='<!&'/$8+6'6-!>84n!!SZ<!$8+!+*&+0*4!>+0+!(2!>/0)/0'2;!/2&!F'&!/$+!$8+!>/0)/0'2;!
/2&!*+&!$(!$(:'<!*+M+*6@!
!
C. Water Soluble Vitamins: /**!/0+!<()/<$(06!'2!E/3(0!L'(<8+E'</*!9/$8>/4!
1. Vitamin C:
/B!.*/66'<!+:/E9*+!()!k'$/E'2!.!&+)'<'+2<4-!(*&+0!9+06(2!(2!$+/!/2&!$(/6$!&'+$!7!
'2&'</$'2=!$8/$!$8+4!/0+!E/*2(#0'68+&U!9$!=+$6!L*++&'2=!()!$8+!=#E6!C!6<#0M4;!&#+!$(!M'$!
.!&+)@!!k'$!.!'6!0+69(26'L*+!)(0!84&0(:4*/$'(2!()!90(*'2+!/2&!*46'2+;!/2&!$8'6!(<<#06!'2!$8+!
l(*='!/99/0/$#6!LZ<!$8/$Q6!>8+0+!9(6$d$0/26*/$'(2/*!E(&')'</$'(2!(<<#06@!!J$6!8/M+!>+/F!
I49+!1!<(**/=+2!LZ<!</22($!<0(66L0'&=+!'$U!$8+0+)(0+;!SkQ6!/0+!#26$/L*+!/2&!=#E6!L*++&@!!!
l+$!L*++&'2=!()!$8+!=#E6;!'2)*/EE/$'(2;!/2&!E/4!*((6+!$++$8@!!!
!
LB!%66(<'/$+&!D#+6$'(2-!>8/$!<(E9*'</$'(2!'6!/66(<'/$+&!>'$8!6+M+0+!8+E(98'*'/!%n!
N+E+/0$80(6+6;!/2&!</#6+&!L4!k'$!.!&+)'<'+2<4!?LZ<!$8+!SkQ6!/0+!#26$/L*+!/2&!$8+4!
0#9$#0+B@!
!
<B!J846'</*!&'/=2(6'6!()!k'$/E'2!.!&+)'<'+2<4-!!%*(2=!>'$8!$8+!$+/!/2&!$(/6$!&'+$;!$8+0+!'6!
/*6(!9+0')(**'<#*/0!8+E(008/=+!?8+E(008/=+!/0(#2&!$8+!8/'0!)(**'<*+6B@!!Y++!0'2=!
6'&+0(L*/6$!?2#<*+/$+&!RS.;!/2&!8/6!$((!E#<8!'0(2!'2!$8+!E'$(<8(2&0'/B;!0'2=!/0(#2&!$8+!
8/'0!)(**'<*+!/2&!/*6(!6++!<(0F!6<0+>!8/'06!&#+!$(!M'$!.!&+)@!!I8+!$(2=#+!*((F6!*'F+!'$!8#0$6!
/2&!9/$'+2$6!>'$8!M'$!.!8/M+!/!6E(($8!$(2=#+!7!=*(66'$'6;!>'$8!F+*(6'6!/0(#2&!/2F*+6;!9*#6!
/!8+E(008/='<!&'/$8+6'6!C!6<#0M4@!
!
48

&B![:<+66!M'$/E'2!.-!M+04!<(EE(2!LZ<!9$6!$/F+!>/4!$((!E#<8!M'$!.!?adt=EB;!E/'2!
<(E9*'</$'(2!'6!R+2/*!6$(2+6!?'2<0+/6+&!#0'<!/<'&!6$(2+6;!/2&!($8+0!F'2&6!()!6$(2+6B@!!!
k'$/E'2!.!/2&!_!L($8!8/M+!$(:'<'$4!6$(2+6@!!!
!
+B!k'$/E'2!.!'6!#6+&!'2!/2<'**/04!R:!)(0!E+$8+E(=*(L'2#0'/U!'$!'6!/!0+&#<'2=!/=+2$!/2&!/!
=0+/$!6</M+2=+0!8#2$+0!)(0!)0++!0/&'</*6!?F2(<F6!$8+E!())B@!!!
!
)B!.()/<$(0!'2!L'(<8+E'</*!9/$8>/4-!!k'$!.!'6!/!<()/<$(0!)(0!<(2M+0$'2=!$8+!</$+<8(*/E'2+!
"[!'2$(![9'@!
!
2. Vitamin B1 (Thiamine)-!!
/B!12M(*M+&!'2!E/24!L'(<8+E'</*!0+/<$'(26-!$0/26F+$(*/6+!0:2Q6!'2!$8+!9+2$(6+!98(698/$+!
68#2$U!/2&!940#M/$+!&+84&0(=+2/6+U!/*98/!F+$(!=*#$/0/$+!&+84&0(=+2/6+U!/2&!/*98/!
F+$(!/<'&!&+84&0(=+2/6+@!!%**!$8+!&+84&0(=+2/6+!0:26!0+D#'0+!$8'/E'2+!/6!/!<()/<$(0@!!
J40#M/$+!&+84&0(=+2/6+!'6!$8+!E/'2!0:2!$8/$!<(2M+0$6!940#M/$+!'2$(!/<+$4*!.(%@!J40#M/$+!
</2!/*6(!L+!<(2M+0$+&!$(!G%%!>'$8!/!</0L(:4*/6+!+2c4E+@!!g8+2!4(#!<(EL'2+!/<+$4*!
.(%!>'$8!G%%;!4(#!E/F+!<'$0/$+;!/2&!4(#!/0+!'2!$8+!I.%!<4<*+@!!!
!
LB!Y(;!')!$8'/E'2+!&+);!LZ<!'$!'6!'2M(*M+&!'2!$8+!940#M/$+!&+84&0(=+2/6+!0:2!?>8'<8!
<(2M+0$6!940#M/$+!$(!/<+$4*!.(%B;!4(#!>'**!2($!8/M+!/!*($!()!/<+$4*!.(%!/0(#2&;!$8+0+)(0+;!
>(2Q$!8/M+!E#<8!<'$0/$+!/0(#2&;!$8+0+)(0+;!4(#!>(2Q$!8/M+!$8+!I.%!<4<*+!>(0F'2=!
+))'<'+2$*4;!/2&!X[YY!%IJ@!!I8+0+)(0+;!$8+!90(L*+E!>'$8!$8'/E'2+!&+)!'6!%IJ!&+9*+$'(2@!!
g8+2!4(#!=(!)0(E!940#M/$+!$(!/<+$4*!.(%;!4(#!=+2+0/$+!H!"%_NQ6!/2&!6'2<+!$8'6!'6!'2!
$8+!E'$(;!4(#!=+$!a!%IJ!?6(;!3#6$!)0(E!=('2=!)0(E!940#M/$+!$(!/<+$4*d.(/;!='M+6!a!%IJBU!
/2&!$8+2!>'$8!I.%;!=+$!H^!%IJQ6@!!a!O!H^!C!PV!%IJU!$8+!$($/*!4(#!</2!=+$!)0(E!
<(E9*+$+*4!E+$/L(*'c'2=!=*#<(6+!'6!Pt!%IJU!6(;!')!4(#!/0+!$8'/E'2+!&+);!4(#!/0+!(#$!PV!
%IJQ6U!6(;!$8+!E/'2!90(L!()!$8'/E'2+!&+)!'6!%IJ!&+9*+$'(2@!
!
<B!12!$8'/E'2+!&+)!4(#Q**!6++!)(($!&0(9!?&04!L+0'L+0'B;!/2&!9'$$'2=!+&+E/!?>+$!L+0'L+0'B@!
N(>!&(+6!$8'6!+:9*/'2!>+$Z&04!L+0'L+0'n!
!
,B!_04!L+0'L+0'!C!9+0'98+0/*!2+#0(9/$84;!/2&!0+)+06!$(!g+02'<F+Q6!F(06/F())!964<8(6'6!
?</2Q$!0+E+EL+0!(*&!/2&!2+>!$8'2=6!7!*'F+!/2!+:/E!7!'+!i#6+&!$(!F2(>!$8/$;!L#$!</2Q$!
0+E+EL+0!2(>jU!/!E+E(04!90(L*+EB@!!1$!$/F+6!/!*($!()!%IJ!)(0!642$8+6'6!()!E4+*'2U!
>'$8(#$!E4+*'2;!4(#!>'**!=+$!9+0'98+0/*!2+#0(9/$84!/2&!)(($!&0(9!?&#+!$(!<(EE(2!
9+0(2+/*!9/*64B;!</2!=+$!>0'6$!&0(9!?0/&'/*!2+0M+!9/*64B;!/2&!<*/>!8/2&!?#*2/0!2+0M+!
9/*64B@!!g+02'<F+Q6!+2<+98/*(9/$84!'6!<(2)#6'(2;!/$/:'/;!/2&!246$/=E#6@!%**!()!$8+6+!
/0+!&#+!$(!&+E4+*'c/$'(2@!
HB!g+$!L+0'L+0'!C!8+/0$!)/'*#0+U!K..!$8'/E'2+!&+)!C!/*<(8(*!?2($!9(*'68+&!0'<+B@!!
%*<(8(*'<6!/0+!$8+!K.!9+(9*+!>'$8!$8'/E'2+!&+)@!!g+$!L+0'L+0'!'6!0+)+00'2=!$(!
</0&'(E4(9/$84!7!</#6+-!XNT!>+2$!'2$(!RNT!>8'<8!*+/&!$(!9'$$'2=!+&+E/@!!N+/0$!2++&6!
%IJ!$(!)#2<$'(2;!$8+0+)(0+;!$8+!9$!>'$8!8/M+!<(2=+6$'M+!</0&'(E4(9/$84U!$8+'0!8+/0$!>'**!
8/M+!L'M+2$0'<#*/0!+2*/0=+E+2$!?$8+!>8(*+!<8+6$!>'**!L+!8+/0$B;!>'$8!*+)$!/2&!0'=8$!NT!
?9'$$'2=!+&+E/!'6!/!6'=2!()!0'=8$!NT!&#+!$(!'2<0+/6+&!84&0(6$/$'<!90+66#0+!L+8'2&!$8+!
)/'*+&!8+/0$B@!!1)!4(#!='M+!1k!$8'/E'2+;!</2!0+M+06+U!/2&!'2!6(E+!</6+6!'$Q6!0+*/$+&!$(!
$(:'<'$4!()!/*<(8(*;!/2&!</22($!>(0F@!
!
49

&B![:/E9*+-!9$!'2![R!='M+2!1k!()!eW!&+:$0(6+!/2&!2(0E/*!6/*'2+U!/**!()!6#&&+2;!9$!
&+M+*(96!<(2)#6'(2;!246$/=E#6;!/2&!/$/:'/;!/2&!(9$8/*E/9*+='/@!!_'/=2(6'6-!6#L<*'2'</*!
$8'/E'2+!&+)'<'+2<4@!!%6!6((2!/6!$8+!=*#<(6+!>/6!8#2=!#9;!$8+!940#M/$+!>+2$!$(!/<+$4*!
.(%!/2&!#6+&!$8+!0+6$!()!$8'/E'2+@@@$8+2!>+2$!'2$(!/<#$+!g+02'<F+Q6!+2<+98/*(9/$84@!!
I8+0+)(0+;!E(0/*!()!$8+!6$(04-!='M+!1k!$8'/E'2+!L+)(0+!8/2='2=!#9!1k!=*#<(6+;!+69+<'/**4!
'2![R@!!!
!
)B!g8+2!9+(9*+!<(E+!'2!<(E/$(6+!(0!6+E'<(E/$(6+;!6+M+0/*!$8'2=6!4(#!/*>/46!&(-!,B!
eVW!=*#<(6+!')!/!849(=*4<+E'/!90(L*+E!HB!2/*(:(2+!?G_B!PB!1k!$8'/E'2+!
!
3. Vitamin B3 (Niacin):
Y*'&+-!R/68!'2!6#2!+:9(6+&!/0+/!C!9+**/=0/!?/F/!&+0E/$'$'6B;!&#+!$(!2'/<'2!&+)!?/*6(!
&'/008+/;!&+0E/$'$'6;!&+E+2$'/BU!849+09'=E+2$/$'(2!'2!6#2d+:9(6+&!/0+/6!C!./66+*Q6!
2+<F*/<+!?&+0E/$'$'6Z9+**/=0/BU!!
!
"%_Z"%_J!0:26!?"!6$/2&6!)(0!2'<($'2/E'&+;!/2&!$8+!2'<($'2/E'&+!>/6!&+0'M+&!)0(E!
2'/<'2B@!!I8+0+)(0+;!/**!$8+!(:'&/$'(2!0:26!0:2Q6!/0+!2'/<'2!&+9+2&+2$@!![:/E9*+-!940#M/$+!
$(!/<+$4*!.(%!C!>+2$!)0(E!"%_!$(!"%_N!/2&!2'/<'2!'6!'2M(*M+&!8+0+@!
!
I049$(98/2!</2!#6+&!'2!642$8+6'c'2=!2'/<'2!/2&!6+0($(2'2!?>84!'$Q6!/2!+66+2$'/*!//BU!L#$!
'$Q6!2($!$8+!E/'2!6(#0<+!()!2'/<'2;!L#$!/!=((&!6(#0<+@!!!
!
"'<($'2'<!/<'&!C!*+/6$!+:9+26'M+!*'9'&!*(>+0'2=!&0#=U!6++!$8+!)*#68'2=!/66(<!>'$8!'$U!
6#99(6+&!$(!$/F+!/69'0'2!>'$8!'$!$(!0+E(M+!$8+!)*#68'2=!0+*/$+&!$(!2'<($'2'<!/<'&!?#6+&!'2!
$0+/$'2=!)/E'*'/*!849+0*'9'&+E'/B;!'$!'6!$8+!_G.!)(0!+*+M/$+&!849+0Il+E'/@!
!
4. Vitamin B2 (Riboflavin):
T%_ZTK"!7!0:26!/0+!0'L()*/M'2!<()/<$(0!0:26!?$8+0+)(0+;!>8+2+M+0!4(#!8/M+!T%_!/2&!
TK"!0:26;!$8+6+!/0+!0'L()*/M'2!<()/<$(0!0:26B@!
?"'/<'2!)(0!"%_Z"%_J!0:26;!/2&!0'L()*/M'2!)(0!T%_ZTK"!0:26B@!
%*6(;!$8+!)'06$!0:2-!=*#$/$8'(2+!0+&#<$/6+!<(2M+0$6!(:'&'c+&!=*#$/$8'(2+!'2$(!=*#$/$8'(2+!
>8'<8!0'L()*/M'2!'6!/!<()/<$(0!)(0@!!!
5. Vitamin B6 (Pyridoxine)-!
g+Q0+!$/*F'2=!/L(#$!E'<0(<4$'<!/2+E'/@!!T'06$!0:2!'2!$8+!642$8+6'6!()!8+E+!'2M(*M+6!
6#<<'24*!.(/;!9*#6!=*4<'2+@!!I8+!+2c4E+!'6!%X%!642$8/6+;!/2&!$8+!<()/<$(0!'6!Sa@!!
I8+0+)(0+;!'$!'6!'E9!$(!$8+!642$8+6'6!()!8+E(=*(L'2!/2&!8+E+!90($+'26@!I8+!<4$(<80(E+!
646$+E!'6!$8+!8+E+!646$+E;!$((@!!K4(=*(L'2!'6!&'))+0+2$!)0(E!NL!?8/6!(2+!8+E+!=0(#9B;!
>8'*+!NL!8/6!)(#0!8+E+!=0(#96@!!I8+0+!'6!/*6(!8+E+!'2!$8+!*'M+0;!'2!$8+!<4$(<80(E+!
646$+E@!!J40'&(:'2+!'6!'2M(*M+&!'2!$8+!642$8+6'6!()!8+E+;!>8'<8!'6!'2!9(09840'2@!!
J40'&(:'2+!'6!'2!$8+!$0/26/E'2/6+6!0:2@!!K(6$!/L#2&/2$!6#L6$0/$+!)0(E!E/F'2=!=*#<(6+!'2!
$8+!)/6$'2=!6$/$+!C!/*/2'2+!?//!)0(E!E#6<*+!7!//Q6!L0(F+2!&(>2!)0(E!E#6<*+!$(!=+$!
=*#<(6+;!M'/!=*#<(2+(=+2+6'6B@!!N(>!</2!/2!//!L+!#6+&!$(!E/F+!=*#<(6+n!
I0/26/E'2/$'(2@!!I0/26/E'2/$'(26!?YlGI;!YlJIB!)0(E!$8+!*'M+0!</2!$/F+!$0/26/E'2/6+6U!
$8+4!$/F+!/E'2(!=0(#96!(#$!/2&!9#$!$8+E!'2$(!($8+0!$8'2=6U!')!4(#!$/F+!$8+!/E'2(!=0(#9!
(#$!()!/*/2'2+;!$8'6!90(&#<+6!940#M/$+!?/2!/*98/!F+$(!/<'&B@!1)!4(#!$/F+!/69/0$/$+!/2&!
$/F+!$8+!//!(#$;!4(#!8/M+!G%%;!>8'<8!'6!/!6#L6$0/$+!)(0!=*#<(2+(=+2+6'6@!!1)!4(#!$/F+!
940#M/$+;!/2&!/&&!/2!/E'2(!=0(#9;!</2!642$8+6'c+!/*/2'2+@!!1)!4(#!$/F+!G%%;!/2&!/&&!/2!
/E'2(!=0(#9;!4(#!</2!E/F+!/69/0$/$+@!!I8'6!'6!>8/$!$8+!$0/26/E'2/6+6!&(;!>'$8!Sa!/6!/!
50

<()/<$(0@!!Sa!'6!/*6(!'2M(*M+&!'2!$8+!642$8+6'6!()!2+#0($0/26E'$$+06@!!I8+0+)(0+;!/!<8'*&!
$8/$!'6!Sa!&+)'<'+2$;!$8+4!+2&!#9!>'$8!6+M+0+!2+#0(*(='</*!90(L*+E6!LZ<!2(!
2+#0($0/26E'$$+06!?Sa!'E9!$(!642$8+6'c'2=!$8+!2+#0($0/26E'$$+06B@!1E9(0$/2$!'2!
$0/26/E'2/$'(2;!2+#0($0/26E'$$+0;!/2&!8+E+!642$8+6'6@!
!
K..!&+)!Sa!&+)!C!'6(2'/c'&U!>'$8(#$!Sa;!>'**!&+M+*(9!2+#0(*(='<!90(L*+E6!/2&!
6'&+0(L*/6$'<!/2+E'/!0+*/$+&!$(!8+E+!90(L*+E@!
D. Other important co-factors
1. Pantothenic acid!'6!0+*/$+&!$(!T%!642$8/6+U!2($!$8+!0/$+!*'E'$'2=!0:2;!L#$!'E9!'2!E/F'2=!
9/*E'$'<!/<'&!?/!,a!.!T%B;!/2&!8+*96!'2!E/F'2=!.(%!?'+!/<+$4*!.(%;!NKl!.(%BU!9/2$($8+2'<!
/<'&!'6!$8+!<()/<$(0!)(0!$8+6+!0:26@!
!
2. Biotin
.()/<$(0!)(0!($8+0!0:2!()!940#M/$+!$(!/<+$4*!.(/!M'/!940#M/$+!&+84&0(=+2/6+!C!$8'/E'2+!
'6!$8+!<()/<$(0;!>8'*+!L'($'2!'6!$8+!<()/<$(0!)(0!J40#M/$+!&+</0L(:4*/6+!$(!G%%@!!
I8+0+)(0+;!$8'/E'2+!8+*96!)(0E!/<+$4*!.(%!)0(E!940#M/$+;!>8'*+!L'($'2!8+*96!)(0E!G%%!
)0(E!940#M/$+@!!!
1)!4(#!/0+!&+);!2++&!$(!+/$!HV!0/>!+==6Z&/4!
_+)'<'+2<4-!=+$!/!0/68!/2&!=(!L/*&!?/*(9+<'/B@!!1)!L'($'2!&+);!</22($!)(0E!G%%;!/2&!
</22($!)0(E!<'$0/$+!+'$8+0!?$8'6!'6!$8+!)'06$!6$+9!'2!=*#<(2+(=+2+6'6;!$8+0+)(0+!4(#!</2!+2&!
#9!>'$8!)/6$'2=!849(=*4<+E'/B@!1)!4(#!L#'*&!940#M/$+;!'$!>'**!L+!)(0<+&!$(!=(!$(!*/<$'<!/<'&@!
!
3. Trace elements
/B!.80(E'#E!C!=*#<(6+!$(*+0/2<+!)/<$(0;!/2&!8+*96!'26#*'2!&(!'$6!3(L@!
G/$E+/*!</2!/*6(!&+<0+/6+!=*#<(6+!>'$8!/**!$8+!)'L+0U!=((&!)(0!/!$49+!11!&'/L+$'<!$(!L+!(2!
<80(E'#E@!
!
LB!.(99+0!7!*46*!(:'&/6+!7!9#$6!<0(66L0'&=+!L+$>++2!<(**/=+2!)'L0'*6!/2&!+*/6$'<!$'66#+@!!
I8+0+)(0+;!')!.#!&+);!8/M+!>+/F!<(**/=+2!/2&!>+/F!+*/6$'<!$'66#+;!90+&'69(6'2=!$(!
&'66+<$'2=!/(0$'<!/2+#046E@!!R+&!8/'0!'2!F>/68'(0F(0!/*6(!&#+!$(!.#!&+)@!
!
<B!T*#(0'2+!2++&+&!$(!90+M+2$!&+2$/*!</00'+6U!$((!E#<8!)*#(0'2+!*+/&6!$(!>8'$+;!<8/*F4!
$++$8;!/*6(!'2!.(*(0/&(!LZ<!>/$+0!8/6!$((!E#<8!)*#(0'2+@!1$!>'**!/*6(!=+$!</*<')'</$'(2!()!
$8+!*'=/E+2$6;!>8+0+!*'=/E+2$6!=(!'2$(!L(2+U!$8+!</*<')'+&!*'=/E+2$6!/0+!6#L3+<$!$(!
0#9$#0+U!/24!=((&!0/&'(*(='6$!</2!&+$+<$!)*#(0'2+!$(:'<'$4@!
!
&B!Y+*+2'#E!7!'2!9+2$(6+!98(698/$+!68#2$;!)(0E!=*#$/$8'(2+;!/2&!8/M+!0'L()*/M'2!8+*9'2=!
$8/$!+2c4E+@!l*#$/$8'(2+!</2!2+#$0/*'c+!9+0(:'&+;!/2&!$8'6!0+D#'0+6!=*#$/$8'(2+!
9+0(:'&/6+U!6+*+2'#E!'6!$8+!<()/<$(0!)(0!$8'6!0+/<$'(2@!!I8+0+)(0+;!'2!($8+0!>(0&6;!'$!'6!/2!
/2$'(:'&/2$!LZ<!')!4(#!/0+!&+)!'2!'$U!$8+!=*#$/$8'(2+!</22($!L0+/F&(>2!$8+!9+0(:'&+@!!?k'$!
[!#6#/**4!<(E+6!>'$8!6+*+2'#E!7!6(!(2+!>(0F6!(2!=*#$/$8'(2+;!>8'*+!$8+!($8+0!90($+<$6!
$8+!*'9'&!E+EL0/2+!)0(E!)0++!0/&'</*!&/E/=+!/2&!6</M+2=+6!(:'&'c+&!X_XB@!
!
+B!q'2<!7![:/E9*+-!(*&+0!9+06(2!>'$8!&46=#6'/!?/L2(0E/*!$/6$+B!/2&!/2(6E'/!?*/<F!()!
6+**BU!6E+**!/2&!$/6$+!/0+!L($8!&+)!'2!c'2<!&+)@!!q'2<!'6!/!E+$/**(+2c4E+U!$8+0+)(0+!'$!8/6!/!
$0/<+!E+$/*!/6!/!<()/<$(0@!!.(**/=+2/6+!'6!/!E+$/**(+2c4E+!LZ<!'$!8/6!c'2<!'2!'$;!/2&!'$!
L0+/F6!&(>2!$8+!$49+!P!<(**/=+2;!6(!4(#!</2!)(0E!$49+!,!<(**/=+2@!!I8+0+)(0+;!')!
51

&+)'<'+2$!'2!'$;!>'**!8/M+!9((0!>(#2&!8+/*'2=;!/2&!4(#!=+$!/!0/68!(2!$8+!)/<+@!!Y(;!0/68!(2!
)/<+;!&46=#6'/;!/2(6E'/;!9((0!>(#2&!8+/*'2=!C!c'2<!&+)'<'+2<4mmm!!_'/L+$'<6!/0+!c'2<!&+);!
#2*+66!$/F'2=!6#99*+E+2$6@!
!
4. Dietary fiber (insoluble and soluble)!7!6(*#L*+!)'L+0!</2!*(>+0!<8(*+6$+0(*!?2($!$8+!
'26(*#L*+!)'L+0B@!N(>!'$!>(0F6!?'+!(/$E+/*B-!(/$E+/*!8/6!'26(*#L*+!)'L+0;!>8+2!'$Q6!'2!$8+!=#$;!
'$!>'**!6#<F!#9!>/$+0!'2$(!'$!)0(E!$8+!<(*(2;!/2&!/*6(!6#<F!#9!L/&!$8'2=6!7!*'9(9(*'<!/<'&@!!reW!
()!L'*+!/<'&6!/2&!L'*+!6/*$6!/0+!0+/L6(0L+&!'2!$8+!$+0E'2/*!'*+#E@!!I8+!eW!/0+!*'9(9(*'<!/<'&6;!
>8'<8!/0+!</0<'2(=+2'<!?90(&#<+6!<(*(2!</2<+0B@!!Y(;!)'L+0!?'26(*#L*+!/2&!6(*#L*+B;!'$!6#<F6!
$8+!*'9(9(*'<!/<'&!#9;!'2$(!$8+!'2$+0'(0!()!$8+!6$((*;!6(!'$!8/6!2(!<(2$/<$!>'$8!$8+!L(>+*!
E#<(6/@!!J*#6;!&+)+</$+!E(0+!()$+2!/2&!$8+0+)(0+!*'9(9(*'<!/<'&6!8/M+!+M+2!*+66!<(2$/<$!>'$8!
$8+!6$((*@!!g(E+2!/0+!*#<F4!LZ<!$8+4!0+<4<*+!+6$0(=+26U!E/'2!>/4!()!+:<0+$'2=!+6$0(=+26!'6!
'2!L'*+!/2&!(#$!()!4(#0!6$((*;!L#$!/!6E/**!W!()!+6$0(=+26!/0+!0+<4<*+&!L/<F!'2$(!$8+!646$+E@!!
b(#!E/4!2($!2+<+66/0'*4!2++&!$8/$;!6(;!>8+2!(2!)'L+0;!'2<0+/6+&!+6$0(=+2!'6!9/66+&!(#$;!
$8+0+)(0+;!&+<0+/6'2=!<8/2<+!()!L0+/6$!</2<+0;!(M/0'/2!</2<+0;!/2&!#$+0'2+!</2<+0!LZ<!)'L+0!
'2!$8+!&'+$@!!!!
!
IV. Special diets protein restriction
g8/$!H!&cQ6!>(#*&!4(#!0+6$0'<$!90($+'2!'2n!!
!
,B!R+2/*!)/'*#0+!LZ<!+:<+66!90($+'2!L0(F+2!&(>2!$(!/EE(2'/!/2&!($8+0!$8'2=6!7!$8+!/EE(2'/!'6!
E+$/L(*'c+&!'2!$8+!#0+/!<4<*+;!>'**!8/M+!'2<0+/6+!#0+/!/2&!$8+!F'&2+4!>'**!8/M+!$(!=+$!0'&!()!E(0+!
#0+/@!
!
HB!.'008(6'6!()!$8+!*'M+0!7!&+)+<$'M+!#0+/!<4<*+!$8+0+)(0+!</22($!E+$/L(*'c+!/EE(2'/U!E(6$!()!$8+!
/EE(2'/!$8/$!>+!8/M+!'2!(#0!L(&'+6!<(E+6!)0(E!L/<$+0'/!'2!(#0!<(*(2!$8/$!8/M+!#0+/6+!'2!$8+E!
?N@!94*(0'BU!/2&!$8+4!L0+/F&(>2!#0+/!$(!/EE(2'/!'2!(#0!<(*(2@!%EE(2'/!'6!0+/L6(0L+&;!/2&!
6#99(6+&!$(!=(!L/<F!$(!(#0!*'M+0!/2&!=(!'2$(!$8+!#0+/!<4<*+;!L+<(E+!#0+/!/2&!=+$!0'&!()!'$@!S#$!
>'$8!<'008(6'6;!2(!#0+/!<4<*+;!6(!$8+!/EE(2'/!*+M+*6!'2<0+/6+!'2!$8+!L*((&;!*+/&'2=!$(!8+9/$'<!
+2<+98/*(9/$84;!E+2$/*!6$/$#6!/L2(0E/*'$'+6;!/6$+0':'6U!/*6(!</#6+&!L4!(<$9/2+E+;!L+2c('<!/<'&;!
2+#0($0/26E'$$+06@!!!
!
Y(;!$>(!6'$#/$'(26!$(!0+6$0'<$!90($+'2-!<'008(6'6!/2&!<80(2'<!0+2/*!)/'*#0+@!
52

CHAPTER 5. NEOPLASIA
!
I. Nomenclature: B9 vs. malignant!
A. Main difference!7!Sr!#6#/**4!&(+6!2($!E+$/6$/6'c+;!E/*'=2/2$!8/6!$8+!</9/<'$4!$(!
E+$/6$/6'c+@!!![:<+9$'(2-!Sr!$#E(0!$8/$!E+$/6$/6'c+-!'2M/6'M+!E(*+!?E+$/6$/6'c+!$(!*#2=6;!L#$!
=(+6!/>/4B@!!!
!
B. Slides:
/B!K.!6F'2!</2<+0!1"k%_[Y!L#$!&(+6!2($!E+$/6$/6'c+-!L/6/*!<+**!</0<'2(E/@!
LB!!\$+0#6-!*+'(E4(E/U!K.!Sr!$#E(0!'2!>(E/2!'6!K.!*(</$+&!'2!>8'<8!(0=/2n!\$+0#6!7!'$Q6!/!
*+'(E4(E/U!$#E(0!()!6E(($8!E#6<*+m!
<B!!T'L0('&6!7!6E(($8!E#6<*+U!L+<(E+!M+04!8/0&!
&B!!K.!Sr!$#E(0!'2!E/*+!?4+**(>B!C!*'9(E/!
+B!!Sr!$#E(0!()!=*/2&6!C!/&+2(E/6!?'+!/&0+2/*!/&+2(E/!7!$8'2!/&0+2/*!<(0$+:!LZ<!'$!'6!
)#2<$'(2/*U!'$!<(#*&!L+!E/F'2=!<(0$'6(*;!$8+0+)(0+!6#990+66'2=!%.IN;!/2&!$8+!)/6'<#*/$/!/2&!
0+$'<#*/0'6!>(#*&!#2&+0=(!%IRGJNbA*+/&6!$(!.#68'2=Q6@!!1)!$#E(0!6+<0+$'2=!
E'2+0/*(<(0$'<('&6!7!'$!'6!.(22Q6!642&0(E+;!</#6'2=!/$0(984!()!$8+!c(2+!=*(E+0#*(6/!?lTR!7!
6/*$4!6>++$!6+:B!
!
)B!I#L#*/0!/&+2(E/!C!K.!90+<#06(0!*+6'(2!)(0!<(*(2!</2<+0!?*((F6!*'F+!6$0/>L+004!(2!/!6$'<FB!
!
C. Carcinoma vs. sarcoma
,@!!./0<'2(E/!7!E/*'=2/2<4!()!+9'$8+*'/*!$'66#+!?P!+9'$8+*'/*!$'66#+6!7!6D#/E(#6;!=*/2&#*/0;!
/2&!$0/26'$'(2/*B!
!
/B!YD#/E(#6!</0<'2(E/!7!8(>!$(!0+<(=2'c+n!X'$$*+!6>'0*6!()!'2<0+/6+&!0+&2+66!?L0'=8$!
0+&B!</**+&!6D#/E(#6!9+/0*6U!!
!
LB!l*/2&#*/0!</0<'2(E/!7!R(#2&!=*/2&6;!>'$8!6(E+$8'2=!'2!$8+!E'&&*+!C!/&+2(</0<'2(E/!
!
<B!I0/26'$'(2/*!<+**!</0<'2(E/!7!)0(E!L*/&&+0;!#0+$+0;!0+2/*!9+*M'6!?)0(E!=+2'$/*!#0'2/04!
$0/<$B!7!/**!>'$8!$0/26'$'(2/*!+9'$8+*'#E!
!
I8+0+)(0+!P!</0<'2(E/6!C!6D#/E(#6;!/&+2(</0<'2(E/;!/2&!$0/26'$'(2/*!<+**!</0<'2(E/6@!
!
&B![:/E9*+-!!K/*'=2/2$!E+*/2(E/!7!)'06$!6$+9!'2!E/2/=+E+2$n!![:<'6'(2!?Lr!M+06'(2!C!
2+M#6B;!L($8!/0+!&+0'M+&!)0(E!E+*/2(<4$+6@!!I8'6!'6!$8+!E(6$!0/9'&*4!'2<0+/6'2=!</2<+0!'2!
$8+!\Y%;!2($!K.@!!I8+4!/0+!Yd,VV!%=!iOj!$#E(06!7!/9#$!$#E(06!
!
+B!%9#$!I#E(06-!!Yd,VV!%=!iOj!$#E(06!7!/9#$!$#E(06U!/9#$!'6!90+<#06(0!#9$/F+!&+</0L(:4*/$'(2;!
E+/2'2=!$8/$!$8+4!/0+!()!2+#0(6+<0+$(04!(0!2+#0/*!<0+6$!(0'='2@!!I8+0+)(0+;!(2![K;!8/M+!
2+#0(6+<0+$(04!=0/2#*+6@!!Yd,VV!%=!'6!#6+&!$(!6$/'2!$8'2=6!()!/9#$!(0'='2!(0!2+#0/*!<0+6$!(0'='2!
?E(6$;!2($!/**;!>'**!$/F+!#9!$8/$!%=B@!!
[:/E9*+6!()!/9#$!$#E(06-!E+*/2(E/U!6E/**!<+**!</0<'2(E/!()!$8+!*#2=U!L0(2<8'/*!
</0<'2('&U!</0<'2('&!$#E(0!/$!$8+!$'9!()!$8+!/99+2&':U!2+#0(L*/6$(E/!?6+<0+$(04!
$#E(0B;!'+!H!4Z(!>'$8!$#E(06!/**!(M+0!6F'2;!/2&!(2!L'(964;!'$!'6!Yd,VV!iOj;!$#E(0!>/6!
)0(E!/&0+2/*!E+&#**/;!E+$/6$/6'c+!$(!6F'2@!
!
H@!Y/0<(E/6!7/0+!E/*'=2/2<4!()!K[Y[".NbK%X!$'66#+!?2($!+9'$8+*'/*B@!
53

Y/0<(E/!()!6E(($8!E#6<*+!C!*+'(4E4(6/0<(E/U!Y$0'/$+&!E#6<*+!C!08/L&(E4(6/0<(E/U!
T/$!C!*'9(6/0<(E/U!?$8+6+!/0+!E/*'=2/2<'+6!()!E+6+2<84E/*!$'66#+;!>8'*+!</0<'2(E/Q6!
/0+!()!+9'$8+*'/*!$'66#+B@!!!
!
[:/E9*+6-!
/B!S(2+;!6++!E+$/9846'6;!6++!.(&E/2Q6!$0'/2=*+;!/2&!6#2L#06$!/99+/0/2<+!(2!:d0/4!LZ<!
$8'6!$#E(0!/<$#/**4!E/F+6!L(2+@!!_:!C!(6$+(=+2'<!6/0<(E/!?L(2+!E/F'2=!6/0<(E/B@!!!
!
LB!S'(964!)0(E!='0*!8/M'2=!2+<0($'<!E/66!<(E'2=!(#$!()!8+0!M/='2/;!k'E+2$'2!/2&!F+0/$'2!
idi;!/2&!&+6E'2!iOj;!&:n![EL04(2/*!08/L&(E4(6/0<(E/!?6++!6$0'/$'(2!()!E#6<*+B@!I8'6!'6!
$8+!K.!6/0<(E/!()!<8'*&0+2!?M/='2/!'2!*'$$*+!='0*6!/2&!9+2'6!'2!*'$$*+!L(46B!
!
<B!K(M/L*+!E/66!/$!/2=*+!()!3/>!C!E':+&!$#E(0!?'2!9/0($'&BU!]E':+&Q!LZ<!$>(!
8'6$(*(='</**4!8/M+!$>(!&'))+0+2$!$49+6!()!$'66#+!L#$!&+0'M+&!)0(E!Y%K[!<+**!*/4+0!?2($!/!
$+0/$(E/;!>8'<8!'6!)0(E!$80++!<+**!*/4+06B;@!!K.!(M+0/**!6/*'M/04!=*/2&!$#E(0!?#6#/**4!LrB!
C!E':+&!$#E(0!
!
&B!I+0/$(E/!C!$(($8;!8/'0;!&+0'M+&!)0(E!/**!$80++!<+**!*/4+06!?+<$(&+0E;!E+6(&+0E;!/2&!
+2&(&+0EB!%F/!=+0E!<+**!$#E(06!7!LZ<!$8+4!/0+!$($'9($+2$'/*;!/2&!6$/4!E'&*'2+@!![:@!
/2$+0'(0!E+&'/6$'2#E;!(0!9'2+/*!=*/2&U!$8+0+)(0+;!$+0/$(E/6!/0+!=+0E!<+**;!E'&*'2+!
$#E(06@!!
!
+B!.46$'<!$+0/$(E/!()!$8+!(M/0'+6-!,a!4Z(!='0*!>'$8!6#&&+2!(26+$!()!RXp!9/'2!?&(2Q$!
<(2)#6+!>'$8!/99+2&'<'$'6;!.0(82Q6!&c;!+<$(9'<!90+=2/2<4;!)(**'<#*/0!<46$B@!!G2!:d0/4;!6++!
</*<')'</$'(26!()!$8+!9+*M'<!/0+/m!7!.46$'<!$+0/$(E/!?$8+!</*<')'</$'(26!</2!L+!L(2+!(0!
$++$8B@!\6#/**4!&+M+*(9!'2!E'&*'2+!7!=+0E!<+**!$#E(0@!!
54

II. Nomenclature: Leukemia and lymphoma
K.!(2!$8+!L(/0&6-!%#+0!0(&!)0(E!E4+*(L*/6$;!/2&!849+06+=E+2$+&!2+#$0(98'*!)0(E!S,H!/2&!
)(*/$+!&+)'<'+2<4@!
A. Leukemia!C!E/*'=2/2<4!()!6$+E!<+**6!'2!$8+!BM;!/2&!$8+4!</2!E+$/6$/6'c+!?*'F+!/**!</2<+0B!
/2&!$(!*4E98!2(&+6;!*+/&'2=!$(!=+2+0/*'c+&!*4E98/&+2(9/$84!/2&!8+9/$(69*+2(E+=/*4@!!
_+0'M+&!)0(E!6$+E!<+**6!'2!$8+!E/00(>!/2&!E+$/6$/6'c+@!
B. Malignant lymphoma-!/0'6+!)0(E!LYMPH nodes;!/2&!</2!E+$/6$/6'c+!/24>8+0+;!'2<*#&+!
SK@!!!
!
I8+!K.!6'$+!'2!L(&4!)(0!*4E98(E/!"GI!&+M+*(9'2=!'2!*4E98!2(&+- stomach!
K(6$!+:$0/2(&/*!?(#$6'&+!*4E98!2(&+B!90'E/04!*4E98(E/6!(<<#0!'2!$8+!6$(E/<8U!
N@!94*(0'!</2!90(&#<+!$8+6+@!!!
H2&!K..!*(</$'(2!?*4E98('&!(0=/2!'2!$8+!l1!$0/<$B!C!Payers patches!?*(</$+&!'2!$8+!
$+0E'2/*!'*+#EB@!
!
K.!*4E98(E/!C!)(**'<#*/0!S!<+**!*4E98(E/@!!I8'6!'6!/2!+:/E9*+!()!F2(<F'2=!())!/9(9$(6'6!
=+2+!d,^-,t!$0/26*(</$'(2!()!/!8+/M4!<8/'2U!>8+2!4(#!=+$!$8+!$0/26*(</$'(2;!S!<+**6!>'**!E/F+!
L<*dH;!>8'<8!'2/<$'M/$+6!/9(9$($'<!=+2+!'2!$8+!S!<+**;!$8+0+)(0+;!$8+!/9(9$($'<!=+2+!'6!
'EE(0$/*;!*+/&6!$(!</2<+0@!
!
III. Nomenclature of Trophoblastic Tumors
A. Hydatidiform mole;!90+6+2$6!>'$8!<*#6$+0!()!=0/9+6@!!1$!E/2')+6$6!'2!$8+!)'06$!$0'E+6$+0!>'$8!
6'=26!()!90++<*/E96'/!?NJ;!90($+'2#0'/;!+&+E/!'2!$8+!)'06$!$0'E+6$+0B@!!G2!#*$0/6(#2&;!>'**!6++!
#$+0#6!$((!*/0=+!)(0!'$6!=+6$/$'(2/*!/=+;!>'$8!/!62(>6$(0E!/99+/0/2<+!C!<*/66'<!<(E9*+$+!E(*+U!
/2&!</2!90(=0+66!$(!<8(0'(</0<'2(E/@!
!
B. Choriocarcinoma!mole!'6!/!L+2'=2!$#E(0!()!$8+!<8(0'(2'<!M'**#6U!<8(0'(2'<!M'**'!/0+!*'2+&!
>'$8!$0(98(L*/6$'<!<+**6;!'2<*#&'2=!642<$'($0(98(L*/6$!(2!$8+!(#$6'&+!?8/6!<(2$/<$!>'$8!$8+!L*((&;!
)0(E!>8'<8!GH!'6!+:$0/<$+&BU!#2&+0!$8+!642<$'($0(98(L*/6$!'6!$8+!<4$($0(98(L*/6$;!$8+2!8/M+!
>/0$+2Q6!3+**4!'2!$8+!<8(0'(2'<!M'**#6;!$8+2!8/M+!M+66+*!$8/$!L+<(E+6!$8+!#EL'*'</*!M+'2;!>8'<8!8/6!
$8+!E(6$!GH!'2!$8+!M+66+*6!()!$8+!)+$#6@!!
!
Y(;!84&/$'&')(0E!E(*+!'6!/!Sr!$#E(0!()!$8+!gNGX[!<8(0'(2'<!M'**#6;!/2&!'$!*((F6!*'F+!=0/9+6!LZ<!
'$Q6!&'*/$+&!#9@!.8(0'(</0<'2(E/!'6!/!E/*'=2/2<4!()!$8+!*'2'2=!()!$8+!<8(0'(2'<!M'**#6-!$8+!
642<$'($0(98(L*/6$!/2&!$8+!<4$($0(98(L*/6$!?2($!$8+!/<$#/*!<8(0'(2'<!M'**#6B@!!g8'<8!E/F+6!
8(0E(2+6n!I8+!642<4$'($0(98(L*/6$!642$8+6'c+6!SdN.l!/2&!8#E/2!9*/<+2$/*!*/<$(=+2!?=0(>$8!
8(0E(2+!()!90+=2/2<4!7!'$!='M+6!//Q6!/2&!=*#<(6+!)0(E!E(E!$(!L/L4B@!!Y(;!>8+2!=+6$/$'(2/**4!
&+0'M+&;!/2&!+M+2!>8+2!$8+4!E+$/6$/6'c+!$(!$8+!*#2=6;!$8+4!0+69(2&!>+**!$(!<8+E($8+0/94!
?E+$8($0+:/$+;!<8*/L#<'*B@!!I8+0+)(0+;!$8+6+!/0+!8'=8*4!E/*'=2/2$!$#E(06;!L#$!=(!/>/4!>'$8!
<8+E($8+0/94@!
IV. Things that end in oma:
[M+04$8'2=!$8/$!+2&!'2!7(E/!'6!2($!2+<+66/0'*4!Lr!7!'+!E+*/2(E/!?E/*'=2/2$!$#E(0!()!
E+*/2(<4$+6B;!*4E98(E/!?E/*'=2/2$!$#E(0!()!*4E98!2(&+6B!
!
%*6(;!/**!$8/$!+2&6!'2!7(E/!'6!2($!2+<+66/0'*4!/!2+(9*/6E!7!'+!8+E/0$(E/!C!(M+0=0(>$8!()!$'66#+!
$8/$!'6!2(0E/**4!90+6+2$!'2!$8/$!/0+/@!![:/E9*+-!%!L0(2<8'/*!8+E/0$(E/!6++2!*#2=!>8'<8!'6!Lr!
55

</0$'*/=+!/2&!/!6(*'$/04!<('2!*+6'(2!'6!6++2!'2!*#2=!?/*6(!>(2&+0!')!'$Q6!/!=0/2#*(E/B@!!I8+!9(*49!'2!
J+#$c!f+=8+06!642&0(E+!'6!/!8+E/0$(E/!?2($!+M+2!/!2+(9*/6EB;!$8/$Q6!>84!$8+0+!'6!2(!'2<0+/6+!
'2!0'6F!()!9(*4!</2<+0@!!N49+09*/6$'<!9(*49!?K.!9(*49!'2!l1B!'6!/!8+E/0$(E/;!'$Q6!/!Sr!$'66#+!'2!
9*/<+!'$!'6!2($!6#99(6+!$(!L+!?'+!9/2<0+/$'<!$'66#+!'2!$8+!6$(E/<8B!7!$8'6!'6!</**+&!/!<8(0'6$(E/;!
(0!8+$+0($(9'<!0+$@!
!
K+<F+*Q6!_'M+0$'<#*#E!
K.!<(E9*'</$'(2!()!K+<F+*Q6!_'M+0$'<#*#E!C!L*++&'2=!)0(E!/!=/6$0'<!E#<(6/!$8/$!'6!#*<+0/$+&;!(0!
9/2<0+/$'<!$'66#+!$8/$!'6!#*<+0/$+&@!!Y8(#*&!=/6$0'<!E#<(6/!L+!'2!$8+!E+<F+*Q6!&'M+0$'<#*#En!"(;!
LZ<!'$!'6!'2!$8+!6E/**!L(>+*!?/L(#$!H!)$!)0(E!$8+!'*+(<+</*!M/*M+B@!!N+E/0$(E/6!/0+!2(2d
2+(9*/6$'<;!/2&!$8+0+)(0+!&(!2($!8/M+!</2<+0!90(&#<'2=!9($+2$'/*@!!!
!
V. Malignant Cells
12<0+/6+&!E'$($'<!0/$+!&(+6!2($!E+/2!</2<+0@!!g8/$!E/F+6!E'$(6'6!E/*'=2/2$!'6!8/M'2=!/2!
/$49'</*!E'$($'<!69'2&*+!?$8+4!/0+!/2+#9*('&!/2&!8/M+!E(0+!$8/2!$8+!2(0E/*!â!<Q6(E+6). Key
thing that determines if it is malignant is its ability to metastasize@!!K/*'=2/2$!<+**6!
#6#/**4!8/M+!/!*(2=+0!<+**!<4<*+!$8/2!$8+!<+**6!$8+4!&+0'M+&!)0(E@!How many doubling times
does it take to get a tumor that can be detected clinically? 30 doubling times!E+/26!
$8/$!$8+!$#E(0!=(+6!$80(#=8!$8+!<+**!<4<*+!PV!$'E+6;!/2&!/!$#E(0!()!(2+!6(2(E+$+0!'2!6'c+!'6!
90(&#<+&U!,Vr!'2!E/66@!!K/*'=2/2$!<+**6!/0+!'EE(0$/*!7!$8+4!&(2Q$!*'F+!+/<8!($8+0!/2&!*/<F!
/&8+6'(2U!')!$8+4!>+0+!6$#<F!$(!+/<8!($8+0;!$8+4!>(#*&!8/M+!90(L*+E6!'2)'*$0/$'2=!$'66#+@!!
K/*'=2/2$!<+**6!8/M+!6'E9*+!L'(<8+E'</*!646$+E6;!$49'</**4!/2/+0(L'<!E+$/L(*'6E;!/2&!8/M+!
E/24!+2c4E+6!6#<8!/6!90($+/6+6!?#6+&!$(!L0+/F!$80(#=8!$'66#+B;!<(**/=+2/6+6!?#6+&!$(!L0+/F!
$80(#=8!SKB@!!I8'6!'6!>8/$!E/F+6!/!E/*'=2/2$!<+**!E/*'=2/2$@!
!
VI. Mechanisms of Metastasis: lymphatic, hematogenous, seeding
A. Lymphatic metastasizes:
N(>!&(!carcinomas!#6#/**4!E+$/6$/6'c+n!X4E98!2(&+6!7!$8+4!&0/'2!$(!$8+'0!0+='(2/*!*4E98!
2(&+6U!'+!L0+/6$!</2<+0!=(+6!$(!/:'**/04!2(&+6!(0!'2$+02/*!E/EE/04!2(&+6@!!T(0!<(*(2!
</2<+0;!=(!$(!2(&+6!/0(#2&!$8+E!?$8+!*(</*!*4E98!2(&+6BU!6/E+!>'$8!</0<'2(E/!()!$8+!
+6(98/=#6@!!g8/$!9/0$!()!$8+!*4E98!2(&+!&(!E+$/6$/6+6!=(!$(n!Y#L</96#*/0!6'2#6@!!1)!$8+4!
</2!=+$!$80(#=8!$8+!*4E98!2(&+;!$8+4!=(!$(!$8+!+))+0+2$!*4E98/$'<6!>8'<8!&0/'26!'2$(!$8+!
$8(0/<'<!&#<$;!/2&!$8+2!'2$(!$8+!6#L<*/M'/2;!/2&!$8+2!$8+4!L+<(E+!8+E/$(=+2(#6@!!
I8+0+)(0+;!</0<'2(E/!</2!L+<(E+!8+E/$(=+2(#6;!$8'6!E+/26!$8/$!$8+4!,6$!>+2$!$80(#=8!$8+!
*4E98!2(&+6U!2(>;!$8+4!</2!690+/&!$(!($8+0!(0=/26!?'+!L(2+;!*'M+0;!+$<B@!!I8'6!'6!L+$$+0!$8/2!
6/0<(E/!LZ<!</2!)++*!$8+!*4E98!2(&+6!L4!<*'2'</*!+:/E!/2&!9'<F!#9!L+)(0+!'$!690+/&6@!
B. Hematogenous metastasizes:
G2!$8+!($8+0!8/2&;!sarcomas!&(!2($!*'F+!$(!=(!$(!*4E98!2(&+6@!!I8+4!=(!0'=8$!$80(#=8!SkQ6!
/2&!/0+!<8/0/<$+0'c+&!L4!8+E/$(=+2(#6!690+/&;!/2&!$8/$Q6!>84!*#2=6!/2&!L(2+6!/0+!
<(EE(2!6'$+6!()!6/0<(E/6@!!I8+4!&(2Q$!*'F+!$(!=(!$(!*4E98!2(&+6@!!I8+0+)(0+;!$8+4!/0+!/!
*'$$*+!>(06+!LZ<!$8+4!'EE+&'/$+*4!=(!8+E/$(=+2(#6;!/2&!&(!2($!='M+!/!<*#+!$8/$!$8+4!/0+!
690+/&'2=@!![:/E9*+-!8/M+!/2='(6/0<(E/!()!$8+!L0+/6$U!>(#*&!4(#!&(!/!0/&'</*!&'66+<$'(2!()!
$8+!/:'**/n!"(;!LZ<!/2='(6/0<(E/!&(+6!2($!=(!$(!$8+!*4E98!2(&+6;!$8+0+)(0+;!&(!/!6'E9*+!
E/6$+<$(E4@!!1)!'$!'6!L0+/6$!</0<'2(E/;!$/F+!L0+/6$!/2&!*#E9+<$(E4!/2&!*(</*!/:'**/04!*4E98!
2(&+6!/2&!<(E9*+$+!$8+!&'66+<$'(2@!!!
!
56

[:<+9$'(26-!T(**'<#*/0!</0<'2(E/!()!$8+!$840('&!?$8'2F6!'$Q6!/!6/0<(E/B!7!6F'96!*4E98!2(&+6!
/2&!=(+6!6$0/'=8$!$(!SkQ6;!/2&!$/F+6!$8+!8+E/$(=+2(#6!0(#$+@!
R+2/*!/&+2(</0<'2(E/!7!=(+6!$(!0+2/*!M+'26!?/*6(!&+$+0E'2+6!90(=2(6'6B!
N+9/$(<+**#*/0!</0<'2(E/!7!*'F+!$(!/$$/<F!$8+!M+66+*6!
!
12!=+2+0/*;!</0<'2(E/6!,6$!*'F+!$(!=(!$(!*4E98!2(&+6;!/2&!$8+!8/M+!$8+!9($+2$'/*!$(!L+<(E+!
8+E/$(=+2(#6@!!Y/0<(E/6!=(!8+E/$(=+2(#6;!E/F'2=!$8+E!&/2=+0(#6@!
!
C. Seeding-!.*/66'</*![:/E9*+-!!</2<+06!$8/$!/0+!'2!</M'$'+6!/2&!8/M+!/!9($+2$'/*!()!6++&'2=;!*'F+!
*'$$*+!E/*'=2/2$!'E9*/2$6@!!K(6$!(M/0'/2!</2<+06!/0+!6#0)/<+!&+0'M+&!</2<+06;!$8+0+)(0+!&+0'M+&!
)0(E!*'2'2=!/0(#2&!$8+!(M/04;!/2&!$8+4!6++&!*'F+!*'$$*+!'E9*/2$6@!!I8+0+)(0+;!+/64!$(!$80(>!(#$!
$8+6+!'E9*/2$6!/2&!)(0!'$!$(!E+$/6$/6'c+!$(!$8+!(E+2$#E;!/2&!'2$(!$8+!9(#<8!()!_(#=*/6@!!I8+!
9(#<8!()!_(#=*/6!'6!9(6$+0'(0!$(!$8+!#$+0#6!/2&!/2$+0'(0!$(!$8+!0+<$#E!/2&!'6!)+*$!L4!&'='$/*!0+<$/*!
+:/E@!!I8+!9(#<8!()!_(#=*/6!'6!$(!/!>(E/2;!/6!$8+!90(6$/$+!=*/2&!'6!$(!$8+!E/2@!!1)!4(#!&(!/!
0+<$/*!(2!/!E/2;!/2&!9#68!)(0>/0&;!4(#!>'**!)++*!$8+!90(6$/$+@!!1)!4(#!&(!/!0+<$/*!(2!/!>(E/2!
/2&!9#68!)(0>/0&;!$8'6!'6!$8+!9(#<8!()!_(#=*/6@!!I8'6!'6!/2!'E9!/0+/!LZ<!'$Q6!$8+!E(6$!&+9+2&+2$!
/0+/!()!/!>(E/2Q6!9+*M'6!/2&!E/24!$8'2=6!=(!8+0+!7!<*($$+&!L*((&!'2!/!0#9$#0+!+<$(9'<!
90+=2/2<4;!>8+0+!+2&(E+$0'/*!'E9*/2$6!=(!'2!+2&(E+$0'(6'6;!/2&!>8+0+!6++&'2=!=(+6!'2!(M/0'/2!
</2<+06!?9(#<8!()!_(#=*/6B@!!Y(;!6++&'2=!()!(M/0'/2!</2<+0!$(!$8+!(E+2$#E!/2&!</2!/<$#/**4!
'2M/&+@!!./2!/*6(!6++&!'2!$8+!9*+#0/*!</M'$4;!)(0!+:/E9*+-!9+0'98+0/**4!*(</$+&!*#2=!</2<+0!$8/$!
</2!6++&!'2$(!$8+!9*+#0/*!</M'$4@!!lSK!?K.!90'E/04!E/*'=2/2<4!()!$8+!L0/'2!'2!/&#*$6B!</2!6++&!
'2$(!$8+!69'2/*!)*#'&!/2&!'E9*/2$!'2$(!$8+!+2$'0+!69'2/*!<(0&;!/6!</2!/!E+&#**(L*/6$(E/!'2!/!<8'*&@!!!
!
Y(;!$8+!P!E+<8/2'6E6!)(0!E+$/6$/6'6!/0+!*4E98/$'<;!8+E/$(=+2(#6;!/2&!6++&'2=@!
!
VII. Most Common (MC) cancers
I8+!)'06$!D#+6$'(2!'6!$(!/6F-!i16!$8+!E+$/6$/6'6!E(0+!<(EE(2!$8/2!90'E/04!</2<+0nj!!
!
12!E(6$!</6+6;!E+$/6$/6'6!'6!$8+!K.!</2<+0!'2!/2!(0=/2!?2($!/!90'E/04!</2<+0B@!![:<+9$'(2-!0+2/*!
/&+2(</0<'2(E/!?>8'<8!'6!E(0+!<(EE(2!$8/2!E+$/6$/6'6!$(!'$B@!
!
Lung-!K.!</2<+0!'6!E+$/6$/6'6!)0(E!$8+!L0+/6$!</2<+0@!!I8+0+)(0+;!K.!</2<+0!'2!$8+!*#2=!'6!
L0+/6$!</2<+0@!!I8+0+)(0+;!>(E+2!/0+!E(0+!*'F+*4!$(!=+$!*#2=!</2<+0@!
!
Bone-!K.!</2<+0!'2!L(2+!'6!E+$/6$/6'6!?2($!E#*$'9*+!E4+*(E/!(0!(6$+(=+2'<!6/0<(E/B@!!K.!
</2<+0!$8/$!E+$/6$/6'6!$(!L(2+!'6!L0+/6$!</2<+0!LZ<!$8+!L/$6(E!646$+EU!'$!'6!/!M+2(#6!<(E9*+:!
=('2=!)0(E!L/6+!()!$8+!6F#**!&(>2!$(!$8+!6/<0#E;!/2&!8/6!2(!M/*M+6!'2!'$@!!I8+!*'$$*+!$0'L#$/0'+6!
<(EE#2'</$+!>'$8!$8+!M+2/!</M/!/2&!/*6(!=(!0'=8$!'2$(!$8+!M+0$+L0/*!L(&'+6@!!I8+2!$8+4!<(**+<$!
/0(#2&!$8+!69'2/*!<(0&!/2&!=(!#9@!!T(0!+:/E9*+-!/!*/&4!8/6!/!*'$$*+!9*#=!()!$#E(0!'2!$8+!
'2$+0<(6$/*!M+'2;!/2&!L+2&6!&(>2!$(!9'<F!#9!6(E+$8'2=!())!$8+!=0(#2&;!>8'<8!</#6+6!$8+!</2<+0!
$(!L+!&'6*(&=+&!)0(E!$8+!M+'2!$(!$8+!M+2/!</M/!$(!$8+!L/$6(2!9*+:#6!'2!$8+!M+0$+L0/*!L(&'+6;!/2&!
P!E(2$86!*/$+0!68+!'6!<(E9*/'2'2=!()!*(>+0!L/<F!9/'2@!!%**!()!/!6#&&+2;!68+!'6!6$/=+!)(#0!</2<+0@!
!
K.!L(2+!E+$/6$/6'6!IG!$8+!M+0$+L0/*!<(*#E2@!!H2&!K.!'6!$8+!8+/&!()!$8+!)+E#0!?'2!/!>(E/2;!
$8'6!'6!&#+!$(!L0+/6$!</2<+0!7!'+!L0+/6$!</2<+0!'2!8+/&!()!)+E#0;!>8+2!$8+4!$8(#=8$!'$!>/6!
&+=+2+0/$'M+!/0$80'$'6B@!
!
MC organ metastasis to = lymph nodes!?</0<'2(E/6!/0+!E(0+!<(EE(2!$8/2!6/0<(E/6;!/2&!
</0<'2(E/6!*'F+!$(!=(!$(!*4E98!2(&+6;!E+/2'2=!'$!'6!$8+!K.!E+$/6$/6'6!$(B!
57

!
Liver: K.!</2<+0!()!*'M+0 C!E+$/6$/6'6!)0(E!*#2=!'2$(!*'M+0!?2($!<(*(2!7!<(*(2!'6!H2&!LZ<!9(0$/*!
M+'2!&0/'2/=+B@!
!
Testicular Cancer: g8+0+!>(#*&!$+6$'<#*/0!</2<+0!E+$/6$/6'c+!)'06$n!J/0/(0$'<!*4E98!2(&+6U!
"GI!$8+!'2=#'2/*!*4E98!2(&+6!LZ<!'$!&+0'M+&!)0(E!$8+!/L&(E+2;!/2&!$8+2!&+6<+2&+&@!![:/E9*+-!!
6+E'2(E/!?E/*'=2/2$B!>'**!E+$/6$/6'c+!$(!9/0/(0$'<!2(&+6!LZ<!$8/$!'6!>8+0+!'$!</E+!)0(E!!
!
Left supraclavicular node, aka Virchows node@!!I8+!K.!90'E/04!E+$/6$/6'c+!$(!k'0<8(>Q6!
2(&+6!C!6$(E/<8!</2<+0m!I8+0+!'6!/!E/66!'2!$8+!*+)$!6#90/<*/M'<#*/0!2(&+6!/*(2=!>'$8!>$!*(66!
/2&!+9'=/6$0'<!&'6$0+66@!
!
58

Bone-!!S+6$!$+6$!*((F'2=!)(0!L(2+!E+$6n!R/&'(2#<*+'&+!6</2@!![:/E9*+-!+M+04>8+0+!$8/$!'6!L*/<F!
'2!/!>(E/2!'6!E+$6!)0(E!L0+/6$!</2<+0@!!K.!L(2+!E+$/6$/6'6!$(!C!M+0$+L0/*!<(*#E2m!!!
!
K+$6!$8/$!/0+!lytic!?L0+/F!L(2+!&(>2B!/2&!E+$6!$8/$!/0+!blastic!?E+$6!=(!'2$(!L(2+!/2&!
'2&#<+!(6$+(L*/6$'<!0+69(26+B@!!
!
%@!X4$'<!K+$/6$/6'6-!!
T(0!*4$'<!E+$6;!$8+4!</2!*+/&!$(!9/$8(*(='<!)0/<$#0+6!/2&!849+0</*<+E'/@!
Multiple myeloma!>'$8!9#2<8+&!(#$!*+6'(26!LZ<!/**!E/*'=2/2$!9*/6E/!<+**6!8/M+!1Xd,!'2!
$8+E!?/F/!(6$+(<*/6$!/<$'M/$'2=!)/<$(0B!
S@!S*/6$'<!E+$/6$/6'6-!
T(0!L*/6$'<!E+$6;!alkaline phosphatase!>'**!L+!+*+M/$+&@!![:/E9*+-!$8'6!'6!/!E/*+!>'$8!
90(6$/$+!</2<+0!?90(6$/$+!</2<+0!'6!L*/6$'<mBU!'$!'6!E/F'2=!L(2+!/2&!>'**!0+*+/6+!/*F/*'2+!
98(698/$/6+!
!
MC location for mets = lumbar vertebrae
[:/E9*+-!!tV!4Z(!E/2!>'$8!*(>+0!*#EL/0!9/'2!>'$8!9$!$+2&+02+66U!>8/$!'6!)'06$!6$+9!'2!
E/2/=+E+2$n!_'='$/*!0+<$/*!+:/E!>(#*&!L+!$8+!)'06$!$8'2=!$(!&(!LZ<!$8'6!>(#*&!L+!6$/=+!)(#0!
&c;!/2&!$8+!90(6$/$+!'6!9/*9/L*+U!6(;!$8'6!'6!$8+!+/6'+6$!/2&!<8+/9+6$!$+6$!?2($!JY%;!(0!
0/&'(2#<*+'&+!L(2+!6</2!$(!E/F+!6#0+!'$6!2($!E+$6B@!!!
!
X4$'<!E+$6!7!8/M+!*#<+2<4!?/L6+2<+!()!L(2+B!7!'+!M+0$+L0/+!<(**/96+!
S*/6$'<!E+$6!7!8/M+!+2$'$4!(2!:!0/4!
!
If you see any specimen with multiple lesions in it, it is METS (primary cancers are
confined to one area of the organ).
!
K.!</2<+0!L0/'2!C!E+$6!
K.!</2<+0!F'**+0!'2!E+2!/2&!>(E+2!C!*#2=!</2<+0!
K.!90'E/04!6'$+!)(0!</2<+0!'2!L0/'2!C!*#2=!
K.!</2<+0!'2!*#2=!C!E+$6!)0(E!L0+/6$!
!
K.!E+$6!$(!/&0+2/*!C!*#2=!7!$8+0+)(0+!$8+4!/*>/46!&(!/!.I!()!$8+!8'*/0!*4E98!2(&+6;!/2&!
/&0+2/*!=*/2&6!'2!$8+!6$/='2=!()!/**!*#2=!</2<+06@!
S(2+!C!L*/6$'<;!$8+0+)(0+!$8+!E(6$!*'F+*4!</#6+!'6!90(6$/$+!</2<+0@!!!
!
VIII. Stains and EM used to help dx dz:
!
Stains-!&+6E'2!7!=((&!6$/'2!)(0!E#6<*+!7!'+!#6+&!)(0!08/L&(E4(6/0<(E/!
Y$/'2!)(0!F+0/$'2!?E(6$!</0<'2(E/6!8/M+!F+0/$'2!'2!'$;!$8+0+)(0+!6$/'2!)(0!$8/$B!
Y$/'26!8+*9!1_!&'))!$49+6!()!$#E(06!
k'E+2$'2d!E+6+2<84E/*!<+**6!
!
EM-!!\6+&!>8+2!2($8'2=!+*6+!8+*96!
%#9#$!$#E(0!7!6++!2+#0(6+<0+$(04!=0/2#*+6@!!
N'6$'(<4$+!$#E(0!?'+!8'6$'(<4$(6'6!hB!7!6++!L'0L+<F!=0/2#*+6;!>'$8!._!,!
K#6<*+!7!6++!/<$'2!/2&!E4(6'2!)'*/E+2$6!
k/6<#*/0!E/*'=2/2<4!7!g'LL*+!9/*/&!L(&'+6!?8/M+!MgT!'2!$8+EBU!$8+4!/0+!()!+2&($8+*'/*!(0'='2!
59

52(>!=/9!3#2<!?>8'<8!<(EE#2'</$+;!>8'<8!&(2Q$B!
!
IX. Oncogenesis:
A. Big picture of oncogenesis
,B!12'$'/$'(2!?E#$/$'(2!7!'+!>'$8'2!$8+!<+**!<4<*+B!
HB!J0(E($'(2!?>8+0+!E#*$'9*+!<(9'+6!()!$8+!E#$/$'(2!/0+!E/&+B!
PB!J0(=0+66'(2!?6#Ld69+<'/*'c'2=B!&'))!$49+6!()!</2<+0!<+**6!8/M+!&'))!)#2<!7!E/*'=2/2$!<+**6!
>'$8!(2+!9#09(6+!7!$(!F'**!4(#@!!_'))!<+**6!>'$8!&'))!)#2<-!6(E+!6$/4!>8+0+!$8+4!/0+U!6(E+!
'2M/&+!?/2&!/0+!='M+2!69+<'/*!$8'2=6!)(0!'$!$(!L+!/L*+!$(!'2M/&+BU!6(E+!8/M+!69+<'/*!0+<+9$(06!
$(!8(E+!'2!$(!69+<')'<!(0=/26U!6(E+!0+6'6$!<8+E(;!6(E+!690+/&;!6(E+!E/F+!+2c4E+6!$(!
9+2+$0/$+!$'66#+6@!
!
H!6+$6!()!=+2+6!'2M(*M+&!>'$8!</2<+0-!
,B!12M(*M+&!'2!=0(>$8!90(<+66!?<+**!<4<*+!0+*/$+&B!
HB!l+2+6!$8/$!6#990+66!$8'2=6!?6#990+66(0!=+2+6B!
!
B. Things that are involved in trying to get a cell to divide:
lTQ6!?+9'&+0E/*!&+0'M+&!lTBU!90($((2<(=+2+6!7!2(0E/*!=+2+6;!>8'<8!8/M+2Q$!L++2!/<$'M/$+&;!
/2&!8/M+!2(0E/*!)#2<$'(2@!!g8+2!$8+4!8/M+!L++2!/<$'M/$+&;!$8+4!L+<(E+!(2<(=+2+6;!>8'<8!/0+!
L/&!/2&!L+<(E+!</2<+0(#6@!!.+0$/'2!90($((2<(=+2+6!<(&+!)(0!=0(>$8!)/<$(06!7!'+!6'6;!>8(6+!
)#2<!'6!$(!E/F+!lTQ6@!!!
!!
%**!lTQ6!8/M+!$(!8((F!'2$(!/!0+<+9$(0U!$8+0+)(0+!<+0$/'2!90($((2<(=+2+6!>8(6+!E/'2!3(L!'6!$(!
E/F+!0+<+9$(06!7!'+!+0LdH!C!L0+/6$!</2<+0;!>8'<8!<(&+6!)(0!/!0+<+9$(0!/2&!0+$!C!6++2!'2!K["!
642&0(E+!?K["!1!/2&!11/!/2&!11LB@!!!
!
g+!8/M+!$(!6+2&!/!E+66/=+!$(!$8+!2#<*+#6;!6(!8/M+!/2($8+0!6+$!()!=+2+6;!>8(6+!3(L!'6!$(!6+2&!
$8+!E+66/=+U!6(E+!*(</$+&!'2!$8+!<+**!E+EL0/2+@!![:/E9*+-!0/6!90($((2<(=+2+!6+2&6!/!lIJ!?/!
98(698(04*/$+&!90($+'2!E+66/=+B;!$8+0+)(0+!'$Q6!/!<+**!E+EL0/2+!*(</$+&!E+66+2=+0!646$+E@!!
%2($8+0!+:/E9*+-!!/L*!90($((2<(=+2+!>8'<8!*'M+6!'2!$8+!<4$(6(*;!M+04!<*(6+!$(!$8+!2#<*+/0!
E+EL0/2+!/2&!/*6(!'6!'2M(*M+&!'2!E+66/=+6@!!!
!
g8(!'6!$8+!E+66+2=+0!6+2$!$(n!I8+!E+66/=+!'6!6+2$!$(!/!=0(#9!()!90($((2<(=+2+6!'2!$8+!
2#<*+#6@!!G2<+!$8/$!E+66/=+!'6!6+2$!$(!$8+E;!$8+0+!'6!6$'E#*/$'(2!()!2#<*+/0!$0/26<0'9$'(2!()!$8/$!
E+66/=+U!'2!($8+0!>(0&6;!$8+!<+**!&'M'&+6!/2&!E/F+6!>8/$+M+0!'$!'6!6#99(6+&!$(!E/F+@!Classic
protooncogenes there are myc protooncogenes = n-myc and c-myc (n-myc is for
neuroblastoma, and c-myc is for Burkitts lymphoma).
!
Y(;!$8+!90($((2<(=+2+6!'2M(*M+&!E/F+!lTQ6;!=0(>$8!)/<$(0!0+<+9$(06U!6+2&!E+66/=+6!?>8'<8!/0+!
()$+2!98(698(04*/$+&!90($+'26B@!![:/E9*+!7!'+!'26#*'2!8((F6!'2$(!0+<+9$(0!(2!/&'9(6+!/2&!
/<$'M/$+&!$40(6'2+!F'2/6+!?*(</$+&!0'=8$!(2!$8+!0+<+9$(0B;!>8'<8!E/F+6!/!98(698(04*/$+&!90(&#<$;!
=(+6!$(!$8+!2#<*+#6!?$(!&'M'&+B;!/2&!/*6(!=(+6!$(!l%!/2&!/$$/<8+6!$(!lX\Id^;!>8'<8!'6!E/&+!
)0(E!=(*='!/99/0/$#6;!=(+6!$(!$8+!<+**!E+EL0/2+!/2&!$8+0+Q6!$8+!0+<+9$(0!)(0!=*#<(6+@!!
I8+0+)(0+!$8+!E+66/=+6!=(!$(!2#<*+/0!$0/26<0'L+06!'2!$8+!2#<*+#6!/2&!$8+6+!/0+!E4<!(2<(=+2+6@!!!
!
The suppressor genes are controlling the cell cycle. The 2 most imp are Rb
suppressor gene and p53 suppressor gene.!"(0E/**4;!$8+4!<(2$0(*!$8+!<+**!<4<*+!/2&!&(!2($!
*+$!<+**!<4<*+!90(=0+66!$(!Y!98/6+@!!1)!#20+=#*/$+&;!<+**6!=(!$(!Y!98/6+!/2&!L+<(E+!]'2'$'/$+&Q@!!!
!
60

N(>!&(!>+!'2'$'/$+!/!<+**n!K#$/$'(267E+<8/2'6E6-!#6#/**4!/!9('2$!E#$/$'(2!'+!6#L6$'$#$+6!//!)(0!
+Z(@!!I8+!9eP!6#990+66(0!=+2+!/2&!$8+!0/6!(2<(=+2+6!'6!/!9$!E#$Q2@!!%**!6#990+66(0!=+2+6!/0+!
&#+!$(!9$!E#$Q2@!!G$8+0!E#$/$'(26!'2<*#&+-!!
%E9*')'</$'(2!7!E/F+!E#*$'9*+!<(9'+6!?+0LdH!'6!/2!/E9*')'</$'(2!646$+EB!/2&!
!
I0/26*(</$'(2!?9#$$'2=!'2!/2($8+0!9*/<+!/2&!</2Q$!=(!L/<FB!<*/66'<-!.KX!$0/26*(</$'(2!()!/L*!?2(2!
0+<+9$(0!$40(6'2+!F'2/6+!/<$'M'$4!)0(E!<Q6(E+!r!$(!HH@!!G2!<Q6(E+!HH;!'$!)#6+6!(2!/!<*#6$+0!0+='(2!
()!$8+!)#6'(2!=+2+;!/2&!LZ<!()!$8+!$40(6'2+!F'2/6+!/<$'M'$4;!'$!6+2&6!/!E+66/=+!/2&!6$+E!<+**6!
F++9!&'M'&'2=U!/F/!J8'**4!<Q6(E+@!!%2($8+0!+:/E9*+-!!./2<+0!/66(<!>'$8![96$+'2!S/00!M'0#6!7!
$0/26*(</$'(2!()!E4<!2#<*+/0!$0/26<0'L+0!=+2+!)0(E!<Q6(E+!t!/2&!9#$6!'$!(2!<Q6(E+!,Û!'$!&(+62Q$!
*'F+!'$!$8+0+;!6(!'$!*+/&6!$(!S#0F'$$6!*4E98(E/@!!R+<+9$(0!)(0![96$+'2!L/00!M'0#6!(2!/**!S!<+**6!7!._!
H,U!>8+2!'$!8((F6!(2!$(!0+<+9$(0;!'$!</#6+6!S!<+**6!$(!L+<(E+!9*/6E/!<+**6!/2&!E/F+!%L!
?$8+0+)(0+;!$8'6!M'0#6!'6!/2!/E/c'2=!6$'E#*/$'2=!()!%L!642$8+6'6;!/6!'6!$8+!.Kk!M'0#6@B!
I8+!E(0+!/!<+**!&'M'&+6;!$8+!>(06+!'$!'6!')!6(E+$8'2=!8/99+26!$(!'$U!'+![Sk!M'0#6!;!t;,^!
$0/26*(</$'(2!()!E4<!(2<(=+2+6!)0(E!t!$(!,^!/2&!/**!()!/!6#&&+2!4(#!/0+!E/F'2=!E#*$'9*+!
<(9'+6;!/2&!*+/&6!$(!*4E98(E/!?=0+/$+0!<8/2<+!$8/$!4(#!&(!6(E+$8'2=;!$8+!=0+/$+0!<8/2<+!$8/$!
4(#!>'**!6<0+>!#9B@!!!
!
T(**'<#*/0!S!<+**!*4E98(E/!7!$0/26*(</$'(2!()!,^-,tU!'2/<$'M/$'(2!()!6#990+66(0!=+2+@!!!
!
Translocation 15:17 = acute progranulocytic leukemia; Rx Vit A (retinoic acid) b/c
it matures the blasts, therefore the malignant cell becomes B9.
!
C. Suppressor genes
Y#990+66(0!=+2+6!6#990+66;!$8+0+)(0+!')!F2(<F+&!());!>8/$+M+0!$8+4!>+0+!6#990+66'2=!F++96!(2!
=('2=. Key suppressor genes: p53, Rb gene, adenomatos polyposis coli (familial
polyposis), neurofibromatosis, wilms tumor gene, brca1 and 2 ?L($8!'2M(*M+&!'2!_"%!
0+9/'0;!/2&!(2+!'6!(2!<Q6(E+!,P!>8'*+!$8+!($8+0!'6!(2!<Q6(E+!,`BU!L0</,!</2!L+!L0+/6$!</2<+0;!
(M/0'/2!</2<+0;!(0!($8+06U!brca2 is TOTALLY related to breast cancer.!!G2*4!,eW!()!L0+/6$!
</2<+06!8/M+!=+2+$'<!/66(<!>'$8!$8+6+!=+2+6;!$8+0+)(0+;!E(6$!</6+6!/0+!69(0/&'<@!!!
!
X. Common things that predispose mutations:
J0($((2<(=+2+6!/0+!/<$'M/$+&;!>8'*+!6#990+66(0!=+2+6!/0+!'2/<$'M/$+&!
P!E/'2!>/46!$8'6!(<<#06-!<8+E'</*6;!M'0#6+6;!0/&'/$'(2!
!
A. Chemicals-!
g8'<8!()!$8+!$80++!'6!E(6$!<(EE(2!'2!'2'$'/$'2=!/!<+**!90(&#<'2=!/!E#$/$'(2n!Chemicals
smoking = MCC death in USA due to polycyclic hydrocarbons.
S4!'$6+*);!6E(F'2=!'6!K.!$8/2!M'0/**4!'2&#<+&!(0!0/&'/$'(2!'2&#<+&!</2<+06@!!YE(F'2=!</#6+6!
*#2=!</2<+0;!6D#/E(#6!</2<+0!()!$8+!E(#$8;!*/042:;!*#2=;!9/2<0+/6;!L*/&&+0;!/2&!')!'$Q6!2($!
$8+!s,!</#6+;!'$Q6!()$+2!sH;!6#<8!*+#F+E'/6;!<+0M'</*!</;!/2&!<(*(2@!
!
K..!9/9'**/04!$#E(0!()!$8+!L*/&&+0!C!$0/26'$'(2/*!</2<+0!?6E(F'2=B!
g8/$!')!4(#!>(0F+&!'2!/!&4+!'2&#6$04n!%2'*'2+!
!
What if you had Wegeners granulomatosis, put on a drug and got hematuria, did
cytology and saw cells, what drug is pt on? Cyclophosphamide (hemorrhagic
cystitis); prevent with mesna, and can cause transitional cell carcinoma
(therefore acts as a carcinogen!)
61

!
X#2=!</2<+0!7!K..!C!9(*4<4<*'<!84&0(</0L(26!)0(E!6E(F+U!E(6$!()$+2!/66(<!>'$8!6E(F'2=!'6!
6E/**!<+**!/2&!6D#/E(#6U!
!
B. Viruses:
k'0#6!/66(<!</2<+0-!/!M'0#6!>'$8!2(290#0'$'<!0/'6+&!0+&!*+6'(26@!_:n!5/9(6'Q6!6/0<(E/!?&#+!$(!
NNk!tB!
!
Burkitts; due to Epstein barr varies which also causes nasopharyngeal carcinoma,
esp. in Chinese
!
liver Hepatocellular carcinoma due to hepatitis B from Asia; also due to a mold
aflatoxin B; combo of hep B, cirrhosis, plus aflatoxin makes is common in Asia;
can also be caused by hep C
!
N1k!'6!/66(<!>'$8!90'E/04!."Y!*4E98(E/@!!I8+4!>'**!/6F-!$8+!0/9'&*4!'2<0+/6'2=!'2<'&+2<+!()!
90'E/04!."Y!*4E98(E/!</2!L+!&'0+<$*4!/$$0'L#$+&!$(!>8/$n!
N1k!
!
NJk!</#6+6!6D#/E(#6!</2<+0!()!<+0M':;!M/='2/;!/2&!M#*M/;!/2&!/2#6!()!8(E(6+:#/*6!&#+!$(!
#290($+<$+&!'2$+0<(#06+U!&#+!$(!NJk!,a;!,t;!P,@!!I8'6!M'0#6!</#6+6!/2/*!6D#/E(#6!<+**!
</0<'2(E/!'2!8(E(6+:#/*6@!I8+!M'0#6!>(0F6!L4!E/F'2=!$>(!90($+'26;!E6 which knocks off
p53, while E7 knocks of Rb@!
!
C. Radiation
MC cancer assoc with radiation = leukemia
MC leukemia assoc with radiation = CML (9, 22 translocation of abl)
!
J/9'**/04!</0<'2(E/!()!$840('&!'6!/*6(!<(EE(2*4!6++2!/6!/!0+6#*$!()!0/&'/$'(2@!![:/E9*+-!9$!
8/&!0/&'/$'(2!'2!8+/&!/2&!2+<F;!/2&!8/6!2(2$+2&+0!2(&#*/0!E/66+6!'2!<+0M'</*!0+='(2!C!
E+$/6$/$'<!9/9'**/04!</0<'2(E/!()!$8+!$840('&!0+*/$+&!$(!'(2'c'2=!0/&'/$'(2@!
!
[:/E9*+-!(6$+(=+2'<!6/0<(E/!
!
[:/E9*+-!>8'<8!E+&'</*!90()+66'(2!'6!E(6$!6#L3+<$!$(!*+#F+E'/n!R/&'(*(='6$;!*+#F+E'/6!/0+!
<(EE(2*4!</#6+&!L4!0/&'/$'(2!/2&!'$Q6!$8+!0/&'(*(='6$!$8/$!/0+!<(EE(2*4!'2M(*M+&!>'$8!$8'6@!!
!
[:/E9*+-!')!4(#!8/M+!f/<(L!.0#$c)+*$!&c;!>8/$!&0!/0+!4(#n!"+#0(dJ/$8(*(='6$!?L<!>(0F!>'$8!
L0/'26!/2&!90'(26B!
!
[:/E9*+-!L/6/*!<+**!</0<'2(E/!?9'<B;!E#*$')(</*U!$8'6!'6!2(2!'(2'c'2=!0/&'/$'(2!?'(2'c'2=!
0/&'/$'(2!'6!$8+!L/&!6$#))B@!!I8'6!'6!\k!S!*'=8$!?L!'6!L/&BU!\k!%!*'=8$!'6!)(0!)*#(0+6<'2=!
6#9+0)'<'/*!&+0E/$(984$+6!?>((&Q6!*'=8$B!(0!=0++2Q6!9/$<8+6!'2!$#L+0(#6!6<*+0(6'6!?$8+0+)(0+!
#6+&!L4!&+0E/$(*(='6$6B;!/F/!L*/<F!*'=8$@!\k!S!*'=8$!'6!>8/$!4(#!90($+<$!4(#06+*)!)0(E!$(!
90+M+2$!=+$$'2=!6F'2!</2<+06!?L/6/*!<+**!C!K.;!$8+2!6D#/E(#6!<+**;!$8+2!E+*/2(E/B@!!\k!_!C!
$84E'&'2+!&'EE+06!
!
[:/E9*+-!*+6'(2!'2!6#2!+:9(6+&!/0+/6!$8/$!'6!6<0/9+&!())!/2&!=0(>6!L/<F!7!/F/!6(*/0!?/<$'2<B!
F+0/$(6'6U!'$!90+&'69(6+6!$(!6D#/E(#6!&469*/6'/@!%06+2'<!'6!/!E+$/*!$8/$!'6!/66(<'/$+&!>'$8!
62

6F'2!</2<+0. Bangladesh has bad water supply which contains arsenic, therefore
they have a high number of squamous skin cancers, and with time it can lead to
cancer of the lung, and angiosarcoma of the liver.
[:/E9*+-!F'&!>'$8!>8'$+!+4+!0+)*+:!7!0+$'2(L*/6$(E/!7!<Q6(E+!,P@!I8'6!&c!'6!69(0/&'<!/2&!
)/E'*'/*@!!1$!$/F+6!$8+!69(0/&'<!&c!H!6+9/0/$+!E#$Q2!$(!L+<(E+!0+$'2(L*/6$(E/!?F2(<F!())!(2!
+/<8!<Q6(E+!,PB@!!1)!'$!'6!)/E'*'/*;!>8'<8!'6!%#$(6(E/*!&(E'2/2$!'$!$/F+6!3#6$!(2+!E#$Q2;!LZ<!
4(#!/0+!L(02!>'$8!(2+!/*0+/&4!'2/<$'M/$+&;!$8+0+)(0+!(2*4!2++&!(2+!E(0+!E#$/$'(2!(2!$8+!
($8+0!<80(E(6(E+!'2!(0&+0!$(!&+M+*(9!0+$'2(L*/6$(E/@!!!White eye reflex is not MC due
to retinoblastoma the MCC is congenital cataract (which can be due to CMV,
rubella, or any congenital infections). Which drug predisposes to cataracts?
Corticosteroids; therefore a person with Cushings dz may develop cataracts.
!
63

XI. Genetic dz
!
Xeroderma pigmentosa 7!6#2!+:9(6+&!/0+/6;!/#$(!0+<+66'M+;!</2!</#6+!/**!6F'2!</2<+06!?S..;!
Y..;!/2&!E+*/2(E/6B;!/2&!the defect is in DNA repair enzymes@!G$8+0!_"%!0+9/'0!&+)+<$6!
/0+!/66(<'/$+&!>'$8!SR.%,!/2&!SR.%H;!9eP;!$8+4!69*'<+!(#$!$8+!&+)+<$6;!$8'6!=0(#9!'6!</**+&!$8+!
<80(E(6(E/*!'26$/L'*'$4!642&0(E+6!7!>'6F($$!%*&0'<8;!S*((E6;!%$/:'/!I+*/2='+<$/6'/6;!/2&!
T/2<(2'Q6;!/**!8/M+!90(L6!>'$8!_"%!0+9/'0@!!
!
Basic rule of thumb for BCC and SCC:
Upper lip and up is basal cell carcinoma;
lower lip and down is squamous cell
(therefore, lesion on lower lip = sq cell; lesion on upper lip = basal cell)
!
[:/E9*+-!'26'&+!2(6+!'6!S..;!LZ<!/L(M+!$8+!#99+0!*'9!
!
[:/E9*+-!F+*('&!7!6D!<+**!</0<'2(E/6!/2&!P0&!&+=0++!L#026!/2&!6D!<+**!</0<'2(E/!&+M+*(9'2=!'2!
/0+/6!()!&0/'2/=+!)0(E!$8+!6'2#6!/2&!#*<+0!$8/$!&(+62Q$!8+/*!)0(E!/2$'L'($'<6@!!Y(;!>8+0+M+0!
$8+0+!'6!<(26$/2$!'00'$/$'(2;!/2&!&'M'6'(2!()!<+**6!0+*/$+&!$(!'00'$/$'(2;!$8+0+!'6!/2!'2<0+/6+!
6#6<+9$'L'*'$4!$(!</2<+0@!!I8'6!&(+6!2($!8(*&!$0#+!)(0!6</0!</2<+0!$'66#+!0+*/$+&!</2<+06!()!$8+!
*#2=6!(0!/&+2(</0<'2(E/!?3#6$!/99*'+6!$(!$8'2=6!(2!$8+!6F'2!7!'+!L#026!/2&!&0/'2'2=!()!6'2#6!
$0/<$6B@!
!
G2*4!L/<$+0'/!/66(<!>'$8!</2<+0n!N@!94*(0'!7!/&+2(</0<'2(E/!/2&!*(>!=0/&+!E/*'=2/2$!
*4E98(E/6@!!!
!
XII. Grade vs Stage
!
A. Grade!C!what does it look like?!I8+!$+0E!>+**!&'))+0+2$'/$+&!E+/26!$8/$!$8+!$#E(0!'6!
E/F'2=!6(E+$8'2=!*'F+!F+0/$'2!(0!=*/2&6;!/2&!')!'$Q6!'&+2$')'/L*+!'$Q6!</**+&!*(>!=0/&+@!!g8+2!$8+!
<+**6!/0+!/2/9*/6$'<;!9((0*4!&'))+0+2$'/$+&!#2&+0!$8+!E'<0(6<(9+;!/2&!')!4(#!</22($!$+**!>8/$!'$!'6;!
$8+2!'$Q6!</**+&!8'=8!=0/&+@!
[:/E9*+-!6D!<+**!</0<'2(E/!</2!6++!F+0/$'2!9+/0*6U!</2!1_!'$;!6(!'$Q6!/!*(>!=0/&+!</2<+0@!!
[:/E9*+-!6++!=*/2&!*'F+!69/<+6;!</2!1_!6(!'$6!*(>!=0/&+!
!
B. Stage = (TNM)!K.!6$/='2=!646$+EU!=(+6!)0(E!*+/6$!'E9!$(!E(6$!'E9!?I"KB!
[:/E9*+-!L0+/6$!</2<+0!>'$8!/:'**/04!2(&+!'2M(*M+E+2$U!$8+0+)(0+;!$8+!"C,;!L#$!$8+!iKj!'6!
>(06+;!LZ<!'$!'2&'</$+6!$8/$!</2<+0!8/6!690+/&!$(!($8+0!(0=/26!*'F+!L(2+;!+$<@!
f#6$!LZ<!'$!=(+6!$(!*4E98!2(&+6!&(+62Q$!E+/2!'$!'6!$8+!E(6$!'E9!90(=2(6$'<!)/<$(0@!
!
TC6'c+!()!$#E(0U!')!$#E(0!'6!(M+0!H!6(2(E+$+06;!'$!8/6!/!<8/2<+!()!E+$6!
NC2(&+6!?2+:$!E(6$!'E9!)(0!90(=2(6'6B!
MCE+$6!(#$6'&+!()!2(&+6!?E(6$!'E9!90(=2(6$'<!)/<$(0B!
Y$/=+!'6!E(0+!'E9(0$/2$!$8/2!=0/&+!)(0!90(=2(6'6U!/2&!>'$8'2!6$/='2=;!K!'6!$8+!E(6$!'E9!)/<$(0!
)(0!90(=2(6'6!
[:/E9*+-!9$!>'$8!90(6$/$+!</2<+0;!>8'<8!()!)(**(>'2=!8/6!'$!$8+!>(06$n!I8+!/26>+0!<8('<+6!>+0+!
</2<+0!*'E'$+&!$(!90(6$/$+;!'$!>+2$!'2$(!6+E'2/*!M+6'<*+6;!'$!'2M(*M+&!$8+!>/**!()!L*/&&+0;!>+2$!$(!
*4E98!2(&+6;!(0!L(2+n!!%26>+0!C!L(2+!?L(2+!0+90+6+2$6!$8+!iKj!()!$8+!I"K!646$+E!7!$8'6!'+!'6!
6$/=+!^!L4!&+)'2'$'(2CE+$6B!
!
64

[:/E9*+-!/!6*'&+!()!/!<(*(2!</2<+0!/2&!/!*4E98!2(&+-!>8/$!'6!E(6$!'E9(0$/2$!7!6'c+!()!$#E(0!(0!
*4E98!2(&+!'2M(*M+E+2$n!X4E98!2(&+@!!1)!'$!>/6!/*6(!'2!$8+!*'M+0;!>8/$!'6!E(6$!'E9n!X'M+0!
69+<'E+2!'6!$8+!E(6$!'E9!90(=2(6$'<!)/<$(0@!
!
XIII. Host defenses!7!E(6$!'E9(0$/2$!'6!.4$($(:'<!._t!I!<+**!!
G$8+06!7!"5!<+**6;!%LQ6;!E/<0(98/=+6;!$49+!H!NJb!!
12!8(69'$/*;!$8+4!*((F!)(0!/*$+0+&!KN.!<*/66!1!%=Q6!'2!$8+!</2<+0!9$;!LZ<!</2<+0!>/2$6!$(!F'**!I!<+**6U!
$8+4!&(!$8'6!L4!9#$$'2=!'2!9+0)(0'26;!>8'<8!/<$'M/$+!</69/6/6+6;!/2&!$8'6!*+/&6!$(!/9(9$(6'6!?$8+!
6'=2/*;!)0(E!$8+!9+0)(0'26;!/<$'M/$+!$8+!</69/6/6+6;!>8'<8!8/M+!90($+/6+6;!>8'<8!L0+/F!&(>2!$8+!
2#<*+#6!/2&!E'$(<8(2&0'/;!/2&!<+**!&'+6;!>'$8(#$!/24!'2)*/EE/$(04!'2)'*$0/$+B@!
!
XIV. Other diseases seen in malignancy:
A. Cachexia!7!</#6+!'6!I"T!/*98/U!'$!'6!'00+M+06'L*+!
G2<+!4(#!6++!/!9$!>'$8!&'66+E'2/$+&!</2<+0!/L(#$!$(!=(!'2$(!</$/L(*'<!6$/$+;!</2!='M+!$8+2!$($/*!
2#$0'$'(2;!L#$!6$'**!>(2Q$!8+*9@!?g'**!2($!=+$!E#6<*+!E/66!L/<F;!/2&!$8'6!'6!&#+!$(!I"Td/*98/B!
!
B. Many hematologic causes of anemia seen in malignancy!
K.!/2+E'/!'2!E/*'=2/2<4!'6!%2+E'/!()!<80(2'<!&'6+/6+!?$8'6!'6!$8+!(M+0/**!E(6$!<(EE(2B!
!
Colon cancer: left side obstructs w/ right side bleeds; if you have RT side bleed in
colon cancer, Fe def anemia is very common.
!
K+$6!$(!SK!/2&!0+9*/<+!SK!
!
G0;!#6+!<8+E($8+0/94!&0#=6!$8/$!/0+!<+**!<4<*+!69+<')'<!(0!<+**!<4<*+!2(269+<')'<!7!$8+4!>'9+!(#$!
$8+!E/00(>!
!
./2!8/M+!/#$('EE#2+!E+<8/2'6E!>'$8!<+0$/'2!E/*'=2/2$!&c@!
C. Associations with disseminated cancers:
,@!!K(6$!9$6!>'$8!&'66+E'2/$+&!</2<+06!/0+!hypercoagulable;!E+/2'2=!$8/$!$8+4!8/M+!/!
$+2&+2<4!)(0!)(0E'2=!<*($6@!.*/66'<![:/E9*+-!!/!9$!>'$8!9/'2*+66!3/#2&'<+;!*+)$!6#90/<*/M'<#*/0!
2(&+!?$8'6!'6!/!&'6$0/<$+0B;!8/&!*'=8$!<(*(0!6$((*6;!*+6'(26!$8/$!3#E9!)0(E!(2+!9/0$!()!L(&4!$(!
2+:$!7!$0(#66+/#Q6!6'=2-!/!6#9+0)'<'/*!E'=0/$(04!$80(EL(98*+L'$'6!&#+!$(!</0<'2(E/!()!$8+!
8+/&!()!$8+!9/2<0+/6B@!!J/2<0+/$'<!</2<+06!</2!%XYG!E+$6!$(!*+)$!6#90/<*/M'<#*/0!2(&+!
?M'0<8(>Q6!2(&+B;!/2&!()$+2!&+6<0'L+!$0(#66+/#Q6!6'=2;!>8'<8!'6!/!M/6<#*/0!90(L*+E!'2!$8+!
M+'26!$8/$!3#E96!)0(E!(2+!9*/<+!$(!$8+!2+:$@!!!
H@!!%2($8+0!<(EE(2!$8'2=!6++2!'6!&'66+E'2/$+&!</2<+06!'6!thrombocytosis!7!/2!+*+M/$+&!
9*/$+*+$!<(#2$@!G$8+0!</#6+6!()!$80(EL(<4$(6'6-!T+!&+);!69*+2+<$(E4!?'+!6++!6</0!(2!
/L&(E+2B;!IS;!/2+E'/6@!1)!4(#!</22($!)'2&!/24!(LM'(#6!</#6+!()!$80(EL(<4$(6'6!$8+2!$8+!
</#6+!'6!</2<+0@!
^VW!()!&'66+E'2/$+&!</2<+06!/0+!$80(EL(<4$(6'6!
G0!/!&(!/!6$((*!=#/'<!)(0!<(*(2!</2<+0!
!
D. MCC fever in malignancy = gram neg. infection@!%2![@!<(*'!')!4(#!8/M+!/2!'2&>+**'2=!
</$8+$+0U!J6+#&(E(2/6!')!4(#!8/M+!/!0+69'0/$(0;!6$/98!/#0+#6!</2!/*6(!L+!$8+!</#6+!)0(E!/2!
'2&>+**'2=!</$8+$+0;!L#$!$8'6!'6!=0/E!iOj@!!!
K..!&+/$8!'2!</2<+0!C!'2)+<$'(2!
!
65

XV. Paraneoplastic syndromes
I8+6+!/0+!6'=26!/2&!6(E+$'E+6!64E9$(E6!6/4'2=!$8/$!4(#!E/4!8/M+!/2!#2&+0*4'2=!</2<+0!
90+6+2$@!!1$6!'E9(0$/2$!LZ<!>8+2!4(#!0+<(=2'c+!$8+!6'=26!/2&!64E9$(E6;!$8+2!4(#!</2!</$<8!$8+!
</2<+0!L+)(0+!'$!E+$/6$/6'c+@!
MC Paraneoplastic syndrome = hypercalcemia
H!E+<8/2'6E!)(0!849+0</*<+E'/!'2!E/*'=2/2<4-!!
!
,B!E+$6!$(!L(2+;!90(&#<+!/!<8+E'</*!?1Xd,;!Jl[H;!L($8!()!>8'<8!/<$'M/$+!(6$+(<*/6$6B!$8/$!
90(&#<+6!*4$'<!*+6'(26!'2!L(2+;!/2&!4(#!=+$!849+0</*<+E'/!
!
HB!0+2/*!/&+2(</0<'2(E/!(0!6D#/E(#6!</0<'2(E/!()!E/'26$+E!L0(2<8#6!$8/$!6'$6!$8+0+!/2&!
E/F+6!JINd*'F+!9+9$'&+!/2&!</#6+6!849+0</*<+E'/!LZ<!'$!/<$6!*'F+!JIN!/2&!L0+/F6!&(>2!L(2+@!!
I8'6!'6!J/0/2+(9*/6$'<;!L#$!'$Q6!2($!$8+!E(6$!<(EE(2!(2+@!
!
[:/E9*+-!H!L*/<F!*+6'(26!7!L($8!/0+!E/0F+06!)(0!=/6$0'<!/&+2(</0<'2(E/U!#6#/**4!#2&+0!$8+!/0E!
7!</**+&!/</2$8(6'6!2'=0'</26;!/2&!($8+0!'6!</**+&!6+L(008+'<!F+0/$(6'6!?$8+6+!/0+!2($!2+(9*/6E6BU!
8(>+M+0;!>8+2!$8+6+!6#&&+2*4!&+M+*(9!(M+02'=8$;!4(#!=+$!E#*$'9*+!(#$<0(99'2=6!?*+66+00!$0++d/0!
6'=2B;!/2&!$8+!(#$<0(99'2=6!'6!/!98+2($49'<!E/0F+0!)(0!gastroadenocarcinomaU!$8'6!'6!+/64!$(!
0+E+EL+0!LZ<!H!L*/<F!*+6'(26!/0+!E/0F+06!)0(E!=/6$0(/&+2(</0<'2(E/@!!!
!
[:/E9*+-!clubbing!7!'2)*/EE/$'(2!L+2+/$8!(2!$8+!L(2+!</**+&!9+0'(6$'$'6U!'2)*/EE!()!#2&+0*4'2=!
L(2+!</#6+6!90(*')+0/$'(2!()!$8+!6()$!$'66#+!/0(#2&!'$;!>8'<8!*+/&6!$(!<*#LL'2=!?</**+&!
849+0$0(98'<!(6$+(/0$80(9/$84B@!!.*#LL'2=!'6!2($!/*>/46!/66(<!>'$8!</2<+0U!/*6(!/66(<!>'$8!
L0(2<8'+<$/6'6;!1SY@!!S#$;!')!'$Q6!/!E/*'=2/2<4;!'$!'6!&#+!$(!90'E/04!*#2=!&c@!
!
[:/E9*+-!*+/6$!<(EE(2!<(**/=+2!M/6<#*/0!&c;!L#$!$8+!E(6$!()$+2!/66(<!>'$8!/!<+0$/'2!</2<+0@!!
I8+4!8/M+!/2!+*+M/$'(2!()!6+0#E!.5U!$8'6!'6!&+0E/$(E4(6'$'6U!0/<<((2!+4+6;!6(!4(#!6++!
'2)*/EE/$'(2!()!6F'2!/2&!E#6<*+U!8'=8!/66(<!>'$8!*+#F+E'/6;!*4E98(E/6!/2&!*#2=!</2<+0@!!
9/$<8+6!()!F2#<F*+6!7!=(*$0'2Q6!9/$<8+6!?6++2!'2!&+0E/$(E4(6'$'6B@!
!
[:/E9*+-!M+=+$/$'(26!?6$+0'*+B!(2!$8+!E'$0/*!M/*M+!7!/66(<!>'$8!E#<(#6!90(&#<'2=!</2<+06!6#<8!
/6!<(*(2!</2<+0U!$8'6!'6!</**+&!E/0/2$'<!+2&(</0&'$'6d/F/!2(2L/<$+0'/*!$80(EL($'<!+2&(</0&'$'6U!
$8+4!/0+!2($!'2)+<$'(26!/2&!$8+6+!E/0/2$'<!M+=+$/$'(26!/0+!/66(<!>'$8!E#<(#6!6+<0+$'2=!<(*(2!
</2<+06@!!./2!$8+4!+EL(*'c+n!b+6@!!b(#!>'**!2++&!8'6$(04!$(!6+9/0/$+!)0(E!08+#E/$'<!)+M+0;!L#$!
8'6$(04!>'**!0+*/$+!E(0+!$(!<(*(2!</2<+0!?'+!9(*4/0$80'$'6B!
!
[:/E9*+-!849(2/$0+E'/!(0!.#68'2=Q6!7!</2<+0!'2!$8+!*#2=!C!6E/**!<+**!</0<'2(E/;!>8'<8!'6!
6+<0+$'2=!+'$8+0!%_N!(0!%.INU!/*6(;!)(0!6E/**!<+**;!$8+4!/0+!/9#$!$#E(06;!!
Yd,VV!%=!9(6'$'M+;!2+#0/*!<0+6$!(0'='2;!2+#0/*!!
6+<0+$(04!=0/2#*+6@!!
[:/E9*+-!N49+0</*<+E'/!(0!6+<(2&/04!9(*4<4$8+E'/-!0+2/*!/&+2(</0<'2(E/!?</2!E/F+!JIN!*'F+!
9+9$'&+!/2&Z(0![JGB@!
!
Example: Hypoglycemia or secondary polycythemia: Hepatocellular carcinoma (they
can make EPO or insulin-like factor).
!
[:/E9*+-!N49(</*<+E'/!(0!.#68'2=Q6-!/#$(!&(E'2/2$;!/2&!$8+!0/0+!$#E(0!E/0F+0!$8/$!</2!L+!
<(2M+0$+&!$(!/E4*('&!?</*<'$(2'2B!7!E+&#**/04!</0<'2(E/!()!$8+!$840('&@!
66

!
XVI. Tumor markers
%@!H!E/0F+06!/66(<'/$+&!>'$8!I+6$'<#*/0!</2<+0!7!/*98/!)+$(!90($+'2!?%TJB!?>8'<8!'6!0+/**4!$8+!
/*L#E'2!()!/!)+$#6B!/2&!N.l@!!%TJ!'6!/!E/F+0!)(074(*F!6/<!$#E(0!?+2&(&+0E/*!6'2#6!$#E(0B@!!Y(!$8+!
$#E(06!'2!F'&6!/0+!4(*F!6/<!$#E(06!?/*98/!)+$(!90($+'2B!
!
%TJ!'6!/*6(!/66(<!>'$8!N+9/$(<+**#*/0!</0<'2(E/;!'2<0+/6+&!'2!2+#0/*!$#L+!&+)+<$6!?E#6$!L+!(2!)(*/$+!
>8'*+!90+=2/2$!$(!90+M+2$!2+#0/*!$#L+!&+)+<$6B@!!12!_(>2Q6!642&0(E+!%TJ!'6!&+<0+/6+&@!
!
K/0F+0!)(0!E/*'=2/2<4!'2!L(2+;!/66(<!>'$8!E(2(<*(2/*!69'F+-!S+2<+!f(2+6!J0($+'26!?*'=8$!<8/'2!1=B;!
/66(<!>'$8!K#*$'9*+!K4+*(E/@!
!
I#E(0!E/0F+0!)(0!90(6$/$+!</2<+0-!JY%U!2($!69!)(0!</2<+0!LZ<!'$!</2!L+!/*6(!'2<0+/6+&!'2!
849+09*/6'/U!'$!'6!6+26'$'M+!L#$!2($!69+<')'<@!!1)!4(#!&(!/!0+<$/*!+:/E;!'$!'6!2($!'2<0+/6+&@!!JY%!'6!"GI!
/2!+2c4E+U!'$!'6!/2!%=!/2&!'6!>'$8'2!$8+!/<$#/*!<+**@!!1$!>'**!2($!'2<0+/6+!>'$8!/!0+<$/*!+:/E@!!!
!
S0+/6$!</2<+0!?6#0)/<+!&+0'M+&B!7!,e;!P@!
.[%7,He-!GM/0'/2!</2<+0!!
.[%!7%=!)(0!<(*(2!</2<+0U!/2&!6(E+$'E+6!#6+&!)(0!6E/**!<+**;!/2&!L0+/6$!</@!!.[%!</2!L+!/!9/0$!()!
/2!'EE#2+!<(E9*+:;!/2&!>'**!=+$!.[%-!/2$'d.[%!'EE#2+!<(E9*+:+6!>8'<8!&+9(6'$!'2!$8+!F'&2+4;!
/2&!*+/&!$(!2+980($'<!642&0(E+!7!$8'6!'6!&'))#6+!E+EL0/2(#6!=*(E+0#*(2+980'$'6!C!K.!(M+0/**!</#6+!
()!2+980($'<!642&0(E+@!K/24!()!$8+6+!/0+!0+*/$+&!$(!E/*'=2/2<4!LZ<!.[%!</2!L+!$8+!%=!$8/$!'6!
&+9(6'$6!'2!$8+!=*(E+0#*'@!!!
>(E/2!>'$8!/!$0(98(L*/6$'<!E(*+;!>8/$!>(#*&!4(#!=+$n!S+$/!N.l!
!
g8/$!'6!K.!90'E/04!$#E(0!()!$8+!L0/'2!'2!F'&6n!.+0+L+**/0!<46$'<!/6$0(<4$(E/!?SrB@!!1$Q6!2($!
E+&#**(L*/6$(E/@!!%**!/6$0(<4$(E/6!/0+!Sr!?')!/6F+&!>8/$!'6!$8+!E(6$!<(EE(2!E/*'=2/2$!90'E/04!
$#E(0;!/2&!$8+2!$8+!/26>+0!'6!E+&#**(L*/6$(E/;!>8'<8!&+0'M+6!)0(E!<+0+L+**#EB@!!K.!/<$#/*!$#E(0!
()!$8+!L0/'2!7!<+0+L+**/0!$#E(0!&+0'M+&!)0(E!/6$0(<4$+6U!!
!
MC childhood cancer!C!%XX!*+#F+E'/!?($8+0!<8'*&8((&!$#E(06!'2<*#&+!."Y!$#E(06;!
2+#0(L*/6$(E/6!?'2!$8+!/&0+2/*!E+&#**/B;!S#0F'$$6;![>'2=Q6!?$#E(0!()!L(2+!>'$8!(2'(2!6F'22'2=B;!
+EL04(2/*!08/L&(E4(6/0<(E/@B!
!
Adults-!'2<'&+2<+-!
'2!>(E/2-!L0+/6$;!*#2=;!<(*(2!
12!E+2-!!90(6$/$+;!*#2=;!/2&!<(*(2!
!
5'**+06-!*#2=!'6!s,!'2!L($8!?)(**(>+&!L4!90(6$/$+ZL0+/6$!/2&!<(*(2B!
H2&!K.!</2<+0!/2&!</2<+0!F'**+0!'2!E+2!/2&!>(E+2!<(EL'2+&!C!<(*(2!
!
I8+0+)(0+;!)0(E!/=+!eV!/2&!(2;!4(#!68(#*&!=+$!/!0+<$/*!+:/E!/2&!/!6$((*!=#/'<@!
%)$+0!eV;!K..!</2<+0!()!iOj!6$((*!=#/'<!'6!<(*(2!</2<+0@!!
!
MC gyn cancer:!+2&(E+$0'/*!?sH!'6!(M/0'/2;!/2&!sP!'6!<+0M':B!
.+0M':!'6!*+/6$!<(EE(2!LZ<!J/9!6E+/0@!!g8+2!4(#!&(!/!<+0M'</*!9/9;!9'<F'2=!#9!<+0M'</*!&469*/6'/;!
2($!<+0M'</*!</2<+0!?$8+0+)(0+!$8+!]'2<'&+2<+Q!'62Q$!$8+!8'=8+6$B@!
67

SZ<!<+0M'</*!9/9!6E+/06U!$8+!'2<'&+2<+!()!<+0M'</*!</2<+0!8/6!=(2+!&(>2!6'=2')'</2$*4!LZ<!$8+!
&+$+<$'(2!()!$8+!90+<#06(0!*+6'(2;!<+0M'</*!&469*/6'/@!Y(;!LZ<!<+0M'</*!J/9!6E+/0;!'2<'&+2<+!()!<+0M'</*!
</2<+0!8/6!=(2+!&(>2!&0/E/$'</**4!?9'<F'2=!#9!$8+!90+<#06(0!*+6'(2BU!>'$8!E/EE(=0/984;!$8+!
'2<'&+2<+!()!L0+/6$!</2<+0!&+<0+/6+6;!6/E+!>'$8!JY%@!
!
MC Gyn cancer killer:!(M/0'/2!?sH!C!<+0M'</*;!sP!C!+2&(E+$0'/*BU!$8+0+)(0+!$(!0+E+EL+0;!$8+!K.!
8/6!$8+!L+6$!90(=2(6'6!7!+2&(E+$0'/*!'6!K.!/2&!8/6!$8+!L+6$!90(=2(6'6@!!!
!
g8/$!'6!$8+!(2*4!F2(>2!+:'6$'2=!$#E(0!M/<<'2+n!NSk!A>84n!
!
K.!'2)+<$'(2!$0/26E'$$+&!L4!/<<'&+2$/*!2++&*+!6$'<F!'2!$8+!8(69'$/*!C!N+9/$'$'6!S!
!
SZ<!M'0/*!L#0&+2!()!N+9/$'$'6!S!'6!=0+/$+0!$8/2!/24!'2)+<$'(2;!+M+2!E(0+!6(!$8/2!N1k@!!!
!
Y(;!>'$8!$8+!N+9/$'$'6!S!M/<<'2+;!4(#!>(2Q$!=+$!$80++!$8'2=6!?,B!N+9/$'$'6!S;!?HB!N+9/$'$'6!_!?0+D#'0+6!
N+9!SB;!/2&!?PB!8+9/$(<+**#*/0!</0<'2(E/!?0+*/$+&!$(!N+9/$'$'6!S!0+*/$+&!<'008(6'6B@!
!
N(>!&(!4(#!+0/&'</$+!8+9/$(<+**#*/0!</0<'2(E/n!k/<<'2/$'(2!?'+!'2!$8+!T/0![/6$B@!
68

CHAPTER 6. HEMATOLOGY: RBC
!
I. Think big picture.
A. MCV < 80: Microcytic anemias:!T+!&+)!C!K.!/2&!%2+E'/!()!<80(2'<!&c;!$8/*/66+E'/6;!
6'&+0(L*/6$'<!/2+E'/6!
B. MCV > 100: Macrocytic anemias: S,HZT(*/$+!&+)!C!K.U!#6#/**4!)(*/$+!&+)!'2!/2!/*<(8(*'<!
C. MCV 80-100: Normocytic anemias: *(>!0+$'<#*(<4$+!<$!<(00+<$+&-!/9*/6$'<!/2+E'/;!0+2/*!
&cU!8'=8!<(00+<$+&!0+$'<#*(<4$+!<$-!8+E(*4$'<!/2+E'/6!7!8+0+&'$/04!698+0(<4$(6'6;!6'<F*+!<+**;!
laJ_!&+);!/#$('EE#2+!8+E(*4$'<!/2+E'/;!E'<0(/2='(9/$8'<!
!
II. Reticulocyte!count: R+$'<#*(<4$+!<(#2$!2+:$!$(!.S.!'6!$8+!)'06$!6$+9!'2!$8+!>(0F!#9!()!/24!
/2+E'/6@!!g8/$!'6!0+$'<#*(<4$+n!b(#2=!RS.@!!12!H^!806;!/!0+$'<#*(<4$+!>'**!L+<(E+!/!E/$#0+!RS.!
>'$8!/!L'<(2</M+!&'6F@!!!
!
1)!4(#!8/M+!/2!/2+E'/;!$8+!0+$'<#*(<4$+!<(#2$!'6!'E9!LZ<!'$!$+**6!4(#!>8+0+!$8+!90(L*+E!'6-!'6!$8+!
90(L!'2!$8+!SK!'2!E/F'2=!$8+!RS.;!(0!'6!'$!/!90(L!(#$6'&+!$8+!SK!</#6'2=!$8+!90(L*+En!!I(!
&+$+0E'2+!$8'6;!*((F!/$!0+$'<#*(<4$+!<$@!!1)!$8+!SK!>/6!$8+!90(L;!$8+2!$8+!0+$'<#*(<4$+!<$!>(#*&!
2($!8/M+!/2!/990(90'/$+!0+69(26+@!!g8/$!'6!/2!/990(90'/$+!0+69(26+n!b(#!>(#*&!8/M+!/!SK!>'$8!
849+09*/6'/;!$8/$!8/6!0+MQ&!'$6+*)!#9;!/2&!E/F'2=!RS.Q6!/2&!68(#*&!L+!9#$$'2=!0+$'<#*(<4$+6!(#$!
90+E/$#0+*4;!$8+0+)(0+!>(0F'2=!<(00+<$*4!$(!<(00+<$!$8+!/2+E'/@!!I8+0+)(0+;!'$!$+**6!>8+$8+0!$8+!
SK!'6!0+69(2&'2=!/990(90'/$+*4!(0!2($@!!1)!4(#!8/M+!L*((&!*(66!0'=8$!2(>;!&(!2($!+:9+<$!
0+$'<#*(<4$+!<$!$(!L+!+*+M/$+&!'2!H^!806U!'$!$/F+6!/$!*+/6$!ed`!&/46!$(!=+$!$8+!0+69(26+!()!E/F'2=!
E(0+!0+$'<#*(<4$+6!?*'F+!$8+!F'&2+4!E/F'2=!L'</0L;!>8'<8!$/F+6!/!)+>!&/46!?Pd^B!$(!E/F+B@!!1)!
2($8'2=!'6!>0(2=!>'$8!$8+!SK;!$8+2!'$!68(#*&!8(6$!/!2(0E/*!0+$'<#*(<4$+!0+69(26+U!')!$8+0+!'6!
6(E+$8'2=!>0(2=;!>'**!2($!8/M+!/!2(0E/*!0+69(26+!?'E9!LZ<!E'=8$!&+<'&+!>8+$8+0!4(#!8/M+!$(!
&(!/!SK!+:/E!(0!2($B@!I8+0+)(0+;!')!4(#!8/M+!/!2(0E/*!0+$'<#*(<4$+!<$;!&(!2($!&(!/!SK!+:/E@!!!
!
N/M+!$(!<(00+<$!$8+!0+$'<#*(<4$+!<(#2$!)(0!$8+!&+=0++!()!/2+E'/@!!!
Corrected reticulocyte ct = Hct of the pt 45 ! reticulocyte ct!$8/$!4(#!/0+!='M+2!
[:/E9*+-!9$Q6!N<$!'6!,eW!?>8'<8!'6!M+04!6+M+0+!/2+E'/B;!/2&!$8+!0+$'<#*(<4$+!<$!$8/$!>/6!'2'$'/**4!
E+/6#0+&!'6!rW!?>8'<8!'6!'2<0+/6+&!7!/24$8'2=!(M+0!PW!'6!'2<0+/6+&B@!
I8'6!]*((F6Q!*'F+!$8+!SK!'6!0+69(2&'2=!<(00+<$*4!LZ<!$8+!0+$!<$!'6!rW!?L#$!8/M+!$(!<(00+<$!)(0!$8+!
&+=0++!()!/2+E'/B@!!,eZê!h!r!'6!PU!6(;!>8+2!>+!<(00+<$!)(0!$8+!/2+E'/;!>+!8/M+!PWU!$8/$Q6!
>8/$!$8+!<(00+<$+&!'6!7!$8+0+)(0+;!PW!(0!=0+/$+0!C!=((&!0+69(26+U!PW!(0!*+66!C!L/&!0+69(26+U!
6(;!$8'6!)'=#0+!'6!6/4'2=!$8/$!'$!'6!/!0+/6(2/L*+!0+69(26+!(<<#00'2=!'2!$8+!9$@!!!
!
Y*'&+!()!/!0+$'<#*(<4$+!?F2(>!>8/$!'$!*((F6!*'F+B!7!2++&!$(!&(!/!69+<'/*!='+E6/!6$/'2!$(!6++!$8+!
L*/<F!)'*/E+2$6!?>8'<8!/0+!R"%!)'*/E+2$6BU!LZ<!$8+4!/0+!R"%!)'*/E+2$6;!$8+!0+$'<#*(<4$+!'6!6$'**!
642$8+6'c'2=!NL@!!!Y(;!'2!/L(#$!H^!806;!HeW!$8+!2(0E/*!NL!'6!L+'2=!642$8+6'c+&!/2&!2++&!R"%!
)'*/E+2$6U!</22($!6++!$8+6+!>'$8(#$!&('2=!/!69+<'/*!6$/'2!?*((F!*'F+!*'$$*+!L*/<F!>(0E6!'2!$8+!RS.!
7!&(!2($!<(2)#6+!>'$8!N+'2c!L(&4B@!!%2($8+0!6*'&+!#6'2=!0'=8$!='+E6/!6$/'2!()!0+$'<#*(<4$+!>'$8!
L*#'68!6$/'2!7!9(*4<80(E/6'/@!I8+6+!/0+!4(#2=+0!L*((&!<+**6!$8/2!$8+!H^!80!(*&!0+$'<#*(<4$+6@!!
I8+4!6$'**!8/M+!$8+!L/6(98'*'/;!>8'<8!'6!2($!2(0E/**4!90+6+2$!'2!$8+!9+0'98+0/*!L*((&U!6(;!>8+2!
>+!6++!$8+E;!'$!E+/26!$8/$!$8+!SK!'6!0+/**4!0+69(2&'2=;!/2&!9#68'2=!+M+2!$8+!4(#2=+0!(2+6!
(#$@!!I8+0+)(0+;!>8+2+M+0!$8+!L(/0&6!6/4Q6!]9(*4<80(E/6'/Q;!$8+4!/0+!$/*F'2=!/L(#$!$8+6+!<+**6!
/2&!$8+6+!<+**6!$/F+!HdP!&/46!L+)(0+!$8+4!L+<(E+!/!E/$#0+!RS.@!!g84!'6!$8'6!'E9n!SZ<!>+!8/M+!
$(!E/F+!/2!/&&'$'(2/*!<(00+<$'(2!7!>84n!g8+2!>+!/0+!>(0F'2=!#9!/2!/2+E'/;!>+!&(!/!<(00+<$+&!
0+$!<$!/2&!>/2$!$(!F2(>!8(>!$8+!SK!'6!0+69(2&'2=!0'=8$!2(>!/$!$8'6!&/4@!!"($!'2$+0+6$+&!/L(#$!
69

>8/$!>'**!8/99+2!'2!HdP!&/46;!L#$!>8/$!>'**!8/99+2!0'=8$!2(>@!!N+0+Q6!$8+!90(L-!>8+2!$8+4!&(!/!
0+$'<#*(<4$+!6$/'2;!$8+6+!=#46!>'**!/*6(!8/M+!R"%!)'*/E+2$6!/2&!>'**!L+!<(#2$+&!'2!$8+!0+$!<$!/2&!'$!
>'**!68(>!/!)/*6+*4!+*+M/$+&!0+$!<$!?>+!&(2Q$!>/2$!$8+6+!LZ<!$8+4!$/F+!HdP!&/46!L^!$8+4!L+<(E+!/!
E/$#0+!RS.B!'26$+/&!>+!>/2$!$8+!2(0E/*!=#46!$8+0+@!!Y(;!8(>!&(!>+!)/<$(0!$8+E!(#$n!_'M'&+!L4!
H@!!Y(;!E/F+!$8+!)'06$!<(00+<$'(2!)(0!$8+!&+=0++!()!/2+E'/!?&'&!'$!>'$8!PW!'2!$8'6!</6+B;!*((F!/$!
.S.!/2&!6++!2($8'2=!$8/$!6/46!9(*4<80(E/6'/@!!X+$Q6!6/4!$8+!.S.!<$!6/46!]9(*4<80(E/6'/!90+6+2$Q!
7!$8+2!8/M+!$(!E/F+!/2!/&&'$'(2/*!<(00+<$'(2!L4!&'M'&'2=!L4!H@!!%**!()!/!6#&&+2;!'$!'6!2(>!,@eW!
/2&!$8'6!'6!2($!/!=((&!0+$'<#*(<4$+!0+69(26+m!!So, when you see the term polychromasia,
then you have to make an additional correction by dividing by 2.!
!
[:/E9*+-!0+$'<#*(<4$+!7!</22($!6++!>'$8!0'=8$!='+E6/!6$/'2U!#6+!69+<'/*!='+E6/!6$/'2!$(!6++!R"%!
)'*/E+2$6;!/2&!0'L(6(E+6!?*((F!*'F+!&($6!7!S%YGJN1X1.!YI1JJX1"l;!6++2!'2!*+/&!9('6(2'2=B@!!!
!
III. Side notes:
!
g8+2!*((F'2=!/$!.S.!4(#!</2!E/F+!E/24!&:Q6@!
R#*+!()!P!'6!=((&-!NL!:!P!68(#*&!0(#=8*4!+D#/*!$8+!N<$!
[:/E9*+-!)(0!90+M'(#6!'+;!8/&!,eW!N<$;!$8+0+)(0+!$8+!NL!>/6!/!e!
!
I0/26)#6'(2!()!9/<F+&!RS.Q6!7!)(0!+M+04!#2'$!$0/26)#6+&!'2<0+/6+!$8+!NL!L4!,!/2&!$8+!N<$!L4!
PW@!![:/E9*+-!9$!>'$8!e!=0/E!NL;!/2&!='M+2!P!#2'$6!()!9/<F+&!RS.Q6@!!I8+!)(**(>'2=!&/4!$8+!NL!
'6!a!/2&!$8+!N<$!'6!,t;!'6!$8/$!/2!/990(90'/$+!0+69(26+n!"G;!'$!68(#*&QM+!L++2!t;!>'$8!N<$!()!H^@!!
1$!>/62Q$!t!LZ<!$8+!9$!8/6!/!l1!L*++&!?9$!>/6!L*++&'2=B@!
MCC anemia worldwide = Fe def anemia
MCC cause of Fe def (overall) = GI bleed
Therefore, the MC reason why Hb and Hct dont go up after transfusion is b/c blood
loss, MC due to GI tract bleed.
70

IV. RBC indices MCV!7!8(>!L'=!'6!$8+!<+**n!S+6$!>/4!$(!<*/66')4!'6!>'$8!K.k!?E+/2!<(09#6<#*/0!
M(*#E+B!YE/**;!2(0E/*!(0!L'=n!!I8+!E/<8'2+!8/6!$8+!RS.Q6!9/66!$80(#=8!/2!/9+0$#0+!/2&!6'c+6!'$@!
%2&!$8+2!$/F+6!/2!/M+0/=+U!$8'6!'6!$8+!L+6$!>/4!)(0!<*/66')4'2=!/2!/2+E'/!
!
K.k-!y!tV;!'$!'6!E'<0(<4$'<!?')!4(#!9*/4!(&&6;!'$6!T+!&+)B!
K.k!?2(0E/*B-!tV!d,VV!CU!8/M+!"(0E(<4$'<!/2+E'/U!!
K.k!/L(M+!,VV!C!E/<0(<4$'<!?L,H!(0!)(*/$+B!
!
1)!4(#!8/M+!6E/**!/2&!*/0=+!<+**6!?&'E(098'<!9(9<(02!()!RS.Q6B!'$!>'**!L+!"(0E(<4$'<!
?X'F+!$8+!E+$!/<'&(6'6;!/2&!0+69!/*F;!L#$!2(0E/*!9NB@!!Y(;!8(>!<(#*&!4(#!8/M+!/!T+!&+)!/2+E'/!
/2&!/!)(*/$+!&+)!/2+E'/!/$!$8+!6/E+!$'E+n!52(>!>8+0+!$8+6+!$8'2=6!/0+!0+/L6(0L+&!7!T+!
0+/L6(0L+&!'2!$8+!&#(&+2#E;!T(*/$+!'6!0+/L6(0L+&!'2!$8+!3+3#2#E;!/2&!S,H!'6!0+/L6(0L+&!'2!$8+!
$+0E'2/*!'*+#E@!Y(!')!4(#!8/M+!/**!$8+6+;!4(#!8/M+!small bowel dz (ie celiac dz)U!9$!8/6!
E/*/L6(09$'(2!$8/$!/))+<$6!&'))!/0+/6!()!$8+!L(>+*@!![:/E9*+-!<+*'/<!690#+!?K..!E/*/L6(09$'(2B!7!
'2M(*M+6!&#(&+2#E!/2&!3+3#2#E;!$8+0+)(0+!>'**!8/M+!&+)!()!T+!/2&!)(*/$+;!/2&!>'**!8/M+!6E/**!
<+**6!/2&!*/0=+!<+**6@!![:/E9*+-!')!'$!'2M(*M+6!$8+!3+3#2#E!/2&!$+0E'2/*!'*+#E;!4(#!>'**!8/M+!)(*/$+!
/2&!S,H!&+)@!!
!
V. RDW RBC Distribution Width
!
I8'6!E/<8'2+!*((F6!/$!$8+!RS.Q6!/2&!$+**6!')!$8+!RS.Q6!<(E'2=!(#$!()!$8+!/9+0$#0+!/0+!/**!
#2')(0E*4!6E/**;!2(0E/*;!E/<0(<4$'<;!(0!&'))+0+2$!'2!6'c+@!!Y(;!$8+!R_g!&+$+<$6!/!<8/2=+!'2!6'c+!
()!$8+!RS.Q6!/2&!'$!0+9(0$6!'$!/6!/!2#EL+0@!![:/E9*+-!E'<0(<4$'<!/2+E'/;!>'$8!/2!'2<0+/6+&!
R_gU!$8'6!$+**6!#6!$8/$!'6!E'<0(<4$'<;!/2&!$8+0+!/0+!&'))+0+2$!6'c+&!E'<0(<4$'<!<+**6@!![:/E9*+-!')!
4(#!&+M+*(9!E'<0(<4$'<!/2+E'/!(M+02'=8$!/2&!/**!$8+!<+**6!/0+!T+!&+);!$8+!<+**6!&(2Q$!L+<(E+!
E'<0(<4$'<!'EE+&'/$+*4U!$8+4!/0+!2(0E(<4$'<!)'06$!L+)(0+!$8+4!L+<(E+!E'<0(<4$'<;!/2&!$8+0+!>'**!
L+!/!6'c+!M/0'/$'(2!9'<F+&!#9!L4!$8+!R_g@!!!
!
N+0+Q6!$8+!$0'<F-!>8+2!4(#!*((F!/$!$8+!.S.;!/2&!'$!68(>6!decreased MCV with an increased
RDW, this is Fe def anemia ?2($!$8/*/66+E'/6!LZ<!$8/$!'6!=+2+$'<!/2&!%XX!$8+!<+**6!/0+!
E'<0(<4$'<B@!
!
Y*'&+!>'$8!8'=8!R_g!7!8/6!*/0=+!/2&!6E/**!<+**6@!!%2($8+0!6*'&+!>'$8!698+0(<4$+!?8/M+!$((!*'$$*+!
E+EL0/2+;!/2&!$8+0+)(0+!</22($!8(*&!/!L'<(2</M+!&'6F!d!/2!/2(0+:'<!<+**B;!/2&!$/0=+$!<+**!?8/6!
$((!E#<8!E+EL0/2+!/2&!$((!E#<8!NL!<(**+<$6!'2!$8+0+!/2&!*((F6!*'F+!/!L#**Q6d+4+!7!/2!(L+6+!
<+**B@!!I/0=+$!<+**6!/0+!'E9!E/0F+06!)(0!/*<(8(*'<6!LZ<!$8+4!8/M+!/*$+0+&!<+**!E+EL0/2+!&#+!$(!/2!
/*$+0+&!<8(*+6$+0(*!<(2<+2$0/$'(2!()!$8+!E+EL0/2+!/2&!E/0F+06!)(0!8+E(=*(L'2(9/$8'+6!?'+!
$8/*/66+E'/6;!Y._;!NL.B@!
!
K/$#0+!RS.!*((F6!*'F+!L'<(2</M+!&'6F!/2&!'6!$8'2!'2!$8+!E'&&*+!LZ<!$8+0+!'6!*+66!NL!$8+0+;!/2&!
E(0+!'6!<(2<+2$0/$+&!/$!$8+!+&=+6U!$8'6!'6!>84!$8+0+!'6!/!<+2$0/*!/0+/!()!9/**(0!'2!/!2(0E/*!RS.!
>8+2!'$!*4'2=!)*/$@!!%**!E'<0(<4$'<!/2+E'/6!8/M+!(2+!$8'2=!'2!<(EE(2-!&+<0+/6+&!NL!642$8+6'6U!
>'$8!*+66!NL;!$8+!0+&2+66!()!$8+!<+**!>'$8!&+<0+/6+!/2&!6++!=0+/$+0!/0+/!()!9/**(0!>'**!'2<0+/6+!
?/2&!')!4(#!9*/4!(&&!'$Q6!1_%B@!!Y98+0(<4$+!7!$((!*'*!E+E;!$8+0+)(0+!'$Q6!/!698+0+U!"G!<+2$0/*!/0+/!
()!9/**(0m!?%**!0+&;!2(!<+2$0/*!/0+/!()!9/**(0B@!!K'<0(<4$'<!/2+E'/6!/**!8/M+!/!J%X[;!L*/2F!<(*(0!$(!
$8+EU!$8+0+)(0+;!'$!'6!M+04!+/64!$(!1_!698+0(<4$+!/2&!E'<0(<4$'<!<+**6!>'$8!849(<80(E'/!/2&!1_%!
()!<80(2'<!&c@!!!
%#&'(!_/4!P-!N+E/$(*(=4!T'*+!H!
VI. Normocytic Anemia:
71

!
T(0!2(0E(<4$'<!/2+E'/;!4(#!2++&!$(!*((F!/$!$8+!0+$'<#*(<4$+!<(#2$@!T'06$;!4(#!8/M+!$(!<(00+<$!)(0!
$8+!&+=0++!()!/2+E'/!?N<$Zê!h!0+$!<$B@!!I8+2!*((F!$(!6++!')!$8+0+!'6!9(*4<80(E/6'/;!')!$8+0+!'6!
9(*4<80(E/6'/!?$8+2!&'M'&+!L4!HBU!PW!(0!8'=8+0!C!SK!0+69(2&'2=!2(0E/**4;!/2&!HW!(0!*(>+0!C!
2($!0+69(2&'2=!90(9+0*4@!
!
Physical signs of anemia:!7!69((2!2/'*6!C!T+!&+)!?/F/!F+*(6'6B;!0'L()*/M'2!&+)!
J/**(0!()!<(23#2<$'M/!C!8/M+!a!=0/E6!(0!*+66!()!NL!
J/*E+0!<0+/6+!7!>(0F6!)(0!>8'$+!9+(9*+!7!')!&(2Q$!6++!0+&;!9$!'6!/2+E'<!
1+!>(E+2;!()$+2!&#+!$(!T+!&+)!
X+/&!*'2+!7!&'6<(*(0/$'(2!'2!=#E6!&#+!$(!*+/&!9('6(2'2=!
"+#0(*(='<!+:/E!M+04!'E9!'2!S,H!&+)!LZ<!$8+!9(6$+0'(0!<(*#E26!/0+!F2(<F+&!())!/2&!*/$+0/*!
<(0$'<(69'2/*!$0/<$;!$8+0+)(0+!8/M+!90(9'(<+9$'(2!/L2(0E/*'$'+6!/2&!&+<0+/6+&!M'L0/$'(2!
6+26/$'(2!/2&!L/L'26F'!?*/$+0/*!<(0$'</*B@!!!
!
VII. Microcytic anemias
A. Fe studies four Fe studies:
,@!!Y+0#E!T+!?2(0E/*!C!,VV;!*'F+!$8+!/*M+(*/0!GHB;!
H@!!Y+0#E!)+00'$'2@!!L+6$!$+6$!7!$8'6!'6!/!6(*#L*+;!<'0<#*/$'2=!)(0E!()!T+!6$(0/=+U!'$!0+9!$8+!
/E(#2$!()!T+!6$(0+&!'2!$8+!SK;!6(;!')!4(#!8/&!$(!9'<F!(2+!$+6$!)(0!&:!()!T+!&+);!/2+E'/!()!/!
<80(2'<!&c;!(0!T+!(M+0*(/&;!4(#!>(#*&!9'<F!6+0#E!)+00'$'2!LZ<!$8'6!'6!$8+!L+6$!6<0++2'2=!$+6$@!
P@!!I1S.!?$($/*!T+!L'2&'2=!</9/<'$4BU!$8+!</004'2=!90($+'2!)(0!T+!'6!$0/26)+00'2!?$0/26!C!
]</0046QB!/2&!'$!'6!E/&+!'2!$8+!X1k[R@!!!
^@!!W!6/$#0/$'(2C!6+0#E!T+!&'M'&+&!L4!I1S.!
B. 3 rules:
,@!I0/26)+00'2!/2&!$8+!I1S.!'6!$8+!Y%K[m!?R+E+EL+0!$0/26)+00'2!'6!>8/$!</00'+6!T+B@!
H@!!I8+0+!'6!/!0+*/$'(268'9!()!T+!6$(0+6!'2!SK!>'$8!$8+!$0/26)+00'2!642$8+6'c+&!'2!$8+!*'M+0@!!
g8+2!$8+!T+!6$(0+6!'2!$8+!SK!/0+!&+)'<'+2$!?'+!T+!&+)!/2+E'/B;!$8/$!'6!$8+!6'=2/*!)(0!$8+!*'M+0!
$(!E/F+!E(0+!$0/26)+00'2;!6(!'$Q6!'2<0+/6+&U!$8+0+)(0+;!I1S.!>'**!/*6(!L+!'2<0+/6+&!'2!T+!&+)@!!
I8+0+)(0+;!*(>!T+!6$(0+6!C!'2<0+/6+&!$0/26)+00'2!642$8+6'6!/2&!'2<0+/6+&!I1S.!?/2!'2M+06+!
0+*/$'(268'9BU!/*6(;!')!T+!6$(0+6!'2<0+/6+;!$0/26)+00'2!/2&!I1S.!>'**!&+<0+/6+!?'+!T+!(M+0*(/&!7!
8+E(<80(E/$(6'6;!$0/26)#6'(26B!
P@!!W!6/$#0/$'(2!'6!/!</*<#*/$'(2!C!6+0#E!T+ZI1S.!?2(0E/*!6+0#E!T+!'6!,VV!/2&!2(0E/*!I1S.!
'6!PVV;!$8+0+)(0+;!$8+!W!6/$Q2!'6!2(0E/**4!,VVZPVV!C!PPW!d!$8+0+)(0+;!,ZP!()!$8+!L'2&'2=!
6'$+6!/0+!(<<#9'+&!>'$8!T+@!!!
I8+6+!/0+!$8+!$+0E6!/2&!T+!6$#&'+6!>+!#6+;!+69!)(0!E'<0(<4$'<!/2+E'/6!?0+*/$+&!$(!T+!
90(L*+E6B@!
C. Pathogenesis of microcytic anemias
%**!E'<0(<4$'<!/2+E'/6!/0+!E'<0(<4$'<!?LZ<!$8+4!8/M+!/!90(L*+E!E/F'2=!NLB@!!g8+2!$8+!RS.!
'6!&+M+*(9'2=!'2!$8+!E/00(>;!'$Q6!$8+!NL!<(2<+2$0/$'(2!>'$8'2!$8+!RS.!$8/$!&+$+0E'2+6!$8+!
2#EL+0!()!<+**!&'M'6'(26@!!I8+0+)(0+;!')!$8+!NL!642$8+6'6!'6!&+<0+/6+&;!'$!'6!/!6'=2/*!'2!$8+!
E/00(>!$(!'2<0+/6+!$8+!2#EL+0!()!E'$(6+6@!!g8+2!<+**6!E'$(6+6;!$8+4!=(!)0(E!6(E+$8'2=!
(0'='2/**4!L'=!$(!6(E+$8'2=!6E/**@!!Y(!LZ<!()!$8+!&+<0+/6+!'2!NL!642;!$8+0+!/0+!+:$0/!&'M'6'(26!
/2&!$8+0+)(0+!$8+!<+**!'6!6E/**+0@!!!
!
%**!)(#0!=0(#96!()!E'<0(<4$'<!/2+E'/6!8/M+!/!&+<0+/6+!'2!NL@!
72

NL!C!8+E+!O!=*(L'2U!N+E+!C!T+!O!90($(9(09840'2U!l*(L'2!'6!E/&+!L4!$8+!L(&4!7!/*98/!
? B;!L+$/ ;!&+*$/!? B;!=/EE/!? BU!NL%!7H H U!NL%H7H H U!NLT7!H H !!
g+!</2!&'69+26+!H!()!$8+!^!E'<0(<4$'<!/2+E'/6!'EE+&'/$+*4-!
Fe def!C!&(2Q$!8/M+!T+;!$8+0+)(0+!$8+0+!'6!2(!T+!$(!)(0E!>'$8!90($(9(09840'2!$(!)(0E!8+E+U!
6(;!no Fe = no heme = no Hb!
!
D. Pathogenesis of Anemia of chronic dz!!
g8+2!>+!8/M+!'2)*/EE/$'(2;!(#0!L(&'+6!0+69(2&!$(!'2)*/EE/$'(2!/6!')!'$!'6!/2!'2)+<$'(2@!!!12!
E'<0(;!L#=6!'2<0+/6+!$8+'0!0+90(&#<$'(2!>'$8!T+;!$8+0+)(0+;!$8+!E(0+!T+!$8+4!8/M+;!$8+!E(0+!
$8+4!0+90(&#<+@!!Y/E+!<(2<+9$-!>'$8!/2+E'/!()!<80(2'<!'2)*/EE/$'(2!/2&!L(&4!/66#E+6!'$!'6!
6#L3+<$!$(!/!L/<$+0'/*!'2)+<$'(2;!$8+!(L3+<$!'6!$(!F++9!T+!/>/4!)0(E!$8+!L/<$+0'/@!!N(>!&(+6!'$!
&(!$8/$n!1$6!*'F+!/!6/)+$4!&+9(6'$!L(:;!/2&!4(#!8/M+!$8+!F+4!7!T+!'6!2(0E/**4!6$(0+&!'2!
E/<0(98/=+6!'2!$8+!SK!7!$8'6!'6!>8+0+!$0/26)+00'2!=(+6!?$(!$8+!E/<0(98/=+B!$(!9'<F!#9!$8+!
T+!/2&!$/F+!'$!$(!$8+!RS.@!!1)!4(#!&(2Q$!>/2$!L/<$+0'/!$(!8/M+!/<<+66!$(!$8+!T+;!'$!>'**!L+!
*(<F+&!/>/4!'2!$8+!E/<0(98/=+6!'2!$8+!SK!/2&!$8+!]F+4Q!$(!$8+!E/<0(98/=+6!>'**!L+!*(6$U!
$8+0+)(0+;!$8+0+!'6!*($6!()!T+!'2!$8+!E/<0(98/=+6!()!$8+!SK;!L#$!</22($!=+$!'$!(#$@!!N(>+M+0;!
$8+!=((&!2+>6!'6!$8/$!4(#!/0+!F++9'2=!'$!/>/4!)0(E!$8+!L#=6!6(!$8+4!&(2Q$!0+90(&#<+@!!S/&!
2+>6!7!F++9'2=!'$!/>/4!)0(E!$8+!RS.Q6;!/2&!$8+0+)(0+!8/M+!/2!&+<0+/6+!'2!NL!642$8+6'6@!!
N(>+M+0;!#2*'F+!T+!&+)'<'+2<4;!>8+0+!$8+0+!'6!2(!T+!'2!$8+!E/<0(98/=+6!()!$8+!SK;!$8+0+!'6!
J1X[Y!()!T+;!L#$!$8+!]F+4Q!8/M+!L++2!*(6$!/2&!4(#!</22($!=+$!'$!(#$@!!Y(;!'00+69+<$'M+!()!$8/$;!
4(#0!6+0#E!T+!'6!&+<0+/6+&!LZ<!'$!'6!/**!*(<F+&!'2!$8+!E/<0(98/=+6;!/2&!4(#!&(2Q$!8/M+!
+2(#=8!T+!$(!E/F+!8+E+@!!Y(;!'$Q6!$8+!6/E+!E+<8/2'6E!/6!T+!&+);!L#$!)(0!&'))+0+2$!0+/6(26-!
?,B!4(#!8/M+!2(!T+!?1_%B!/2&!?HB!4(#!8/M+!*($6!()!'$;!L#$!'$6!*(<F+&!'2!$8+!6/)+$4!&+9(6'$!L(:!
/2&!4(#!</22($!=+$!'$!7!6(;!+'$8+0!>/4;!4(#!</22($!E/F+!8+E+!/2&!$8+0+)(0+!4(#!</22($!
E/F+!8+E(=*(L'2@!To distinguish between IDA and ACDz, there are high ferritin
levels in ACDz, whereas there is a high TIBC in Fe def anemia!!!
!
E. Heme synthesis!
.+0$/'2!0:26!'2!L'(<8+E!(<<#0!'2!$8+!<4$(6(*;!$8+!'22+0!E'$(!E+EL0/2+!?(:!98(6B;!E'$(!
E/$0':!?L+$/!(:!()!T%Q6;!I.%B;!/2&!'2!$8+!<4$(6(*!%"_!$8+!E'$(<8(2&0'/!?=*#<(2+(=+2+6'6;!
>8'<8!6$/0$6!'2!$8+!E'$(!/2&!+2&6!#9!'2!$8+!<4$(6(*;!#0+/!642$8+6'6;!>8'<8!6$/0$6!'2!$8+!E'$(!
/2&!=(+6!$(!$8+!<4$(6(*!/2&!L/<F!'2$(!$8+!E'$(;!/2&!8+E+!642!7!'2!E'$(;!$8+2!<4$(6(*;!/2&!
$8+2!/=/'2!'2!$8+!E'$(B@!!Y(;!$8+0+!/0+!P!L'(<8+E'</*!0:26!'2!$8+!E'$(!/2&!<4$(6(*@!!!
!
T'06$!9/0$!()!8+E+!642!?/F/!9(09840'2!642B!L+='26!'2!$8+!E'$(@!!T'06$!0:2!'6!6#<<'24*!<(%!
?6#L6$0/$+!'2!I.%!<4<*+!/2&!6#L6$0/$+!)(0!=*#<(2+(=+2+6'6B;!>8'<8!</2!L+!9#$!$(=+$8+0!>'$8!
=*4<'2+!?>8'<8!'6!/2!'28'L'$(04!2+#0($0/26E'$$+0!()!E#6<*+;!L*(<F+&!L4!$+$/2#6!$(:'2!08+6#6!
6/0&(2'<#6!/2&!$+$/2'<!<(2$0/<$'(2!7!6(!>8+2!=*4<'2+!'6!'28'L'$+&;!$8+!E#6<*+6!/0+!'2!/!$(2'<!
6$/$+!()!<(2$0/<$'(2B@!!!52(>!/**!R%I[!X1K1I1"l![2c4E+Q6!?RX[B!)(0!+M+04!L'(<8+E'</*!0:2@!
?RX[!'2!<8(*+6$+0(*!642!C!NKl!.(%!0+&#<$/6+B@!
!
RX[!'2!8+E+!642$8+6'6!C!%X%!642$8/6+;!<()/<$(0!C!940'&(:'2+@!!Y(;!90($(9(09840'2!'6!E/&+!
/2&!=(+6!L/<F!$(!$8+!E'$(@!!Y(!4(#!8/M+!90($(9(09840'2!9*#6!T+;!6(!4(#!8/M+!/!E+$/*!9*#6!
90($(9(09840'2@!!.8+*/$/6+!9#$6!$8+6+!$(=+$8+0U!6(;!'$!'6!</**+&!)+00(<8+*/$/6+;!>'$8!<(EL'2+6!
T+!>'$8!90($(9(09840'2!/2&!)(0E6!8+E+@!!N+E+!8/6!/!)++&L/<F!E+<8/2'6E!>'$8!%X%!
642$8/6+!?/**!RX[Q6!8/M+!/!)++&L/<F!E+<8B@!Y(;!>'$8!'2<0+/6+&!8+E+;!'$!>'**!&+<0+/6+!642!()!
%X%!642$8/6+;!/2&!>8+2!8+E+!'6!&+<0+/6+&;!'$!>'**!'2<0+/6+!%X%!642$8/6+!642@!
!
73

F. Pathogenesis of Sideroblastic anemias!?*+/6$!<(EE(2!()!$8+!E'<0(<4$'<!/2+E'/6B@!!
i6'&+0(j!C!T+@!!R/0+6$!()!E'<0(<4$'<!/2+E'/6!C!sideroblastic anemiasU!$8+4!8/M+!P!</#6+6-!
!
,@!!%*<(8(*!?6'&+0(L*/6$'<!/2+E'/!'6!"GI!$8+!K.!/2+E'/!'2!/*<(8(*;!K..!()!6'&+0(L*/6$'<!
/2+E'/!'6!/*<(8(*U!K.!/2+E'/!(M+0/**!C!%._c;!)(**(>+&!L4!)(*/$+!&+)B@!!%*<(8(*!'6!/!
E'$(<8(2&0'/*!9('6(2!/2&!#2<(#9*+6!(:!98(6;!/2&!&/E/=+6!'22+0!E'$(!E+EL0/2+;!/**(>'2=!
90($(26!$(!=(!'2!/2&!&0/'2!$8+E!())@!!G2![K!()!$8+!E'$(!()!/2!/*<(8(*'<!'6!8#=+!LZ<!$8+4!/0+!
&/E/=+&!?</**+&!E+=/E'$(<8(2&0'/B@!!I8+0+)(0+;!/24!90(<+66!$8/$!(<<#06!'2!$8+!E'$(!'6!
6<0+>+&!#9@!!I8'6;!$8+0+)(0+;!'2<*#&+6!8+E+!642$8+6'6@!!Y(;!T+!'6!&+*'M+0+&!$(!$8+!RS.!L4!
$0/26)+00'2!/2&!&(+62Q$!F2(>!>8+0+!$(!=(@!!Y(E+!'6!6$(0+&!/6!)+00'$'2;!>8'*+!E(6$!()!'$!=(+6!
$(!$8+!E'$(;!>8'<8!'6!S%_!2+>6m!!g84n!SZ<!'$!</2!=+$!'2;!L#$!.%""GI!=+$!(#$@!!Y(;!$8+0+!'6!
&/E/=+&!E'$(<8(2&0'/!$8/$!>+0+!&/E/=+&!L4!/*<(8(*;!T+!=(+6!'2!/2&!2(>!</22($!=(!(#$@!!
Y(;!$8+0+!>'**!*($6!()!T+!</#=8$!/2&!T+!L#'*&6!#9!>'$8'2!$8+!E'$(@!!K'$(!'6!*(</$+&!/0(#2&!$8+!
2#<*+#6!()!/2!RS.!'2!$8+!SK;!*+/&'2=!$(!/!0'2=+&!6'&+0(L*/6$@!!I8'6!'6!$8+!E/0F+0!<+**!)(0!
6'&+0(L*/6$'<!/2+E'/U!/*6(!'2!T+!(M+0*(/&!&c!7!>'**!+:<+66!'0(2;!/2&!>'**!2($!=+$!8+E+!LZ<!
E'$(!&+6$0(4+&!?6(!/*<(8(*!'6!$8+!K..B@!
74

HB!laJ_!&+)!7!940'&(:'2+!&+)U!'+!2($!$/F'2=!k'$!Sa!&#0'2=!R:!()!IS@!Y(;!2(!k'$!Sa!C!2(!8+E+;!
/2&!$8+!)'06$!0:2!>'**!2($!8/99+2@!!S#$!T+!&(+62Q$!F2(>!$8/$U!/=/'2;!T+!=(+6!$(!$8+!E'$(;!
>/'$'2=!)(0!9(09840'2;!*+/&'2=!$(!0'2=+&!6'&+0(L*/6$@!
!
PB!*+/&!9('6(2'2=!7!6(!*+/&!*+/&6!$(!6'&+0(L*/6$'<!/2+E'/@!!X+/&!'6!/!&+2/$#0+0@!!%**!8+/M4!
E+$/*6!&+2/$#0+!90($+'26!?+2c4E+6!/0+!90($+'26B@!!X+/&Q6!)/M(0'$+!+2c4E+!$(!&+2/$#0+!'6!
)+00(<8+*/$/6+;!6(!'$!>(2Q$!>(0F;!/2&!2(!8+E+!C!2(!NL;!*+/&'2=!$(!E'<0(<4$'<!/2+E'/@!!X+66!
()!'28'L'$(04!+))+<$;!L#$!&(+6!8/M+!/!*'$$*+!(2+!(2!/E'2(*+M#*'2'<!/<'&!&+84&0/$/6+@!!S#$!'6!
KGYI!<(EE(2*4!F2(<F6!())!)+00(<8+*/$/6+@!!Y(;!>8+2!T+!<(E+6!'2$(!E'$(;!'$!</22($!L'2&!$(!
90($(9(09840'2!$(!)(0E!8+E+@!!No heme = decreased Hb = microcytic anemia@!!!
[:/E9*+-!!')!)+00(<8+*/$/6+!'6!&+<0+/6+&Z'28'L'$+&;!8+E+!&+<0+/6+6;!L#$!>8/$!8/99+26!$(!
90($(9(09840'2!L+)(0+!$8+!L*(<Fn!1$!'2<0+/6+6!?#6+&!$(!L+!6<0++2'2=!$+6$!()!<8('<+!)(0!*+/&!
9('6(2'2=B@!"($!#6+&!/24E(0+@!g84n!SZ<!')!4(#!&(2Q$!8/M+!T+!LZ<!%._cZT+!&+);!>8/$!>'**!
8/99+2!$(!$8+!90($(9(09840'2!'2!$8+!E'$(n!1$!>'**!'2<0+/6+@!!Y(;!$8+4!)(#2&!(#$!$8/$!E/24!
9+(9*+!8/&!/2!'2<0+/6+!'2!RS.!90($(9(09840'2;!/2&!=($!idi!$+6$!)(0!*+/&!9('6(2'2=;!/2&!$8+2!
F2+>!$8/$!$8+!9$6!8/&!+'$8+0!T+!&+)!(0!%._c;!/2&!<(2<*#&+&!$8/$!'$!>/6!2($!/!=((&!6<0++2'2=!
$+6$@!
!
Y(;!2(>!L*((&!*+/&!*+M+*!'6!$8+!6<0++2'2=!/2&!<(2)'0E/$(04!$+6$!)(0!*+/&!9('6(2'2=;!2($!RS.!
90($(9(09840'2!?$((!E/24!)/*6+!iOjQ6B!
!
G. Pathogenesis of Thalassemias: %#$(!0+<!&cQ6!
1. Alpha thalassemias!7!>8(!&(!>+!6++!/*98/!$8/*/66+E'/6!'2n!%6'/26!?T/0!+/6$+02B!/2&!
L*/<F6!?/**!=+2+$'<!8+E/$(*(='<!&cQ6!/0+!6++2!'2!$8+!L*/<F!9(9Q2!7!/*98/ZL+$/!$8/*;!laJ_!&+);!
Y._cB@!!!
,@!!NL!+*+<$0(98(0+6'6!7!6+9/0/$+6!$8'2=6!L/6+&!(2!6'c+!/2&!<8/0=+;!$8+0+)(0+!4(#!</2!
<*+/0*4!6+9/0/$+!NL%;!NLT;!/2&!NL%H!<*+/0*4!(2!<+**#*(6+!/<+$/$+!LZ<!$8+4!8/M+!&'))+0+2$!
E'=0/$'(26@!!Y(;!$8+4!)*#(0+6<+!'$;!/2&!NL%;!NLT!/2&!NL%H!/**!6+$$*+!&(>2@!I8+2!$8+4!
6$/'2!$8+!<+**#*(6+!/<+$/$+!$(!6++!8(>!E#<8!'6!$8+0+@!!I8+2;!'$!90(&#<+6!&+26'$4;!/2&!$8+!
&+26'$4!<(00+*/$+6!>'$8!$8+!<(2<+2$0/$'(2!()!+/<8!()!$8+!NLQ6@!!N(>!>'**!$8+4!F2(>!$8+!
9+0<+2$n!g'$8!/!&+26'$(E+$+0!7!'$!<(2M+0$6!$8+!&+26'$4!()!$8+!6$/'2!$(!$8+!9+0<+2$/=+@!!1$!
$#026!(#$!$8/$!NL%!?H H B!'6!$8+!90+&(E'2/2$!NL!'2!/2!/&#*$!?redreWB@!!NL%H!'6!,dHWU!
NLT!C!,W@!I8+6+!/0+!$8+!2(0E/*;!>8'<8!/0+!+:90+66+&!/6!/!9+0<+2$/=+@!!!
!
H@!!%*98/!$8/*/66+E'/6;!/#$(!0+<;!8/6!/!90(L*+E!'2!E/F'2=!/*98/!=*(L'2!<8/'26@!!_(!NL%H!
/2&!NLT!0+D#'0+!NL%!$(!L+!E/&+n!b+6@!!I8+0+)(0+;!/**!>'**!L+!+D#/**4!&+<0+/6+&@!!I8'6!
>'**!"GI!68(>!#9!(2!/2!+*+<$0(98(0+6'6;!LZ<!/**!/0+!+D#/**4!&+<0+/6+&;!$8+0+)(0+;!'$!
68(>6!$(!L+!$($/**4!2(0E/*@!!I8+0+!/0+!)(#0!=+2+6!$8/$!<(2$0(*!/*98/!=*(L'2!642$8+6'6@!!
_+*+$'(2!()!(2+!()!$8+6+!)(#0!>'**!2($!</#6+!/2+E'/@!!_+*+$'(2!()!H!=+2+6!C!90(L*+E!LZ<!
E'2'E/**4!&+<0+/6+&;!/2&!$8+0+)(0+!/!E'*&!/2+E'/@!!1$!'6!E'<0(<4$'<!LZ<!$8+!=*(L'2!9/0$!'6!
&+<0+/6+&;!E+/2'2=!4(#!>'**!=+$!/!E'<0(<4$'<!/2+E'/!?&+<0+/6+!'2!NL!<(2<Q2;!>8'<8!>'**!
L+!$8+!6$'E#*#6B@!!I8'6!</**+&!/*98/!$8/*/66+E'/!E'2(0;!6++2!'2!$8+!)/0!+/6$+02!9(9Q2!/2&!
L*/<F!9(9Q2@!!!
g'$8!/!$80++!=+2+!&+*+$'(2;!$8/$Q6!2($!=((&;!/2&!9$!'6!0+/**4!&+<0+/6+&!?$8+0+!'6!/*6(!/!
8+E(*4$'<!<(E9(2+2$!$(!'$B@!!I8+!L+$/!<8/'26!=+$!'00'$/$+&!$8/$!$8+0+!'6!2(!/*98/!<8/'26!
/0(#2&;!6(!$8+4!)0(E!$8+'0!(>2!L+$/!=*(L'2!<8/'26@!!Y(;!)(#0!L+$/!<8/'26!=+$!$(=+$8+0!
/2&!)(0E!NLN@!!1)!4(#!&(!/2!+*+<$0(98(0+6'6;!$8+0+!>'**!L+!/!&'))+0+2$!0+6#*$@!!NLN!'6!/!
&'))!NL;!/2&!$8+0+)(0+!>'**!2($!E'=0/$+!$(!$8+!6/E+!9*/<+!/6!($8+0!NLQ6@!!Y(;!4(#!</2!&:!
$8'6!/*98/!$8/*/66+E'/!>'$8!NL!+*+<$0(98(0+6'6!?>84!'$6!</**+&!NLN!&cB@!!T(#0!=+2+!
75

&+*+$'(26!7!69(2$/2+(#6!/L(0$'(26!?#6#/**4;!$8+0+)(0+!2($!#6#/**4!L(02!/*'M+!7!/F/!
84&0(96!)+$/*'6B@!l/EE/!<8/'26!)(0E!$(=+$8+0!?*'F+!$8+!L+$/!<8/'26!&'&!+/0*'+0B!/2&!)(0E!
/!NL!>'$8!^!=/EE/6;!>8'<8!'6!</**+&!NL!S/0$6@!!I8'6!>'**!68(>!#9!(2!+*+<$0(98(0+6'6;!L#$!
>(2Q$!E/$$+0!LZ<!L/L4!'6!&+/&!/*0+/&4@!!g8/$!'6!$8+!69(2$/2+(#6!/L(0$'(2!0/$+!'2!)/0!
+/6$n!N'=8!LZ<!$8'6!'6!>8+0+!/*98/!$8/*/66+E'/!'6!E(6$!<(EE(2*4!*(</$+&@!!I8+0+)(0+;!')!
$8+!'2<'&+2<+!()!69(2$/2+(#6!/L(0$'(26!'6!'2<0+/6+&;!>8/$!</2<+0!0'6F!'6!'2<0+/6+&n!
.8(0'(</0<'2(E/!?'2<0+/6+&!84&/$'&')(0E!E(*+6;!>8'<8!*+/&6!$(!<8(0'(</0<'2(E/B@!!Y(;!
$8+0+!'6!/!8'=8!'2<'&+2<+!()!<8(0'(</0<'2(E/!'2!$8+!)/0!+/6$!LZ<!()!/*98/!$8/*/66+E'/@!!R:!
7!_G!"GI!='M+!T+!?>'**!T+!(M+0*(/&!$8+EB@!!Y(;!3#6$!*+/M+!$8+E!/*(2+@!!?H2&!K..!3/#2&'<+!
C!l'*L+0$Q6!&c!7!+69!>'$8!*/<F!()!)((&B@!
!
2. Beta thalassemia!7!L*/<F6;!l0++F6;!1$/*'/26@!!S!?L4!'$6+*)B!C!E/F'2=!2(0E/*!L+$/!<8/'26U!
S!?>'$8!/!iOjB!C!E/F'2=!L+$/!<8/'26;!L#$!2($!+2(#=8U!S!?>'$8!/!iVjB!C!2($!E/F'2=!L+$/!
<8/'26!/$!/**@!!!S+$/!$8/*!'6!/#$(!0+<;!/2&!8/6!$(!&(!>'$8!69*'<'2=!&+)+<$6;!6$(9!<(&(26@!!I8+!
E(6$!6+M+0+!)(0E!'6!&#+!$(!6$(9!<(&(2!?$8+0+)(0+!$+0E'2/$+!642$8+6'6!()!L+$/!<8/'26;!/2&!
&(2Q$!+M+2!E/F+!$8+EB@!!Mild thalassemia-!6*'=8$*4!&+<0+/6+&!L+$/!<8/'26;!90(L!&#+!$(!/!
69*'<'2=!&+)+<$U!L+$/!<8/'26!/0+!6*'=8$*4!&+<0+/6+&;!/*98/!<8/'26!/0+!(F/4;!&+*$/!<8/'26!/0+!
(F/4;!=/EE/!<8/'26!)'2+!?<(2)'2+&!$(!)+$#6B@!!Y(;!NL%!>'**!&+<0+/6+;!/2&!&+*$/!>'**!=+$!
$(=+$8+0!?8+2<+!'2<0+/6+!'2!NL%HB!/2&!=/EE/!<8/'26!=+$!$(=+$8+0!?8+2<+!'2<0+/6+!'2!NLTB@!
I8+0+)(0+;!6++!/!&+<0+/6+!'2!NL%!/2&!/2!'2<0+/6+!'2!NL%H!/2&!NLTU!$8'6!g1XX!68(>!#9!(2!
+*+<$0(98(0+6'6@!!I8'6!8/99+2+&!LZ<!L+$/!<8/'2!'6!&+<0+/6+&;!/2&!'$!68(>+&!/!&+<0+/6+&!
NL%@!!1$!'6!3#6$!/!E'*&!$8/*/66+E'/!/2&!'6!M+04!<(EE(2@!!Y(;!(2*4!>/4!$(!&:!S+$/!$8/*!'6!>'$8!
NL!+*+<$0(98(0+6'6@!!./22($!&(!/24$8'2=!/L(#$!'$@!!N(9+)#**4!'$!'6!2($!$8+!6+M+0+!$49+;!>8+0+!
2($!E/F'2=!/24!L+$/!<8/'26!7!/F/!.((*+4Q6!/2+E'/!/2&!>'**!2($!*'M+!9/6$!PV!4Z(@!!g'**!8/M+!/!
<(26$/2$!$0/26)#6'(2!0+D#'0+E+2$U!E/24!()!$8+6+!9$6!&'+!)0(E!T+!(M+0*(/&;!(0!N+9!.!(0!
E#*$'9*+!$0/26)#6'(26!(0!N1k@!
!
K.!'2!L*/<F!9(9Q2!7!L+$/d&+*$/!$8/*/66+E'/!?&+<0+/6+&!L+$/!<8/'26!/2&!&+<0+/6+&!&+*$/!<8/'26;!
6(!>8/$Q6!*+)$!/0+!/*98/!/2&!=/EE/!<8/'26B@!!g8/$!>'**!$8+!+*+<$0(98(0+6'6!68(>n!NLT@!!I8'6!
</**+&!8+0+&'$/04!9+06'6$+2<+!()!NLT@!!"(!/2+E'/;!3#6$!&(E'2/2$!NLT@!
!
T(0!$8/*/66+E'/6;!F2(>!$8+4!/0+!=+2+$'<;!>8/$!=0(#96!()!9+(9*+!$8+4!/0+!'2;!/2&!$8/$!4(#!_G"QI!
&(!/24$8'2=!$(!$8+E;!+69!='M'2=!T+!LZ<!/**!$8+'0!T+!6$#&'+6!/0+!2(0E/*@!!!
!
76

H. Iron Deficiency Anemia (IDA):
,@!!./#6+6!()!T+!&+)!/2+E'/!7!*((F!/$!/=+!L0/<F+$6-!
/B!!J0+E/$#0'$4!7!+M+04&/4!/!L/L4!'6!2($!'2!#$+0(;!'$!'6!*(6'2=!T+!?/**!$8+'0!T+!6$(0+6!/0+!
&+<0+/6+&;!6(!L/L4!E#6$!L+!='M+2!T+!6#99*+E+2$6B@!
LB!!"+>L(02!7!<8+<F!6$((*!)(0!$8+'0!L*((&U!2++&!$(!F2(>!'$Q6!2($!E(EQ6!L*((&;!>8'<8!</2!
L+!6>/**(>+&@!!I8'6!'6!&(2+!>'$8!$8+!/9$!$+6$@!!K(6$!()!L*((&!$8/$!<(E+6!(#$!()!L/L4Q6!
E+<(2'#E!'6!L*((&!$8+!L/L4!6>/**(>+&!)0(E!E(E;!/2&!'$!8/6!NL%!'2!'$@!!N(>+M+0;!')!'$!
>/6!NLT!L*((&!$8/$!</E+!(#$;!$8+!K..!'6!L*++&'2=!E+<F+*Q6!&'M+0$'<#*#E@!!I8+0+)(0+;!
L*++&'2=!E+<F+*Q6!&'M+0$'<#*#E!C!K..!T+!&+)!'2!/!2+>L(02!/2&!<8'*&@!!K+<F+*Q6!
&'M+0$'<#*#E!'6!"GI!$8+!</#6+!()!T+!&+)!'2!/2!/&#*$;!LZ<!E(6$!8/M+!L*+&!L4!)(#0!4+/06!()!
/=+;!/2&!/*0+/&4!>(#*&!8/M+!F2(>2!9$!8/6!'$@!
<B!!g(E/2!#2&+0!eV!7!K..!T+!&+)!C!E+2(008/='/;!$8+0+)(0+!2++&!$(!=+$!/!=((&!
E+26$0#/*!8:U!&#+!$(!/2(M#*/$(04!<4<*+6!?L+$>++2!HVd^V!4Z(;!&#+!$(!(M#*/$(04!<4<*+6;!
'2/&+D#/$+!*#$+/*!98/6+;!90+=2/2<4!0+*/$+&!L*++&6;!+2&(E+$0'/*!9(*49!$8/$!'6!L*++&'2=B@!!!
&B!!K+2!#2&+0!eV!7!K..!T+!&+)!C!J\_!?#6#/**4!&#(&+2/*!#*<+0B@!!!
+B!!K+2!/2&!>(E+2!(M+0!eV!7!K..!T+!&+)!C!.(*(2!</2<+0!
!
H@!!X/L!I+6$!76+0#E!T+!C!*(>;!I1S.!C!8'=8;!W!6/$Q2!?T+ZI1S.B!C!*(>!
!1)!4(#!&(2Q$!8/M+!T+;!6/$Q2!'6!&+<0+/6+&!LZ<!2(!T+!$(!9#$!(2!'$@!!Y+0#E!)+00'$'2!*+M+*!C!*(>!
!
I. ACDz!7!0+*/$+&!$(!'2)*/EE/$'(2@!!T+!'6!*(<F+&!'2!6/)+$4!&+9(6'$!L(:;!6(!4(#!8/M+!9*+2$4;!L#$!
</22($!=+$!'$!(#$!
Y+0#E!T+C*(>U!I1S.C*(>!?8'=8!T+!YIGR[Y!C!&+<0+/6+!$0/26)+00'2!642B!!
W!6/$!C!*(>;!6+0#E!)+00'$'2!C!8'=8!
I8+0+)(0+;!E/'2!$+6$!$(!&'6$'2=#'68!%._c!)0(E!T+!&+)!C!6+0#E!T+00'$'2m!
!
J. Mild alpha and beta thal!7!"GRK%X!T+!6$#&'+6!LZ<!2($8'2=!$(!&(!>'$8!T+;!L#$!=*(L'2!
<8/'26@!
!
K. Sideroblastic!d!'+!6E+/0!>'$8(#$!/990(90'/$+!/E(#2$!()!NL!'2!$8+!<+**6;!$8+0+)(0+;!$8+4!/0+!
E(0+!$8/2!*'F+*4!$(!L+!/!E'<0(<4$'<!/2+E'/!?T+!&+);!%._c;!$8/*/66+E'/;!*+/&!9('6(2'2=B@!!Y*'&+-!
0'2=+&!6'&+0(L*/6$!?(2*4!6++2!'2!SK;!/2&!'6!6$/'2+&!>'$8!J0#66'/2!L*#+;!>8'<8!6$/'26!T+!LZ<!E'$(!
/0(#2&!$8+!2#<*+#6;!/**!)'**+&!#9!>'$8!T+!7!</**+&!/!0'2=+&!6'&+0(L*/6$!7!$8'6!'6!9/$8(=2(E(2'<!()!
/!6'&+0(L*/6$'<!/2+E'/B@!Y(!')!4(#!$8'2F!$8/$!Sa!'6!</#6'2=!$8+!/2+E'/;!2++&!$(!90(M+!'$@!!"++&!$(!
=+$!SKU!')!4(#!$8'2F!/*<(8(*!'6!$8+!</#6+;!4(#!8/M+!$(!90(M+!'$@!!!
!
L. Lead poisoning!1)!4(#!6#69+<$!*+/&!9('6(2'2=U!3#6$!&(!/!*+/&!*+M+*!?2($!/!SK!+:/EB@!!7!<+**6!
>'$8!L*#+!69($6!7!</**+&!L/6(98'*'<!6$'99*'2=@!!_(!2($!2++&!/!69+<'/*!6$/'2!$(!6++!L/6(98'*'<!
6$'99*'2=!?68(>6!#9!(2!='+E6/!6$/'2B@!!Y++!L*#+!&($6!7!*+/&!&+2/$#0+6!0'L(2#<*+/6+;!/2&!$8+!
9#09(6+!()!0'L(2#<*+/6+!'6!$(!L0+/F!&(>2!0'L(Q6U!')!'6!&+2/$#0+&;!/2&!&(+62Q$!L0+/F&(>2;!
0'L(6(E+!9+06'6$6@!!I8+0+)(0+;!$8+4!='M+!/!=0+/$!E/0F+0!'2!$8+!9+0'98+0/*!L*((&!7!L/6(98'*'<!
6$'99*'2=@!!1)!'$Q6!/2!R"%!)'*/E+2$;!$/*F'2=!/L(#$!0+$'<#*(<4$+@!!1)!>+!>+0+!$/*F'2=!/L(#$!9+06'6$+2$!
0'L(!C!*+/&!9('6(2'2=@!!G2!:d0/4!7!+9'9846+6!()!)'2=+0!()!<8'*&U!(2*4!8+/M4!E+$/*!$8/$!</2!&+9(6'$!
'2!$8+!+9'9846'6!()!L(2+!'6!*+/&!?E+0<#04!</22($;!/06+2'<!</2$;!(2*4!*+/&!</2B@!!I8+0+)(0+;!</2!
6++!&+9(6'$6!'2!+9'9846+6@!!I8'6!'6!>84!$8+4!8/M+!)/'*#0+!$(!=0(>@!!1)!4(#!6<0+>!#9!$8+!+9'9846+6!
()!$8+!F'&;!$8+4!>'**!2($!L+!/L*+!$(!=0(>!90(9+0*4@!!.*'2'</*!6<+2/0'(!7!<8'*&!+/$'2=!9/'2$Z9*/6$+0!
*+/&6!$(!*+/&!9('6(2'2=;!8/M+!6+M+0+!/L&(E'2/*!<(*'<;!90(L!>'$8!<+0+L0/*!+&+E/;!<(2M#*6'(26;!
6+M+0+!E'<0(<4$'<!/2+E'/;!6++!*+/&!'2!'2$+6$'2+6!?)*/$!9*/$+B@!!b(#Q**!6++!T+!'2!$8+!'2$+6$'2+6U!$80++!
$8'2=6!</2!</#6+!$8'6!'6!T+!$/L*+$6!'2=+6$+&!'2!/!F'&;!*+/&;!E+0<#04B@!%*6(;!$8+0+!'6!/!)/'*#0+!$(!
77
$80'M+@!!K+<8/2'6E!()!<+0+L0/*!+&+E/n!R+*/$+&!$(!'2<0+/6+&!M+66+*!9+0E+/L'*'$4!()!L0/'2!/2&!
L#'*&#9!()!&+*$/d*+E/M'24*'2'<!/<'&@!!!1)!4(#!L*(<F!)+00(<8+*/$/6+;!+M+04$8'2=!&'6$/*!$(!$8+!L*(<F!
>'**!'2<0+/6+!?90($(9(09840'2;!&+*$/*+E/M'24*'2'<!/<'&B!$8'6!'6!$(:'<!$(!2+#0(26;!*+/&'2=!$(!<+0+L0/*!
+&+E/@!
[:/E9*+-!=#4!/$!/2!/#$(E(L'*+!68(9;!<(E9*/'26!()!/L&(E'2/*!<(*'<!/2&!&'/008+/@!!I8'6!'6!*+/&!
9('6(2'2=!LZ<!+:9(6#0+!$(!L/$$+0'+6@!!12!9*/2$6;!$8+0+!'6!+:9(6#0+!$(!'2<'2+0/$'(2!()!L/$$+0'+6;!/2&!
9$6!/0+!+:9(6+&!$(!*+/&!'2!/#$(!)/<$(0'+6!
!
[:/E9*+-!E((268'2+!7!E/F+!/*<(8(*!'2!(*&!0/&'/$(06;!*+/&6!$(!*+/&!9('6(2'2=!
!
[:/E9*+-!9($$+04!9/'2$+0!7!9($$+04!'6!<(EE(2*4!9/'2$+&!>'$8!*+/&!L/6+&!9/'2$6@!!%!*($!$'E+6!$8+4!
*'<F!$8+!$'9!()!$8+!L0#68;!/2&!*+/&6!$(!*+/&!9('6(2'2=@!!!
!
[:/E9*+-!'2!<+0$/'2!<(#2$04;!$8+4!#6+!*+/&dL/6+&!9($$+04!)(0!&'68+6;!>8'<8!*+/&6!$(!*+/&!
9('6(2'2=@!!%&#*$6!>'**!=+$!$8+!2+#0(9/$8'+6!7!6*/99'2=!=/'$!?9+0'2+/*!9/*64B;!>0'6$!&0(9!?0/&'/*!
9/*64B;!<*/>!8/2&!?#*2/0!9/*64B;!*+/&!*'2+6!'2!$++$8!?#6#/**4!=+$!>'$8!<(*'<!/2&!&'/008+/B!
!
M. Fe/TIBC/%sat/ferritin:
T+!&+)-!*;!8;!*;!*!
%._c-!*;!*;!*;!8!
%*98/ZL+$/!$8/*-!2;!8;!8;!8;!&(!2($8'2=!/L(#$!'$!
X+/&!9('6(2'2=!?/2&!6'&+0(L*/6$'<!/2+E'/6!7!T+!(M+0*(/&!*'F+!8+E(<80(E/$(6'6B-!
N;!*;!8;!8!?I1S.!'6!*(>!LZ<!T+!6$(0+6!/0+!8'=8mB!7!'2!T+!(M+0*(/&!+M+04$8'2=!'6!8'=8;!I1S.!'6!
XGg!
!
Anemia
10(2!_+)'<'+2<4!%2+E'/!
%2+E'/!()!.80(2'<!_'6+/6+!
%*98/!/2&!S+$/!I8/*/66+E'/6!
X+/&!(M+0*(/&!>Z!8+E(<80(E/$(6'6!
Iron
XGg!
XGg!
"X!
N1lN!
TIBC
N1lN!
XGg!
N1lN!
XGg!
% saturation
XGg!
XGg!
N1lN!
N1lN!
Ferritin
XGg!
N1lN!
N1lN!
N1lN!
!
!
%#&'(!_/4!P-!N+E/$(*(=4!T'*+!P!
VIII. Macrocytic anemias
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</22($!E/F+!_"%;!69+<')'</**4!LZ<!4(#!8/M+!/!90(L!>'$8!E/F'2=!_KJ!?&+(:4$84E'&'2+!
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?'EE/$#0+!2#<*+'!&(!2($!8/M+!/!*($!()!_"%!'2!$8+E;!L#$!/6!4(#!E/F+!E(0+!_"%;!$8+!2#<*+'!
L+<(E+!E(0+!E/$#0+&;!/2&!$8+!2#<*+#6!L+<(E+6!6E/**+0!/2&!E(0+!<(2&+26+&B@!!SZ<!_"%!
</22($!L+!E/&+;!$8+2!4(#!8/M+!*/0=+!2#<*+#6;!/2&!/**!2#<*+/$+&!$8+!<+**6!'2!4(#0!L(&4!/0+!L'=!7!
>84!$8+4!/0+!</**+&!MEGAloblastic anemias@!!%!=((&!9/$8(*(='6$!</2!&:!S,H!/2&!)(*/$+!&+)!'2!
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2#<*+#6!8/6!_"%!'2!'$;!6(!/24!<+**!>'$8!_"%!>'**!L+!L'=!7!2($!3#6$!$8+!8+E/$(9(+'$'<!<+**6!$8/$!/0+!
8#=+;!%XX!2#<*+/$+&!<+**6!'2!$8+!L(&4!/0+!L'=!7!'+!l1;!6D#/E(#6!<+**6B!
!
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?$+$0/!C!)(#0B@!!J#09(6+!()!<(L/*/E'2!?S,HB!'6!$(!$/F+!$8+!E+$84*!=0(#9!())!()!
E+$84*$+$0/84&0()(*/$+@!!I8+2!'$Q6!</**+&!$+$0/84&0()(*/$+@!!1)!4(#!&(2Q$!=+$!$8+!E+$84*!=0(#9!())!
78

()!)(*/$+;!4(#!>'**!2($!E/F+!_"%@!!Y(;!')!4(#!/0+!S,H!&+);!4(#!</2Q$!=+$!$8+!E+$84*!=0(#9!())!/2&!
</22($!E/F+!_"%@!!1)!4(#!/0+!&+)!'2!)(*/$+;!4(#!</2Q$!E/F+!_"%@!!!
!
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8(E(<46$+'2+;!'$!L+<(E+6!E+$8'(2'2+@!!K+$8'(2'2+!C!//!)(0!,!</0L(2!$0/26)+0!0:26@!!?K+$84*!C!
.NPB@!!1)!4(#!/0+!S,H!(0!)(*/$+!&+);!>8/$!/0+!$8+!6+0#E!8(E(<46$+'2+!*+M+*6n!N'=8@!!g'$8!/!high
serum homocysteine, it produces thromboses, including MIs; it damages endothelial
cells, leading to thromboses, and predisposing to MI. Y(;!>8/$!'6!K..!()!'2<0+/6+&!
8(E(<46$+'2+n!1$!'6!"GI!8(E(<46$'2#0'/!?0/0+!/#$(!0+<!&cB;!L#$!S,H!&+)!(0!)(*/$+!&+);!/2&!)(*/$+!
'6!K.!$8/2!S,H@!!I8+0+)(0+;!$8+!K..!()!'2<0+/6+&!8(E(<46$+'2+!'6!)(*/$+!&+);!/2&!8/M+!/2!
'2<0+/6+&!'2<'&+2<+!()!$80(EL(6'6!/2&!K1@!!I8'6!'6!>84!</0&'(*(='6$6!(0&+0!6+0#E!8(E(<46$+'2+!
*+M+*6@!!12!)(*/$+!&+);!2(!E+$84*!=0(#9!$(!/&&!$(!8(E(<46$+'2+!?6(!8(E(<46$+'2+!'2<0+/6+6BU!>'$8!
S,H!&+);!2(!E+$84*!=0(#9!$(!/&&!$(!E+$8'(2'2+!$(!E/F+!8(E(<46$+'2+!$8+0+)(0+!E+$8'(2'2+!
'2<0+/6+6@!
!
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'6!>8+0+!_"%!'6!E/&+@!!_\KJ!'6!<(2M+0$+&!$(!__I;!E/F'2=!_"%@!!I8+0+)(0+;!$8'6!6#L6$0/$+!'6!
2+<+66/04!$(!E/F+!_"%@!!Y(;!'$!'6!#6+&!'2!$8+!E/F'2=!()!_"%!L4!/2!+2c4E+!</**+&!&'84&0()(*/$+!
0+&#<$/6+!>8'<8!<(2M+0$6!(:'&'c+&!&'84&0()(*/$+!$(!$+$0/84&0()(*/$+@!!K/24!&0#=6!L*(<F!
&'84&0()(*/$+!0+&#<$/6+!7!E+$8($0+:/$+;!IKJdYKh@!!I8+!&0#=6!L*(<F!_"%!642$8+6'6!?'+!
&+<0+/6'2=!_"%!642$8+6'6B!$8+0+L4!*+/&'2=!$(!E/<0(<4$'<!/2+E'/@!!Y(;!$8+!)#2<$'(2/*!S,H!$/F+6!
$8+!E+$84*!=0(#9!)0(E!$+$0/84&0()(*/$+!/2&!='M+6!'$!$(!8(E(<46$+'2+!$(!E/F+!E+$8'(2'2+@!%2&!
$+$0/84&0()(*/$+!>'**!6$/0$!$8+!<4<*+!)(0!E/F'2=!_"%@!!
A. B12!!
,@!!S,H!R+/<$'(26-!!!S,H!'6!8#E'*'/$+&!L4!8/M'2=!$(!$0/26)+0!E+$84*!=0(#96@!!I8'6!'6!/2!(&&!
0+D#+6$!7!6(!>8(+M+0!8+!/6F+&!6/'&!$8/$!$8+4!</2!$/F+!</0+!()!+M+2!<8/'2+&!T%Q6;!L#$!>+!
8/M+!/!90(L*+E!>'$8!G__!<8/'2+&!T%Q6!LZ<!>+!</2!(2*4!L0+/F!&(>2!$'**!90(90'(24*!.(%;!
>8'<8!*+/&6!$(!&+E+2$'/!/2&!90(90'(<+9$'(2!*(66@!!B12 helps in odd chain FA
metabolism@!!I8+0+)(0+;!'$!'6!'2M(*M+&!'2!90(90'(2/$+!E+$/L(*'6E;!>8'<8!'6!E+$/L(*'6E!()!
/2!(&&!<8/'2!T%@!!J0(90'(2/$+!)(0E6!E+$84*E/*(24*!.(%;!>8+0+!S,H!<(E+6!'2!/2&!8+*96!
<(2M+0$!E+$84*E/*(24*!.(%!$(!6#<<'24*!.(%;!>8'<8!</2!=(!'2$(!$8+!I.%!<4<*+@!!12!S,H!&+);!
<+0$/'2!$8'2=6!>'**!L#'*&!#9;!6#<8!/6!90(90'(2/$+!/2&!E+$84*E/*(24*!.(%@!!K+$84*E/*(24*!.(%!
L+<(E+6!E+$84*E/*(2*4*'<!/<'&;!>8'<8!'6!/!6+26'$'M+!/2&!69+<')'<!$+6$!)(0!S,H!&+)@!!Y(;!>'$8!
S,H!&+);!=+$!/!E+$84*E/*(2*4*'<!/<'&!$+6$!?>8'<8!>'**!L+!'2<0+/6+&B@!R+/6(2!)(0!2+#0(*(='</*!
90(L*+E6!'6!LZ<!90(90'(2/$+!E+$/L(*'6EU!>'$8(#$!S,H;!</22($!<(2M+0$!(&&!<8/'2!T%Q6!'2$(!
6#<<'24*!.(%;!/2&!$8+4!L#'*&!#9;!/2&!'$!6<0+>6!#9!E4+*'2!?</22($!642!E4+*'2B!7!/2&!*+/&6!$(!
&+E4+*'2/$'(2!()!9(6$+0'(0!<(*#E26;!/2&!()!$8+!*/$+0/*!<(0$'<(69'2/*!$0/<$;!/*(2=!>'$8!
&+E+2$'/@!!SZ<!'$!'6!/!9(6$+0'(0!<(*#E2!&c;!4(#!>'**!8/M+!90(L6!>'$8!90(90'(<+9$'(2;!M'L0/$'(2U!
LZ<!4(#!F2(<F!())!$8+!*/$+0/*!<(0$'</*!69'2/*!$0/<$;!4(#!>'**!=+$!\K"!*+6'(26!?69/6$'<'$4;!
L/L'26F'B;!/2&!$8+2!&+E+2$'/@!!!
!
g'**!/*>/46!$+**!4(#!$8/$!4(#!</2!8/M+!S,H!&+);!/2&!<(00+<$!$8+!/2+E'/!>'$8!8'=8!&(6+6!()!
)(*/$+;!L#$!</22($!<(00+<$!$8+!2+#0(*(='<!&c@!!I8+0+)(0+;!E#6$!E/F+!$8+!69+<')'<!&:@!SZ<!')!
4(#!$8'2F!'$6!)(*/$+!&+)!/2&!='M+!)(*/$+;!4(#!>'**!<(00+<$!$8+!8+E/$(*(='<!90(L*+E;!L#$!2($!$8+!
2+#0(*(='</*!90(L*+E;!$8+0+)(0+!8/M+!S,H!&+)@!!Y(;!'2!differential of dementia;!'2<*#&+!
S,H!&+)!?/*(2=!>'$8!%*c8+'E+0Q6B@!!b(#!&(2Q$!8/M+!$(!8/M+!/2+E'/!>'$8!S,H;!L#$!</2!8/M+!
2+#0(*(='</*!90(L6@!!Y(;!>'$8!&+E+2$'/;!=+$!/!IYN!*+M+*!?$(!$80(>!(#$!849($840('&'6EB;!/2&!/!
S,H!*+M+*!$(!0#*+!(#$!S,H!&+)!LZ<!$8+6+!/0+!R[k[RY1SX[!</#6+6!()!&+E+2$'/@!
79

!
J#0+!M+=/2!M6@!(M(d*/<$(M+=/2-!12!(M(d*/<$(M+=/2!$/F'2=!&/'04!90(&#<$6!?>8'<8!/0+!/2'E/*!
90(&#<$6B;!$8+0+)(0+;!&(!2($!8/M+!$(!$/F+!S,H!6#99*+E+2$6@!!N(>+M+0;!/!9#0+!M+=/2!&(+6!
8/M+!$(!$/F+!S,H!6#99*+E+2$6@!!!
!
H@!!"(0E/*!6+D#+2<+!()!S,H!/L6(09$'(2-!!N/M+!$(!+/$!E+/$6!(0!&/'04!90(&#<$6!$(!=+$!S,H@!!
I8+!)'06$!$8'2=!S,H!&(+6!'6!L'2&6!$(!R!)/<$(0!'2!6/*'M/@!!R!)/<$(0!90($+<$6!S,H!)0(E!&+6$0#<$'(2!
L4!/<'&!'2!$8+!6$(E/<8@!!12$0'26'<!)/<$(0!?1TB!E/&+!L4!9/0'+$/*!<+**6!'2!$8+!L(&4!)#2&#6U!$8+4!
/*6(!E/F+!/<'&@!!1T!'6!2($!&+6$0(4+&!L4!/<'&;!$8+0+)(0+!&(+6!2($!2++&!/24$8'2=!$(!90($+<$!'$@!!
Y(!$8+!S,HZR!)/<$(0!<(E9*+:!=(+6!'2$(!$8+!&#(&+2#E;!>8+0+!$8+0+!'6!1T!>/'$'2=!)(0!'$@!!R!
)/<$(0!E#6$!L+!<*+/M+&!());!>8'<8!'6!&(2+!>'$8!+2c4E+6!)0(E!$8+!)#2<$'(2'2=!9/2<0+/6@!
I8+2;!1T!/2&!S,H!L'2&!$(!+Z(!/2&!$/F+!/!*(2=!$0'9@!!_(!2($!=(!$(!&#(&+2#E!?T+!<(#2$04B;!&(!
2($!=(!$(!*'=/E+2$#E!()!$0'+$c!'2!$8+!3+3#2#E!?)(*/$+!<(#2$04BU!6(!$8+4!=(!/**!$8+!>/4!$(!$8+!
$+0E'2/*!'*+#E;!>8+0+!$8+0+!/0+!0+<+9$(06!)(0!1T;!/2&!'$!'6!0+/L6(0L+&@!!I8'6!'6!$8+!6/E+!
9*/<+!L'*+!6/*$6!/0+!0+/L6(0L+&;!/2&!$8+!6/E+!9*/<+!$8+!.0(82Q6!&c!8'$6@!!I8+0+)(0+;!'$!'6!)/'0!
$(!6/4!$8/$!>'$8!.0(82Q6!&c;!4(#!/*6(!8/M+!L'*+!6/*$!0+/L6(09$'(2!90(L*+E6!/2&!S,H!&+)@!!!
P@!!./#6+6!()!S,H!&+)'<'+2<4-!!
a) MCC B12 def = pernicious anemiaU!$8'6!'6!/2!/#$('EE#2+!&c!>'$8!&+6$0#<$'(2!()!
$8+!9/0'+$/*!<+**6U!/#$(%LQ6!/$$/<F!$8+!9/0'+$/*!<+**6!/2&!$8+0+!/0+!/#$(%LQ6!/=/'26$!1T!/2&!
&+6$0(46!$8+!9/0'+$/*!<+**6!>8'<8!/0+!*(</$+&!'2!$8+!L(&4!/2&!)#2&#6@!![M+04$8'2=!=+$6!
&+6$0(4+&!*+/&'2=!$(!/2!/$0(98'<!=/6$0'$'6!()!$8+!L(&4!/2&!)#2&#6@!!"(!9/0'+$/*!<+**6!C!2(!
/<'&!C!/<84*(0'&0'/;!/2&!2(!1T@!!%<84*(0'&0'/!'6!/!E/3(0!90+&'69(6'2=!)/<$(0!)(0!=/6$0'<!
/&+2(</0<'2(E/@!
!
LB!./#6+6!()!S,H!&+)-!!9#0+!M+=/2U!<80(2'<!9/2<0+/$'$'6!6++2!'2!/*<(8(*'<6!?$8'6!*+/&6!$(!
S,H!&+)!LZ<!</2Q$!<*+/M+!())!$8+!R!)/<$(0BU!_@!*/$#E!?)'68!$/9+>(0E!$8/$!+/$6!S,H!?0/0+6$B!
7!)0(E!)'68!'2!*/F+!$0(#$!'2!*/F+6!()!.8'</=(BU!$+0E'2/*!'*+#E!&c!?.0(82Q6B@!!%2&!L/<$+0'/*!
(M+0=0(>$8!&#+!$(!9+0'6$/*6'6!90(L!/2&Z(0!&'M+0$'<#*/0!9(#<8+6!/2&Z(0!6$/6'6@!!g8+2+M+0!
$8+0+!'6!6$/6'6!4(#Q**!=+$!L/<$+0'/*!'2)+<$'(2!?/*6(!L*/&&+0!'2)+<$'(2BU!L/<$+0'/!*(M+!S,H!/2&!
L'*+!6/*$6!>'$8!L/<$+0'/*!(M+0=0(>$8@!!%**!()!$8+6+!>'**!*+/&!$(!S,H!&+)'<'+2<4@!
!
B. Folate
T(*/$+!'6!6++2!'2!/2'E/*!/2&!9*/2$!90(&#<$6;!$8+0+)(0+!2($!6++2!'2!M+=/26@!!T(*/$+!8/6!E/24!
98/0E!$'+6!?'+!&'84&0()(*/$+!0+&#<$/6+B@!!g8+2!4(#!+/$!)(*/$+;!'$Q6!'2!/!9(*4=*#$/E/$+!)(0E;!
E+/2'2=!4(#!</22($!0+/L6(0L!'$!'2!$8+!3+3#2#EU!$8+0+)(0+!'$!8/6!$(!L+!<(2M+0$+&!$(!/!
E(2(=*#$/E/$+!)(0E@!!12$+6$'2/*!<(23#=/6+!?'2!$8+!6E/**!'2$+6$'2+B!'6!0+69(26'L*+!)(0!$8'6@!!
What drug blocks intestinal conjugase? Phenytoin. Y(;!')!$8+4!/6F!/L(#$!9$!(2!
J8+24$('2;!>'$8!E/<0(<4$'<!/2+E'/;!849+06+=E+2$+&!2+#$0(98'*6;!2+#0(*(='</*!+))+<$6!/0+!
"GI!90+6+2$!7!$8+0+)(0+!)(*/$+!&+)!?LZ<!$8+0+!/0+!2(!2+#0(*(='</*!90(L*+E6;!$8'6!0Z(!L,H!
&+)@B!!"(>!4(#!8/M+!E(2(=*#$/E/$+;!>8'<8!'6!/L6(0L+&!'2!$8+!3+3#2#E@!!I8+0+!/0+!H!$8'2=6!
$8/$!'28'L'$!'$6!/L6(09$'(2-!?,B!L'0$8!<(2$0(*!/2&!?HB!/*<(8(*!(MCC folate def =
alcoholism)@!!g'$8!S,H;!8/M+!adr!4+/0!6#99*4!'2!*'M+0;!$8+0+)(0+!'$6!#2<(EE(2!$(!=+$@!!
T(*/$+!(2*4!8/6!Pd^!E(2$8!6#99*4!7!6(;!+M+2!')!4(#!8/M+!/2!+:<+**+2$!&'+$;!4(#!</2!8/M+!
)(*/$+!&+)!')!4(#!/0+!$/F'2=!(2+!()!$8+6+!$>(!$8'2=6@!!!
!
Y#EE/04-!<'0<#*/$'2=!)(0E!()!)(*/$+!'6!E+$84*$+$0/84&0()(*/$+;!/2&!S,H!$/F+6!$8+!)(*/$+!());!/2&!
='M+6!'$!$(!8(E(<46$+'2+!>8'<8!L+<(E+6!E+$8'(2'2+U!$8+!E+$84*$+$0/84&0()(*/$+!L+<(E+6!
$+$0/84&0()(*/$+;!/2&!>'$8!$8+!8+*9!()!&'84&0()(*/$+!0+&#<$/6+;!_"%!'6!E/&+@!!!
80

!
[:/E9*+-!!9'<!>'$8!849+06+=E+2$+&!2+#$0(98'*!?&+)'2'$'(2-!e!(0!E(0+!*(L+6mB@!!N49+06+=E+2$+&!
2+#$0(98'*!'2&'</$+6!S,H!(0!)(*/$+!&+);!+M+2!')!4(#!&(2Q$!8/M+!/2+E'/@!!1$!'6!$8+!)'06$!$8'2=!$8/$!
<(E+6!#9!L+)(0+!/2+E'/@!%2&!')!$8+!2+#0(*(='</*!$+6$!'6!2(0E/*;!'$Q6!/!)(*/$+!&+)@!!I+6$!)(0!
90(90'(<+9$'(2-!R8(EL+0=!$+6$!7!')!4(#!8/M+!9(6$!<(*#E2!&c;!90(L!>'$8!90(90'(<+9$'(2!LZ<!&(!
2($!F2(>!>8+0+!4(#0!3('2$6!/0+U!&(+6!2($!68(>!<+0+L+**/0!/$/:'/!?>'**!8/M+!$8+6+!>'$8!+4+6!
(9+2+&!%"_!<*(6+&B@!!!\6+!M'L0/$'2=!$#2'2=!)(0F!$(!6++!')!9$!8/6!90(90'(<+9$'(2!(2!$8+!E/**+(#6@!
!
N+E/$(9(+$'<!<+**6!/0+!E/&+!(#$6'&+!$8+!6'2#6('&6!'2!$8+!SK@!1$Q6!/2/*(=(#6!$(!$8+!<(0&6!()!
L'*0($8!'2!$8+!69*++2!?>8+0+!$8+0+!/0+!)':+&!E/<0(98/=+6!/2&!$8+2;!$8+!RS.Q6!/2&!gS.Q6!8/M+!
$(!=+$!L/<F!'2$(!$8+!6'2#6('&6!/2&!<'0<#*/$+!$80(#=8!8(*+6@!!I8+4!=+$!$80(#=8;!/2&!/0+!'2!
6'2#6('&6B@!!I8+!6/E+!$8'2=!(<<#06!'2!$8+!SK!7!$8+4!8/M+!/!9*/<+!+D#'M/*+2$!$(!$8+!<(0&6!()!
L'*0($8!/2&!$8/$!'6!>8+0+!$8+4!/0+!E/&+@!!I(!=+$!'2$(!$8+!<'0<#*/$'(26;!$8+4!8/M+!$(!)'$!$80(#=8!*'*;!
2/00(>!8(*+6!$(!=+$!'2$(!$8+!6'2#6('&6!'2!$8+!SK!/2&!'2$(!$8+!L*((&!6$0+/E@!Y(E+$8'2=!M+04!L'=!
>'**!2($!L+!/L*+!$(!=+$!$80(#=8!$8+!*'*!8(*+6!/2&!'2$(!$8+!6'2#6('&6@!!I8+0+)(0+;!E/<0(98/=+6!>'**!
>/2$!$(!)+/6$!(2!$8+!E/<0(<4$'<!<+**6!?gS.Q6;!RS.Q6;!9*/$+*+$6B!$8/$!</22($!=+$!'2$(!$8+!
6'2#6('&6@!!Y(;!$8+!E/<0(98/=+6!F'**!$8+E!/**@!Y(!'2!$8+!9+0'98+0/*!L*((&;!>'**!6++!"GIN1"l!7!
9/2<4$(9+2'/U!6+M+0+!E/<0(<4$'<!/2+E'/;!2+#$0(9+2'/;!$80(EL(<4$(9+2'/!7!>8'<8!'6!
<8/0/<$+0'6$'<!()!S,H!Z)(*/$+!&+)@!?+M+04$8'2=!'2!$8+!E/00(>!'6!$((!L'=!/2&!</22($!=+$!(#$!'2$(!$8+!
<'0<#*/$'(2B@!!!
!
Schillings test!7!=((&!$+6$!)(0!*(</*'c'2=!S,H!&+)@!!g+!F2(>!2(>!$8/$!'$Q6!/!S,H!&+)'<'+2<4;!/2&!
>+!>/2$!$(!F2(>!>8/$!</#6+&!'$@!!Y$+96!)(0!6<8'**'2=!$+6$-!l'M+!0/&'(/<$'M+!S,H!L4!E(#$8U!$8+4!
$8+2!<(**+<$!$8+!H^!80!#0'2+!$(!6++!')!/24!<(E+6!(#$!'2!$8+!#0'2+!/2&!2($8'2=!<(E+6!(#$;!
$8+0+)(0+!90(M+!$8/$!$8+4!8/M+!/!90(L*+E!/L6(0L'2=!S,H@!!!
!
,6$!6$+9-!='M+!0/&'(/<$'M+!S,H!/2&!1T;!<(**+<$!#0'2+!)(0!H^!806;!/2&!9'*+6!'2!$8+!#0'2+!C!
J+02'<'(#6!/2+E'/U!LZ<!/&&+&!>8/$!>/6!E'66'2=!?1TBU!')!'$!&'&2Q$!>(0F;!4(#!</2![h.X\_[!
9+02'<'(#6!/2+E'/@!!!
!
Y/4!$8'6!&'&2Q$!>(0F;!$8+2!4(#-!
!
H2&!6$+9-!='M+!,V!&/46!>(0$8!()!L0(/&!69+<$0#E!/2$'L'($'<U!9$!<(E+6!L/<F!/2&!/=/'2!4(#!='M+!
$8+E!0/&'(/<$'M+!S,HU!6++!9'*+6!()!0/&'(/<$'M+!S,H!'2!$8+!#0'2+;!>8/$!'6!&:n!S/<$+0'/*!
(M+0=0(>$8!LZ<!F2(<F+&!())!$8+!L#=6!+/$'2=!S,H!
!
Y/4!$8'6!&'&2Q$!>(0F;!$8+2!4(#-!
!
P0&!6$+9-!9/2<0+/$'<!+:$0/<$;!6>/**(>!9'**6;!$8+2!='M+!0/&'(/<$'M+!S,HU!H^!806!*/$+0;!6++!>8/$!
8/99+26U!')!$8+0+!'6!0/&'(/<$'M'$4!'2!#0'2+;!9$!8/6!<80(2'<!9/2<0+/$'$'6@!
!
1)!$8/$!&'&2Q$!>(0F;!<(#*&!L+!.0(82Q6;!>(0E;!+$<@!!!
!
Y#EE/04-!!
1)!S,H!E/*/L6(09$'(2!>/6!<(00+<$+&!L4!/&&'2=!1T;!9$!8/6!9+02'<'(#6!/2+E'/!
1)!S,H!<(00+<$+&!L4!/&&'2=!/2!/2$'L'($'<;!9$!8/6!L/<$+0'/*!(M+0=0(>$8!
1)!S,H!'6!<(00+<$+&!L4!/&&'2=!9/2<0+/$'<!+:$0/<$;!9$!8/6!<80(2'<!9/2<0+/$'$'6@!
!
81

IX. Normocytic anemias
g8+2!4(#!&(!$8+!<(00+<$'(26!)(0!$8+!/2+E'/!/2&!*((F!)(0!9(*4<80(E/6'/U!')!<(00+<$'(2!'6!*+66!
$8/2!HW;!'$!'6!/!L/&!0+69(26+!?SK!2($!0+69(2&'2=!<(00+<$*4B@!!T'06$!$>(!$8'2=6!4(#!6++-!+/0*4!1_%!
/2&!%._c!7!0+E+EL+0!$8/$!4(#!8/M+!$(!8/M+!/!2(0E(<4$'<!/2+E'/!)'06$!$(!L+<(E+!E'<0(<4$'<@!!
_(+62Q$!(<<#0!(M+02'=8$@!!I8+0+)(0+;!>'$8!/!&+<0+/6+&!0+$!<$!?'+!*+66!$8/2!HWB;!E#6$!'2<*#&+!
E'<0(<4$'<!/2+E'/Q6!'2!$8+!&'))+0+2$'/*;!/2&!4(#!2++&!$(!=+$!/!)+00'$'2!*+M+*@!!!
!
1_%!=(+6!$80(#=8!&'))!6$/=+6-!)'06$!$8'2=!$8/$!8/99+26!7!&+<0+/6+&!)+00'$'2;!$8+2!T+!&+<0+/6+6;!
I1S.!'2<0+/6+&;!W!6/$!&+<0+/6+;!/2&!6$'**!>(2Q$!8/M+!/2+E'/@!!12!($8+0!>(0&6;!/**!T+!6$#&'+6!/0+!
%S"GRK%X!L+)(0+!4(#!8/M+!/2+E'/@!!I8+2!4(#!=+$!E'*&!2(0E(<4$'<!/2+E'/;!/2&!+M+2$#/**4!
E'<0(<4$'<!/2+E'/@!!!
A. Causes:
,@!!S*((&!*(66!*+66!$8/2!/!>++F!C!2(0E(<4$'<!/2+E'/U!2(!'2<0+/6+!'2!0+$!0+69(26+!LZ<!
2($8'2=!>0(2=!>'$8!$8+!SK;!/2&!2($!+2(#=8!$'E+!?2++&!ed`!&/46!)(0!SK!$(!=+$!0+MQ&!#9B!7!
6(;!/)$+0!(2+!>++F;!>(#*&!=+$!/2!/990(90'/$+!0+69(26+@!!!!!
H@!!%9*/6$'<!/2+E'/!7!2(!E/00(>U!')!$8/$!'6!$0#+;!$8+!9+0'98+0/*!L*((&!>'**!68(>!9/2<4$(9+2'/!
?/**!8+E/$(9(+$'<!<+**6!/0+!&+6$0(4+&!'2!$8+!E/00(>BU!8/M+!2(0E(<4$'<!/2+E'/;!
$80(EL(<4$(9+2'/;!/2&!2+#$0(9+2'/@!
P@!!K.!F2(>2!.!C!&0#=6-!<8*(0/E98+2'</*!7!#6+&!'2!0(<F4!E$2!69($$+&!)+M+0;!'2&(E+$8/<'2;!
98+24*L#$/c(2+;!/2&!$840('&!0+*/$+&!&0#=6!
^@!!H2&!K..!C!'2)+<$'(26!7!+69@!N+9!.!?>'9+6!(#$!+M+04$8'2=BU!/9*/6'/!()!RS.!C!9/0M(M'0#6!!!!!!
e@!!R/&'/$'(2!/2&!E/*'=2/2<4!
a@!![/0*4!1_%!/2&!%._c!?2++&!$(!8/M+!6+0#E!)+00'$'2!*+M+*6B!
`@!!K+<8/2'6E!()!2(0E(<4$'<!/2+E'/!>'$8!*+66!$8+2!HW!0+$!<$!7!0+2/*!)/'*#0+;!/2&!&+<0+/6+&!
[JG!?</2!L+!='M+2!+:(=+2(#6*4B!7!&+<0+/6+&!'2!8+9!S;!.;!/2&!N1k@!!%$8*+$+6!$8/$!]&(9+Q!/0+!
='M+2![JG;!$(!'2<0+/6+!RS.Q6!$(!/**(>!E(0+!GH!&+*'M+04!$(!L(&4!
B. Mechanisms of hemolysis 2 ways to kill an RBC:
"(0E(<4$'<!/2+E'/6!>'$8!<(00+<$'M+!0+$!<$!/L(#$!PW-!
!
,@!![:$0/M/6<#*/0*4!?(#$6'&+!()!$8+!SkB@!!!
I8+4!/0+!F'**+&!L4!E/<0(98/=+6;!#6#/**4!'2!<(0&6!()!L'*0($8!'2!$8+!69*++2;!6(E+$'E+6!'2!*'M+0!
6'2#6('&6@!![M+04!RS.!E#6$!=(!$(!$8+!<(0&6!()!L'*0($8!/!)+>!$'E+6!9+0!&/4!/2&!=+$!+:/E'2+&!
L4!/!E/<0(98/=+!7!')!$8+!<+**!9'<F+&!#9!/2!1=l!(0!.PL;!'$!'6!E/0F+&!)(0!&+6$0#<$'(2!M'/!
98/=(<4$(6'6!LZ<!$8+!E/<0(98/=+!8/6!0+<+9$(06!)(0!1=l!/2&!.PL@!!1)!4(#!&(2Q$!8/M+!1=l!(0!
.PL;!</2!6$'**!&'+!LZ<!$8+!<+**!'6!'2!L/&!68/9+!7/L2(0E/*!68/9+-!'+!698+0+!>'**!2($!L+!/L*+!$(!
)'$!$80(#=8!/!H!E'<0(2!8(*+!$(!=+$!$(!$8+!6'2#6('&6!7!'$!</2Q$!7!$8+0+)(0+;!698+0(<4$+6!/0+!
0+E(M+&!+:$0/M/6<#*/0*4!LZ<!$8+4!</22($!=+$!(#$U!6'<F*+!<+**6!</22($!=+$!(#$!+'$8+0!LZ<!$8+4!
8/M+!/!L/&!68/9+@!!%2($8+0!0+/6(2!)(0!$8+'0!&+6$0#<$'(2!'6!LZ<!$8+4!8/M+!6(E+$8'2=!'26'&+!
$8+E!$8/$!$8+4!68(#*&2Q$!7/!9'+<+!()!2#<*+#6U!>8/$!'6!$8'6!</**+&n!N(>+**!3(**4!L(&4U!
E/<0(98/=+!>'**!=+$!0'&!()!'$@!!!!
I8+0+!/0+!/#$('EE#2+!8+E(*4$'<!/2+E'/6;!/2&!</2!L+!&#+!$(!1=l!(0!.PL!(2!$8+!6#0)/<+!()!
$8+!RS.;!(0!+:$0/M/6<#*/0!8+E(*4$'<!/2+E'/6!'6!>8+0+!4(#!8/M+!/L2(0E/*!68/9+!?'+!698+0+;!
Y'<F*+!<+**!7!>'**!2($!E/F+!'$!(#$!()!$8+!69*++2!LZ<!0+E(M+&!L4!E/<0(98/=+6B@!!!
!
[2&!90(&#<$!()!98/=(<4$(6'2=!/2!RS.-!#2<(23#=/$+&!L'*'0#L'2@!!g8+2!$8+!RS.!'6!L0(F+2!
&(>2;!4(#!8/M+!8+E(=*(L'2;!/2&!$8+0+!'6!/2!+2c4E+!$8/$!69*'$6!8+E+!)0(E!=*(L'2!/2&!$8+!
=*(L'2!'6!L0(F+2!'2$(!//Q6!/2&!$8+0+)(0+!=(+6!$(!$8+!//!9((*@!I8+2;!$/F+6!$8+!8+E+;!69*'$6!'$!
82

(9+2;!/2&!6/M+6!$8+!T+@!"(>!4(#!8/M+!90($(9(09840'2;!/2&!69'$!'$!(#$U!+2&!0+6#*$!'6!
#2<(23#=/$+&!L'*'0#L'2!'2!$8+!E/<0(98/=+!>'$8'2!$8+!69*++2@!!I8+2;!$8+!E/<0(98/=+!69'$6!
(#$!$8+!#2<(23#=/$+&!L'*'0#L'2!'2$(!L*((&!6$0+/E!?>8'<8!'6!'26(*#L*+!LZ<!'$Q6!#2<(23#=/$+&B@!!
I8+!#2<(23#=/$+&!L'*'0#L'2!$8+2!L'2&6!/*L#E'2!/2&!=(+6!$(!$8+!*'M+0!/2&!'6!<(23#=/$+&@!!Y(;!
>8/$!<*'2'</*!)'2&'2=!>'**!4(#!6++!'2!9$6!>'$8!+:$0/M/6<#*/0!8+E(*4$'<!/2+E'/n!f/#2&'<+@!!_(+6!
$8/$!L'*'0#L'2!=+$!'2$(!$8+!#0'2+n!"(@!g84n!H!0+/6(26-!!?,B!X'9'&!6(*#L*+!/2&!?HB!S(#2&!$(!
/*L#E'2!?/*L#E'2!&(+6!2($!=+$!'2$(!$8+!#0'2+B!7!6(!4(#!/0+!3/#2&'<+&;!L#$!&(+62Q$!=+$!'2$(!
$8+!#0'2+!
!
H@!!12$0/M/6<#*/0!?>'$8'2!$8+!SkB!
12$0/M/6<#*/0!'6!*+66!<(EE(2!7!E+/2'2=!$8/$!4(#!&'+!>'$8'2!$8+!Sk@!!N(>!&(+6!$8/$!8/99+2n!
b(#!&'+!>'$8'2!$8+!M+66+*!')!4(#!L#E9!'2$(!6(E+$8'2=@!![:/E9*+-!<(2=+2'$/*!L'<#69'&!/(0$'<!
M/*M+!>'$8!</*<'#E!$8+0+!7!')!4(#!L#E9!'2$(!$8/$;!4(#!>(#*&!&/E/=+!4(#06+*)!/2&!&'+@!!
[:/E9*+-!')!4(#!8/M+!1=K!(2!$8+!6#0)/<+!()!$8+!RS.!?1=K!'6!$8+!E(6$!9($+2$!/<$'M/$(0!()!$8+!
<(E9*+E+2$!646$+EBU!$8'6!>'**!=(!)0(E!,dr;!E+/2'2=!$8/$!'$!>'**!6'$!(2!$8+!RS.;!/<$'M/$+!$8+!
<(E9*+E+2$!/2&!&'+6!'2$0/M/6<#*/0*4U!6(;!/24$8'2=!$8/$!'6!1=K!E+&'/$+&!C!'2$0/M/6<#*/0!
8+E(*46'6@!!Y(;!>8/$!>'**!4(#!0+*+/6+!'2$(!$8+!L*((&6$0+/E!')!4(#!/0+!F'**'2=!$8+!RS.n!NL@!!
_(2Q$!>/2$!$(!*(6+!/**!()!'$!/2&!2++&!$(!0+$0+/$!'$!7!L4!=+$$'2=!L/<F!$8+!//Q6!/2&!0+$0'+M'2=!$8+!
T+@!!Y9+<')'<!90($+'2!$8/$!'6!E/&+!'2!$8+!*'M+0!$8/$!'6!0+*+/6+&!>8+2!$8+0+!'6!'2$0/M/6<#*/0!
8+E(*46'6!7!haptoglobin!?/F/!6#'<'&+!90($+'2!7!LZ<!)(0E6!<(E9*+:!>'$8!NL!/2&!'6!
98/=(<4$(6+&!L4!$8+!E/<0(98/=+B;!$8+0+)(0+!='M'2=!*')+!$(!0+$0'+M+!$8+!NL;!$8+0+)(0+!'2!9$6!
>'$8!'2$0/M/6<#*/0!8+E(*46'6;!$8+!8/9$(=*(L'2!*+M+*6!&+<0+/6+@!!16!'$!9(66'L*+!$(!=+$!3/#2&'<+n!
b+6;!L#$!#6#/**4!&(2Q$!LZ<!E/<0(98/=+!'6!98/=(<4$(6'2=@!!12$0/M/6<#*/0!8+E(*46'6-!
8+E(=*(L'2#0'/;!/2&!*(>!8/9$(=*(L'2!*+M+*6
!
P@!!Y#EE/04-!!
[:$0/M/6<#*/0!C!E/<0(98/=+6!0+E(M+!C!#2<(23!L'*'0#L'2!'6!$8+!+2&!90(&#<$!C!3/#2&'<+!'6!
$8+!<*'2'</*!E/2')+6$/$'(2!
12$0/M/6<#*/0!C!NL!'2!#0'2+;!&+<0+/6+&!8/9$(=*(L'2!
!
83

C. Intrinsic vs. Extrinsic Hemolytic anemia:
,@!!12$0'26'<!7!6(E+$8'2=!>0(2=!>'$8!RS.;!</#6'2=!'$!$(!8+E(*4c+-!6#<8!/6!2(!69+<$0'2;!(0!2($!
&+</4!/<<+*+0/$'2=!)/<$(0!$(!2+#$0/*'c+!<(E9*+E+2$;!2(!laJ_!+2c4E+!'2!9+2$(6+!98(698/$+!
68#2$;!(0!/L2(0E/*!NL!?'+!NLYB@!!I8+0+)(0+;!6(E+$8'2=!>0(2=!'26'&+!$8+!NL!E(*+<#*+;!
</#6'2=!'$!$(!8+E(*4c+@!
!
H@!![:$0'26'<!7!2($8'2=!>0(2=!>'$8!$8+!RS.;!3#6$!/$!$8+!>0(2=!9*/<+!/$!$8+!>0(2=!$'E+U!'+!'$!
3#6$!8/99+2+&!$(!6E/68!'2$(!$8+!</*<')'+&!M/*M+!?2($8'2=!>/6!>0(2=!>'$8!'$;!#2$'*!'$!8'$!$8+!
M/*M+B@!I8+2!'$!>'**!L+!&0+/&'2=!=('2=!$(!$8+!<(0&6!()!L'*0($8!>'$8!&+6$0(4!'$!LZ<!'$!8/6!L++2!
E/0F+&!>'$8!1=l!/2&!.PL!)(0!98/=(<4$(6'6@!
!
D. Something intrinsically wrong with the RBC causing it to hemolyze!L#$!$8+0+Q6!
2($8'2=!>0(2=!>'$8!$8+!SK!?L#$!6(E+$8'2=!'2$0'26'</**4!>0(2=!>'$8!$8+!RS.B;!/2&!$8+!<(00+<$'M+!
0+$!<$!'6!=0+/$+0!$8/2!PW@!!!
MAD!7!K.!'2$0'26'<!90(L6!
M+EL0/2+!&+)+<$!?698+0(<4$(6'6;!9/0(:46E/*!2(<$#02/*!8+E(=*(L'2#0'/B;!AL2(0E/*!NL!
?Y.!$0/'$!_cB;!!
D+)'<'+2<4!()!+2c4E+!?laJ_!&+)B@!!
1.!Membrane Defects:!
(a) Spherocytosis-!&(!2(!6++!/!<+2$0/*!/0+/!()!9/**(0!$8+0+)(0+!E#6$!L+!/!698+0(<4$+!
/2&!E#6$!L+!0+E(M+&!+:$0/M/6<#*/0*4@!!.*'2'</**4!E/2')+6$!>'$8!3/#2&'<+!)0(E!
#2<(23#=/$+&!L'*'0#L'2@!!Y9+<$0'2!&+)+<$!/2&!%_!&cU!69*+2(E+=/*4!/*>/46!6++2!(M+0!/!
9+0'(&!()!$'E+@!!l/**L*/&&+0!?lSB!&c!'6!<(EE(2!LZ<!$8+0+!'6!/!*($!E(0+!#2<(23#=/$+&!
L'*'0#L'2!90+6+2$+&!$(!$8+!*'M+0!/2&!E(0+!<(23#=/$'(2!'6!(<<#00'2=!/2&!E(0+!L'*'0#L'2!'6!'2!
$8+!L'*+!$8/2!#6#/*@!Y(;!>8+2+M+0!4(#!6#9+06/$#0/$+!/24$8'2=!$8/$!'6!/!*'D#'&;!4(#!0#2!$8+!
0'6F!()!)(0E'2=!/!6$(2+U!')!4(#!6#9+06/$#0/$+!#0'2+!>'$8!./;!4(#!0#2!$8+!0'6F!()!=+$$'2=!/!
./!6$(2+U!')!4(#!6#9+06/$#0/$+!L'*+!>'$8!<8(*+6$+0(*;!4(#!>'**!=+$!/!<8(*+6$+0(*!6$(2+U!')!
4(#!6#9+06/$#0/$+!>'$8!L'*'0#L'2;!4(#!>'**!=+$!/!./dL'*'0#L'2/$+!6$(2+@!!I8+0+)(0+;!9$6!8/M+!
lS!&c!0+*/$+&!$(!=/**6$(2+!&c!/2&!$8+2!&(!/!.S.!>'$8!2(0E(<4$'<!/2+E'/!/2&!/!<(00+<$+&!
0+$!<$!$8/$!'6!+*+M/$+&;!/2&!6++!congenital spherocytosis@!!g8/$Q6!$8+!&'/=2(6$'<!$+6$n!
G6E($'<!)0/='*'$4!7!$8+4!9#$!$8+6+!RS.Q6!>/**!$(!>/**!'2!&'))+0+2$!$(2'<'$'+6!()!6/*'2+;!/2&!
$8+!RS.Q6!>'**!9(9!?$8+0+)(0+!8/M+!/2!'2<0+/6+&!(6E($'<!)0/='*'$4B@!!!
R:-!!69*+2+<$(E4!?2++&!$(!0+E(M+!(0=/2!$8/$!'6!0+E(M'2=!$8+E!7!$8+4!>'**!6$'**!L+!
698+0(<4$+6!/2&!>'**!2($!L+!/L*+!$(!)(0E!/!L'<(2</M+!&'6FB@!!
!
(b) Paroxysmal Nocturnal Hemoglobinuria!C!&+)+<$!'2!&+</4!/<<+*+0/$'2=!)/<$(0@!!
Y(!>8+2!>+!6*++9;!>+!8/M+!/!E'*&!0+69!/<'&(6'6!LZ<!>+!L0+/$8+!6*(>*4!?')!4(#!8/M+!
(L6$0#<$'M+!6*++9!/92+/;!$8+!/<'&(6'6!'6!>(06+B@!g8+2!4(#!8/M+!/<'&(6'6!$8/$!90+&'69(6+6!
$8+!<(E9*+E+2$!$8/$Q6!6'$$'2=!(2!%XX!<+**6!<'0<#*/$'2=!'2!9+0'98+0/*!L*((&@!!RS.6;!gS.6;!
/2&!9*/$+*+$6!/**!8/M+!<(E9*+E+2$!6'$$'2=!(2!'$@!!I8+0+!'6!2(!<(E9*+E+2$!&+6$0#<$'(2!()!
$8+6+!<+**6!LZ<!'2!(#0!E+EL0/2+6!>+!8/M+!&+*/4!/<<+*+0/$'2=!)/<$(0@!!I8'6!)/<$(0!</#6+6!
'2<0+/6+&!&+=0/&/$'(2!()!$8+!<(E9*+E+2$!6(!'$!&(+62Q$!8/M+!/2!(99!$(!&0'**!/!8(*+!'2!(#0!
E+EL0/2+;!$8+0+)(0+!>+!&(2Q$!>/F+!#9!'2!$8+!E(02'2=!>'$8!8+E(=*(L'2#0'/;!2+#$0(9+2'/!
/2&!$80(EL(<4$(9+2'/@!!Y(;!')!4(#!/0+!E'66'2=!&+</4!/<<+*+0/$'2=!)/<$(0;!$8+!<(E9*+E+2$!
>'**!L+!/<$'M/$+&!/2&!=(+6!)0(E!.,dr;!*+/&'2=!$(!'2$0/M/6<#*/0!8+E(*46'6@!!I8'2F!/L(#$!
$8+!2/E+!?9/0(:46E/*!2(<$#02/*!8+E(=*(L'2#0'/B-!(<<#06!/$!2'=8$;!/2&!>8+2!4(#!>/F+!
#9!'2!$8+!E(02'2=;!4(#!9++!(#$!8+E(=*(L'2@!!Y(;!>8+2!4(#!&(!/!.S.;!2($!(2*4!8/M+!/!
6+M+0+!/2+E'/;!L#$!/*6(!/!2+#$0(9+2'/!/2&!/!$80(EL(<4$(9+2'/-!9/2<4$(9+2'/B@!
84

!
2. Abnormal Hb: Sickle Cell Trait/Dz!
g'$8!6'<F*+!<+**!$0/'$;!$8+0+!'6!"G!/2+E'/!/2&!"G!6'<F*+&!<+**6!'2!$8+!9+0'98+0/*!L*((&@!!
b(#!</2!8/M+!6'<F*+&!<+**6!'2!/!<+0$/'2!9/0$!()!4(#0!L(&4!7!'2!$8+!0+2/*!E+&#**/!>'$8'2!$8+!
9+0'$#L#*/0!</9'**/0'+6!?&+<0+/6+&!GH!$+26'(2B;!L#$!2($!'2!$8+!9+0'98+0/*!L*((&@!!I8'6!'6!LZ<!
'2!Y._c;!$8+!/E(#2$!()!6'<F*+&!NL!'2!$8+!RS.!&+$+0E'2+6!>8+$8+0!'$!6'<F*+6!(0!2($@!!
Magic # = 60%U!')!4(#!8/M+!aVW!(0!E(0+;!NLY!</2!69(2$/2+(#6*4!6'<F*+@!!G:4=+2!
$+26'(2!'2!$8+!L*((&!/*6(!&+$+0E'2+6!>8+$8+0!/!<+**!>'**!6'<F*+!(0!2($@!!%$!*(>+0!GH!
$+26'(26;!<+**6!/0+!E(0+!*'F+*4!$(!6'<F*+@!I8'6!'6!/2!/#$(!0+<!&c;!E+/2'2=!$8/$!L($8!9/0+2$6!
E#6$!8/M+!/L2(0E/*!=+2+!(2!$8+'0!<Q6(E+!?6(!'$6!H!$0/'$6BU!$8+0+)(0+;!HeW!<(E9*+$+!
2(0E/*;!eVW!8+$+0(c4=(#6!/64E9$(E/$'<!</00'+0;!HeW!<(E9*+$+!&c!?6/E+!>'$8!<46$'<!
)'L0(6'6B@!
!
SC Trait vs. SCDz:!
?/B!!12!sickle cell trait;!L*/<F!'2&'M'&#/*!>'$8!2(0E/*!J[!/2&!2(0E/*!.S.;!L#$!
E'<0(6<(9'<!8+E/$#0'/;!$8+!)'06$!6$+9!'6!6'<F*+!<+**!6<0++2!LZ<!E'<0(6<(9'<!8+E/$#0'/!'6!
%Xg%bY!/L2(0E/*!/2&!E#6$!L+!>(0F+&!#9!L#$!'2!L*/<F6!C!,Zt!9+(9*+!8/M+!$8+!$0/'$@!!
Y(;!Y.!$0/'$!'6!>8/$!4(#!/0+!$8'2F'2=!()U!2($!0+2/*!6$(2+6;!(0!1=%!=*(E+0#*(2+980'$'6;!
L#$!'6!Y.!$0/'$!2(0E/**4@!
!
?LB!!SCDz!7!H!$8'2=6!/0+!8/99+2'2=-!!N+E(*4$'<!/2+E'/!?#6#/**4!+:$0/M/6<#*/0B!7!</2!
L+!M+04!6+M+0+!/2&!<(EE(2*4!0+D#'0+6!/!$0/26)#6'(2!/2&!G<<*#6'(2!()!6E/**!SkQ6!L4!
$8+!6'<F*+&!<+**6!?L*(<F/=+!()!<'0<#*/$'(2B!7!*+/&!$(!M/6((<*#6'M+!<0'6'6;!/2&!$8'6!
'6<8+E'/!*+/&6!$(!9/'2@!!I8+0+)(0+;!$8+4!/0+!9/'2)#*!<0'6'6!?(<<#0!/24>8+0+!'2!$8+!
L(&4!7!*#2=6;!*'M+0;!69*++2;!SK;!8/2&6Z)++$!?L/<$#*'$'6BB@!!GM+0!$'E+;!'$!*+/&6!$(!
&/E/=+!()!(0=/26!7!F'&2+46;!69*++2!/#$('2)/0<$+&!?/#$(69*+2+<$(E4B!7!'2!)'06$!,V!
4+/06!()!*')+;!9$!>'**!8/M+!69*+2(E+=/*4!LZ<!$0/99+&!RS.Q6;!/2&!+M+2$#/**4!
/#$(69*+2+<$(E4!/0(#2&!/=+!,r!?69*++2!>'**!L+!$8+!6'c+!()!/!$8#ELB@!!%)$+0!H!4+/06;!'$!
'6!2(2)#2<$'(2/*!7!6(!+M+2!$8(#=8!4(#!8/M+!/!L'=Z6>(**+2!69*++2;!'$!'62Q$!>(0F'2=@!!
N(>!>'**!4(#!F2(>!>8/$!$8/$!8/6!8/99+2+&n!N(>+**!f(**4!L(&4!?RS.!>'$8!/!9'+<+!()!
2#<*+#6!$8/$!68(#*&!2($!L+!'2!$8+!69*++2!7!')!$8+!69*++2!>+0+!>(0F'2=;!/!)':+&!
E/<0(98/=+!>(#*&!8/M+!$/F+2!</0+!()!'$B@!!I8'6!(<<#06!/$!/L(#$!H!406!()!/=+@!!I8'6!'6!
)(0$#2/$+!LZ<!$8'6!'6!/L(#$!$8+!/=+!>8+0+!4(#!</2!=+$!92+#E(M/:@!!g'$8!/!
2(2)#2<$'(2/*!69*++2!>8/$!'2)+<$'(2!'6!=#/0/2$++&n!Y$0+9!92+#E(2'/+!6+96'6@!
MCC death in child with SCDz = strep pneumoniae sepsis@!
I8+4!$04!$(!<(M+0!>'$8!/2$'L'($'<6!/2&!92+#E(M/:!7!92+#E(M/:!</2!L+!='M+2!/$!$8+!
/=+!()!H!/2&!$8/$Q6!/L(#$!$8+!$'E+!>8+2!$8+!69*++2!6$(96!>(0F'2=!?6$/0$!$(!6++!
N(>+**!3(**4!L(&'+6B@!!Y*'&+!>'$8!N(>+**!3(**4!L(&4!/2&!6*'&+!>'$8!6'<F*+&!<+**6;!$8+2!>'**!
/6F;!>8/$Q6!>0(2=!>'$8!$8+!69*++2n!1$Q6!&46)#2<$'(2/*U!N(>+**!3(**4!>(#*&!8/M+!L++2!
0+E(M+&!')!$8+!69*++2!'6!)#2<$'(2/*@!!!
!
g8+2!&(!$8+4!=+$!$8+'0!)'06$!6'<F*+!<+**!<0'6'6n!g8+2!*'$$*+!F'&6!=+$6!9/'2)#*!8/2&6;!/2&!
/0+!6>(**+2!#9!?</**+&!L/<$#*'$'6B!7!&(+6!2($!(<<#0!/$!L'0$8;!LZ<!NLT!'28'L'$6!6'<F*'2=!
/2&!2+>L(026!'2!2+>L(026;!`VdtVW!()!$8+'0!RS.Q6!/0+!NLT@!!12!Y._c;!aVd`VW!RS.Q6!
8/M+!NLT;!>8'*+!$8+!0+6$!/0+!NLYm!
%$!$8'6!6$/=+;!$8+0+!'6!+2(#=8!NLT!$(!'28'L'$!$8+!6'<F*'2=U!8(>+M+0;!/6!$8+!RS.Q6!/0+!
L0(F+2!&(>2!/2&!0+9*/<+&;!$8+!NLT!&+<0+/6+6!/2&!NLY!'2<0+/6+6;!/2&!L4!adr!
E(2$86!()!/=+;!$8+0+!'6!/!8'=8!+2(#=8!<(2<+2$0/$'(2!$(!'2&#<+!6'<F*'2=!/2&!$8+'0!)'06$!
85

M/6((<*#6'M+!<0'6'6;!90(&#<'2=!L/<$#*'$'6@!!Y(;!L/<$#*'$'6!&(+62Q$!<(E+!#2$'*!adr!E(2$86!
LZ<!NLT!'28'L'$6!$8+!6'<F*'2=@!!!
S(2+!'2)/0<$'(26!(<<#0!)0(E!6'<F*'2=!$8+!SK@!!!
G6$+(E4+*'$'6!7!$8+6+!9$6!/0+!6#6<+9$'L*+!$(!(6$+(E4+*'$'6!)0(E!6/*E(2+**/!&#+!$(!/!
&46)#2<$'(2/*!69*++2@!!Y/*E(2+**/!'6!&+6$0(4+&!L4!E/<0(98/=+6@!!I8+!69*++2!2(0E/**4!
)'*$+06!(#$!6/*E(2+**/;!L#$!'6!&46)#2<$'(2/*@!!K..!(6$+(E4+*'$'6!'6!6$/98;!L#$!K..!'2!
Y._c!9$!C!6/*E(2+**/@!!!
!
g8/$!&0#=!'6!#6+&!$(!&+<0+/6+!$8+!'2<'&+2<+!()!M/6((<*#6'M+!<0'6+6n!N4&0(:4#0+/@!!
N(>!&(+6!'$!>(0Fn!1$!'2<0+/6+6!NLT!642$8+6'6@!!!
3. Deficiency of enzyme: G6PD deficiency
laJ_!&+)!'6!hd*'2F+&!0+<+66'M+@!!!
!
K(6$!+2c4E+!&+)Q6!/0+!/#$(!0+<+66'M+!'+!J5\;!/*L'2'6E;!8(E(<46$'2#0'/B@!!g8/$!/0+!$8+!
$>(!hd*'2F+&!0+<+66'M+!+2c4E+!&+)Q6n!laJ_!&+)!/2&!X+6<8d"48/2!642&0(E+!?'2M(*M+6!
9#0'2+!E+$/L(*'6E!>'$8!E+2$/*!0+$/0&/$'(2;!6+*)!E#$'*/$'(2;!'2<0+/6+&!#0'<!/<'&;!&+)!()!
NlJRIB@!!
!
l*#<(6+!a!98(698/$+!8/6!6+M+0/*!)#2<$'(26-!?,B!$(!E/F+!=*#$/$8'(2+;!?HB!$(!E/F+!0'L(6+!
e!</0L(2!6#=/06!)(0!E/F'2=!_"%;!/2&!?PB!$(!E/F+!=*4<(=+2!)0(E!laJ!?<(2M+0$+&!$(!l,J;!
\_Jd=*#<(6+!/2&!=*4<(=+2B@!!!
!
5+4-!>'$8!$8'6!+2c4E+;!>+!</2!E/F+!"%_JN;!>8'<8!'6!$8+!E/'2!)/<$(0!)(0!E/F'2=!
/2/L(*'<!$49+6!()!L'(<8+E'</*!0:2!?'+!6$+0('&!642$8+6'6B@!!"%_JN!>'**!0+&#<+!(:'&'c+&!
=*#$/$8'(2+!$(!=*#$/$8'(2+U!'$6!3(L!'6!$(!2+#$0/*'c+!9+0(:'&+!$(!>/$+0@!!g8'<8!M'$/E'2!
</$/*4c+6!$8'6!0:2n!R'L()*/M'2@!!g8'<8!+2c4E+!8+*96!=*#$/$8'(2+!2+#$0/*'c+!9+0(:'&+n!
l*#$/$8'(2+!9+0(:'&/6+@!!g8'<8!$0/<+!E+$/*!'6!'2M(*M+&n!Y+*+2'#E@!![M+04!*'M'2=!<+**!
E/F+6!9+0(:'&+!/6!/2!+2&!90(&#<$;!$8+0+)(0+!+M+04!<+**!E#6$!/!>/4!$(!8/2&*+!'$@!!
./$/*/6+!7!90+6+2$!'2!/**!<+**6!+:<+9$!RS.Q6!/2&!'$!</2!2+#$0/*'c+!9+0(:'&+@!!1$!'6!6$(0+&!'2!
9+0(:'6(E+6@!!G$8+0!>/4!$(!2+#$0/*'c+!9+0(:'&+!'6!>'$8!=*#$/$8'(2+!?(2*4!$8'2=!/M/'*/L*+!
$(!RS.Q6!LZ<!$8+4!&(2Q$!8/M+!</$/*/6+B@!!Y(;!')!4(#!/0+!&+)'<'+2$!'2!$8'6!+2c4E+;!$8+0+!'6!/!
90(L*+E@!!Y(;!9+0(:'&+!'2<0+/6+6!$(!$8+!9('2$!()!8+E(*4c'2=!RS.Q6!>84!>(#*&!$8/$!(<<#0n!
SZ<!')!4(#!8/&!/2!12)+<$'(2;!(0!')!4(#!$((F!/2!(:'&'c'2=!&0#=!?'+!6#*)/!&0#=;!2'$04*!&0#=B;!
>8'<8!>'**!*+/&!$(!/!*($!E(0+!9+0(:'&+!*4'2=!/0(#2&@!!J+0(:'&+!>'**!2($!L+!/L*+!$(!L+!
2+#$0/*'c+&!')!4(#!/0+!&+)'<'+2$!'2!</$/*/6+@!!Y(;!>8/$!>'**!8/99+2!'6!$8+!9+0(:'&+!>'**!
/))+<$!$8+!NL@!I8+!9+0(:'&+!>'**!</#6+!$8+!NL!$(!<*#E9!/2&!)(0E!N+'2c!L(&'+6!?NL!
<*#E9+&!#9!$(=+$8+0B@!!!g'**!/*6(!/))+<$!$8+!RS.!E+EL0/2+!LZ<!'$!&/E/=+6!$8+!
E+EL0/2+!6(!E#<8!$8/$!$8+!90'E/04!E+<8/2'6E!()!&+6$0#<$'(2!'6!'2$0/M/6<#*/0@!!X'$$*+!
+*+E+2$!'6!+:$0/M/6<#*/0;!L#$!E(6$*4!'2$0/M/6<#*/0@!!1$!'6!90+<'9'$/$+&!L4!'2)+<$'(26!/2&Z(0!
&0#=6@!!2 MC drugs: 1) primaquine7!E'66'(2/04!=($!E/*/0'/;!0+<+'M+&!/!&0#=;!/2&!HdP!
&/46!*/$+0!$8+!=($!8+E(=*(L'2#0'/;!<8'**6;!/2&!/!8+E(*4$'<!/2+E'/!?$8'6!'6!90'E/D#'2+!
'2&#<+&!8+E(*46'6B@!!2) Dapsone!'6!#6+&!'2!$0+/$'2=!*+90(64U!+M+04!9+06(2!>'$8!*+90(64!
'6!='M+2!/!6<0++2!)(0!laJ_!&+)!LZ<!()!$8+!8'=8!'2<'&+2<+!()!90(&#<'2=!8+E(*46'6@!!Y++!$8'6!
&c!'2!$8+!6/E+!9(9#*/$'(2!/6!S+$/!$8/*!7!L*/<F6;!l0++F6;!1$/*'/26@!!Y*'&+-!6E+/0!>'$8!
/<$'M+*4!8+E(*4c'2=!L*((&!<+**6!7!Heinz bodies!7!>8+2!'$!=(+6!'2$(!$8+!<(0&6!()!L'*0($8;!
$8+!E/<0(98/=+!>'**!$/F+!/!L'=!L'$+!(#$!()!'$!/2&!6(E+$'E+6;!'6!/!6E/**!L'$+!(#$!()!$8+!
E+EL0/2+;!/2&!$8+!<+**!=(+6!$(!$8+!9+0'98+0/*!<'0<#*/$'(2!/2&!'6!</**+&!/!ibite cell
?RS.!>'$8!*'$$*+!E+EL0/2+B@!!"++&!$(!&(!69+<'/*!6$/'26!$(!1_!N+'2c!L(&'+6@!!12!l0++F6!(0!
86

1$/*'/26!>'$8!6+M+0+!)(0E6!()!laJ_!&+);!$8+4!</2!+/$!)/M/!L+/26!>8'<8!</2!90+<'9'$/$+!/2!
+9'6(&+!?/F/!)/M'6EB@!
Dx!7!>8+2!4(#!8/M+!/2!/<#$+!8+E(*4$'<!+9'6(&+;!$8+!*/6$!$8'2=!4(#!>/2$!$(!=+$!/!
&'/=2(6'6!'6!$(!=+$!/2!+2c4E+!/66/4@!!g84n!!SZ<!$8+!(2*4!<+**6!$8/$!/0+!8+E(*4c+&!/0+!
$8+!(2+6!E'66'2=!$8+!+2c4E+6@!!I8+!(2+6!$8/$!8/M+!$8+!+2c4E+!/0+!6$'**!=(22/!L+!$8+0+;!
6(!4(#!8/M+!/!2(0E/*!/66/4@!!Y(;!"[k[R!#6+!+2c4E+!/66/46!)(0!/<$'M+!8+E(*46'6@!!"++&!
$(!69+<'/*!6$/'2!$(!1_!$8+!N+'2c!L(&4@!g8+2!$8+!8+E(*4$'<!+9'6(&+!'6!(M+0!$8/$Q6!>8+2!$8+!
&:!'6!<(2)'0E+&;!$8'6!'6!&(2+!>'$8!/!laJ_!/66/4@!!Will get a question on G6PD
deficiency, either dapsone related or primaquine related.!
!
X. Autoimmune hemolytic anemias
g/0E!0+/<$'2=!/2$'L(&'+6!/0+!1=l!/2&!<(*&!0+/<$'2=!'6!1=K!
K.!/#$('EE#2+!8+E(*4$'<!/2+E'/!C!>/0EU!K..!()!'$!C!X#9#6!
!
g8+2!4(#!8/M+!/#$('EE#2+!&c!'2!4(#0!)/E'*4;!4(#!8/M+!<+0$/'2!NX%!$49+6!$8/$!90+&'69(6+!4(#!
$(!$8/$!/#$('EE#2+!&c@!!I8+0+)(0+;!4(#!68(#*&!2($!L+!6#090'6+&!')!4(#!8/M+!(2+!/#$('EE#2+!&c!
4(#Q0+!*'F+*4!$(!8/M+!/2($8+0@!!Y(;!9$6!>'$8!*#9#6!<(EE(2*4!/*6(!8/M+!/#$('EE#2+!8+E(*4$'<!
/2+E'/;!/#$('EE#2+!$80(EL(<4$(9+2'/;!/#$('EE#2+!2+#$0(9+2'/;!/2&!/#$('EE#2+!
*4E98(9+2'/@!!
!
T(0!+:/E9*+-!$8+!K..!()!849($840('&'6E!C!8/68'E($(Q6!$840('&'$'6U!$8+6+!9$6!<(EE(2*4!8/M+!
($8+0!/#$('EE#2+!&cQ6!7!'+!9+02'<'(#6!/2+E'/;!M'$'*'=(;!/#$('EE#2+!&+6$0#<$'(2!()!E+*/2(<4$+6B@!!
Y(;!')!4(#!8/M+!(2+!/#$('EE#2+!&c;!4(#!/0+!*'F+*4!$(!8/M+!($8+06!?'+!')!4(#!8/M+!/!8+E(*4$'<!
90(L;!'$!'6!90(L!/#$('EE#2+!0+*/$+&B@!!!
I8'6!'6!LZ<!()!$8+!NX%!0+*/$'(268'9@!!I8+0+)(0+;!')!4(#!8/M+!/!)/E'*4!$8/$!8/6!/2!/#$('EE#2+!&c;!
>8/$!>(#*&!L+!$8+!6'2=*+!L+6$!6<0++2'2=!$+6$!$(!#6+n!NX%!?'+!')!$8+4!8/M+!$8+!NX%!$49+!69+<')'<!
)(0!*#9#6!7!$8+0+!/0+!69+<')'<!NX%Q6!)(0!&'))!&cQ6B@!!I8+0+)(0+;!NX%!'6!$8+!L+6$!>/4!$(!6++!')!9$!'6!
90+&'69(6+&!$(!6(E+$8'2=@!
!
MCC autoimmune anemia = LupusU!'$!8/6!1=l!/2&!.PL!(2!$8+!6#0)/<+!()!$8+!RS.;!6(!'$!>'**!
L+!0+E(M+&!L4!$8+!E/<0(98/=+@!!I8'6!'6!/2!+:$0/M/6<#*/0!8+E(*4$'<!/2+E'/@!!N(>!&(!>+!F2(>!
$8/$!$8+0+!/0+!1=l!(0!.PL!%LQ6!(2!$8+!6#0)/<+n!!Direct Coombs test-!&+$+<$!_1R[.IXb!$8+!
90+6+2<+!()!1=l!/2&Z(0!.PL!(2!$8+!6#0)/<+!()!RS.Q6@!!12&'0+<$!<((EL6!'6!>8/$!$8+!>(E+2!=+$;!
>8+2!$8+4!/0+!90+=2/2$!/2&!$8+4!&(!/2!%L!6<0++2!(2!4(#!?*((F'2=!)(0!/24!F'2&!()!%LBU!6(;!>8+2!
4(#!*((F!)(0!%L!'2!$8+!6+0#E!?"GI!(2!RS.;!(2!Y[R\KB;!$8'6!'6!/2!'2&'0+<$!.((EL6@!!I8+0+)(0+;!
/2($8+0!2/E+!)(0!$8+!'2&'0+<$!.((EL6!C!%L!6<0++2U!>'$8!&'0+<$!<((EL6;!>+!/0+!&+$+<$'2=!1=l!
/2&Z(0!.PL!(2!$8+!Y\RT%.[!()!RS.Q6@!!4(#!</22($!&(!&'0+<$!<((ELQ6!(2!9*/$+*+$6!(0!2+#$0(98'*6;!
L#$!(2*4!RS.Q6@!
So, the test of choice if you suspect an autoimmune hemolytic anemia is Coombs
test.
A. Drug induced autoimmune hemolytic anemias:
I8+0+!/0+!P!$49+6!()!&0#=!'2&#<+&!8+E(*4$'<!/2+E'/!?H2&!K..!/#$('EE#2+!8+E(*4$'<!
/2+E'/!C!&0#=!'2&#<+&U!K..!C!*#9#6B!
1. PCN!7!E+<8/2'6E-!$8+!L9(!=0(#9!()!J."!/$$/<8+6!$(!RS.!?*'*!9'+<+!()!J."!'6!
/$$/<8+&!(2!RS.!E+EL0/2+B@!!I8'6!'6!L/&!')!/2!1=l!%L!&+M+*(96!/=/'26$!'$!LZ<!')!'$!&(+6;!
$8/2!$8+!1=l!/$$/<8+6!$(!$8+!L9(!=0(#9;!=(+6!$(!$8+!69*++2!/2&!'6!0+E(M+&!
+:$0/M/6<#*/0*4U!$8'6!'6!/2!'+!()!$49+!11!NJb!
87

[:/E9*+-!9$!(2!J."!&+M+*(96!/!0/68!7!>8/$!$49+!()!NJbn!I49+!1@!![:/E9*+-!!J$!(2!J."!
&+M+*(96!/!8+E(*4$'<!/2+E'/!7!>8/$!$49+!()!NJbn!Type II!
!
2.!!Methyldopa!7!/F/!/*&(E+$@!!\6+-!/2$'dNI"!)(0!90+=2/2$!>(E/2!?($8+0!/2$'dNI"!
#6+&!'2!90+=2/2<4!C!84&0/*/c'2+B@!!K+$84*&(9/!/2&!84&0/*/c'2+!8/M+!<(E9*'</$'(26!7!
E+$84*&(9/!</2!</#6+!/!8+E(*4$'<!/2+E'/U!84&0/*/c'2+!</2!*+/&!$(!&0#=d'2&#<+&!*#9#6!
?H2&!$(!90(</'2/E'&+!)(0!&0#=!'2&#<+&!*#9#6B@!!K+$84*&(9/!>(0F6!&'))+0+2$*4!)0(E!J."-!
E+$84*&(9/!E+66+6!>'$8!R8!%=!(2!6#0)/<+!()!RS.!/2&!/*$+06!$8+E@!!I8+4!/0+!/*$+0+&!6(!
E#<8!$8/$!1=l!%LQ6!/0+!E/&+!/=/'26$!$8+!R8!%=!?(#0!Gg"!R8!%=B@!Y(;!$8+!&0#=!'6!2($!
6'$$'2=!(2!$8+!E+EL0/2+;!'$!3#6$!</#6+6!)(0E/$'(2!()!IgG!%LQ6!/2&!$8+4!/$$/<8!$(!RS.!$(!
8/M+!E/<0(98/=+!F'**!'$!7!>8/$!$49+!()!NJb!!'6!$8'6n!Type II@!!I8+0+)(0+;!E+$84*&(9/!
/2&!J."!/0+!$49+!11!)(0!8+E(*4$'<!/2+E'/@!
!
3. Quinidine-!$8'6!'6!$8+!]'22(<+2$!L46$/2&+0Q!LZ<!'EE#2+!<(E9*+:+6!/0+!)(0E+&@!!
p#'2'&'2+!/<$6!/6!$8+!8/9$+2;!/2&!$8+!IgM!%L!/$$/<8+6U!6(;!$8+!&0#=!/2&!1=K!/0+!
/$$/<8+&!$(=+$8+0;!<'0<#*/$'2=!'2!$8+!L*((&6$0+/E@!!I8'6!'6!/!&'))+0+2$!HPY type III;!
/2&!>'**!&'+!/!&'))+0+2$!>/4;!LZ<!$8'6!'6!1=K@!!g8+2!1=K!6++6!$8+!'EE#2+!<(E9*+:;!'$!>'**!
6'$!'$;!/2&!/<$'M/$+!$8+!<*/66'</*!9/$8>/4!,dr;!*+/&'2=!$(!'2$0/M/6<#*/0!8+E(*46'6;!/2&!
8/9$(=*(L'2!>'**!L+!&+<0+/6+&;!/2&!'2!$8+!#0'2+;!NL!>'**!L+!90+6+2$@!
XI. Microangiopathic hemolytic anemia
!
RS.Q6!/**!)0/=E+2$+&!7!6<8'6$(<4$+6!?6<8'6$(!7!E+/26!69*'$B@!!MCC chronic intravascular
hemolysis = aortic stenosis;!'2!$8'6!&c;!$8+!<+**6!8'$!6(E+$8'2=U!$8+0+)(0+!8/M+!'2$0/M/6<#*/0!
8+E(*46'6;!NL!'2!$8+!#0'2+!/2&!8/9$(=*(L'2!'6!&(>2@!!I8'6!'6!/!<80(2'<!'2$0/M/6<#*/0!8+E(*46'6;!
/2&!4(#!>'**!L+!*(6'2=!/!*($!()!NL!'2!$8+!#0'2+U!>8/$!&(+6!NL!8/M+!/$$/<8+&!$(!'$n!T+U!6(!>8/$!'6!
/2($8+0!9($+2$'/*!/2+E'/!4(#!</2!=+$!)0(E!$8+6+!9$6n!T+!&+)!/2+E'/@!![:/E9*+-!!>'**!&+6<0'L+!
/(0$'<!6$+2(6'6!?646$(*'<!+3+<$'(2!E#0E#0;!H2&!1.Y;!0/&'/$+6!$(!$8+!</0($'&6;!Y^;!'2<0+/6+&!(2!
+:9'0/$'(2;!90(E'2+2$!JK1B;!/2&!$8+4!8/M+!$8+!)(**(>'2=!.S.!)'2&'2=6-!*(>!K.k;!/2&!
])0/=E+2$+&Q!RS.Q6!?6<8'6$(<4$+6B!7!$8'6!'6!/!E'<0(/2='(9/$8'<!8+E(*4$'<!/2+E'/!0+*/$+&!$(!/(0$'<!
6$+2(6'6@!!!
!
G$8+0!</#6+6!()!6<8'6$(<4$+6-!_1.!?*'*!)'L0'2!6$0/2&6!69*'$!RS.6!0'=8$!/9/0$!LZ<!RS.!'6!M+04!)0/='*+BU!
$80(EL($'<!$80(EL(<4$(9+2'<!9#09#0/;!N\Y!7!6++!6<8'6$(<4$+6@!!g8+2!4(#!8/M+!9*/$+*+$!9*#=6!
+M+04>8+0+!'2!$8+!L(&4;!$8+!RS.6!/0+!L/2='2=!'2$(!$8+6+!$8'2=6!</#6'2=!6<8'6$(<4$+6!/2&!
E'<0(/2='(9/$8'<!8+E(*4$'<!/2+E'/@!![:/E9*+-!!0#22+0Q6!/2+E'/;!+69@!*(2=!&'6$/2<+!4(#!6E/68!
RS.Q6!/6!4(#!8'$!$8+!9/M+E+2$U!M+04!<(EE(2*4;!4(#!=(!9++!/2&!6++!NL!'2!'$U!$(!90+M+2$;!#6+!
L/$80((E!L^@!!!
!!
%2($8+0!</#6+!()!8+E(*4$'<!/2+E'/-!malaria falciparum LZ<!4(#!8/M+!E#*$'9*+!0'2=!)(0E6!
?=/E+$(<4$+!?<(EE/!68/9+&!/2&!0'2=+&!)(0EB@!!1$!90(&#<+6!/!8+E(*4$'<!/2+E'/;!>8'<8!<(00+*/$+6!
>'$8!$8+!)+M+0@!!I8+!)+M+0!(<<#06!>8+2!$8+!<+**6!0#9$#0+!?$8+!8+E(*4$'<!/2+E'/B@!
!
88

CHAPTER 6. HEMATOLOGY: WBC
!
I. Non-neoplastic Lymphoid Proliferations:
A. Neutrophils!7!>8+2!4(#!8/M+!/<#$+!'2)*/EE/$'(2!C!'+!/99+2&'<'$'6;!2+#$0(98'*'<!
*+#F(<4$(6'6;!*+)$!68')$;!$(:'<!=0/2#*/$'(2;!/2&!*+#F/E('&!0:2@!!X+#F/E('&!0:2!E+/26!$8/$!'$!
*((F6!*'F+!*+#F+E'/!L#$!'$!'62Q$!/2&!'$Q6!L+2'=2@!!\6#/**4!'2M(*M+6!/24!()!<+**!*'2+6@!!g8/$!
</#6+6!*+#F/E('&!0:26n!IS!/2&!6+96'6@!!b(#!6++!=0+/$+0!$8/2!PVdeV;VVV!<+**6!'2!$8+!L*((&@!!
5'&6!=+$!$8+6+!/!*($!?'+!($'$'6!E+&'/B@!!%&#*$!>'$8!($'$'6!E+&!C!,H;VVVU!F'&6!>'$8!PV;VVV!
?+:/==+0/$+&B@!![:/E9*+-!!Pertussus whooping cough lymphocytosis!?aV;VVVB!7!
9+&'/$0'<'/26!/0+!>(00'+&!/L(#$!%XX!*+#F+E'/;!L#$!F'&!&(+62Q$!8/M+!/2+E'/!(0!
$80(EL(<4$(9+2'/U!F'&!<(E+6!'2!9/*+;!<(#=8'2=@!!X4E98(<4$+6!/0+!E/$#0+!/2&!/0+!$($/**4!
2(0E/*@!!X4E98(<4$(6'6!>Z!M'0/*!'2)+<$'(2!(0!>'$8!9+0$#66#6@!!!
!
12!atypical lymphocytosis!7!$8'6!'6!/!*4E98(<4$+!$8/$!'6!&('2=!>8/$!'$Q6!6#99(6+&!$(!&(!
>8+2!90+6+2$+&!$(!/2&!%=@!!!1$Q6!0+69(2&'2=!$(!$8+!%=!L4!&'M'&'2=!/2&!=+$$'2=!L'==+0;!6(!
L/6'</**4!'$Q6!/2!/2$'=+2'<!6$'E#*/$+&!*4E98(<4$+@!!g8+2!$/*F'2=!/L(#$!/$49'</*!*4E98(<4$+;!
$8+!/L6(*#$+!)'06$!$8'2=!$8/$!9(96!'2$(!$8+!E'2&!'6-!mononucleolosis EBV@!!G$8+0!&c!$8/$!
/0+!6++2!>'$8!*/0=+;!L+/#$')#**4!6$/'2'2=!L*#'68!<+**6-!.Kk;!$(:(9*/6E(6'6;!/24!</#6+!()!M'0/*!
8+9/$'$'6;!98+24$('2@!![Sk!'6!</**+&!$8+!F'66'2=!&c!LZ<!$8+!M'0#6!8(*&6!#9!'2!$8+!6/*'M/04!
=*/2&6@!![Sk!/))+<$6!S!<+**6!/2&!._!H,@!!K(2(!</#6+6!M'0+E'/;!=+2+0/*'c+&!9/'2)#*!
*4E98/&+2(9/$84;!M+04!<(EE(2*4!=+$!+:#&/$'M+!$(26'**'$'6;!3/#2&'<+!?8/0&*4!+M+0!6++2B;!
'2<0+/6+&!$0/26/E'2/6+6!?())!$8+!<8/0$B;!/2&!69*++2!+2*/0=+E+2$!/2&!</2!0#9$#0+@!!
I8+0+)(0+!&(2Q$!9*/4!69(0$6!LZ<!</2!0#9$#0+&!69*++2!</2!(<<#0;!6(!/M('&!<(2$/<$!69(0$6!
#6#/**4!)(0!adt!>++F6@!!%*6(!</#6+6!E/<0(<4$'<!/2+E'/!M'/!'28'L'$'2=!'2$+6$'2/*!<(23#=/6+B@!
%#&'(!_/4!P-!N+E/$(*(=4!T'*+!e!
!
[:/E9*+-!!$8+!L(/0&6!>'**!='M+!4(#!/!<*/66'<!8:!()!E(2(;!/2&!/6F!>8'<8!$+6$6!4(#!0#2;!L#$!
E(2(69($!$+6$!'6!2($!(2!$8+!<8('<+6!LZ<!$8/$Q6!$8+!$0/&+!2/E+;!6(!9'<F!8+$+0(98'*+!/2$'L(&'+6!
?8+$+0(!C!&'));!98'*+!C!*(M'2=B@!!N+$+0(98'*+!%LQ6!/0+!/2$'d8(06+!RS.!%LQ6!?(0!/2$'d68++9BU!
$8+4!/0+!&'))+0+2$;!8+2<+!i8+$+0(j98'*+!%LQ6@!!G2<+!4(#!8/M+!E(2(;!4(#!/*>/46!8/M+!'$!/2&!
>'**!8/M+!Pd^!0+<#00+2<+6!(M+0!4(#0!*')+$'E+!7!'+!0+/<$'M/$'(2!<(26'6$6!()!6>(**+2!=*/2&6;!M+04!
$'0+&;!+$<@!![Sk!*'M+6!'2!S!<+**6U!$8+!/$49'</*!*4E986!'2!E(2(!/0+!I!<+**6!0+/<$'2=!/=/'26$!$8+!
'2)+<$+&!S!<+**6@!!!
!
B. Monocyte!C!F'2=!()!<80(2'<!'2)*/EE/$'(2;!$8+0+)(0+!+:9+<$!E(2(<4$(6'6!'2!9$6!>'$8!<80(2'<!
'2)+<$'(26!7!'+!08+#E/$('&!/0$80'$'6;!.0(82Q6;!#*<+0/$'M+!<(*'$'6;!*#9#6;!E/*'=2/2<4!
!
Side Note:!<0+/$'2+!='M+6!+2+0=4!LZ<!'$!L'2&6!$(!98(698/$+;!/2&!$8/$!'6!$8+!98(698/$+!4(#!=+$!)0(E!
E/F'2=!%IJ!7!6(!>8/$!6+0#E!$+6$!'6!E/0F+&*4!+*+M/$+&!'2!6(E+(2+!$/F'2=!<0+/$'2+!)(0!$8+'0!
E#6<*+6n!.0+/$'2'2+m!SZ<!$8+!+2&!90(&#<$!()!<0+/$'2+!E+$/L(*'6E!'6!.0+/$'2'2+@!!I8+!S\"!'6!2(0E/*!
'2!$8'6!9+06(2@!g(0$84!L(/0&!D#+6$'(2@!
C. Eosinophilia
b(#!>(#*&!6++!+(6'2(98'*'/!'2!N/4!)+M+0;!0/68!'2!9$!>'$8!J.";!6$0(2=(*('&+6!
J0($(c(/!'2)+<$'(26!_G[Y!"GI!90(&#<+!+(6'2(98'*'/;!$8+0+)(0+!'$!0#*+6!(#$!/E/L'/6'6!
?9'2>(0EB;!='/0&'/;!/2&!E/*/0'/@!!G2*4!'2M/6'M+!8+*E'2$8+6!90(&#<+6!+(6'2(98'*'/@!!%&#*$!
/6</0'/6'6!&(+6!"GI!</#6+!+(6'2(98'*'/!LZ<!/**!$8+4!&(!'6!(L6$0#<$!L(>+*6;!'$Q6!>8+2!$8+!
'2M/6'M+!*/0M/+!)(0E!<0(66+6!'2$(!$8+!*#2=6!$8/$!</#6+6!+(6'2(98'*'/@!!Y(!/24$8'2=!$8/$!'6!
I49+!1!NJb!</#6+6!+(6'2(98'*'/U!90($(c(/!&(!2($!</#6+!+(6'2(98'*'/U!/6</0'/6'6;!/2&!
9'2>(0E6!&(!"GI!</#6+!+(6'2(98'*'/!?/**!($8+06!7!'+!>8'9>(0E6!&(!LZ<!$8+4!'2M/&+B@!
89

!
II. Myeloproliferative Dz: Polycythemia!7!'2<0+/6+&!RS.!<$;!'2<0+/6+&!NL!/2&!N<$!
_'))+0+2<+!L+$>++2!6+0#E!"/!/2&!$($/*!L(&4!"/n!4+6@!!Y+0#E!"/!'6!E'**'+D#/M/*+2$6!9+0!*'$+0!()!
9*/6E/U!$($/*!L(&4!"/!'6!E'**'*'$+06!9+0!F=!L(&4!>$!?$8+!$($/*!/E(#2$!4(#!8/M+B@!!Y'E'*/0*4-!RBC
mass!C!$($/*!s!()!RS.Q6!'2!+2$'0+!L(&4!'2!EXZF=!'2!L(&4!>$!
RBC ct!C!s!()!RS.Q6ZE'<0(*'$+0!()!L*((&;!$8+0+)(0+!'$6!8(>!E/24!4(#!8/M+!'2!/!<+0$/'2!M(*#E+!
()!L*((&@!!g84!'6!$8'6!/!L'=!&+/*n!![:/E9*+-!!>+2$!0#22'2=!/2&!M(*!&+9*+$+&!7!RS.!<$!>(#*&!L+!
8+E(<(2<+2$0/$+&;!$8+0+)(0+!>(#*&!*((F!*'F+!E(0+!RS.Q6!9+0!E'<0(*'$+0!()!L*((&!?LZ<!4(#!
&+9*+$+&!$8+!9*/6E/!M(*#E+B;!L#$!>8/$!>(#*&!$8+!RS.!E/66!L+n!"(0E/*!?2($!/<$#/**4!
642$8+6'c'2=!RS.Q6B@!!Y(;!$8+0+!/0+!H!$49+6!()!RS.Q6-!0+*/$'M+!/2&!/L6(*#$+@!!Relative!C!
&+<0+/6+!'2!9*/6E/!M(*!</#6'2=!/2!'2<0+/6+!'2!RS.!<$;!L#$!$8+!RS.!E/66!'6!2(0E/*@!!Absolute!
'2<0+/6+!7!'6!/990(90'/$+!(0!'2/990(90'/$+n!
g8+2!>(#*&!'$!L+!/990(90'/$+n!Y42!()!RS.Q6!7!$'66#+!849(:'/;!6(;!/24!6(#0<+!()!$'66#+!849(:'/!
>(#*&!L+!/2!/990(90'/$+!0+69(26+@!![:/E9*+-!!')!4(#!8/M+!*#2=!&c;!849(:+E'/;!.GJ_;!8'=8!
/*$'$#&+!7!$8+6+!/0+!'+Q6!()!/990(90'/$+!9(*4<4$8+E'/6@!!g8/$!')!>+!8/M+!2(0E/*!L*((&!=/6+6;!L#$!
&'&2Q$!8/M+!$'66#+!849(:'/n!I8'6!>(#*&!L+!/2!'2/990(90'/$+!9(*4<4$8+E'/@!!Y(;!$8+0+!/0+!$>(!
$8'2=6!$(!$8'2F!/L(#$!>'$8!increased RBC mass:!!polycythemia rubivera;!>8'<8!'6!/2!'+!()!/!
6$+E!<+**!90(*')+0/$'M+!&c!()!$8+!SK;!E+/2'2=!$8/$!$8+!6$+E!<+**6!/0+!&'<$/$(06;!/2&!2($8'2=!F++96!
$8+E!'2!<8+<F!7!/!2+(9*/6$'<!&cU!$8+4!</2!L+<(E+!*+#F+E'/6@!!Y(;!'$!>(#*&!L+!'2/990(90'/$+!$(!
8/M+!2(0E/*!L*((&!=/6+6!/2&!2(!+M'&+2<+!()!$'66#+!849(:'/!/2&!8/M+!/2!'2<0+/6+!'2!RS.!E/66@!!
HB!Tumor or cyst with an excess production of EPO-!!0+2/*!/&+2(</0<'2(E/!E/F'2=![JG;!
</#6'2=!/2!'2<0+/6+!'2!RS.!E/66!7!$8'6!'6!'2/990(90'/$+!LZ<!/!$#E(0!'6!'2/990(90'/$+*4!E/F'2=!'$@!!!
!
12!6#EE/04-!9(*4<4$8+E'/!'6!0+*/$'M+!(0!/L6(*#$+@!!R+*/$'M+!E+/26!$8/$!4(#!3#6$!*(6$!9*/6E/!M(*!
?'+!)0(E!0#22'2=B!>'$8!RS.!<$!'2<0+/6+&;!/2&!E/66!'6!2(0E/*@!!%L6(*#$+!'2<0+/6+-!'6!'$!
/990(90'/$+!(0!'2/990(90'/$+n!%990(90'/$+!7!/24$8'2=!$8/$!'6!/!849(:'<!6$'E#*#6!)(0![JG!0+*+/6+@!!
1)!$8+0+!'62Q$!/!849(:'<!<(2&'$'(2!</#6'2=!$8+![JG!90(&#<$'(2;!$8+2!4(#!/0+!+<$(9'</**4!E/F'2=!
[JG!)0(E!/!$#E(0!(0!<46$!(0!4(#!8/M+!9(*4<4$8+E'/!0#L'M+0/!?/!E4+*(90(*')+0/$'M+!&cB@!
90

III. Myeloproliferative dz!7!2+(9*/6$'<!6$+E!<+**!&c!$8/$!8/6!*(6$!/**!0+=#*/$'(2!/2&!2($8'2=!</2!
'28'L'$!'$!/24E(0+@!!^!&cQ6!$8/$!)'$!#2&+0!$8'6!&+)'2'$'(2-!
,@ J(*4<4$8+E'/!0#L'M+0/!
H@ .KX!?(2*4!*+#F+E'/!'2!$8'6!</$+=(04B!
P@ %=2(=+2'<!E4+*('&!E+$/9*/6'/!7!SK!'6!0+9*/<+&!L4!)'L0(#6!$'66#+!
^@ [66+2$'/*!$80(EL(<4$8+E'/!7!>8+0+!/!6$+E!<+**!$8/$!E/F+6!9*/$+*+$6!=(+6!<0/c4!/2&!E/F+!,!
E'**'(2;!aVV!9*/$+*+$6!)(0!E'<0(*'$+0;!!
e@ K4+*(&469*/6$'<!642&0(E+!!
!
A. Polycythemia rubivera:!!^!NQ6-!!
!
1. Hyperviscosity!?0+E+EL+0!J(#6+/#Q6!*/>!C!IJR!C!M'6<(6'$4Z0/&'#6^B@!!g'$8!
9(*4<4$8+E'/;!'$!>'**!8/M+!/2!'2<0+/6+&!0+6'6$/2<+!/2&!IJR!>'**!=(!#9U!'$!>'**!90+&'69(6+!$(!
$80(EL(6'6;!>8'<8!F'**6!4(#!7!$80(EL(6'6!()!/24$8'2=!7!'+!&#0/*!6'2#6+6U!K..!S#&&!<8'/0'!C!
8+9/$'<!M+'2!$80(EL(6'6U!<(0(2/04!/0$+04;!YKk;!/24$8'2=!</2!L+!$80(EL(6+&!LZ<!L*((&!
6*#=='2=!/0(#2&!/2&!$8'6!'6!>84!98*+L($(E4!'6!&(2+@!!J8*+L($(E4!'6!9+0)(0E+&!$(!E/F+!4(#!
T+!&+)!7!$8+4!>/2$!$(!E/F+!4(#!T+!&+)!7!>84n!1)!4(#!E/F+!$8+E!T+!&+);!LZ<!$8+2!'$!>'**!$/F+!
*(2=+0!$(!E/F+!RS.Q6;!6(!4(#!9#09(6+)#**4!6*(>!&(>2!$8+!90(<+66@!!
!
2.!!Hypovolemia!7!(2*4!9(*4<4$8+E'/!$8/$!8/6!/2!'2<0+/6+!'2!9*/6E/!M(*#E+!$8/$!E/$<8+6!
$8+!'2<0+/6+!'2!RS.!E/66U!2(2+!()!$8+!($8+0!</#6+6!8/M+!/2!'2<0+/6+!'2!9*/6E/!M(*!?$8+6+!
/0+!E+/6#0+&!>'$8!0/&'(/<$'M+!$+<82'D#+6B@!!Y(;!'$!'6!M+04!0/0+!$(!6++!/2!'2<0+/6+!'2!9*/6E/!
M(*!>'$8!9(*4<4$8+E'/;!+:<+9$!)(0!$8'6!</6+@!!g84n!K4+*(90(*')+0/$'M+!&cQ6!$/F+!4+/06!/2&!
4+/06!$(!&+M+*(9!$8+0+)(0+!9*/6E/!M(*!'6!/L*+!$(!F++9!#9U!$8+0+)(0+!L($8!'2<0+/6+!$(=+$8+0!
(M+0!$'E+@!
!
3.!!Histaminemia!7!/**!<+**6!/0+!'2<0+/6+&-!RS.Q6;!gS.Q6;!9*/$+*+$6;!'2<*#&'2=!E/6$!<+**6!/2&!
L/6(98'*6@!!![:/E9*+-!!.*/66'<!8:-!!9$!$/F+6!/!68(>+0!/2&!=+$6!'$<84!/**!(M+0!L(&4!7!$8'6!'6!/!
$'9!())!)(0!9(*4<4$8+E'/!0#L'M+0/!7!>84n!K/6$!<+**6!/2&!L/6(98'*6!/0+!*(</$+&!'2!$8+!6F'2!/2&!
$+E9+0/$#0+!<8/2=+6!</2!&+=0/2#*/$+!E/6$!<+**6;!</#6'2=!/!0+*+/6+!()!8'6$/E'2+;!*+/&'2=!$(!
=+2+0/*'c+&!'$<8'2=!?M+04!)+>!$8'2=6!</#6+!=+2+0/*'c+&!'$<8'2=!7!L'*+!6/*$!&+9(6'$'(2!'2!$8+!
6F'2!'2!9$6!>'$8!(L6$0#<$'M+!3/#2&'<+;!/2&!9$6!>'$8!E/6$!<+**!&+=0/2#*/$'(2B;!)/<+!'6!0+&!
*((F'2=;!$((!LZ<!()!8'6$/E'2+!LZ<!M/6(&'*/$/$'(2;!*+/&'2=!$(!E'=0/'2+d*'F+!8+/&/<8+6@!
!
4. Hyperuricema!7!LZ<!2#<*+/$+&!8+E/$(9(+$'<!<+**6!/0+!+*+M/$+&;!$8+4!$8+2!&'+;!/2&!$8+!
2#<*+'!8/M+!9#0'2+6!'2!$8+E@!!I8+!9#0'2+6!>'**!=(!'2$(!9#0'2+!E+$/L(*'6E!/2&!L+<(E+!#0'<!
/<'&@!![:/E9*+-!!9$!(2!<8+E($8+0/94!E#6$!/*6(!L+!9#$!(2!/**#9#0'2(*!$(!90+M+2$!#0/$+!
2+980(9/$84!/2&!90+M+2$!0+2/*!)/'*#0+!)0(E!#0'<!/<'&@!?/**#9#0'2(*!L*(<F6!:/2$8/2+!(:'&/6+B@!!
g8+2!F'**'2=!<+**6!4(#Q0+!0+*+/6'2=!E'**'(26!()!9#0'2+6!>8+2!$8+!2#<*+/$+&!<+**6!/0+!F'**+&!/2&!
$8+!$#L#*+6!/0+!)'**+&!>'$8!#0'<!/<'&;!*+/&'2=!$(!0+2/*!)/'*#0+@!!K#6$!9#$!$8+E!(2!/**#9#0'2(*@!
I8'6!</**+&!$#E(0!*46'6!642&0(E+@!I8+!6/E+!$8'2=!(<<#06!'2!9(*4<4$8+E'/!0#L'M+0/!LZ<!$8+0+!
'6!/2!'2<0+/6+!'2!2#EL+0!()!<+**6!$8/$!+M+2$#/**4!&'+!/2&!4(#!0#2!$8+!0'6F!()!849+0#0'<+E'/@!
B. RBC mass/plasma vol/O2 sat/EPO
!
J(*4<4$8+E'/!0#L'M+0/!7!8;8;"!?'2/990(90'/$+B;!*(>!?8/M+!$((!E#<8!GH!LZ<!4(#!8/M+!9'*+6!()!
RS.6!/2&!$8+0+)(0+!6#990+66![JG!?'$Q6!/!8(0E(2+B@!!I8+!8'2$!>/6!GH!<(2$+2$C,@P^!o!NL!o!
GH!6/$!O9GH!
!
91

.GJ_;!$+$0/*(=4!()!)/**($;!8'=8!/*$!7!N;!";!X;!N!?/990(90'/$+!9(*4<4$8+E'/!LZ<!'$Q6!0+69(2&'2=!
$(!849(:'/B!
!
R+2/*!/&+2(</0<'2(E/;!8+9/$(<+**/0!</0<'2(E/;!/24!<46$!?0+2/*;!+69@!'+!84&0(2+980(6'6;!
>'*EQ6!$#E(0B!7!N;!";!";!N!?+M+2!>'$8!2(0E/*!=/6!6$#&'+6!LZ<!+<$(9'</**4!90(&#<+&B!
!
R+*/$'M+!J(*4<4$8+E'/!7!";!X;!";!"!
!
IV. Leukemias
I8+4!/0+!/!E/*'=2/2<4!()!$8+!SK!/2&!E+$6!/24>8+0+!'$!>/2$6@!
!
A. General characteristics of Leukemia; therefore, will always have:
,@!l+2+0/*'c+&!*4E98/&+2(9/$84;!8+9/$(69*+2(E+=/*4;!+$<A!
H@!%L2(0E/*!<+**6!'2!$8+!9+0'98+0/*!L*((&!7!SX%YIY!?E4+*(L*/6$6;!*4E98(L*/6$6;!E(2(L*/6$6;!
E+=/F/04(L*/6$6B!7!6(!6(E+!/L2(0E/*!L*/6$6!/0+!'2!$8+!9+0'98+0/*!L*((&!
P@!!SZ<!'$!'6!/0'6'2=!'2!$8+!SK;!>'**!/*>/46!<0(>&!(#$!$8+!2(0E/*!8+E/$(9(+$'<!<+**6;!/2&!>'**!
%Xg%bY!8/M+!/2!/2+E'/;!#6#/**4!2(0E(<4$'<!
^@!!I80(EL(<4$(9+2'/!LZ<!<0(>&'2=!(#$!$8+!2(0E/*!E+=/F/04(<4$+6!)0(E!E/F'2=!9*/$+*+$6!
e@!!\6#/**4!/2!'2<0+/6+!'2!gS.6!<$!>'$8!/L2(0E/*!<+**6!90+6+2$!
a@!!%<#$+!M6@!<80(2'<!7!_(!/!L(2+!E/00(>!$+6$!/2&!*((F!/$!L*/6$6!7!')!L*/6$6!/0+!yPVW;!$8'6!'6!
<80(2'<U!')!$8+!W!L*/6$6!'6!uPVW;!'$!'6!/<#$+@!!I8+0+)(0+!$8+!L*/6$!<$!$+**6!')!'$6!/<#$+!M6!
<80(2'<!
!
B. Age brackets: Know age brackets
Vd,^!C!%XX!!
,edPr!C!%KX!7!E4+*(L*/6$!>'$8!%#+0!0(&6!'2!9+0'98+0/*!L*((&!
^Vder!%KX;!.KX!?6+9/0/$+!>'$8!SK!7!%KX!>'$8!uPVW!/2&!.KX!>'$8!yPVW;!r;!HH;!J8'**4!
<Q6(E+B!
aVO!C!.XX!
K.!(M+0/**!*+#F+E'/!0+=/0&*+66!()!/=+!C!.XX!
K..!=+2+0/*'c+&!2(2$+2&+0!*4E98/&+2(9/$84!'2!9$!aVO!C!.XXU!2($!LZ<!'$Q6!/!*4E98(E/;!L#$!
LZ<!'$!E+$6!$(!*4E98!2(&+6B@!
92

C. Different Types of Leukemia:
[:/E9*+-!!9+0'98+0/*!6E+/0!()!^r!4Z(;!,eV;VVV!gS.!<$;!,W!E4+*(L*/6$!'2!9+0'98+0/*!L*((&!
/2&!SK;!=+2+0/*'c+&!2(2$+2&+0!*4E98/&+2(9/$84;!8+9/$(69*+2(E+=/*4;!$80(EL(<4$(9+2'/;!
/2&!2(0E/*!/2+E'/!7!&:n!.KX!?*((F!/$!/=+!L0/<F+$!/2&!W!L*/6$6B@!!I(!90(M+;!=+$!r;!HH!6$#&4!
?/L*!90($((2<(=+2+!>'$8!2(20+/<$(0!$40(6'2+!F'2/6+!/<$'M'$4!/2&!=(+6!)0(E!r!$(!HH!/2&!)#6+6!
>'$8!$8+!<*#6$+0!)#6'(2!=+2+B@!!X%J!7!*+#F(<4$+!/*F/*'2+!98(698/$/6+!6$/'2!</2!/*6(!L+!#6+&@!!
X((F!/$!>8'<8!2+#$0(98'*6!$/F+!'$!#9!7!E/$#0+!2+#$0(98'*6!/**!8/M+!X%J!'2!$8+EU!2+(9*/6$'<!
2+#$0(98'*6!&(!2($!7!>84n!SZ<!$8+4!/0+!2+(9*/6$'<@!!Y(;!')!2(!6$/'2;!F2(>!'$6!2+(9*/6$'<!
?2(0E/*!<+**6!$/F+!#9!6$/'2B@!!./**+&!/!X%J!6<(0+!7!/*>/46!*(>!'2!.KX@!!Y(;!$8+!$>(!$+6$6-!
J8'**4!<Q6(E+!/2&!X%J!6<(0+;!>8'<8!'6!/*>/46!*(>@!
!
[:/E9*+-!!$+/0!&0(9!<+**!LZ<!$8+0+!>/6!/!&'<$/$(0!'2!SK;!/2&!<+**6!8/M+!$(!E(M+!$(!$8+!
69*++2;!6(!$8+0+!'6!/!E'=0/$'(2!()!8+E/$(9(+$'<!<+**6!)0(E!$8+!SK!$(!$8+!69*++2@!!g8+2!4(#!
$/F+!#9!8+E/$(9(+6'6!/24>8+0+!($8+0!$8/2!$8+!L(2+!E/00(>;!$8'6!'6!</**+&!+:$0/E+&#**/04!
8+E/$(9(+6'6@!!Y(;!$8+!69*++2!'2!8#=+!7!+69@!'2!/$8+0(=+2'<!E4+*('&!E+$/9*/6'/@!!Y(E+!()!
$8+!E+=/F/04(<4$+6!=(!L/<F!$(!$8+!E/00(>!$(!*/4!&(>2!<(**/=+2U!/2&!E+=/F/04(<4$+6!=(!
L/<F@!!T'L0(6'6!()!$8+!SK!(<<#06!?#6+&!$(!L+!</**+&!E4+*()'L0(6'6!E+$/9*/6'/B@!Y(;!2($!
+M+04(2+!*+)$!$8+!SK;!/2&!6$/4!'2!$8+!)'L0($'<!E/00(>@!!T(0!$8+E!$(!=+$!$(!$8+!69*++2;!$8+4!
8/M+!$(!>(0F!$8+'0!>/4!$80(#=8!6$0/2&6!()!)'L0($'<!$'66#+;!()$+2!$'E+6!&/E/='2=!$8+'0!
E+EL0/2+;!*+/&'2=!$(!$+/0!&0(9!<+**6!?6(;!'$!=+$6!9/66+&!$8+!]L/0L+&!>'0+Q!7!)'L0(#6!$'66#+!7!
/2&!=+$$'2=!'2$(!$8+!6'2#6('&6;!$8+4!/0+!$+/0!&0(9!<+**6!'2!$8+!9+0'98+0/*!L*((&B@!!Y(;!9$!>'$8!
8#=+!69*++2;!>'$8!$+/0!&0(9!<+**6!7!atherogenic myeloid metaplasia@!
!
[:/E9*+-!!$((!E/24!9*/$+*+$6!7!essential thrombocythemia!?E/F+6!$((!E/24!9*/$+*+$6B!
!
[:/E9*+-!!^!4Z(!9$!$8/$!90+6+2$6!>'$8!6$+02/*!$+2&+02+66;!)+M+0;!=+2+0/*'c+&!2(2$+2&+0!
*4E98/&+2(9/$84;!8+9/$(69*+2(E+=/*4;!2(0E(<4$'<!/2+E'/;!eV;VVV!gS.!<(#2$!E/24!()!
>8'<8!8/&!/2!/L2(0E/*!/99+/0/2<+!<+**6@!!g8/$!'6!$8+!&:n!ALL (acute lymphoblastic
leukemia.!K.!</2<+0!'2!F'&6U!$8+!E(6$!<(EE(2!$49+!'6-!<(EE(2!%XX!%=!S!<+**!*+#F+E'/@!!
._,VOU!</**/O!%=!Sd<+**!%XX;!/66(<'/$+&!>'$8!&(>2Q6!642&0(E+!
!
[:/E9*+-!!ae!4Z(;!2(0E/*!<0'$+0'/;!6E#&=+!<+**6!/2&!2(0E(<4$'<!/2+E'/@!!I8+4!/*6(!8/M+!
849(=/EE/=*(L'2+E'/!LZ<!$8+4!/0+!2+(9*/6$'<!S!<+**6!/2&!</22($!<8/2=+!$(!9*/6E/!<+**6!$(!
E/F+!1=6@!!!I8+0+)(0+;!K..!&+/$8!'2!.XX!C!'2)+<$'(2!0+*/$+&!$(!849(=/EE/=*(L'2+E'/@!!
g8/$!'6!$8+!_:n!!CLL!
!
[:/E9*+-!!aH!4Z(;!2(0E/*!<0'$+0'/;!69+<'/*!6$/'2!()!IR%J!?$/0$0/$+!0+6'6$/2$!/<'&!98(698/$/6+!
6$/'2B!7!hairy cell leukemia!?F2(>!$8+!IR%J!6$/'2B!
!
[:/E9*+-!!Pe!4Z(!9$;!>'$8!2(0E/*!<0'$+0'/;!>'$8!eV;VVV!/L2(0E/*!gS.6!/2&!%#+0!0(&6!
?/L2(0E/*!*46(6(E+6B;!`VW!L*/6$!<+**6!'2!$8+!SK@!!g8/$!'6!$8+!_:n!!AML. 52(>!>8/$!%#+0!
0(&6!*((F!*'F+;!F2(>!$8+!*+#F+E'/!$8/$!'2)'*$0/$+6!=#E6!?/<#$+!E(2(<4$'<!/2+E'/!7!KeB;!/2&!
/<#$+!90(=0/2#*(<4$'<!/2+E'/!?KPB!7!$8+4!/*>/46!8/M+!_1.;!8/6!/!$0/26*(</$'(2!,e;,`@!!R:!C!
0+$'2('<!/<'&!?M'$!%!7!</#6+6!L*/6$6!$(!E/$#0+!'2$(!Lr!<+**6B@!
V. Lymph nodes
!
A. General Characteristics:
93

,@!!J/'2)#*!M6!9/'2*+66-!*4E98/&+2(9/$84!$8/$!'6!9/'2)#*!'6!2($!E/*'=2/2$U!E+/2!$8/$!4(#!
8/M+!'2)*/EE/$'(2!</#6'2=!'$!?&(+6!2($!/*>/46!E+/2!'2)+<$'(2B!7!4(#!/0+!6$0+$<8'2=!$8+!
</96#*+;!'$Q6!/2!'2)*/EE/$(04!<(2&'$'(2!?*#9#6B;!/2&!$8/$!90(&#<+6!9/'2@!g8+2!4(#!8/M+!2(2d
$+2&+0;!$8'2F!E/*'=2/2$;!+'$8+0!?,B!E+$6!(0!HB!90'E/04!*4E98(E/!(0'='2/$'2=!)0(E!'$@!!%*>/46!
$+**!')!9/'2)#*Z*+66@!!!
!
H@!!X(</*'c+&!M6@!=+2+0/*'c+&!*4E98/&+2(9/$84-!X(</*'c+&!?'+!+:#&/$'M+!$(26'**'$'6!=(+6!$(!
*(</*!2(&+6U!L0+/6$!</2<+0!=(+6!$(!*(</*!2(&+6@!!l+2+0/*'c+&!?646$+E'<!&c!7!'+!N1k;![Sk;!
X#9#6B@!
!
P@![:/E9*+6-!!
?/B!S0#$(2Q6!/=/EE/=*(L'2+E'/!7!=+0E'2/*!)(**'<*+!/L6+2$-!Sd<+**!
?LB!_'l+(0=+!642&0(E+7!9/0/$0/L+<#*/+!E+66+&!#9-!Id<+**!<(#2$04!
?<B!N'6$'(<4$+6!?N/2!68<#**+0!.80'6$'/2Z*+$$+0E/2!6'+M+!&cB!7!'2M(*M+6!6'2#6+6!
?&B!Y.1_!?/&+2'2+!&+/E'2/6+!&+)B!7!S!/2&!I!<+**!&+)'<'+2<4;!$8+0+)(0+!2(!=+0E'2/*!)(**'<*+!
/2&!2(!9/0/$0/L+<#*/+!L#$!>'**!8/M+!6'2#6+6@!!!
?+B!R+/<$'M+!*4E98/&+2(9/$84-!K/<0(98/=+!$/F+6!%=;!/2&!90+6+2$6!$(!=+0E'2/*!)(**'<*+6!
/2&!$8+4!69'$!(#$!/!9*/6E/!<+**;!E/F'2=!%LQ6!
!
B. Non-Hodgkins lymphoma
T(**'<#*/0!*4E98(E/!C!K.!"(2dN(&=F'2Q6!X4E98(E/-!!Sd<+**U!$0/26*(</$'(2!,^;,tU!/2&!
/9(9$(6'6!=+2+!F2(<F+&!());!6(!$8+!<+**6!/0+!'EE(0$/*@!
!
What 2 tissues are resistant to invasion by cancer cells? Cartilage and elastic
tissue
!
[:/E9*+-!!BurkittsU!</#6+&![SkU!I0/26*(</$'(2!t;,^;!E4<!(2<(=+2+6;!6$/004!6F4!7!2(0E/*!
E/<0(98/=+6!*((F'2=!*'F+!6F4!/$!2'=8$;!sP!K..!</2<+0!'2!F'&6U!</2!<#0+U!K.!*4E98(E/!'2!
F'&6;!#6#/**4!'2!$8+!/L&(E+2!?'+!9/4+06!9/$<8+6;!9/0/(0$'<!*4E98!2(&+6;!/*6(!L#$!0/0+*4!'2!
$8+!3/>;!(0!$+6$+6B!
!
[:/E9*+-!!9*/D#+!*'F+!*+6'(26;!2(!$++$8;!2($!/!!)#2=/*!'2)+<$'(2!7!/<$#/**4!$8+!'2)*/EE/$(04!
<+**6!/0+!0+/**4!2+(9*/6$'<U!6(!$8+!8+*9+0!I!<+**!'2!mycosis fungoides!'6!2+(9*/6$'<;!$8+0+)(0+!
'$Q6!/!I!<+**!E/*'=2/2<4@!12M(*M+6!$8+!6F'2!/2&!*4E98!2(&+6!M6@!Sezary!<+**!642&0(E+!>8'<8!
'6!6++2!'2!9+0'98+0/*!L*((&!?E/*'=2!8+*9+0!I!<+**!$8/$!'6!'2!9+0'98+0/*!L*((&;!'2!E4<(6'6!
)#2=('&+6B!
!
[:/E9*+-!!F'&!>'$8![K!()!+<c+E/$(#6!0/68!/**!(M+0!7!=+2+0/*'c+&!2(2$+2&+0!
8+9/$(69*+2(E+=/*4;!;![K!()!E(2(E(098'<!<+**6!>8'<8!>+0+!._!,O!<+**6!7!8'6$'(<4$(6'6!h!
?letterman sieve dzB!?L'0L+<F!=0/2#*+6;!*((F!*'F+!$+22'6!0/<F+$!7!
<*(6$0'&'#E!$+$/2'!>8'<8!8/6!/!69(0+!/*6(!*((F6!*'F+!/!$+22'6!0/<F+$B!
!
%#&'(!&/4!P-!8+E/$(*(=4!)'*+!a!
!
J/'2)#*!*4E98/&+2(9/$84!C!6(E+!$49+!()!'2)*/EE/$(04!<(2&'$'(2;!2($!E/*'=2/2$!
!
J/'2*+66!*4E98/&+2(9/$84!C!E/*'=2/2<4-!K.!E/*'=2/2<4!()!*4E98!2(&+!C!E+$/6$/6'6!
K.!90'E/04!</2<+0!()!*4E98!2(&+!C!
94

2(2!N(&=F'2Q6!*4E98(E/-!!)(**'<#*/0!S!<+**!*4E98(E/!?$0/26*(</$'(2-!,^;!,t@!!I8'6!F2(<F6!())!
/9(9$(6'6!=+2+!/2&!$8+!<+**!'6!'EE(0$/*B@!
C. Hodgkins Dz7!)(#0!&'))+0+2$!$49+6@!!12!N(&=F'2Q6!$8+!</0&'2/*!6'=26!/0+-!)+M+0;!2'=8$!
6>+/$6;!/2&!>$!*(66!?#6#/**4!IS!#2*+66!90(M+2!($8+0>'6+B@!!1$!'6!#6#/**4!*(</*'c+&;!2(2$+2&+0!
*4E98/&+2(9/$84@!!G2!E'<0(-!$8+!E/*'=2/2$!<+**!'6!R+'&!Y$+'2L+0=!<+**6;!RY!<+**6!7!(>*!+4+6!d!
<(EE(2!(2!L(/0&6!?/*6(!='/0&'/;!.Kk;!/68())!2(&#*+!'2!08+#E/$'<!)+M+0B@!!X+66!s!C!L+$$+0!
90(=2(6'6U!E(0+!C!>(06+!
!
I8+!E(6$!'E9(0$/2$!(2+!'6!Nodular Sclerosis-!K.!C!2(&#*/0!6<*+0(6'6;!6++2!'2!>(E+2U!'$!'6!
2(&#*/0!?8+2<+!$8+!2/E+B;!/2&!8/6!*($6!()!6<*+0(6'6!?<(**/=+2!&+9(6'$'(2;!6(!'$Q6!8/0&!/2&!
2(2d9/'2)#*!2(&+B@!!b(#!>(#*&!6++!'$!'2!/!>(E/2!>'$8!*4E98!2(&+!'2M(*M+E+2$!'2!H!9*/<+6-!
,B!/2$+0'(0!E+&'/6$'2#E!/2&!HB!6(E+>8+0+!/L(M+!$8+!&'/980/=Ed!'+!$8+!<+0M'</*!2(&+6;!
6#9+0<*/M'<#*/0!2(&+6;!2+<F@!!I8'6!<(EL'2/$'(2!()!E/66!'2!2+<F!/2&!/2$+0'(0!E+&'/6$'2#E!C!
2(&#*/0!6<*+0(6'6@!!b(#!>(#*&!6++!RY!<+**6!(2!E'<0(@!!!
!
H@!I+0E6-!9(*4!/2&!E(2(<*(2/*!?$8'6!>'**!8+*9!$(!#2&+06$/2&!$8+!&'))!)0(E!E#*$'9*+!E4+*(E/!
/2&!($8+0!$8'2=6!$8/$!'2<0+/6+!=/EE/!=*(L#*'2!9B@!G2!6+0#E!90($+'2!+*+<$0(98(0+6'6;!
/*L#E'2!E'=0/$+6!$8+!)/0$8+6$!LZ<!'$!8/6!$8+!E(6$!2+=!<8/0=+;!>8+0+/6!=/EE/!=*(L#*'2!3#6$!
6'$6!$8+0+@!
!
?/B!J(*4<*(2/*-!i9(*4j!C!E/24;!i<*(2/*j!C!9*/6E/!<+**6;!$8+0+)(0+!4(#!8/M+!E/24!<*(2+6!
()!9*/6E/!<+**6!LZ<!$8+!=/EE/!=*(L#*'2!0+='(2!'6!>8+0+!$8+!=/EE/!=*(L#*'26!/0+@!!!I8'2F!
i=d/dEj!$(!F2(>!$8+!(0&+0!()!E(6$!/L#2&/2$Z=0+/$+6$!2#EL+0!()!=*(L#*'2@!I8+0+)(0+;!(2!
+*+<$0(98(0+6'6;!4(#!6++!/!*'$$*+!9+/F;!$8'6!'6!/2!'2<0+/6+!'2!1=l!LZ<!'$Q6!$8+!E(6$!/L#2&/2$!
1=l!7!$8'6!E/F+6!6+26+!LZ<!)(0!<80(2'<!'2)*/EE/$'(2;!$8+!E/'2!1=!'6!1=l;!/2&!)(0!/<#$+!
'2)*/EE/$'(2!$8+!E/'2!1=!'6!1=K@!!Y(;!'2!<80(2'<!'2)*/EE/$'(2!?'+!.0(82Q6;!08+#E/$('&!
/0$80'$'6;!\.B!$8+0+!'6!/2!'2<0+/6+!'2!1=l!7!>8'<8!>'**!68(>!/!*/0=+!&'))#6+!+*+M/$'(2!?/!
2'<+!0(#2&!E$2B@!!I8'6!'6!</**+&!9(*4<*(2/*!=/EE(9/$84!LZ<!E/24!L+2'=2!9*/6E/!<+**6!/0+!
E/F'2=!1=l@!!J(*4<*(2/*!=/EE(9/$84!/*>/46!E+/26!L+2'=2!/2&!<80(2'<!'2)*/EE/$'(2@!!
g'**!2($!8/M+!9(*4<*(2/*!=/EE(9/$84!>'$8!/<#$+!'2)*/EE/$'(2!?'+!/<#$+!/99+2&'<'$'6BU!
$8'6!2($!/24!0'6+!'2!$8+!=/EE/!=(L#*'2!0+='(2!)(0!/<#$+!'2)*/EE/$'(2!7!$8+!E/'2!1=!'6!
1=K!)(0!/<#$+@!
!
?LB!K(2(<*(2/*!C!(2+!<*(2+!()!9*/6E/!<+**6!/0+!E/F'2=!1=Q6U!($8+0!9*/6E/!<+**6!/0+!2($!
E/F'2=!1=Q6!LZ<!$8+4!/0+!6#990+66+&@!!Y(;!>8+2!4(#!6++!/!E(2(<*(2/*!9+/F;!$8'6!E+/26!
'$Q6!/!E/*'=2/2<4!()!9*/6E/!<+**6@!!K+/2>8'*+;!/**!($8+0!9*/6E/!<+**6!/0+!6#990+66+&!L4!
'EE#2(*(='<!E+<8/2'6E6@!!I8+!E/*'=2/2$!<*(2+!E/F+6!'$6!(>2!1=U!E(6$!()!$8+!$'E+!'$!'6!
/2!1=l!E/*'=2/2<4@!!I8+4!/0+!E/F'2=!E/24!*'=8$!<8/'26!/2&!=+$!'2$(!$8+!#0'2+!7!$8+6+!
/0+!</**+&!S+2<+!f(2+6!90($+'26@!K(2(<*(2/*!#6#/**4!E+/26!E/*'=2/2<4!/2&!/*>/46!
E+/26!E#*$'9*+!E4+*(E/@!!
!
?<B!J+/F6!?'2!(0&+0B-!/*L#E'2;!/*98/!,;!/*98/!H;!L+$/;!=/EE/!7!8/M+!!
!
/!9$!He!4Z(;!2(2d6E(F+0;!8/&!+E9846+E/!()!$8+!*(>+0!*#2=6;!2(!/*98/!,!9+/F!7!>8/$!'6!
_:n!%*98/!,!/2$'$0496'2!&+)@!
!
VI. Plasma Cell Disorders:
A. Multiple Myeloma (MM)
95

KK!'6!/!M+04!L/&!&c;!'2<#0/L*+;!/2&!#2*+66!4(#!=+$!SK!$0/269*/2$;!4(#!>'**!&'+@!!1$Q6!#6#/**4!
6++2!'2!9+(9*+!(M+0!eV;!/!*'$$*+!E(0+!<(EE(2!'2!>(E+2@!!I8+!E(6$!<(EE(2!)(0E!'6!1=!
F/99/;!>8'<8!'6!/L#2&/2$@!!J*/6E/!<+**6!8/M+!1Xd,!?/F/!(6$+(<*/6$!/<$'M/$'2=!)/<$(0BU!$8'6!'6!
>84!4(#!6++!*($6!()!*4$'<!*+6'(26!'2!$8+!6F#**!(0!L(2+6@!!!I8+!*4$'<!0+='(26!/0+!0(#2&;!/2&!
2'<+*4!<#$!?'2!<(2$0/6$!$(!J/=+$Q6!&c;!$8+!*4$'<!0+='(26!/0+!)#cc4!/2&!2($!68/09*4!<#$B@!!g8'*+!'2!
KK!*+6'(26!8/M+!/!)'2+;!68/09!?<((F'+!<#$$+0!<#$B!L(0&+0;!LZ<!1Xd,!/<$'M/$+6!(6$+(<*/6$6;!
*+/&'2=!$(!$8+!9#2<8+&!(#$!*+6'(26@!!!
!
[:/E9*+-!')!$8+0+!>/6!/!*4$'<!*+6'(2!'2!$8+!0'L6!/2&!9$!<(#=8+&;!>8/$!>(#*&!9($+2$'/**4!
8/99+2n!J/$8(*(='<!)0/<$#0+6!/2&!$8+6+!/0+!+:$0+E+*4!<(EE(2@!!!
!
[:/E9*+-!!+*&+0*4!>(E/2!<(#=86!/2&!&+M+*(96!6+M+0+!9/'2!7!4(#!6++!*4$'<!*+6'(2!()!$8+!0'L;!
6(!>8/$!&(+6!$8+!9$!8/M+n!K#*$'9*+!E4+*(E/!
!
52(>!>8/$!9*/6E/!<+**!*((F6!*'F+!7!8/6!L0'=8$!L*#+!<4$(9*/6E!/2&!2#<*+#6!'6!+<<+2$0/**4!
*(</$+&!?/0(#2&!$8+!2#<*+#6!/0+!<*+/0!/0+/6!90+6+2$B@!!G2![K;!>'**!6++!*/4+0!/2&!*/4+06!()!
R[R;!LZ<!$8+4!/0+!<(26$/2$*4!E/F'2=!90($+'2!?0'L(Q6!/0+!>8+0+!0'L(6(E/*!R"%!6'$6!(2B@!!K#6$!
F2(>!>8/$!9*/6E/!<+**!*((F6!*'F+!(2![K!/2&!='+E6/!6$/'2@!!Y#EE/04!()!E#*$'9*+!E4+*(E/!7!
*4$'<!*+6'(26;!S+2<+!f(2+6!90($+'26;!/2&!6++2!'2!+*&+0*4!9$6@!
!
1. Amyloidosis: '6!/!<*'2'</*!<8/0/<$+0'6$'<!()!KK!
%E4*('&!(2![K!'6!/!2(2dL0/2<8'2=;!*'2+/0!<(E9(#2&!>'$8!/!8(*+!(2!$8+!<+2$+0!()!'$@!!
I8+4!/*>/46!/6F!/!D#+6$'(2!(2!/E4*('&(6'6!LZ<!'$!+2&6!#9!'2!$8+!&'))+0+2$'/*!&:!)(0!E#*$'d
646$+E!&c!?646$+E'<!/E4*('&(6'6B@!!%E4*('&!'6!/!90($+'2;!L#$!>8/$Q6!'2$+0+6$'2=!'6!$8/$!
E/24!($8+0!&'))+0+2$!90($+'26!</2!L+!$0/26)(0E+&Z<(2M+0$+&!'2$(!$8'6!#2'D#+!90($+'2!7!'+!
90+d/*L#E'2;!!
x </*<'$(2'2!?$#E(0!E/0F+0!)(0!E+&#**/04!</0<'2(E/!()!$8+!$840('&B;!!
x *'=8$!<8/'26!'2!KK;!/2&!
x $0'6(E4!H,@!!12!I0'6(E4!H,!?_(>2Q6!642&0(E+B;!$8+!<Q6(E+!H,!<(&+6!)(0!L+$/!
/E4*('&;!/2&!')!4(#!8/M+!$80++!()!$8+6+;!4(#!>'**!E/F+!E(0+!L+$/!/E4*('&!
90($+'2@!!%2&!L+$/!/E4*('&!90($+'2!'6!$(:'<!$(!2+#0(26U!6(;!')!4(#!8/M+!$0'6(E4!H,!
/0+!E/F'2=!E(0+!L+$/!/E4*('&!90($+'2;!$8+2!4(#!>'**!L+!*(6'2=!E(0+!2+#0(26!LZ<!
4(#!/0+!*(6'2=!E(0+!()!$8'6!90($+'2!$8/$!'6!$(:'<!$(!2+#0(26@!!I8'6!'6!>84!$8+4!
/*>/46!/6F!$8+!D#+6$'(2!/L(#$!/!9$!&4'2=!/$!)(0$4!/2&!(2!/#$(964;!4(#!6++!
/$0(984!()!$8+!L0/'2!/2&!'$!0+M+/*6!6+2'*+!9*/D#+6!'2!)0(2$/*!/2&!$+E9(0/*!*(L+6;!
/2&!>'**!/6F!>8/$!9$!8/&!7!_(>2Q6!642&0(E+@!!%**!&(>2Q6!9$6!>'**!=+$!%*c8+'E+0Q6@!!
_(>2Q6!9$6!&'+!)0(E!,!()!H!$8'2=6-!+'$8+0!)0(E!?,B!+2&(</0&'/*!<#68'(2!&+)+<$6!7!
>8'<8!*+/&6!$(!8+/0$!&+)+<$6!/2&!/2!%Y_!?'2!<8'*&8((&B!/2&!/!kY_!(0!?HB!
%*c8+'E+0Q6!&c!?&+/$8!LZ<!<80(E(6(E+!H,!'6!E/F'2=!$((!E#<8!L+$/!/E4*('&!
90($+'2B@!![:/E9*+-!^V!4Z(!>'$8!%*c8+'E+0Q6!&c!8/6!&(>26!642&0(E+@!!S+$/!
/E4*('&!'6!E(6$!'E9(0$/2$!90($+'2@!
!
VII. Lysosomal storage dzs
I>(!&'))+0+2$!<+**6!$8/$!$8+4!*'F+!$(!/6F!D#+6$'(26!/L(#$@!!!
,@!!l/#<8+0!&c-!$8+0+!'6!/!E/<0(98/=+!>'$8!/!<0'2F*+&!9/9+0!*'F+!/99+/0/2<+!'2!$8+!
<4$(9*/6E@!!I8+0+!/0+!*46(6(E+6!)'**+&!>'$8!=*#<(<+0+L0(6'&+;!$8+0+)(0+!9$!8/6!l/#<8+0!&c@!!
1$Q6!/2!/#$(!0+<+66'M+!&c!>'$8!/!E'66'2=!=*#<(<+0+L0(6'&+@!!!
!
96

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'2!$8+!*46(6(E+6;!$8+0+)(0+!$8+!9$!8/6!"'+E/22dJ'<F!&c;!E'66'2=!698'2=(E4+*'2/6+@!
!
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=*4<(=+2!6$(0/=+!&c!$8/$!'6!*46(6(E/*!LZ<!$8+4!/0+!E'66'2=!/2!+2c4E+!$(!L0+/F!=*4<(=+2!
&(>2!'2!$8+!*46(6(E+6@!!N(>!&(+6!9$!&'+n!_'+!)0(E!</0&'/<!)/'*#0+!LZ<!+:<+66!&+9(6'$'(2!()!
2(0E/*!=*4<(=+2!'2!$8+!8+/0$@!!
!
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*46(6(E/*!6$(0/=+!&c!
!
97

CHAPTER 6: HEMODYNAMIC DYSFUNCTION
I. Thrombogenesis: The Coagulation System
N+E(6$/6'6-!$8'2=6!'2!(#0!L(&4!$8/$!90+M+2$6!<*($6!)0(E!&+M+*(9'2=!'2!SkQ6@!!1)!$8+6+!<*($6!>+0+!2($!
90+M+2$+&;!$8+!9$!+'$8+0!8/6!_1.;!$80(EL($'<!$80(EL(<4$(9+2'<!9#09#0/!?IIJB;!(0!N\Y;!/2&!/**!()!
$8+E!*+/&!$(!&+/$8@!!Y(;!>84!&(2Q$!>+!)(0E!<*($6!'2!(#0!6E/**!SkQ6n!z6E/**!L*((&!M+66+*6!'2<*#&+!
/0$+0'(*+6;!M+2#*+6;!/2&!</9'**/0'+6;!>8'*+!6E/**!/'0>/46!'2<*#&+!$+0E'2/*!L0(2<8'(*+6;!0+69!
L0(2<8'(*+6;!/*M+(*/0!&#<$;!/2&!/*M+(*#6{@!
!
A. So, why dont we form clots?!SZ<!>+!8/M+!<(/=#*/$'(2!)/<$(06!6#<8!/6-!8+9/0'2;!Jl1H;!
J0($+'2!.!/2&!Y;!/2&!$'66#+!9*/6E'2(=+2!/<$'M/$(0@!!Y(!/**!()!$8+6+!$8'2=6!/0+!#6+&!$(!90+M+2$!
*'$$*+!<*($6!(<<#00'2=!'2!(#0!6E/**!L*((&!M+66+*6@!
!
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90+M+2$!)(0E/$'(2!()!<*($6@!N(>!&(+6!8+9/0'2!>(0Fn!1$!["N%".[Y!/2$'$80(EL'2!111@!
%2$'$80(EL'2!111!'6!E/&+!12!$8+!X'M+0!?*'F+!/**!($8+0!90($+'26B@!!I8+0+)(0+;!8+9/0'2!=+$6!$8+!
<0+&'$!)(0!/2$'<(/=#*/$'2=!4(#;!L#$!'$6!/2$'$80(EL'2!111!&(+6!/**!$8+!>(0F@!!%2$'$80(EL'2!111!
2+#$0/*'c+6!E(6$!()!$8+!<(/=#*/$'(2!)/<$(06@!!Y(;!>+!8/M+!/!*'$$*+!L'$!()!8+9/0'2!'2!(#0!6E/**!
M+66+*6;!>8'<8!90+M+2$6!<*($$'2=!)0(E!(<<#00'2=@!!!
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!
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!
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+/$6!+M+04$8'2=!'2!6'$+@!!!
!
B. Deficiency in any of the anticoagulants-!Y(;!')!>+!/0+!&+)!'2!/24!()!$8+6+!$8'2=6!
?8+9/0'2;!Jl1H;!90($+'2!.!/2&!Y;!/2&!$dJ%B;!<*($6!>(#*&!)(0E@!12!($8+0!>(0&6!9$!>'**!L+!
$80(EL(=+2'<@!
!
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'2<0+/6+6!642!()!)'L0'2(=+2;!/2&!'28'L'$6!/2$'$80(EL'2!111@!!Y(;!L'0$8!<(2$0(*!9'**6!/0+!L*(<F'2=!
8+9/0'2!L4!'28'L'$'2=!%I111@!!I8+0+)(0+;!$8+!+6$0(=+2!()!$8+!9'**!'6!$80(EL(=+2'<;!$8+0+L4!
/66'6$'2=!'2!$8+!)(0E/$'(2!()!<*($6@!_+/&*4!&#(-!>(E/2!(2!L'0$8!<(2$0(*!/2&!6E(F'2=!C!L/&U!
6E(F'2=!'6!$80(EL(=+2'<!LZ<!'$!&/E/=+6!+2&($8+*'/*!<+**6!?6(!L($8!/0+!$80(EL(=+2'<B@!
C. Formation of a stable clot
T(0!+:/E9*+-!/!9$!'6!68/M'2=!/2&!<#$!8'E6+*)@!!N(>!&(!>+!6$(9!L*++&'2=!>8+2!4(#!<#$!/!
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98

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!
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!
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!
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!
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99

90+)(0E+&!<8+E'</*6-!8'6$/E'2+;!6+0($(2'2;!/2&!+(6'2(98'*!<8+E($/<$'<!)/<$(0B@!!I8+6+!
<8+E'</*6!$8+2!6$/0$+&!$8+!'2)*/EE/$(04!0:2!'2!/!$49+!1!NJb!0:2@!!I8+!E/6$!<+**!0+*+/6+&!
/0/<8'&(2'<!/<'&!)0(E!'$6!E+EL0/2+!/2&!>+!+2&+&!#9!E/F'2=!JlQ6!/2&!*+#F($0'+2+6@!!I8+4!
>+0+!0+*+/6+&!PV!E'2#$+6!$(!/2!8(#0!*/$+0!/2&!)#0$8+0+&Z+28/2<+&!$49+!1!NJb!
?'2)*/EE/$(04B!0:26@!!Y(!$8+!E/6$!<+**!8/&!/!0+*+/6+!0:2!()!90+)(0E+&!+*+E+2$6!/2&!'$!E/&+!
'$6!(>2!JlQ6Z*+#F($0'+2+6@!!I8/$!'6!>8/$!9*/$+*+$6!&'&-!0+*+/6+&!'$6!90+)(0E+&!<8+E'</*6!/2&!
E/&+!'$6!(>2!<8+E'</*-!I:%H@!
!
J*#=!'6!$+E9(0/04!7!'$!'6!/!L#2<8!()!9*/$+*+$6!6$#<F!$(=+$8+0!/2&!8+*&!$(=+$8+0!L4!)'L0'2(=+2;!
/2&!'6!+2(#=8!$(!90+M+2$!L*++&'2=!?$(!6$(9!L*++&'2=!$'E+B;!L#$!')!4(#!6<0/$<8!(0!$04!$(!(9+2!
$8+!>(#2&;!'$!>(#*&!6$/0$!L*++&'2=!/=/'2;!6(!'$Q6!2($!/!6$/L*+!9*#=@!
!
^@!.(2&'$'(26!$8/$!/0'6+!>'$8!'2<0+/6+&!(0!&+<0+/6+&!L*++&'2=!$'E+-!X+$6!6<0+>!#9!L*++&'2=!
$'E+-!!!
!
?/B!g8/$!>(#*&!L+!/2!(LM'(#6!E+66!#9!()!L*++&'2=!$'E+n!I80(EL(<4$(9+2'/-!&+<0+/6+&!
9*/$+*+$!<(#2$!$8+0+)(0+!')!4(#!8/M+!*+66!$8/2!rV;VVV!9*/$+*+$6;!4(#!>'**!8/M+!/!90(*(2=+&!
L*++&'2=!$'E+!LZ<!4(#!>'**!2($!8/M+!+2(#=8!$(!/==0+=/$+@!!%2($8+0!&c!$8/$!8/6!/!90(L*+E!
>'$8!/&8+6'(2!E(*+<#*+!&+)+<$!'6!MgS!&c!?K.!=+2+$'<!8+0+&'$/04!&c;!%_B!
!
?LB!K..!90(*(2=+&!L*++&'2=!$'E+!C!$/F'2=!/69'0'2U!E+<8/2'6En!%69'0'2!L*(<F6!9*/$+*+$!
.Gh;!2($!I:%H!?L*(<F+&!L4!_'9400/E'&/*B@!![2&($8+*'/*!<+**6!8/M+!.Gh;!$((U!6(!>84!&'&2Q$!
$8+!+2&($8+*'/*!<+**6!'28'L'$!.Gh!)0(E!E/F'2=!Jl1Hn!I8+!9*/$+*+$!.Gh!M6!$8+!+2&($8+*'/*!
.Gh!0+/<$6!&'))+0+2$*4!$(!/69'0'2@!!_'))+0+2$!<(E9(#2&6!/<$!&'))+0+2$*4!$(!2(2d6$+0('&/*@!!
1$Q6!/!r-,!0/$'(!?/69'0'2!L*(<F!9*/$+*+$!.Gh!E(0+!$8/2!+2&($8+*'/*!.GhBU!</22($!2+#$0/*'c+!
L($8!7!>(#*&!L+!L/&@!!Y(;!/69'0'2!'6!'00+M+06'L*+!/2&!($8+0!"Y%1_6!/0+!0+M+06'L*+!)(0!^t!
806@!!Y(;!')!4(#!$((F!/2!/69'0'2;!'$!90+M+2$6!9*/$+*+$6!)0(E!/==0+=/$'2=;!/2&!$8+0+)(0+!$8+4!
&(!2($!>(0F;!6(!')!4(#!<#$!4(#06+*);!$8+!L*++&'2=!$'E+!>'**!L+!'2<0+/6+&@!!%69'0'2!'28'L'$6!
9*/$+*+$6!)0(E!/==0+=/$'2=U!2(!I:%H;!6(!'$!>(2Q$!>(0F!/2&!4(#!>'**!<(2$'2#+!L*++&'2=@!!!
!
e@!!.(2$'2#/$'(2!()!.*($$'2=-!!R+</**!$8/$!$8+!0+*+/6+!()!$dJ%!>8'<8!>'**!/<$'M/$+!+:$0'26'<!
646$+E!/2&!'$!/*6(!/<$'M/$+6!$8+!N/=+E/2!)/<$(0!,H!LZ<!()!<(**/=+2!L+'2=!+:9(6+&!$8+0+)(0+!
$8+!'2$0'26'<!646$+E!'6!/*6(!/<$'M/$+&@!![2&!90(&#<$!()!<(/=#*/$'(2!'6!$80(EL'2;!/2&!$80(EL'2!
<(2M+0$6!)'L0'2(=+2!'2$(!)'L0'2@!!Y(;!>+!8/M+!9'*+!()!9*/$+*+$6!6$#<F!$(=+$8+0!/2&!$8+4!/0+!
L(#2&!>'$8!)'L0'2(=+2@!!g8/$!>'**!8/99+2!0'=8$!/)$+0!$8+!L*++&'2=!$'E+!+2&6n!I8+!/<$'M/$+&!
$80(EL'2!?90(&#<+&!L4!$8+!+:$0'26'<!/2&!'2$0'26'<!9/$8>/46B!>'**!<(2M+0$!$8+!)'L0'2(=+2!
?>8'<8!'6!8(*&'2=!$8+!9*/$+*+$6!$(=+$8+0!*((6+*4B!'2$(!)'L0'2;!E/F'2=!/!E(0+!6$/L*+!9*/$+*+$!
9*#=!$8/$!4(#!/0+!2($!/L*+!$(!&'6*(&=+@!Y(;!>8(!>'**!0+E(M+!$8/$!9*/$+*+$!9*#=!)0(E!$8+!
M+66+*n!J*/6E'2'2(=+2;!/2&!>8+2!'$!'6!/<$'M/$+&!/2&!9*/6E'2!/0+!)(0E+&U!9*/6E'2!>'**!&0'**!/!
8(*+!$80(#=8!'$!/2&!0+</2/*'c+;!6(!$8+!M+66+*!'6!2(0E/*!/=/'2@!!!
!
D. Platelet deficiency vs Coagulation deficiency
Y(;!>'$8!L*++&'2=!$'E+;!$8+!9*/$+*+$6!?>8'<8!/0+!8+*&!$(=+$8+0!>'$8!)'L0'2(=+2B!)(0E!/!$+E9(0/04!
8+E(6$/$'<!9*#=@!!I8'6!6$(96!$8+!L*++&'2=!$'E+;!L#$!'$Q6!M+04!#26$/L*+@!!g8+2!$8+!.(/=#*/$'(2!
646$+E!E/F+6!$80(EL'2;!'$!<(2M+0$6!)'L0'2(=+2!'2$(!)'L0'2;!E/F'2=!/!6$0(2=!9*/$+*+$!9*#=@!!I8'6!
&'))+0+2<+!'6!M+04!'E9!LZ<!'$!&'6$'2=#'68+6!/!&'))+0+2<+!L+$>++2!/!9*/$+*+$!/L2(0E/*'$4!M6!
<(/=#*/$'(2!)/<$(0!&+)'<'+2<4!
!
100

,@!!1)!4(#!8/M+!/!9*/$+*+$!90(L*+E;!>8/$!>'**!8/99+2!$(!L*++&'2=!$'E+n!J0(*(2=+&;!LZ<!')!$8+!
9$!<#$6!/!M+66+*;!>8/$!>'**!8/99+2n!1$!>'**!<(2$'2#+!$(!L*++&!?$8+0+)(0+!/!9*/$+*+$!90(LB@!!
I8+0+)(0+;!'2!9*/$+*+$!/L2(0E/*'$'+6;!4(#!6++!L*++&'2=!)0(E!6#9+0)'<'/*!6<0/$<8+6!(0!<#$6!?9$!
<(2$'2#+6!$(!L*++&!LZ<!4(#!</2Q$!)(0E!/!$+E9(0/04!8+E(6$/$'<!9*#=B@!!12!/&&'$'(2;!4(#!E+66!
#9!$8+!'2$+=0'$4!()!6E/**!M+66+*6!>8+2!9*/$+*+$6!/0+!E+66+&!#9;!*+/&'2=!$(!9+$+<8'/!
?8+E(008/=+!(2*4!6++!'2!/!9*/$+*+$!/L2(0E/*'$4!7!9'29('2$!/0+/!()!8+E(008/=+B;!+<84E(6+6!
?9#09#0/B;!+9'6$/:'6!?2(6+!L*++&;!>8'<8!'6!$8+!K.!E/2')+6$/$'(26!'2!9*/$+*+$!90(L*+EB@!
!
"G"[!()!$8+6+!E/2')+6$/$'(26!?9+$+<8'/;!+<84E(6+6;!+9'6$/:'6;!/2&!L*++&'2=!)0(E!6#9+0)'<'/*!
6<0/$<8+6B!(<<#06!'2!.(/=#*/$'(2!)/<$(0!&+)'<'+2<4mmm!
!
H@!.(/=#*/$'(2!&+)'<'+2<4-!![:/E9*+-!9$!>Z!8+E(98'*'/!%!7!&+)!'2!)/<$(0!tU!>8/$!'6!L*++&'2=!
$'E+n!"(0E/*@!!g8/$!$49+!()!90(L*+E6!&(!$8+6+!9$6!0#2!'2$(n!X%I[!0+dL*++&'2=@!![:/E9*+-!
/99+2&+<$(E4!7!+M+04$8'2=!>+2$!)'2+;!9$!>(F+!#9;!6$/0$'2=!E(M'2=!/0(#2&!/2&!L*((&!
6$/0$+&!<(E'2=!(#$!?E/66'M+!/E(#2$6!()!L*((&!7!</E+!(#$!()!$8+!>(#2&!/2&!9$!L*+&!$(!
&+/$8B@!SZ<!$8+!(2*4!$8'2=!$8/$!>/6!8(*&'2=!$8+!L*((&!'2!>/6!6#$#0+6!/2&!$+E9(0/04!
8+E(6$/$'<!9*#=6@!!1)!4(#!8/M+!/!.(/=#*/$'(2!)/<$(0!&+);!4(#!</22($!<(2M+0$!)'L0'2(=+2!'2$(!
)'L0'2;!/2&!$8+!9*/$+*+$6!>'**!)/**!/>/4;!*+/&'2=!$(!*/$+!0+dL*++&'2=@!!!J$!'6!/L*+!$(!8/2&*+!
6#9+0)'<'/*!6<0/$<8+6Z<#$6@!!N(>+M+0;!>'**!2($!8(*&!M+66+*!<*(6+&!)(0!$((!*(2=!LZ<!*/$+!0+d
L*++&'2=!>'**!$/F+!9*/<+@!!S+6$!D#+6$'(2!$(!/6F!$(!6++!')!$8+4!8/M+!/!.(/=#*/$'(2!&+)-!8/M+!
4(#!8/&!/!E(*/0!$(($8!0+E(M+&!?'+!/!>'6&(E!$(($8Bn!X+$Q6!6/4!68+!6/46!4+6U!I8+2!/6F;!&'&!
4(#!8/M+!/24!90(L*+E6!>'$8!L*++&'2=n!"G;!?$8+0+)(0+!9$!&(+6!"GI!8/M+!.(/=!)/<$(0!&+)@BU!
>84n![:$0/<$'(2!()!/!>'6&(E!$(($8!'E9(6+6!$8+!=0+/$+6$!8+E(6$/$'<!6$0+66!(2!$8+!646$+E!
$8/$!+M+0!+:'6$6;!'$6!+M+2!>(06+!/)$+0!/!$8(0/(<$(E4;!/2&!*($6!()!6#0='</*!90(<+&#0+6@!!Y(!')!
/)$+0!+:$0/<$'(2!()!/!>'6&(E!$(($8!2(!L*++&'2=!(<<#00+&;!$8+2!$8+4!8/M+!2(0E/*!.(/=!
)/<$(06@!
!
[:/E9*+-!1)!9$!8/&!/!>'6&(E!$(($8!+:$0/<$+&;!/2&!8/&!8+E(98'*'/!%;!9$!8/&!2(!90(L*+E6!
>'$8!L*++&'2=U!8(>+M+0;!>8/$!'6!$8+!G"Xb!$8'2=!8(*&'2=!$8+!>(#2&!68#$n!X'*!$+E9(0/04!
9*/$+*+$!9*#=6!$8/$!/0+!8+*&!$(=+$8+0!L4!)'L0'2(=+2!?2($!)'L0'2B@!_+2$'6$!$+**6!4(#!$(!>/68!
E(#$8!(#$!?>'$8!6/*$!(0!/!*'$$*+!L'$!()!9+0(:'&+B!>8+2!4(#!=+$!8(E+U!L/&!LZ<!4(#!>'**!L*++&!$(!
&+/$8!/2&!6#))(</$+!(2!4(#0!(>2!L*((&!?/**!8+E(6$/$'<!9*#=6!/0+!=(2+!/2&!9$!L*++&6!$(!
&+/$8B@!I8'6!'6!X%I[!0+L*++&'2=U!2($!)0(E!6#9+0)'<'/*!6<0/$<8+6@!!G$8+0!<(2&'$'(26!()!
<(/=#*/$'(2!&+)'<'+2<4-!!K+2(008/='/!7!E(0+!()!.(/=!&+);!$8/2!/!9*/$+*+$!90(L*+E;!/2&!$8+!
9($+2$'/*!)(0!N+E+/0$80(6+6-!>8+0+!4(#!L*++&!'2$(!<*(6+&!69/<+6@!
!
Y#EE/04-!!Y(;!9*/$+*+$!90(L*+E!?+9'6$/:'6;!+<84E(6+6;!9+$+<8'/;!L*++&'2=!)0(E!6#9+0)'<'/*!
6<0/$<8+6B!M6!<(/=#*/$'(2!90(L*+E!?*/$+!0+dL*++&;!K+2(008/='/;!l1!L*++&6;!8+E/0$80(6+6B@!!I8'6!
'6!/**!L/6+&!(2!F2(>'2=!>8/$!8/99+26!$(!6E/**!M+66+*6@!
!
E. Tests for platelet abnormalities!
,@!!T'06$!&(!9*/$+*+$!<(#2$-!')!4(#!$((F!/2!/69'0'2!4(#!6$'**!8/M+!/!2(0E/*!s!()!9*/$+*+$6;!L#$!
$8+4!&(2Q$!>(0F@!!
!
H@!Y+<(2&*4!&(!S*++&'2=!$'E+!7!/66+66+6!9*/$+*+$!)#2<$'(2!
!
P@!I+6$!)(0!MgTn!R'6$(<+&'2!<()/<$(0!/66/4!d!')!E'66'2=!MgT;!0'6$(<+&'2!</2Q$!</#6+!9*/$+*+$6!
$(!<*#E9!?E(6$!6+26'$'M+!$+6$!)(0!&:Q'2=!MgT!&cB@!
!
101

Y(;!$80++!$+6$6!$8/$!/66+66!9*/$+*+$6-!9*/$+*+$!<(#2$;!L*++&'2=!$'E+;!0'6$(<+&'2!<()/<$(0!/66/4!
?)(0!MgS!_cB!
!
[:/E9*+-!!(*&+0!E/2!>'$8!(6$+(/0$80'$'6!7!90(6$/$+!>/6!0+6+<$'(2!/2&!E/66'M+!L*++&6-!')!8/M+!
(6$+(/0$80'$'6;!4(#!8/M+!9/'2;!/2&!')!4(#!8/M+!9/'2;!4(#!>'**!L+!(2!9/'2!E+&'</$'(2;!/2!
"Y%1_Y;!/2&!>'**!='M+!$+6$!0+6#*$6!7!JIZJIIZ9*/$+*+$!<(#2$!/**!2(0E/*!7!L*++&'2=!$'E+!'6!
*(2=+0@!!R:!7!9*/$+*+$!9/<F!$0/26)#6'(2!7!>8+2!4(#!='M+!)0(E!/!&(2(0;!'$!g1XX!>(0F!?&(2(0Q6!
9*/$+*+$6!/0+!2(0E/*B@!!Y(;!')!4(#0!$/F'2=!"Y%1_6;!9*/$+*+$6!2($!>(0F'2=!/2&!')!4(#!8/M+!/!
90(L!&#0'2=!6#0=+04;!='M+!9$!9*/$+*+$6!)0(E!&(2(0@!
%#&'(!&/4!P-!8+E/$(*(=4!)'*+!`!
F. Extrinsic vs. Intrinsic system:
,@!!T/<$(06!'2M(*M+&-!
[:$0'26'<!C!)/<$(0!`!
12$0'26'<!C!)/<$(06!,H;!,,;!r;!t!
S($8!68/0+!$8+!6/E+!)'2/*!<(EE(2!9/$8>/4!7!)/<$(0!,V@!!?g8/$!'6!/2($8+0!646$+E!$8/$!
8/6!/!)'2/*!<(EE(2!9/$8>/4n!.(E9*+E+2$7>8+$8+0!L4!$8+!<*/66'</*!9/$8>/4;!$8+!
/*$+02/$+!9/$8>/4;!(0!L4!$8+!K%.!9/$8>/4;!/**!'2<*#&+6!.PB!
g8/$!&(!>+!8/M+!*+)$n!,V;!e;!H!?J0($80(EL'2B;!,!?)'L0'2(=+2B!/2&!$8+2!$8+!<*($@!
!
H@!!I+6$6!'2M(*M+&-!
!
/B!J0($80(EL'2!$'E+!?JIB-!
[M/*#/$+6!$8+!+:$0'26'<!646$+E!/**!$8+!>/4!&(>2!$(!$8+!)(0E/$'(2!()!/!<*($!7!6(!'$!(2*4!
&+/*6!>'$8!`;!,V;!e;!H;!/2&!,@![2&!6$/=+!()!$8+!$+6$!'6!/!<*($!'2!$8+!$+6$!$#L+@!1"R!C!
6$/2&/0&'c+&!>/4!()!&('2=!'$!7!6$/2&/0&'c/$'(2!$+<82'D#+!?6/E+!+M+04>8+0+!'2!>(0*&B@!
!
LB!!J/0$'/*!$80(EL(9*/6$'2!$'E+!?JIIB-!
[M/*#/$+6!$8+!'2$0'26'<!646$+E!/**!$8+!>/4!&(>2!$(!/!<*($!7!6(!'$!&+/*6!>'$8!,H;!,,;!r;!t;!
,V;!e;!H;!/2&!,@!
!
[:/E9*+-!JI!'6!90(*(2=+&;!L#$!JII!'6!2(0E/*;!>8/$!'6!$8+!)/<$(0!&+)n!`!!
SZ<!$8+!90($80(EL'2!>/6!90(*(2=+&U!$8'6!'2<*#&+6!`;!,V;!e;!H;!(0!,@!!%2&!$8+!JII!/0+!
2(0E/*;!E+/2'2=!$8/$!,H;!,,;!r;!t;!,V;!e;!H;!,!/0+!/**!2(0E/*@!Y(!$8+!(2*4!(2+!0+69(26'L*+!
'6!`@!
[:/E9*+!JII!'6!90(*(2=+&;!L#$!JI!'6!2(0E/*;!>8/$!'6!$8+!)/<$(0!&+)n!T/<$(0!t!?9*/4!(&&6B@!!
g84n!1)!JII!'6!90(*(2=+&;!'$!'6!,H;!,,;!r;!t;!,V;!e;!H;!/2&!,!$8/$!'6!$8+!90(L*+E@!!N(>+M+0!
$8+!JI!'6!2(0E/*;!$8+0+)(0+!`;!,V;!e;!H;!/2&!,!/0+!2(0E/*@!!I8+0+)(0+;!'$6!(2+!$8+!JII!
)/<$(06!?,H;!,,;!r;!tB@!!g+!F2(>!>8/$!8+E(98'*'/!%!?2+:$!$(!MgS!_cB!'6!$8+!K.!)/<$(0!
&+);!$8+0+)(0+;!')!4(#!9*/4!(&&6;!'$Q6!/!)/<$(0!t!&+)@!!
!
[:/E9*+-!>8/$!&'&!>/0)/0'2!L*(<Fn![9(:'&+!0+&#<$/6+@!!Y(;!$8/$!90+M+2$+&!$8+!=/EE/!
</0L(:4*/$'(2!()!T/<$(06-!H;!`;!r;!/2&!,V@!!Y(;!>8/$!&(!4(#!)(**(>!>'$8!>/0)/0'2n!JI@!!
g8/$!'6!$8+!(2*4!)/<$(0!4(#!/0+!2($!+M/*#/$'2=!$(!>8+2!4(#!/0+!&('2=!/!JI!$'E+!)(0!/!
9+06(2!(2!>/0)/0'2n!T/<$(0!r!7!LZ<!'$6!9/0$!()!$8+!'2$0'26'<!646$+E@!!g8/$!'6!$8+!JII!'2!/!
9+06(2!(2!>/0)/0'2n!J0(*(2=+&!LZ<!)/<$(06!H!/2&!,V!/0+!M'$!5!&+9+2&+2$!)/<$(06!'2!$8+!
)'2/*!<(EE(2!9/$8>/4@!!N(>+M+0;!JI!&(+6!/!L+$$+0!3(L!'2!+M/*#/$'2=!>/0)/0'2!LZ<!P!(#$!
()!$8+!^!$8'2=6!$8/$!'$Q6!'2M(*M+&!'2!/0+!'2!$8+!90($80(EL'2!$'E+@!!Y(;!L($8!JI!/2&!JII!/0+!
90(*(2=+&!>8+2!4(#!/0+!(2!>/0)/0'2;!L#$!JI!'6!L+$$+0!&'/=2(6$'<!$((*@!
!
102

[:/E9*+-!!>8/$!&(!4(#!)(**(>!8+9/0'2!$8+0/94!>'$8n!JII!?+M/*#/$+6!$8+!'2$0'26'<!
9/$8>/4B@!!T/<$(06!$8/$!/2$'$80(EL'2!111!F2(<F6!())-!,H;!,,;!`;!,V;!H;!,!/0+!/**!2+#$0/*'c+&!
L4!/2$'$80(EL'2!111@!!Y(;!>'$8!9$!(2!8+9/0'2;!JII!'6!90(*(2=+&;!>8/$!'6!$8+!JIn!
J0(*(2=+&@!!1$Q6!3#6$!$8/$!$8+!JII!&(+6!/!L+$$+0!3(L!/$!+M/*#/$'2=!8+9/0'2!?E/24!)/<$(06!
/2$'$80(EL'2!111!'2M(*M+&!>'$8B!!
!
Y(;!SGIN!JI!/2&!JII!/0+!90(*(2=+&!')!(2!>/0)/0'2!(0!8+9/0'2U!8(>+M+0;!'$!$#026!(#$!$8/$!
JII!'6!L+$$+0!/$!+M/*#/$'2=!8+9/0'2!/2&!JI!'6!L+$$+0!)(0!>/0)/0'2@!!!
!
II. Fibrinolytic system: Plasmin
!
J*/6E'2!7!*+/M+6!<0#EL6!7!'$6!L0+/F6!&(>2!$8'2=6!?)'L0'2(=+2;!)'L0'2;!<(/=#*/$'(2!)/<$(06B!7!$8'2F!
)'L0'2(XbI1.!646$+E@!!g8+2!'$!L0+/F6!&(>2!/!<*($;!$8+0+!/0+!E/24!9'+<+6!?'+!)'L0'2B!*+)$!/0(#2&;!
>8'<8!/0+!)'L0'2!&+=0/&/$'(2!90(&#<$6@!!!
!
g8/$!'6!$8+!6'2=*+!L+6$!6<0++2'2=!$+6$!)(0!_1.n!D-dimers!?L+$$+0!/26>+0B!(0!)'L0'2!69*'$!90(&#<$6@!
g8/$!9*/6E'2!&(+6!'6!L0+/F6!$8'2=6!/9/0$;!*+/M'2=!<0#EL6!L+8'2&!/2&!4(#!8/M+!&+=0/&/$'(2!
90(&#<$6@!_!&'E+06!/0+!$8+!/L6(*#$+!L+6$!$+6$!)(0!_1.!?&'d!E+/26!HB@!!g8+2!4(#!)(0E!/!)'L0'2!<*($;!
)/<$(0!,P!?)'L0'2!6$/L'*'c'2=!)/<$(0B!E/F+6!$8+!<*($!6$0(2=+0@!!N(>!&(!4(#!6$/L'*'c+!6$0/2&6n!X'2F!$8+E!
L4!9#$$'2=!<(22+<$'(26!L+$>++2!$8+E!$(!E/F+!$8+E!6$0(2=+0!?$8'6!'6!>8/$!)/<$(0!,P!&(+6B@!!Y(;!8(>!
&(!4(#!E/F+!<(**/=+2!6$0(2=+0n!S4;!*'2F'2=!$8+E!$(!'2<0+/6+!$8+!$+26'*+!6$0+2=$8!?)/<$(0!,P!>'**!9#$!
/!<0(66L0'&=+!'2!)'L0'2B@!!g8/$!_d&'E+0!'6!&+$+<$'2=!/0+!(2*4!$8(6+!)'L0'2!)/<$(06!$8/$!8/M+!/!*'2F!?'+!
>8+2!$8+0+!/0+!$>(!()!$8+E!8+*&!$(=+$8+0;!$8'6!>8/$!$8+!$+6$!9'<F6!#9B@!!g8/$!&(+6!$8'6!/L6(*#$+*4!
90(M+n!I8/$!$8+0+!'6!/!)'L0'2!<*($@!!_(!4(#!6++!$8'6!'2!_1.n!b+6@!!!
!
[:/E9*+-!!g(#*&!4(#!6++!'$!')!4(#!L0(F+!/9/0$!/!9*/$+*+$!$80(EL#6!'2!/!<(0(2/04!/0$+04n!?R+E+EL+0!
/!9*/$+*+$!$80(EL#6!'6!/!L#2<8!()!9*/$+*+$6!8+*&!$(=+$8+0!L4!)'L0'2B@!Y(;!>8/$!>(#*&!$8+!_!&'E+0!
/66/4!L+!')!4(#!L0(F+!/9/0$!$8/$!<*($n!12<0+/6+&;!4(#!>(#*&!6++!'2<0+/6+&!_!&'E+06!/2&!>(#*&!6++!
$8+!*'$$*+!)'L0'2!6$0/2&6!8+*&!$(=+$8+0!L4!<0(66!*'2F'2=@!!I8+4!()$+2!&(!$8/$!$(!6++!')!4(#!8/M+!
0+</2/*'c+&!(0!')!4(#!=($!0'&!()!4(#0!$80(EL#6@!
!
[:/E9*+-!!'$!'6!()$+2!/*6(!6++2!>'$8!/!9#*E(2/04!+EL(*#6;!LZ<!')!4(#!8/M+!/!9#*E(2/04!+EL(*#6;!
(2+!$+6$!'6!/!_!&'E+0!LZ<!4(#!>'**!)(0E!/!<*($!$8/$!>'**!/<$'M/$+!$8+!)'L0'2(*4$'<!646$+E;!/2&!'$!>'**!$04!
$(!6$/0$!L0+/F'2=!'$!&(>2;!/2&!$8+0+!>'**!L+!/!0+*+/6+!()!_!&'E+06@!!Y'2=*+!L+6$!$+6$!)(0!_1.@!l((&!
$+6$!)(0!9'<F'2=!#9!9#*E(2/04!+EL(*#6;!/*(2=!>'$8!M+2$'*/$'(2Z9+0)#6'(2!6</26@!![:<+**+2$!$+6$!$(!6++!
')!4(#!8/M+!0+9+0)#6'(2!/)$+0!='M+2!$dJ%!LZ<!'$!90(M+6!$8/$!')!_!&'E+06!>+0+!90+6+2$;!/!)'L0'2!<*($!
E#6$!L+!90+6+2$!?)'L0'2!>/6!$8+0+!6(!'$!90(M+6!'$B@!
!
III. Vessel abnormalities
A. Senile purpura-!Y++2!(2!$8+!L/<F!()!8/2&6!()!/2!(*&!9+06(2!7!$8+4!8'$!$8'2=6!/2&!=+$!6+2'*+!
9#09#0/U!M+66+*6!=+$!#26$/L*+!/6!4(#!=+$!(*&+0!/2&!6#L<#$/2+(#6!$'66#+!$8'26@!g8+2!4(#!8'$!
4(#06+*);!SkQ6!0#9$#0+!/2&!4(#!=+$!+<84E(6+6!7!</**+&!6+2'*+!9#09#0/;!/2!/=+!&+9+2&+2$!)'2&'2=@!!
G2*4!90+6+2$!'2!9*/<+6!$8/$!2(0E/**4!8'$!$8'2=6;!L/<F!()!$8+!8/2&6!/2&!$8+!68'26@!![:/E9*+-!K(E!
>/6!9#$!'2!(*&!/=+!8(E+!/2&!$8+!<8'*&0+2!>+0+!=(22/!6#+!$8+!(*&!/=+!8(E+!)(0!/L#6+@!!_(!$8+!
<8'*&0+2!8/M+!/!</6+n!"(;!LZ<!'$!8/6!2($8'2=!$(!&(!>'$8!/L#6+!/2&!'6!/2!/=+!&+9+2&+2$!)'2&'2=@!!
[:/E9*+-!!2(>!')!$8+4!/*6(!6/>!+<84E(6+6!(2!L#$$(<F6!/2&!L/<F;!$8'6!'6!2($!/!2(0E/*!9*/<+!$(!
=+$!$0/#E/!0+*/$+&!$(!3#6$!L#E9'2=!'2$(!$8'2=6!7!$8/$!>(#*&!L+!/L#6+@!!Y+2'*+!9#09#0/!'6!$8+!
103

</#6+!()!+<84E(6+6!(2!$8+!L/<F!()!$8+!+*&+0*4Q6!8/2&@!![M+04(2+!>'**!=+$!$8'6;!+M+04(2+;!2(!(2+!
'6!+:+E9$@!
!
B.!!Osler Weber Rendu Dz aka hereditary telangiectasias-!K/24!()!$8+6+!9$6!8/M+!<80(2'<!
T+!&+)!/2+E'/;!0+*/$+&!$(!9+06'6$+2$!l1!L*++&6@!b(#!</2!E/F+!$8+!&:!>'$8!J[!()!$8+!9$@!!I8+!9$!
>'**!8/M+!6E/**!0+&!&($6!</**+&!$+*/2='+<$/6'/6!/2&!')!4(#!*((F!(2!$8+!*'96!/2&!$(2=#+!4(#!>'**!6++!
$+*/2='+<$/6'/6;!/2&!')!4(#!&(!+2&(6<(94;!4(#!>'**!6++!$8+!*'$$*+!0+&!&($6!$80(#=8(#$!$8+!l1!$0/<$@!!
g8/$!&(+6!$8'6!9$!8/M+n!G6*+0!g+L+0!R+2&#!_c!/F/!8+0+&'$/04!$+*/2='+<$/6'/6@!!!1$!'6!$8+!K.!
=+2+$'<!M/6<#*/0!&c@!!I8+0+)(0+;!4(#!</2!6++!>84!4(#!=+$!<80(2'<!T+!&+)!/2&!L*++&6!LZ<!$8+!
$+*/2='+<$/6'/6!>'**!0#9$#0+@!!!1$!'6!F'2&!()!*'F+!$8+!/2='(&469*/6'/!()!$8+!6F'2!
!!
Y(;!$8+6+!/0+!$8+!$>(!M+66+*!&cQ6-!6+2'*+!9#09#0/!/2&!G6*+0!g+L+0!R+2&#!&c;!/2&!/*6(!6<#0M4@!
IV. Platelet Abnormalities
!
T'2&'2=6!()!9*/$+*+$!90(L*+E6-!!/**!8/M+!/!90(L*+E!'2!E/F'2=!/!8+E(6$/$'<!9*#=;!+9'6$/:'6!?K.B;!
9+$+<8'/;!+<84E(6+6;!/2&!L*++&'2=!)0(E!6#9+0)'<'/*!6<0/$<8+6Z<#$6@!
!
[:/E9*+-!,H!4Z(!F'&;!>'$8!\R1!(2+!>++F!/=(;!90+6+2$6!>'$8!+9'6$/:'6@!!J+0)(0E!J[;!/2&!4(#!6++!
*+6'(26!$8/$!&(!"GI!L*/2<8!?2++&!$(!F2(>!$8+!&'))+0+2<+!L+$>++2!9+$+<8'/!/2&!69'&+0!/2='(E/6-!
9+$+<8'/6!&(!2($!L*/2<8!LZ<!L*++&'2=!'2$(!$8+!6F'2U!69'&+0!/2='(E/!g1XX!L*/2<8!LZ<!'$Q6!/2!%k!
)'6$#*/B@!!J*/$+*+$!<(#2$!'6!HV;VVV@!!g8/$!'6!4(#0!&:n!1&'(9/$8'<!$80(EL(<4$(9+2'<!9#09#0/@!!!
K+<8/2'6E-!1=l!/=/'26$!$8+!9*/$+*+$@!g8/$!$49+!()!NJb!'6!$8'6n!I49+!11@!!g8(!'6!0+E(M'2=!$8+!
9*/$+*+$n!K/<0(98/=+6!'2!$8+!69*++2!?LZ<!1=l!E/0F+&!$8+!9*/$+*+$!)(0!&+6$0#<$'(2!L4!$8+!
E/<0(98/=+B@!I8'6!'6!6'E'*/0!$(!/#$('EE#2+!8+E(*4$'<!/2+E'/;!L#$!$8'6!'6!/#$('EE#2+!
INRGKSG<4$(9+2'/@!!R:!7!')!$8+4!/0+!M+04!64E9$(E/$'<;!='M+!<(0$'<(6$+0('&6U!')!2($;!*+/M+!/*(2+!/2&!
'$!>'**!=(!/>/4@!
!
[:/E9*+-!>(E/2!>'$8!iOj!69+/0E/2!%L!$+6$;!+9'6$/:'6;!9+$+<8'/;!=+2+0/*'c+&!$+2&+0!
*4E98/&+2(9/$84;!/2&!69*+2(E+=/*4@!!J$!8/6!X\J\Y;!/#$('EE#2+!$80(EL(<4$(9+2'/;!6/E+!
E+<8/2'6E-!1=l!/#$(d/2$'L(&'+6!/=/'26$!9*/$+*+$6;!/!$49+!11!NJb!0:2;!>'$8!E/<0(98/=+!0+*/$+&!
0+E(M/*@!
!
A. TTP ?$80(EL($'<!$80(EL(<4$(9+2'<!9#09#0/B!/2&!HUS ?8+E(*4$'<!#0+E'<!642&0(E+B!
S($8!8/M+!6'E'*/0!9/$8(9846'(*(=4@!!I8+6+!/0+!"GI!_1.;!$8+0+)(0+!4(#!/0+!2($!<(26#E'2=!
<(/=#*/$'(2!)/<$(06U!$8+!JI!/2&!JII!/0+!$($/**4!/2&!#2+D#/**4!2(0E/*@!!g8/$!4(#!6++!'6!/!
)(0E/$'(2!()!/!$+E9(0/04!8+E(6$/$'<!9*#=!()!6E/**!L*((&!M+66+*6!?L*++&'2=!$'E+B!/2&!$8+!
<(/=#*/$'(2!646$+E!<(2M+0$'2=!)'L0'2(=+2!$(!)'L0'2!$(!)(0E!/!6$0(2=!9*/$+*+$!9*#=@!!Y(!'2!IIJ!
/2&!N\Y;!6(E+$8'2=!'2!$8+!9*/6E/!&/E/=+6!6E/**!M+66+*6!$80(#=8(#$!4(#0!L(&4;!6(!$8/$!
9*/$+*+$6!6$'<F!/2&!9*/$+*+$6!/==0+=/$+!/2&!+M+2$#/**4!)(0E!)'0E!9*/$+*+$!9*#=6!'2!/**!$8+!
M+66+*6!()!$8+!+2$'0+!L(&4@!!g(#*&!4(#!<(26#E+!/**!$8+!9*/$+*+$6!>'$8!/**!$8/$!6$'<F'2=!=('2=!
(2n!b+6@!!g'**!4(#!L*++&!LZ<!()!$8/$n!b+6@!!g8/$!>'**!4(#!6++!'2!4(#0!9+0'98+0/*!L*((&n!RS.!
>'**!L+!6E/68+&;!*+/&'2=!$(!6<8'6$(<4$+6@!I8+0+)(0+!4(#!>'**!8/M+!/!E'<0(/2='(9/$8'<!
8+E(*4$'<!/2+E'/@!!J$6!>'**!8/M+!$80(EL(<4$(9+2'/;!)+M+0;!0+2/*!)/'*#0+!?LZ<!=*(E+0#*/0!
</9'**/0'+6!>'**!8/M+!$8+6+!9*/$+*+$!9*#=6!'2!$8+EB@!!%L6(*#$+*4!8/M+!$(!8/M+!6<8'6$(<4$+6!'2!
$8+!9+0'98+0/*!L*((&!>'$8!8+E(*4$'<!/2+E'/!$(!E/F+!$8+!&:@!!!
!
,@!!H!</#6+6!()!N\Y-!!
!
104

/B!V,e`-N`![@!<(*'!?$(:'2!90(&#<'2=![@!<(*'!$8/$!</2!L+!90+6+2$!'2!#2&+0<((F+&!L++)@!!
I8+!$(:'2!&/E/=+6!$8+!M+66+*;!*+/&'2=!$(!$8+!&c;!/2&!$8'6!'6!</**+&!N\Y@!!G2+!()!$8+!
K.!</#6+6!()!/<#$+!0+2/*!)/'*#0+!'2!<8'*&0+2!C!N\Y@!
!
LB!Y8'=+**/!$(:'2!?M+04!9($+2$B!$8/$!*+/&6!$(!68'=+**(6'6!/2&!$8+2!N\Y@!!
12!IIJZN\Y!>'**!6++!*(>!9*/$+*+$!<(#2$;!90(*(2=+&!L*++&'2=!$'E+;!/2&!2(0E/*!JIZJII!
LZ<!4(#Q0+!2($!<(26#E'2=!<(/=#*/$'(2!)/<$(06;!L#$!(2*4!<(26#E'2=!9*/$+*+$6@!!!
V. Coagulation deficiency
!
12!.(/=#*/$'(2!&+)'<'+2<4;!4(#!&'))+0+2$!6'=2Q6!64E9$(E6;!6#<8!/6-!&+*/4+&!L*++&'2=!'+!=(!$80(#=8!
(9+0/$'(2!>'$8!2(!90(L;!$8+2!$8+!9$!6$/0$6!E(M'2=!/0(#2&!$8/$Q6!>8+2!'$Q6!L/&@!!g8+2!9$!8/6!/2!
(9+0/$'(2!/2&!$8+4!6$/0$!L*++&'2=!(#$!()!$8+!>(#2&;!$8+!K..!'6!2($!/!<(/=#*/$'(2!)/<$(0!&+)'<'+2<4U!
$8+!K..!'6!&#+!$(!6#$#0+!6*'99+&!(0!/!L*++&@!!g8+2!4(#!8/M+!/!<(/=!&+)'<'+2<4;!3#6$!8/M+!$(!$'+!'$!
())@!!!
!
[:/E9*+-!!E(*/0!+:$0/<$'(2!>'$8!<(26$/2$!((c'2=!()!L*((&!LZ<!2($8'2=!8(*&'2=!$8(6+!6E/**!M+66+*6!
$(=+$8+0!+:<+9$!/!$+E9!8+E(6$/$'<!9*#=!7!2++&!/!$'=8$!)'L0'2!L(2&!$(!9*#=!'$!#9@!!!
!
[:/E9*+-!1$!'6!68(>'2=!8+E(008/=+!'2$(!$8+!)/6<'/*!<(E9/0$E+2$!()!$8+!$8'=8@!!12!$8+!F2++;!$8+0+!
/0+!0+9+/$+&!8+E/0$80(6+6!/2&!$8+!9$!8/6!8+E(98'*'/!%@!!g'**!2($!6++!8+E/0$80(6+6!(0!L*++&'2=!'2$(!
69/<+6!>'$8!9*/$+*+$!/L2(0E/*'$'+6;!L#$!(2*4!<(/=#*/$'(2!)/<$(0!&+)'<'+2<4@!!
!
A. Must know the difference between hemophilia A and vWB Dz!?$8+6+!/0+!$8+!F+4!
<(/=#*/$'(2!&+)'<'+2<'+6B!!
!
,. vWB Dz!7!E'66'2=!MgT;!$8+0+)(0+!$8+0+!'6!/!9*/$+*+$!/&8+6'(2!&+)+<$;!$8+0+)(0+;!$8+4!
8/M+!/**!$8+!6'=26!/2&!64E9$(E6!()!/!JX%I[X[I!90(L*+E@!!N(>+M+0;!$8+4!/*6(!8/M+!/!)/<$(0!
t!&+)'<'+2<4;!L#$!'$!'6!M+04!E'*&!/2&!2+M+0!6+M+0+@!!Y(;!$8+4!8/M+!IgG!/L2(0E/*'$'+6!7!$8+4!
8/M+!/!9*/$+*+$!&+)+<$!%"_!/!<(/=#*/$'(2!)/<$(0!&+)+<$@!I8'6!'6!>84!$8+4!</2!8/M+!
E+2(008/='/!/2&!l1!L*++&'2=6!?$8'6!$8+!<(/=#*/$'(2!9/0$!()!'$BU!>'**!/*6(!6++!8'6$(04!()!
+9'6$/:'6!/2&!$8+4!L0#'6+!+/64@!!I8+0+!/0+!P!9/0$6!()!$8+!)/<$(0!t!E(*+<#*+-!MgT;!)/<$(0!t!
<(/=#*/$+!?9/0$!()!'2$0'26'<!646$+EB;!t!%=@!!I8+!t!%=!8/6!/!</00'+0!)#2<$'(2-!'$!</00'+6!/0(#2&!
MgT!/2&!)/<$(0!t!<(/=#*/2$!'2!$8+!L*((&!?6(!'$Q6!/!<8/#))+#0B!d!6(!'$!)#2<$'(26!/6!/!</00'+0!
90($+'2@!!%**!P!()!$8+6+!</2!L+!E+/6#0+&@!!
!
2. Differences in two dzs:
/B!l+2+$'<6-!12!9$6!>'$8!8+E(98'*'/!%!'$Q6!/2!h!*'2F+&!0+<+66'M+!&c;!$8+0+)(0+!E/*+6!=+$!$8+!
&c@!!g8+0+/6!Mg_c!'6!%#$(6(E/*!&(E'2/2$;!/2&!(2*4!(2+!()!$8+!9/0+2$6!8/M+!$(!8/M+!$8+!
/L2(0E/*'$4!/2&!eVW!()!$8+!F'&6!>'**!8/M+!$8+!9($+2$'/*!$(!=+$!$8+!&c@!
!
LB!"#EL+0!()!&+)'<'+2$!)/<$(06-!N+E(98'*'/!%!(2*4!8/6!(2+!)/<$(0!$8/$!'6!&+)'<'+2$-!t!
/2$'<(/=#*/2$U!$8+4!8/M+!2(0E/*!t!%=!*+M+*6!/2&!2(0E/*!MgT!*+M+*6@!!Mg_c!8/6!%XX!P!
$8'2=6!&+<0+/6+&-!t!%=;!)/<$(0!t!/2$'<(/=#*/2$!?E'*&*4!&+<0+/6+&B;!/2&!MgT@!
!
B. What drug can increase the synthesis of all three of these factor 8 molecules?!I8+!
&0#=!<(E+6!)0(E!%_N!/2&!'6!</**+&!&+6E(90+66'2!?&&/&9B@!!I8'6!</2!'2<0+/6+!$8+!642$8+6'6!()!/**!
$80++!)/<$(0!t!E(*+<#*+6@!!1$!>'**!8+*9!$0+/$!E'*&!8+E(98'*'/!%;!/2&!'6!$8+!_G.!)(0!Mg_c@!
105

12!>(E/2;!')!$8+4!8/M+!E+2(008/='/!/2&!2(0E/*!+M+04$8'2=!+*6+;!4(#!8/M+!Mg_c@!I8+4!9#$!4(#!
(2!L'0$8!<(2$0(*!/2&!$8/$!$((F!$8+!L*++&'2=!/>/4@!12!(2+!()!$8+!</6+6;!$8+!_0@!(0&+0+&!JI;!JII;!
/2&!L*++&'2=!$'E+!$+6$6@!!I8+!$+6$6!)(0!JI!/2&!JII!>+0+!2(0E/*!/2&!$8+!L*++&!$'E+!>/6!2(0E/*@!
I8+!6+26'$'M'$4!)(0!$8+6+!$+6$6!'6!(2*4!eVW;!6(!&(!2($!&+9+2&!(2!$8+6+@!!I8+!0'6$(<+&'2!<()/<$(0!
/66/4!'6!$8+!$+6$!()!<8('<+!)(0!Mg_c;!/2&!>'**!L+!/L2(0E/*@!![6$0(=+2!'2<0+/6+6!$8+!642$8+6'6!()!
/**!)/<$(0!t!E(*+<#*+6@!!!
!
Y(;!H!$8'2=6!'2<0+/6+!$8+!642$8+6'6!()!/**!$8+!)/<$(0!t!E(*+<#*+6-!&+6E(90+66'2!/2&!L'0$8!<(2$0(*!
9'**6!?_G.!)(0!>(E+2B@!
!
C. USMLE Step 2-!%2$'d98(698(*'9'&6!642&0(E+!?(2+!()!$8+!</#6+6!()!69(2$/2+(#6!/L(0$'(2B!
'2<*#&+6-!X#9#6!/2$'<(/=#*/2$!?2($!/2!/2$'<(/=#*/2$;!L#$!$8+!(99(6'$+-!$80(EL(=+2'<B!/2&!/2$'d
</0&'(*'9'2!/2$'L(&'+6@!!S($8!()!$8+6+!/2$'L(&'+6!</#6+!M+66+*!$80(EL(6'6@!!X#9#6!/2$'<(/=#*/2$!'6!
9/0$!()!$8+!642&0(E+!$8/$!90(&#<+6!M+66+*!$80(EL(6'6@!!%*6(!6++2!'2!N1k!9$@!!%2$'d</0&'(*'9'2!
/2$'L(&'+6!8/M+!/!8'6$(04!()!8/M'2=!/!L'(*(='</*!)/*6+!O!6498'*'6!6+0(*(=4@!!Y(;!8+0+!4(#!/0+!>'$8!
k_RX!/2&!RJR!L+'2=!9(6'$'M+@!I(!<(2)'0E;!TI!%SY!>(#*&!L+!2+=/$'M+!?$+6$!%=!'6!L++)!
</0&'(*'9'2B@!!I8+0+)(0+!E/F+6!$8+!k_RX!/2&!RJR!)/*6+!9(6'$'M+;!LZ<!$8+!<(2)'0E/$(04!$+6$!>/6!
2+=/$'M+@!Y(!>84!>/6!$8+!RJR!9(6'$'M+!'2!$8+!)'06$!9*/<+;!LZ<!$8+!$+6$!/2$'=+2!'6!L++)!</0&'(*'9'2@!!
I8+0+)(0+!6498'*'6!/2$'L(&'+6!0+/<$!$(!/=/'26$!$8/$!L++)!</0&'(*'9'2;!/2&!90(&#<'2=!/!9(6'$'M+!
0+/<$'(2@!!S#$!6(!$8+!/2$'d</0&'(*'9'2!/2$'L(&'+6@!!I8+0+)(0+!4(#!=+$!/!L'(*(='</*!)/*6+!iOj!>'$8!/!
6498'*'6!6+0(*(=4@!!1)!4(#!8/M+!/!>(E/2!>'$8!/!L'(*(='</*!)/*6+!iOj!6498'*'6!6+0(*(=4;!>8/$!'6!$8+!
M+04!)'06$!$+6$!4(#!68(#*&!=+$n!Y+0#E!/2$'!%"%!/2$'L(&4!LZ<!68+!</2!&+M+*(9!*#9#6@!!%2$'d
</0&'(*'9'2!/2$'L(&'+6!/0+!/!M+04!<(EE(2!)+/$#0+!()!X\J\Y@!K/$$+0!()!)/<$;!/!L'(*(='</*!)/*6+!iOj!
>'$8!/!6498'*'6!6+0(*(=4!'6!/!<0'$+0'/!)(0!&'/=2(6'2=!X#9#6@!!
!
106

D. Disseminated Intravascular Coagulation (DIC)
_'66+E'2/$+&!C!/**!(M+0!$8+!L(&4!
12$0/M/6<#*/0!C!>'$8'2!$8+!M+66+*!!
.(/=#*/$'(2!C!<*($$'2=!?)(0E'2=!<*($6!$80(#=8(#$!$8+!L(&4B!
!
g8/$!'6!<(26#E+&!'2!/!<*($n!T'L0'2(=+2;!e;!t;!90($80(EL'2;!9*/$+*+$6!
!
12!<*($!$#L+!)(0E!/!<*($!7!(2!$(9!'6!6+0#E!/2&!$8+!6+0#E!'6!E'66'2=!>8/$!'6!<(26#E+!'2!/!<*($!
?)'L0'2(=+2;!e;!t;!90($80(EL'2;!9*/$+*+$6B@!!I8'6!'6!>8/$!4(#!8/M+!'2!_1.!7!<(26#E'2=!$8+6+!
<(/=#*/$'(2!)/<$(06;!'2<*#&'2=!9*/$+*+$6;!'2!$8(6+!<*($6!$80(#=8(#$!$8+!L(&4U!$8+0+)(0+!4(#!8/M+!H!
&cQ6!/$!(2<+@!!b(#!8/M+!?/B!$80(EL'!'2!M+66+*6;!/2&!/$!$8+!6/E+!$'E+!4(#!/0+!?LB!/2$'<(/=#*/$+&!
LZ<!/**!4(#!8/M+!<'0<#*/$'2=!/0(#2&!'6!6+0#E;!4(#!&(2Q$!8/M+!9*/6E/!LZ<!4(#!<(26#E+&!$8+!
<(/=#*/$'(2!)/<$(067</**+&!/!8+E(008/='<!$80(EL(6'6!642&0(E+@!!I8+!642&0(E+!'6!M+04!#2#6#/*!
/2&!$>(!$8'2=6!/0+!8/99+2'2=!/$!$8+!6/E+!$'E+@!!g8/$!6$/0$+&!/**!$8'6!())n!I8+!'2$0/M/6<#*/0!
<(/=#*/$'(2!'6!0+69(26'L*+!)(0!<(26#E'2=!/**!$8+6+!$8'2=6@!!!
!
Y(;!>8/$!</#6+6!$8'6n!!K..!C!Y+9$'<!68(<F!?K..!6+9$'<!68(<F!C![@!<(*'B;!62/F+!L'$+!?2($!$8+!
2+#0($(:'2!$49+6;!L#$!$8+!0/$$*+62/F+6B;!/2&!%R_Y@!!!
k+04!6'E9*+!$(!0+<(=2'c+!7!$8+4!L*++&!)0(E!+M+04!(0')'<+!(0!6<0/$<8;!/2&!+M+2!')!$8+0+!'6!/!
9#2<$#0+!>(#2&@!
!
.*/66'<!_1.!C!_:!'6!+/64;!LZ<!')!4(#!<(26#E'2=!/**!$8+!.(/=#*/$'(2!)/<$(06;!JI!/2&!JII!
90(*(2=+&!/2&!9*/$+*+$!<(#2$!'6!&+<0+/6+&;!&!&'E+06!iOj@!I8+!$+6$!)(0!_:!'6!_d&'E+0!$+6$@!
!
[:/E9*+-!!9$!>'$8!/L0#9$'(!9*/<+2$/!/2&!8/&!/E2'($'<!)*#'&!+EL(*'6E@!!%E2'($'<!)*#'&!=+$6!'2$(!
<'0<#*/$'(2!()!$8+!E(E;!>8'<8!<(2$/'26!$80(EL(9*/6$'2;!6(;!&+/$8!'6!)0(E!_1.;!2($!)0(E!$8+!
/E2'($'<!+EL(*'6E@!!SZ<!$8+!$80(EL(9*/6$'2!>'$8'2!$8+!/E2'($'<!)*#'&!90+<'9'$/$+&!_1.@!
!
[:/E9*+-!!8+0+&'$/04!$80(EL(6'6!C!4(#2=!9+06(2!>Z!_kI;!2($!2(0E/*!/2&!)/E'*4!8:!
!
[:/E9*+-!)/<$(0!e!*+'&+2!7!/L2(0E/*!)/<$(0!e!$8/$!90($+'2!.!/2&!Y!</22($!L0+/F&(>2;!$8+0+)(0+!
$8+0+!'6!/2!'2<0+/6+!'2!)/<$(0!e;!>8'<8!90+&'69(6'2=!$(!$80(EL(6+6!
!
[:/E9*+-!!!%2$'$80(EL'2!111!&+)'<'+2<4!7!K..!>(E/2!L'0$8!<(2$0(*!?$8+0+)(0+;!$8+!K..!'6!
/<D#'0+&!7!</2!/*6(!L+!=+2+$'<!7!'+!9$!>'$8!_kI;!9#$!(2!>/0)/0'2!/2&!8+9/0'2;!/2&!&(!/!JII!'6!
2(0E/*!/)$+0!8+9/0'2;!6(!4(#!='M+!E(0+!8+9/0'2;!/2&!$8+!JII!'6!6$'**!2(0E/*@!!Y(;!9$!>'$8!_kI;!
='M+!8+9/0'2;!JII!0+E/'26!2(0E/*!C!%I!111!&+)@!LZ<!8+9/0'2!>(0F6!(2!%I!111@!!"(0E/**4;!$8+!
8+9/0'2!)/<'*'$/$+6!/2$'$80(EL'2!111!$8+0+L4!'2<0+/6'2=!$8+!JII@!!12!$8'6!</6+;!2(!E/$$+0!8(>!
E#<8!8+9/0'2!'6!'23+<$+&;!$8+0+!'6!2(!<8/2=+!'2!JII;!$8+0+)(0+!$8+0+!'6!2(!%2$'$80(EL'2!111!)(0!
$8+!8+9/0'2!$(!>(0F!(2!?$8'6!'6!8(>!&:!'6!#6#/**4!E/&+!7!L4!E'6$/F+B@!
!
E. Coagulation disorders summary:
J*/$+*+$!<$ZL*++&'2=!$'E+ZJIZJII!?L/6'<!$+6$6!$(!+M/*#/$+!N+E(6$/6'6B!
%69'0'2-!";!N;!";!"!
1&'(9/$8'<!$80(EL(<4$(9+2'<!9#09#0/!?K..!()!$80(EL(<4$(9+2'/!'2!F'&6B-!X;!N;!";!"!
IIJZN\Y-!X;!N;!";!"!
N+E(98'*'/!%-!";!";!";!N!
Mg_c-!";!N;!";!N!?6(;!)(0!*/L!$+6$6;!E/'2!&'))!)0(E!8+E+!%!'6!L*++&'2=!$'E+B!
>/0)Z8+9-!";!";!N;!N!?1"R!JI!C!>/0)/0'2;!;!JII!C!8+9B!!
107

!
_'6+/6+!
%69'0'2!
1IJ!
IIJZN\Y!
N+E(98'*'/!%!
MgS!_c!
g/0)/0'2ZN+9/0'2
_1.!
J*/$+*+$!.(#2$!
"X!
XGg!
XGg
"X!
"X!
"X!
XGg!
S*++&'2=!I'E+!
N1lN!
N1lN!
N1lN
"X!
N1lN!
"X
N1lN!
JI!
"X!
"X!
"X
"X!
"X!
N1lN!?gB!
N1lN!
JII!
"X!
"X!
"X!
N1lN!
N1lN!
N1lN!?NB
N1lN!
VI. Blood Groups

!
A. Different blood groups and what is floating around in the serum-!G!'6!E(6$!<(EE(2;!
%!'6!H2&!E(6$!<(EE(2;!S!'6!P0&!<(EE(2;!/2&!%S!'6!$8+!0/0+6$!
O-!8/M+!/2$'d%!1=K;!/2$'dS!1=K;!/2$'d%S!1=l!!
A-!/2$'!S!1=K!
B-!/2$'!%!1=K!
AB-!2($8'2=!
Newborn-!2($8'2=;!>84n!I8+4!&(2Q$!L+='2!642$8+6'c'2=!1=K!#2$'*!/)$+0!$8+4!/0+!L(02!/2&!
(2*4!/)$+0!HdP!E(2$86!&(!$8+4!6$/0$!642$8+6'c'2=!1=l@!
Elderly-!2($8'2=!7![:/E9*+-!/2!(*&!9+06(2!>8(!'6!L*((&!=0(#9!%!/2&!L4!E'6$/F+!0+<+'M+&!
L*((&!=0(#9!S;!L#$!&'&!2($!&+M+*(9!/!8+E(*4$'<!$0/26)#6'(2!0:2!7!>84n!I8+'0!*+M+*6!()!%LQ6!
/0+!*(>!>8+2!$8+4!=+$!(*&+0!$8/$!$8+0+!>/62Q$!/24$8'2=!/0(#2&!$(!/$$/<F!$8(6+!<+**6@!
B. Associated Diseases:
!
g8'<8!'6!/66(<'/$+&!>'$8!=a6$0'<!</2<+0n!%!
g8'<8!'6!/66(<'/$+&!>'$8!&#o&+2/*!#*<+0n!G!
\2'M+06/*!&(2(0n!G!?</2!='M+!$8+'0!L*((&!$(!/24(2+!LZ<!8/M+!"G!/2$'d%!(0!/2$'dS!%=B@!
g8/$!'6!$8+!(2*4!L*((&!=0(#9!G!</2!=+$n!G!
\2'M+06/*!0+<'9'+2$n!%S!LZ<!$8+4!8/M+!2(!%LQ6!$(!/$$/<F!$8(6+!<+**6!
!
C. Other Antigens:
,@!R8!O!/2$'=+2!E+/26!$8/$!4(#!/0+!iOj!)(0!_!/2$'=+2!
!
H@!_#))4!%=!'6!E'66'2=!'2!L*/<F!9(9Q2U!$8+0+)(0+!2($!/6!*'F+*4!$(!=+$!9*/6E(&'#E!M'M/:!
?E/*/0'/B!LZ<!$8+!%=!$8+!J@!M'M/:!2++&6!$(!9/0/6'$'c+!$8+!RS.Q6!'6!$8+!_#))4!/=!/2&!')!4(#!
&(2Q$!8/M+!$8+!%=!$8+!J@!M'M/:!</2Q$!=+$!'$@!?laJ_!&+);!$8/*/66+E'/6;!Y._c!9$6!90($+<$+&!)0(E!
)/*<'9/0#E!7!$8+4!/0+!90($+<$+&!LZ<!$8+4Q0+!RS.Q6!8/M+!/!68(0$+0!*')+69/2!7!6(;!$8+!9/0/6'$+!
</22($!*'M+!(#$!$8+'0!<4<*+;!/2&!RS.Q6!/!68(0$+0!*')+69/2B!
!
D. Major crossmatch:!9$!=(22/!=+$!L*((&U!$8+'0!6+0#E!'6!'2!/!$+6$!$#L+;!>'$8!$8+!L*((&!()!$8+!
&(2(0!#2'$!/2&!$8+4!E':!$8+!H!$(=+$8+0!7!6(!$8+4!E':!$8+!9$Q6!6+0#E!>'$8!$8+!&(2(0Q6!RS.Q6!$(!
6++!')!$8+4!/0+!<(E9/$'L*+U!*((F'2=!)(0!/24$8'2=!'2!$8+!9$6!6+0#E!$8/$!>'**!/$$/<F!$8+!/2$'=+26!'2!
$8+!&(2(0Q6!RS.Q6@!!%2($8+0!9/0$!()!$8+!>(0F#9!)(0!<0(66E/$<8'2=!'6!$(!&(!/2!/2$'L(&4!6<0++2!
>8'<8!'6!/2!'2&'0+<$!<((ELQ6!L+)(0+!E':'2=!?0+E+EL+0!$8/$!'$!&+$+<$6!$8+!%"I1SG_bB@!!1)!$8'6!
$+6$!'6!2+=/$'M+;!$8+!<0(66E/$<8!'6!<(E9/$'L*+!?6(;!$8+0+!'6!2(!%L!'2!$8+!9$6!6+0#E!$8/$!>'**!
/$$/<F!$8+!&(2(0Q6B@!!I8'6!&(+6!2($!90+M+2$!/!$0/26)#6'(2!0:2;!(0!$8/$!%LQ6!>'**!&+M+*(9!*/$+0!
/=/'26$!$8+!&(2(0@!!g8/$!'6!$8+!<8/2<+!$8/$!/24(2+!8/6!$8+!6/E+!%=!E/F+#9!/6!/2($8+0n!q+0(@!!
108

Y(;!+M+2!')!1!=+$!/!L*((&!=0(#9!G!>8+2!1QE!=0(#9!G;!$8+0+!'6!6$'**!/2!'2<0+/6+!0'6F!()!/L!/$$/<F@!!
K(0/*!()!$8+!6$(04n!_(2Q$!$0/26)#6+!#2*+66!'$Q6!/L6(*#$+*4!2+<+66/04!!
%#&'(!_/4!P-!8+E/$(*(=4!t!
VII. Side Notes
%@!p#+6$'(26!/6F+&!&#0'2=!$8+!L0+/F!/L(#$!849+06+26'$'M'$4-!!
X#9#6!?2($!+M+04$8'2=!'6!$49+!111B!!
J(6$!6$0+9!?2($!+M+04$8'2=!'6!$49+!111;!+'$8+0B!7!</2!</#6+!$49+!11!')!'$6!9(6$!6$0+9@!08+#E/$'<!
)+M+0;!8(>+M+0;!')!'$!'6!9(6$!6$0+9!=*(E+0#*(2+980'$'6;!$8/$!'6!$49+!111!
I80(EL(<4$(9+2'/!/2&!N+E(*4$'<!/2+E'/!C!$49+!11!
J."!0/68!C!$49+!1!
J."!8+E(*4$'<!/2+E'/!C!$49+!11!?1=l!%LQ6!/=/'26$!$8+!J."!=0(#9!/$$/<8+&!$(!$8+!RS.!
E+EL0/2+B!
!
[:/E9*+-!!E(6$!<(EE(2!%L!'2!$8+!\Y%!'6!%2$'d.Kk!?+M+04(2+!8/6!L++2!+:9(6+&B@!!!
!
b(#!/0+!6/)+6$!)0(E!=+$$'2=!N1k!)0(E!L*((&!$0/26)#6'(2!$8/2!)0(E!/**!$8+!($8+0!'2)+<$'(26!
?,ZaHe;VVV!9+0!#2'$!()!L*((&!<8/2<+!()!=+$$'2=!N1k7!$8+0+)(0+!#2<(EE(2!=+$!$(!=+$!N1k!)0(E!
L*((&B@!!I8'6!'6!&#+!$(!/**!$8+!6<0++2'2=!$+6$6!$8/$!$8+4!9+0)(0E@!!I8+4!&(!$8+![*'6/!$+6$!7!>8'<8!
*((F6!)(0!/2$'d=9,HV!%LQ6!?0+E+EL+0;!'$Q6!$8+!=9d,HV!%=!$8/$!/$$/<8+6!$(!8+*9+0!I!<+**!?._^B!
E(*+<#*+B@!!G2!>+6$+02!L*($;!*((F'2=!)(0!E(0+!?P!(0!^B!%LQ6;!E/F'2=!'$!E(0+!69+<')'<;!6(!')!4(#!
=+$!$8'6!iOj!(2!P!(0!E(0+;!4(#!/0+!/!$0#+!9(6'$'M+@!
@!
g8/$!'6!$8+!K.!'2)+<$'(2!$0/26E'$$+&!L4!L*((&!$0/26)#6'(2n!.Kk;!>8'<8!'6!$8+!K.!(M+0/**!
'2)+<$'(2@!!I8/$!'6!>84!$8'6!/2$'L(&4!'6!$8+!E(6$!<(EE(2@!
!
g8/$!'6!K..!9(6$!$0/26)#6'(2!8+9/$'$'6n!N+9!.!?,ZPVVVB!
!
12!2+>L(02;!>/2$!$(!90+M+2$!=0/)$!M6@!8(6$!&c!/2&!.Kk!LZ<!2(!'EE#2+!&+)+26+6;!$8+0+)(0+;!
2++&!$(!'00/&'/$+!$8+!L*((&@!!I8+!'00/&'/$'(2!F'**6!())!$8+!*4E98(<4$+6!/2&!6'2<+!$8+!.Kk!*'M+6!'2!
*4E98(<4$+6;!>+!F'**!())!$8+!.Kk!M'0#6!/*6(@!!I8'6!>84!>+!0/&'/$+!L*((&!L+)(0+!='M'2=!$(!
2+>L(026@!
!
%<<'&+2$/*!2++&*+!6$'<F!)0(E!/!9$!4(#!F2(>!2($8'2=!/L(#$!7!>8/$!'6!$8+!K.!'2)+<$'(2!4(#!</2!
=+$n!N+9!S@!
!
%<<'&+2$/*!2++&*+!6$'<F!)0(E!N1k!iOj!9$U!>8/$!'6!$8+!<8/2<+!()!=+$$'2=!N1kOn!,ZPVV@!!g8/$!&(!
4(#!&(!/L(#$!'$n!b(#!=(!(2!$8+0/94!/6!')!4(#!/0+!N1kO@!!l(!(2!$(!$0'9*+!$8+0/94!?H!RI1Q6!7!%qI!
/2&!/!90($+/6+!'28'L'$(0B!)(0!6':!E(2$86!/2&!=+$!<(26$/2$!<8+<F6!7!&(!J.R!$+6$!*((F'2=!)(0!R"%!
'2!$8+!M'0#6!?E(6$!6+26'$'M+B;!&(![*'6/!$+6$@!12!)/<$;!$8+!K.!E+<8/2'6E!()!/!8+/*$8</0+!>(0F+0!
=+$$'2=!N1k!C!/<<'&+2$/*!2++&*+!6$'<F!
!
_(!2($!$0/26)#6+!/24$8'2=!'2$(!/!9+06(2!#2*+66!$8+4!/0+!64E9$(E/$'<!'2!>8/$!$8+4!/0+!&+)'<'+2$!
'2@!![:/E9*+-!!1)!4(#!8/M+!,V!=0/E6!()!NL;!/2&!8/M+!2(!64E9$(E6!'2!$8+!9$;!&(!2($!$0/26)#6+@!!
b(#!68(#*&!$0/26)#6+!$8+!9$!')!$8+4!8/M+!.GJ_!/2&!/0+!6$/0$'2=!$(!8/M+!/2='2/!0+*/$+&!$(!$8+!,V!
=0/E6@!![:/E9*+-!!eV;VVV!9*/$+*+$!<$!7!2(!+9'6$/:'6!C!&(!2($!$0+/$!$8+EU!')!$8+4!&(!8/M+!
+9'6$/:'6;!$0+/$!$8+!9$@!
!
[M+04!L*((&!90(&#<$!'6!&/2=+0(#6!LZ<!4(#!</2!=+$!'2)+<$'(26!)0(E!'$@!
!
109

B. Fresh frozen plasma!7!68(#*&!2+M+0!L+!#6+&!$(!+:9/2&!/!9$6!9*/6E/!M(*#E+!$(!0/'6+!SJ!7!
#6+!2(0E/*!6/*'2+!?'$!'6!$((!+:9+26'M+!/2&!4(#!0#2!$8+!0'6F!()!$0/26E'$$'2=!&cB@!!\6+!)0+68!)0(c+2!
9*/6E/!)(0!E#*$'9*+!<(/=#*/$'(2!)/<$(0!&+)'<'+2<'+6!7!'+!>(#*&!L+!*+='$'E/$+!$(!='M+!)0(c+2!9*/6E/!
$(!0+9*/<+!<(26#E+&!)/<$(06;!/6!'2!_1.@!!!
[:/E9*+-!9$!>'$8!>/0)/0'2!'6!(M+0!/2$'<(/=#*/$'(2!/2&!L*++&'2=!$(!&+/$8!7!2($!$(!='M+!1K!M'$!5!
>'**!$/F+!$(!*(2=!$(!>(0F!?$/F+6!adt!806!$(!>(0FB;!6(!$8+!$0+/$E+2$!()!<8('<+!'6!)0+68!)0(c+2!
9*/6E/!$(!'EE+&'/$+*4!0+9*/<+!'$@!!Y(;!)0+68!)0(c+2!9*/6E/!'6!*'E'$+&!$(!#6+!()!E#*$'9*+!)/<$(0!
&+)'<'+2<'+6!?'+!<'008(6'6!()!$8+!*'M+0!/2&!4(#!/0+!L*++&'2=!7!6'2<+!E(6$!()!$8+!)/<$(06!/0+!E/&+!'2!
$8+!*'M+0;!$8+4!/0+!&+)'<'+2$!'2!/**!90($+'26B@!
_G.!)(0!8+9/0'2!(M+0&(6+!'6!$(!='M+!90($/E'2+!6#*)/$+@!!!
!
C. Know the diff transfusion rxns
!
,@!!K.!$0/26)#6'(2!0:2!C!allergic rxn!?'$<8'2=;!8'M+6;!/2/984*/:'6B!d!$8'6!'6!/2!+:/E9*+!()!/!
$49+!1!NJb!0:2!7!'+!8/M+!#2'$!()!L*((&;!/2&!'2!$8+'0!9*/6E/!4(#!/0+!/**+0='<!$(!6(E+$8'2=!?'+!
J."BU!R:!C!L+2/&04*;!/2$'8'6$/E'2+6!
!
H@!!H2&!$0/26)#6'(2!0:2!C!febrile rxnU!'$!'6!&#+!$(!NX%!%LQ6U!9$!8/6!NX%!%LQ6!/=/'26$!
*+#F(<4$+6!()!&(2(0!%=@!!Y(;!>8+2!$8+!#2'$!()!L*((&!'6!$0/26)#6+&!'2$(!E+;!/2&!$8+0+!/0+!
6(E+!*+#F(<4$+6!>'$8!NX%!%L!(2!$8+E;!E4!%L!>'**!0+/<$!/=/'26$!'$;!&+6$0(4!$8+!<+**!/2&!
0+*+/6+!$8+!94(=+2+6!)0(E!2+#$0(98'*;!*+/&'2=!$(!)+M+0@!
!
1)!1QM+!2+M+0!L++2!$0/26)#6+&;!68(#*&!1!8/M+!NX%!%LQ6!/=/'26$!/24$8'2=n!"(m!!.(2$'2#'2=!
D#+6$'(2-!g8(!'6!E(6$!/$!0'6F!)(0!8/M'2=!/!)+L0'*+!0:2!>'$8!$0/26)#6'(2n!g(E/2!7!LZ<!68+!'6!
8/6!L++2!90+=2/2$!7!+M+04!>(E/2!$8/$!8/6!8/&!/!L/L4!8/6!8/&!/!)+$/*!E/$+02/*!L*++&;!6(!
6(E+!()!$8+!L/L'+6!*+#F(<4$+6!=($!'2$(!$8+!L*((&6$0+/E;!/2&!$8+!>(E/2!&+M+*(9+&!/2!/2$'!
NX%!%L!?$8+!NX%Q6!/0+!)0(E!$8+!8#6L/2&;!$8/$!8/M+!L++2!9/66+&!(2!$(!$8+!>(E/2B@!!Y(;!$8+!
E(0+!90+=2/2<'+6!/!>(E/2!8/6!8/&;!$8+!E(0+!/2$'!NX%!%LQ6!68+!>'**!&+M+*(9!LZ<!()!8+0!
90+M'(#6!90+=2/2<'+6@!!I8'6!'6!/*6(!$0#+!)(0!69(2$/2+(#6!/L(0$'(26!7!4(#!</2!6$'**!=+$!NX%!
%LQ6@!!Y(;!>(E+2!/0+!E(0+!*'F+*4!$(!8/M+!$0/26)#6'(2!'2&#<+&!)+L0'*+!0:26!LZ<!$8+4!/0+!E(0+!
*'F+*4!$(!8/M+!/2$'dNX%!%LQ6!?>+!68(#*&!2($!8/M+!8#E/2!L+'2=Q6!NX%Q6!'2!(#0!L*((&!6$0+/E!
LZ<!>+!8/M+2Q$!L++2!+:9(6+&!$(!8#E/2Q6!L*((&B@!!!
!
[:/E9*+-!!g8(!8/6!$8+!=0+/$+6$!0'6F!'2!&+M+*(9'2=!)+L0'*+!0:2n!!I8+!/26>+0!<8('<+6!)(0!$8'6!
D#+6$'(2!>(#*&!L+!/!2+>L(02;!,H!4Z(!>'$8(#$!$0/26)#6'(2;!>(E/2!>'$8!(2+!90+=2/2<4;!
>(E/2!>'$8!69(2$/2+(#6!/L(0$'(2;!/2&!E/2@!!I8+!/26>+0!'6!>(E/2!>'$8!69(2$/2+(#6!
/L(0$'(2!LZ<!$8/$!'6!/!90+=2/2<4!/2&!$8+0+!'6!/!9($+2$'/*!)(0!NX%!/LQ6!$(!*+/F!(#$!()!$8+!)+$#6!
'2$(!$8+!E($8+0@!!!
T+L0'*+!0:2!'6!/!$49+!11!NJb!0:2!/=/'26$!$8+!NX%!%L!?/**+0='<!0:2!'6!$49+!1B!
!
P@!!Hemolytic transfusion rxns!/0+!M+04!0/0+@!![:/E9*+-!!1)!4(#!/0+!L*((&!=0(#9!%;!/2&!
='M+2!=0(#9!S!L4!6$#9'&'$4!LZ<!$8+!9$!8/6!/2$'dS!1=K!?0+E+EL+0!$8/$!1=K!'6!$8+!E(6$!9($+2$!
<(E9*+E+2$!/<$'M/$(0!/2&!$8/$!<+**!>'**!2($!*/6$!(2*4!/L(#$!,!E6+<B!I8'6!'6!LZ<!$8+!1=K!>'**!
/$$/<F!'$;!.,d.r-!K%.;!/2/984*/$(:'26!/0+!0+*+/6+&;!/2&!68(<F!>'**!+26#+!7!M+04!6+0'(#6!7!
/F/!<*+0'</*!+00(0B@!
!
[:/E9*+-!!9$!8/6!%L!/=/'26$!%=!(2!RS.Q6!'2!$8+!#2'$!7!4(#!>(#*&!$8'2F!$8/$!$8'6!68(#*&2Q$!
8/99+2!LZ<!$8+!<0(66E/$<8!6/'&!'$!'6!<(E9/$'L*+U!/2&!&'&!/2!%L!6<0++2!$8/$!>/6!2+=/$'M+!
?12&'0+<$!.((EL6B@!!N(>+M+0;!6(E+!%LQ6!/0+!2($!90+6+2$;!/2&!4(#!8/M+!E+E(04!S!<+**6@!!
110

Y#99(6+!')!1!=($!L*((&!$0/26)#6'(2!PV!4+/06!/=(;!$8+0+!/0+!2(!%L!$'$+06!2(>!LZ<!$8+4!
>(#*&QM+!=(2+!/>/4!7!8(>+M+0;!$8+0+!/0+!E+E(04!S!<+**6U!$8+6+!/LQ6!>'**!L+!>/4!L+*(>!$8+!
6+26'$'M'$4!()!/2!%L!6<0++2;!<(E+!(#$!<(E9/$'L*+!)0(E!/!<0(66E/$<8;!/2&!>'**!8/M+!2+=!
'2&'0+<$!<((ELU!8(>+M+0;!/)$+0!$0/26)#6'(2;!E+E(04!S!<+**6!>(#*&!&+$+<$!$8+!)(0+'=2!%=@!!
%)$+0!$8+!S!<+**!&+$+<$6!$8+!%=;!'$!>'**!6$/0$!&'M'&'2=!'2!$8+!=+0E'2/*!)(**'<*+!/2&!6$/0$!&'M'&'2=!
/2&!L+<(E+!/!9*/6E/!<+**;!>8'<8!>(#*&!E/F+!/2$'d</**/!%L@!!I8'6!</2!(<<#0!'2!/!)+>!806!(0!
E/4!(<<#0!'2!/!>++F!7!&+9+2&'2=!(2!$8+!%L@!!I8/$Q6!$8+!(2+!$8+4!*'F+!(2!$8+!L(/0&6!7!
delayed hemolytic transfusion rxn@!!!
!
[:/E9*+-!!>(E/2!9(6$9/0$#E;!&'))'<#*$!&+*'M+04!?/L0#9$'(!9*/<+2$/B!>/6!$0/26)#6+&!P!#2'$6!()!
L*((&@!g8+2!68+!*+)$!$8+!8(69'$/*;!68+!8/&!/2!NL!()!$+2@!!G2+!>++F!*/$+0;!68+!'6!3/#2&'<+!
/2&!>++F;!/2&!8/6!/2!#2<(23#=/$+&!849+0L'*'0#L'2+E'/!/2&!8/6!/2!NL!()!t@!!g8/$!'6!$8+!&:n!
NL!>/6!*+66!$8/2!>8/$!68+!*+)$!$8+!8(69'$/*;!/2&!$8+4!>'**!2($!E+2$'(2!$8+!<((EL6!$+6$B!7!
g8/$!'6!E(6$!*'F+*4!</#6+n!N/*($8/2+!?2(!LZ<!$8/$!$/F+6!(M+0!/!>++F!$(!&+M+*(9B;!8+9/$'$'6!
?2(;!>8'<8!$/F+6!adt!>++F6!$(!&+M+*(9B@!!%26>+0-!&+*/4+&!8+E(*4$'<!$0/26)#6'(2!0:2!7!6(;!
$8+4!E'=8$!/6F!>8/$!$+6$!>(#*&!4(#!=+$n!12&'0+<$!<((EL6!$+6$!$(!90(M+!'$!LZ<!4(#!>'**!6++!$8+!
%L!.(/$'2=!$8+!RS.@!!K(0/*!()!$8+!6$(04n!Transfused with certain level of Hb, 1 week
later have jaundice and less Hb = delayed hemolytic transfusion rxn = type II
HPY!
!
VIII. ABO/Rh incompatibility
!
A. ABO incompatibility:
1)!L*((&!=0(#9!G!>(E/2!8/M+!/!L/L4;!$8+!E(E!>'**!8/M+!/!90(L*+E!>'$8!%SG!'2<(E9/$'L'*'$4!
LZ<!E(E!/*0+/&4!8/M+!/2!%L!$8/$!</2!<0(66!$8+!9*/<+2$/!?L*((&!=0(#9!G!9+(9*+!8/M+!/2$'!%!
1=K;!/2$'!S!1=K!/2&!/2$'!%S!1=l;!2(0E/**4B@!!"(0E/**4;!$8+0+!'6!/2!/2$'!%S!1=l!%L!>8'<8!</2!
<0(66!$8+!9*/<+2$/;!/2&!/$$/<F!/2!%!(0!S!RS.@!Y(;!$8+0+!<(#*&!L+!/!90(L*+E!'2!$8+!M+04!)'06$!
90+=2/2<4@!!!
!
[:/E9*+-!!E(E!'6!L*((&!=0(#9!G!2+=/$'M+!/2&!L/L4!'6!L*((&!=0(#9!%!2+=/$'M+@!!16!$8+0+!/2!
'2<(E9/$'L'*'$4!()!L*((&!=0(#96n!b+6@!16!$8+0+!/2!'2<(E9/$'L'*'$4!'2!R8!=0(#96n!"(@!!f#6$!$8+!
L*((&!=0(#96;!6'2<+!$8+!E(E!'6!G!>8'*+!L/L4!'6!%@!!I8+!E(E!'6!G;!68+!8/6!/2$'!%S!1=l;!
>8'<8!>'**!<0(66!$8+!9*/<+2$/U!$8+!%!9/0$!()!$8+!%L!>'**!/$$/<8!$(!$8+!%!9/0$!()!$8+!%!<+**6!()!
$8+!L/L4Q6@!!I8+!L/L4Q6!E/<0(98/=+6!()!$8+!69*++2!>'**!&+6$0(4!'$;!>8'<8!'6!I49+!11!NJb;!E'*&!
/2+E'/;!/2&!#2<(23#=/$+&!L'*'0#L'2!>8'<8!'6!8/2&*+&!L4!$8+!E(EQ6!*'M+0U!2(!F+02'<$+0#6;!2(!
90(L6!>'$8!3/#2&'<+!'2!$8+!L/L4!LZ<!'2!#$+0(;!$8+!E(EQ6!*'M+0!>'**!$/F+!</0+!()!'$@!!g8+2!$8+!
L/L4!'6!L(02!$8+!L/L4;!'$!>'**!8/M+!/!E'*&!/2+E'/!/2&!3/#2&'<+@!!K..!3/#2&'<+!'2!$8+!)'06$!H^!
806!)(0!/!2+>L(02!C!%SG!'2<(E9/$'L'*'$4!?2($!9846'(*(='<!3/#2&'<+!()!$8+!2+>L(02!7!$8/$!
6$/0$6!(2!&/4!PB@!!g84!&'&!$8+!L/L4!&+M+*(9!3/#2&'<+n!SZ<!$8+!L/L4Q6!*'M+0!</22($!<(23#=/$+!
L'*'0#L'2!4+$!/2&!E#6$!8/2&*+!#2<(23#=/$+&!L'*'0#L'2!(2!'$6!(>2!2(>;!6(!'$!L#'*&6!#9@!I8'6!'6!
/2!+:<8/2=+!$0/26)#6'(2!0:2!)(0!%SG!'2<(E9/$'L'*'$4!7!E(6$!()!$8+!$'E+!'6!Lr;!/2&!9#$!#2&+0!
\k!S!*'=8$@!!N(>!&(+6!\k!S!*'=8$!>(0Fn!1$!<(2M+0$6!$8+!L'*'0#L'2!'2!$8+!6F'2!'2$(!&'d940(*;!
>8'<8!'6!>/$+0!6(*#L*+!/2&!$8+4!9++!'$!(#$!?R:!)(0!3/#2&'<+!'2!2+>L(02B@!!%2+E'/!'6!E'*&!LZ<!
'$!'6!2($!/!6$0(2=!%=!/2&!&(+62Q$!8(*6$+0!/!L0'6F!8+E(*4$'<!/2+E'/@!!1)!4(#!&(!/!<((ELQ6!$+6$;!
'$!>'**!L+!9(6'$'M+!LZ<!1=lQ6!(2!$8+!RS.Q6@!!Y(!/*>/46!/2!G!E(E!>'$8!/!L*((&!=0(#9!%!(0!%S!
L/L4@!!I8'6!</2!(<<#0!)0(E!$8+!)'06$!90+=2/2<4!?2($!*'F+!R8!6+26'$'c/$'(2!>8+0+!$8+!)'06$!
90+=2/2<4!'6!2($!/!90(L*+EB@!!12!/24!90+=2/2<4;!')!E(E!'6!L*((&!=0(#9!G;!/2&!68+!8/6!/!
L/L4!>'$8!L*((&!=0(#9!%!(0!S;!$8+0+!>'**!L+!/!90(L*+E!?L*((&!=0(#9!G!C!2(!90(L*+EB@!
!
111

B. Rh incompatibility
K(E!'6!R8!2+=/$'M+!/2&!L/L4!'6!R8!9(6'$'M+@!![:/E9*+-!!E(E!'6!G!2+=/$'M+!/2&!L/L4!'6!G!
9(6'$'M+!?2($!%SG!'2<(E9/$'L*+;!L#$!R8!'2<(E9/$'L*+B@!!12!$8+!)'06$!90+=2/2<4-!&+*'M+0!L/L4!
>'$8(#$!=('2=!$(!/!_0;!/2&!$8+0+!'6!/!)+$/*!E/$+02/*!L*++&;!6(E+!()!$8+!L/L'+6!G!9(6'$'M+!%LQ6!
=($!'2$(!E4!L*((&6$0+/E;!>8'<8!'6!2($!=((&@!Y(;!E(E!>'**!&+M+*(9!/2!/2$'!S!%L!/=/'26$!'$@!!
Y(;!E(E!'6!6+26'$'c+&!>8'<8!E+/26!$8/$!$8+0+!'6!/2!%L!/=/'26$!$8/$!_!%=!/2&!2(>!E(E!'6!
/2$'!_@!!,!4+/0!*/$+0;!E(E!'6!90+=2/2$!/=/'2;!/2&!6$'**!G!2+=/$'M+;!/2&!8/M+!/2$'!_!/2&!$8+!
L/L4!/=/'2!'6!G!9(6'$'M+@!!I8'6!'6!/!90(L*+E!LZ<!'$!'6!/2!1=l!%L;!>8'<8!>'**!<0(66!$8+!9*/<+2$/;!
/$$/<8!$(!$8+!L/L'+6!_!%=!9(6'$'M+!<+**6!?()!/**!$8+!%=6;!$8+!_!%=!8(6$6!$8+!>(06$!8+E(*4$'<!
/2+E'/B@!!Y(;!$8+!L/L4!>'**!L+!6+M+0+*4!/2+E'<!>'$8!R8!$8/2!>'**!%SG!'2<(E9/$'L'*'$4@!!I8+!
6/E+!$8'2=!8/99+26!$8(#=8!7!L/L4Q6!E/<0(98/=+6!98/=(<4$(6+!/2&!E(EQ6!*'M+0!>'**!>(0F!
8/0&+0@!!g8+2!$8+!L/L4!'6!L(02;!$8+!L'*'0#L'2!*+M+*6!/0+!M+04!8'=8;!/!6+M+0+!/2+E'/!(<<#06;!
/2&!$8+0+!'6!/2!+:<+**+2$!<8/2<+!$8/$!/2!+:<8/2=+!$0/26)#6'(2!>'**!L+!2+<+66/04!?rrW!
<8/2<+B;!6(!$/F+!/**!$8+!L*((&!(#$!?=+$6!0'&!()!/**!$8+!L'*'0#L'2!/2&!6+26'$'c+&!RS.Q6!/2&!
$0/26)#6+!LZ<!L/L4!'6!/2+E'<B@!!Y(;!$8+4!>'**!#6#/**4!/*>/46!8/M+!/!+:<8/2=+!$0/26)#6'(2@!
!
I8+0+)(0+;!)(0!$8+!)'06$!90+=2/2<4;!$8+!L/L4!'6!2($!/))+<$+&;!/2&!$8'6!'6!>8+2!$8+!E($8+0!=+$6!
6+26'$'c+&@!!12!)#$#0+!90+=2/2<'+6;!$8+!L/L4!>'**!/!*($!>(06+@!
!
N(>!&(!>+!90+M+2$n!K(E!>'**!&(!/2!%L!6<0++2!$+6$!/2&!68+!'6!R8!2+=/$'M+@!!%0(#2&!$8+!Ht$8!
>++F;!='M+!8+0!R8!1=;!>8'<8!'6!90(984*/<$'<@!!I8'6!'6!/2$'!_;!>8'<8!<(E+6!)0(E!>(E/2U!'$!8/6!
L++2!6+26'$'c+&!/2&!8+/$!$0+/$+&!/2&!</22($!<0(66!$8+!9*/<+2$/@!!g84!&(!$8+4!='M+!/$!Ht!
>++F6n!J$!E/4!=+$!)+$/*!E/$+02/*!L*++&6!L+)(0+!$8+!90+=2/2<4!(0!/!</0!/<<'&+2$!(0!)/**!</2!
</#6+!L/L'+6!L*((&!$(!=+$!'2$(!E(EQ6!<'0<#*/$'(2@!!Y(;!E(E!8/6!/2$'!_!%LQ6!$(!6'$!(2!$8+!_!
9(6'$'M+!<+**6!/2&!&+6$0(4!$8+E;!6(!E(E!>(2Q$!=+$!6+26'$'c+&@!I8+2;!E(E!='M+6!L'0$8!$(!L/L4!
?*+$6!6/4!'$!'6!R8!9(6B@!!_(!/!J*48(>/L+2$'!$+6$!/2&!$/F+6!E(EQ6!L*((&!$(!1_!?')!/24!B!)+$/*!
RS.Q6!'2!$8+!<'0<#*/$'(2!/2&!<(#2$!$8+EU!$8+4!</2!6/4!8(>!E#<8!'6!'2!$8+0+@!!_+9+2&'2=!(2!
$8/$;!$8/$!>'**!&+$+0E'2+!8(>!E/24!M'*+6!()!/**+0=+2!1=!4(#!='M+!$8+!E(E!$(!90($+<$!8+0!
)#0$8+0!?/2$'!_!(2*4!*/6$!$80++!E(2$86;!/2&!2++&!$(!='M+!E(0+!/$!L'0$8;!+69+<'/**4!')!$8+!L/L4!
'6!R8!9(6'$'M+B@!
!
[:/E9*+-!!K(E-!G!2+=/$'M+U!S/L4-!%!9(6'$'M+!H!90(L*+E6-!%SG!'2<(E9/$'L*+!/2&!R8!
'2<(E9/$'L*+@!!S#$;!$8+0+!'6!2($!=('2=!$(!L+!/!90(L!>'$8!6+26'$'c/$'(2@!"(!g84n!%)$+0!&+*'M+04!
()!L/L4;!6(E+!()!$8+!L/L'+6!<+**6!?>8'<8!/0+!%!<+**6B!=+$!'2$(!$8+!E(EQ6!L*((&!?>8'<8!E(E!
8/6!/2$'!%!1=KB!U!$8(6+!<+**6!>'**!L+!&+6$0(4+&!6(!)/6$;!$8/$!'2!E(6$!</6+6!$8+!E(E!</22($!
=+2+0/$+!%L!/=/'26$!$8(6+!<+**6!LZ<!$8+4!8/M+!L++2!&+6$0(4+&@!!Y(;!%SG!'2<(E9/$'L'*'$4!
90($+<$6!/=/'26$!R8!6+26'$'c/$'(2@!!b(#!6$'**!>(#*&!='M+!R8!1EE#2(=*(L#*'2@!Y(!')!4(#!/0+!%SG!
/2&!R8!'2<(E9/$'L*+;!R8!6+26'$'c/$'(2!>'**!L+!90($+<$+&!/=/'26$@!
!
5'&!>'$8!+04$80(L*/6$(6'6!)+$/*'6!>'**!8/M+!R8!'2<(E9/$'L'*'$4!7!>8/$!&(!$8+4!&'+!()n!N+/0$!
)/'*#0+!7!6+M+0+!/2+E'/6!>'**!&+<0+/6+!M'6<(6'$4!()!L*((&;!6(!$8+4!=+$!/!8'=8!(#$9#$!)/'*#0+-!
XNT;!$8+2!RNT;!8#=+!*'M+06!LZ<!+:$0/E+&#**/04!8+E/$(9(+6'6!LZ<!$8+4!/0+!6(!6+M+0+!/2+E'<@!!!
!
[:/E9*+-!<0(66!6+<$'(2!()!L0/'26$+E!)0(E!F'&!7!>8/$!'6!$8+!</#6+!()!<(*(0!<8/2=+n!!1$6!
4+**(>'68!7!&#+!$(!F+02'<$+0#6!7!90(L!)0(E!/!L/L4!$8/$!8/&!R8!'2<(E9/$'L'*'$4@!!R+E+EL+0;!
'$Q6!/2!#2<(23#=/$+&!849+0L'*'0#L'2+E'/!LZ<!'$Q6!/!8+E(*4$'<!/2+E'/!/2&!*'9'&!6(*#L*+U!*'M+0!
</22($!642!'$U!=(+6!$(!L0/'2!/2&!'6!M+04!$(:'<!*+/&'2=!$(!6+M+0+!&+L'*'$/$'2=!&c!(0!&+/$8@!
112

./0&'(*(=4!/#&'(6d!^!8(#06!$($/*!
!
III. Rxn to Injury Theory
!
.+**6!'2M(*M+&d!9*/$+*+$6;!E(2(<4$+6;!E/<0(98/=+6;!<4$($(:'<!$!<+**6!>'$8!<4$(F'2+6!
?2+#$0(98'*6!2($!'2M(*M+&B!!
!
%$8+0(6<*+0(6'6!'2!/2!/(0$/!7!0:2!$(!'23#04!$8+(04!C!'23#04!$(!+2&($8+*'/*!<+**6!*'2'2=!$8+!+*/6$'<!
/0$+0'+6!/2&!E#6<#*/0!/0$+0'+6!7!>8/$!'6!'23#0'2=!'$n!%EE(2'/!'2!<'=!6E(F+;!.G!'2!<'=!6E(F+U!6(;!
9('6(26!&/E/=+!$8+!+2&($8+*'/*!<+**6U!X_X!&/E/=+6!'$;!/2&!')!'$6!(:'&'c+&;!'$!&/E/=+6!'$!>(06+U!M'0/*!
'2)+<$'(26!&/E/=+!'$;!$((. Chlamydia pneumoniae (2nd MCC atypical pneumoniae); pts with
MI most had Abs against Chlamydia pneumonia, homocysteine all these things
damage endothelial cells
!
g8/$!8/99+26!>8+2!4(#!&/E/=+!+2&($8+*'/*!<+**6n!J*/$+*+$6!6$'<F!$(!'$!/2&!J_lT!'6!0+*+/6+&!'2$(!$8+!
/0$+04!/2&!J_lT!</#6+6!6E(($8!E#6<*+!<+**6!>'$8'2!$8+!E+&'/!$(!90(*')+0/$+!/2&!$8+4!#2&+0=(!
849+09*/6'/!/2&!$8+2;!$8+4!<8+E($/<$'</**4!E'=0/$+!$(!$8+!6#L'2$'E/*!*+M+*@!!I8+4!8/M+!/**!$8+6+!
6E(($8!E#6<*+!<+**6!E'=0/$'2=!$(!$8+!'2$'E/!()!$8+!M+66+*@!!K(2(<4$+6!8/M+!/<<+66!'2$(!$8+!M+66+*!
LZ<!'$!8/6!L++2!'23#0+&!/2&!E(2(<4$+6!/*6(!8/M+!lT6@!!%6!$8+!X_X!'2<0+/6+6;!$8+!E/<0(98/=+6!
98/=(<4$(6+!$8+E@!!!K/<0(98/=+6!/2&!6E(($8!<+**6!8/M+!X_X!>Z'2!$8+EU!$8+!X_X!L+<(E+6!(:'&'c+&!
/2&!/!)/$$4!6$0+/F!'6!90(&#<+&@!!GM+0!$'E+;!/!)'L0()/$$4!9*/D#+!&+M+*(96;!>8'<8!'6!9/$8(=2(E(2'<!()!
/$8+0(6<*+0(6'6@!1$!</2!L+!<(E9*'</$+&!L4!&46$0(98'<!</*<')'</$'(2;!)'66#0'2=;!$80(EL(6'6!/2&!/!
<(E9*'</$+&!/$8+0(6<*+0(6'6@!
!
IV. Arterial Disorders:!
A. Atherosclerosis is a primary factor for certain dzs!!!
.%_U!/$8+0(6<*+0($'<!6$0(F+!0+*/$+6!$(!9*/D#+6U!/L&(E'2/*!/2+#046E!&#+!$(!>+/F+2'2=!()!$8+!M+66+*U!
2(2$0/#E/$'<!/E9#$/$'(2!()!*(>+0!+:$0+E'$4!?9+0'98+0/*!M/6<#*/0!&cBU!E+6+2$+0'<!/2='2/;!6E/**!
L(>+*!'2)/0<$'(2;!0+2(M/6<#*/0!/$8+0(6<*+0(6'6!()!$8+!0+2/*!/0$+0'+6@!!Atherosclerosis!only
involves muscular arteries and elastic arteries@!!./2!6E/**!M+66+*;!6#<8!/6!/0$+0'(*+6!=+$!
8/0&+2+&n!b+6@!![:/E9*+-!*((F!/$!$8+!69*++2!7!84/*'2+!/0$+0'(*/0!6<*+0(6'6!/2&!849+09*/6$'<!/0$+0'(*/0!
6<*+0(6'6!?(2'(2!6F'22'2=B@!!!!!
!
!
1. Hyaline arteriosclerosis!'6!/!6E/**!M+66+*!&cU!*#E+2!'6!2/00(>U!>8+2+M+0!$8+0+!'6!/!*($!()!9'2F!
6$/'2'2=!6$#));!$8'6!'6!84/*'2+@!![:/E9*+-!6E/**!M+66+*!&c!()!&'/L+$+6!/2&!NI"!7!$>(!E/3(0!&cQ6!$8/$!
90(&#<+6!/!6E/**!M+66+*!&c!>'$8!&'))+0+2$!E+<8/2'6E6-!!
!
a. Diabetes-!2(2+2c4E/$'<!=*4<(6*4c/$'(2!7!/F/!NL%,<U!=*4<(6*4c/$'(2!'6!=*#<(6+!/$$/<8'2=!$(!//!
/2&!90($+'2@!T(0!NL%;!'$6!=*#<(6+!/$$/<8'2=!$(!//!/2&!NL%;!/2&!$8+!NL%!'6!=*4<(64*/$+&@!!NL%,<!
*+M+*6!<(00+*/$+!>'$8!$8+!L*((&!=*#<(6+!*+M+*6!()!$8+!*/6$!adt!>++F6;!6(!$8'6!'6!$8+!L+6$!>/4!()!*((F'2=!
/$!*(2=!$+0E!=*#<(6+!*+M+*6@!!%**!$8+!&/E/=+!6++2!'2!&'/L+$+6!'6!&#+!$(!=*#<(6+@!!T(0!/!&'/L+$'<;!4(#!
68(#*&!L+!#2&+0!aW;!E+/2'2=!$8/$!4(#!/0+!'2!/!2(0E/*!=*#<(6+!0/2=+@!I8+0+!'6!2($8'2=!#2'D#+!
/L(#$!&'/L+$+6!+:<+9$!)(0!/!*/0=+!=*#<(6+!*+M+*;!4(#!F++9!$8/$!2(0E/*;!/2&!'$Q6!/6!')!4(#!&(2Q$!8/M+!
&'/L+$+6@!!I8+!only two pathologic processes are this:!nonenzymatic glycosylation!()!6E/**!
SkQ6!'2<*#&'2=!</9'**/0'+6!'2!$8+!F'&2+4;!/2&!osmotic damage@!!I8(6+!$'66#+6!$8/$!<(2$/'2!/*&(6+!
0+&#<$/6+!7!*+26;!9+0'<4$+6!'2!$8+!0+$'2/;!6<8>/22!<+**6!7!/**!8/M+!/*&(6+!0+&#<$/6+!/2&!</2!<(2M+0$!
=*#<(6+!'2$(!6(0L'$(*!/2&!6(0L'$(*!'6!(6E($'</**4!/<$'M+!6#<F6!>/$+0!'2$(!'$!/2&!$8(6+!<+**6!&'+;!*+/&'2=!
113

$(!</$/0/<$6;!E'<0(/2+#046E6!'2!$8+!+4+!LZ<!$8+!9+0'<4$+6!/0+!&+6$0(4+&!/2&!>+/F+2+&!/2&!$8+!
0+$'2/*!M+66+*6!=+$!/2+#046E6;!/2&!4(#!=+$!9+0'98+0/*!2+#0(9/$84!LZ<!6<8>/22!<+**6!/0+!&+6$0(4+&@!!
I8+4!/**!0+*/$+&!$(!+:<+66!=*#<(6+@!!Y(;!$'=8$!=*#<(6+!<(2$0(*!C!2(0E/*!*')+@!
!
!
g8/$!&(+6!2(2+2c4E/$'<!=*4<(64*/$'(2!$(!&(!$8+!L/6+E+2$!E+EL0/2+!()!6E/**!M+66+*6n!1$6!0+2&+06!
$8+E!9+0E+/L*+!$(!90($+'2;!6(!$8+!90($+'2!'2!$8+!9*/6E/!*+/F6!$80(#=8!$8+!SK!/2&!=(+6!'2$(!$8+!
M+66+*!>/**;!90(&#<+6!/!84/*'2+!<8/2=+!/2&!2/00(>6!$8+!*#E+2@!!g8/$!')!$8+0+!'6!2(2+2c4E/$'<!
=*4<(64*/$'(2!()!$8+!lSKn!1$!>'**!0+2&+0!'$!9+0E+/L*+!$(!90($+'2!7!</**+&!E'<0(/*L#E'2#0'/@!!I8'6!'6!
$8+!)'06$!<8/2=+!$(!L+!6++2!'2!&'/L+$'<!2+980(9/$84@!!Y(;!>8/$!'6!$8+!E+<8/2'6En!"(2+2c4E/$'<!
=*4<(64*/$'(2@!!!
!
b. Hypertension
_(+6!2($!#6+!2(2+2c4E/$'<!=*4<(64*/$'(2@!!1$!3#6$!#6+6!L0#'$!)(0<+!/2&!&0'M+6!?LZ<!()!'2<0+/6+!'2!
&'/6$(*'<!90+66#0+B!$8+!90($+'26!$80(#=8!$8+!SK!/2&!90(&#<+6!$8+!+))+<$@!!g8+2!>+!*((F!/$!/!F'&2+4!
'2!NI";!'$!'6!680#2F+2;!8/6!/!<(LL*+6$(2+!/99+/0/2<+!7!$8'6!'6!LZ<!$8+0+!'6!84/*'2+!/0$+0'(*(6<*+0(6'6!
()!$8+!/0$+0'(*+6!'2!$8+!<(0$+:;!'6<8+E'/;!/2&!'6!>/6$'2=!/>/4!>'$8!)'L0(6'6!/2&!/$0(984!()!$'66#+@!!!
X/<#2/+0!6$0(F+6!?$'24!/0+/6!()!'2)/0<$'(2!$8/$!(<<#0!'2!$8+!'2$+02/*!</96#*+B!/0+!/!84/*'2+!
/0$+0'(6<*+0(6'6!90(L*+E!0+*/$+&!$(!NI"@!!
2. Hyperplastic arteriosclerosis!
Y++2!'2!E/*'=2/2$!NI"U!E(0+!<(EE(2!'2!L*/<F6!$8+2!>8'$+6;!E/'2*4!LZ<!NI"!'6!E(0+!<(EE(2!'2!
L*/<F6!$8/2!>8'$+6@!!K/'2*4!6++!$8'6!M+66+*!&c!'2!E/*'=2/2$!NI"!?'+!>8+2!9$!8/6!SJ!()!H^VZ,aVB@!
!
B. Aneurysm!
1. Definition-!/0+/!()!(#$9(#<8'2=!()!/!M+66+*!&#+!$(!>+/F+2'2=!()!$8+!M+66+*!>/**@!!
%$8+0(6<*+0(6'6!</2!</#6+!>+/F+2'2=!()!$8+!/L&(E'2/*!/(0$/!*+/&'2=!$(!/2!/2+#046E@!!!
!
g8/$!>(#*&!L+!$8+!/2/*(=(#6!*+6'(2!'2!$8+!*#2=6!>'$8!>+/F+2'2=!/2&!(#$9(#<8'2=n!S0(2<8'+<$/6'6!7!
&#+!$(!<46$'<!)'L0(6'6!>'$8!'2)+<$'(2;!&+6$0#<$'(2!()!+*/6$'<!$'66#+!*+/&'2=!$(!(#$9(#<8'2=!/2&!
&'*/$/$'(2!()!$8+!L0(2<8'@!![:/E9*+-!>8/$!'6!$8+!l1!/2+#046En!_'M+0$'<#*/0!&c!7!8/M+!/!>+/F+2'2=!
/2&!(#$9(#<8'2=!()!E#<(6/!/2&!6#LE#<(6/!!
!
2. Law of Laplace!7!$8+!>/**!6$0+66!'2<0+/6+6!/6!0/&'#6!'2<0+/6+6@!!12!$+0E6!()!$8'6;!(2<+!4(#!6$/0$!
&'*/$'2=!'$;!'$!&(+62Q$!6$(9!LZ<!/6!4(#!&'*/$+!6(E+$8'2=;!4(#!'2<0+/6+!$8+!>/**!6$0+66!/2&!+M+2$#/**4!'$!
0#9$#0+6@!!Y(;!'2!($8+0!>(0&6;!/**!/2+#046E6!>'**!0#9$#0+!7!'$Q6!3#6$!/!E/$$+0!()!>8+2@!
!
3. Abdominal Aorta Aneurysm: g84!'6!$8+!/L&(E'2/*!/(0$/!$8+!K.!/0+/!()!/2+#046En!SZ<!$8+0+!
'6!2(!M/6/!M/6(0#E!(0!L*((&!6#99*4!$(!$8+!/(0$/!L+*(>!$8+!0+2/*!/0$+0'+6@!!Y(;!$8+!(2*4!>/4!/L&@!
/(0$/!=+$6!GH!/2&!2#$0'+2$6!'6!)0(E!$8+!L*((&!$8/$Q6!'2!$8+!*#E+2@!!Y(;!9/0$!)#0$8+6$!)0(E!'$!E=+$6!
6<0+>+&@!!I8+0+)(0+;!/9/0$!)0(E!$8+!9/0$!$8/$!'6!2($!=+$$'2=!E#<8!GH!/2&!2#$0'+2$6;!'$!>'**!L+!E(0+!
6#6<+9$'L*+!$(!'23#04;!$8+0+)(0+!/$8+0(6<*+0(6'6!*+/&6!$(!>+/F+2'2=!()!$8+!>/**!/2&!/2+#046EZ'23#04!
(<<#06@!!!
/@!!K.!<(E9*'</$'(2!/L&(E'2/*!/(0$'<!/2+#046E!C!0#9$#0+@!!I8+!triad of s/s are-!!/!6#&&+2!(26+$!
()!6+M+0+!*+)$!)*/2F!9/'2!LZ<!$8+!/(0$/!'6!0+$0(9+0'$(2+/*!(0=/2!/2&!6(!'$!&(+6!2($!L*++&!'2$(!$8+!
9+0'$(2+/*!</M'$4;!L#$!'2$(!$8+!9+0'$(2+/*!$'66#+@!!Y(;!severe left flank pain, HypoTN, and
pulsatile mass on PE. I8+6+!/0+!$80++!$8'2=6!$8/$!/*>/46!(<<#0!>8+2!$8+0+!'6!/!0#9$#0+&!/(0$'<!
/L&(E'2/*!/2+#046E@!!MC complication of any aneurysm = rupture
114

4. Aneurysm of the arch of the aorta!!MCC = tertiary syphilis@!!J/$8(*(=4!()!6498'*'6!'6!
M/6<#*'$'6!()!/0$+0'(*+6@!.8/2<0+;!$((@!!1$6!9/'2*+66!LZ<!')!4(#!6+<$'(2!'$;!4(#!>'**!6++!*'$$*+!/0$+0'(*+6!
6#00(#2&+&!L4!9*/6E/!<+**6!/2&!$8+!*#E+2!()!$8+!M+66+*!'6!<(E9*+$+*4!68#$;!6(!'$!'6!'6<8+E'<!
2+<0(6'6@!!12!($8+0!>(0&6;!'$!'6!'6<8+E'/!()!$8+!(M+0*4'2=!$'66#+!#2&+0=('2=!2+<0(6'6@!!SZ<!2+0M+6!/0+!
2+:$!$(!M+66+*6;!$8+4!/0+!F2(<F+&!());!$((;!/2&!'$!'6!9/'2*+66@!!All of syphilis is a vasculitis@!!I8/$!
'6!>8/$!$8+!I0+9(2+E/!'2)+<$6!7!6E/**!M+66+*6!/2&!/0$+0'(*+6@!!g8/$!/0+!$8+4!/))+<$'2=!'2!$8+!/0<8!()!
$8+!/(0$/n!I8+!M/6/!M/6(0#EU!$8+!0'<8+6$!6#99*4!()!M/6/!M/6(0#E!'6!'2!$8+!/0<8;!6(!'$6!*(='</*!$8/$!
$8+!I0+9(2+E/!>'**!9'<F!'$!7!*+/&6!$(!+2&/0$+0'$'6!(L*'$+0/26!?$8+4!/0+!(L*'$+0/$'2=!$8+!*#E+2B;!
'6<8+E'/;!>+/F+2'2=!#2&+0!646$(*'<!90+66#0+6;!*+/&6!$(!&+90+66'(2!'2!$8+!/0<8!()!$8+!/(0$/!?*((F6!
*'F+!/!</$<8+0Q6!E'$$B@!!g8/$!>'**!$8/$!&(!$(!$8+!/(0$'<!M/*M+!0'2=n!1$!>'**!6$0+$<8!'$!7!>8'<8!E#0E#0!>'**!
$8'6!*+/&!$(n!%(0$'<!0+=#0=@!!K#0E#06!</2!(<<#0!LZ<!$8+0+!'6!M/*M#*/0!&/E/=+!(0!LZ<!$8+!M/*M#*/0!0'2=!
'6!6$0+$<8+&@!!Y(;!$8+0+!</2!L+!6$0+$<8'2=!()!$8+!0'2=!/2&!2($8'2=!>0(2=!>'$8!$8+!M/*M+6;!/2&!8/M+!/!
E#0E#0;!(0!4(#!</2!8/M+!&/E/=+!$(!$8+!M/*M+6!/2&!8/M+!/!E#0E#0@!!Y498'*'6!'6!/2!+:/E9*+!()!
6$0+$<8'2=!()!$8+!/(0$'<!M/*M+!0'2=!*+/&'2=!$(!/!E#0E#0!/2&!/(0$'<!0+=#0=@!!
!
%(0$/!68(#*&!L+!<*(6'2=!&#0'2=!&'/6$(*+!7!/6!4(#!9#E9!$8+!L*((&!(#$;!/2&!$8+!Yk!=(+6!&(>2;!/2&!
LZ<!$8+!/(0$'<!</22($!<*(6+!90(9+0*4;!(2*4!6(E+!()!$8+!L*((&!>'**!&0'9!L/<F!'2@!!Y(!4(#!>'**!8/M+!E(0+!
M(*#E+!()!L*((&!'2!$8+!*+)$!M+2$0'<*+!'2!6(E+(2+!>'$8!/(0$'<!0+=#0=@!!T0/2Fd6$/0*'2=!)(0<+6!>'**!L+!
>(0F'2=@!!%6!4(#!6$0+$<8!</0&'/<!E#6<*+;!4(#!'2<0+/6+!$8+!)(0<+!()!<(2$0/<$'(2@!!"(0E/**4;!4(#!8/M+!
/!,HV!E*Q6!()!L*((&!/2&!=+$!(#$!tV;!6(!$8+![T!'6!tVZ,HV!CaaW@!!X+$6!6/4!4(#!8/M+!HVV!E*6!()!L*((&!
'2!$8+!Xk!LZ<!L*((&!'6!&0'99'2=!L/<F!'2;!/2&!)0/2Fd6$/0*'2=!)(0<+!=+$6!(#$!,VV!E*6!()!L*((&;!>8'<8!8/6!
/2![T!()!eVW@!!Y(!$8'6!'62Q$!/6!+))'<'+2$@!I8+0+)(0+;!)0/2Fd6$/0*'2=!(<<#06!'2!/!9/$8(*(='<!<(2&'$'(2@!!1)!
4(#!8/M+!,VV!E*6!()!L*((&!<(E'2=!(#$!()!4(#0!/(0$/;!$8/$Q6!2($!=((&!LZ<!$8+'0!8+/&!'6!>(LL*'2=;!/2&!
>8+2!$8+4!(9+2!$8+'0!E(#$8!4(#!</2!6++!#M#*/!9#*6/$'2=;!</2!$/F+!$8+'0!2/'*!/2&!*')$!'$!#9!/2&!6++!
9#*6/$'(26!()!$8+!M+66+*6!#2&+0!$8+!2/'*;!g/$+0d8/EE+0!9#*6+;!/2&!>8+2!*'6$+2'2=!>'$8!$8+!
6$+$8(6<(9+!()!$8+!)+E(0/*!/0$+04!4(#!</2!8+/0!_#0/6/2+Q6!6'=2@!!I8'6!'6!/**!&#+!$(!$8+!'2<0+/6+!'2!Yk!
<(E'2=!(#$!0+*/$+&!$(!$8+!)/<$!$8/$!$8+0+!'6!E(0+!L*((&!'2!$8+!Xk@!!6498'*'$'<!/2+#046E6!()!$8+!
/L&(E'2/*!/(0$/!'6!$8+!<*/66'<!+:/E9*+!()!$8'6@!!%2/$(E4!<(00+*/$'(2-!$8+!X+)$!R+<#00+2$!X/042=+/*!
"+0M+!>0/96!/0(#2&!$8+!/0<8!/2&!$8+0+)(0+!</2!=+$!8(/06+2+66@!!%=/'2!$8+!K.!<(E9*'</$'(2!'6!
0#9$#0+@!
!
5. Dissecting aortic aneurysm:
a. Key factor that causes a tear in the aorta is HTN!LZ<!'$!'E9(6+6!6$0+66!(2!$8+!>/**!()!$8+!
M+66+*@!!I8+0+!E#6$!L+!>+/F+2'2=!$8+!+*/6$'<!/0$+04!/2&!'6!</#6+&!L4!+*/6$'<!$'66#+!)0/=E+2$/$'(2@!
Cystic medial necrosis-!$8/$Q6!>8+0+!$8+!l%lQ6!E':!$(=+$8+0!/2&!$8+0+Q6!E#<'2(#6!E/$+0'/*!>Z'2;!
/2&!>/**6!()!/(0$/!0#L!#9(2!'$6+*);!/2&!>8+2!/&&'2=!/!*'$$*+!L'$!()!NI"!*+/&6!$(!/!$+/0@!!g8+0+M+0!$8+!
/0+/!()!>+/F2+66!'2!$8+!+*/6$'<!/0$+04!'6!>8+0+!$8+!L*((&!>'**!&'66+<$!/2&!$+/0!7!L*((&!</2!=(!$(!$8+!
9+0'</0&'/*!6/<;!*+/&'2=!$(!</0&'/<!$/E9(2/&+@!!I8'6!'6!</**+&!$8+!90(:'E/*!&'66+<$'(2!?K.B@!!K(6$!()!
$8+!$+/06!#9!'2!$8+!/0<8U!$8+0+)(0+!4(#!>(#*&!$8'2F!$8+!9$!E/4!8/M+!/2!/L6+2$!9#*6+U!$8'6!'6!M+04!
<(EE(2!'2!9$6!>'$8!$+/06!$8/$!/0+!90(:'E/*@!!g8+2!'$!&'66+<$6;!'$!<*(6+6!*#E+2!$(!6#L<*/M'/2!/0$+04!
/2&!'$!#6#/**4!&'66+<$6!(2!$8+!*+)$!/2&!</#6+6!/2!/L6+2$!9#*6+!(2!*+)$@!
!
b. Chest pain!'2!K1!'6!&'))!$8/2!$8+!<8+6$!9/'2!'2!/!&'66+<$'2=!/2+#046E@!!K1!8/6!<8+6$!$'=8$2+66!
0/&'/$'2=!$(!*+)$!/0E!/2&!3/>U!'2!/(0$'<!&'66+<$'(2;!$8+0+!'6!/!$+/0'2=!9/'2!0/&'/$+6!$(!$8+!L/<FU!/2&!'6!
/!0+$0(6$+02/*!9/'2@!!J#*6+!(2!*+)$!'6!&'E'2'68+&!M6@!$8+!(2+!(2!$8+!0'=8$@!!G2!<8+6$!:d0/4;!>'&+2'2=!()!
$8+!/(0$'<!F2(L@!!g'$8!L*((&!$8+0+;!&'/E+$+0!()!/(0$/!>'**!L+!+2*/0=+&;!/6!6++2!(2!:d0/4;!/2&!$8'6!
$+6$!'6!teW!6+26'$'M+!'2!&+$+<$'2=!'$;!$8+0+)(0+!'$!'6!$8+!6<0++2'2=!$+6$!()!<8('<+U!6++!>'&+2'2=!()!$8+!
proximal aortic knob@!!I(!90(M+;!&(!$0/26+6(98/=+/*!#*$0/6(#2&!(0!/2='(=0/984!$(!<(2)'0E!&:@!
!
115

c. Many dzs can predispose to aortic dissections-!
?,B!Marfan syndrome!?+#2(<8('&!90(9(0$'(26!7!8$!()!9+*M'<!L0'E!$(!)++$!'6!=0+/$+0!$8/2!)0(E!
9+*M'<!L0'E!$(!$8+!8+/&@!%*6(;!/2($8+0!&+)'2'$'(2!'6!$8/$!/0E!69/2!'6!=0+/$+0!$8/2!$8+!8+'=8$@!%_!
'28+0'$/2<+;!<Q6(E+!,e;!&+)+<$!'2!)'L0'**'2;!>8'<8!'6!/!<(E9(2+2$!'2!+*/6$'<!$'66#+@!_#+!$(!$8+!&+)+<$!'2!
)'L0'**'2;!$8+!+*/6$'<!$'66#+!'6!>+/F!7!$8'6!'6!>84!$8+4!8/M+!&'6*(</$+&!*+26+6!/2&!8/M+!&'66+<$+&!/(0$'<!
/2+#046E6!?K..!&+/$8!'2!E/0)/26!'6!KkJB@!!!
!
?HB!Ehler Danlos!8/6!/!<(**/=+2!&+)+<$;!K..!()!&+/$8!
!
?PB!Pregnant women!/0+!6#6<+9$'L*+!$(!&'66+<$'2=!/(0$'<!/2+#046E6!LZ<!'2!90+=2/2<4!$8+4!8/M+!
$>'<+!$8+!/E(#2$!()!9*/6E/!M(*!M6@!/!2(2d90+=2/2$!>(E/2@!!I8+0+!'6!/2!'2<0+/6+!()!9*/6E/!M(*!L4!H!
/2&!RS.!E/66!L4!,;!6(!'$Q6!/!H-,!0/$'(!()!'2<0+/6'2=!9*/6E/!M(*!$(!RS.!E/66U!>8'<8!&+<0+/6+6!$8+!
NL!<(2<+2$0/$'(2@!!I8/$Q6!>84!/**!90+=2/2$!>(E+2!8/M+!&+<0+/6+&!8+E(=*(L'2U!#6#/**4!/0(#2&!,,@e!
'6!$8+'0!<#$())!)(0!/2+E'/!/2&!$8+!<#$())!'6!,H@e!)(0!2(0E/*!>(E+2@!!I8'6!'6!LZ<!()!&'*#$'(2/*!+))+<$!
>'$8!+:<+66!'2!9*/6E/!M(*@!!%99/0+2$*4!'2!6(E+!>(E+2;!$8+!+:<+66!9*/6E/!M(*#E+!)(0!r!E(2$86!</2!
</#6+!>+/F+2'2=!()!$8+!/(0$/!/2&!$8+0+L4!</#6'2=!/2!/2+#046E@!!!
!
V. Venous Disorders:
A. Superior vena cava lung syndrome!'2!/!6E(F+0!>'$8!90'E/04!*#2=!</2<+0;!2(>!<(E9*/'2'2=!
()!8+/&/<8+!/2&!L*#004!M'6'(2!7!*((F!/$!8'6!0+$'2/!/2&!6++!0+$'2/*!M+'2!+2=(0=+E+2$;!/2&!<(2=+6$+&!
7!&:n!Superior vena cava lung syndrome!7!#6#/**4!&#+!$(!90'E/04!*#2=!</2<+0!F2(<F'2=!())!$8+!
6#9!M+2/!</M/;!*+/&'2=!$(!L/<F#9!()!M+2(#6!L*((&!'2$(!$8+!3#=#*/0!M+2(#6!646$+E!/2&!$(!$8+!&#0/*!
6'2#6+6U!$8'6!'6!/!M+04!L/&!&c;!/2&!>'**!*+/&!$(!&+/$8@!!\6#/**4!$0+/$!>'$8!0/&'/$'(2!$(!680'2F!$8+!
$#E(0!$(!=+$!2(0E/*!L*((&!)*(>@!!_(2Q$!<(2)#6+!>'$8!Pancoast Tumor!7!/66(<'/$+&!>'$8!N(02+0Q6!
642&0(E+@!!Y(;!Yk.!642&0(E+!8/6!2($8'2=!$(!&(!>'$8!N(02+0Q6;!/6!(99(6+&!$(!J/2<(/6$@!
B. Varicose Veins
VI. Tumors of Blood Vessels:
A. Sturge Weber syndrome!7!!i>+LA!*((F6!*'F+!/!E'2'!E/9!(2!$8+'0!)/<+j!!
'$Q6!/!M/6<#*/0!E/*)(0E/$'(2!'2!$8+!)/<+!/2&!2($'<+!'$Q6!'2!$8+!$0'=+E'2/*!2+0M+!&'6$0'L#$'(2!?E/F'2=!'$!
+/64!$(!&cB@!!N(>+M+0;!(2!$8+!6/E+!6'&+!()!$8+!L0/'2!$8+0+Q6!/2!%k!E/*)(0E/$'(2;!90+&'69(6'2=!$(!
L*++&'2=@!!Y(;!2($!(2*4!/!M/6<#*/0!E/*)(0E/$'(2!()!$8+!)/<+;!L#$!/*6(!/2!%k!E/*)(0E/$'(2!'2!$8+!
6/E+!6'&+!()!$8+!L0/'2;!>8'<8!90+&'69(6+6!$(!L*++&'2=@!!%*6(;!$8+6+!9$6!/0+!/!*'$$*+!E+2$/**4!0+$/0&+&@!!
?6(E+!9$6!68(>!'$!(2!$8+!+2$'0+!6'&+!()!$8+!)/<+B!
!
B. Osler Weber Rendu aka Hereditary hemorrhagic telangiectasia!7!6E/**!$+*/2='+<$/6'/!'2!
l1@!!%_!'28+0'$/2<+!<8/0/<$+0'c+&!L4!*(</*'c+&!$+*/2='+<$/6+6!()!$8+!6F'2!/2&!E#<(#6!E+EL0/2+6!
/2&!L4!0+<#00+2$!8+E(008/=+!)0(E!$8+6+!*+6'(26@!!!
!
C. Spider angioma/spider telangiectasia-!1)!4(#!90+66!&(>2!(2!$8'6;!$8+!*'$$*+!$+2$/<*+6!>'**!=(!
/>/4!?$8+0+)(0+!'$!L*/2<8+6B!7!</**+&!69'&+0!/2='(E/@!!1$!'6!&#+!$(!849+0+6$0'2'6E@!!I8'6!'6!2(0E/*!'2!
90+=2/2<4@!!1)!/!E/*+!8/6!69'&+0!/2='(E/;!8+!8/6!<'008(6'6!?K..!<'008(6'6!C!/*<(8(*B@!!g84!>(#*&!/!
E/*+!8/M+!/!69'&+0!/2='(E/n!SZ<!')!4(#!8/M+!<'008(6'6;!4(#!</22($!E+$/L(*'c+!+6$0(=+2!7!6(!'$!L#'*&6!
#9;!*+/&'2=!$(!=42+<(E/6$'/;!>/0E!6F'2;!9/*E+0!+04$8+E/;!/2&!69'&+0!/2='(E/!0+*/$+&!$(!
849+0+6$0'2'6E@!%2($8+0!0+/6(2!>(#*&!L+!LZ<!$8+4!</22($!E+$/L(*'c+!,`!F+$(6$+0('&6!+'$8+0;!
$8+0+)(0+!$8+4!>'**!L+!/0(E/$'c+&!$8(6+!'2!$8+!/&'9(6+!$'66#+!'2$(!+6$0(=+2@!!Y(;!$8+4!/0+!H!>/46!()!
=+$$'2=!849+0+6$0'2'6E!'2!<'008(6'6@!!Y(;!8(>!'6!$8'6!&'))+0+2$!)0(E!9+$+<8'/n!1$!*((F6!&'))U!/*6(;!'$!>'**!
116

L*/2<8!>8+2!4(#!90+66!'$!'2!LZ<!'$Q6!/2!%k!)'6$#*/!7!'2!($8+0!>(0&6;!$8+!L*((&!=(+6!&'0+<$*4!)0(E!
/0$+0'(*+!$(!/!M+2#*+!/2&!'6!L49/66'2=!$8+!</9'**/0'+6@!!!
D. Capillary Hemangioma-!!9'<!()!<8'*&!>'$8!0+&!*+6'(2!?2($!L'*/$+0/*!>'&+!+4+!*+6'(2!7!6(!'$6!2($!
0+$'2(L*/6$(E/BU!>8/$!&(!4(#!&(n!Leave it aloneU!&(!2($!6#0='</**4!0+E(M+!LZ<!L4!t!4Z(;!'$!>'**!L+!
=(2+!7!6(;!*+/M+!</9'**/04!/2='(E/6!/*(2+!LZ<!$8+4!>'**!=(!/>/4@!!!
!
E. Bacillary angiomatosis:
5/9(6'!6/0<(E/!'6!</#6+&!L4!$8+!NNk t!(0=/2'6E@!!1)!$8+0+!>/6!/!*+6'(2!6++2!(2*4!'2!%1_6!9$6!$8/$!
*((F6!*'F+!5/9(6'!6/0<(E/;!L#$!'$Q6!2($U!>8/$!'6!'$!&#+!$(n!!1$Q6!&#+!$(!L/<$+0'/!7!bacillary
angiomatosis!7!due to bartenella hensilai!7!6++2!>'$8!6'*M+0!6$/'2@!!R:n!Y#*)/!&0#=@!!I8'6!
(0=/2'6E!/*6(!</#6+6!./$!Y<0/$<8!_c@!
!
F. Angiosarcoma of the liver!7!<(EE(2!</#6+6!ik%Ij!C!k'24*!<8*(0'&+!?9+(9*+!>8(!>(0F!>'$8!
9*/6$'<6!/2&!0#LL+0B;!%06+2'<!?9/0$!()!9+6$'<'&+6;!<(2$/E'2/$+&!>/$+0B;!/2&!I8(0($0/6$!?/!0/&'(/<$'M+!
&'/=2(6$'<!/=+2$!$8(0'#E!&'(:'&+B@!
!
VII. Vasculitis Syndromes!
A. Concept of Vasculitis:!!k/6<#*'$'6!()!6E/**!M+66+*6!?/0$+0'(*+6;!M+2#*+6;!</9'**/0'+6B;!E#6<#*/0!
/0$+0'+6;!/2&!+*/6$'<!/0$+0'+6@!!%**!()!$8+6+!M/6<#*'$'6!90+6+2$!>'$8!&'))+0+2$!6'=26!/2&!64E9$(E6!?'+!
*'F+!<(/=#*/$'(2!&'6(0&+06!M6@!9*/$+*+$!&'6(0&+06B@!
!
1. Small vessel vasculitis!7!rrW!()!$8+!$'E+!'$!'6!&#+!$(!/!$49+!111!NJb;!E+/2'2=!'$!'6!'2M(*M+6!
'EE#2+!<(E9*+:!&+9(6'$'(2;!$8/$!>'**!&+9(6'$!'2!$8+!6E/**!M+66+*;!/<$'M/$+!<(E9*+E+2$!/2&!/$$0/<$!
2+#$0(98'*6!?.e/B;!/2&!>'**!=+$!)'L0'2('&!2+<0(6'6!/2&!&/E/=+!$(!$8+!6E/**!M+66+*!/2&!PALPABLE
PURPURAU!?0+E+EL+0!$8+!(*&!9+06(2!>'$8!9#09#0/!(2!$8+!L/<F!()!$8+!8/2&!7!$8/$!>/6!2($!
9/*9/L*+!/2&!>/6!&#+!$(!8+E(008/=+!'2$(!$8+!6F'2;!$8+0+!>/6!2(!'2)*/EE/$(04!90(L*+E!7!'$!3#6$!
0#9$#0+&!'2$(!$8+!6F'2B!L#$!')!'$!>/6!9/*9/L*+;!'$!>(#*&!L+!<(26'&+0+&!/!YK%XX!k[YY[X!M/6<#*'$'6!2($!
/!9*/$+*+$!90(L*+E@!!!
[:/E9*+-!!!
X+#F(<4$(<*/6$'<!M/6<#*'$'6!?849+06+26'$'M'$4!M/6<#*'$'6BU!!
2#<*+/0!&#6$!C!)'L0'2('&!2+<0(6'6!/2&!'EE#2+!<(E9*+:!&cQ6U!/2&!!
N+2(<8dY<8(2*+'2!9#09#0/@!!So, SMALL VESSEL vasculitis = PALPABLE purpura (always told
in the stem of the question).
!
2. Muscular artery vasculitis!7!J(*4/0$+0'$'6!"(&(6/!/2&!g+=+2+0!=0/2#*(E/$(6'6@!!I8+6+!>'**!
=+$!INRGKSGY1Y!()!$8+!M+66+*;!2($!9/*9/L*+!9#09#0/@!!g'**!8/M+!INFARCTION@!![:/E9*+-!!
5/>/6/F'Q6!_c!'2!<8'*&0+2!i<0'E6j!<(0(2/04!/0$+04!M/6<#*'$'6!;0/68;'2)/0<$'(2;E';!6>+**'2=!!
7!=+$!<(0(2/04!/0$+04!M/6<#*'$'6!7!K..!K1!'2!<8'*&0+2!C!5/>/6/F'Q6!&c!7!LZ<!9/0$!()!$8+!642&0(E+;!'2!
/&&'$'(2!$(!E#<(<#$/2+(#6!'2)*/EE/$'(2;!&+6D#/E/$'(2!()!6F'2;!/2&!*4E98/&+2(9/$84;!$8+0+!'6!/!
<(0(2/04!/0$+04!M/6<#*'$'6!7!$80(EL(6'6!(<<#06!/2&!*'$$*+!<8'*&!>'**!8/M+!/2!'2)/0<$'(2@!!So, infarction
is what you see with a muscular artery vasculitis. [:/E9*+6-!!J(*4/0$+0'$'6!"(&(6/;!g+=+2+0!
=0/2#*(E/$(6'6;!5/>/6/F'Q6!&c!'2!F'&6@!
!
3. Elastic artery vasculitis!7!g8+2!4(#!F2(<F!())!/2!+*/6$'<!/0$+04;!$8+2!4(#!&+/*!>'$8!/0<8!
M+66+*6;!/2&!$8+4!>'**!=+$!9#*6+*+66!&cCI/F/4/6#Q6!/0$+0'$'6!7!$8+!M/6<#*'$'6!>'**!L*(<F!())!$8+!*#E+2!()!
117

(2+!()!$8+!/0<8!M+66+*6;!*+/&'2=!$(!STROKES!/2&!</2!F2(<F!())!$8+!'2$+02/*!</0($'&@!![:/E9*+-!!
I/F/4/6#Q6!7!4(#2=;!)/0!+/6$+02!*/&4!>'$8!/L6+2$!9#*6+@!
!
So, palpable purpura = small vessel vasculitis
Infarction = muscular vasculitis
Involves pulse/stroke = elastic artery vasculitis
!
B. Temporal Arteritis!7!#2'*/$+0/*!8+/&/<8+;!/<8+6!/2&!9/'26!/**!(M+0!L(&4;!*(66!()!M'6'(2!()!6/E+!
6'&+!()!8+/&/<8+;!8#0$6!>8+2!9$!<8+>6!'2!$+E9(0/*!/0+/@!!I8'6!'6!/!=0/2#*(E/$(#6!?8/M+!
E#*$'2#<*+/$+&!='/2$!<+**B!M/6<#*'$'6!()!$8+!$+E9(0/*!/0$+04;!/!$49+!()!='/2$!<+**!/0$+0'$'&+6@!!1$!</2!
'2M(*M+!($8+0!9(0$'(26!()!$8+!/0$+04!'2<*#&'2=!$8+!(98$8/*E'<!L0/2<8!/2&!90(&#<+!L*'2&2+66@!!I8/$Q6!
>84!$8+!6+&'E+2$/$'(2!0/$+!'6!$8+!G"Xb!6<0++2!&'6<0++$!)(0!$+E9(0/*!/0$+0'$'6@!!g84n!"($!$8/$!'$!'6!
69+<')'<;!L#$!LZ<!$8'6!'6!/2!/0$+0'$'6;!?/2!'2)*/EE/$'(2B!$8+!6+&!0/$+!68(#*&!L+!+*+M/$+&@!!1)!$8+!6+&!
0/$+!'6!"GI!+*+M/$+&;!'$!<(#*&!L+!/!$0/26'+2$!'6<8+E'<!/$$/<F@!!I8'6!'6!=((&!6<0++2!LZ<!'$!$/F+6!$'E+!$(!
$/F+!/!L'(964!/2&!*((F!/$!'$;!/2&!$8+!9$!<(#*&!=(!L*'2&@!!Y(;!4(#!E#6$!9#$!$8+!9$!(2!<(0$'<(6$+0('&6!
'EE+&'/$+*4!?0'=8$!$8+0+!/2&!$8+2B!3#6$!L/6+&!(2!8:!/*(2+@!!I8+!9$!>'**!L+!(2!<(0$'<(6$+0('&6!)(0!(2+!
4+/0@!!!1$Q6!/66(<'/$+&!>'$8!9(*4E4/*='/!08+#E/$'</!7!E#6<*+!/<8+6!/2&!9/'26@!!I8+4!>/2$!4(#!$(!6/4!
'$!'6!9(*4E4(6'$'6;!L#$!'$!'62Q$@!!J(*4E4/*='/!08+#E/$'</!&(+6!2($!8/M+!/2!+*+M/$'(2!()!6+0#E!.5;!/2&!
8/M+!/<8+6!/2&!9/'26!()!E#6<*+6!/2&!3('2$6@!!12!9(*4E4(6'$'6;!'$Q6!/2!'2)*/EE/$'(2!()!E#6<*+@!
!
C. Buerger dz (aka thromboangiitis obliterans smokers dzBU!!i+>!L((=+06!/2&!6E(F+!
E/F+!E+!6(!6'<F!E4!)'2=+06!/2&!$(+6!<#0*j!!
E/*+6;!4(#2=;!&'='$/*!M+66+*!$80(EL(6'6;!*+/&'2=!$(!/#$('2)/0<$'(2!()!$8+'0!)'2=+06;!%"_!$(+6@!!1$Q6!/2!
/<#$+!'2)*/EE/$'(2!'2M(*M'2=!6E/**!$(!E+&'#Ed6'c+&!/0$+0'+6@!!!
!
Henoch-Schonlein purpura-!?L#$$;!3('2$6;!='$;!0+2/*;6F'2B!?9/*9/L*+!9#09#0/!(2!L#$$;!2!*+=6;!3('2$!
90(L6;!/2&!F'&2+4!90(L6B!
,^!4Z(;!\R1!(2+!>++F!/=(;!90+6+2$6!>'$8!9(*4/0$80'$'6;!3('2$!9/'26;!8+E/$#0'/;!>'$8!RS.!</6$6!/2&!
9/*9/L*+!9#09#0/!()!L#$$(<F6!/2&!*(>+0!+:$0+E'$4!7!&:n!!N+2(<8dY<8(2*+'2!9#09#0/!C!K.!M/6<#*'$'6!
'2!<8'*&0+2!7!'EE#2+!<(E9*+:!?/6!'6!/**!6E/**!M+66+*!M/6<#*'$'6B7!/2$'!1=%!'EE#2+!<(E9*+:;!/2&!$8+!
RS.!</6$6!/0+!&#+!$(!=*(E+0#*(2+980'$'6@!!_(!2($!<(2)#6+!>'$8!1=%!=*(E+0#*(2+980'$'6!7!S+0=+0Q6!&c!!
!
E. Wegener granulomatosis
-if u had to go listen to wagner in concert, you would pretend u had to use the
bathroom or get pneumonia
infarcn, lung, urt, renal , saddle nose ,cancacyclophosamine rx
!9$!>'$8!6/&&*+!2(6+!&+)(0E'$4!!?2($!<(2=+2'$/*!6498'*'6B!7!/*6(!90(L6!!>'$8!6'2#6!'2)+<$'(26;!\R1Q6;!
*#2=!90(L6!>'$8!2(&#*/0!E/66+6;!/2&!=*(E+0#*/0!&c!7!&:n!!g+=+2+0!=0/2#*(E/$(6'6!?K..!()!6/&&*+!
2(6+!&+)(0E'$4B@!I8'6!'6!/!=0/2#*(E/$(#6!'2)*/EE/$'(2!%"_!M/6<#*'$'6@!!I8+0+)(0+;!'$!'2M(*M+6!$8+!
#99+0!/'0>/46;!*#2=6;!/2&!F'&2+46U!/*6(;!$8+0+!'6!/2!%L!$8/$!'6!8'=8*4!69+<')'<!)(0!'$!7!
c-ANCA (anti-neutrophil cytoplasmic Ab). Rx - Cyclophosphamide!?>8'<8!</2!*+/&!$(!
8+E(008/='<!<46$'$'6!/2&!L*/&&+0!</2<+0!/2&!8(>!</2!4(#!90+M+2$!$8+!8+E(008/='<!<46$'$'6n!K+62/B@!
!
F. Polyarteritis Nodosa!7!
i!9/2</;!8L6/=;!F'&2+4;!8+/0$!90(L*+E6;!'2)/0<Q2j!
!E/*+!&(E'2/2$!&c!$8/$!'2M(*M+6!E#6<#*/0!/0$+0'+6;!$8+0+)(0+!'2)/0<$'(2!'6!/!9/0$!()!'$@!!N/6!p-ANCA
Ab and a high association with Hep B surface Agemia@!![:/E9*+-!!8/M+!1k_%!>'$8!<80(2'<!
N+9!S!>8(!8/6!/!2(&#*/0!'2)*/E+&!E/66!(2!$8+!*(>+0!+:$0+E'$4!/2&!8+E/$#0'/!?&#+!$(!F'&2+4!
118

'2)/0<$BU!>8/$!&(+6!$8+!9$!8/M+n!J(*4/0$+0'$'6!"(&(6/!LZ<!$8+!9$!8/6!/!<80(2'<!8+9!S!'2)+<$'(2!
$8+0+)(0+!8/6!8+9!S!6#0)/<+!/2$'=+26@!!Y(;!0+E+EL+0!p-ANCA and Hep B surface Ag.
!
G. Bacterial infections:!!M+66+*!'2!RMSF@!!I8+!0'<F+$$6'/*!(0=/2'6E6!'2)+<$!+2&($8+*'/*!<+**6U!$8+!
69($6!/0+!9+$+<8'/U!#2*'F+!($8+0!0'<F+$$6'/*!&cQ6!>'$8!0/68;!$8'6!6$/0$6!(2!$8+!+:$0+E'$'+6!/2&!=(+6!$(!
$8+!$0#2F!?>8+0+/6!($8+06!6$/0$!(2!$8+!$0#2F!/2&!$(!$8+!+:$0+E'$'+6B@!!%*6(!8/M+!$(!0+E+EL+0!$8+!
M+<$(0-!$'<F@!!G$8+0!$'<F!L(02!&cQ6-!X4E+!&c!?L(00+*'/!L#0=&(0)+0'!7!L@!0+<#0+2$'6!'6!0+*/96'2=!)+M+0;!
/2&!8/6!/2$'=+2'<!68')$6U!'$!'6!/!69'0(<8+$+!?X+9$(69'0/!/2&!6498'*'6!/0+!/*6(!69'0(<8+$+6B@!!Y(;!P!
69'0(<8+$+6!7!X+9$(69'0/;!I0+9(2+E/;!S(00+*'/!?iSXIjB!
!
F. Fungus!!$8/$!'6!>'&+!/2=*+;!2(26+9$/$+!;!9$!8/6!_5%;!/2&!<+0+L0/*!/L6<+66+6!0+*/$+&!$(!)#2=#6!7!
mucormycosis!?F2(>!0+*/$'(268'9!()!$8'6!)#2=#6!/2&!_5%BU!
_'/L+$'<6!<(EE(2*4!8/M+!E#<(0!'2!$8+'0!)0(2$/*!6'2#6+6U!6(!>8+2!$8+4!=(!'2$(!F+$(/<'&(6'6!/2&!6$/0$!
90(*')+0/$'2=;!$8+4!=(!$80(#=8!$8+!<0'L')(0E!9*/$+!'2$(!$8+!)0(2$/*!*(L+6!>8+0+!$8+4!'2)/0<$!'$!/2&!
'2)+<$!'$!>'$8!$8+!&c@!
!
VIII. Functional Vascular Disorders: Raynaud Dz!
I8+0+!/0+!E/24!</#6+6!$8'6U!6(E+!'2M(*M+!<(*&!0+/<$'2=!%LQ6!/2&!<(*&!0+/<$'2=!=*(L#*'26@!!J+(9*+!
>8(!=(!(#$6'&+!'2!$8+!<(*&!>+/$8+0!>'**!=+$!R/42/#&Q6!/2&!<4/2(6'6!'2!$8+!2(6+!/2&!+/06!?$8/$!
<(E+6!/2&!=(+6!/>/4BU!6(;!'$!'6!&#+!$(!1=K!<(*&!/==*#$'2'2!&c!(0!<04(=*(L'2+E'/!'2!(*&!E/2!>'$8!
N+9!.@!
!
N(>+M+0;!>+!8/M+!($8+0!&cQ6!$8/$!/0+!collagen vascular dz!/2&!)'06$!E/2')+6$/$'(2!'6!R/42/#&Q6U!
$8'6!'2M(*M+6!/!&'='$/*!M/6<#*'$'6!/2&!+M+2$#/**4!/!)'L0(6'6!7!90(=0+66'M+!646$+E'<!6<*+0(6'6!?/F/!
6<*+0(&+0E/B;!/2&!'$6!<(#2$+09/0$!.R[YI!642&0(E+@!
k/6<#*'$'6!()!)'2=+06!/2&!*+/&6!$(!)'L0(6'6!7!>'**!+M+2$#/**4!/#$(d/E9#$/$+!)'2=+0!?*'F+!S+0=+0Q6B@!!
!
CREST syndrome!7!./*<'2(6'6!?&46$0(98'<!</*<')'</$'(2B!/2&!.+2$0(E+0+!%L!?69+<')'<!)(0!<0+6$!
642&0(E+B;!R/42/#&Q6;![6(98/=+/*!&46E($'*'$4;!Y<*+0(&/<$4*4!?)'2=+0!$8/$!'6!M+04!2/00(>B;!
I+*/2='+<$/6'/!?M+04!6'E'*/0!$(!$8+!9'2!9('2$!8+E(008/=+6!7!/*6(!6++2!'2!G6*+0!g+L+0!
R+2&#B@ooooooooooo!
!
G$8+0!</#6+6!&#+!$(!M/6(<(26$0'<$'(2!7!<(EE(2!'2!9$6!$8/$!$/F+!&0#=6!)(0!E'=0/'2+!7!&0#=6!)(0!
E'=0/'2+6!</#6+!M/6(<(26$0'<$'(2!()!M+66+*6@!Y(;!R/42/#&Q6!</2!(<<#0!/)$+0!$/F'2=![0=($!&+0'M/$'M+6U!
S#+0=+0!&c;!$((@!
!
Therefore, general causes of Raynauds: vasoconstriction, vasculitis of the digits (ie
CREST and scleroderma), and cold reacting Abs and globulins .
!
IX. Hypertension (HTN)
!
K..!&+/$8!>'$8!NI"!C!K1!?H2&!C!6$0(F+;!P0&!C!0+2/*!)/'*#0+B!
[66+2$'/*!NI"C!K.!
!
A. Multifactorial Inheritance:!!g8/$!0/<'/*!=0(#9!8/6!8'=8+6$!'2<'&+2<+!()!NI"n!S*/<F6@!!g84n!
K#*$')/<$(0'/*!'28+0'$/2<+!?/F/!9(*4=+2'<!'28+0'$/2<+U!($8+0!&cQ6!'2<*#&+-!=(#$;!.%_;!I49+!11!&'/L+$+6;!
/))+<$'M+!&'6(0&+06;!<(2=+2'$/*!94*(0'<!6$+2(6'6;!+66+2$'/*!NI"B@!!I8'6!E+/26!$8/$!4(#!8/M+!/!
$+2&+2<4!$(!TGR!$8+!&c;!L#$!&(2Q$!2+<+66/0'*4!=+$!$8+!&c@!!g84n!SZ<!'$Q6!K\XI1)/<$(0'/*m!
!
119

[:/E9*+-!!1!/E!L*/<F;!>8/$!68(#*&!1!&(!$(!90+M+2$!)0(E!=+$$'2=!'$n!1!</22($!=+$!0'&!()!=+2+$'<6;!/2&!
E4!=+2+$'<6!/0+!$8/$!1!cannot get rid of salt in my urine!!d!0+$/'2'2=!$((!E#<8!6/*$!(which is
the basic mechanism of essential HTN in blacks and elderlyB@!Y(;!</22($!<(2$0(*!=+2+$'<6;!
L#$!1!</2!<(2$0(*!P!$8'2=6-!?,B!>+'=8$!8/6!/!&'0+<$!<(00+*/$'(2!>'$8!NI"U!?HB!0+&#<+!6/*$!'2$/F+U!/2&!
?PB!+:+0<'6+@!![:/E9*+-!!)/E'*4!8:!()!=(#$;!>8/$!</2!1!&(!6(!1!/M('&!=(#$n!%M('&!0+&!E++$;!2(!
/*<(8(*!?>8'<8!>'**!&+<0+/6+!9#0'2+!E+$/L(*'6EB@!![:/E9*+-!!1)!4(#!8/&!/!)/E'*4!8:!()!_K!$49+!11!7!
L+!6F'224!?*+/2!/2&!E+/2B7!/6!4(#!*(6+!/&'9(6+;!#90+=#*/$+!'26#*'2!0+<+9$(0!642$8+6'6!/2&!$8/$!
/*(2+!<(#*&!90+M+2$!4(#!)0(E!8/M'2=!$8+!&c@!
!
B. Mechanism of HTN!7!LZ<!4(#!retain salt!?'$Q6!2($!$8+!(2*4!E+<8/2'6E;!L#$!$8+!K.!(2+B@!!
g8+2!4(#!0+$/'2!6/*$;!>8/$!<(E9/0$E+2$!>'**!$8+!6/*$!L+!0+$/'2+&!'2n![.T!7!')!$8/$!'6!$0#+;!>8/$!>'**!
L+!$8+!9*/6E/!M(*#E+!')!4(#!8/M+!+:<+66!6/*$!'2!4(#0!M/6<#*/0!/2&!'2$+06$'$'/*!<(E9/0$E+2$n!
12<0+/6+&!7!')!4(#0!9*/6E/!M(*!'6!'2<0+/6+&;!4(#0!6$0(F+!M(*#E+!>'**!L+!'2<0+/6+&!7!>8'<8!'6!4(#0!
systolic HTN (b/c increase in PLASMA vol)@!!g8+2!4(#!8/M+!+:<+66!6/*$;!6/*$!>/2$6!$(!=(!'2$(!
6E(($8!E#6<*+!<+**6!?'2$(!9+0'98+0/*!0+6'6$/2<+!/0$+0'(*+6B@!!g8+2!6(&'#E!+2$+06!E#6<*+;!'$!(9+26!
<+0$/'2!<8/22+*6!)(0!./!$(!=(!'2U!./!=(+6!'2!/2&!6E(($8!E#6<*+!>'**!<(2$0/<$;!6(!$8+!9+0'98+0/*!
0+6'6$/2<+!/0$+0'(*+6!/0+!M/6(<(26$0'<$'2=@!!IJR!C!M'6<(6'$4Z0/&'#6Û!>+!/0+!&+<0+/6'2=!0/&'#6;!
'2<0+/6'2=!0+6'6$/2<+;!/2&!retaining more blood in the arteriole system (that registers as an
increase in diastolic pressure).!!I8'6!'6!>84!$8+!R:!()!<8('<+!)(0!+66+2$'/*!NI"!'2!L*/<F6!/2&!
+*&+0*4!C!84&0(<8*(0($8'/c'&+!7!LZ<!4(#!0'&!6/*$!/2&!>/$+0!$(!&+<0+/6+!SJU!8(>+M+0;!&(!2($!#6+!')!9$!
8/6!849+0*'9'&+E'/;!6(!#6+!%.[!'28'L'$(06@!
!
16!$8'6!/!8'=8!(0!*(>!0+2'2!$49+!()!NI"n!X(>!0+2'2!LZ<!'2<0+/6+&!9*/6E/!M(*#E+!C!'2<0+/6+&!L*((&!
)*(>!$(!$8+!0+2/*!/0$+04!C!&+<0+/6+&!0+2'2@!!Y(!$8/$Q6!$8+!L/6'<!E+<8/2'6E!()!NI"@!
!
C. Complications-!NI"!'6!/!E/3(0!0'6F!)/<$(0!)(0!.%_;!*+/&'2=!$(!MI (MCC deathB@!!!Y$0(F+!C!
sH@!!!S*((&!'6!*(</$+&!'2!=*(L#6!9/**'&#6!/2&Z(0!9#$/E+2!7!$8'6!'6!>8+0+!/*E(6$!/**!()!$8+!NI"Q'M+!
L*++&6!(<<#0!'2!$8+!L0/'2@!!I8'6!'6!LZ<!$8+!*+2$'<#*(6$0'/$+!M+66+*6!?>8'<8!/0+!6E/**!M+66+*6!()!$8+!
E'&&*+!<+0+L0/*!/0$+04B!#2&+0!'2<0+/6+&!90+66#0+!)(0E!/2+#046E6!</**+&!Charcot Bouchard
aneurysms;!/2&!$8+4!0#9$#0+@!I8'6!'6!2($!/!=((&!9*/<+!$(!0#9$#0+@!!I8+0+)(0+;!$8'6!'6!2($!/2!'2)/0<$!
7!'$!'6!/!8+E/$(E/!7!'$Q6!/!L*((&!<*($!0'=8$!$8+0+@!"+#0(6#0=+(26!</2!6#<F!$8+6+!(#$@!!I8+0+)(0+!$8+!
2nd MCC death is HTNve bleed@!![:/E9*+-!!F'&2+4!!$8/$!'6!$((!6E/**!>'$8!/!9+LL*4!6#0)/<+!&#+!$(!
84/*'2+!/0$+0'(*(6<*+0(6'6!7!/!6E/**!M+66+*!&c!'6!</#6'2=!'6<8+E'/!()!$8+!F'&2+4;!/$0(984!()!$#L#*+6;!
&+6$0#<$'(2!()!=*(E+0#*';!680'2F/=+!()!F'&2+4;!/2&!*+/&6!$(!F'&2+4!)/'*#0+@!!I8'6!'6!$8+!3rd MCC
death in HTN. K.!(M+0/**!/L2(0E/*'$4!'2!NI"!C!XkN!?E+<8-!/)$+0*(/&!90(L!LZ<!$8+!8+/0$!8/6!$(!
<(2$0/<$!/=/'26$!'2<0+/6+&!0+6'6$/2<+!/2&!')!'$!0+E/'26!(M+0!/!9+0'(&!()!$'E+!'$!>'**!+M+2$#/**4!*+/&!$(!
8+/0$!)/'*#0+@!
!
!
!
!
%#&'(!./0&'(M/6<#*/0!H!
CHAPTER 7: CARDIOVASCULAR
THE HEART!
!
I. Hypertrophy of the Heart:
120

Concentric (thick) HPYd heart vs. Dilated HPY heart-!!H!&'))+0+2$!+$'(*(='+6;!/2&!$8+4!'2M(*M+!
>(0F@!!1$!0+D#'0+6!/!*($!()!>(0F!$(!<(2$0/<$!/2&!9#68!L*((&!$80#!/!6$+2($'<!/(0$'<!M/*M+;!(0!'2<0+/6+&!
IJR!)0(E!NI"@!!I8+6+!>'**!</#6+!/2!increased afterload = concentric HPY.!!
!1)!4(#!8/M+!/!M/*M#*/0!90(L*+E;!/2&!8/M+!+:<+66!M(*#E+!()!L*((&!'2!$8+!M+2$0'<*+6!7!'2<0+/6+&!
90+*(/&!C!'2<0+/6+&!>(0F@!!I8+0+)(0+;!$8+!)0/2F!6$/0*'2=!=(+6!'2$(!+))+<$!LZ<!6$0+$<8'2=!/2&!
'2<0+/6'2=!90+*(/&!'2!$8+0+;!/2&!4(#!8/M+!$(!>(0F!8/0&+0!$(!'2<0+/6+!$8+!)(0<+!()!<(2$0/<$'(2!7!$8'6!
90(&#<+6!&'*/$+&!NJb@!!I8+0+)(0+;!concentric HPY = afterload problem; dilated HPY =
volume overload = preload problem (increased volume)!
!
II. Heart sounds!!!
S1 heart sound!C!L+='22'2=!()!Y46$(*+!C!E'$0/*!/2&!$0'<#69'&6!<*(6+!?E'$0/*!<*(6+6!L+)(0+!$8+!
$0'<#69'&!LZ<!8'=8+0!90+66#0+6B!
S2 heart sound!C!L+='22'2=!()!_'/6$(*+!C!9#*E(2'<!/2&!/(0$'<!<*(6+!!?M/0'/$'(2!>'$8!0+69'0/$'(2!7!
/6!&'/980/=E!=(+6!&(>2!$8+4!'2<0+/6+!$8+!'2$0/$8(0/<'<!90+66#0+@!!S*((&!'6!L+'2=!6#<F+&!'2$(!$8+!
0'=8$!6'&+!()!$8+!8+/0$;!/2&!$8+!9#*E(2'<!M/*M+!>'**!<*(6+!*/$+0!$8/2!$8+!/(0$'<!M/*M+@!!Y(;!$8+!6+<(2&!
8+/0$!6(#2&!8/6!/!M/0'/$'(2!>'$8!'269'0/$'(2!7!$8+!JH!6+9/0/$+6!/>/4!)0(E!%H!LZ<!E(0+!L*((&!
<(E'2=!'2$(!$8+!0'=8$!8+/0$;!6(!$8+!M/*M+!<*(6+6!/!*'$$*+!L'$!*/$+0@!
S3 heart sound = 2(0E/*!#2&+0!Pe!4Z(Q6@!!%)$+0!$8/$;!'$!'6!9/$8(*(='<@!!Y,!C!L+='22'2=!()!646$(*+!
/2&!YH!C!L+='22'2=!()!&'/6$(*+U!(LM'(#6*4;!YP!C!+/0*4!&'/6$(*+@!!YP!'6!&#+!$(!L*((&;!'2!+/0*4!&'/6$(*+;!
=('2=!'2$(!/!<8/EL+0!$8/$!'6!M(*#E+!(M+0*(/&+&@!!Y(;!L*((&!)0(E!$8+!*+)$!/$0'#E!'6!=('2=!'2$(!
(M+0*(/&+&!<8/EL+0;!</#6'2=!$#0L#*+2<+;!>8'<8!'6!$8+!YP!8+/0$!6(#2&@!!G2*4!8+/0!S3 heart sound
in volume overloaded chamber@!!1$!<(#*&!L+!)0(E!XNT!?*+)$!M+2$0'<*+!(M+0*(/&+&B!(0!RNT!?0'=8$!
M+2$!(M+0*(/&+&B;!6(!$8+0+!/0+!*+)$!6'&+&!YPQ6!/2&!0'=8$!6'&+&!YPQ6!7!'$!E+/26!M(*#E+!(M+0*(/&!'2!$8+!
<8/EL+0@!!%2/*(=4-!!0'M+06!=('2=!'2$(!(<+/2!7!*+/&6!$(!$#0L#*+2<+!?(<+/2!'6!$8+!M+2$0'<*+!>'$8!/!*($!
()!)*#'&!'2!'$!/2&!$8+!0'M+0!'6!$8+!L*((&!<(E'2=!'2!&#0'2=!&'/6$(*+U!$8+!0'M+0!8'$6!$8'6!*/0=+!E/66!()!)*#'&!
'2!$8+!M+2$0'<*+;!</#6'2=!$#0L#*+2<+!/2&!/2!YP!8+/0$!6(#2&B@!
!
S4 heart sound!C!*/$+!&'/6$(*+!7!$8'6!'6!>8+2!$8+!/$0'#E!'6!<(2$0/<$'2=!/2&!4(#!=+$!$8+!*/6$!L'$!()!
L*((&!(#$!()!$8+!/$0'#E!'2$(!$8+!M+2$0'<*+6;!*+/&'2=!$(!Y^!6(#2&@!Y^Q6!(<<#0!')!$8+0+!'6!/!90(L*+E!>'$8!
<(E9*'/2<+@!!.(E9*'/2<+!'6!/!)'**'2=!$+0E@!!!
Y(;!>8+2!$/*F'2=!/L(#$!<(E9*'/2<+;!0+)+00'2=!'$Q6!/L'*'$4!$(!)'**!$8+!M+2$0'<*+@!!!I8+!*+)$!/$0'#E!'6!
<(2$0/<$'2=;!$04'2=!$(!=+$!L*((&!'2$(!/!$8'<F!M+2$0'<*+U!!$8+!M+2$0'<*+!'6!2(2<(E9*'/2$;!/2&!$8+0+)(0+!
0+6'6$/2<+!>'**!(<<#0@!!I8'6!>'**!<0+/$+!/!M'L0/$'(2;!*+/&'2=!$(!/2!Y^!8+/0$!6(#2&@!!%2!S4 heart
sound is due to a problem with compliance@!!I8+!*+)$!/$0'#E!'6!+2<(#2$+0'2=!/!90(L*+E!'2!
9#$$'2=!L*((&!'2!*/$+!&'/6$(*+!'2$(!$8+!*+)$!M+2$0'<*+!/2&!'$!&(+62Q$!>/2$!$(!)'**!#9!/24E(0+@!!I8'6!<(#*&!
L+!&#+!$(!H!0+/6(26-!?,B!LZ<!'$Q6!849+0$0(98'+&!?'$!&(+62Q$!>/2$!$(!)'**!/24E(0+70+6$0'<$'2=!)'**'2=!#9B!
(0!?HB!'$Q6!/*0+/&4!)'**+&!#9!/2&!8/6!$(!9#$!E(0+!L*((&!'2!/2!/*0+/&4!(M+0)'**+&!<8/EL+0@!!!
!
Summary: Slides:
k(*!(M+0*(/&+&n!"(!YP@!Y(!</2!'$!8/M+!/2!Y^n!b+6@!
!
1)!4(#!8/M+!NI";!>8'<8!$49+!()!8+/0$!>'**!4(#!8/M+n!.(2<+2$0'<!NJb@!Y(;!'2!NI";!>8'<8!$49+!()!
8+/0$!6(#2&!>'**!4(#!8/M+n!Y^@!
!
k(*!(M+0*(/&+&n!b+6@!Y(!</2!'$!8/M+!/2!YPn!b+6U!</2!'$!/*6(!8/M+!/2!Y^n!b+6@!g84!</2!'$!/*6(!8/M+!
/2!Y^n!SZ<!'$!</2Q$!)'**!#9!/24E(0+@!!%2/*(=4-!$#0F+4!&'22+0!7!/**!)'**+&!#9;!L#$!/*>/46!0((E!)(0!&+6+0$!
121

7!*'*!M'L0/$'(2!$8/$!(<<#06!>8+2!'$!)'**6!'6!/2!Y^!8+/0$!6(#2&@!!Y(!4(#!8/M+!L($8!YP!/2&!Y^!8+/0$!
6(#2&!C!=/**(9!084$8E!?$8+4!8/M+!Y,;!H;!P;!/2&!^B@!
!
N(>!&(!4(#!F2(>!')!'$6!)0(E!$8+!*+)$!(0!0'=8$n!1$!'6!L0+/$8'2=@!!g8+2!4(#!L0+/$8!'2;!4(#!/0+!6#<F'2=!
L*((&!$(!$8+!0'=8$!6'&+!()!$8+!8+/0$@!!All right sided heart murmurs and abnormal heart
sounds (ie S3, S4) increase in intensity on inspiration!7!$8'6!'6!E(0+!(LM'(#6!LZ<!$8+0+!'6!
E(0+!L*((&!'2!$8+0+;!/2&!'$!+E98/6'c+6!$8(6+!/L2(0E/*!6(#2&6@!!J0(L!=+$!$8+E!(2!expiration
with positive intrathoracic pressures!$8/$!/0+!8+*9'2=!$8+!*+)$!M+2$0'<*+!9#68!L*((&!(#$!()!$8+!
8+/0$!7!$8'6!'6!>8+2!/L2(0E/*!8+/0$!6(#2&6!/2&!/L2(0E/*!E#0E#06!>'**!'2<0+/6+!'2!'2$+26'$4!(2!
+:9'0/$'(2@!!Y(;!/**!4(#!8/M+!$(!&(!'6!)'=#0+!(#$!$8/$!$8+0+!'6!/2!YP!8+/0$!6(#2&@!!oooooI8+2;!4(#!
8/M+!$(!)'=#0+!(#$!>8'<8!6'&+!'$!'6!<(E'2=!)0(E@!X(#&+0!(2!+:9'0/$'(2;!$8+0+)(0+!'$6!)0(E!$8+!0'=8$!
6'&+@!!
![:/E9*+-!+66+2$'/*!NI"!C!*+)$U!!
K'$0/*!0+=#0=!C!0'=8$U!!
/2&!K'$0/*!6$+2(6'6!C!E'&&*+@!
!
III. Murmurs
Stenosis!C!90(L!'2!opening;!$8/$!'6!>8+2!$8+!M/*M+!'6!(9+2'2=;!/2&!$8/$!'6!>8+2!$8+!E#0E#0!
(<<#06@!!!
Regurgitation!C!90(L!'2!closing!$8+!M/*M+;!$8/$!'6!>8+2!$8+!M/*M+!'6!<*(6'2=;!/2&!$8/$!'6!>8+2!$8+!
E#0E#0!(<<#06@!!!
!
"++&!$(!F2(>!>8+0+!M/*M+6!/0+!8+/0&!L+6$!7!0'=8$!H2&!1.Y!?/(0$'<!M/*M+B;!*+)$!H2&!1.Y!?9#*E(2'<B;!*+)$!
9/0/6$+02/*!L(0&+0!?$0'<#69'&B;!/9+:!?E'$0/*B!7!$8'6!'62Q$!2+<+66/0'*4!>8+0+!$8+!M/*M+!'6;!L#$!>8+0+!$8+!
2('6+!'6!8+/0&!$8+!L+6$@!!
A. Stenosis:
1. Systolic Murmurs:
g8(!'6!opening in systole = aortic and pulmonic valves C!$8+0+)(0+;!E#0E#06!()!/(0$'<!
6$+2(6'6!/2&!9#*E(2'<!6$+2(6'6!/0+!(<<#00'2=!'2!646$(*+@!!I8'6!'6!>8+2!$8+4!/0+!(9+2'2=U!$8+4!8/M+!
$(!9#68!$8+!L*((&!$80(#=8!/!2/00(>!6$+2($'<!M/*M+@!!!
a. Aortic Stenosis!7!Xk!<(2$0/<$6!/2&!'$!'6!+2<(#2$+0'2=!0+6'6$/2<+!d!!'2$+26'$4!()!$8+!E#0E#0!=(+6!
#9U!/6!'$!'6!9#68'2=!/2&!9#68'2=;!'$!=+$6!$(!/!9+/F!/2&!$8'6!'6!&'/E(2&!68/9+!<(2)'=#0/$'(2!7!$8'6!'6!
>84!'$!'6!</**+&!/2!ejection murmur.!!Y(;!$8+4!()$+2!8/M+!&'/=0/E6!()!$8+!<(2)'=#0/$'(26!(2!$8+6+!
E#0E#06@!!g'$8!/2!+3+<$'(2!E#0E#0!?/(0$'<!6$+2(6'6B;!'$!>'**!8/M+!/!<0+6<+2&(d&+<0+6<+2&(!?8+2<+;!
&'/E(2&!68/9+&!<(2)'=#0/$'(2B@!!Y(;!>'$8!/(0$'<!6$+2(6'6;!$8+0+!'6!/2!+3+<$'(2!E#0E#0!'2!646$(*+;!
8+/0&!L+6$!/$!$8+!0'=8$!H2&!1.Y;!>8'<8!0/&'/$+6!$(!$8+!</0($'&6;!/2&!$8+!E#0E#0!'2$+26'$4!'2<0+/6+6!
(2!+:9'0/$'(2;!/2&!>'**!90(L/L*4!8+/0!/2!Y^!
!
b. Pulmonic Stenosis!7!8+/0&!L+6$!(2!*+)$!H2&!1.Y;!+3+<$'(2!E#0E#0;!/2&!'2<0+/6+6!(2!+:9'0/$'(2@!
!
2. Diastolic murmurs: 12!&'/6$(*+;!E'$0/*!/2&!$0'<#69'&!M/*M+6!/0+!(9+2'2=@!
a. Mitral Stenosis!?90(L*+E!'2!(9+2'2=!$8+!M/*M+B!7!>8(!8/6!$8+!90(L*+En!X+)$!/$0'#E@!N+0+Q6!$8+!
90(L*+E;!$8+!E'$0/*!M/*M+!&(+62Q$!>/2$!$(!(9+2!L#$!'$!8/6!$(!'2!(0&+0!$(!=+$!L*((&!'2$(!$8+!*+)$!
M+2$0'<*+@!!Y(;!$8+!*+)$!/$0'#E!>'**!=+$!6$0(2=!LZ<!'$!8/6!/2!/)$+0*(/&!$(!&+/*!>'$8!7!'$!L+<(E+6!&'*/$+&!
/2&!849+0$0(98'+&!?$8+!/$0'#EB!7!>8'<8!90+&'69(6+6!$(!/$0'/*!)'L;!$80(EL(6'6;!/2&!6$/6'6!()!L*((&@!!
122

Y(;!$8+!/$0'#E!'6!&0+/&'2=!&'/6$(*+!LZ<!'$!8/6!$(!=+$!$8+!L#'*&#9!()!L*((&!'2$(!$8+!*+)$!M+2$0'<*+@!!g'$8!
$8+!L#'*&!#9!()!90+66#0+;!$8+!E'$0/*!M/*M+!i62/96j!(9+2;!/2&!$8/$!'6!$8+!(9+2'2=!62/9@!!!%**!$8+!L*((&!
$8/$!>/6!L#'*$!#9!'2!$8+!/$0'#E!<(E+6!=#68'2=!(#$!'2$(!$8+!M+2$0'<*+;!</#6'2=!/!E'&d&'/6$(*'<!0#EL*+@!
Y(;!4(#!8/M+!/2!opening snap followed by a rumbling sound!?&#+!$(!+:<+66!L*((&!=#68'2=!
'2$(!XkB@!!g'$8!E'$0/*!6$+2(6'6;!$8+0+!'6!/!90(L*+E!>'$8!(9+2'2=!$8+!M/*M+;!/2&!$8+0+)(0+!4(#!/0+!
#2&+0!)'**'2=!$8+!*+)$!M+2$0'<*+;!/2&!$8+0+)(0+!>'**!L+!2(!NJb!LZ<!4(#!/0+!#2&+0!)'**'2=!'$@!!1)!4(#!/0+!
8/M'2=!$0(#L*+!=+$$'2=!L*((&!'2$(!'$;!4(#!/0+!2($!(M+0>(0F'2=!$8+!M+2$0'<*+U!$8+!*+)$!/$0'#E!8/6!$(!&(!
E(6$!()!$8+!>(0F@!!N+/0&!L+6$!/$!$8+!/9+:!/2&!>'**!'2<0+/6+!'2!'2$+26'$4!(2!+:9'0/$'(2@!!(same
concept with tricuspid stenosis, just a different valve).
!
B. Regurgitation !90(L*+E!'2!<*(6'2=!$8+!M/*M+@!!!
!
1. Systolic Murmurs:!mitral and tricuspid are closing in systole@!!
a) Mitral Regurg-!1)!$8+4!/0+!'2<(E9+$+2$!/2&!E'$0/*!M/*M+!</22($!<*(6+!90(9+0*4@!![:/E9*+-!!tV!
E*6!()!L*((&!C!2(0E/*!6$0(F+!M(*#E+U!*+$6!6/4!PV!E*6!'2$(!$8+!*+)$!/$0'#E!/2&!(2*4!eV!E*6!*+/M+6!$8+!
/(0$/@!!Y(;!/2!+:$0/!PV!E*6!()!L*((&!'2!$8+!*+)$!/$0'#E;!9*#6!$04'2=!$(!)'**!#9!/2&!8/M+!+:<+66!L*((&!
$8+0+!7!>/4!E(0+!L*((&!+2&6!#9!'2!$8+!*+)$!M+2$0'<*+!/2&!'$!L+<(E+6!volume overloaded@!!Y(;!8(>!
>(#*&!$8+!E#0E#0!<8/0/<$+0'6$'<6!L+!')!$8+0+!'6!/!90(L*+E!'2!<*(6'2=!$8+!M/*M+n!1$!>'**!2($!L+!/2!
+3+<$'(2!E#0E#0U!>'**!3#6$!6(#2&!*'F+!i>8((((68j!/**!$8+!>/4!$80(#=8;!/6!L*((&!/**!$8+!>/4!$80(#=8!
646$(*+!'6!=('2=!$80(#=8!$8+!'2<(E9+$+2$!E'$0/*!M/*M+;!L/<F!'2$(!$8+!*+)$!/$0'#E!7!$8+0+)(0+!'$!'6!
9/2646$(*'<!(0!/*E(6$!9/2646$(*'<!7!6(!'$Q6!/!]6$0/'=8$!*'2+Q!+))+<$@!!Y(E+$'E+6;!'$!>'**!(L*'$+0/$+!Y,!/2&!
YH@!!So, is an apical murmur, pansystolic, S3 and S4 (b/c a problem with compliance and
volume overload, increased in intensity on expiration.
!
b. Tricuspid Regurg-!'$!>'**!L+!9/2646$(*'<;!YP!/2&!Y^;!*+)$!9/0/6$+02/*!L(0&+0;!/2&!'2<0+/6+6!(2!
'2$+26'$4!(2!'269'0/$'(2B@!![:/E9*+-!!1k_%!>'$8!)+M+0;!9/2646$(*'<!E#0E#0!/*(2=!9/0/6$+02/*!L(0&+0;!
YP!/2&!Y^!8+/0$!6(#2&;!/<<+2$#/$'(2!()!$8+!2+<F!M+'26;!>8/$!'6!$8+!E(6$!*'F+*4!&:n!12)+<$'M+!
+2&(</0&'$'6!()!$0'<#69'&!M/*M+;!>8'<8!'6!$8+!K.!'2)+<$'(2@!!Y(;!'$!>/6!+:$0+E+*4!'E9!$(!F2(>!')!$8+!
E#0E#0!'2<0+/6+&!(2!'269'0/$'(2!?>8'<8!'6!0'=8$!6'&+&B@!!1)!$8+!D#+6$'(2!6/'&!$8/$!$8+!E#0E#0!8/&!
'2<0+/6+&!(2!+:9'0/$'(2;!'$!>(#*&!L+!12)+<$'M+!+2&(</0&'$'6!()!$8+!E'$0/*!M/*M+!?>8'<8!'6!*+)$!6'&+&B@!!!
!
2. Diastolic Murmurs:!want the aortic and pulmonic valves to close!?>8/$!4(#!3#6$!9#E9+&!
(#$!&(+62Q$!>/2$!$(!<(E+!L/<F!'2B@!!!
Aortic Regurg!!?/6!6++2!'2!6498'*'6!/2+#046E!L#$!$8'6!'6!&#+!$(!$8+!6$0+$<8'2=!()!$8+!0'2=B@!!12!
646$(*+!$8+!L*((&!=(+6!(#$!/2&!$8+!M/*M+!68(#*&!L+!<*(6'2=!90(9+0*4!;!L#$!'$!&(+62Q$;!6(!6(E+!L*((&!
>'**!$0'<F*+!L/<F!'2@!![:/E9*+-!tV!<<!>+2$!(#$!'2'$'/**4!/2&!PV!<<!'6!&0'99+&!L/<F!'2@!!%6!L*((&!F++96!
&0'99'2=!L/<F!'2;!4(#!>'**!=+$!/!volume overloaded!<8/EL+0@!![M+2$#/**4!4(#!>'**!8/M+!/2&![_k!()!
HVV!E*6!?'26$+/&!()!,HVB@!Y(;!)(0!/(0$'<!0+=#0=;!>8+2!4(#!8+/0!$8+!E#0E#0n!%)$+0!$8+!H2&!8+/0$!
6(#2&!LZ<!'$!'62Q$!<*(6'2=!/2&!L*((&!'6!&0'99'2=!L/<F!'2!7!$8/$!E/F+6!$8+!6(#2&!()!/!8'=8!9'$<8+&!
L*(>'2=!&'/6$(*'<!E#0E#0!'2$(!$8+!0'=8$!6+<(2&!1.Y;!'2<0+/6+6!'2!'2$+26'$4!(2!+:9'0/$'(2;!YP!/2&!Y^!
8+/0$!6(#2&6;!M(*!(M+0*(/&+&;!/2&!L(#2&'2=!9#*6+6@!!g8/$!M/*M+!*+/)*+$!'6!&0'99'2=!L*((&n!%2$+0'(0!
*+/)*+$!()!E'$0/*!M/*M+@!I8'6!'6!(2+!6'&+!()!$8+!(#$)*(>!$0/<$!(#$!()!$8+!/(0$/@!!g8/$!E#0E#0!&(+6!$8/$!
<0+/$+n!Austin flint murmur@!!1)!4(#!8/M+!/(0$'<!0+=#0=!>'$8!/2!%#6$'2!)*'2$!E#0E#0;!4(#!2++&!$(!
</**!$8+!</0&'/<!6#0=+(2@!!"++&!$(!0+9*/<+!$8+!M/*M+!LZ<!4(#!/0+!6'=2')'</2$*4!&0'99'2=!L*((&@!!
I8+0+)(0+;!$8'6!E#0E#0!'6!'E9!LZ<!>8+2!'$!'6!$8+0+;!4(#!8/M+!$(!9+0)(0E!6#0=+04@!
!
IV. Heart Failure: Left or Right Heart Failure
123

!
X+)$!NT!C!*#2=6!/2&!J/0(:46E/*!2(<$#02/*!&4692+/Z9'**(>!(0$8(92+/!
!
R'=8$!C!X'M+0!
!
A. Left heart failureC)(0>/0&!)/'*#0+;!</2$!=+$!L*((&!(#$!()!$8+!8+/0$!LZ<!$8+!Xk!)/'*6!!
I8+0+)(0+!4(#0!*+)$!M+2$0'<*+!8/6!$(!9#68!/=/'26$!/2!/)$+0*(/&!/2&!)/'*6U!(0!'$!8/6!$(!&+/*!>'$8!+:<+66!
M(*#E+!/2&!)/'*6U!(0!4(#QM+!8/&!6(!E/24!'2)/0<$6!$8/$!$8+!*+)$!M+2$0'<*+!'6!2(!*(2=+0!E#6<*+!L#$!2(>!
)'L0(#6!$'66#+!/2&!$8'6!0+&#<+6!<(2$0/<$'*'$4!/2&!'$!)/'*6@!!1$Q6!/!)(0>/0&!)/'*#0+!LZ<!4(#!/0+!8/M'2=!
90(L*+E6!=+$$'2=!L*((&!(#$6'&+!()!$8+!8+/0$@!I8'6!E+/26!$8/$![_k!>'**!'2<0+/6+!LZ<!4(#!</22($!=+$!
/**!$8+!L*((&!(#$!LZ<!4(#!</22($!9#68!'$!(#$@!!I8+!90+66#0+!/2&!M(*#E+!>'**!=(!L/<F!'2!$(!$8+!*+)$!
/$0'#E;!L/<F!'2$(!$8+!9#*E(2/04!M+66+*6;!'2<0+/6+!$8+!84&0(6$/$'<!90+66#0+;!/2&!$8+2!9#*E(2/04!
+&+E/@!!g'$8!<80(2'<!*+)$!8+/0$!)/'*#0+;!$8'6!>'**!*+/&!$(!8+E(008/=+!/2&!/*M+(*/0!E/<0(98/=+6!>'**!
98/=(<4$(6+!RS.Q6;!*+/&'2=!$(!0#6$4!<(*(0+&!69#$#E@!!G2!<4$(*(=4;!4(#!>'**!6++!8+/0$!)/'*#0+!<+**6;!
>8'<8!/0+!/*M+(*/0!E/<0(98/=+6!$8/$!8/6!98/=(<4$(6+&!RS.Q6!/2&!'6!L0(F+2!&(>2!$(!8+E(6'&+0'2@!!
Pulmonary edema is always left heart failure@!!Left heart failure is a diagnosis of
symptoms, b/c the main symptom in LHF is dyspnea (SOB), have trouble breathing b/c
fluid in there.
!
B. Right Heart Failure:!!_'/=2(6'6!()!6'=26-!!S/<F>/0&!T/'*#0+U!</2$!=+$!L*((&!'2$(!$8+!8+/0$@!
RNT!'6!/!90(L*+E!()!$8+!0'=8$!8+/0$!=+$$'2=!L*((&!$80(#=8!$8+!9#*E(2/04!M+66+*6!$(!$8+!*+)$!8+/0$@!!
Y(;!')!'$!)/'*6;!L*((&!L#'*&6!#9!L+8'2&!'$;!/2&!'$!'6!/!L/<F>/0&!)/'*#0+@!!SZ<!')!'$!</22($!=+$!L*((&!
$80(#=8!9#*E(2/04!M+66+*6!'2$(!$8+!8+/0$;!L*((&!>'**!L#'*&!#9!L+8'2&!'$;!/2&!84&0(6$/$'<!90+66#0+6!
>'**!L#'*&!'2!$8+!M+2(#6!<'0<#'$@!!I8'6!*+/&6!$(!2+<F!M+'2!&'6$+26'(2U!/*6(;!>'**!=+$!8+9/$(E+=/*4!
?>8'<8!'6!9/'2)#*B;!/2&!/!2#$E+=!*'M+0!LZ<!()!$8+!'2<0+/6+&!90+66#0+6!'2!$8+!M+2/!</M/!/0+!
$0/26E'$$+&!$(!$8+!8+9/$'<!M+'2;!>8'<8!+E9$'+6!'2$(!'$;!$8+2!L/<F!'2$(!$8+!*'M+0!/2&!$8+!<+2$0/*!M+'2;!
$8+2!>'**!=+$!0+&!&($6!/**!(M+0!*'M+0;!>8'<8!*((F6!*'F+!/!2#$E+=@!!MCC congested hepatomegaly =
RHF@!g8/$!</#6+&!$8+!'2<0+/6+&!'2!84&0(6$/$'<!90+66#0+!/*6(!=('2=!$(!90(&#<+!9'$$'2=!+&+E/!/2&!
9(66'L*4!/6<'$+6!7!$8+0+)(0+!'$6!E(0+!6'=26!$8/2!'$!'6!64E9$(E6@!!Y(;!neck vein distension, pitting
edema, hepatomegaly, nut meg liver, ascites@!!!
!
C. Examples of LHF:
g8+2!4(#!*'+!&(>2!$(!=(!$(!6*++9;!4(#!</2!0+/L6(0L!#9!$(!,!*'$+0!()!)*#'&!LZ<!'$!>'**!=(!)0(E!$8+!
'2$+06$'#E!$(!$8+!M+2(#6!6'&+!LZ<!$8+0+Q6!2(!+))+<$'M+!=0/M'$4@!!I8+0+)(0+;!$8+0+!'6!+:$0/!L*((&!=('2=!
L/<F!$(!$8+!0'=8$!8+/0$!/2&!'2$(!$8+!*+)$!8+/0$@!!N(>+M+0;!>8/$!')!4(#!8/&!*+)$!NTn!I8+0+!>'**!L+!
+:<+66!L*((&!<(E'2=!L/<F!?$8/$!>/62Q$!$8+0+!>8+2!4(#!>+0+!6$/2&'2=!#9B!/2&!$8+!*+)$!8+/0$!'6!
8/M'2=!$0(#L*+!=+$$'2=!L*((&!(#$;!>'$8!+M+2!E(0+!L*((&!<(E'2=!L/<F!'2@!!I8+2!$8+!8+/0$!</22($!
8/2&*+!'$!/2&!=(+6!L/<F!$(!$8+!*#2=6;!*+/&'2=!$(!&4692+/!/2&!<(2$'2#+6!)(0!$8+!2+:$!PV!E'2#$+67!
$8'6!'6!paroxysmal nocturnal dyspnea@!![M+2$#/**4!'$!6+$$*+6!&(>2;!4(#!=(!L/<F!$(!6*++9;!>/F+!
#9!/=/'2;!/2&!'$!(<<#06!/=/'2@!!J$!0+/*'c+6!$8/$!/)$+0!4(#!6$/2&!#9;!$8+2!'$!+M+2$#/**4!=(+6!/>/4!7!
$8+0+)(0+!$8+4!9#$!/!9'**(>!#2&+0!$8+E!$(!&+<0+/6+!$8+!&4692+/!>8+2!$8+4!>/F+@!!!I8'6!'6!</**+&!
pillow orthopnea@!!1)!'$6!(2+!9'**(>!(0$8(92+/;!'$6!2($!$8/$!L/&U!8(>+M+0;!')!4(#!8/M+!$(!6'$!#9;!
4(#!8/M+!6+0'(#6!*+)$!8+/0$!)/'*#0+!LZ<!4(#!/0+!'E9(6'2=!=0/M'$4@!!f#6$!L4!9#$$'2=!8+/&!(2!(2+!9'**(>!
>'**!&+<0+/6+!M+2(#6!0+$#02!L/<F!$(!$8+!8+/0$@!!1)!4(#!9#$!H!9'**(>6!#2&+0;!'$!>'**!&+<0+/6+!$8+!
&4692+/!+M+2!E(0+!LZ<!()!+))+<$'M+!=0/M'$4@!!Y(;!pillow orthopnea and paroxysmal nocturnal
dyspnea are signs of LEFT heart failure.!!!
!
D. Treatment:
124

1)!4(#!8/M+!8+/0$!)/'*#0+!?0'=8$!(0!*+)$B;!>8/$!'6!$8+!L+6$!2(298/0E/<(*(='<!$0+/$E+2$n!R+6$0'<$!>/$+0!
/2&!6/*$@!
!
What the king of Rx of HF? ACE inhibitor b/c it decreases afterload AND preload at the
same time. ACE inhibitors '2<0+/6+!*(2=+M'$4!L4!?,B!&+<0+/6+&!/*&(6$+0(2+;!$8+0+)(0+!&+<0+/6+&!
6/*$!/2&!>/$+0!0+/L6(09$'(2!>8'<8!&+<0+/6+6!90+*(/&!/2&!?HB!L4!L*(<F'2=!%2='($+26'2!11;!>'**!*+/&!$(!
/!&+<0+/6+!'2!M/6(<(26$0'<$(0!+))+<$!(2!9+0'98+0/*!0+6'6$/2<+!/0$+0'(*+6;!>8'<8!>'**!&+<0+/6+!
/)$+0*(/&@!!!
!
J$6!>'$8!spironolactone + ACE inhibitor!&'&!L+$$+0!LZ<!/*&(6$+0(2+!>'**!+M+2$#/**4!L0+/F!$80(#=8!
/2&!L+<(E+!+*+M/$+&!/=/'2;!$8+0+)(0+!%.[!'28'L'$(0!/<$'2=!/=/'26$!/*&(6$+0(2+!'6!2($!/!9+0E/2+2$!
6#990+66'(2@!!Y(!69'0(2(*/<$(2+!>8'<8!69+<')'</**4!L*(<F!/*&(6$+0(2+;!9*#6!$8+!%.[!'28'L'$(0!'6!/2!
'2<0+/6+!'2!90(=2(6'6@!!I8+0+)(0+;!2(>!'$Q6!2(0E/*!$(!9#$!$8+!9$!(2!69'0(2(*/<$(2+!/2&!%.[!'28'L'$(0!
LZ<!'$!>'**!'2<0+/6+!*(2=+M'$4@!!!
!
E. High output failure!!
G2+!</#6+!'6!endotoxic shock!7!9+0'98+0/*!0+6'6$/2<+!/0$+0'(*+6!/0+!&'*/$+&;!$8+0+)(0+!/2!'2<0+/6+!
'2!.P/;!.e/;!"G;!*+/&'2=!$(!'2<0+/6+&!M+2(#6!0+$#02!$(!$8+!8+/0$!/2&!$8+!8+/0$!+M+2$#/**4!='M+6!#9@!!
I8+0+!/0+!/*6(!E/24!($8+0!</#6+6;!/2&!$8+4!0+*/$+!$(!J(#6+/#Q6!*/>!7!M'6<(6'$4Z0/&'#6!$(!$8+!)(#0$8!
9(>+0@!!Y(;!')!4(#!M/6(&'*/$+!$8+!9+0'98+0/*!0+6'6$/2<+!/0$+0'(*+6;!/2&!4(#!&+<0+/6+!IJR;!E(0+!L*((&!
0+$#026!$(!$8+!0'=8$!8+/0$;!$8+!*+)$!8+/0$!8/6!$(!&+/*!>'$8!'$;!$((;!/2&!9$!0#26!$8+!0'6F!()!8'=8!(#$9#$!
)/'*#0+@!!Y(;!(2+!</#6+!()!$8+!M/6(&'*/$/$'(2!'6!septic shock;!>8'*+!$8+!($8+0!'6!thiamine
deficiency@!!J0(L*+E!'2!$8'/E'2+!&+)-!%IJ!&+9*+$'(2-!6E(($8!E#6<*+!<+**6!/2&!9+0'98+0/*!0+6'6$/2<+!
/0$+0'(*+6!2++&!%IJ;!$8+0+)(0+!$8+4!&(!2($!>(0F!/6!>+**;!/2&!$8+0+!'6!M/6(&'*/$/$'(2!()!$8+!9+0'98+0/*!
/0$+0'(*+6;!*+/&'2=!$(!8'=8!(#$9#$!)/'*#0+@!!Y(;!$8'/E'2+!&+)!</2!90(&#<+!8'=8!(#$!9#$!)/'*#0+!LZ<!
M/6(&'*/$/$'(2!()!$8(6+!M+66+*6@!
!
Gravess dz!7!849+0$840('&'6E!7!$840('&!8(0E(2+!'2<0+/6+6!$8+!642$8+6'6!()!L+$/!0+<+9$(06!'2!$8+!
8+/0$@!!l+$!/2!'2<0+/6+!'2!)(0<+!()!<(2$0/<$'(2;!/2&!E(0+!L*((&@!!Y46$(*'<!90+66#0+6!/0+!8'=8+0;!/2&!
=(!'2$(!8'=8!(#$9#$!)/'*#0+@!!!
!
AV fistulas!7!'+!=+$!6$/L*+&!'2!$8+!*+=U!/2&!&+M+*(9!/2!%k!E/*)(0E/$'(2;!>8+0+!$8+0+!'6!/0$+0'(*+!
L*((&!L49/66'2=!$8+!E'<0(<'0<#*/$'(2!=('2=!&'0+<$*4!$(!$8+!M+2(#6!<'0<#*/$'(2!/2&!$8+!L*((&!<(E+6!
L/<F!)/6$+0!$(!$8+!8+/0$!$8/2!2(0E/*U!/!L0#'$!</2!L+!8+/0&!(M+0!$8+!E/66!/2&!'$!>'**!L+!9#*6/$'*+U!')!
4(#!90+66!$8+!90(:'E/*!9(0$'(2!()!'$;!8+/0$!0/$+!>(#*&!6*(>!?S0+28/EQ6!6'=2B!7!$8+6+!/0+!/**!6'=26!()!
%k!)'6$#*/;!*+/&'2=!$(!8'=8!(#$9#$!)/'*#0+@!
!
So, 3 examples of high output failure are endotoxic shock, graves, and AV fistulas
!
V. Congenital heart dz
A. Know fetal circulation!?>8'<8!M+66+*6!8/M+!$8+!*+/6$ZE(6$!GHBU!0+E+EL+0!$8/$!$8+!L/L4!'6!
"GI!+:<8/2='2=!L*((&!>'$8!GH!'2!$8+!*#2=6@!!J#*E(2/04!M+66+*6!'2!$8+!)+$#6!*((F!*'F+!$8+4!8/M+!
9#*E(2/04!NI"!7!$8+4!/0+!6(!$8'<F!$8/$!'$!'6!+:$0+E+*4!8/0&!$(!=+$!L*((&!$80(#=8!$8+!9#*E(2/04!
/0$+04!'2$(!$8+!Xk!LZ<!M+04!*'$$*+!L*((&!</2!=(!$8+0+!7!$8'6!'6!>84!L/L4!2++&6!/!9/$+2$!&#<$#6!$(!=+$!
L*((&!(#$@!!!g8+0+!'6!GH!<(E'2=!)0(En!.(E'2=!)0(E!<8(0'(2'<!M'**#6!&'99'2=!'2$(!*/F+!()!L*((&;!>8'<8!
&+0'M+6!)0(E!E(EQ6!69'0/*!/0$+0'(*+6@!!N/M+!<8(0'(2'<!M'**'!&'99'2=!'2$(!L*((&!/2&!+:$0/<$'2=!GH!)0(E!
'$@!!GLM'(#6*4;!$8'6!'6!2($!/6!=((&!/2!GH!6(#0<+!/6!$8+!*#2=6U!$8+0+)(0+;!4(#!>/2$!/!8'=8!/))'2'$4!NL!
$(!L+!/L*+!$(!=+$!>8/$!*'$$*+!GH!'6!&(>2!'2!$8+!/0+/!7!$8'6!'6!>84!L/L'+6!8/M+!NLT;!LZ<!()!'$6!8'=8!
/))'2'$4!$(!=0/L!GH!)0(E!$8+!L*((&@!!S/&!2+>6!'6!$8/$!'$!=+$6!$8+!GH;!L#$!&(+62Q$!>/2$!$(!='M+!'$!#9!
125

?6/46!E'2+B!7!'$!*+)$!68')$6!$8+!<#0M+@!!g8/$!'6!<(E9+26/$(04!0+69(26+n!I8'6!*+)$!68')$!</#6+6!$'66#+!
849(:'/;!>8'<8!>'**!</#6+![JG!$(!L+!0+*+/6+&!/2&!$8+!F'&!>'**!8/M+!/2!,t!=0/E!NL!7!LZ<!()!$8'6;!/**!
2+>L(026!?'2!/!6+26+B!8/M+!9(*4<4$8+E'/@!!I8'6!'6!$8+!>/4!/0(#2&!NLTQ6!8'=8!/))'2'$4!)(0!GH!7!E(0+!
RS.Q6!E/&+;!E(0+!NL;!/2&!L/L4!=+$6!E(0+!GH@!!!
!
Order of O2 passing: GH!=(+6!$80(#=8!642<4$'($0(98(L*/6$!()!<8(0'(2'<!M'**#6;!'2$(!$8+!
<4$($0(98(L*/6$;!$8+2!$80(#=8!$8+!E4:(E/$(#6!6$0(E/!()!$8+!<8(0'(2'<!M'**#6;!$8+2!'2$(!$8+!L*((&!
M+66+*@!!I8+!L*((&!M+66+*6!()!$8+!<8(0'(2'<!M'**'6!/**!<(/*+6<+!$(!)(0E!$8+!umbilical vein@!!I8'6!8/6!
$8+!highest O2 content@!!1$!=(+6!$(!$8+!*'M+0!/2&!'$!</2!=(!$>(!>/46-!,B!'2$(!$8+!8+9/$'<!6'2#6('&6!
/2&!0+<(**+<$6!'2$(!$8+!8+9/$'<!M+'2!/2&!=+$6!&#E9+&!'2$(!$8+!1k.U!/2&!HB!&#<$#6!M+2(6'6!/2&!
6$0/'=8$!'2$(!$8+!1k.@!!I8+2!'$!=(+6!#9!$8+!0'=8$!6'&+!()!$8+!8+/0$U!$8+!)(0/E+2!(M/*+!'6!(9+2!'2!/**!
)+$#6+6!?'$6!2($!<*(6+&B!7!6(!/**!$8'6!L*((&!'6!<(E'2=!#9!$8+!1k.!7!>'**!'$!=(!6$0/'=8$!/<0(66;!$80(#=8!
$8+!)(0/E+2!(M/*+!/2&!'2$(!$8+!*+)$!/$0'#E;!(0!>'**!'$!=(!'2$(!$8+!1k.!'2$(!$8+!0'=8$!/$0'#E;!&(>2!$(!
$80(#=8!$8+!$0'<#69'&!M/*M+;!/2&!'2$(!$8+!0'=8$!M+2$0'<*+n!1$!>'**!=(!$80(#=8!$8+!)(0/E+2!(M/*+@!!Y(;!
/**!$8'6!(:4=+2/$+&!L*((&!>'**!=(!&'0+<$*4!)0(E!$8+!0'=8$!/$0'#E!()!$8+!)(0/E+2!(M/*+!'2$(!$8+!*+)$!
/$0'#E;!$8+2!$8+!*+)$!M+2$0'<*+!/2&!(#$!$8+!/(0$/@!!g8/$!/L(#$!Yk.!L*((&!M/*M+n!1$!'6!<(E'2=!)0(E!
$8+!6#9+0'(0!9/0$!()!$8+!0'=8$!/$0'#E!?'$6!2($!=(22/!E/F+!/!*+)$!$#02!/2&!=(!$80(#=8!$8+!)(0/E+2!
(M/*+B@!!1$!>'**!=(!6$0/'=8$!&(>2;!$80(#=8!$8+!$0'<#69'&!M/*M+!'2$(!$8+!0'=8$!M+2$0'<*+@!!"(>;!'$!>'**!=(!
(#$!$8+!9#*E(2/04!/0$+04@!!I8'6!'6!/!JRGSX[K!LZ<!$8+!9#*E(2/04!M+66+*6!/0+!$((!$8'<F!/2&!'$Q6!
+2<(#2$+0'2=!$8'6!$0+E+2&(#6!/E(#2$!()!90+66#0+@!I(!<(#2$+0!$8'6!90(L*+E;!F+9$!$8+!9/$+2$!&#<$#6!
(9+2!?>8'<8!'6!F+9$!(9+2!L4!$8+!Jl[H;!/!M/6(&'*/$(0;!E/&+!L4!$8+!9*/<+2$/B!7!6(;!$8+0+!'6!/!0'=8$!$(!
*+)$!68#2$!/2&!L*((&!</2!=+$!(#$!()!$8+!9#*E(2/04!/0$+04!/2&!&#E9+&!L/<F!'2$(!$8+!/(0$/@!!I8+2;!
>8+2!$8+!L/L4!'6!L(02!/2&!$/F+6!'$6!)'06$!L0+/$8;!$8+!9#*E(2/04!M+66+*6!?$8/$!>+0+!/**!68#$B;!/**!(9+2!
>'$8'2!/!E'**'6+<(2&;!/2&!L*((&!'6!=('2=!$80(#=8!$8(6+!9#*E(2/04!/0$+0'+6!/2&!=/6!+:<8/2=+!'6!
(<<#00'2=!$80(#=8!$8+!*#2=6!'2!*'$+0/**4!6+<(2&6@!!%*6(;!$8+!9/$+2$!&#<$#6!<*(6+6!/2&!)(0E6!$8+!
*'=/E+2$#E!/0$+0'(6#E@!!!I8'6!'6!2(0E/*!)+$/*!<'0<#*/$'(2@!!k+66+*6!>'$8!$8+!*+/6$!GH!/0+!$8+!H!
#EL'*'</*!/0$+0'+6;!/2&!$8+!(2+!>'$8!$8+!E(6$!/E(#2$!()!GH!'6!$8+!#EL'*'</*!M+'2@!!!
!
B. Shunts:
X((F!/$!GH!6/$#0/$'(26!?$8'6!'6!8(>!$8+4!&:!$8+E!7!$8+4!</$8+$+0'c+;!E+/6#0+!GH!6/$#0/$'(26!'2!
&'))+0+2$!<8/EL+06;!/2&!F2(>!>8'<8!&'0+<$'(2!$8+!68#2$6!/0+!=('2=@!
!
"++&!$(!=+$!#6+&!$(!$>(!$+0E6!7!6$+9!#9!/2&!6$+9!&(>2@!!!
1)!4(#!8/M+!/!left to right shunt;!/2&!8/M+!(:4=+2/$+&!L*((&!=('2=!'2$(!#2GHQ&!L*((&;!>8/$!'6!
8/99+2'2=!$(!GH!6/$#0/$'(2!(2!$8+!0'=8$!6'&+n!Step up b/c mixing O2d with unO2d blood.
!
1)!4(#!8/M+!/!right to left shunt!>'$8!unO2d blood going into the O2d bloodn!!Step down@!!!
I8+!GH!6/$#0/$'(2!(2!$8+!0'=8$!6'&+!()!$8+!8+/0$!'2!L*((&!0+$#02'2=!)0(E!$8+!L(&4!'6!èW@!!I8+!GH!
6/$#0/$'(2!(2!$8+!*+)$!6'&+!'6!reW@!!
!
C. VSD (MC)
g8(Q6!6$0(2=+0!!d!*+)$!(0!0'=8$!M+2$0'<*+n!X+)$;!$8+0+)(0+!$8+!&'0+<$'(2!()!$8+!68#2$!'6!*+)$!$(!0'=8$@!!Y(;!
(:4=+2/$+&!L*((&!>'**!L+!&#E9+&!'2$(!$8+!0'=8$!M+2$0'<*+;!*+/&'2=!$(!6$+9!#9@!!%*6(;!'$!>'**!9#E9!'$!
(#$!()!$8+!9#*E(2/04!/0$+04;!*+/&'2=!$(!6$+9!#9@!!Y(;!4(#!8/M+!/!6$+9!#9!()!GH!'2!0'=8$!M+2$!/2&!9#*!
/0$+04@!g8/$!')!$8'6!'6!2($!<(00+<$+&n!g'$8!$8'6!E+<8;!4(#!/0+!M(*#E+!(M+0*(/&'2=!$8+!0'=8$!6'&+!()!
$8+!8+/0$!LZ<!()!/**!$8/$!L*((&!<(E'2=!(M+0@!!I8+!(#$<(E+!()!$8'6!>'**!L+!pulmonary HTN!?$8+!
9#*E(2/04!/0$+04!8/6!$(!&+/*!>'$8!E(0+!L*((&!/2&!E#6$!<(2$0/<$!E(0+!7!*+/&'2=!$(!9#*!NI"B!7!G2<+!
9#*!NI"!(<<#06;!0'=8$!M+2$0'<*+!>'**!8/M+!/!90(L*+E!<(2$0/<$'2=!/2&!'$!>'**!=+$!849+0$0(98'+&@!!
Y#&&+2*4;!4(#!0#2!$8+!0'6F!()!0+M+06'2=!/!68#2$!LZ<!$8+2!0'=8$!M+2$0'<*+!<(#*&!+M+2$#/**4!L+!6$0(2=+0!
126

$8/2!$8+!*+)$@!!Y(;!'$!>'**!L+!/!0'=8$!$(!*+)$!68#2$!7!$8'6!'6!</**+&!Eisenmengers syndrome@!!Y(;!/2!
#2<(00+<$+&!*+)$!$(!0'=8$!68#2$!8/6!$8+!9($+2$'/*!)(0!90(&#<'2=!['6+2E+2=+0Q6!642&0(E+@!!%)$+0!
0+M+06/*!()!$8+!68#2$!(<<#06;!9$!>'**!8/M+!cyanosis!?/F/!<4/2(6'6!$/0&'M+B@!!K(6$!kY_Q6!<*(6+!
69(2$/2+(#6*4!/2&!6(E+!2++&!$(!L+!9/$<8+&@!!!
!
D. ASD
"(0E/*!)(0!/!)+$#6!$(!8/M+!/!9/$+2$!)(0/E+2!(M/*+U!'$!'6!2($!2(0E/*!(2<+!$8+4!/0+!L(02@!!g8'<8!
&'0+<$'(2!>'**!L*((&!=(!$80(#=8!$8+!)(0/E+2!(M/*+n!X+)$!$(!0'=8$!?LZ<!$8+!*+)$!6'&+!'6!/*>/46!6$0(2=+0!
$8/2!$8+!0'=8$B@!!I8+0+)(0+;!>8/$!>'**!8/99+2!$(!$8+!0'=8$!/$0'#En!Step up 7!6(!'$!>'**!=(!)0(E!è!$(!
tVW@!!g8/$!>'**!8/99+2!$(!$8+!0'=8$!M+2$0'<*+!/2&!9#*E(2/04!/0$+04n!Step up@!!Y(;!what is the
main diff in O2 saturations in VSD vs ASD? ASD is step up of O2 also in the right atrium@!!
%0+!4(#!M(*#E+!(M+0*(/&'2=!$8+!0'=8$!8+/0$n!b+6@!Y(!&(!4(#!0#2!/!risk for Eisenmengersn!b+6@!!
g8/$!+*6+!/0+!/$!'2<0+/6+&!0'6F!)(0n!J/0/&(:'</*!+EL(*'c/$'(2@!!g8/$!')!4(#!>+0+2Q$!*#<F4!+2(#=8!$(!
8/M+!/!_kI!'2!$8+!*+=;!/2&!'$!+EL(*'c+!#9!/2&!$8+!90+66#0+6!()!$8+!0'=8$!6'&+!()!$8+!8+/0$!/0+!
'2<0+/6'2=;!/2&!4(#!8/M+!/!9/$+2$!)(0/E+2!(M/*+!7!>'**!$8+0+!L+!/2!+EL(*#6!$8/$!</2!=(!)0(E!$8+!
0'=8$!/$0'#E!$(!$8+!*+)$!/$0'#E!/2&!>'**!8/M+!/!M+2(#6!<*($!'2!/0$+0'/*!<'0<#*/$'(2n!b+6!7!$8'6!(<<#06!'2!
9$6!>'$8!%Y_@!!MC teratogen that has ASD associated with it? Fetal alcohol syndrome
(1/5000)
!
E. PDA
1$Q6!2(0E/*!'2!/!)+$#6!L#$!2($!>8+2!$8+4!/0+!L(02@!!.(22+<$'(2!L+$>++2!$8+!/(0$/!/2&!9#*E(2/04!
/0$+04!7!>8'<8!'6!6$0(2=+0n!%(0$/@!!Y(;!(:4=+2/$+&!L*((&!=(+6!)0(E!*+)$!/2&!=+$!&#E9+&!'2!$8+!
9#*E(2/04!/0$+04!L+)(0+!=('2=!'2$(!$8+!*#2=6@!Y(;!>8/$!8/99+26!'2!$8+!9#*E(2/04!/0$+04n!Y$+9!#9@!!
Y(;!2(>!'$6!tVW!GH!6/$#0/$'(2!7!the pulmonary artery is the only thing that has a step up of
O2@!!I8+2!>'**!=(!#2&+0!$8+!*#2=6!/2&!$8+!9#*E(2/04!M+'2!>'**!8/M+!$8+!2(0E/*!reW!GH!6/$@!!!SZ<!
$8+0+!'6!/2!(9+2'2=!L+$>++2!$8+6+;!$8+0+!'6!L*((&!=('2=!L/<F!/2&!)(0$8!&#0'2=!646$(*+!/2&!&'/6$(*+!7!
machinery murmur!7!>8+0+!'6!'$!8+/0&!L+6$n!S+$>++2!68(#*&+0!L*/&+6@!!./2!4(#!M(*@!(M+0*(/&!$8+!
0'=8$!8+/0$n!b+6@!!J#*E(2/04!NI"n!b+6@!!"(>!>8'<8!>/4!>'**!$8+!68#2$!=(n!g'**!=(!$8+!6/E+!>/4!
>8+2!'$!>/6!/!)+$#6U!4(#!>'**!8/M+!#2GHQ&!L*((&!&#E9'2=!'2$(!$8+!/(0$/@!!g8+0+!&(+6!$8+!&#<$#6!
+E9$4n!_'6$/*!$(!$8+!6#L<*/M'/2!/0$+04!7!6(;!$8+!L/L4!>'**!8/M+!9'2F!(2!$(9!/2&!L*#+!(2!L($$(E!LZ<!
&#E9'2=!#2GHQ&!L*((&!L+*(>!$8+!6#L<*/M'/2!/0$+04;!$8+0+)(0+!>'**!8/M+!differential cyanosis
pink on top, cyanotic on bottom@!!g8/$!'6!$8+!$+0/$(=+2!/66(<!>'$8!J_%n!.(2=+2'$/*!R#L+**/@!!1)!
4(#!8/&!/!J_%;!</2!4(#!<*(6+!'$!())!>'$8(#$!6#0=+04n!b+6@!!N(>n!Indomethacin - this is a
potent NSAID, which would inhibit PGE2;!/2&!$8+0+)(0+!>(#*&!6$/0$!<(26$0'<$'2=!/2&!<*(6+!(2!
'$6!(>2@!!!
!
F. Tetralogy of Fallot
K.!<4/2($'<!<(2=+2'$/*!&c-!!i$+$0/j!C!)(#0!7!(M+00'&'2=!/(0$/-!'$6!6$0/&&*'2=!$8+!6+9$#EU!9#*E(2'<!
6$+2(6'6!L+*(>!$8+!M/*M+;!RkN;!E+EL0/2(#6!!6+9$/*!&+)+<$!?kY_B@!!g8/$!&+$+0E'2+6!>8+$8+0!4(#!
=+$!<4/2(6'6!(0!2($n!_+=0++!()!9#*E(2'<!6$+2(6'6U!2($!/**!L/L'+6!8/M+!<4/2(6'6!/2&!/0+!/<4/2($'<!7!
</**+&!acyanotic tetralogyU!>84!&(+6!$8'6!(<<#0n!!X+$6!6/4!$8+!&+=0++!()!9#*E(2'<!6$+2(6'6!'6!2($!
$8/$!L/&!7!>8+2!$8+!0'=8$!M+2$!<(2$0/<$6;!/!*($!()!$8+!L*((&!=(+6!#9!$8+!9#*E(2/04!/0$+04!$(!=+$!
GHQ&!/2&!*+66!L*((&!=+$6!'2$(!$8+!*+)$!M+2$0'<*+;!/2&!$8+0+)(0+!90(L/L*4!!>'**!2($!8/M+!<4/2(6'6!/$!
L'0$8@!!g8/$!')!'$!>/6!/!6+M+0+!6$+2(6'6!/2&!>8+2!$8+!0'=8$!M+2$!<(2$0/<$6;!M+04!*'*!L*((&!=($!#9!
$8+0+n!K(6$!>'**!L+!68#2$+&!0'=8$!$(!*+)$!/2&!$8+0+!>'**!L+!/!6$+9!_Gg"!'2!GH!'2!$8+!*+)$!M+2$!/2&!
L/L4!>'**!L+!<4/2($'<@!!Y(;!it is the degree of pulmonic stenosis that determines whether
you have cyanosis or not.!!g8'<8!()!$8+!=0(#96!()!68#2$6!'6!</0&'(d90($+<$'M+!'2!/!9$!>'$8!
$+$0/*(=4!()!)/**($n!!J_%;!%Y_!7!=((&!7!*+$6!6/4!$8+0+!'6!/2!%Y_;!$8+0+)(0+!L*((&!>'**!=(!*+)$!$(!0'=8$!
LZ<!>+!=+$!GHQ&!L*((&!+E9$4'2=!'2$(!$8+!0'=8$!/$0'#E@!!I8'6!>(#*&!</#6+!/!6$+9!#9!()!L*((&!'2$(!$8+!
127

0'=8$!/$0'#E!?$8'6!'6!=((&B@!!N(>!/L(#$!/!J_%n!X+$6!E/F+!L+*'+M+!$8'6!(<<#06!7!6(;!#2GHQ&!L*((&!
9#68+&!)0(E!*+)$!)0(E!$8+!/(0$/!&(>2!$(!$8+!9#*!/0$+04!$(!=+$!GHU!6(E+!()!$8+!#2GHQ&!L*((&!9#$!
L/<F!'2$(!$8+!9#*!/0$+04;!>8+0+!'$!=+$6!GHQ&!/2&!E(0+!=+$6!(#$!7!good to have PDA and ASD
(foramen of ovale) with tetralogy of fallot.
!
Right to left leads to polycythemia and a real risk for infective endocarditis!LZ<!68#2$6!
=('2=!'2$(!*+)$!6'&+;!$8+0+)(0+!</2!=+$!M+=+$/$'(26!=('2=!'2$(!$8+!L0/'2!/2&!($8+0!646$+E'<!(0=/26@!!
All congenital heart defects lead to infective endocarditis.
!
G. Transposition of Great vessels
[:/E9*+-!'2!5/0$/=+2+0Q6!642&0(E+!>'$8!642&0(E+!>'$8!6'2#6!'2M+06#6!7!$8'6!2($!$8+!</6+!>'$8!
$0/269(6'$'(2!()!=0+/$!M+66+*6!7!8/M+!!/!2(0E/*!8+/0$!$8/$!'6!(2!$8+!0'=8$!6'&+!?+M+04$8'2=!'62Q$!
0+M+06+&!$8+!>/4!'$!'6!'2!6'2#6!'2M+06#6B@!!g8/$Q6!$0/269(6+&n!"($!$8+!0'=8$!/$0'#E!7!'$!'6!6$'**!=+$$'2=!
#2(:4=+2/$+&!L*((&@!1$6!2($!$8+!*+)$!/$0'#E!7!'$!'6!6$'**!=+$$'2=!reW!GH!6/$#0/$+&!L*((&!)0(E!$8+!
9#*E(2/04!M+'2@!!The problem is in the ventricles!7!$8+!0'=8$!M+2$0'<*+!'6!L+'2=!+E9$'+&!L4!$8+!
/(0$/U!/2&!$8+!*+)$!'6!L+'2=!+E9$'+&!L4!$8+!9#*E(2/04!/0$+04@!!Y(;!$8+!$8'2=!$8/$!'6!$0/269(6+&!/0+!
$8+!M+2$0'<*+6!?$8+!/$0'/!/0+!)'2+B@!!I8'6!'6!'2<(E9/$'L*+!>'$8!*')+!#2*+66!4(#!8/M+!68#2$6-!!kY_;!%Y_;!
/2&!J_%!</2!>(0F@!!N(>Q6!&(+6!$8'6!>(0Fn!!
!
Y$/0$!/$!$8+!/$0'/*!6'&+!7!8/M+!reW!GH!<(E'2=!'2$(!*+)$!/$0'#E!/2&!'$!'6!=('2=!)0(E!$8+!*+)$!$(!0'=8$U!
$8+0+!>'**!L+!/!6$+9!#9!()!GH!'2!$8+!0'=8$!/$0'#E!/2&!$8+0+)(0+!/*6(!/!6$+9!#9!()!GH!'2!$8+!0'=8$!
M+2$0'<*+@!!Y(E+!>'**!=(!(#$!$8+!/(0$/!/2&!0+6$!>'**!=(!$(!$8+!*+)$!M+2$0'<*+@!!I8'6!'6!=((&!LZ<!$8+!*+)$!
M+2$0'<*+!'6!L+'2=!+E9$'+&!L4!$8+!9#*E(2/04!/0$+04;!6(!$8+!L*((&!>'**!L+!$/F+2!$(!$8+!*#2=6!$(!L+!
(:4=+2/$+&@!!Y(;!$8+6+!68#2$6!/0+!2+<+66/04@!!G$8+0>'6+;!$8+!0'=8$!M+2$!L+'2=!+E9$'+&!L4!$8+!/(0$/!
>(#*&!L+!/**!(:4=+2/$+&!L*((&!/2&!$8+!*+)$!M+2$0'<*+!L+'2=!+E9$'+&!>'$8!$8+!9#*E(2/04!/0$+04!>(#*&!
2($!L+!(F/4@!!Y(;!L4!8/M'2=!$8+!68#2$6;!</2!=+$!/0(#2&!$8+6+!&+)+<$6@!!%2!%Y_!'6!2+<+66/04!6(!4(#!
</2!=+$!GHQ&!L*((&!'2$(!$8+!0'=8$!/$0'#E;!/2&!)0(E!$8+!0'=8$!/$0'#E!$8+0+!>'**!L+!/!6$+9!#9!()!GH!'2!
$8+!0'=8$!M+2$0'<*+;!>8'<8!'6!L+'2=!+E9$'+&!L4!$8+!/(0$/U!(LM'(#6*4!$8'6!L*((&!'62Q$!reW!6/$#0/$+&!
?E/4L+!tVWB;!/2&!$8'6!'6!>84!$8+0+!'6!<4/2(6'6!'2!$8+6+!9/$'+2$6@!!%$!*+/6$!6(E+!L*((&!</2!=+$!(#$!
()!$8+!/(0$/!/2&!8/M+!6(E+!GH!$(!$8+!9$!/2&!$8+4!</2!6#0M'M+!)(0!/!*'$$*+!>8'*+@!!SZ<!()!$8+!0'=8$!$(!
*+)$!68#2$;!$8/$!L*((&!'6!L+'2=!+E9$'+&!L4!$8+!9#*E(2/04!/0$+04!/2&!$8/$!'6!=('2=!$(!$8+!*#2=6!/2&!
L+'2=!(:4=+2/$+&@!!Y(;!$8+!68#2$6!/0+!2+<+66/04!)(0!*')+@!!Y(;!>'$8!5/0$/=+2+0Q6;!$8+0+!'6!"GI!/!
<(E9*+$+!$0/269(6'$'(2!()!M+66+*6;!L#$!/!2(0E/*!8+/0$!(2!$8+!0'=8$!6'&+!?</**+&!6'2#6!'2M+06#6B@!
!
H. Coarctation!7!8/M+!90+&#<$/*!/2&!9(6$&#<$/*!
J0+!C!L+)(0+!9/$+2$!&#<$#6U!9(6$!C!/)$+0!9/$+2$!&#<$#6!?/)$+0!$8+!*'=/E+2$#E!/0$+0'(6#EB!
Preductal!(<<#0!'2!I#02+0!642&0(E+!/2&!=(!6$0/'=8$!'2$(!)/'*#0+;!$8+0+)(0+!E#6$!L+!<(00+<$+&!
'EE+&'/$+*4@!!Postductal!/0+!2($!90+6+2$!/$!L'0$8!/2&!</2!(<<#0!/$!/24!$'E+!&#0'2=!$8+!9$Q6!/&#*$!
*')+@!!1E9(0$/2$!$(!0+<(=2'c+!LZ<!$8+4!/0+!/!6#0='</**4!<(00+<$/L*+!</#6+!()!NI"@!!!
Y$+2(6'6!'2!/(0$/!7!>8/$!'6!8/99+2'2=!90(:'E/*n!I8+0+!'6!$0(#L*+!=+$$'2=!L*((&!$80(#=8!$8/$;!
$8+0+)(0+!$8+0+!>'**!L+!/!E#0E#0!8+/0&!L+6$!L+$>++2!$8+!68(#*&+0!L*/&+6!7!/!646$(*'<!E#0E#0@!!
I8+0+!'6!/!*($!()!90+66#0+!L#'*$!#9!90(:'E/**4;!6(!$8+!90(:!/(0$/!>'**!L+!&'*/$+&!/2&!$8+0+!>'**!L+!/!*($!
()!90+66#0+!=('2=!'2$(!$8+!M+66+*6!7!$8+!6#L<*/M'/2;!'2$+02/*!</0($'&6!7!$8+0+)(0+!$8+!BP in the
upper extremities will be higher than it is in the lower extremities.!!%*6(;!>'$8!'2<0+/6+&!
L*((&!)*(>!'2$(!$8+!L0/'2;!/$!$8+!3#2<$'(2!>8+0+!$8+!<(EE#2'</$'2=!L0/2<8+6!8'$!$8+!E/'2!<+0+L0/*!
L0/2<8+6;!>+!8/M+!2(!'2$+02/*!+*/6$'<!*/E'2/!/2&!2(!6E(($8!E#6<*+!$8+0+;!$8+0+)(0+!'$!'6!/!>+/F!
/0+/!?)(0!%XX!9+(9*+BU!$8+0+)(0+;!everybody has the potential to develop berry aneurysms@!!
g8/$!>(#*&!+:/<+0L/$+;!(0!E/F+!$8+!L+004!/2+#046E!/!0+/*'6$'<!$8'2=n!HTN!?/24!</#6+!()!NI"!</2!
</#6+!L+004!/2+#046E6!7!'+!%_J5_;!+66+2$'/*!NI";!$8+!L($$(E!*'2+!'6!NI";!/2&!ALL hypertensive
128

pts run the risk of berry aneurysms!7!>+!/**!8/M+!$8+!6/E+!&+)+<$!/$!$8+!3#2<$'(2!)(0E!/24!
</#6+!()!NI"!7!'$6!2($!#2'D#+!$(!%_J5_;!'$6!'2!/**!</6+6!()!NI"!7!($8+0!0+*/$'(26!$(!NI"!C!
6#L/0/<82('&!L*++&6;!6$0+$<8Z&'*/$/$'(2!()!/(0$'<!M/*M+!0'2=!/2&!$8+0+)(0+!/!E#0E#0!()!/(0$'<!0+=#0=@!!
%**!$8+!90+66#0+!(2!$8+!>/**!()!$8+!90(:'E/*!/(0$/!can also predispose to dissecting aortic
aneurysm@!!g8/$!'6!&'6$/*!$(!$8'6n!_+<0+/6+&!L*((&!)*(>;!claudication!?/2='2/!()!9+0'98+0/*!
M+66+*6!7!6(!>8+2!$8+4!>/*F;!$8+4!>'**!=+$!</*)!9/'2;!L#$$(<F!9/'2;!$8+2!$8+4!6$(9!/2&!'$!=(+6!/>/4;!
$8+4!>/*F!'$!8#0$6B!7!$8'6!'6!/**!&#+!$(!'6<8+E'/;!/2&!$8+!E#6<*+!&+M+*(9E+2$!$(!$8+!*(>+0!
+:$0+E'$'+6!>'**!2($!L+!$((!=((&;!+'$8+0@!!K#6<*+!E/66!>'**!L+!&+<0+/6+&;!SJ!&'))+0+2<+!L+$>++2!
#99+0!/2&!*(>+0!+:$0+E'$'+6;!/2&!$8+!L*((&!)*(>!$(!$8+!0+2/*!/0$+0'+6!'6!&+<0+/6+&;!*+/&'2=!$(!
/<$'M/$'(2!()!$8+!R%%!>'**!*+/&!$(!NI"@!!Y(!$8+!HTN in pts with Coarctation is due to activation
of RAA!7!6(!'$!'6!/!8'=8!0+2'2!NI"@!!Y(;!')!4(#!</2!<(00+<$!'$!$8+!NI"!>'**!=(!/>/4@!!g8+2!$8+0+!'6!/!
90(L*+E!?'+!/!0(/&L*(<FB;!>+!8/M+!$(!=(!/0(#2&!'$!7!'+!2++&!<(**/$+0/*6@!!N(>+M+0;!$8+!/(0$/!'6!2($!/!
=((&!9*/<+!$(!8/M+!!/!0(/&L*(<F!LZ<!(2*4!8/M+!$>(!>/46!$(!=+$!/0(#2&!$8+!L*(<F-!,B?0/0+6$B!
6#9+0)'<'/*!+9'=/6$0'<!/0$+04;!>'$8!$8+!'2$+02/*!E/EE/04!/0$+04!</2!=+$!/0(#2&!$8'6U!$8'6!'6!/$!$8+!
*/$+0/*!L(0&+0!()!8/66+*L/<8!?$8+!6#9+0)'<'/*!+9'=/6$0'<!/0$+04B@!Y(;!>8+2!4(#!6$'<F!4(#0!)'2=+0!'2!$8+!
</2/*!/2&!8/M+!/2!'2&'0+<$!'2=#'2/*!8+02'/@!R'=8$!$80(#=8!$8+!E+&'/*!6'&+!>'**!)++*!/!9#*6/$'(2!?>8+0+!
$8+!6#9!+9'=/6$0'<!/0$+04!'6B@!HB!'2$+0<(6$/*6!7!(2!$8+!#2&+06#0)/<+!()!$8+!0'L6!/2&!=+$$'2=!+:$0/!L*((&!
$80(#=8!$8+E!7!*+/&'2=!$(!notching of ribs!?M'6#/*'c+&!(2!:d0/4B@!
!
VI. Major risk factors for coronary artery dz:!52(>!$8+!0'6F!)/<$(06m
%=+!'6!$8+!E(6$!'E9!0'6F!)/<$(0!?</22($!<(2$0(*B!dê!)(0!E/*+6U!ee!)(0!>(E+2!7!>84n!N'=8+0!
+6$0(=+2!*+M+*6;!>8'<8!/))+<$!N_X!*+M+*6@!!R'6F!)/<$(0!)(0!.%_!'6!2($!X_X;!'$6!N_X@!!N_X!M'6'$6!)/$$4!
6$0+/F6;!6#<F6!X_X!(#$;!$/F+6!'$!$(!$8+!*'M+0!$(!L+!E+$/L(*'c+&@!!ee!'2!>(E+2!LZ<!$8/$!'6!$8+!/=+!()!
E+2(9/#6+U!2($!$/F'2=!+6$0(=+26!/2&!$8/$!'6!$8+!/=+!>8+2!+6$0(=+26!=(!&(>2U!N_X!*+M+*6!=(!&(>2!
/2&!0'6F!=(+6!#9@!!T/E'*4!8'6$(04!()!90+E/$#0+!/0$+04!&c;!<'=!6E(F'2=;!NJ;!N_XyPe;!&'/L+$+6;!X_X!
?<8(*+6$+0(*!'6!2($!/!0'6F!)/<$(0;!X_X!'6B!LZ<!/**!$8+0/9+#$'<!&+<'6'(26!/0+!L/6+&!(2!X_X!*+M+*6;!2($!
<8(*+6$+0(*!*+M+*6@!!N_X!'6!/!2+=/$'M+!0'6F!)/<$(0-!')!4(#0!N_X!'6!=0+/$+0!$8/2!aV;!4(#!</2!6#L$0/<$!
(2+!)0(E!4(#0!E/3(0!0'6F!)/<$(0!!d!'+!et!4Z(;!L#$!N_X!'6!/L(M+!aV;!</2!6#L$0/<$!$8+!/=+!0'6F!)/<$(0!
/2&!>'**!8/M+!2(!0'6F!)/<$(06@!
VII. Ischemic Heart Disease:
4 types: Angina, Myocardial Infarct, Sudden Cardiac Death Syndrome, Chronic Ischemic
Heart Disease
A. Sudden cardiac death syndrome!C!&+/$8!>'$8'2!$8+!*/6$!80!7!>8/$!>'**!4(#!6++!/$!/#$(964n!
g'**!"GI!6++!/!<(0(2/04!$80(EL#6;!>'**!6++!6+M+0+!<(0(2/04!/0$+04!/$8+0(6<*+0(6'6@!!Y(;!#6#/**4!
$8+6+!9$6!&(!2($!8/M+!/!$80(EL#6;!L#$!&(!8/M+!6+M+0+!<(0(2/04!/0$+04!&c;!*+/&'2=!$(!'6<8+E'/;!
Jk.Q6;!M+2$0'<#*/0!)'L0'**/$'(2!?&'+!()!M+2$0'<#*/0!/0084$8E'/!3#6$!*'F+!'2!K1BU!&'+!6(!)/6$!$8/$!$8+0+!/0+!
2(!<8/2=+6!'2!$8+!8+/0$!?'+!9/**(0Z.(/=#*/$'(2!2+<0(6'6BU!6++!6+M+0+!<(0(2/04!/0$+04!&c!/2&!&:!
6#&&+2!</0&'/<!&+/$8@!k+04!8'=8!0'6F!'2!6E(F+06@!!!
!
B. Chronic ischemia heart dz!71$Q6!/!*($!()!(#0!9/0+2$6;!#2<*+6!/2&!/#2$6!>8(!8/M+!<(0(2/04!
/0$+04!&c!>'$8!*'$$*+!'2)/0<$6;!(0!8/&!/!6E/**!8+/0$!/$$/<F;!L/6'</**4!$/*F'2=!/L(#$!6#L+2&(</0&'/*!
'2)/0<$'(26@!!g8/$!8/99+26!'6!$8/$!$8+!E#6<*+!=+$6!0+9*/<+&!L4!)'L0(#6!$'66#+!/2&!+M+2$#/**4!$8+!
9((0!Xk!'6!/**!)'L0(#6!$'66#+;!>'$8!2(!E#6<*+!$8+0+)(0+!$8+!+3+<$'(2!)0/<$'(2!'6!M+04!*(>@!!1$6!V@H!
'26$+/&!()!$8+!2(0E/*!V@aa!/2&!$8+4!&'+!)0(E!8+/0$!)/'*#0+@!!T'L0(#6!$'66#+!&(+6!2($!8/M+!
<(2$0/<$'*'$4U!$8'6!&c!'6!$8+!H2&!K.!'2&'</$'(2!)(0!/!8+/0$!$0/269*/2$@!!!
!
C. Angina (MC type of heart dz)
3 types exertional, prinzmetal, unstable (resting) angina
129

!
,@!!Exertional!7!<8+6$!9/'2!(2!+:+0$'(2;!=(+6!/>/4!>'$8'2!ed,V!E'2#$+6!()!0+6$'2=U!YI!&+90+66'(2!
(2![5l!?,dH!EE!&+90+66'(2B!7!$8+0+)(0+!/!</2&'&/$+!)(0!<(0(2/04!/2='(=0/E!$(!6++!>8/$Q6!=('2=!
(2@!
!
H@!!Prinzmetals!7!6++2!'2!>(E+2;!(<<#06!'2!E(02'2=U!&#+!$(!M/6(69/6E!()!$8+!<(0(2/04!/0$+0'+6;!
"GI!/$8+0(6<*+0(6'6@!!12!6(E+!9+(9*+;!I:%H!'6!'E9*'</$+&!)(0!$8+!M/6(69/6E@!!ST depression
means subendocardial ischemia@!!.(0(2/04!/0$+0'+6!9+2+$0/$+!$8+!(#$6'&+!()!$8+!8+/0$!/2&!=(!
'2;!6(!$8+!6#L+2&(</0&'/*!$'66#+!=+$!6<0+>+&!LZ<!'$6!)#0$8+0+6$!)0(E!$8+!L*((&!6#99*4@!!I8+0+)(0+;!
>'$8!<(0(2/04!/0$+04!/$8+0(6<*+0(6'6;!/2&!&+<0+/6+&!L*((&!)*(>;!>8(!=+$6!6<0+>+&n!Y#L+2&(</0&'#E!
/2&!'$!0+/<$6!$(!'$!>'$8!9/'2!/2&!YI!&+90+66'(2@!!g'$8!M/6(69/6E!()!<(0(2/04!/0$+04;!=+$!$0/26E#0/*!
'6<8+E'/!7!$8+0+)(0+!$8+0+!'6!'6<8+E'/!$80(#=8(#$!$8+!+2$'0+!$8'<F2+66!()!$8+!E#6<*+!7!$8'6!90(&#<+6!
YI!+*+M/$'(2@!!Y(;!J0'2cE+$/*Q6!/2='2/!8/6!YI!+*+M/$'(2!LZ<!$0/26E#0/*!'6<8+E'/@!!!
!
P@!!Unstable!7!/F/!90+d'2)/0<$'(2!/2='2/!7!=+$!/2='2/!(2!0+6$'2=@!!.*/66'<!8:-!'2'$'/**4!8/&!6$/L*+!
/2='2/;!2(>!9$!3#6$!=+$!'$!>8+2!$8+4!/0+!6'$$'2=@!I8'6!E+/26!$8/$!$8+4!>'**!2++&!/2='(9*/6$4!/2&!9#$!
'2$(!$8+!8(69'$/*@!_(!2($!9#$!(2!$0+/&E'**;!$8+4!>'**!&'+@!g8/$!M+'26!&(!$8+4!#6+n!Y/98+2(#6!M+'2!7!
(M+0!,V!4+/06!>'**!L+<(E+!/0$+0'/*'c+&!?'$!>'**!*((F!+:/<$*4!*'F+!/2!/0$+04B@!!1)!4(#!$/F+!/!M+'2;!/2&!9#$!
/0$+0'/*!90+66#0+6!'2$(!'$;!'$!>'**!<8/2=+!'$6!8'6$(*(=4!/2&!*((F!+:/<$*4!*'F+!/2!/0$+04@!!I8+4!8/M+!/!
8'=8!$+2&+2<4!)(0!)'L0(6'2=!())!/)$+0!,V!4+/06!LZ<!$8+4!/0+!M+'26@!
12$+02/*!E/EE/04!'6!/2!/0$+04;!$8+0+)(0+!>(2Q$!8/M+!$8+!6/E+!90(L*+E!LZ<!'$!'6!#6+&!$(!$8(6+!
90+66#0+6@!!I8+4!>'**!0+E/'2!9/$+2$;!L#$!</22($!&(!)(#0!M+66+*!L49/66!>'$8!(2+!'2$+02/*!E/EE/04!
/0$+04@!Y(;!$8+4!#6+!$8+!6/98+2(#6!M+'2;!>8'<8!8/6!$8+!$+2&+2<4!$(!#2&+0=(!)'L0(6'6!(M+0!$'E+!LZ<!
$8+4!/0+!/0$+0'/*'c+&!#2&+0!90+66#0+@!!I8+4!</2!/*6(!#6+!$8+!'2$+02/*!E/EE/04@!
!
D. Acute MI
I80(EL#6!<(E9(6+&!()!=0(#9!()!9*/$+*+$!<+**6!L(#2&!$(=+$8+0!>'$8!)'L0'2@!!IJ%!&(+62Q$!8/M+!/!
90(L*+E!>'$8!$8'6!LZ<!'$!3#6$!L0+/F6!$8+!)'L0'2!L(2&6!$(!&+6$0(4!$8+!<*($@!!1$!8/6!/!E#<8!L'==+0!
90(L*+E!>'$8!$8+!L0+/F&(>2!()!/!M+2(#6!<*($!LZ<!$8(6+!8/M+!E(0+!)'L0'2@!!I8+!$80(EL(6+6Z<*($6!'2!
$8+!8+/0$!&(!2($!8/M+!$8/$!E#<8!)'L0'2@!!%2($8+0!)/<$(0!$(!&+/*!>'$8!'6!0+9+0)#6'(2!'23#04!7!GHQ&!
L*((&!=(+6!'2$(!'23#0+&!$'66#+;!6#9+0(:'&+!)0++!0/&'</*6!)(0E;!./!)(0E;!/2&!/!)+>!()!$8+!'23#0+&!
E4(</0&'/*!<+**6!>'**!&'+@!!G2<+!$8(6+!&'+;!'$!>'**!6$'**!'E90(M+!*(2=+M'$4@!
1. Complications of MI:
a) LAD coronary artery!'6!K.!M+66+*!$80(EL(6+&;!/2&!6#99*'+6!+2$'0+!/2$+0'(0!9/0$!()!4(#0!8+/0$!
/2&!$8+!/2$+0'(0!HZPQ6!()!$8+!'2$+0M+2$0'<#*/0!6+9$#E@!!Y(;!$8+0+!>'**!L+!9/*+2+66;!>'$8!$8+!/2$!HZPQ6!
F2(<F+&!())@!!g8+0+!/0+!E(6$!()!$8+!<(2&#<$'(2!L#2&*+6n!%2$+0'(0!HZPQ6@!!Y(;!')!4(#!8/M+!<(E9*+$+!
8+/0$!L*(<F!$8/$!0+D#'0+6!+<$(9'<!9/<+E/F+0;!>8/$!'6!$8+!E(6$!*'F+*4!M+66+*!$80(EL(6+&n!X%_@!!!
g8+2!4(#!8/M+!X%_!(<<*#6'(2;!4(#!8/M+!classical signs pain radiating the jaw, pain down
the left arm, substernal chest pain.!
!
b) RCA!C!H2&!K.!$80(EL(6+&!/0$+04!7!>8'<8!6#99*'+6!$8+!+2$'0+!9(6$+0'(0!9/0$!()!$8+!8+/0$!/2&!$8+!
9(6$+0'(0!,ZP!()!$8+!M+2$0'<#*/0!6+9$#E!/2&!$8+!+2$'0+!0'=8$!M+2$0'<*+@!!Y(;!'$!6#99*'+6!$8+!9(6$!8+/0$;!
9(6$!,ZP!()!$8+!6+9$#E!/2&!$8+!+2$'0+!0'=8$!M+2$0'<*+@!!I8+!E'$0/*!M/*M+!8/6!$>(!M/*M+6!>'$8!9/9'**/04!
E#6<*+6!7!9(6$+0(E+&'/*!9/9'**/04!E#6<*+!/2&!9(6$+0(E+&'(!9/9'**/04!E#6<*+@!Y(;!>8/$!6#99*'+6!$8+!
9(6$+0'(0n!R.%@!!%*6(!8/M+!$8+!Y%!2(&+!/2&!%k!2(&+@!!I8+!Y%!2(&+!8/6!/2!+D#/*!&'6$0'L#$'(2!
L+$>++2!*+)$!/2&!0'=8$@!!N(>+M+0;!$8+!AV node has a 95% supply from the branches of the
RCA!7!$8'6!L0'2=6!#9!'2$+0+6$'2=!<(E9*'</$'(26@!![:/E9*+-!!9$!>'$8!E'$0/*!0+=#0=!E#0E#0;!>8'<8!'6!
130

0+*/$+&!$(!9(6$+0(E+&'/*!9/9'**/04!E#6<*+!&46)#2<$'(2;!(0!E/4!L0+/F!7!>8/$!'6!$8+!90(L*+En!
I80(EL(6'6!()!$8+!R.%!LZ<!$8+!R.%!6#99*'+6!$8/$!9/9'**/04!E#6<*+@!!Y(;!E'$0/*!0+=#0=!E#0E#0!$8/$!
(<<#06!&#0'2=!K1!>(#*&!L+!&#+!$(!R.%@!!If you knock off the AV node, this is sinus
bradycardia, and atypical chest pain@!!I8+!R.%!'6!&/2=+0(#6!LZ<!6(E+$'E+6!9$!>'**!=+$!
epigastric pain;!>8'<8!'6!/2!/$49'</*!9/'2@!!I8'6!6'E#*/$+6!l[R_U!'+!9$!6+2$!8(E+!>'$8!9+9$(!
L'6E(*;!/2&!+2&6!#9!&4'2=!/$!8(E+!?LZ<!()!E'66+&!&:B@!!I8+4!68(#*&!8/M+!L++2!6+2$!$(!8(69'$/*@!
I8+0+)(0+;!+*&+0*4!9$!>'$8!epigastric pain could be GERD or coronary artery thrombosis of
the RCA.
2. Gross/microscopic features
"++&!$(!F2(>!>8+2!$8+!8+/0$!'6!6()$+6$!/2&!8/6!/!<8/2<+!)(0!0#9$#0'2=!7!$8'6!'6!L+$>++2!Pd`!&/46@!!
g8+2!&(!4(#!6++!=0(66!E/2')+6$/$'(2!()!L+'2=!/!9/*+!'2)/0<$n!H^!806!7!L+='2!6++'2=!9/*+2+66@!!
.(/=#*/$'(2!2+<0(6'6!'2!^da!806@!!!
!
[:/E9*+-!!X%_!$80(EL(6'6!LZ<!6++!9/*+!/2$+0'(0!HZP!()!8+/0$@!!R#9$#0+!7!9+0'</0&'#E!)'**+&!>'$8!
L*((&!?8+E(9+0'</0&'#EB!7!E(6$!/0+!'2$+0'(0;!/2&!$8+0+)(0+!'6!)0(E!$8+!X%_!$80(EL(6'6!7!8(>!&(+6!
$8'6!E/2')+6$!'$6+*)n!_/4!P!(0!&/4!^!<(E9*/'2!()!<8+6$!9/'2;!8/M+!E#))*+&!8+/0$!6(#2&6;!2+<F!M+'2!
&'6$+26'(2;!/2&!F2(>!$8+4!8/M+!0#9$#0+&@!!!
!
[:/E9*+-!0#9$#0+!()!9(6$!E+&'/*!9/9'**/04!E#6<*+!7!/2&!'$!>/6!'2)0/<$+&;!$8+0+)(0+!$8+!R.%!'6!$8+!
</#6+!!
()!$8+!0#9$#0+!7!6(;!>8/$!>(#*&!$8+!E#0E#0!L+n!K'$0/*!0+=#0=!7G2!&/4!P!9$!=(+6!'2$(!8+/0$!)/'*#0+;!
8/M+!/!9/2646$(*'<!E#0E#0;!'2<0+/6+6!(2!+:9'0/$'(2;!/2&!YP!/2&!Y^!8+/0$!6(#2&@!!1$!>/62Q$!$8+0+!/!
&/4!L+)(0+!7!E+/2'2=!$8+!9(6$+0'(0!E+&'/*!9/9'**/04!E#6<*+!>/6!&46)#2<$'(2/*!LZ<!'$!>/6!'2)0/<$+&!(0!
'$!0#9$#0+&@!Y(;!'$Q6!6(E+$8'2=!$8/$!>/62Q$!$8+0+!L+)(0+!/2&!6#&&+2*4!/0'6+!L+$>++2!&/46!Pd`@!!g'**!
=(!'2$(!8+/0$!)/'*#0+!LZ<!E/66'M+!M(*#E+!(M+0*(/&!/2&!=(!0'=8$!L/<F!$(!$8+!*#2=6@!
!
[:/E9*+-!0#9$#0+!()!/2$!>/**!
[:/E9*+-!0#9$#0+!()!9/9'**/04!E#6<*+;!/2&!$8+!9(6$+0(E+&'/*!(2+!'6!K.!
[:/E9*+-!.(/=!2+<0(6'6!
[:/E9*+-!'2$+0M+2$0'<#*/0!6+9$#E!0#9$#0+6;!$8+0+)(0+!/!*+)$!$(!0'=8$!68#2$!/2&!/!6$+9!#9@!!K(6$!
'2$+0M+2$0'<#*/0!0#9$#0+6!/0+!X%_!$80(EL(6+6@!!!
!
[:/E9*+-!mural thrombus!?E#0/*!C!>/**B!7!'2!$8'6!</6+;!E#0/*!'6!/!$80(EL#6;!(2!$8+!>/**@!!I8+4!
/0+!/*E(6$!/*>/46!X%_!$80(EL'!LZ<!2++&!/!9*/<+!$(!6$'<F@!!g'$8!/2$+0'(0!K1;!/*>/46!='M+!/69'0'2!/2&!
9#$!9$!(2!>/0)/0'2Z8+9/0'2!7!>84!&(!$8+4!&(!$8/$n!I(!90+M+2$!E#0/*!$80(EL#6!)0(E!)(0E'2=@!!Y(;!
>8+2!4(#!8/M+!/2!/2$+0'(0!90(L;!$8+4!>'**!/2$'<(/=#*/$+!4(#@!!Mural thrombi are mixed clots!7!
$8+4!/0+!2($!/!9#0+!M+2(#6!*'F+!<*($!(0!/!9*/$+*+$!*'F+!<*($;!$8+4!/0+!E':+&@!!N+0+Q6!8(>!'$!>(0F6-!!4(#!
8/M+!/!$0/26E#0/*!'2)/0<$'(2!/2&!$8+0+)(0+!'23#04!$(!+2&($8+*'/*!<+**6!()!$8+!8+/0$;!$8+0+)(0+!9*/$+*+$6!
>'**!6$'<F!7!6(!9*/$+*+$6!/0+!$8+!)'06$!$8'2=6!$8/$!6$'<F!/2&!$8+2!LZ<!$8+!E#6<*+!'6!2($!<(2$0/<$'2=!$8/$!
>+**!?LZ<!'2)0/<$+&!E#6<*+!&(+6!2($!<(2$0/<$B;!$8+0+!'6!6$/6'6;!/2&!6(!(2!$(9!()!$8+!9*/$+*+$6!'6!/!
M+2(#6!*'F+!<*($;!>8'<8!.(/=#*/$'(2!)/<$(0!e;t;!/2&!RS.Q6;!6(!'$6!E':+&!?9*/$+*+$6!>'$8!)'L0'2!/2&!
M+2(#6!<*($!)0(E!6$/6'6B@!!g'$8!aspirin;!4(#!2($!(2*4!90+M+2$'2=!/!<(0(2/04!$80(EL#6!>'$8!
&+<0+/6'2=!9*/$+*+$!/==0+=/$'(2;!L#$!/*6(!90+M+2$'2=!/!E#0/*!$80(EL#6!)0(E!'2'$'/**4!)(0E'2=!LZ<!'$!
'28'L'$6!$8+!9*/$+*+$6!)0(E!/==0+=/$'2=@!!%*6(;!by putting on warfarin and heparin;!4(#!90+M+2$!
$8+!($8+0!9/0$!()!$8+!<*($!)0(E!)(0E'2=@!!_(2Q$!>/2$!$8+6+!LZ<!'$!</2!+EL(*'c+!/2&!$8+0+)(0+!/0+!M+04!
&/2=+0(#6@!
!
3. Fibrinous pericarditis!7!</2!(<<#0!H!$'E+6!'2!/!9+06(2!>'$8!K1-!,B!,6$!>++F!7!=+$!/!)0'<$'(2!0#L;!
<8+6$!9/'2!?0+*'+M+&!>8+2!*+/2'2=!)(0>/0&!/2&!>(06+!>8+2!*+/2'2=!L/<F!d!/!P!<(E9(2+2$!)0'<$'(2!
131

0#LB@!!I8/$Q6!&#+!$(!$0/26E#0/*!'2)/0<$'(2!/2&!'2<0+/6+&!M+66+*!9+0E+/L'*'$4@!%2&!HB!8:!()!$0/26E#0/*!
'2)/0<$;!<(E+6!'2!a!>++F6!*/$+0!>'$8!)+M+0;!E#6<*+!/<8+6!/2&!9/'26;!/2&!/!P!<(E9(2+2$!)0'<$'(2!0#L!
'2!$8+!<8+6$!C!Dresslerss syndrome , which is an autoimmune pericarditis@!!g8+2!8/&!
'2)/0<$;!&/E/=+!()!$8+!9+0'</0&'/*!6#0)/<+!*+&!$(!/#$(%LQ6!/=/'26$!9+0'</0&'/*!$'66#+@!!I8'6!$((F!a!
>++F6!$(!L#'*&!#9;!/2&!$8+4!6$/0$!/$$/<F'2=!$8+!9+0'</0&'#E!*+/&'2=!$(!646$+E'<!64E9$(E6!0+*/$+&!$(!
'EE#2(*(='<!0:2!C!_0+66*+06Q6@!!I8+0+)(0+;!2 types are 1st week, not autoimmune, and 6
weeks, autoimmune. S/6'</**4!$0+/$!>'$8!"Y%1_Y@!
!
4. Later complications ventricular aneurysm
[:/E9*+-!9$!P!>++F6!(#$!()!K1!7!<8+6$!L#*=+6!7!>8/$!#2&+0!$8+0+n!K/66'M+!9+<$(0/*'6!E/3(0!7!'+!
systolic bulge of pericardium is ventricular aneurysm@!!S*((&!'6!<(**+<$'2=!'2!$8+!/2+#046E!
/2&!E/F'2=!$8+!<8+6$!L#*=+!(#$@!!I8'6!'6!/!*/$+!E/2')+6$/$'(2!7!F2(>!'$Q6!/!M+2$!/2+#046EU!$8+!K.!
<(E9*'</$'(2!'6!"GI!0#9$#0+;!$8'6!/2+#046E!'6!*'2+&!L4!6</0!$'66#+!/2&!$8+0+)(0+!>'**!2($!0#9$#0+.
MCC death in a vent aneurysm = heart failure. K(6$!()!8+/0$!8/6!6</0!$'66#+;!>8'<8!*+/&6!$(!
&+<0+/6+&!+3+<$'(2!)0/<$'(2;!$8+0+)(0+;!die of HEART FAILURE not rupture@!
!
[:/E9*+-%<#$+!K1!7!>/62Q$!7!'$!'6!fibrous tissue, which is whiter and more patchy.!!T'L0(#6!
$'66#+!?6</0B!</2!L+!/24>8+0+!)0(E!P!>++F6!$(!,V!4+/06!
K#6$!*((F!/$![T!?+3+<$'(2!)0/<$'(2B!L+)(0+!*+/M'2=!8(69'$/*U!')!4(#!&(2Q$!8/M+!/!=((&![T;!90(L/L*4!>'**!
&'+@!!1)!4(#!8/M+!/!*(>![T;!4(#!8/&!/!L'=!'2)/0<$;!>'$8!/!*($!()!E#6<*+!$8/$!>/6!&+6$0(4+&@!!
I8+0+)(0+;![T!'6!$8+!L'==+6$!90(=2(6$'<!)/<$(0@!!1)!'$6!<*(6+!$(!V@aa;!$8/$Q6!=((&@!!S#$!')!4(#0!V@^;!'+!'$6!
M+04!L/&@!
!
5. How do we dx MI? CK-MB is dx of choice
"($!/2![5l!LZ<!'$!8/6!(2*4!/2!tVW!6+26'$'M'$4!68(>'2=!/!2+>!D!>/M+;!YI!+*+M/$'(2@!!I8+4!8/M+!
=0+/$!69+<')'<'$4-!!I0(9(2'2!1U!.5dKS!'6!/2!'6(+2c4E+!()!<0+/$'2'2+!F'2/6+!7!8/M+!.5dKK;!KS;!/2&!
SS@!!!
!
CK MB!'6!90'E/0'*4!'2!</0&'/<!E#6<*+@!!I8+0+)(0+;!>8+2!4(#!'2)/0<$!$8+!E#6<*+;!4(#!>'**!6++!/!
90'E/04!'2<0+/6+!'2!</0&'/<!E#6<*+;!/2&!>8+2!$8+!E#6<*+!'6!'2)0/<$+&;!>'**!6++!/2!'2<0+/6+!'2!$8/$!
+2c4E+@!Y$/0$6!$(!=(!#9!/$!a!806@!!J+/F6!'2!H^!806;!/2&!=(2+!'2!P!&/46!LZ<!')!.5!KS!'6!90+6+2$!/)$+0!
P!&/46!&+)'2+6!R['2)/0<$'(2@!!Y(;!$8+!0+/99+/0/2<+!()!.5dKS!C!R['2)/0<$'(2@!
!
Troponin I!+*+M/$+6!/!)+>!806!+/0*'+0!$8/2!.5!KS!7!'$6!=(+6!#9!/$!/L(#$!^!806;!/2&!9+/F6!'2!/L(#$!
H^!806;!$((@!!1$!*/6$6!`!&/46;!>8'<8!'6!=((&@!!N(>+M+0;!</22($!&:!0+'2)/0<$'(2@!Y(;!/)$+0!&/4!P!
I0(9(2'2!>'**!6$'**!L+!$8+0+!/2&!$8+0+)(0+;!4(#!</22($!&:!0+'2)/0<$'(2@!!.5dKS!0+9*/<+6!X_N!
'6(+2c4E+6@!!!
!
LDH isoenzyme-!!"(0E/**4;!X_NH!'6!8'=8+0!$8/2!X_N,@!!N(>+M+0;!LDH1 is in cardiac muscle@!!!
Y(;!>8+2!4(#!8/M+!/2!'2)/0<$;!4(#!0+*+/6+!X_N,;!/2&!,!L+<(E+6!8'=8+0!$8/2!H!7!>8'<8!'6!</**+&!$8+!
)*'9@!!g8+2!4(#!'2)/0<$!$80(#=8!$8+!E#6<*+;!,!>'**!L+!8'=8+0!$8/2!H;!/2&!$8/$!'6!$8+!)*'9@!!I8'6!(<<#06!
'2!/L(#$!,t!8(#06!/2&!9+/F6!'2!/L(#$!P!&/46!/2&!*/6$!)(0!/!>++F@!!K(6$!()!$8+!$'E+;!>+!#6+!X_N!
+2c4E+6!')!$8+!9$!</E+!'2!HdP!&/46!/)$+0!64E9$(E6!/2&!.5dKS!>'**!8/M+!L++2!=(2+!L4!$8+2@!!I8+2;!
*((F!/$!X_N!'6(+2c4E+6;!/2&!0+<(=2'c+!$8/$!$8+0+!'6!/!)*'9!/2&!0+/*'c+!$8/$!$8+0+!>/6!/2!K1!)+>!&/46!
/=(@!!I8'6!>'**!L+!0+9*/<+&!L4!I0(9(2'2!,!LZ<!'$6!+*+M/$+&!&#0'2=!$8'6!$'E+!9+0'(&@!
!
VIII. Valvular Heart Disease
A. Mitral Valve Prolapse!7!K.!E'$0/*!M/*M+!*+6'(2!7!E(0+!<(EE(2!'2!>(E+2U!$((!E#<8!M/*M+!
/2&!*((F6!*'F+!/!9/0/<8#$+!?/'0!=(+6!#2&+0!/!9/0/<8#$+!/2&!)'**6!'$!#9!7!6/E+!>'$8!L*((&B!7!L*((&!>'**!
132

90(*/96+!'2$(!*+)$!/$0'#E;!/2&!>8+2!'$!6$(96;!'$!</#6+6!/!<*'<F@!!J0(*/96+!E+/26!$8/$!6(E+$8'2=!'6!
<(E'2=!(#$!7!'+!0+<$/*!90(*/96+@!
!
Y(;!>'$8!E'$0/*!M/*M+!90(*/96+;!'$!'6!+:$+2&'2=!'2$(!$8+!*+)$!/$0'#E@!!g8+2!'$!6$(96;!/2&!</22($!=(!'2!
/24E(0+;!'$!6$(96!/2&!</#6+6!/!<*'<F;!/2&!'$!)(**(>+&!L4!/!68(0$!E'$0/*!0+=#0=!E#0E#0@!!Y(;!'$!=(+6!
i<*'<F!E#0E#0;!<*'<F!E#0E#0j!?2($!i62/9!E#0E#0j!7!(9+2'2=!62/96!(<<#0!'2!E'$0/*!/2&!$0'<#69'&!
6$+2(6'6B@!!g8/$!'6!$8+!9/$8(*(=4n!K4:(E/$(#6!&+=+2+0/$'(2@!!g8/$!l%l!E/F+6!#9!$8+!M/*M+n!
_+0E/$/2!6#*)/$+;!$8+0+)(0+!'$6!/2!+:<+66!()!&+0E/$/2!6#*)/$+!'2!$8+!E'$0/*!M/*M+;!/2&!'$!L+<(E+6!
0+&#2&/2$!?$((!E#<8!()!'$B;!L*((&!=(+6!#2&+0!'$!/2&!</#6+6!/!<*'<F!/2&!E#0E#0@!!16!'$!<*(6+0!$(!Y,!(0!
YHn!1$!&+/*6!>'$8!90+*(/&@!!1)!>+!'2<0+/6+&!M(*!()!L*((&!'2!$8+!*+)$!M+2$0'<*+;!$8+2!$8+!<*'<F!/2&!
E#0E#0!>'**!<(E+!<*(6+0!$(!YH!LZ<!'$!$/F+6!*(2=+0!)(0!/**!$8+!+M+2$6!$(!=+$!L*((&!(#$@!!1)!>+!&+<0+/6+!
$8+!/E(#2$!()!L*((&!<(E'2=!'2$(!$8+!*+)$!M+2$0'<*+!?&+<0+/6+!90+*(/&B;!$8+!<*'<F!/2&!E#0E#0!<(E+!
<*(6+0!$(!Y,@!!Y(;!>8+2!6$/2&'2=!/2&!8/M+!KkJ;!>8/$!'6!90+*(/&!M6@!*4'2=!&(>2n!1$!'6!*+66@!!X+66!
90+*(/&!C!*+66!L*((&!'2!$8+!M+2$0'<*+!C!<*'<F!/2&!E#0E#0!<*(6+0!$(!Y,@!!"(>;!*+$Q6!6/4!9$!*'+6!&(>2!7!
<*'<F!/2&!E#0E#0!<*(6+0!$(!YH!LZ<!'2<0+/6'2=!90+*(/&@!!I8+4!>'**!/6F-!>8/$!>'**!8/99+2!$(!<*'<F!/2&!
E#0E#0!>'$8!/2:'+$4n!g8/$!>'**!8/99+2!$(!8+/0$!0/$+!>'$8!/2:'+$4n!12<0+/6+@!I8+0+)(0+;!>'**!8/M+!
*+66!$'E+!$(!)'**!M+2$0'<*+6;!$8+0+)(0+!>'**!<(E+!<*(6+0!$(!Y,@!
!
!
p#+6$(2!(2!+:/E'2/$'(26!i!%E+0'</2!$(#0'6$!</E+!L/<F!>'$8!&'/008+/A!/26>+0!'6!='/0&'6'6j!!
!
!
B. Aortic Stenosis
K.!M/*M#*/0!</#6+!()!642<(9+!>'$8!+:+0<'6+!
K..!/2='2/!>'$8!+:+0<'6+@!
K..!E'<0(/2='(9/$8'<!8+E(*4$'<!/2+E'/!
!
I8'6!>'**!/2!+3+<$'(2!E#0E#0;!0'=8$!H2&!1.Y;!0/&'/$'(2!'2$(!$8+!2+<F;!646$(*'<;!'2<0+/6+6!'2!'2$+26'$4!(2!
+:9'0/$'(2@!!12$+26'$4!()!E#0E#0!>'$8!&'))+0+2$!9(6'$'(26-!>8/$!>'**!'2<0+/6+!$8+!'2$+26'$4!()!$8+!
E#0E#0!?>8/$!>'**!E/F+!'$!>(06+!/2&!$8+0+)(0+!*(#&+0Bn!12<0+/6'2=!90+*(/&!'2!$8+!M+2$0'<*+@!!g'$8!
&+<0+/6+&!L*((&!'2!$8+!M+2$0'<*+;!'$!>'**!&+<0+/6+!$8+!'2$+26'$4!()!$8+!+3+<$'(2!E#0E#0!LZ<!'$!8/6!$(!
=(!(#$!$8+!6$+2($'<!M/*M+@!!!
1)!4(#!/0+!9#$$'2=!E(0+!L*((&!'2$(!$8+!Xk!/2&!2++&!$(!=+$!'$!(#$;!'$!>'**!'2<0+/6+!$8+!'2$+26'$4!d!$8'6!'6!
'E9!LZ<!'$!&'))+0+2$'/$+6!'$!)0(E!849+0$0(98'<!</0&'(E4(9/$84@!!!
!
g84!&(!$8+4!=+$!/2='2/!>'$8!+:+0<'6+n!J#*6+!'6!&'E'2'68+&!/2&!$8+0+)(0+!$8+!6$0(F+!M(*#E+!>'**!
&+<0+/6+@!!Y(;!>8+2!&(!$8+!<(0(2/04!!/0$+0'+6!)'**!#9n!_'/6$(*+@!!g'$8!*+66!L*((&!$8+0+!?LZ<!<(#*&2Q$!
=+$!'$!(#$!/2&!8/&!$(!=+$!'$!$80(#=8!$8+!M/*M+B;!$8+0+!'6!$8'<F+2+&!E#6<*+!/2&!*+66!L*((&!=('2=!$(!$8+!
8+/0$;!*+/&'2=!$(!/2='2/@!!Y(;!$8'6!'6!$8+!K.!M/*M#*/0!*+6'(2!*+/&'2=!$(!/2='2/@!!%*6(;!>'$8!642<(9+!
>'$8!+:+0<'6+;!LZ<!4(#!8/M+!&+<0+/6+&!</0&'/<!(#$9#$;!4(#!>'**!)/'2$@!
!
C. Mitral stenosis
Y*'&+-!!I80(EL';!*+)$!/$0'#E!'6!&'*/$+&U!murmur in diastole!?6$+2(6'6!90(L!'2!(9+2'2=!/2&!$8'6!M/*M+!
(9+26!'2!&'/6$(*+;!*+/&'2=!$(!62/9!/2&!0#EL*+B;!8+/0&!/$!/9+:!/2&!'2<0+/6+6!'2!'2$+26'$4!(2!
+:9'0/$'(2@!!!
MCC mitral stenosis rheumatic fever (acute)@!!R8+#E/$'<!)+M+0!dM+=+$/$'(26U!&#+!$(!=0(#9!%!
L+$/!8+E(*4$'<!6$0+9$(<(<</*!'2)+<$'(2@!!\6#/**4!(<<#06!/6!9(6$d98/042='$'6@!!%6!(99(6+&!$(!9(6$!
6$0+9$(<(<</*!=*(E+0#*(2+980'$'6;!$8'6!</2!L+!98/042='$'6!(0!/!6F'2!'2)+<$'(2@!!K(6$!()!$'E+!08+#E/$'<!
)+M+0!'6!)0(E!/!90+M'(#6!$(26'**'$'6@!!g8+2!4(#!<#*$#0+!L*((&!'2!9$6!>'$8!08+#E/$'<!)+M+0;!'$!>'**!L+!
133

2+=/$'M+@!!g'**!2($!L+!/L*+!$(!=0(>!$8+!(0=/2'6E6!LZ<!'$6!2($!/2!'2)+<$'M+!+2&(</0&'$'6@!!1$!'6!/2!
'EE#2(*(='<!E+<8/2'6E@!!With strep, M protein is the pathogenic factor for group A strep@!!
.+0$/'2!6$0/'26!8/M+!%=Q6!6'E'*/0!$(!$8+!8+/0$!/2&!3('2$6@!!Y(;!>8+2!>+!E/F+!%LQ6!/=/'26$!$8+!=0(#9!
%!6$0+9;!>+!/0+!/*6(!E/F'2=!%=Q6!/=/'26$!$8+!8+/0$!?(#0!(>2!$'66#+B!7!$8+0+)(0+!>+!/$$/<F!(#0!(>2!
8+/0$;!3('2$6;!L/6/*!=/2=*'/!/2&!+*6+>8+0+@!!I8'6!'6!</**+&!mimicry!LZ<!>+!/0+!&+M+*(9'2=!%LQ6!
/=/'26$!(#0!(>2!$'66#+;!LZ<!$8+0+!/0+!6'E'*/0!%=Q6!'2!$8+!K!90($+'2!()!$8+!L/<$+0'/;!so its is all
immunologicm!!K.!M/*M+!'2M(*M+&!'6!$8+!E'$0/*!M/*M+@!!I8+!M+=+$/$'(26!/0+!6$+0'*+!/2&!*'2+!/*(2=!$8+!
<*(6#0+!()!$8+!M/*M+@!I8+!M+=+$/$'(26!#6#/**4!&(!2($!+EL(*'c+@!!Know Jones criteria for dx of
acute rheumatic!fever!7!'+!4(#2=!9+06(2;!)+>!>++F6!/=(!8/&!/2!+:#&/$'M+!$(26'**'$'6;!2(>!
90+6+2$6!>'$8!3('2$!9/'2!/2&!6>+**'2=!/2&!&4692+/;!0/*+6!'2!$8+!*#2=;!9/2646$(*'<!E#0E#0;!/9+:;!/2&!
'2<0+/6+6!'2!'2$+26'$4!(2!+:9'0/$'(2;!YP!/2&!Y^!8+/0$!6(#2&!7!&#+!$(!/<#$+!08+#E/$'<!)+M+0@!!_:!'6!
08+#E/$'<!)+M+0@!!MC symptom is polyarthritis@!!I8+4!*'F+!$8'6!D#+6$'(2!LZ<!'2!<8'*&0+2;!$8+0+!'6!/!
*'E'$+&!d/d for polyarthritis it includes juvenile rheumatic arthritis, Henoch Schonlein
purpura, rubella, acute rheumatic fever. However, none of these have symptoms of
heart failure and mitral insufficiency except for acute rheumatic!fever.!!Y(;!')!$8+4!/6F!4(#!
$8+!K.!M/*M#*/0!*+6'(2!'2!/<#$+!08+#E/$'<!)+M+0;!'$!'6!"GI!E'$0/*!6$+2(6'6@!!1$!$/F+6!,V!4+/06!$(!8/M+!
/!6$+2($'<!M/*M+!?E'$0/*!6$+2(6'6B@!!Y(;!$8+!E#0E#0!$8/$!4(#!8+/0!'6!E'$0/*!R[l\Rl;!LZ<!/**!9/0$6!()!
$8+!8+/0$!/0+!'2)*/E+&;!*+/&'2=!$(!)0'<$'(2!0#L;!E4(</0&'$'6!?'2)*/E+&!E4(</0&'#EB;!/2&!+2&(</0&'$'6!
?$8+6+!/0+!$8+!M/*M+6!>'$8!$8+!M+=+$/$'(26B@!!Y(;!>'**!=+$!E'$0/*!0+=#0=!E#0E#0!>'$8!/<#$+!08+#E/$'<!
)+M+0@!!G$8+0!)+/$#0+6!()!f(2+6!<0'$+0'/-!3('2$6;!</0&'/<!/L2(0E/*'$'+6;!+04$8+E/!E/0='2/$#E!?6F'2!
c'$B;!6#L<#$/2+(#6!2(&#*+6!?*'F+!08+#E/$'<!2(&#*+6!(2!$8+!+:$+26(0!6#0)/<+6!7!$8+4!/0+!+:/<$*4!$8+!
6/E+B@!!R8!2(&#*+6!/2&!2(&#*+6!/66(<'/$+&!>'$8!/<#$+!08+#E/$'<!)+M+0!/0+!+:/<$*4!$8+!6/E+@!!I8+4!
/0+!L($8!'EE#2(*(='<!&cQ6@!X/$+!E/2')+6$/$'(2!()!f(2+6Q!<0'$+0'/!'6!/L2(0E/*!E(M+E+2$6!7!</**+&!
Y42&8/EQ6!<8(0+/@!![:/E9*+-!9$!>'$8!/<#$+!08+#E/$'<!)+M+0!?=0/&+!P;!9/2646$(*'<;!/9+:;!0/*+6;!YP!
/2&!Y^;!2(&#*+6;!+04$8+E/!E/0='2/$#EB!d!a!>++F6!*/$+0!8/M+!Y42&8/EQ6!<8(0+/@!!ASO titer is
imp, too b/c its a group A strep infection and its elevated. %6<8())!2(&#*+6!7!0+/<$'M+!
8'6$'(<4$+6!'2!$8+!E4(</0&'#EU!(2*4!)'2&!>'$8!L:!(2!&+/$8@!!Y#EE/04-!'EE#2(*(='<!&c;!>'**!2($!
<#*$#0+!(#$!=0(#9!%!6$0+9!'2!$8+!L*((&;!f(2+6!<0'$+0'/!?9(*4/0$80'$'6;!K.!</0&'$'6;!6#L<#$/2+(#6!
2(&#*+6;!+04$8+E/!E/0='2/$#E;!Y42&8/EQ6!<8(0+/@!!!
1+!E'$0/*!6$+2(6'6;!*((F'2=!)0(E!*+)$!/$0'#E;!&(>2!$(!$8+!M+2$0'<*+!7!*((F6!*'F+!/!)'68E(#$8!?)'68E(#$8!
/99+/0/2<+B@!!!
!
[:/E9*+-!>8/$!'6!$8+!E(6$!9(6$+0'(0*4!*(</$+&!<8/EL+0!()!4(#!8+/0$n!X+)$!/$0'#E@!!Y++2!L+6$!(2!
$0/26+6(98/=+/*!#*$0/6(#2&@!!SZ<!'$!'6!9(6$+0'(0*4!*(</$+&;!/2&!+2*/0=+&!>8+2!&'*/$+&;!'$!</2!90+66!(2!
$8+!+6(98/=#6;!*+/&'2=!$(!&6498/='/!>'$8!6(*'&6!?2($!*'D#'&6B@!!%*6(;!'$!</2!6$0+$<8!$8+!*+)$!0+<#00+2$!
*/042=+/*!2+0M+!/2&!</#6+!8(/06+2+66@!!I8'6!'6!</**+&!Orners syndrome@!!!
!
[:/E9*+-!')!$8+4!8/M+!/2!'00+=#*/0!'00+=#*/0!9#*6+;!>8/$!&(+6!$8/$!E+/2n!Atrial fibrillation@!!_(+6!
'$!6#090'6+!4(#!$8/$!$8+4!=+$!$80(EL#6!'2!$8+!*+)$!/$0'#En!"(@!!SZ<!$8+0+!'6!/!*($!()!6$/6'6!LZ<!L*((&!'6!
8/M'2=!$0(#L*+!=+$$'2=!$80(#=8;!*+/&'2=!$(!6$/6'6!/2&!$80(EL(6+6@!!Y(;!8/M+!$(!/2$'<(/=#*/$+!$8+!
9$6;!>8'<8!'6!/!L/&!<(EL(@!!!
%$0'/*!)'L!O!$80(EL#6!C!L/&!<(EL(@!!g8+2!4(#!9'<$#0+!%!)'L;!'$6!*'F+!/!M'L0/$(0!/2&!*'*!<8'96!</2!
<(E+!())!/2&!+EL(*'c+!7!$8'6!'6!M+04!<(EE(2!'2!9/$'+2$6!>'$8!K1IR%X!YI["GY1Y@!!!
!
MVP!7!M/*M+!'6!L+'2=!90(*/96+&!'2$(!/$0'#E;!LZ<!'$!'6!6(!0+&#2&/2$;!/2&;!<8(0&/+!$+2&'2/+!>'**!
0#9$#0+;!*+/&'2=!$(!/<#$+!E'$0/*!'26#))'<'+2<4@!!I8'6!'6!2($!<(EE(2!'2!KkJ!7!E(6$!()!$8+!$'E+!'$!'6!
/64E9$(E/$'<@!!K.!64E9$(E/$'<!$8'2=!C!9/*9'$/$'(26@!
2 genetic dzs with MVP assoc: Marfans and Ehler Danlos syndrome. K/0)/2!9$!/2&!9$!
&'+&!6#&&+2*4;!>84n!"GI!&'66+<$'2=!/(0$'<!/2+#046E!?&(!2($!&'+!'EE+&'/$+*4!>'$8!&'66+<$'(26!7!=+$!
134

9/'2;!0/&'/$'(2!/2&!</0&'/<!$/E9(2/&+B!7!/26>+0!'6!KkJ!/2&!<(2&#<$'(2!&+)+<$6@!!Y(;!pt with
marfan and dies suddenly, this is due to MVP and conduction defects (not dissecting
aortic aneurysm).!
!
Tricuspid regurg!7!F2(>!/L(#$!1k_%!>'$8!'2)+<$'M+!+2&(</0&'$'6@!!!
!
Carcinoid syndrome!7!'2!(0&+0!$(!8/M+!</0<'2('&!642&0(E+;!E#6$!8/M+!E+$/66'6!$(!*'M+0!()!
</0<'2('&!$#E(0@!!Y+0($(2'2!/2&!$8+!$#E(0!2(&#*+6!=+$6!'2$(!8+9/$'<!M+'2!$0'L#$/0'+6!/2&!=+$6!'2$(!
$8+!M+2(#6!L*((&!/2&!L/$8+6!$8+!0'=8$!6'&+!()!$8+!8+/0$;!/2&!6+0($(2'2!90(&#<+6!/!)'L0(#6!$'66#+!
0+69(26+!()!$8+!M/*M+6@!Y(;!>'**!=+$!$0'<#69'&!'26#))!/2&!9#*E(2'<!6$+2(6'6@!I8+6+!/0+!$8+!H!M/*M#*/0!
*+6'(26!/66(<!>'$8!</0<'2('&!642&0(E+@!?I1JYB!
!
IX. Infective endocarditis !
K'$0/*!M/*M+!>'$8!M+=+$/$'(26!/2&!0#9$#0+!<8(0&/+!$+2&'2/+U!M+=+$/$'(26!/0+!L'=!/2&!L#*F4!/2&!
&+6$0(4'2=!$8+!M/*M+!?8+2<+;!'2)+<$'M+B@!!!
g8/$!'6!MCC? Strep viridians; 2nd MCC = Staph!
g8'*+!L0#68'2=!$++$8;!8/M+!/!$0/26'+2$!6$0+9!M'0'&'/26!'2)+<$'(2@!!1)!4(#!8/M+!/2!#2&+0*4'2=!</0&'/<!
&c;!$8+2!4(#!0#2!$8+!0'6F!()!&+M+*(9'2=!/!L/<$+0'/*!+2&(</0&'$'6!LZ<!3#6$!L0#68'2=!4(#0!$++$8!</2!
</#6+!'$!$(!=+$!'2$(!$8+!L*((&6$0+/EU!>'$8!&/E/=+&!M/*M+6;!'$!</2!6++&!'2$(!'$!/2&!90(&#<+!
M+=+$/$'(26@!
Y$/98!/#0+#6!</2!/))+<$!/!"GRK%X!M/*M+!GR!/!&/E/=+&!M/*M+@!!!
K.!M/*M+!'2M(*M+&!'2!'2)+<$'M+!+2&(</0&'$'6!C!E'$0/*!M/*M+U!H2&!K.!M/*M+!C!/(0$'<!M/*M+!
1)!4(#!/0+!/2!1k_%!?>8(!'23+<$!'2$(!M+'26B;!K.!M/*M+!'2M(*M+&!C!I0'<#69'&!M/*M+;!H2&!K.!'6!/(0$'<!!
Tricuspid involved!C!K#0E#0!()!$0'<#69'&!0+=#0=;!9/2646$(*'<;!'2<0+/6+&!(2!'269'0/$'(2!!
Aortic valve involved-!/(0$'<!0+=#0=;!8'=8!9'$<8+&!&'/6$(*'<!/)$+0!YH!
Y$/98!'6!s,!!?K..B!)(0!1k_%!
1)!4(#!8/M+!colon cancer/ulcerative colitis!?/24!$49+!()!#*<+0/$'(2!()!$8+!<(*(2'<!E#<(6/B;!$8+0+!
'6!/!#2'D#+!$49+!()!'2)+<$'M+!+2&(</0&'$'6!7!$8'6!'6!strep bovis C!group D strep commonly
involved with dzs that produce ulceration of the colonic mucosa ie UC or colon cancer.
History of colon cancer and have infective endo organism is strep bovis (not staph).
%(0$'<!M/*M+!7!<*(6+!0+*/$'(268'9!()!E+EL0/2(#6!9(0$'(2!()!$8+!6+9$#E!>'$8!$8+!/(0$'<!M/*M+@!!Y(;!
>84!&'&!9$!=+$!M+=+$/$'(26!()!$8+!/(0$'<!M/*M+n!SZ<!$8+4!=($!kY_!$8/$!>/6!2($!9'<F+&!#9@!!1)!4(#!
8/M+!<(2=+2'$/*!8+/0$!&c;!4(#!8/M+!/2!'2<0+/6+&!0'6F!)(0!'2)+<$'M+!+2&(</0&'$'6@!!kY_!$8/$!6(E+(2+!
&'&!2($!9'<F!#9!</#6+&!/(0$'<!M/*M+!$(!=+$!'2)+<$'M+!/2&!</#6+!/(0$'<!0+=#0=@!!I8+0+)(0+;!(2!$8+!$+6$;!
>'**!L+!E'$0/*!M/*M+!'2)+<$'M+!+2&(;!(0!/(0$'<!'2)+<$'M+!+2&(!>'$8!/!kY_@!!!
Y9*'2$+0!8+E(008/=+6U!J/'2)#*!C!(6*+0Q6!2(&+6U!9/'2*+66!C!3/2+>/4!*+6'(2U!'2!+4+!7!R($8!69($!?0+&!
>'$8!>8'$+!<+2$+0!7!3#6$!*'F+!5(9*'F!69($6!'2!E+/6*+6;!>8'<8!/0+!0+&!>'$8!/!>8'$+!<+2$+0B@!!I8'6!'6!>84!
'$!'6!</**+&!$8+!5(9*'F!69($!()!$8+!+4+@!!g8/$!&(!$8+4!/**!8/M+!'2!<(EE(2!?/6'&+!)0(E!$8+!)/<$!$8/$!
$8+4!/0+!6++2!'2!'2)+<$'M+!+2&(</0&'$'6Bn!!Y9*'2$+0!8+E(008/=+6;!G6*+0Q6!2(&+6;!3/2+>/4!*+6'(26;!R($8!
69($6;!/2&!=*(E+0#*(2+980'$'6n!All are type III HPY@!!%**!$8+6+!*+6'(26!/0+!'EE#2+!<(E9*+:!
M/6<#*'$'6@!!!
k+=+$/$'(26!/**!(M+0!6#0)/<+!()!$8+!M/*M+!/2&!9$!8/6!/!iOj!6+0#E!%"%!7!&:n!!Libman sacs
endocarditis pt has Lupus!?X'LE/2!6/<6!'6!2($!$8+!K.!*+6'(2!()!$8+!8+/0$!>'$8!X#9#6!7!
9+0'</0&'$'6!'6BU!X'LE/2!6/<6!'6!$8+!H2&!K..;!>8'<8!'6!)'L0'2('&!2+<0(6'6!*'F+!08+#E/$'<!)+M+0@!!!
K/0/2$'<!M+=+$/$'(26!'2!E#<(#6!6+<0+$'2=!<(*(2!</2<+0!C!J/0/2+(9*/6$'<!642&0(E+!?'$!'6!E/0/2$'<!
+2&(</0&'$'6!'2!/!9$!>'$8!<(*(2!</2<+0B@!!%<#$+!08+#E/$'<!)+M+0!*((F6!*'F+!'$@!
X. Myocarditis vs. Pericarditis
G2!$8+!$+6$;!')!4(#!8/M+!/2!'2)+<$'(2!D#+6$'(2;!'$!'6!Coxsackie virus.!
K..!()!E4(</0&'$'6!/2&!9+0'</0&'$'6U!!
135

K..!M'0/*!E+2'2='$'6!C!.(:6/<F'+!M'0#6@!!!
./#6+!()!8/2&;!)(($!/2&!E(#$8!&cn!.(:6/<F'+!M'0#6!
N+09/2='2/!'6!&#+!$(!.(:6/<F'+Q6!M'0#6@!!!
[:/E9*+-!J$!>'$8!8+/0$!)/'*#0+!&'&!/2!+2&(E4(</0&'/*!L:!/2&!'$!8/&!*4E98(<4$'<!'2)'*$0/$+!'2!$8+0+;!
/2&!'$!>/6!&#+!$(!.(:6/<F'+Q6!E4(</0&'$'6@!!I(!&:;!2++&!$(!&(!/!L:!()!6#L+2&(</0&'/*!$'66#+;!/2&!>'**!
6++!*4E98(<4$'<!'2)'*$0/$+!?/6!+:9+<$+&!>'$8!%"b!M'0#6B@!!I8+0+)(0+;!'+;!9$!'2!8+/0$!)/'*#0+;!L:!()!
E4(</0&'#E!8/6!*4E98(<4$+6!C!.(:6/<F'+Q6!M'0#6!E4(</0&'$'6!
!
.8+6$!:d0/4!7!6++!>/$+0!L($$*+!<(2)'=!7!$8'6!9$!/6!E#))*+&!8+/0$!6(#2&6!?</22($!8+/0!/24$8'2=B;!
>8+2!$8+!9$!L0+/$86!'2;!2+<F!M+'26!&'6$+2&!?68(#*&2Q$!8/99+2!LZ<!>8+2!4(#!L0+/$8!'2!/2&!'2<0+/6+!
2+=!'2$0/$8(0/<'<!90+66#0+;!$8+!2+<F!M+'26!68(#*&!<(**/96+!(2!'269'0/$'(2B;!0/&'/*!9#*6+!'6!&+<0+/6+&!
(2!'269'0/$'(2;!>8+2!4(#!$/F+!SJ!$8+0+!'6!/!&0(9!()!,VEEN=!&#0'2=!'269'0/$'(2@!_:n!Pericardial
effusion!
g8/$!$8+!2/E+!()!$8+!$0'/&n!S+<FQ6!$0'/&@!!g8/$!'6!$8+!2/E+!()!$8+!6'=2n!Kussmauls sign@!g8/$!'6!
$8+!&0(9!()!,V!EE!NL!(2!'269'0/$'(2n!Pulsus paradoxus.!!N(>!&(+6!/**!$8'6!(<<#0n!SZ<!$8+0+!'6!/2!
+))#6'(2!()!$8+!9+0'</0&'/*!6/<;!E+/2'2=!$8/$!$8/$!8+/0$!</22($!)'**!#9!?LZ<!$8+0+!'6!)*#'&!/0(#2&!'$B!7!
*+/&'2=!$(!E#))*+&!8+/0$!6(#2&6@!!Y(;!>8+2!4(#!L0+/$8!'2!/2&!L*((&!'6!6#99(6+&!$(!=+$!'2$(!$8+!0'=8$!
6'&+!()!4(#0!8+/0$;!'$!</22($!+:9/2&@!!Y(;!$8+!2+<F!M+'26!&'6$+2&!'26$+/&!()!<(**/96+;!>8'<8!'6!</**+&!
5#66E/#*Q6!6'=2@!!g8/$!+M+0!8/99+26!$(!0'=8$!6'&+!()!$8+!8+/0$!/))+<$6!$8+!*+)$!6'&+!()!$8+!8+/0$!LZ<!
$8+!*+)$!6'&+!0+<+'M+!L*((&!)0(E!$8+!0'=8$!6'&+@!Y(;!$8+0+!'6!2(!L*((&!=('2=!'2$(!$8+!0'=8$!8+/0$;!/2&!
$8+0+)(0+;!2(!L*((&!'6!=('2=!(#$!()!$8+!*+)$!8+/0$;!+'$8+0@!!Y(;!(2!'269'0/$'(2;!L*((&!</22($!=+$!(#$!()!
*+)$!6'&+!?LZ<!L*((&!'6!2($!<(E'2=!(#$!()!$8+!0'=8$!8+/0$B;!*+/&'2=!$(!/!&0(9!'2!9#*6+!7!hence pulsus
paradoxus@!!%*>/46!6++!$8+6+!$8'2=6!$(=+$8+0-!2+<F!M+'2!&'6$+26'(2;!&0(9!'2!9#*6+!E/=2'$#&+;!/2&!
&0(9!'2!SJ;!5#66E/#*Q6!6'=2;!9#*6#6!9/0/&(:#6!C!pericardial effusion@!!N(>+M+0;!$8'6!'6!2($!>8/$!
$8+4!>'**!/6F!4(#!7!$8+4!>'**!/6F!>8/$!is first step in management? Echocardiogram!7!68(>6!
$8/$!$8+4!8/M+!)*#'&!?90(M+6!'$!7!LZ<!2++&!$(!</**!6#0=+(2!$(!&(!9+0'</0&'(<+2$+6'6B@!
g8/$!is it MC due to? Pericarditis. What is the MCC pericarditis? Coxsackie.
!
g8/$!')!>(E/2!8/6!$8'6!/2&!/!iOj!6+0#E!%"%n!X#9#6@!
%24!4(#2=!>(E/2!$8/$!8/6!/2!#2+:9*/'2+&!9+0'</0&'/*!(0!9*+#0/*!+))#6'(2!'6!*#9#6!#2$'*!90(M+2!
($8+0>'6+@!!g84n!Y+0(6'$'6!C!'2)*/E+!6+0(6/*!E+EL0/2+6!7!'$6!=(22/!*+/F!)*#'&;!*+/&'2=!$(!+))#6'(26@!
%2&!'6!/!)+/$#0+!()!X#9#6@!
E. Constrictive pericarditis
12!$8'0&!>(0*&!<(#2$0'+6;!IS!'6!K.@!!12!\Y%;!&#+!$(!90+M'(#6!</0&'/<!6#0=+04!LZ<!8/M+!$(!=(!$80(#=8!
9+0'</0&'#E@!!Y*'&+!()!/!8+/0$!/2&!$8'<F+2+&!9+0'</0&'#E;!2(!)*#'&;!6(!>8+2!4(#!L0+/$8+!'2!L*((&!
=(+6!$(!0'=8$!8+/0$;!)'**6!#9!/2&!8'$6!>/**!7!</**+&!pericardial knock!7!$8+0+)(0+!to differentiate
pericardial effusion from constrictive pericarditis, have muffled heart sounds in effusion
with no knock in pericardial effusion, and in have some filling up with a pericardial
knock in constrictive pericarditis. g8'$+!6$#))!'2!9+0'</0&'#E!'6!&46$0(98'<!</*<')'</$'(2;!/2&!</2!
6++!'$!(2!:d0/4@!!J$!=(+6!$(!R#66'/!/2&!=+$6!&'/008+/!C!='/0&'/6'6B!
!
!
XI. Cardiomyopathies
X/0=+!*+)$!M+2$0'<*+!/2&!0'=8$!M+2$0'<*+!
!
A.!!Congestive cardiomyopathy (aka dilated cardiomyopathy)!7![:/E9*+-!>(E/2!a!>++F6!
9(6$9/0$#E;!/2&!&(!/!<8+6$!:d0/4!/2&!68+!8/6!/!=+2+0/*'c+&!</0&'(E+=/*4!7!8+/0$!'6!8#=+;!8/6!
+))#6'(26!/$!L($8!*#2=!L/6+6!7!&:n!.(2=+6$'M+!</0&'(E4(9/$84U!$8'6!'6!/!&c!()!$8+!</0&'/<!E#6<*+!
/2&!8/6!E/24!</#6+6@!!J$!8/6!L($8!*+)$!/2&!0'=8$!8+/0$!)/'*#0+@!!./#6+6-!a!>++F6!9(6$9/0$#E!?&(2Q$!
136

F2(>!>84B;!.(:6/<F'+Q6!E4(</0&'$'6;!/*<(8(*;!&0#=6U!K..!$0/269*/2$6!'6!&#+!$(!<(2=+6$'M+!
</0&'(E4(9/$84@!!./0&'($(:'<!&0#=6!7!&/#2(0#L'<'2;!$0'<4<*'<6!C!&0#=!'2&#<+&!</0&'(E4(9/$8'+6!C!
<(2=+6$'M+!</0&'(E4(9/$84@!!%*<(8(*'<!>'$8!L'=!8+/0$!&#+!$(!$8'/E'2+!&+)!C!<(2=+6$'M+!
</0&'(E4(9/$84@!!!
!
B. Hypertrophic cardiomyopathy
K..!6#&&+2!&+/$8!'2!/!4(#2=!/$8*+$+!C!hypertrophic cardiomyopathy.!!I8'<F2+66!()!6+9$#E!
M+04!$8'<F!>'$8!/2!/64EE+$0'<!NJbU!>84n!SZ<!$8+!'2$+0M+2$0'<#*/0!6+9$#E!'6!$8'<F+0@!!S*((&!)*(>!()!
*+)$!M+2$!7!=(+6!$80(#=8!2/00(>!(9+2'2=!?/2$!*+/)*+$!()!E'$0/*!M/*M+!7!6(;!')!4(#!8/M+!/(0$'<!0+=#0=;!
L*((&!>'**!8'$!/2$+0'(0!*+/)*+$!()!E'$0/*!M/*M+!/2&!90(&#<+!%#6$'2!)*'2$!E#0E#0B@!!g84!'6!$8'6!/!2/00(>!
(9+2'2=n!SZ<!'$!'6!$((!$8'<F@!1)!>+!$((F!/!*/6+0!$(!L#02!'$!());!<(#*&!(9+2!'$!#9U!6(;!>8+0+!'6!$8+!
(L6$0#<$'(2!'2!849+0$0(98'<!</0&'(E4(9/$84n!!1$6!2($!/$!$8+!*+M+*!()!$8+!/(0$'<!M/*M+;!L#$!L+*(>!'$@!!
g84!&(+6!'$!(L6$0#<$n!!k+2$#0'!98+2(E+2(2!7!$8'2=6!=(!$80(#=8!/!2/00(>!(9+2'2=!D#'<F*4!/2&!$8+0+!
'6!/!2+=/$'M+!90+66#0+!L+8'2&!'$@!!g8+2!L*((&;!#2&+0!'2<0+/6+&!)(0<+!()!<(2$0/<$'(2!'6!)(0<+&!
$80(#=8;!$8+!2+=/$'M+!90+66#0+!L+8'2&!'$!6#<F6!$8+!/2$+0'(0!*+/)*+$!L+8'2&!$8+!6+9$#E!/2&!6$(96!$8+!
L*((&;!*+/&'2=!$(!(L6$0#<$'(2!()!L*((&!)*(>@!!g8/$!</2!>+!&(!$(!E/F+!$8'6!L+$$+0!?>8/$!</2!>+!&(!$(!
0+&#<+!$8+!'2$+26'$4!()!$8+!E#0E#0!/2&!8/M+!$8+!9$!8/M+!L+$$+0!.GBn!!J#$!E(0+!L*((&!'2$(!$8+!
M+2$0'<*+!7!'2<0+/6+!90+*(/&!/2&!&+<0+/6+!(L6$0#<$'(2!LZ<!'$!>(#*&!9#**!'$!/>/4!LZ<!$8+0+!'6!E(0+!
L*((&!'2!'$@!!%**!$8+6+!$8'2=6!$8/$!'2<0+/6+!90+*(/&!>'**!E/F+!$8+!'2$+26'$4!()!$8+!E#0E#0!*+66!/2&!
'E90(M+!$8+!9$@!!Y(;!')!4(#!/0+!6$/2&'2=!#9;!>'**!$8/$!'E90(M+!$8+!&cn!"(;!LZ<!>(#*&!&+<0+/6+!
90+*(/&;!*+/&'2=!$(!/!8/068!646$(*'<!E#0E#0@!!N(>+M+0;!')!*4'2=!&(>2;!$8+0+!'6!'2<0+/6+&!M+2(#6!
0+$#02!$(!$8+!0'=8$!8+/0$;!/2&!'2<0+/6+&!L*((&!'2!$8+!M+2$;!$8'6!>(#*&!&+<0+/6+!'2$+26'$4!()!E#0E#0@!!
_'='$/*'6!>(#*&!L+!<(2$0/'2&'</$+&!LZ<!'$!>(#*&!'2<0+/6+!)(0<+!()!<(2$0/<$'(2;!E/F+!'$!=(!)/6$+0!/2&!
E/F+!'$!(L6$0#<$!D#'<F+0@!!%!L+$/!L*(<F+0!>(#*&!L+!=((&U!./!<8/22+*!L*(<F+0!>(#*&!/*6(!L+!=((&!LZ<!
'$!>(#*&!&+<0+/6+!)(0<+!()!<(2$0/<$'(2;!6*(>!$8+!8+/0$!0/$+;!/2&!'2<0+/6+!90+*(/&@!!I8'6!'6!K..!
6#&&+2!&+/$8!'2!/!4(#2=!/$8*+$+@!!1)!4(#!$((F!/!6+<$'(2!()!$8+!6+9$#E;!'$6!2($!/!2(0E/*!6+9$#E!7!'$6!
&'6(0=/2'c+&;!/2&!$8+!<(2&#<$'(2!L#2&*+6!/0+!E+66+&!#9;!*+/&'2=!$(!<(2&#<$'(2!&+)+<$6!d!!>'$8!
<(2&#<$'(2!&+)+<$6;!0#2!$8+!0'6F!()!k@!$/<8!/2&!&+/$8!/$!/24!$'E+@!!I8'6!/L2(0E/*!<(2&#<$'(2!646$+E!
/2&!/64EE+$0'<!6+9$#E!'6!0+69(26'L*+@!!1+!,a!4Z(!LL/**!9*/4+0!$8/$!&'+&!6#&&+2*4!7!>8/$!&(!4(#!6++!
/$!/#$(964n!N49+0$0(98'<!</0&'(E4(9/$84@!!K+<8n!%L2(0E/*!<(2&#<$'(2!!
!
C. Endocardial Fibroelastosis!?'+!()!0+6$0'<$+&!</0&'(E4(9/$84B!
1)!'$!'6!0+6$0'<$'M+;!6(E+$8'2=!'6!90+M+2$'2=!$8+!M+2$0'<*+!)0(E!)'**'2=!#9@!!I8'6!'6!$8+!K.!&c!</#6'2=!
0+6$0'<$'M+!</0&'(E4(9/$84!'2!<8'*&0+2;!/2&!'6!</**+&!+2&(</0&'/*!T'L0(+*/6$(6'6@!!I8'6!&c!'6!$8+!K.!
0+/6(2!>84!/!<8'*&!2++&6!/!8+/0$!$0/269*/2$@!!1)!$8+!<8'*&!&(+6!2($!=+$!/!$0/269*/2$;!$8+4!>'**!&'+@!!!
G$8+0!</#6+6!()!0+6$0'<$'M+!</0&'(E4(9/$84!7!J(E9+Q6;!T+!(M+0*(/&;!/E4*('&@!
!
D. Cardiac myxoma
teW!'2!$8+!*+)$!/$0'#E;!,eW!'2!0'=8$!
Sr;!E(M/L*+!7!</2!E(M+!(M+0!/2&!L*(<F!(0')'<+!()!E'$0/*!M/*M+;!*+/&'2=!$(!642<(9+@!!I8+4!</2!
+EL(*'c+!?$8+4!/0+!M+04!6()$!/2&!8/M+!L'$6!/2&!9'+<+6!'26'&+!$8+EB@!!N/M+!/!*($!()!3#2F!'26'&+!$8+E;!
>8'<8!*+/F6!(#$@!!1$!</2!*+/&!$(!)+M+0;!/2&!($8+0!6'=26!/2&!64E9$(E6@!!Y42<(9+!</22($!)'=#0+!'$!(#$U!
$8+2!=+$!/!$0/26+6(98/=+/*!#*$0/6(#2&!/2&!6++!'$@!!Y(;!$8'6!'6!$8+!MC primary b9 tumor of the
heart in adults@!!!
!
I8+4!describe tumor in heart of kid!7!$8'6!'6!rhabdomyoma!?Lr!$#E(0!()!</0&'/<!E#6<*+B!7!
$8+4!/0+!/66(<!>'$8!/#$(!&(E@!&c;!>8'<8!(2+n!Tuberous sclerosis@!!Y(;!')!$8+4!$/*F!/L(#$!/!$#E(0!
'2!$8+!8+/0$!()!/!.N1X_;!&(!2($!9'<!E4:(E/!?6++2!'2!/&#*$6BU!'$Q6!/!08/L&(E4(E/!/2&!'6!E(0+!*'F+*4!
'2!/!<8'*&!>'$8!$#L+0(#6!6<*+0(6'6@!!!
137

!!
!
!
!
!
CHAPTER 8: RESPIRATORY!
!
I. A-a gradient know how to calculate:
!
%*M+(*/0!GH!/2&!/0$+0'/*!9GH!/0+!2+M+0!$8+!6/E+@!!I8+!&'))+0+2<+!L+$>++2!$8+!$>(!'6!</**+&!
/*M+(*/0!/0$+0'/*!=0/&'+2$@!!R+/6(26!)(0!'$-!?,B!k+2$'*/$'(2!/2&!9+0)#6'(2!/0+!2($!+M+2*4!E/$<8+&!
'2!$8+!*#2=6@!!g8+2!6$/2&'2=!#9!$8+!M+2$'*/$'(2!'6!L+$$+0!$8/2!9+0)#6'(2!'2!$8+!/9+:;!>8+0+/6!
9+0)#6'(2!'6!L+$$+0!$8/2!M+2$'*/$'(2!/$!*(>+0!*(L+6@!!I8'6!+:9*/'26!>84!/*E(6$!/**!9#*E(2/04!
'2)/0<$'(26!/0+!'2!$8+!*(>+0!*(L+6!7!9+0)#6'(2!'6!=0+/$+0!$8+0+@!!%*6(;!$8'6!+:9*/'26!>84!
0+/<$'M/$'(2!IS!'6!'2!$8+!/9+:!7!IS!'6!/!6$0'<$!/+0(L+!/2&!2++&6!/6!E(0+!GH;!/2&!$8+0+!'6!E(0+!
M+2$'*/$'(2!'2!$8+!#99+0!*(L+6!?8'=8+0!GH!<(2$+2$B@!!"(0E/**4;!/*M+(*/0!GH!'6!,VV!/2&!$8+!/0$+0'/*!
9GH!'6!re@!!Y(;!2(0E/**4;!$8+!=0/&'+2$!'6!e!EEN=@!%6!4(#!=+$!(*&+0;!$8+!=0/&'+2$!+:9/2&6;!L#$!
2($!$8/$!E#<8@!!K(6$!9+(9*+!#6+!$8+'0!#99+0!*'E'$!()!2(0E/*!7!'2!($8+0!>(0&6;!8/M+!/!M+04!M+04!
8'=8!69+<')'<'$4!()!PV!EEN=@!!1)!4(#!8/M+!/2!A-a gradient of 30 mmHg or higher there is a
problem@!!1$!'6!M+04!8'=8!69+<')'<'$4!?/F/!JJk!7!$0#*4!8/M+!6(E+$8'2=!>0(2=B@!!I8+!<(2<+9$!'6!
+/64!7!4(#!>(#*&!+:9+<$!$8+!=0/&'+2$!L$>2!$8+!/*M+(*/0!GH!/2&!$8+!/0$+0'/*!GH!$(!L+!=0+/$+0!')!
4(#!8/M+!primary lung dz@!!g8/$!>'**!&(!$8'6n!k+2$'*/$'(2!&+)+<$6!?90(&#<+6!849(:+E'/;!/2&!
$8+0+)(0+!90(*(2=6!$8+!=0/&'+2$!7!&0(99'2=!$8+!JGH!/2&!6#L$0/<$'2=;!/2&!$8+0+)(0+!/!=0+/$+0!
&'))+0+2<+!L$>2!$8+!$>(B;!9+0)#6'(2!&+)+<$!?'+!9#*!+EL(*#6B;!/2&!&'))#6'(2!&+)+<$@!S#$!$8+!
&+90+66'(2!()!$8+!E+&#**/04!0+69!<+2$+0!L4!L/0L'$#0/$+6!&(+6!2($!</#6+!/!&'))+0+2<+!'2!%d/!
=0/&'+2$@!!Y(;!prolonged A-a gradient tells you the hypoxemia is due to a problem in
the lungs (vent perfusion/diffusion defect). A normal A-a gradient tells you that
something outside the lungs that is causing hypoxemia (resp acidosis in resp
acidosis, PO2 will go down).!!./#6+6!()!0+69!/<'&(6'6-!!9#*E(2/04!90(L6!?.GJ_B;!&+90+66'(2!
()!0+69!<+2$+0!?(L6$0#<$!#99+0!/'0>/4!)0(E!+9'=*($$'$'6;!*/04='($0/<8+(L0(2<8'$'6;!</)x!<(0(2/04!
?9/0/*4c+&!E#6<*+6!()!0+69B;!l#'**/'2!S/00+!642&0(E+;!/E4($0(98'<!*/$+0/*!6<*+0(6'6;!/2&!9/0/*46'6!
()!&'/980/=E@!!I8+6+!/**!90(&#<+!0+69!/<'&(6'6!/2&!849(:+E'/;!L#$!$8+!%d/!=0/&'+2$!>'**!L+!
"GRK%XB@!!Y(;!90(*(2=+&!%d/!=0/&'+2$;!6(E+$8'2=!'6!>0(2=!>'$8!$8+!*#2=6@!!1)!%d/!=0/&'+2$!'6!
2(0E/*;!$8+0+!'6!6(E+$8'2=!G\IY1_[!()!$8+!*#2=6!$8/$!'6!</#6'2=!/!0+69!90(L*+E@!!!!
!
T+>!$8'2=6!E#6$!/*>/46!L+!</*<#*/$+&-!/2'(2!=/9!?>'$8!+*+<$0(*4$+6B!/2&!%d/!=0/&'+2$!)(0!L*((&!
=/6+6!7!/**!4(#!2++&!$(!&(!'6!</*<!/*M+(*/0!GH@!!g+!</2!calculate the A-a gradient!C!V@H,!:!
`,P!C!,eV!?V@H,!'6!$8+!/$E(698+0'<!GHU!/2&!àV!E'2#6!$8+!>/$+0!M/9(0C`,PB@!!Y(;!150 minus
the pCO2 ?='M+2!'2!$8+!L*((&!=/6B divided by 0.8!?0+69!D#($'+2$B@!!Y(;!2(0E/*!9.GH!C!^V;!
/2&!^VZ@tCeV!/2&!,eVdeV!C!,VVU!6(;!2(>!$8/$!1!8/M+!</*<!$8+!/*M+(*/0!GH;!3#6$!6#L$0/<$!$8+!
E+/6#0+&!/0$+0'/*!9GH!/2&!4(#!8/M+!$8+!%d/!=0/&'+2$@!!I8'6!'6!M+04!6'E9*+!/2&!='M+6!/!*($!()!'2)(!
>8+2!>(0F'2=!#9!849(:+E'/@!!!
!
II. Upper Respiratory Disease:
A. Nasal Polyps:
P!&'))!$49+6!()!2/6/*!9(*496!7!K.!'6!/2!/**+0='<!9(*49@!!"+M+0!$8'2F!()!/!9(*49!'2!$8+!2(6+!()!
F'&!$8/$!'6!/**+0='<!/6!/2!/**+0='<!9(*49@!!%**+0='<!9(*496!&+M+*(9!'2!/&#*$6!/)$+0!/!*(2=!$+0E!
/**+0='+6!6#<8!/6!/**+0='<!08'2'$'6!7![:/E9*+-!!e!4Z(!<8'*&!>'$8!2/6/*!9(*49!/2&!0+69!&+)+<$6;!
138

>8/$!'6!$8+!)'06$!6$+9!'2!E/2/=+E+2$n!Y>+/$!$+6$!7!LZ<!')!4(#!8/M+!/!9(*49!'2!$8+!2(6+!()!$8+!
F'&;!4(#!8/M+!<46$'<!)'L0(6'6U!'$Q6!2($!/2!/**+0='<!9(*49@!!!
B. Triad Asthma!7!$/F+!/2!/69'0'2!(0!"Y%1_;!8/M+!2/6/*!9(*496!/2&!()!<(#06+!8/M+!/6$8E/@!!
I8+4!&(2Q$!$+**!4(#!$8+!9$!$((F!/69'0'2!/2&!$8/$!$8+!9$!8/6!/!9(*49@!!I8+!/69'0'2!(0!"Y%1_!'6!
$8+!/26>+0!L#$!$8'6!'6!8(>!$8+4!>'**!/6F!$8+!D#+6$'(2-!Pe!4Z(!>(E/2!>'$8!<80(2'<!8+/&/<8+6!
(0!)'L0(E4/*='/@!!J$!8/6!6(E+!$49+!()!<80(2'<!9/'2!642&0(E+!/2&!>'**!2($!$+**!4(#!$8/$!$8+!9$!
'6!(2!E+&'</$'(2;!/2&!68+!&+M+*(96!(<</6'(2/*!L(#$6!()!/6$8E/!7!>8/$!'6!$8+!E+<8!()!$8+!
9$Q6!/6$8E/n!SZ<!68+!'6!$/F'2=!/2!"Y%1_@!!g8/$!$8+4!>(2Q$!$+**!4(#!$8/$!68+!8/6!/!9(*49!/2&!
$8/$!68+!'6!(2!/2!"Y%1_U!8(>+M+0;!')!/!9$!'6!'2!9/'2!(0!8/6!<80(2'<!9/'2;!'$!'6!6/)+!$(!/66#E+!
$8+!9$!'6!(2!9/'2!E+&'</$'(2!?'+!/2!"Y%1_;!K($0'2!(0!/69'0'2B@!!K+<8!()!/6$8E/!)0(E!9/'2!
E+&'</$'(2-!>8/$!&(!/69'0'2Z"Y%1_6!L*(<Fn!.Gh;!$8+0+)(0+!/0/<8'&(2'<!/<'&!</22($!)(0E6!
Jl6!L#$!$8+!X'9(:4=+2/6+!9/$8>/4!'6!*+)$!(9+2@!!Y(E+!9+(9*+!/0+!M+04!6+26'$'M+!$(!$8'6!/2&!
XI!.^;!_^;!/2&![^!/0+!)(0E+&;!>8'<8!/0+!9($+2$!L0(2<8(<(26$0'<$(06;!*+/&'2=!$(!/6$8E/@!!!1$!
'6!"GI!/!$49+!1!NJb!0:2@!!1$!'6!/!<8+E'</*!E+&'/$+&!2(2!$49+!1!NJb!0:2@!!So, chronic pain
can lead to asthma b/c of aspirin sensitivity.
!
%2($8+0!/66#E9$'(2!4(#!8/M+!$(!E/F+-!/24!>+**!L#'*$!E/*+!(2!/2/L(*'<!6$+0('&6!?'+!)(($L/**!
9*/4+0;!>0+6$*+0B!>'$8!'2$0/9+0'$(2+/*!8+E(008/=+!7!90(&#<+!L+2'=2!*'M+0!<+**!/&+2(E/6!
>8'<8!8/M+!$8+!$+2&+2<4!()!0#9$#0'2=@!!
!
C. Laryngeal carcinoma (a squamous cell carcinoma)
.(2<+9$!()!642+0='6E-!!!K..!C!YE(F'2=U!H2&!K..!C!/*<(8(*!!
%*<(8(*!/2&!6E(F'2=!8/M+!/!Yb"[Rl1YI1.!+))+<$!>8'<8!*+/&6!$(!*/042=+/*!</0<'2(E/@!!
[:/E9*+-!!*+6'(2!'2!$8'6!6*'&+!'6!/!*/042=+/*!69+<'E+2!7!>8'<8!()!$8+!)(**(>'2=!8/M+!$8+!
=0+/$+6$!0'6F!)/<$(0n!%26>+0!7!alcohol AND smoking!?$8'6!'6!$0#+!)(0!/24!6D#/E(#6!</2<+0!
)0(E!$8+!+6(98/=#6!$(!$8+!E(#$8!$(!$8+!*/042:B@!YE(F'2=!C!K..!</2<+0!'2!E(#$8;!#99+0!
+6(98/=#6!/2&!*/042:@!!%*<(8(*!</2!&(!$8+!6/E+!$8'2=;!6(!')!4(#!/0+!6E(F+0!/2&!/*<(8(*!
<(26#E+0;!4(#!</2!&(#L*+!4(#0!0'6F@!!K.!64E9$(E!/66(<!C!8(/06+2+66!()!$8+!$80(/$@!
!
[:/E9*+-!!+9'=*($$'6U!>8/$!</2!'2)+<$!'$n!N@!'2)*#+2c/!7!>8/$!'6!$8+!64E9$(En!1269'0/$(04!
6$0'&+0@!![:/E9*+-!!P!E(2$8!(*&!<8'*&!&'+&!>'$8!'269'0/$(04!6$0'&+0!7!&:n!.0(#9!7!
9/0/'2)*#+2c/U!$8'6!'6!/!IR%.N[%X!'2)*/EE/$'(2@!!g8+0+/6!+9'=*($$'$'6!'6!+*6+>8+0+@!!S($8!
90(&#<+!#99+0!/'0>/4!(L6$0#<$'(2@!
!
139

III. Respiratory Distress Syndromes:
A. Hyaline membrane dz (Neonatal Resp distress syndrome)
1)!6(E+$8'2=!8/6!/!*($!()!9'2F!'2!'$;!>8/$!'6!'$n!N4/*'2+!
5+4!$(!#2&+06$/2&'2=!$8'6!&c!'6!E/66'M+!/$+*+<$/6'6!
1. What is atelectasis?!.(**/96+!()!/'0>/46@!!g84!&'&!$8+6+!/'0>/4!<(**/96+n!"(!
6#0)/<$/2$!?/F/!*+<'$8'2Z98(698($'&4*!<8(*'2+Z98(698($'&4*!=*4<+0(*!7!$8+4!/0+!/**!6#0)/<$/2$B@!!
Y(;!&+)'<'+2$!()!6#0)/<$/2$!</#6+6!/$+*+<$/6'6!LZ<-!
Collapsing pressure in the airways = surface tension/radius of airway.!!Y(;!(2!
+:9'0/$'(2;!2(0E/**4!$8+!/'0>/4!>'**!L+!6E/**+0!LZ<!$8+0+!'6!/!9(6!'2$0/$8(0/<'<!90+66#0+@!!1)!
4(#!&+<0+/6+!$8+!0/&'#6;!4(#!>'**!'2<0+/6+!$8+!<(**/96'2=!90+66#0+!'2!$8+!/'0>/46@!!I8+0+)(0+;!
(2!+:9'0/$'(2!?'2!/**!()!#6B;!>+!8/M+!$(!&+<0+/6+!6#0)/<+!$+26'(2!?>8'<8!'6!>8/$!6#0)/<$/2$!
&(+6B!7!L4!&('2=!$8'6;!'$!F++96!$8+!/'0>/46!(9+2!(2!+:9'0/$'(2;!90+M+2$'2=!/$+*+<$/6'6@!!!
2. Three causes of RDS:
/@ J0+E/$#0'$4-!!6#0)/<$/2$!L+='26!642!+/0*4;!L#$!'$!9+/F6!/$!PHdPe!>++F;!6(!')!4(#!/0+!
L(02!90+E/$#0+*4;!4(#!>'**!2($!8/M+!+2(#=8!6#0)/<$/2$;!/2&!L/L4!>'**!&+M+*(9!
'2<0+/6+&!0'6F!()!&+M+*(9'2=!R_Y@!!Y(E+$'E+6!E($8+0!8/6!2(!<8('<+!/2&!E#6$!&+*'M+0!
L/L4;!(0!+*6+!'$!>'**!&'+;!/2&!$8+0+!'6!6(E+$8'2=!4(#!</2!&(!$(!$8+!E(E!6(!$8+!L/L4!
8/6!E(0+!6#0)/<$/2$-!='M+!E($8+0!=*#<(<(0$'<('&6!LZ<!$8+4!6$'E#*/$+!6#0)/<$/2$!
642$8+6'6@!![:/E9*+-!!>8/$!</2!4(#!&(!$(!'2<0+/6+!6#0)/<$/2$!?L#$!=*#<(<(0$'<('&6!
>/62Q$!(2+!()!$8+!/26>+0!<8('<+6B!7!$840(:'2+!?$840('&!8(0E(2+B!?/6!&(+6!90(*/<$'2BU!
&(+6!$8/$!E+/2!4(#!='M+!$840(:'2+!L^!&+*'M+0'2=!$8+!L/L4n!"(;!>'**!='M+!E(E!/2&!
L/L4!849+0$840('&'6E@!
!
L@ _'/L+$+6-!=+6$/$'(2/*!&'/L+$+6!C!>(E/2!>8(!>/62Q$!90+=2/2$;!L+<(E+6!90+=2/2$;!
/2&!$8+2!(L$/'26!=*#<(6+!'2$(*+0/2<+!/)$+0!&+*'M+04!7!6(!')!/!&'/L+$'<!=+$6!90+=2/2$;!
$8'6!'6!2($!</**+&!=+6$/$'(2/*!&'/L+$+6;!L#$!/!&'/L+$'<!$8/$!=($!90+=2/2$@!!1$6!'E9!$8/$!/!
>(E/2!'2!90+=2/2<4!8/6!=((&!=*#<(6+!<(2$0(*!LZ<!')!68+!'6!849+0=*4<+E'<;!L/L4!>'**!
L+;!$((@!!SZ<!L/L4!'6!849+0=*4<+E'<;!'$!>'**!6$'E#*/$+!'26#*'2!642$8+6'6;!/2&!'26#*'2!8/6!
/!2+=/$'M+!+))+<$!(2!6#0)/<$/2$!642!/2&!>'**!&+<0+/6+!'$6!642$8+6'6@!!!
!
<@ .!6+<$'(2!7!LZ<!$8+!L/L4!'6!2($!&+*'M+0+&!M/='2/**4;!$8+0+!'6!2(!6$0+66@!!SZ<!$8+!L/L4!
8/6!2($!L++2!6$0+66+&;!$8+!%.IN!/2&!<(0$'6(*!/0+!2($!0+*+/6+&;!/2&!6#0)/<$/2$!'6!2($!
E/&+@!!g8+0+/6!/!<8'*&!$8/$!'6!&+*'M+0+&!M/='2/**4!8/6!/!*($!()!6$0+66!/2&!$8+0+)(0+!/!
*($!()!%.IN!/2&!<(0$'6(*!'6!L+'2=!0+*+/6+&;!>8'<8!6$'E#*/$+6!6#0)/<$/2$!0+*+/6+@!!Y(;!.!
6+<$'(2!90+&'69(6+6!$(!R_Y@!!!
!
Y(;!$8+6+!/0+!$8+!$80++!E/'2!</#6+6!?90+E/$#0'$4;!&'/L+$+6;!/2&!.!6+<$'(2B@!!
!
3. Complications and associated conditions:
/@![:/E9*+-!!>84!/0+!$8+!L/L'+6!()!9((0!=*4<+E'<!<(2$0(*!L'=!?E/<0(6(E'/*Bn!!I8+!L/L4Q6!
'26#*'2!'6!'2<0+/6+&!$(!F++9!$8+!=*#<(6+!&(>2@!!126#*'2!>'**!'2<0+/6+!6$(0/=+!()!$0'=*4<+0'&+!
'2!/&'9(6+!?'$!'2<0+/6+6!)/$!6$(0/=+B@!!g8+0+!'6!E(6$!()!$8+!/&'9(6+!*(</$+&n!.+2$0/**4@!!
Y(;!(2+!()!$8+!0+/6(26!>84!$8+4!8/M+!E/<0(6(E'/!'6!LZ<!'26#*'2!6$'E#*/$+6!642$8+6'6!()!
Il!/2&!&+9(6'$'(2!()!)/$@!!%*6(;!'26#*'2!'2<0+/6+6!#9$/F+!()!//Q6!'2!E#6<*+!?*'F+!=0(>$8!
8(0E(2+B@!!Y(;!'$!>'**!'2<0+/6+!E#6<*+!E/66@!!Y(;!the reason for macrosomia is
140

increased adipose and muscle mass, both due to insulin.!!I8'6!/*6(!+:9*/'26!>84!
$8+4!=+$!849(=*4<+E'/!>8+2!$8+4!/0+!L(02@!!I8+!E($8+0Q6!849+0=*4<+E'/!'6!<(E'2=!'2$(!
$8+!L/L4;!</#6'2=!$8+!L/L4!$(!0+*+/6+!'26#*'2U!$8+!E(E+2$!'26#*'2!'6!E/&+!/2&!$8+!<(0&!'6!
<#$;!/2&!2(!E(0+!'2<0+/6+!'2!=*#<(6+;!=*#<(6+!=(+6!&(>2;!/2&!*+/&6!$(!849(=*4<+E'/@!!
!
L@!Y#9+0(:'&+!)0++!0/&'</*!&/E/=+!6++2!'2!0+$'2(9/$84!()!90+E/$#0'$4!/2&!L*'2&2+66!/2&!
L0(2<8(9#*E(2/04!&469*/6'/@!!!
!
<@!g84!&(!L/L'+6!>'$8!R_Y!<(EE(2*4!8/M+!J_%n!SZ<!$8+4!8/M+!849(:+E'/@!!g8+2!/!
2(0E/*!L/L4!$/F+6!/!L0+/$8;!'$!6$/0$6!$8+!90(<+66!()!)#2<$'(2/*!<*(6#0+!()!$8+!&#<$#6@!!
N(>+M+0;!>'$8!849(:+E'/!/)$+0!$8+4!/0+!L(02;!'$!0+E/'26!(9+2;!/2&!$8+4!8/M+!/!
E/<8'2+04!E#0E#0@!!!
!
&@!N4/*'2+!E+EL0/2+6!/0+!&#+!$(!&+=+2+0/$'(2!()!$49+!11!92+#E(<4$+6!/2&!*+/F/=+!()!
)'L0'2(=+2;!/2&!'$!<(2=+/*6!$(!)(0E!$8+!E+EL0/2+@!!Y(;!$8+4!>'**!='M+!/!<*/66'<!8'6$(04!)(0!
R_Y;!/2&!$8+2!>'**!/6F!)(0!$8+!9/$8(=+2+6'6!()!849(:+E'/!'2!$8+!L/L4@!!I8'6!'6!/!E/66'M+!
M+2$'*/$'(2!&+)+<$!LZ<!+M+04$8'2=!'6!<(**/96'2=@!!I8'6!'6!/!YN\"I!90(L*+E;!>8'<8!*+/&6!$(!
/!E/66'M+!'2$+09#*E(2/04!68#2$@!!R:CJ[[J!$8+0/94!7!9(6'$'M+!+2&!+:9!90+66#0+!LZ<!
$8+6+!/'0>/46!/0+!<(**/96+&!/2&!4(#!2++&!$(!=+$!GH!'2$(!$8+E!/2&!6#0)/<$/2$@!!Y(;!='M+!
GH!/2&!/$!$8+!+2&!()!+:9'0/$'(2;!9#E9!'2!90+66#0+;!>8'<8!F++96!/'0>/46!(9+2!(2!
+:9'0/$'(2;!6(!4(#!</2!F++9!GH!'2!$8+E@!!!
!
[:/E9*+-!!9'<!>'$8!$49+!11!92+#E(<4$+!?>'$8!*/E+**/0!L(&'+6!7!*((F!*'F+!(2'(2;!/2&!
849+09*/6$'<!/0$+0'(*(6<*+0(6'6!LZ<!$8+4!/0+!<(2<+2$0'</**4!68/9+&B@!!I8+6+!*/E+**/0!L(&'+6!
<(2$/'2!6#0)/<$/2$@!!I8'6!>(#*&!1_!'$!/6!/!$49+!11!92+#E(<4$+@!!I8+4!<(EE(2*4!='M+![K6!()!
$8+!*#2=!>'$8!/2!/*M+(*/0!E/<0(98/=+@!!K/<0(98/=+!8/6!]3#2FQ!'2!$8+!<4$(9*/6E@!!I8+!$49+!11!
92+#E(<4$+!'6!$8+!0+9/'0!<+**!()!$8+!*#2=!/2&!642$8+6'c+6!6#0)/<$/2$@!!!
!
B. Adult Respiratory Distress Syndrome (ARDS)
12!$+0E6!()!%R_Y;!+66+2$'/**4!'$!'6!$8+!6/E+!/6!R_Y!'2!9/$8(9846;!L#$!'6!"[\IRGJN1X!0+*/$+&!
'23#04@!!12!R_Y!4(#Q0+!2($!E/F'2=!6#0)/<$/2$!LZ<!4(#!/0+!$((!90+E/$#0+!(0!8/M+!$((!E#<8!
'26#*'2!/2&!3#6$!8/M+!<(**/96+&!/*M+(*'@!!S\I!'2!%R_Y!'$6!LZ<!4(#!8/M+!$((!E#<8!
'2)*/EE/$'(2U!$8+0+!'6!2(!'2)*/EE/$'(2!'2!R_Y@!!!
!!
MCC ARDS = septic shock (MCC septic shock = E coli from sepsis from an
indwelling catheter; MCC DIC = septic shock).!![:/E9*+-!!12!$8+!1.\!7!')!/!9$!<(E+!'2!
>'$8!&4692+/!/2&!'$6!>'$8'2!H^!806!()!8/M'2=!6+9$'<!68(<F;!9$!8/6!%R_Y@!!1)!9$!'6!'2!6+9$'<!
68(<F!/2&!>'$8'2!^t!806!()!/&E'66'(2!/2&!'6!L*++&'2=!)0(E!+M+04!(0')'<+;!8+!8/6!_1.@!!So,
first day = septic shock, second day = ARDS, third day = DIC.
Pathogenesis: "+#$0(98'*6!=+$!'2$(!$8+!*#2=!'2!6+9$'<!68(<F!/2&!6$/0$!&+6$0(4'2=!/**!$8+!
<+**6!()!$8+!*#2=!?$49+!1!/2&!11!92+#E(<4$+6B@!!Y(!6#0)/<$/2$!90(&#<$'(2!&+<0+/6+6!/2&!0+6#*$!
'6!E/66'M+!/$+*+<$/6'6!?<(**/96+B@!!N(>+M+0;!$8'6!'6!2+#$0(98'*!0+*/$+&!?$8+!2+#$0(98'*6!/0+!
&+6$0(4'2=!$8+!$49+!11!92+#E(<4$+@!!!I8+!0+/6(2!>84!$8+4!=+$!84/*'2+!E+EL0/2+6!'2!$8+!
%R_Y!'6!LZ<!$8+!2+#$0(98'*6!8/M+!$(!=+$!'2!$8+!*#2=6!L4!=('2=!$80(#=8!$8+!9#*E(2/04!
</9'**/0'+6;!6(!$8+4!9#$!8(*+6!'2!$8+E!/6!$8+4!=+$!(#$!()!$8+!L*((&6$0+/E!/2&!'2$(!$8+!*#2=6!
?$8'6!'6!>84!'$!'6!</**+&!*+/F4!</9'**/04!642&0(E+B@!!%**!$8+!90($+'2!/2&!)'L0'2(=+2!=+$!'2!/2&!
90(&#<+!84/*'2+!E+EL0/2+6@!!I8+0+)(0+;!4(#!</2!/<$#/**4!6++!84/*'2+!E+EL0/2+6!'2!%R_Y@!!
141

Y(;!$8+0+!'6!E/66'M+!<(**/96+!/2&!$8+!9/$8(9846!'6!'2$0/9#*E(2/04!68#2$'2=@!!I8'6!'6!$8+!
6/E+!'2!R_Y;!L#$!%R_Y!'6!2+#$0(98'*!0+*/$+&;!>8'<8!'6!/!L/&!90(=2(6'6@!!!
!
IV. Pneumothorax
Y9(2$/2+(#6!92+#E($8(0/:!/2&!$+26'(2!92+#E($8(0/:!
A. Spontaneous pneumothorax
MCC spontaneous = ruptured subpleural bleb!7!8/M+!9*+#0/!/2&!0'=8$!#2&+02+/$8!'6!/!
L*+L!?/'0!9(<F+$B@!!I8+!L*+L!?/'0!9(<F+$B!0#9$#0+6!</#6'2=!/!8(*+!'2!$8+!9*+#0/;!6(!$8/$!9/0$!()!
$8+!*#2=!<(**/96+6@!!SZ<!>8/$Q6!F++9'2=!'$!+:9/2&+&!'6!2+=!'2$0/$8(0/<'<!90+66#0+;!>8'<8!
F++96!$8+!*#2=6!+:9/2&+&@!!Y(;!')!4(#!9#$!/!8(*+!'2!$8+!9*+#0/;!$8+2!$8+!/$E(698+0'<!
90+66#0+!'6!2($!2+=/$'M+;!L#$!'6!$8+!6/E+!/6!$8+!/'0!4(#!/0+!L0+/$8'2=@!!Y(;!$8+0+!'6!2($8'2=!
$(!8(*&!'$!(9+2!/2&!$8+0+)(0+!'$!<(**/96+6@!!g8+2!9/0$6!()!$8+!*#2=!<(**/96+;!$8+0+!/0+!$8'2=6!
$8/$!>'**!$/F+!#9!$8+!6*/<F@!!G2+!()!$8(6+!'6!$8+!&'/980/=E@!!1)!4(#!<(**/96+!9/0$!()!$8+!*#2=;!
$8+!&'/980/=E!>'**!=(!#9!(2!$8/$!6'&+!$(!$/F+!#9!$8+!(9+2!69/<+!(2!$8/$!8/6!L++2!*+)$@!!"($!
(2*4!$8/$;!')!$8+0+!'6!/!<(**/96+!(2!(2+!6'&+;!$8+!$0/<8+/!>'**!=(!$(!$8+!6'&+!$8/$!$8+0+!'6!
69/<+@!!Y(;!>'**!8/M+!tracheal deviation to the side of the collapse, and the
diaphragm is up, leading to spontaneous pneumothorax@!!\6#/**4!6++2!'2!$/**!E/*+!7!
$8+4!8/M+!L*+L6!$8/$!0#9$#0+!/2&!*+/&!$(!69(2$/2+(#6!92+#E($8(0/:@!!./2!/*6(!=+$!'2!6<#L/!
&'M+06!LZ<!$8+4!<(E+!#9!$((!D#'<F*4;!>8'<8!*+/&6!$(!0#9$#0+!()!$8+!L*+L6@!!!
!
B. Tension pneumothorax
_'))!)0(E!69(2$/2+(#6!92+#E($8(0/:@!!K.!&#+!$(!F2')+!'23#0'+6!'2$(!$8+!*#2=@!!I8+0+Q6!$+/0!
()!9*+#0/!?)*/9B;!69!>8+2!4(#!L0+/$8+!'2!$8+!)*/9!=(+6!#9!/2&!(2!+:9'0/$'(2!'$!<*(6+6@!!Y(;!$8+!
/'0!6$/46!'2!$8+!9*+#0/*!</M'$4@!!Y(;!+M+04!$'E+!4(#!L0+/$8+;!$8+!)*/9!=(+6!#9;!/'0!6$/46!'2;!/2&!
(2!+:9'0/$'(2!'$!<*(6+6@!!Y(;!)(0!+M+04!L0+/$8!4(#!$/F+;!'$!F++96!'2<0+/6'2=!/2&!$8+!90+66#0+!'2!
$8+!*#2=@!!I8+!*#2=!8/62Q$!<(**/96+&!4+$@!!The increase in pressure starts pushing the
lung and the mediastinum to the opposite side@!!g8+2!'$!9#68+6!'$;!'$!<(E90+66+6!$8+!
*#2=!/2&!'$!*+/&6!$(!<(E90+66'(2!/$+*+<$/6'6!?'$!'6!2($!&+)*/$+&!LZ<!()!/!8(*+!7!$8+0+!'62Q$!/!
8(*+!7!'$Q6!/!$+/0!$8/$!>8+2!$8+!/'0!>+2$!'2!'$!>+2$!#9!/2&!'$!68#$!(2!+:9'0/$'(2;!/2&!$8/$!9(6!
9*+#0/*!90+66#0+!'6!9#68'2=!+M+04$8'2=!(M+0!$(!$8+!(99(6'$+!6'&+B@!!I8'6!<(E90+66'(2!>'**!9#68!
(2!$8+!Yk.;!0'=8$!M+2$;!/2&!*+)$!/$0'#E!(2!$8+!(99(6'$+!6'&+@!!I8'6!>'**!<(E90(E'6+!L*((&!
0+$#02!/2&!L0+/$8'2=;!*+/&'2=!$(!/!E+&'</*!+E+0=+2<4@!!Y(;!'$Q6!*'F+!)'**'2=!$'0+!#9!>'$8!/'0;!L#$!
</22($!=+$!(#$@!%'0!'6!)'**'2=!9*+#0/*!</M'$4!/2&!</22($!=+$!(#$@!!1$!F++96!L#'*&'2=!#9!/2&!6$/0$6!
9#68'2=!+M+04$8'2=!$(!$8+!(99!6'&+@!!g'$8!/!9(6!'2$0/$8(0/<'<!90+66#0+;!$8+!&'/980/=E!>'**!=(!
&(>2!?=(+6!#9!'2!69(2$/2+(#6!92+#E($8(0/:B@!!!
V. Pulmonary Infection
A. Pneumonia
!
1. 2 kinds Typical and Atypical
Typical!7!>/F+!)++*'2=!2(0E/*;!$8+2!6#&&+2*4!&+M+*(9!/!)+M+0;!90(&#<$'M+!<(#=8!
Atypical!7!6*(>;!'26'&'(#6!(26+$!?)++*!L/&!(M+0!)+>!&/46B!
!
2. Community vs. Nosocomial (hospital acquired)
1)!4(#!=+$!92+#E(2'/!'2!$8+!community!/2&!'$Q6!$49'</*;!'$!'6!Y$0+9!92+#E(2'/+@!!1)!4(#!
=+$!92+#E(2'/!'2!$8+!<(EE#2'$4!/2&!'$!'6!/$49'</*;!'$Q6!E4<(9*/6E/!92+#E(2'/+@!!!
142

G0=/2'6E6!'2!$8+!8(69'$/*!?nosocomialB!C![!<(*';!J6+#&(E(2/6;!Y$/98!/#0+#6!?>'**!2($!
=+$!6$0+9!92+#E(2'/+!'2!$8+!8(69'$/*B@!!!
!
3. Productive cough in Typical pneumonia
Reason for productive cough in typical pneumonia: have exudate (pus) and
signs of consolidation in the lung!7!Y*'&+-!4+**(>!/0+/6!>'$8!E'<0(/L<+66+6!>8'<8!/0+!
<(26(*'&/$'(2!'2!$8+!*#2=@!1+!*(L/0!92+#E(2'/!C!6++!<(26(*'&/$'(2!'2!*#2=;!>'$8'2!/*M+(*';!
</#6'2=!<(26(*'&/$'(2@!!I8+0+)(0+;!>'$8!$49'</*;!6++!<(26(*'&/$'(2!/2&!9#6!'2!$8+!*#2=@!!
J846'</*!&:Q$'<!$((*6!()!*#2=!<(26(*'&/$'(2-!&+<0+/6+&!9+0<#66'(2;!'2<0+/6+&!IkT!?>8+2!
$8+!9+06(2!$/*F6;!)++*!M'L0/$'(26!'2!<8+6$!7!')!8/M+!<(26(*'&/$'(2!'2!'+!$8+!#99+0!*+)$!*(L+;!
>'**!8/M+!'2<0+/6+&!IkT!LZ<!'$!'6!/!<(26(*'&/$'(2;!<(E9/0+&!$(!$8+!($8+0!6'&+!7!6(;!
increased TVF indicates consolidationB;!8/M'2=!/2!i[!$(!%j!?+=(98(24B!6'=2!?9$!6/46!
[!/2&!4(#!8+/0!%B;!>8'69+0+&!9+<$(0'*(D#4!?9$!>8'69+06!i,;!H;!Pj!/2&!1!>'**!8+/0!'$!M+04!
*(#&!>'$8!$8+!6$+$8(6<(9+B@!!I8+0+)(0+;!decreased percussion, increased TVF,
egophony, and pectoriloquy = consolidation. !!
!
g8/$!')!$8+0+!'6!/!9*+#0/*!+))#6'(2!(M+0*4'2=!$8+!*#2=n!G2*4!$8'2=!4(#!>(#*&!8/M+!'6!
&+<0+/6+&!9+0<#66'(2!?$8'6!6+9/0/$+6!9*+#0/*!+))#6'(2!)0(E!92+#E(2'/B@!!!
4. Atypical pneumonias
They do not have a high temp and do not have productive cough b/c they are
interstitial pneumonias@!!I8+4!8/M+!'2)*/EE/$'(2!()!$8+!'2$+06$'$'#E!7!$8+0+!'6!2(!
+:#&/$+!'2!$8+!/*M+(*'!7!>8'<8!'6!>84!4(#!/0+!2($!<(#=8'2=!#9!/!*($;!/2&!$8+0+)(0+!&(!2($!
8/M+!6'=26!()!<(26(*'&/$'(2@!!Y(;!>'**!2($!8/M+!'2<0+/6+!IkT;!i[!$(!%j;!>'$8!/2!/$49'</*@!!
%$49'</*!92+#E(2'/!8/6!/2!'26'&'(#6!(26+$;!0+*/$'M+*4!2(290(&#<$'M+!<(#=8;!2(!6'=26!()!
<(26(*'&/$'(2@!!!
!
MCC typical pneumonia = strep pneumoniae (know the pic) gram +
diplococcus (aka diplococcus) Rx = PCN G
!
MCC atypical pneumonia = mycoplasma pneumoniae; 2nd MCC = Chlamydia
pneumoniae;!>8'<8!/0+!/**!'2$+06$'$'/*!92+#E(2'/6@!!
!
S0(2<8(92+#E(2'/-!K.!&#+!$(!6$0+9!92+#E(2'/;!/2&!<(EE#2'$4!/<D#'0+&@!!X(L/0!
92+#E(2'/@!!Y*'&+-!*(L/0!<(26(*'&/$'(2!(2!<8+6$!:d0/4!7!6$0+9@!J2+#E(2'/@!
!
a) Viral pneumonias
1) Rhinovirus!C!K..!<(EE(2!<(*&U!$8+4!/0+!/<'&!*/L'*+!7!E+/2'2=!$8/$!'$!>(2Q$!
*+/&!$(!=/6$0(+2$+0'$'6!'2!$8+!6$(E/<8!LZ<!'6!&+6$0(4+&!L4!$8+!/<'&!'2!$8+!6$(E/<8@!!
"+M+0!>'**!8/M+!/!M/<<'2+!LZ<!,VV!6+0($49+@!
!
2) RSV!7!K..!L0(2<8'(*'$'6!7!>8+2+M+0!4(#!'2)*/E+!6E/**!/'0>/46;!'$6!*+/&6!$(!
>8++c'2=@!!I8'6!'6!/!small airway dz and bronchiolitis is MC due to RSV
and pneumonia@!!Y(;!pneumonia and bronchiolitis is MC due to RSV in
children@!
!
3) Influenza!7!&0')$!/2&!68')$!7!8/M+!8+E/==*#$'2'26;!>8'<8!8+*9!/$$/<8!$8+!M'0#6!$(!
$8+!E#<(6/@!!N/M+!2+#0/E'2'&/6+!L(0+!/!8(*+!$80(#=8!$8+!E#<(6/@!!Antigenic
143

drift = minor change/mutn!'2!+'$8+0!8+E/==*#$'2'26!(0!2+#0/E'2'&/6+U!&(!
2($!2++&!/!2+>!M/<<'2+U!antigenic shift= major change/mutn!'2!+'$8+0!
8+E/==*#$'2'26!(0!2+#0/E'2'&/6+!2++&!/!M/<<'2+@!!The vaccine is against A
Ag.
b) Bacterial pneumonias
1) Chlamydia psittacosis!7!)0(E!L'0&6!?'+!9/00($6;!$#0F+46B@!!!
2) Chlamydia trachomatis!7!/!*'$$*+!F'&!>/6!L(02!/2&!/!>++F!*/$+0!8+!>/6!
>8++c'2=!?L'=!$'E+B;!92+#E(2'/;!'2<0+/6+&!%J!&'/E+$+0;!$4E9/2'<!9+0<#66'(2!
6(#2&6;!2(!)+M+0;!+4+6!/0+!<0#6$4!?L($8!6'&+6B;!>+'0&!<(#=8!7!staccato cough
(short coughs). He got it from his moms infected cervix. (MCC
conjunctivitis in 2nd week = Chlamydia trachomatis). (MC overall of
conjunctivitis is inflammation of erythromycin drops).
c) Hospital-acquired gram-negative pneumonias
1) Pseudomonas!7!>/$+0!*(M'2=!L/<$+0'/;!$8+0+)(0+!6++!'2!9$!'2!1.\!>8+2!(2!/!
R[YJ1R%IGR@!!9$!>/$+0!#2'$!>'$8!=0++2!90(&#<$'M+!<(#=8!>'$8@!
2) Klebsiella!7!)/E(#6!'2!$8+!/*<(8(*'<U!8(>+M+0;!/*<(8(*'<!</2!/*6(!=+$!6$0+9!
92+#E(2'/@!!Y(;!8(>!>'**!4(#!F2(>!6$0+9!M6@!5*+L6'+**/n!%*<(8(*'<!>'$8!8'=8!
69'F'2=!)+M+06;!90(&#<$'M+!<(#=8!()!K\.G1_!/99+/0'2=!69#$#E!7!$8+!</96#*+!()!
5*+L6'+**/!'6!M+04!$8'<F@!X'M+6!'2!$8+!#99+0!*(L+6!/2&!</2!</M'$/$+;!$8+0+)(0+!</2!
<(2)#6+!>'$8!IS@!
3) Legionella!7!/$49'</*!<(#=8;!2(290(&#<$'M+!<(#=8;!M+04!6'<F!</2!F'**!4(#;!)0(E!
>/$+0!<((*+06!?>/$+0!*(M'2=!L/<$+0'/B;!6++2!'2!E'6$6!'2!=0(<+0'+6!(0!/$!0+6$/#0/2$6@!!
[:/E9*+-!<*/66'<!/$49'</*!92+#E(2'/;!$8+2!9$!8/&!849(2/$0+E'/!7!$8'6!'6!
X+='(2+**/@!!X+='(2+**/!3#6$!&(+62Q$!/))+<$!$8+!*#2=6;!/*6(!/))+<$6!$8+!($8+0!(0=/26!
6#<8!/6!*'M+0!&c;!interstial nephritis!/2&!F2(<F6!())!$8+!3#:$/=*(E+0*#0!<+**6;!
/2&!F'**6!$8+!0+2'2!*+M+*6;!*(>!/*&(6$+0(2+!/2&!$8+0+)(0+!*(6+!6/*$!'2!$8+!#0'2+;!
leads to hyponatremia ?*(>!0+2'2!*+M+*6!>'$8!*(>!/*&(6$+0(2+B@!!R:!C!
+04$80(E4<'2!
!
B. Fungal Infections
The two systemic fungus are Candida and Histo
!
1. Candida!7!6++2!'2!'2&>+**'2=!</$8+$+06!?#6#/**4!$8(6+!'2!$8+!6#L<*/M'/2B@!!%2&!=+$!
./2&'&/!6+96'6!
2. Histoplasmosis!C!Midwest!?G8'(ZI+22+66++!M/**+4B!</00'+&!L4!&#2=!()!6$/0*'2=6!/2&!
L/$6!7!()$+2!6++2!'2!</M+!+:9*(0+06;!(0!69+*#2F+06@!!I8+4!&+M+*(9!2(2d90(&#<$'M+!<(#=8@!!
N'6$(!'6!$8+!(2*4!646$+E'<!)#2=#6!$8/$!8/6!4+/6$6!98/=(<4$(6+&!L4!/*M+(*/0!E/<0(98/=+6@!!!
!
3. Cryptococcus!C!Pigeons7!*((F6!*'F+!E'<F+4!E(#6+!7!4+/6$!)(0E6!/0+!2/00(>!L/6+&!
L#&6@!![:/E9*+-!!"b!+:+<!>'$8!9'=+(26!0((6$'2=!'2!/'0!<(2&'$'(2+0!/2&!&+M+*(9+&!2(2!
90(&#<$'M+!<(#=8@!![:/E9*+-!!9/'2$+0!&+M+*(9+&!0+69!'2)+<$'(2!>(0F+&!(2!S0((F*42!
L0'&=+!>'$8!9'=+(26;!8(>!&(!4(#!$0+/$n!Amphotericin B@!!!
!
144

4. Blastomycosis C!Y[!\Y%!C!6F'2!/2&!*#2=!'2)+<$'(26U!L0(/&!L/6+&!L#&!
5. Coccidioidomycosis-!!Yg!\Y%!?2+>!K+:'<(;!%0'c(2/;!6(#$8+02!./*@!C!<(<<'&'(E4<(6+!7!
8/6!698+0#*+!+2&(69(0+6!?F2(>!$8+!9'<B@!![:/E9*+-!!'2!X%!+/0$8D#/F+;!/!s!()!9+(9*+!8/&!
2(290(&#<$'M+!<(#=87$8+!/0$80(69(0+!?$8+!'2)+<$'(#6!)(0EB!'6!'2!&#6$@!!g'$8!$8+!
+/0$8D#/F+;!&#6$!<(E+6!#9;!L0+/$8+!'$!'2@!![:/E9*+-!E/2!$8/$!'6!/2!12&'/2!/0$')/<$!
+:9*(0+0!'2!$8+!6(2/0/2!&+6+0$;!>8'<8!'6!'2!%0'c(2/;!/2&!'6!/!.%k[!+:9*(0+0!$8/$!
&+M+*(9+&!2(290(&#<$'M+!<(#=8!7!$8'6!'6!COCCIOMYCOSIS ?2($!N'6$(!LZ<!2($!$8+!
K'&>+6$B@!
6. Aspergillus!7!P!&'))+0+2$!E/2')+6$/$'(26Z&cQ6-!!
,B!*(M+6!$(!'28/L'$!/L/2&(2+&!IS!)#2=#6!</M'$'+6!7!fungus ball!?/69+0='**(E/;!/!M+04!
<(EE(2!</#6+!()!E/66'M+!8+E(9$46'6B@!![:/E9*+-!*+)$!#99+0!*(L+!</M'$/04!*+6'(2!/2&!
/69!*(M+!$(!*'M+!'2!$8+0+!C!)#2=#6!L/**!
HB!M+66+*!'2M/&+0U!$8+0+)(0+!>'**!'2M/&+!$8+!M+66+*6!'2!*#2=;!*+/&'2=!$(!thrombosis and
infarction!
PB!/**+0='+6!$8+!E(*&;!*+/&'2=!$(!+:$0'26'<!asthma!/2&!$49+!1!NJb!
!
Y(;!$80++!E/2')+6$/$'(26-!)#2=#6!L/**;!'2M/6'M+!M/6<#*/0!&c!90(&#<'2=!8+E(008/='<!
'2)/0<$'(26!()!$8+!*#2=;!/2&!/6$8E/@!![:/E9*+-!9'<!()!<(0(2/!7!<(E9(2+2$!()!%69+0='**#6!
?*((F6!*'F+!/!<0(>2B!7!6+9$/$+!'6!M+04!<8/0/<$+0'6$'<!?E#<(0E4<(6'6!'6!2(26+9$/$+!/2&!8/6!
>'&+!/2=*+6;!>8'*+!%69+0='**#6!8/6!2/00(>!/2=*+6!'2!'$6!L#&&'2=!/2&!<(0(2/Q6B@!
!
7. PCP (Pneumocystitis carinii pneumonia
T#2=#6!?#6+&!$(!L+!/!90($(c(/B!7!LZ<!E(0+!$8'2=6!'2!$8+!<+**!>/**!$8/$!*((F!*'F+!/!)#2=#6@!!
1$Q6!/66(<'/$+&!>'$8!N1k;!K.!%1_6!&+)'2'2=!*+6'(2!?/6!6((2!/6!$8+!8+*9+0!I!<+**!<$!'6!HVV;!'$!
#6#/**4!68(>6!#9B@!!\6+&!$(!L+!K..!&+/$8!'2!%1_6!9$;!L#$!2(>!8/6!=(2+!&(>2;!LZ<!/6!
6((2!/6!4(#0!._^!<$!'6!HVV;!&0@!>'**!9#$!9$!(2!90(984*/<$'<!$8+0/94!>'$8!IKJdYKh@!
!
g8+2!$/F'2=!TMP-SMX and protecting against PCP,!>(#*&!($8+0!(0=/2'6E!'6!$8+!9$!
90($+<$+&!)0(En!Toxoplasmosis@!!?6(;!4(#!=+$!H!)(0!,B@!!K..!69/<+!(<<#94'2=!*+6'(2!
>'$8'2!$8+!L0/'2!'2!/!9$!>'$8!%1_6C!I(:(9*/6E(6'6!
!
Seen with silver stain-!!<46$6!()!J.J!</2!L+!6++2!7!*((F!*'F+!9'2=!9(2=!L/**6;!6++2!'2!
/*M+(*';!*+/&'2=!$(!/*M+(*/0!'2)'*$0/$+;!*+/&'2=!$(!&4692+/;!$/<8492+/;!)(/E4!L#LL*4!
'2)'*$0/$+;!(2!<8+6$!:d0/4;!*((F6!/**!>8'$+!(#$!LZ<!()!$8+!'2M(*M+E+2$!()!$8+!*#2=!7!
8(>+M+0;!2($!(2*4!6++2!'2!*#2=6;!</2!L+!6++2!'2!/24!9/0$!()!$8+!L(&47!/*6(!6++2!'2!*4E98!
2(&+6!()!N1k!iOj@!
!
G$8+0!(0=/2'6E6!$8/$!/0+!(2*4!6++2!>'$8!6'*M+0!6$/'2-!L/0$+2+**/!8+26+*/+!?L/<'**/04!
/2='(E/$(6'6B;!X+='(2+**/!?2($!M'6#/*'c+&!>'$8!=0/E!6$/'2;!$8+0+)(0+!#6+!L#$#*4nnn!6'*M+0!
6$/'2B!
8. TB
G0=/2'6E!'2!#99+0!*(L+!()!*#2=6!7!?9*/4!(&&6B!7!IS!7!6++!</M'$/04!*+6'(2;!>8'<8!'6!
0+/<$'M/$'(2!IS!?2($!90'E/04B@!!J0'E/04!IS!'6!$8+!*(>+0!9/0$!()!$8+!#99+0!*(L+!(0!$8+!
#99+0!9/0$!()!$8+!*(>+0!*(L+!/2&!<*(6+!$(!$8+!9*+#0/!?F'2&!()!'2!$8+!E'&&*+!()!$8+!*(L+B@!!
J0'E/04!IS!8/6!/!l8(2!)(<#6!/2&!/!l8(2!<(E9*+:@!!K(6$!9+(9*+!0+<(M+0U!>8+2!9$!'6!
'EE#2(<(E90(E'6+&;!'$!*+/&6!$(!0+/<$'M/$'(2!/2&!=(+6!'2$(!$8+!/9+:!/2&!90(&#<+6!/!
145

</M'$/04!*+6'(2@!!There is no Ghon focus or complex in reactivation TB, only
primary TB.!!!
!
Other things that cavitate in upper lobes:
g8'<8!646$+E'<!)#2=#6!'6!$8+!iISj!()!$8+!*#2=6n!N'6$(9*/6E(6'6!
g8'<8!</2<+0!</2!</M'$/$+!'2!$8+!*#2=n!YD#/E(#6!.+**!</0<'2(E/!()!$8+!*#2=!
g8'<8!L/<$+0'/!?$8/$!8/6!/!L'=!E#<(#6!>/**!/0(#2&!'$B!</2!/*6(!90(&#<+!</M'$/$'(26!'2!$8+!
#99+0!*(L+n!5*+L6'+**/!92+#E(2'/+@!
g8/$!'6!/<'&!)/6$!6$/'2!6$/'2'2=n!K4<(*'<!/<'&6@!!!
Y(;!3#6$!LZ<!6(E+$8'2=!'6!</M'$/$'2=!$8+!#99+0!*(L+;!'$!'6!2($!2+<+66/0'*4!IS@!!!
C. Foreign Bodies
1)!4(#!/0+!standing or sitting up;!)(0+'=2!L(&'+6!>'**!=(!$(!posterobasal segment of
the right lower lobe@!!I8'6!'6!$8+!E(6$!9(6$+0'(0!6+=E+2$!()!$8+!0'=8$!*(>+0!*(L+@!!!
!
1)!4(#!/0+!*4'2=!&(>2!?K.!>/4!$(!/69'0/$+!$8'2=6B;!)(0+'=2!L(&4!>'**!=(!$(!6#9+0'(0!6+=E+2$!
()!$8+!0'=8$!*(>+0!*(L+@!!!
1)!4(#!/0+!*4'2=!(2!$8+!0'=8$!6'&+;!</2!=(!$(!H!9*/<+6!7!,B!E'&&*+!*(L+!HB!9(6$+0'(0!6+=E+2$!()!
0'=8$!#99+0!*(L+!?$8'6!'6!$8+!G"Xb!(2+!$8/$!'6!'2!$8+!#99+0!*(L+@!!!
1)!4(#!/0+!*4'2=!&(>2!(2!4(#0!*+)$;!/2&!/69'0/$+;!'$!>'**!=(!$(!$8+!*'2=#*/@!!!
!
Y#EE/04-!
Sitting/standing = posterobasal segment of right lower lobe
Back: superior segment of right lower lobe
Right: middle or sup segment of right lower lobe
Left: lingula
!
D. Abscess
MCC abscess = aspiration of oropharyngeal material
Y++2!<(EE(2*4!'2!6$0++$!9+(9*+!$8/$!&(!2($!8/M+!=((&!&+2$'$'(2;!E/4!L+!&0#2F!/2&!)/**!/2&!
(0(98/042=+/*!E/$+0'/*!>'**!L+!/69'0/$+&@!!%69'0/$+!<(26'6$6!()!/+0(L+6!/2&!/2/+0(L+6;!
*+/&'2=!$(!9#$0'&Z6$/2<8!6E+**@!!!!I8+!/69'0/$+!'6!/!E':$#0+!()!/**!$8+6+!(0=/2'6E6-!K':+&!
/+0(L+6!/2&!/2/+0(L+6;!)#6(L/<$+0'#E;!L/<$+0('&+6@!!./2!=+$!/L6+<<+6!'2!$8+!*#2=!)0(E!
92+#E(2'/-!6$/98!/#0+#6;!5*+L6'+**/!?8(>+M+0;!K..!'6!/69'0/$'(2B;!6++!)*#'&!</M'$'+6!'2!*#2=!
(2!:d0/4@!!!
VI. Pulmonary Vascular Disease:

A. Pulmonary Embolus
H!$49+6!()!+EL(*'!7!$'24!(2+6!$8/$!90(&#<+!>+&=+!68/9+&!8+E(008/='<!+EL(*'!(0!</2!<8'9!())!
*/0=+!(2+6@!!g8+0+!&(!E(6$!J#*!+EL(*'!+EL(*'c+!)0(En!!K.!Y1I[!)(0!$80(EL(6'6!'6!$8+!&++9!
M+'26!()!$8+!*(>+0!*+=@!!I8'6!'6!"GI!$8+!E(6$!<(EE(2!6'$+!)(0!+EL(*'c/$'(2U!'$!'6!$8+!)+E(0/*!
M+'2!?$8'6!'6!$8+!K.!6'$+!)(0!+EL(*'c/$'(2B@!!K/F+6!6+26+!LZ<!M+2(#6!<*($6!90(9/=/$+!$(>/0&!
$8+!8+/0$!?&++9!M+'26!$(!$8+!)+E(0/*!M+'2;!/2&!$8+!)+E(0/*!M+'2!'6!/!*/0=+0!M+66+*;!$8+0+)(0+!'$!
'6!E(0+!*'F+*4!$(!<8'9!())B@!!Y(;!$8+!)+E(0/*!M+'2!'6!$8+!K.!6'$+!)(0!+EL(*'c/$'(2!$(!$8+!*#2=@!!
I8+!&++9!M+'26!/0+!$8+!K.!6'$+!>8+0+!&++9!M+2(#6!$80(EL(6'6!L+='26@!!?>8+2!'$!=+$!$(!$8+!
)+E(0/*!M+'2;!'$!'6!&/2=+0(#6!)(0!+EL(*'c/$'(2B@!!Y(;!6E/**!(2+6!90(&#<+6!8+E(008/='<!'2)/0<$!
$8/$!'6!(2*4!')!4(#!8/M+!/2!#2&+0*4'2=!*#2=!&c@!!!1)!1!8/M+!/!6E/**!+EL(*#6;!90(L!>(2Q$!'2)/0<$!
LZ<!&(2Q$!8/M+!/L2(0E/*!*#2=6@!N(>+M+0;!')!4(#!8/M+!90++:'6$'2=!*#2=!&c!4(#!>'**!'2)/0<$@!!
teW!()!$8+!$'E+!+EL(*#6!>'**!2($!90(&#<+!'2)/0<$@!!N(>+M+0;!'2!$8+!,eW;!E(6$!()!$8+!9$6!
146

>'$8!'2)/0<$6!8/M+!90++:'6$'2=!*#2=!&c!?'+!$8+4!/0+!6E(F+06B@!!I8+!($8+0!$49+!()!+EL(*#6!'6!/!
6/&&*+!+EL(*#6!?'$!'6!8#=+B!/2&!L*(<F6!())!$8+!(0')'<+6!()!$8+!9#*E(2/04!M+66+*6!/2&!
9#*E(2/04!/0$+0'+6@!!1)!4(#!F2(<F!())!/$!*+/6$!P!(#$!()!$8+!e!(0')'<+6;!4(#!/0+!&+/&!'2!/!
E'**'6+<(2&;!6(!$8+0+!'6!2(!'2)/0<$'(2!LZ<!4(#!&(2Q$!8/M+!$'E+!$(!'2)/0<$@!!1$!90(&#<+6!/<#$+!
0'=8$!8+/0$!6$0/'2!/2&!'EE+&'/$+!&+/$8@!!Screening test of choice: Ventilation
perfusion scan will have ventilation, no perfusion; confirmatory test is
pulmonary angiogram.
!
VII. Restrictive Pulmonary Disease
Restrictive!7!6(E+$8'2=!'6!0+6$0'<$'2=!'$!)0(E!)'**'2=@!![:/E9*+-!0+6$0'<$+&!)'**'2=!()!$8+!8+/0$!C!
0+6$0'<$'M+!</0&'(E4(9/$84@!!G0!0+6$0'<$'(2!'2!)'**'2=!#9!()!$8+!*#2=6!>'$8!/'0@!!N/M+!H!$+0E6-!
compliance (filling term, inspiration term) and elasticity (recoil, expiration term);!!
!
T(0!0+6$0'<$'M+!*#2=!&c;!9'<$#0+!/!8($!0#LL+0!L($$*+!)(0!0+6$0'<$'M+!*#2=!&c@!!I8+!8($!0#LL+0!L($$*+!
'6!&'))'<#*$!$(!]L*(>!#9Q;!$8+0+)(0+!compliance is decreased!/2&!'$!'6!8/0&!$(!)'**!$8+!*#2=!#9!
>'$8!/'0@!!Y(;!>8/$Q6!90+M+2$'2=!'$!)0(E!L*(>'2=!#9n!T'L0(6'6!?'2$+06$'/*!)'L0(6'6;!K.Q*4B@!!1)!4(#!=+$!
$8+!8($!>/$+0!0#LL+0!L($$*+!)'**+&!>'$8!/'0!/2&!*+$!$8+!/'0!(#$;!>8/$!8/99+26!$(!$8+!+*/6$'<'$4n!
12<0+/6+6@!!Y(;!<(E9*'/2<+!'6!&+<0+/6+&!/2&!</22($!)'**!'$!#9;!L#$!(2<+!4(#!&(!)'**!$8+!*#2=!#9;!'$!
<(E+6!(#$!D#'<F*4!?elasticity increasesB@!!!
!
[:/E9*+-!9$!>'$8!6/0<('&!7!&'))!$(!)'**!*#2=6;!L#$!=+$!'$!(#$!)/6$!?&#+!$(!)'L0(6'6B@!Y(;!/**!IX.;!Rk;!
Ik!?/**!*#2=!</9/<'$'+6!8/M+!/**!+D#/**4!&+<0+/6+&B@!!T[k,ZTk.!(2!69'0(E+$+0!7!$/F+!/!&++9!
L0+/$8!?'+!9$!>'$8!6/0<('&B!7!T[k,!?/E(#2$!4(#!=+$!(#$!'2!(2+!6+<!7!2(0E/**4!'$!'6!^!*'$+06B!'6!
&+<0+/6+&;!Tk.!?$($/*!$8/$!=($!(#$!/)$+0!&++9!'269'0/$'(2B!'6!&+<0+/6+&!?LZ<!'2<0+/6+&!+*/6$'<'$4B!
7!$8'6!'6!$8+!6/E+!/6!T[k,;!6(!$8+!0/$'(!'6!()$+2!,@!!"(0E/**4;!$8+!Tk.!'6!e!*'$+06;!/2&!$8+!T[k,!'6!
2(0E/**4!^!*'$+06!7!6(;!$8+!2(0E/*!T[k,ZTk.!0/$'(!'6!^Ze!CtVW@!!SZ<!$8+!+*/6$'<'$4!'6!'2<0+/6+&;!
$8+!Tk.!'6!$8+!6/E+!/6!T[k,;!/2&!$8+0+)(0+!$8+!ratio is increased!$(!,!'26$+/&!()!V@t@!!
!
Examples of restrictive lung dzs:
1. Pneumoconiosis!7!/'0L(02+Z&#6$L(02+!&cQ6!7!)/E(#6!'2!L'=!<'$'+6!?X%;!"bB@!!.(*+!>(0F+0!
92+#E(<(2'(6'6!7!+69@!'2!>+6$!k'0='2'/ZJ+22;!8/M+!/2!/2$80(<($'<!9'=E+2$!$8/$!</#6+6!/!
)'L0(#6!0:2!'2!$8+!*#2=;!*+/&'2=!$(!0+6$0'<$'M+!*#2=!&c@!!N/M+!/2!'2<0+/6+&!'2<'&+2<+!()!IS;!
L#$!2($!</2<+0@!
!
2. Silicosis!7!Y/2&L*/6$+06!=+$!=0/))'$'!())!$8'2=6;!(0!>(0F!'2!)(#2&0'+6!/2&!&+/*!>'$8!0(<F6!
?'+!D#/0$cB;!/2&!L0+/F!$8+E!&(>2;!/2&!L0+/$8+!'2!&#6$;!*+/&'2=!$(!6'*'<(6+6B@!!N/M+!
2(&#*+6!'2!$8+!*#2=!$8/$!/0+!8/0&!8/6!0(<F!?*'$+0/**4B!LZ<!$8+0+!'6!D#/0$c!'2!$8+E!/2&!'$!
*((F6!*'F+!E+$/6$/$'<!&c!'2!$8+!*#2=!?6'*'</!&'(:'&+!7!>8'<8!'6!6/2&!'2!$8+!*#2=B!7!/=/'2;!
'2<0+/6+&!()!IS;!2($!</2<+0@!!1)!9$!8/99+26!$(!8/M+!08+#E/$('&!/0$80'$'6;!/2&!/*6(!8/6!
(2+!()!$8+6+!92+#E(<(2'(6'6!?'+!.(*+!>(0F+06B;!8/M+!/!9($+2$'/*!)(0!/!642&0(E+;!>8'<8!'6!
</**+&!</9*/2!642&0(E+@!!Caplan syndrome!<(26'6$6!()!08+#E/$('&!2(&#*+6!'2!$8+!*#2=!
?6/E+!/6!+:$+26(0!6#0)/<+6!'2!$8+!/0EB@!!R8+#E/$('&!/0$80'$'6!<(EE(2*4!'2M(*M+6!$8+!
*#2=!>'$8!)'L0(6'6@!!%2&!08+#E/$('&!2(&#*+6!</2!)(0E!'2!$8+!*#2=@!!The combo of
rheumatoid arthritis (rheumatoid nodules) in the lung, plus pneumoconiosis
(silicosis/asbestosis/Cole workers) = caplan syndrome.!!!
3. Asbestos!7!/6L+6$(6!)'L+06!*((F!*'F+!&#ELL+**6!?$8+0+)(0+!+c!$(!0+<(=2'c+B@!!I8+6+!/0+!
</**+&!)+00#='2(#6!L(&'+6@!!%6L+6$(6!)'L+06!<(/$+&!>'$8!'0(2;!$8+0+)(0+!</2!</**!$8+E!
147

+'$8+0!/6L+6$(6!L(&'+6!(0!)+00#='2(#6!L(&'+6@!!K.!9#*E(2/04!*+6'(2!/66(<!>'$8!/6L+6$(6!
'6!2($!</2<+0!7!'$!'6!/!)'L0(#6!9*/D#+!>'$8!/!9*+#0/;!>8'<8!'6!Lr!?2($!/!90+<#06(0!)(0!
E+6($8+*'(E/B@!!MC cancer assoc with asbestos = primary lung cancer, 2nd MCC
= mesothelioma, which is a malignancy of the serosal lining of the lungs. !1)!
4(#!/0+!/!6E(F+0!/2&!8/M+!/6L+6$(6!+:9(6#0+;!4(#!8/M+!/2!'2<0+/6+&!<8/2<+!()!=+$$'2=!
90'E/04!*#2=!</2<+0@!!I8'6!'6!/!=((&!+:/E9*+!()!642+0='6E!?($8+0!</#6+6!()!*#2=!</2<+0!
?Y..B!'2<*#&+!6E(F'2=;!/*<(8(*B@!!%6L+6$(6!O!6E(F+0!C!>'**!=+$!</2<+0@!!I8+0+!'6!2(!
'2<0+/6+&!'2<'&+2<+!()!E+6($8+*'(E/!>'$8!6E(F'2=!?2($!642+0='6$'<B@!![:/E9*+-!!R(()+0!
)(0!He!4+/06;!2(26E(F+0!?&(!$+**!4(#;!L#$!4(#!8/&!$(!F2(>!$8/$!He!4+/06!/=(;!/**!$8+!
0(()'2=!E/$+0'/*!8/&!/6L+6$(6!'2!'$U!'2!($8+0!9/0$6!()!"b;!E/24!L#'*&'2=6!>+0+!$(02!&(>2;!
/2&!$8+0+!>/6!/6L+6$(6!'2!$8+!0(()'2=!()!$8(6+!L#'*&'2=6;!>8'<8!>/6!'28/*+&!L4!E/24!
9+(9*+;!/2&!,VdPV!4+/06!*/$+0!$8+4!&+M+*(9+&!90'E/04!*#2=!</2<+0!(0!/2($8+0!
<(E9*'</$'(2!()!/6L+6$(6'6B@!!g8/$!>(#*&!8+!E(6$!*'F+*4!=+$n!J0'E/04!*#2=!</2<+0!
?90'E/04!9*+#0/*!9*/D#+!>/6!2($!$8+0+B@!!1)!8+!>/6!/!6E(F+0n!J0'E/04!*#2=!</2<+0@!!
K+6($8+*'(E/!$/F+6!HedPV!4+/06!$(!&+M+*(9@!!X#2=!</2<+06!$/F+!/L(#$!,V!4+/06!$(!
&+M+*(9@!!X#2=!</2<+06!/0+!E(0+!<(EE(2;!/2&!4(#!&'+!+/0*'+0@!!g8/$!'6!$8+!E/'2!</#6+!
()!/6L+6$(6!+:9(6#0+n!R(()+06!(0!9+(9*+!>(0F'2=!'2!/!2/M/*!68'94/0&!?LZ<!/**!$8+!9'9+6!'2!
$8+!68'9!/0+!'26#*/$+&!>'$8!/6L+6$(6B;!/*6(!'2!L0/F+!*'2'2=!()!</06!/2&!8+/&=+/0@!
!
4. Sarcoidosis =2nd MCC restrictive lung dz.

[:/E9*+-!!<*/66'<!:d0/4!7!*4E98!2(&+6!?8'*/0!*4E98!2(&+6!/0+!L'=B;!8/c'2+66!6++2;!$((;!
>8'<8!'6!'2$+06$'/*!)'L0(6'6@!!Sarcoid is a granulomatous dz!$8/$!8/6!"G!0+*/$'(268'9!$(!
'2)+<$'(2!?cause = unknownB@!!Causes a noncaseating granuloma!?2($!</6+/$'2=!
LZ<!2(!0+*/$'(268'9!$(!IS!/2&!646$+E'<!)#2=/*!'2)+<$'(26B@!!I8+!*#2=6!/0+!%Xg%bY!
'2M(*M+&!?*#2=6!/0+!$8+!90'E/04!$/0=+$!(0=/2B;!/2&!E(0+!<(EE(2!'2!L*/<F6@!![:/E9*+-!!
L*/<F!9+06(2;!Pe!4Z(;!>'$8!&4692+/;!6++!8'*/0!2(&+6!(2!:d0/4;!#M''$'6!?L*#004!M'6'(2!7!$8'6!
'6!'2)*/EE/$'(2!()!$8+!#M+/*!$0/<$!7!$8'6!&c!/*>/46!/))+<$6!6(E+$8'2=!'2!$8+!)/<+;!/2&!$8+!
)/<+!$8+!H2&!K.!6'$+!/!*+6'(2!>'**!(<<#0!>'$8!$8'6!&c;!</2!/*6(!'2M(*M+!6/*'M/04!=*/2&6!(0!
*/<0'E/*!=*/2&6!7!6(E+$8'2=!'2!$8+!8+/&Z2+<FZ)/<+!/0+/!?L+8'2&!$8+!*#2=6B@!!I8'6!&c!'6!/!
&:!()!+:<*#6'(2;!$8+0+)(0+!E#6$!0#*+!(#$!/24$8'2=!$8/$!</#6+6!=0/2#*(E/!?IS;!N'6$(B;!
/*(2=!>'$8!$8+!<(00+<$!9846'</*!90+6+2$/$'(2!C!Y/0<('&(6'6@!!Rx = steroids@!!%.[!
+2c4E+6!/0+!M+04!8'=8!'2!$8+6+!9$6!LZ<!=0/2#*(E/6!'2!F'&2+4U!hypercalcemia!7!
E/<0(98/=+6!?+9'$8+*('&!<+**6B!E/F+!,d/*98/d84&0(:4*/6+@!!1)!$8+4!/0+!E/F'2=!,d/*98/d
84&0(:4*/6+;!>8/$!'6!$8+!E+<8!()!849+0</*<+E'/n!N49+0M'$/E'2(6'6!_@!!4(#!/0+!6+<(2&!
84&0(:4*/$'(2!E(0+!M'$!_!/2&!$8+0+)(0+!8/M+!+:<+66!M'$!_;!/2&!M'$!_!90(E($+6!
0+/L6(09$'(2!()!</*<'#E!/2&!98(698(0#6;!*+/&'2=!$(!849+0</*<+E'/@!!This is the MC
noninfectious cause of granulomatous hepatitis (TB is the MCC of infectious
hepatitis, 2nd MC = pneumoconiosis).!
!
5. Hypersensitivity pneumonitis (farmers lung, silofillers dz, bysinosisB!
I8+6+!/0+!0+6$0'<$'M+!*#2=!&cQ6@!!_(2Q$!<(2)#6+!)/0E+0Q6!*#2=!/2&!6'*()'**+06!&c!7!$8+4!/0+!
SGIN!6++2!'2!)/0E+06@!!Y(;!0+E+EL+0!(2+;!$8+!($8+0!'6!$8+!($8+0m!
!
Silofillers dz 9#$!$8'2=6!'2!6'*(6;!>8'<8!'6!/!<*(6+&!69/<+;!/2&!)+0E+2$/$'(2!()!=/6!
(<<#06;!$8+!=/6!'6!2'$0(=+2!&'(:'&+!7![:/E9*+-!!)/0E+0!>+2$!'2$(!/!0((E!'2!8'6!L/02!
/2&!6#&&+2*4!&+M+*(9+&!>8++c'2=!/2&!&4692+/;!>84n!SZ<!8+!$((F!'2!2'$0(=+2!
&'(:'&+;!>8'<8!'6!/!)+0E+2$'2=!90(L*+E@!!?6'*(!</2!+:9*(&+!LZ<!=/6!)0(E!
)+0E+2$/$'(2B@!
!
148

Farmers lung thermophilic actinomyces (a mold).
[:/E9*+-!!(2!$0/<$(0;!&#6$!L+'2=!L*(>2!#9!'2!$8+!/'0!/2&!$8+0E(98'*'<!/<$'2(E4<+6!
?>8'<8!'6!/!E(*&B!'6!'28/*+&U!*+/&'2=!$(!849+06+26'$'M'$4!/2&!NJb!92+#E(2'$'6!/2&!
$8+4!+2&!#9!>'$8!/!0+6$0'<$'M+!*#2=!&c@!
!
Bysinosis!7!>(0F+0!'2!$+:$'*+!'2&#6$04;!/2&!$8+4!=+$!&4692+/@!!I8+6+!/0+!$8+!NJb!/2&!
0+6$0'<$'M+!*#2=!&cQ6@!
!
Goodpasture syndrome
S+='26!'2!$8+!*#2=6!>'$8!/!0+6$0'<$'M+!*#2=!&c!?>'$8!<(#=8'2=!#9!L*((&!7!8+E(9$46'6B;!
/2&!+2&6!#9!M+04!68(0$*4!>'$8!0+2/*!&c!?$8+0+)(0+;!'$!6$/0$6!'2!$8+!*#2=!/2&!+2&6!'2!$8+!
F'&2+46B@!!I8'6!'6!/!0+6$0'<$'M+!*#2=!&c@!
!
VIII. Obstructive lung Dz
A. Deals with compliance/elasticity concept
In obstructive lung dz, no prob getting air in, but have a problem in getting the
air out.!!g84!&(2Q$!4(#!8/M+!/!90(L*+E!=+$$'2=!'$!'2n!SZ<!$8+!+*/6$'<!$'66#+!6#99(0$!'6!
&+6$0(4+&;!6(!'$!'6!M+04!+c!$(!)'**!#9!$8+!*#2=6@!!N(>+M+0;!LZ<!$8+!+*/6$'<!$'66#+!6#99(0$!'6!
&+6$0(4+&;!'$!'6!M+04!&'))'<#*$!8/0&!$(!=+$!'$!(#$!LZ<!'$!<(**/96+6!(2!+:9'0/$'(2;!6(!4(#!</2!=+$!
/'0!'2;!L#$!</22($!=+$!/'0!(#$@!!12!/!9$!>'$8!(L6$0#<$'M+!/'0!&c;!$8+4!L0+/$8+!'2!>'$8!2(!
90(L*+E;!L#$!8/M+!$0(#L*+!=+$$'2=!'$!(#$@!!Y(;!6(E+$8'2=!'6!*+)$!(M+0!'2!$8+!*#2=!7!</22($!=+$!
/**!$8+!/'0!(#$;!$8+0+)(0+!$8+!0+6'&#/*!M(*#E+!'6!'2<0+/6+&!?>8+2+M+0!6(E+$8'2=!'6!*+)$!(M+0;!'$!
'6!</**+&!$8+!]0+6'&#/*QB@!!Y(;!')!4(#!</22($!=+$!/'0!(#$;!$8+2!$8+!0+6'&#/*!M(*#E+!'2<0+/6+6;!
>8'<8!E+/26!$8/$!$8+!IX.!>'**!'2<0+/6+;!>8'<8!E+/26!$8/$!$8+!&'/980/=E!>'**!=(!&(>2!LZ<!
/6!$8+!*#2=6!/0+!(M+0!'2)*/$+&;!/2&!$8+!%J!&'/E+$+0!>'**!=(!(#$@!!Y(;!>'$8!(L6$0#<$'M+!*#2=!&c;!
4(#!8/M+!'2<0+/6+&!%J!&'/E+$+0!/2&!&'/980/=E6!=(!&(>2!?&+90+66+&B@!!I8+0+!'6!(2*4!/!
<+0$/'2!/E(#2$!()!+:9/26'(2!4(#0!<8+6$!</2!=(@!![M+2$#/**4;!$8+!<8+6$!6$/0$6!$(!<(E90+66!
($8+0!M(*#E+6!?/6!4(#!$0/9!/'0!/2&!0+6'&#/*!M(*#E+6!=(!#9B@!!Y(;!$'&/*!M(*#E+!6$/0$6!
&+<0+/6'2=;!M'$/*!</9/<'$4!=(+6!&(>2!LZ<!$8+!0+6'&#/*!M(*!'6!'2<0+/6'2=!/2&!4(#!/0+!
<(E90+66'2=!($8+0!M(*#E+6@!!So, TLC and RV increases, everything else decreases.!!
G2!69'0(E+$+0;!T[k,!'6!M+04!*(>!?#6#/**4!,!7!2(0E/**4!'$!'6!^B@!!12!($8+0!>(0&6;!4(#!8/M+!/!
L+$$+0!T[k,!>'$8!0+6$0'<$'M+!*#2=!&c!LZ<!4(#!</2!=+$!/'0!'2@!!I8+!Tk.!?$($/*!/E$!$8+4!</2!=+$!
(#$B!'6!P!*'$+06!?M6@!e!*'$+06B@!!When you do a ratio of FEV1/FVC, the ratio has
decreased, hence distinguishing restrictive from obstructive dzs.!!!
!
Classic COPD x-ray-!8/0&!$(!6++!$8+!8+/0$;!>'$8!&+90+66+&!&'/980/=E6!?/$!*+M+*!()!
#EL'*'<#6B;!'2<0+/6+&!%J!&'/E+$+0!7!&:n!.*/66'<!(L6$0#<$'M+!&c!:d0/4!7!90(L!=+$$'2=!/'0!(#$;!
$8+0+)(0+!$8+!&'/980/=E!'6!&(>2!/2&!%J!&'/E+$+0!'6!'2<0+/6+&@![:/E9*+-!!P!E(2$8!(*&!</2!
8/M+!$8'6!6/E+!)'2&'2=!&#+!$(!RYk!
[:/E9*+-!!"+>L(02!>'$8!.8*/E4&'/!$0/<8(E/$'6!92+#E(2'/!LZ<!8+!'6!$0/99'2=!/'0@!!!
!
B. There are 4 type of obstructive lung dzs: chronic bronchitis, bronchiectasis,
emphysema, asthma@!!I8+!(2+6!/66(<'/$+&!>'$8!6E(F'2=!/0+!L0(2<8'$'6!/2&!+E9846+E/@!!!
!
1. Chronic Bronchitis
Purely a clinical dx = Pt has productive cough for 3 months out of the year for
2 consecutive years. g8+0+!'6!$8+!&cn!I+0E'2/*!L0(2<8'(*+6!?4(#!8/M+!E/'2!6$+E!
L0(2<8#6;!6+=E+2$/*!L0(2<8';!$+0E'2/*!L0(2<8'(*+6;!0+69!L0(2<8'(*+6;!/*M+(*/0!&#<$6;!
149

/*M+(*'B@!!%6!6((2!/6!4(#!8'$!$8+!$+0E'2/*!L0(2<8'(*+6;!$8+6+!/0+!6E/**!/'0>/4U!'$!'6!/**!
$#0L#*+2$!/'0!#9!$(!$+0E'2/*!L0(2<8'(*+6@!!%)$+0!$8/$;!'$!'6!9/0/**+*!L0/2<8'2=!()!$8+!
/'0>/46@!I8+!$#0L#*+2$!/'0!8'$6!$8+!$+0E'2/*!L0(2<8'(*+6!/2&!$8+2!8'$6!/!E/66'M+!<0(66!
6+<$'(2/*!/'0>/4!>8+0+!4(#!</2!=(!&'))!9/$8Q6!LZ<!9/0/**+*!L0/2<8'2=!()!$8+!6E/**!/'0>/46@!!
Y(;!$8+!/'0)*(>!<8/2=+6!)0(E!$#0L#*+2$!$(!*/E'2/0!/'0)*(>@!!S4!$8+!$'E+!4(#!8'$!$8+!0+69!
#2'$;!'$!'6!2($!E(M'2=!$8+!/'0@!!Most small airway dzs are inflammation of the
terminal bronchioles, leads to wheeze.!!I+0E'2/*!L0(2<8'(*+6!/0+!$8+!6'$+!()!<80(2'<!
L0(2<8'$'6@!I8'6!'6!$8+!6/E+!/0+/!/6!/6$8E/!/2&!L0(2<8'(*'$'6@!!K(0+!90(:!$(!$8+!$+0E'2/*!
L0(2<8'(*+6;!'2!L0(2<8'$'6;!4(#!>'**!=+$!/!E#<#6!=*/2&!849+09*/6'/;!/2&!/!*($!()!<0/9!'6!
<(E'2=!#9!?$8/$Q6!$8+!90(&#<$'M+!9/0$B@!!I8+!/<$#/*!/0+/!()!(L6$0#<$'(2!'6!$8+!$+0E'2/*!
L0(2<8'(*+@!!N/M+!=(L*+$!<+**!E+$/9*/6'/!/2&!E#<(#6!9*#=6@!!I8'2F!/L(#$!8/M'2=!(2+!
$+0E'2/*!L0(2<8'(*+!/2&!(2+!E#<(#6!9*#=!7!$8'6!'6!/))+<$'2=!/!E/3(0!<0(66!6+<$'(2/*!/0+/!
()!*#2=!LZ<!/**!$8+!9/0/**+*!L0/2<8+6!$8/$!&+0'M+!)0(E!8+0+!>'**!2($!8/M+!.GH!'2!$8+E;!/2&!
$8+4!/0+!$04'2=!$(!=+$!/'0!9/6$!$8+!E#<(#6!9*#=;!L#$!</22($@!!Y(;!there is a HUGE ventperfusion mismatch@!!I8'6!'6!>84!$8+4!/0+!called blue boaters they are
cyanotic@!!I8+4!8/M+!E#<(#6!9*#=6!'2!$8+!$+0E'2/*!L0(2<8'(*+6!/2&!</22($!0'&!.GH@!
2. Emphysema
!
"($!'2!$8+!$+0E'2/*!L0(2<8'(*+6@!!1$!'6!'2!$8+!0+69!#2'$!?resp unit is where gas
exchange occurs!7!</22($!+:<8/2=+!=/6!'2!$8+!$+0E'2/*!L0(2<8'(*+6!7!/F/!2(20+69!
L0(2<8'(*+BU!'$!'6!$8+!90'E/04!9*/<+!)(0!+:9'0/$(04!>8++c+!/2&!6E/**!/'0>/4!&c;!8(>+M+0@!!
Gas exchange occurs in the resp bronchiole, resp alveolar duct and alveoli@!!
G2*4!2++&!$(!F2(>!2 emphysemas: centrolobular and panacinar@!![E9846+E/!
/))+<$6!=/6!+:<8/2=+!/2&!>8+0+!'$!/))+<$6!$8+!/'0>/4!'6!E(0+!&'6$/*;!<(E9/0+&!$(!<80(2'<!
L0(2<8'$'6!?90(:'E/*B@!!Y(;!>8+2!4(#!8/M+!+E9846+E/!>'$8!/**!$8+!'2)*/EE/$'(2!
/66(<'/$+&!>'$8!'$;!2($!(2*4!&+6$0(4!$8+!0+69!#2'$;!L#$!/*6(!$8+!M/6<#*/$#0+!/66(<'/$+&!
>'$8!'$@!!I8+0+)(0+;!there is an even loss of ventilation and perfusion. So, will
NOT have retention of CO2 in these pts. g8+2!4(#!8/M+!/!90(L*+E!>'$8!/!E#<(#6!
9*#=!'2!$8+!$+0E'2/*!L0(2<8'(*+;!>8'<8!'6!>/4!E(0+!90(:!/2&!/!=0+/$!<0(66!6+<$'(2/*!/0+/!
()!$8+!*#2=!'6!/))+<$+&;!$8+0+!'6!=(22/!L+!/!90(L*+E!$8+0+U!8(>+M+0!>8+2!4(#!/0+!(#$!
$8'6!)/0!?'2!+E9846+E/B!/2&!/*6(!&+6$0(4'2=!$8+!M+66+*6;!4(#!will not have an
increase in CO2@!!I8'6!'6!>84!$8+4!/0+!</**+&!pink puffers;!/2&!$8'6!'6!>84!E/24!()!
$8+E!8/M+!0+69!/*F/*(6'6@!!!
!
a) Centrolobular most associated with smoking and involved with the
upper lobes.!!Y(;!'$!'6!/2!#99+0!*(L+!+E9846+E/;!/2&!$8+!90'E/04!9(0$'(2!()!$8+!
0+69!#2'$!$8/$!'6!&+6$0(4+&!'6!$8+!0+69!L0(2<8'(*+!?$8'6!'6!$8+!M+04!)'06$!$8'2=!$8/$!
6E(F+!8'$6B@!!"+#$0(98'*6!>'**!&/E/=+!'$!LZ<!/**!9+(9*+!$8/$!6E(F+!8/M+!E(0+!
2+#$0(98'*6!'2!$8+'0!*#2=6;!/2&!6E(F+!'6!<8+E($/<$'<!)(0!2+#$0(98'*6@!!%XX!6E(F+06!
8/M+!'2<0+/6+&!2+#$0(98'*6!'2!$8+'0!*#2=6@!!g8/$!&(+6!/*98/d,!/2$'$0496'2!&(n!1$Q6!/2!
/2$'+*/6$/6+!?'$6!(2*4!9#09(6+!'6!$(!&+6$0(4!+*/6$/6+6!90(&#<+&!L4!2+#$0(98'*6!7!$8/$!'6!
'$6!)#2<$'(2@!!1)!4(#!/0+!/!6E(F+0;!$8/$!'6!&+2/$#0+&@!Y(;!4(#!/*6(!8/M+!/2!/<D#'0+&!
/*98/d,!/2$'$0496'2!&+)B@!!_(2Q$!8/M+!/&+D#/$+!/*98/d,!/2$'$0496'2;!/2&!8/M+!$((!
E/24!2+#$0(98'*6!'2!$8+!*#2=6@!!I8'6!'6!/!$+00'L*+!<(EL(@!!I8'6!>84!2+#$0(98'*6!8/M+!
2(!90(L*+E!'2!&+6$0(4'2=!$8+!+*/6$'<!$'66#+!6#99(0$!()!$8+!0+69'0/$(04!L0(2<8'(*+6@!!
Y(;!4(#!L0+/$8!/'0!'2;!>8'<8!'6!2(!90(L*+EU!L#$!4(#!$04!$(!=+$!'$!(#$;!/2&!$8+0+!'6!2(!
+*/6$'<!$'66#+!6#99(0$!/2&!*+/&6!$(!*#2=!+:9/26'(2!7!$8'6!'6!>84!L*+L6!/0+!)(#2&!7!
$8+0+!/0+!L'=!<46$'<!69/<+6!'2!$8+!*#2=!7!'$!8/6!$0/99+&!/'0!'2!$8+0+!LZ<!$8+0+!'6!2(!
150

+*/6$'<!$'66#+;!6(!>8+2!'$!$0'+6!$(!=+$!L4;!'$!3#6$!+:9/2&6@!!I8'6!'6!centrolobular
emphysema of the UPPER lobes@!
!
b) Panacinar Emphysema!?0+E+EL+0!]9/2Q!E+/26!+M+04$8'2=!7!'+!'2!9/2<4$(9+2'/;!
%XX!$8+!<+**6!&+<0+/6+&B@!!Y(;!9/2/<'2/0!E+/26!$8/$!$8+!["I1R[!0+69!#2'$!'6!&+<0+/6+&!
LZ<!'$!'6!/66(<'/$+&!>'$8!NO alpha 1 antitrypsin@!!I8'6!'6!/!=+2+$'<!&c!7!/#$(!0+<! the
LIVER does not make it@!!Y(;!/$!/!4(#2=!/=+;!4(#!&+M+*(9!&+6$0#<$'(2!()!+2$'0+!0+69!
#2'$!()!$8+!XGg[R!*(L+6;!so this is a LOWER lobe emphysema@!!Y(;!4(#!</2!6++!$8/$!
$8+!0+69!L0(2<8'(*+6!/0+!F2(<F+&!(#$;!$8+!/*M+(*/0!&#<$6!/0+!F2(<F+&!(#$;!/*M+(*'!
F2(<F+&!(#$@!!Y(;!4(#!L0+/$8+!'2;!/2&!$8'6!+2$'0+!0+69!#2'$!</$<8+6!'$!7!$8'6!'6!'2!$8+!*(>+0!
*(L+6@!!!
!
YE(F+06;!>8'<8!8/M+!/2!/<D#'0+&!/*98/d,!/2$'$0496'2!&+);!</2!=+$!/2!+*+E+2$!()!
9/2/<'2/0!+E9846+E/!'2!$8+!*(>+0!*(L+6;!$((@!!Y(;!6E(F+06!</2!=+$!H!+E9846+E/Q6-!
<+2$0(*(L#*/0!+E9846+E/!'2!$8+!#99+0!*(L+6!?>8'<8!F2(<F6!())!$8+!0+69!L0(2<8'(*+B!
/2&!'2!$8+!*(>+0!*(L+6;!=+$!/!9/2/<'2/0!$49+!()!9/$$+02@!!I8+0+)(0+;!</2!=+$!#99+0!
%"_!*(>+0!*(L+!+E9846+E/;!/2&!H!&'))!$49+6!()!+E9846+E/@!!!
!
3. Bronchiectasis
N/M+!L0(2<8'+<$/6'6!7!6++!L0(2<8'!=('2=!(#$!$(!$8+!9*+#0/!?/L2(0E/*B@!!g8+2!4(#!6++!
L0(2<8'!=('2=!(#$!)#0$8+0!$8/2!$8+!8'*#E;!$8'6!'6!L0(2<8'+<$/6'6@!!!
Mech: infection, destruction of the elastic tissue support, dilatation of the
airways@!!Y+=E+2$/*!L0(2<8'U!)'**!>'$8!9#6@!![:/E9*+-!!9$!8/6!/!90(&#<$'M+!<(#=8!()!
i<#9)#*6j!?2($!3#6$!/!$/L*+69((2B!()!9#6;!LZ<!$8+4!/0+!$0/99+&@!!!
!
/B!./#6+6-!
,B!K..!L0(2<8'+<$/6'6!'2!\Y%!C!cystic fibrosis.!1)!9/0+2$!>'$8!<8'*&!8/6!<46$'<!
)'L0(6'6;!>'**!6++!8#=+!9#6!<(E'2=!(#$!()!L0(2<8';!/!<(#9*+!$'E+6!9+0!&/4@!!
HB!K..!L0(2<8'+<$/6'6!'2!P0&!>(0*&!<(#2$0'+6!C!TB@!
!
PB!Kartageners syndrome!?/F/!'EE($'*+!<'*'/!642&0(E+B@!!rOH!<(2)'=#0/$'(2!
/00/2=+E+2$!>'$8!<'*'/!/2&!E'<0($#L#*+6@!!I8+!90(L*+E!>'$8!'EE($'*+!<'*'/!642&0(E+!
'6!/2!/L6+2$!&42+'2!/0E@!!I8+!r!E'<0($#L#*+6!(2!$8+!(#$6'&+!8/M+!/0E6!$8/$!F++9!
$8+E!$(=+$8+0!7!$8+6+!&42+'2!/0E6!/0+!E'66'2=@!!Y(;!>8+2!$8+6+!/0E6!/0+!E'66'2=;!
$8+!<'*'/!</22($!E(M+@!!Y(;!$8+!9*/<+6!>'$8!<'*'/!2($!E(M'2=!/0+!/))+<$+&-!$8+6+!9*/<+6!
/0+!6'2#6+6!?>84!sinusitis!'6!/!90(L*+EB;!bronchiectasis!?LZ<!$8+0+!'6!<'*'/!7!
96#+&(6$0/$')'+&!<(*#E2/0!+9'$8+*'#E!'6!/))+<$+&B;!E/*+6!/2&!)+E/*+6!/0+!infertile!
?LZ<!$8+!$/'*!(2!$8+!69+0E!</22($!E(M+!7!$8+!$/'*!'6!/!E(&')'+&!<'*'/!7!$8+4!8+/&!'6!
E(M'2=;!L#$!$8+!$/'*!'6!>+/F@!!g(E+2!/0+!'2)+0$'*+U!$((;!LZ<!$8+!)/**(9'/2!$#L+!2++&6!
<'*'/!$(!</004!$8+!+==!&(>2@!!Organs are located on the opposite side
(dextrocardia, withOUT transposition of great vessels).
!
4. Asthma
./2!L+!+:$0'26'<!?$49+!,!NJbB!/2&!'2$0'26'<-!!12M(*M+6!<8+E'</*6!7!9+(9*+!'2!$8+!
>(0F9*/<+!</2!=+$!$0'/&!/6$8E/;!>8'<8!'2M(*M+6!9+(9*+!$/F'2=!"Y%1_6!!K/24!9+(9*+;!'+!
/$8*+$+6!>'**!=+$!+:+0$'(2/*!/6$8E/!/2&!>8++c+!7!<0(E(*42!"/!'6!$8+!_G.!)(0!$8+6+!
9/$'+2$6@!!.(*&!$+E96!</2!</#6+!/6$8E/@!!I49+!1!NJb!8/6!2($8'2=!$(!&(!>'$8!$8+6+!
</#6+6!()!/6$8E/@!!I8+!>8++c'2=!'6!&#+!$(!'2)*/EE/$'(2!()!$8+!$+0E'2/*!L0(2<8'(*+6!7!'$!
151

'6!2($!&#+!$(!6E(F'2=;!L#$!LZ<!)/<$(06!*'F+!XI!.^;!_^;![^;!JlQ6!</#6'2=!'2)*/EE/$'(2!/2&!
2/00(>'2=!()!$8+!/'0>/46@!!!
IX. Lung Cancer
A. Peripherally located vs. centrally located
1. Centrally located (mainstem bronchus):
N/M+!$8+!8'=8+6$!/66(<'/$'(2!>'$8!6E(F'2=@!12<*#&+!6D#/E(#6!<+**!</0<'2(E/!/2&!6E/**!
<+**!</0<'2(E/@!!I8+6+!/0+!=+2+0/**4!<+2$0/**4!*(</$+&;!8+2<+!E/'26$+E!L0(2<8#6!$49+6!()!
*(</$'(26@!!YD#/E(#6!<+**!/0+!E(0+!<(EE(2!$8/2!6E/**!<+**!</0<'2(E/6@!!
2. Peripherally located:
Adenocarcinomas!?$8+!E(0+!<(EE(2!90'E/04!*#2=!</2<+0;!E(0+!<(EE(2!$8/2!
6D#/E(#6B!/0+!E(0+!9+0'98+0/*!$8/2!<+2$0/*@!!Y8')$+&!$(!$8+!9+0'98+04!LZ<!()!$8+!)'*$+06!()!
$8+!<'=/0+$$+6@!!I8+!)'*$+06!90+M+2$+&!$8+!*/0=+!</0<'2(=+26!)0(E!9/66'2=!'2;!L#$!$8+!6E/**!
</0<'2(=+26!6$'**!9/66+&!$80(#=8;!/2&!$8+4!/0+!2($!$0/99+&!'2!$8+!E/'2!6$+E;!L#$!$0/99+&!
'2!$8+!9+0'98+04@!!!
!
I8+0+!/0+!/$!*+/6$!P!(0!^!$49+6!()!/&+2(</0<'2(E/@!!G2+!(LM'(#6*4!&(+6!8/M+!/!6E(F'2=!
0+*/$'(268'9;!>8'*+!$8+!($8+06!&(!2($@!!I8+!(2+6!$8/$!&(!2($!8/M+!/!6E(F'2=!0+*/$'(268'9!
'2<*#&+!L0(2<8'(*/0!/*M+(*/0!</0<'2(E/;!/2&!*/0=+!<+**!/&+2(</0<'2(E/!()!$8+!*#2=!?6</0!
</2<+06B@!!!
!
B. Cytology:!F2(>!>8/$!6D#/E(#6!</2<+0!*((F6!*'F+!>'$8!/!9/9!6E+/0@!!%!*($!()!9+(9*+!$8'2F!
$8/$!$8+!J/9/2'<(*/(#!6$/'2!'6!(2*4!&(2+!)(0!<+0M'</*!</0<'2(E/@!I8'6!'6!2($!$8+!</6+@!!This is a
famous stain!?9/9!6E+/0B!used for all cytological specimens on for all organs.!!The
stain stains keratin bright red.!!Y*'&+-!?9'<B!9$!$8/$!'6!/!6E(F+0!>'$8!/!<+2$0/**4!*(</$+&!
E/66@!!Y8(>'2=!69#$#E!6/E9*+!>'$8!/!J/9/2'<(*/(#!?9/9!6E+/0B!6$/'2!7!8/6!0+&!F+0/$'2;!>8'<8!
'6!6D#/E(#6!<+**!</0<'2(E/@!1)!$8'6!>+0+!/!<+0M'</*!9/9!6E+/0!)0(E!/!>(E/2!$8/$!'6!^V!4+/06!()!
/=+;!$8'6!'6!6D#/E(#6!<+**!</0<'2(E/@!!I8+!F+0/$'2!'6!6$/'2'2=!L0'=8$!0+&m!?L0'=8$!0+&!<4$(9*/6E!C!
F+0/$'2!C!6D#/E(#6!<+**!</0<'2(E/B@!J/9/2'<(*/(#!6$/'26!F+0/$'2!L0'=8$!0+&@!!!
!
[:/E9*+-!6E/**!<+**6!$8/$!*((F!*'F+!*4E98(<4$+6!7!$8'6!'6!small cell carcinoma@!!I8'6!'6!E(0+!
&'))'<#*$!$(!&:;!LZ<!6(E+$'E+6!&'))!$(!$+**!$8+!&'))+0+2<+!)0(E!*4E98(<4$+6@!Y*'&+!68(>6!E/*'=2/2$!
<+**6@!!YE/**!<+**!</0<'2(E/!'6!$8+!E(6$!E/*'=2/2$!</2<+0!()!$8+!*#2=@!!R:n!R/&'/$'(2!/2&!<8+E(!
?2($!6#0=+04B@!!These are auput tumors with neurosecretory granules and S-100 Ag
positive. I8+4!</2!E/F+!%_N!/2&!%.IN@!!!
!
%!6*'=8$*4!*+66!E/*'=2/2$!$#E(0!>'$8!/#9#$!(0'='2!'6!$8+!bronchiocarcinoid@!!1$!'6!/!*(>!=0/&+!
E/*'=2/2<4!()!$8+!6/E+!$49+6!()!<+**6!$8/$!90(&#<+!6E/**!<+**!</0<'2(E/@!!Y(;!$8+4!</2!'2M/&+;!
E+$;!/2&!90(&#<+!</0<'2('&!642&0(E+!')!$8+4!E/F+!'2<0+/6+&!/E(#2$!()!6+0($(2'2@!!I8+4!&(2Q$!
8/M+!$(!E+$6!$(!90(&#<+!</0<'2('&!642&0(E+!7!'$!3#6$!=(+6!6$0/'=8$!'2$(!$8+!L*((&6$0+/E@!!1$!'6!
M+04!#2<(EE(2@!
!
!
C. Cancer:
K.!</2<+0!()!*#2=!C!E+$6!7!'+!6++!E/24!E+$/6$/$'<!2(&#*+6!/**!(M+0!*#2=U!')!4(#!9*/4!(&&6;!
>8/$!'6!$8+!90'E/04!</2<+0n!L0+/6$!?>8'<8!$8+!K.!E+$!$(!$8+!*#2=;!(0!'2!($8+0!>(0&6;!'$!'6!
$8+!K.!</2<+0!()!$8+!*#2=B@!
!
152

Summary of lung cancer in the lung:
MC cancer = mets
MC primary cancer = primary adenocarcinoma of the lung, followed by squamous
and small cell carcinoma.
Worst cancer (worst prognosis): small cell carcinoma.
!
Horners syndrome!7!9/2<(/6$!$#E(0Z6#9+0'(0!6#*<#6!$#E(0!7!$#E(06!$8/$!/0+!'2!$8+!#99+0!*(L+!
9(6$+0'(0*4!?'2!9(6$!E+&'/6$'2#EBU!E(6$!()!$8+!$'E+!'6!</#6+&!L4!6D#/E(#6!</0<'2(E/!'2!$8/$!/0+/@!
g8/$Q6!8/99+2'2=!8+0+n!I#E(0!'6!*(</**4!'2M/&'2=!'2$(!$8+!*(</*!9/0$!()!$8+!*(>+0!$0#2F!()!$8+!
L0/<8'/*!9*+:#6;!6(!</2!=+$!*(>+0!$0#2F!L0/<8'/*!9*+:#6!*'F+!)'2&'2=6;!/2&!</2!/*6(!/))+<$!$8+!6#9+0'(0!
<+0M'</*!=/2=*'(2@!!I8'6!'6!'2!$8+!9(6$+0'(0!E+&'/6$'2#E;!$8+0+)(0+!>'**!+2&!#9!>'$8!N(02+0Q6!
642&0(E+U!/6!/!0+6#*$;!>'**!+2&!#9!knocking OFF sympathetic activity!7!ptosis!?*'&!'6!*(>+0B;!
anhydrous!?*/<F!()!6>+/$'2=B;!miosis!?'2!64E9/$8+$'<;!>8'<8!'6!)'=8$!(0!)*'=8$;!2(0E/**4!8/M+!
E4&0'/6'6;!>8'<8!&'*/$+6!$8+!9#9'*!7!>'$8!)'=8$!(0!)*'=8$;!>/2$!/6!E#<8!*'=8$!/6!9(66'L*+;!$8+0+)(0+!
&'*/$'2=!9#9'*;!L#$!$8'6!'6!<#$!());!*+/&'2=!$(!E'(6'6B@!!_(!2($!<(2)#6+!>'$8!Yk.!642&0(E+U!$8'6!'6!3#6$!
L*(<F'2=!())!Yk.@!
!
K4/6$8+2'/!8/6!$(!&(!>'$8!$84E(E/;!>8'<8!'6!*(</$+&!'2!$8+!/2$+0'(0!E+&'/6$'2#E@!
!
[:#&/$+!M6@!$0/26#&/$+!?y!P!=0/E6;!>'$8(#$!E/24!<+**6!'2!'$B!
K..!9*+#0/*!+))#6'(2!&#+!$(!$0/26#&/$+!C!NT!
!
[:#&/$+!C!90($+'2!u!P!=0/E6;!/2&!8/6!<+**6!'2!'$!?'+!92+#E(2'/Q6;!9#*E(2/04!'2)/0<$'(2B!
153

CHAPTER 9: GI
I. Diseases of the Mouth
A. Herpes simplex; N+09+6!*/L'/*'6d?)+M+0!L*'6$+06!/2&!<(*&!6(0+6BU!90'E/04!8+09+6!'6!/!
646$+E'<!'2)+<$'(2@!!N/M+!)+M+0;!M'0+E'/;!=+2+0/*'c+&!*4E98/&+2(9/$84;!/2&!=(+6!/>/4U!'$!
6$/46!'2!$8+!6+26(04!=/2=*'/!?&(0E/2$!'2!$8+!6+26(04!=/2=*'/B!7!+M+04!2(>!/2&!$8+2!'$!</2!
<(E+!(#$!>'$8!6$0+66;!E+26+6;!>8/$+M+0;!/2&!>'**!)(0E!M+6'<*+6@!!R+<#00+2$!8+09+6!'6!2(!
*(2=+0!646$+E'<!7!$8+0+!'6!2(!E(0+!)+M+0;!/2&!2(!E(0+!*4E98/&+2(9/$84@!!G$8+0!M'0#6!$8/$!
0+E/'2!*/$+2$!7!8+09+6!c(6$+0!7!0+E/'26!*/$+2$!'2!$8+!6+26(04!=/2=*'/U!</2!'2M(*M+!$8+!6F'2;!
*'96;!&+0E/$(E+6@!Y(;!primary herpes is systemic, recurrent herpes is not. (No fever
= no lymphadenopathyB@1)!>+!+20(($!/2&!6$/'2;!>'**!6++!'2<*#6'(2!'2!8+09+6!7!'$!'6!/!
E#*$'2#<*+/$+&!<+**!>'$8!'2$+02#<*+/0!'2<*#6'(26@!!S'(964!()!/!E#*$'2#<*+/$+&!<+**!)0(E!/!9$!
>'$8!N1k;!>'$8!E#*$'9*+!'2$+02#<*+/0!'2<*#6'(26!7!8+09+6!+6(98/='$'6@!!!
!
B. Hairy Leukoplakia
I8'6!'6!2($!/2!%1_6!&+)'2'2=!*+6'(2;!L#$!1Y!/!90+%1_6!$49+!()!'2)+<$'(2!7!/6!'6!$80#68;!
68'2=*+6@!!X(</$+&!(2!$8+!*/$+0/*!L(/0&+0!()!$8+!$(2=#+@!!N/6!2($8'2=!$(!&(!>'$8!&469*/6'/!
?*+#F(9*/F'/B@!!1$!'6!/!0+6#*$!()!/2!infection from EBV@!!Y(;!&(!2($!=+$!$8+!'&+/!$8/$!'$!'6!/!
90+2+(9*/6$'<!*+6'(2@!!Y$/0$!6++'2=!$8'6!L+)(0+!$8+!8+*9+0!I!<+**!<(#2$!=+$!$(!HVV@!!R:!d!
%<4<*(M'0!
!
C. Thrush (oral candidiasis)

12!/2!/&#*$;!$8+0+)(0+!</2!/66#E+!$8/$!'$!'6!'2!/2!'EE#2(<(E90(E'6+&!9/$'+2$;!>8+0+!$8+0+!
'6!/!&+)+<$!'2!<+**#*/0!'EE#2'$4@!!12!F'&6!?2+>L(026B;!$8+4!</2!=+$!'$!)0(E!$8+!E(E!(2!$8+!
>/4!(#$@!N(>+M+0;!'$!'6!2($!/!6'=2!()!'EE#2(<(E90(E'6+@!!!
Y(;!/&#*$!C!1.Q&!
D. Exudative tonsillitis
30% chance that it is group A beta hemolytic strep@!!70% chance that it is a
virus; adenovirus, EBV. Y(;!>8+2!4(#!6++!+:#&/$'M+!$(26'**'$'6;!</22($!/66#E+!'$!'6!
L/<$+0'/!/2&!'EE+&'/$+*4!='M+!J."@!!N(>!&(!4(#!90(M+!'$!'6!=0(#9!%!6$0+9n!X/$+:!
/==*#$'2/$'(2!$+6$@!!Y(;!E(6$!9#6!$(26'*6!/0+!2($!L/<$+0'/@!![:/E9*+-!!1$!'6!=0(#9!%!6$0+9;!/2&!
P!>++F6!*/$+0;!8/6!L'*/$+0/*!0/*+6;!9/2646$(*'<!E#0E#0!/9+:!0/&'/$'2=!'2$(!$8+!/:'**/;!
9(*4/0$80'$'6!7!&:n!R8+#E/$'<!)+M+0@!!g8+2!4(#!&(!/!L*((&!<#*$#0+!7!>8/$!>(#*&!4(#!)'2&n!
"($8'2=!7!'$Q6!2($!/2!'2)+<$'M+!+2&(</0&'$'6@!
!
E. Leukoplakia
g8'$+!*+6'(2;!9*/D#+!*'F+;!$04!$(!6<0/9!());!L#$!>(2Q$!<(E+!())!C!<*'2'</*!&:!()!*+#F(9*/F'/!7!
>8/$!'6!$8+!)'06$!6$+9!'2!E/2/=+E+2$n!S:!
!
I0#+!'2!$8+!M#*M/Z9+2'6!/0+/!7!>8'$+!(0!0+&&'68d>8'$+!9*/D#+!*'F+!*+6'(2!$8/$!&(+6!2($!6<0/9+!
())!7!)'06$!6$+9!'2!E/2/=+E+2$n!S:@!g84n!R#*+!(#$!&469*/6'/!/2&Z(0!'2M/6'M+!</2<+0@!
!
F. Cancer of the mouth
K..!6D#/E(#6!&469*/6'/!/2&!</2<+0!C!6E(F'2=!
H2&!K..!C!/*<(8(*!
1)!4(#!&(!L($8;!4(#!'2<0+/6+!$8+!0'6F!()!L($8@!
12M/6'M+!6D#/E(#6!</2<+0!C!<(*(0!<8/2=+!
154

!
Lower lip cancer? Squamous cell carcinoma
Upper lip? Basal cell carcinoma
!
k+0/<'(#6!</0<'2(E/!7!)0(E!<8+>'2=!$(L/<<(!?6D#/E(#6!</0<'2(E/BU!/*6(!8/6!/!NJk!M'0#6!
/66(<'/$+&!>'$8!'$@!!
!
G.!!N49+09'=E+2$/$'(2!7!&:n!Addisons!
%&&'6(2Q6-!&'))#6+!9'=E+2$/$'(2;!*(>!<(0$'6(*!*+M+*6;!'2<0+/6+&!%.IN!?%.IN!8/6!E+*/2(<4$+6!
6$'E#*/$'2=!90(9+0$'+6BU!M+04!)'06$!9*/<+!4(#!6++!849+09'=E+2$/$'(2!'6!'2!$8+!S#<</*!E#<(6/@!!!
!
H. Peutz-Jeghers
S*($<84!?2($!&'))#6+B!/0+/6!()!849+09'=E+2$/$'(2@ Polyps in small intestine.!!I8'6!'6!(2+!
()!$8+!+:<+9$'(26!$(!0#*+!)(0!9(*496!'2!$8+!6E/**!'2$+6$'2+@!!K(6$!9(*496!'2!$8+!l1!*(</$+&!'2!
$8+!6'=E('&!<(*(2U!8(>+M+0;!9(*496!()!J+#$c!f+=8+06!/0+!*(</$+&!'2!$8+!6E/**!'2$+6$'2+;!/2&!
$8+4!/0+!8/E/0$(E/6;!$8+0+)(0+!$8+4!/0+!2($!2+(9*/6$'<;!/2&!$8+'0!/L'*'$4!$(!<8/2=+!$(!</2<+0!
'6!q[RG@!
!
II. Diseases of the Salivary Glands
Pleomorphic adenoma aka Mumps / mixed tumor!?7!"GI!/!$+0/$(E/;!L#$!/!E':+&!$#E(0!
7!'$!8/6!$>(!&'))!$49+6!()!$'66#+6;!6/E+!<+**!*/4+0B@!!1$!'6!$8+!K.!6/*'M/04!=*/2&!$#E(0!(M+0/**;!/2&!
'6!'2!$8+!K.!*(</$'(2!7!$8+!9/0($'&@!
Mumps!7!9/0/E:4(M'0#6;!'2<0+/6+!'2!/E4*/6+U!'6!$8+!'2<'&+2<+!()!(0<8'$'6!8'=8n!"(U!&(+6!'$!
</#6+!'2)+0$'*'$4n!"(;!>84n!SZ<!'$6!#2'*/$+0/*!7!')!'$!>+0+!L'*/$+0/*!$8+2!'$!>(#*&!/!E#<8!=0+/$+0!
<8/2<+@!!\6#/**4!'2!(*&+0!$++2/=+!E/*+6!(0!E/*+!/&#*$6!'6!>8+0+!(0<8'$'6!>'**!(<<#0@!!./2!/*6(!
(<<#0!'2!)+E/*+6!d!((98(+0'$'6!7!K.!#2'*/$+0/*;!$8+0+)(0+!'2)+0$'*'$4!'6!0/0+@!
!
III. Diseases of the esophagus
A. Dysphagia and odynophgia = difficulty swallowing

K(6$!()!$8+!$'E+;!$8+0+!>'**!L+!eda!<*#+6!9+0!D#+6$'(2@!!%!9$!8/6!90(L*+E!6>/**(>'2=!)((&6;!'6!
'$!6(*'&6!(0!*'D#'&6n!!
!
1)!$8+!9$!</2!$/F+!&(>2!*'D#'&6!/2&!2($!6(*'&6!?difficulty in swallowing solidsB;!'$!'6!due
to obstruction!7!</2!L+!&#+!$(!+6(98/=+/*!>+L!'2!J*#EE+0!k'26(2!642&0(E+;!1_%!>'$8!
=*(66'$'6!/2&!<8+'*(6'6!/2&!/2!+6(98/=+/*!>+L;!+6(98/=+/*!</2<+0!
!
1)!9$!has problem swallowing solids AND liquids, it is a peristalsis problem, >8'<8!'6!
M+04!L/&@!!1)!'$Q6!$8+!#99+0!,ZP!()!$8+!+6(98/=#6!?>8'<8!'6!/**!6$0'/$+&!E#6<*+B;!'$!'6!&#+!$(!
E4/6$8+2'/!=0/M'6!?LZ<!'$!/))+<$6!6$0'/$+&!E#6<*+B@!!1)!'$Q6!$8+!E'&&*+!,ZP!?<(EL(!()!6E(($8!
/2&!6$0'/$+&!E#6<*+B@!!%2&!')!'$Q6!$8+!*(>+0!,ZP!?6E(($8!E#6<*+B!'$Q6!&#+!$(!Y<*+0(&+0E/!?/F/!
90(=0+66'M+!646$+E'<!6<*+0(6'6!/2&!.R[YI!642&0(E+B!/2&!/<8/*/6'/@!!Y(;!$8+4!>'**!$+**!4(#!
'EE+&'/$+*4!')!$8+4!</2!6>/**(>!*'D#'&6!/2&Z(0!6(*'&6;!(0!2+'$8+0!?>8'<8!'6!/!9+0'6$/*6'6!
90(L*+EB@!!N(>!</2!4(#!&'6$'2=#'68!JYYZ.R[YI!)0(E!/<8/*/6'/n!12!/<8/*/6'/;!$8+4!M(E'$!#9!
$8+!)((&!$8+4!/$+!>8+2!$8+4!=(!$(!L+&!/$!2'=8$U!(0!$8+4!>'**!$+**!4(#!9$!8/6!R/42/#&Q6;!
'2&'</$'2=!$8/$!'$!'6!.R[YI@!!
!
Odynophgia = PAINFUL swallowingU /*>/46!/L2(0E/*!
155

12!N1k!9$!C!./2&'&/!+6(98/='$'6!7!'6!'$!%1_6!&+)'2'2=n!b+6@!!!
K.!)#2=/*!'2)+<$'(2!'2!N1k!C!./2&'&/!
g8+2!'$!=+$6!'2$(!$8+!+6(98/=#6;!'$!'6!%1_6!&+)'2'2=!
g8+2!'$!'6!/!$80#68;!'$!'6!JR[!%1_Y!*+6'(2!?2($!/'&6!&+)'2'2=B!
!
Helpful hints with other diseases:
Palpable purpura = immune HPY type III = Henoch Schonlein (MC)
Epistaxis = platelet problem (dont think hemophilia)they give clues!
Pansystolic murmur increases on inspiration = tricuspid regurg
Pansystolic murmur increases on expiration = mitral regurg
!
B. Tracheoesophageal fistula
S*'2&*4!+2&'2=!+6(98/=#6!?90(:!+6(98/=#6!+2&6!L*'2&*4B!7!&'6$/*!+6(98/=#6!/00'M+6!)0(E!$8+!
$0/<8+/@!!g8/$!&(+6!$8+!E(E!8/M+n!J(*484&0/E2'(6!7!/E2'($'<!)*#'&!'6!L/L4!#0'2+;!6(!8/M+!
$(!0+<4<*+!'$;!(0!E(E!>'**!8/M+!L'=!L+**4@!!Y(;!$8+!L/L4!6>/**(>6!'$!/2&!'$!'6!0+/L6(0L+&!'2!$8+!
6E/**!'2$+6$'2+@!!Y(;!')!4(#!8/M+!(L6$0#<$'(2!'2!$8+!+6(98/=#6;!(0!90(:'E/*!9(0$'(26!()!$8+!
&#(&+2#E;!E(E!>'**!8/M+!9(*484&0/E2'(6@!!Y(;!$8+0+!/0+!H!/26>+06-!,B!I0/<8+(+6(98/=+/*!
)'6$#*/!HB!&#(&+2/*!/$0+6'/!'2!_(>2Q6!642&0(E+!7!$8+6+!H!/0+!/66(<'/$+&!>'$8!
9(*484&0/E2'(6@!!I8+4!L*(<F!$8+!/L'*'$4!$(!0+/L6(0L!/E2'($'<!)*#'&;!*+/&'2=!$(!
9(*484&0/E2'(6@!!%*6(;!>8+2!$8+6+!F'&6!+/$;!)((&!=+$6!</#=8$!/2&!F'&6!<(#=8!/2&!69#$$+0!
LZ<!$8+!&'6$/*!+6(98/=#6!/0'6+6!)0(E!$8+!$0/<8+/!/2&!*+/&6!$(!&'6$+26'(2!()!$8+!6$(E/<8@!!
I8'6!'6!M+04!<8/0/<$+0'6$'<@!
!
C. Zenkers diverticulum
%0+/!()!>+/F2+66!7!<0'<(98/042=+(#6!E#6<*+@!!1$!8/6!/!*'*!6*'$!'2!L+$>++2!$8+!)'L+06!()!'$@!!"($!
$8+!>8(*+!/0+/!'6!<#$!?>8'<8!>(#*&!L+!/!$0#+!&'M+0$'<#*#E!7!$8'6!'6!/!)/*6+!&'M+0$'<#*#EB@!!1$!
=(+6!(#$!/2&!=+$6!/!9(#<8@!!I8+!9(#<8!<(**+<$6!)((&!/2&!*+/&6!$(!8/*'$(6'6@!!I8+4!8/M+!/!
$+2&+2<4!()!0+=#0='$/$'2=!#2&'=+6$+&!)((&!(#$!()!$8+!2(6+@!
!
D. Achalasia
Peristalsis prob prob with relaxation of the LES;!$8+0+)(0+!'$!'6!'2!69/6E!/**!$8+!$'E+@!!
g84n!1)!4(#!L:!$8/$!/0+/;!$8'6!E+/26!$8/$!$8+!=/2=*'(2!<+**6!/0+!E'66'2=@!!g8/$!&c!&(+6!$8'6!
0+E'2&!4(#!()n!Hirschsprung dz@!!g8/$!'6!'2!$8(6+!=/2=*'(2!<+**6n!k/6('2$+6$'2/*!9+9$'&+!
?k1JB@!!g8/$!'6!'$6!)#2<$'(2n!I(!0+*/:!$8+!X[Y@!Y(;!>8+2!4(#!&+6$0(4!$8(6+!=/2=*'(2'<!<+**6;!
2($!(2*4!&(!4(#!&+6$0(4!$8+!E(M+E+2$!()!$8+!*(>+0!+6(98/=#6;!L#$!4(#!/*6(!0+&#<+!k1J!
*+M+*6@!!Y(;!4(#!8/M+!<(26$/2$!<(26$0'<$'(2!()!$8+!X[Y;!*+/&'2=!$(!L'0&!L+/F@!!J0(:!9(0$'(2!'6!
&'*/$+&@!!!
!
E. Parasites
_c!()!Y(#$8!%E+0'</!>8+0+!$8+!*+'68E/2'/!)(0E6!'2M/&+6!$8+!=/2=*'(2!<+**6!()!$8+!X[Y!/2&!
$8+!0+<$#E!77!90(&#<+!/<D#'0+&!/<8/*/6'/!/2&!N'06<8690#2=!&c!C!Chagas dz;!M+<$(0!C!
0+&#M'&!L#=!?/F/!F'66'2=!L#=BU!6>+**'2=!()!$8+!+4+!6'=2n!R(E/2/Q6@!!g8/$!&(+6!'$!&(!'2!$8+!
8+/0$n!./#6+6!E4(</0&'$'6!/2&!<80(2'<!8+/0$!)/'*#0+!7!<(2=+6$'M+!</0&'(E4(9/$84@!!I8'6!'6!
(2+!()!$8+!E(0+!<(EE(2!</#6+6!()!8+/0$!&c!'2!Y(#$8!%E+0'</@!
!
F. Barrett esophagus
\*<+0/$+&!E#<(6/!'2!$8+!&'6$/*!+6(98/=#6@!!S:-!6++!=*/2&#*/0!E+$/9*/6'/U!$8+0+)(0+!6++!
=(L*+$!<+**6!/2&!E#<(#6!<+**!?>8'<8!68(#*&2Q$!L+!$8+0+B@!!I8+4!/0+!$8+0+!LZ<!$8+!+6(98/=#6!
</22($!90($+<$!'$6+*)!)0(E!+6(98/=+/*!'23#04@!!I8+0+)(0+;!0#2!$8+!0'6F!()!/&+2(</0<'2(E/!()!
156
$8+!&'6$/*!+6(98/=#6@!![:/E9*+-!1)!$8+!*+6'(2!'2!+6(98/=#6;!&6498/='/!()!6(*'&6;!L#$!2($!
*'D#'&6;!*+6'(2!'2!2($+&!'2!&'6$/*!+6(98/=#6!7!&(!"GI!9'<F!6D#/E(#6!<+**!</0<'2(E/!7!$8'6!'6!
'2!$8+!K1_!+6(98/=#6@!!1)!'$!'6!&'6$/*;!'$!'6!/&+2(</0<'2(E/;!/2&!$8+!90+<#06(0!*+6'(2!'6!
S/00+$$Q6!+6(98/=#6@!!!
G. Esophageal varices
_'*/$+&!6#LE#<(6/*!+6(98/=+/*!M+'26!C!$8+0+)(0+!9$!8/6!<'008(6'6;!>8(!>/6!/2!/*<(8(*'<@!!J$!
/*6(!8/6!9(0$/*!NI"!7!$8+!*+)$!=/6$0'<!M+'2!'6!'2M(*M+&!?(2+!()!$8+!L0/2<8+6!())!$8+!9(0$/*!M+'2!
'6!*+)$!=/6$0'<!M+'2B@!!I8+!*+)$!=/6$0'<!M+'2!&0/'26!$8+!&'6$/*!+6(98/=#6!/2&!90(:'E/*!6$(E/<8@!!
g8/$!&0/'26!'2$(!$8+!*+)$!=/6$0'<!M+'2n!%c4=(#6!M+'2@!!g8+0+!&(+6!$8+!*+)$!=/6$0'<!M+'2!&0/'2!
'2$(n!J(0$/*!M+'2@!N(>+M+0;!LZ<!()!<'008(6'6;!9(0$/*!M+'2!</22($!+E9$4!L*((&!6#))'<'+2$*4!'2$(!
'$;!$8+!84&0(6$/$'<!90+66#0+!'2<0+/6+6U!4(#!0+M+06+!L*((&!)*(>!'2$(!$8+!*+)$!=/6$0'<!M+'2;!
69*+2'<!M+'2;!/2&!($8+0!M+'26;!/2&!+2&!#9!90(&#<'2=!M/0'<+6!$8/$!0#9$#0+@!!!
Hematemisis C!M(E'$'2=!L*((&
Hemoptysis C!<(#=8'2=!#9!L*((&
Hematochezia C!L*((&!9(#0'2=!(#$!()!/2#6!?/<$#/*!&0'99'2=!()!L*((&!7!2($!<(/$'2=!()!6$((*!
>'$8!L*((&;!$8/$!'6!6++2!'2!/2#6B@!!K..!C!&'M+0$'<#*(6'6U!2($!&'M+0$'<*#*'$'6!LZ<!$8+!M+66+*!'6!
2+:$!$(!$8+!&'M+0$'<#*/0!6/<;!6(!')!'$!>+0+!]d$'$'6Q;!'$!>(#*&!L+!6</00+&!())@!!g'$8!d(6'6;!'$!'6!
'2$/<$;!/2&!3#6$!8/M+!$(!+0(&+!'$;!*+/&'2=!$(!a!EX!L*++&@!!
157

H. Mallory Weiss Syndrome
I+/0!/$!+6(98/=(d=/6$0'<!3#2<$'(2@!![:/E9*+-!*+$Q6!6/4!'$6!4(#2=!>(E/2!?9*/4!(&&6B!7!>8/$!
&(+6!68+!8/M+n!S#*'E'/@!!.*/66'<![:/E9*+-!/*<(8(*'<!>'$8!0+$<8'2=!?$04'2=!$(!M(E'$;!L#$!
2($8'2=!'6!<(E'2=!(#$!7!</#6+6!$0+E+2&(#6!90+66#0+6;!*+/&'2=!$(!$+/0!?8+E/$+E'6'6B!(0!
9#2<$#0+!?S(08/M+Q6!d!$8'6!'6!>8+2!$8+!/'0!=+$6!'2$(!$8+!9*+#0/*!</M'$4;!/2&!*+/&6!$(!N/E/2Q6!
<0#2<8!()!$8+!/2$+0'(0!E+&'/6$'2#EB@!
Y(;!6++2!>'$8!L#*'E'/!/2&!*+/&6!$(!S(08/M+Q6!?M6@!/2!/*<(8(*'<B@!
!
I. Esophageal cancer
YD#/E(#6!</2<+0!?2($!&'6$/*;!L#$!E'&BU!K..Q6!C!6E(F'2=!/2&!/*<(8(*!?H2&!K..B!
_4698/='/!6++2!'2!$8'6!9$!d!'2'$'/**4;!9$!</22($!6>/**(>!6(*'&6;!L#$!</2!$/F+!&(>2!*'D#'&6@!!
[:/E9*+-!eV!4Z(;!E/*+;!/*<(8(*'<;!>$!*(66;!90(L!6>/**(>'2=!)((&6;!2($!*'D#'&6!7!&:n!
[6(98/=+/*!</2<+0!7!6D#/E(#6!<+**!</0<'2(E/!()!$8+!E'&d+6(98/=#6!?9*/4!(&&6B@!![:/E9*+-!
9'<!()!$0/<8+/!/2&!6++!</0$'*/=+!0'2=6;!/2&!+*/6$'<!/0$+04!?+6(98/=+/*!'2!E'&&*+B!$8'6!'6!
+6(98/=+/*!</2<+0@!
!
IV. Diseases of the Stomach
A. Congenital Pyloric Stenosis
[:/E9*+-!E/*+;!P!>++F6!(*&!/2&!6$/0$+&!vomiting non bile stained fluid at 3 wksU!
9/*9/$+&!$8+!/L&(E+2!/2&!)+*$!/!F2($!'2!R\p!/2&!6++!849+09+0'6$/*6'6@!!I8'6!'6!"G"!L'*+!
6$/'2!)*#'&!/$!P!>++F6@!!.(2=+2'$/*!J4*(0'<!Y$+2(6'6!
!
What if it is duodenal atresia in a downs kid?!I8/$!>(#*&!L+!at birth!vomiting!()!
L'*+!6$/'2+&!)*#'&@!!%2&!&(#L*+!L#LL*+!6'=2!7!/$0+6'/!?*/<F!()!&+M+*(9E+2$!()!$8+!*#E+2B!'6!
&'6$/*!$(!>8+0+!$8+!L'*+!&#<$!<(E+6!'2;!6(!L'*+!</2!6$'**!+2$+0!$8+!90(:'E/*!9(0$'(2!()!$8+!
&#(&+2#E!7!$8'6!'6!>84!'$!'6!L'*+!6$/'2'2=!7!LZ<!$8+0+!'6!2(!E(M+E+2$;!$8+0+!>'**!L+!/'0!
$0/99+&!'2!$8+0+;!/2&!/'0!'6!$0/99+&!'2!$8+!6$(E/<8;!$8+0+)(0+!$8+0+!'6!/'0!'2!$8+!6$(E/<8!/2&!
90(:!&#(&+2#E!7!/!&(#L*+!L#LL*+!6'=2@!!%*6(;!E(E!>'**!8/M+!9(*484&0/E2'(6@!!Y(;!&(!2($!
<(2)#6+!<(2=+2'$/*!94*(0'<!6$+2(6'6!?>8'<8!8/6!2(!0+*/$'(268'9!$(!&(>2Q6B!>'$8!&#(&+2/*!
/$0+6'/@!!!
!
1$!&(+6!8/M+!E#*$')/<$(0'/*!'28+0'$/2<+U!$8+0+)(0+!'$!</2!L+!'2<0+/6+&!'2!)#$#0+!<8'*&0+2@!!./2!
6++!94*(0'<!6$+2(6'6;!/6!'$!8/6!$8'<F+2+&@!I(!R:;!69*'$!$8+!E#6<*+!?</**+&!94*(0(9*/6$4B@!!!!
!
B. NSAID ulcers
"(2!6$+0('&/*!>'**!L*(<F!Jl[H;!>8'<8!'6!0+69(26'L*+!)(0!$8+!E#<(#6!L/00'+0!()!$8+!6$(E/<8;!
/2&!M/6(&'*/$/$'(2!()!$8+!M+66+*6;!E#<(#6!6+<0+$'(2;!/2&!6+<0+$'(2!()!L'</0L!'2$(!$8+!E#<(#6!
L/00'+0@!!Y(;!>8+2!4(#!$/F+!"Y%1_Y!)(0!/!9+0'(&!()!$'E+;!$8+!>8(*+!$8'2=!'6!&+6$0(4+&@!!
X+/&6!$(!E#*$'9*+!#*<+06!/2&!6'=2')'</2$!L*((&!*(66!(M+0!$'E+@!!I8+4!/0+!9#2<8+&!(#$@!
!
C. H. pylori
Silver stain (as is PCP, Legionella, bartenella hensilai).!!.(EE/!68/9+&!(0=/2'6E6!
?*'F+!</E94*(L/<$+0B;!L#$!)(#2&!(#$!$8/$!$8+4!8/M+!&'))+0+2$!<+**!>/**6!/2&!+$<@!!"/6$4!L#=!
LZ<!'$!E/F+!*($6!()!<4$(F'2+6!/2&!#0+/6+!>8'<8!<(2M+0$6!#0+/!$(!/EE(2'/;!/2&!'6!(2+!()!$8+!
0+/6(26!>84!$8+4!</2!L#00(>!$80(#=8!$8+!E#<(#6!*/4+0!7!/EE(2'/!'6!M+04!$(:'<!7!$8'6!'6!$8+!
$+6$!>+!#6+!7!>8+2!>+!$/F+!L:!()!=/6$0'<!E#<(6/;!>+!&(!/!#0+/6+!$+6$!(2!'$!/2&!')!'$6!
9(6'$'M+;!F2(>!N!94*(0'!'6!'2!'$@!!!./2!/*6(!#6+!6+0(*(='</*!$+6$6!7!%LQ6!/=/'26$!'$@!1$Q6!(2*4!=((&!
)(0!$8+!)'06$!$'E+@!!g84n!SZ<!$8+!%LQ6!&(!2($!=(!/>/4!/2&;!$8+0+)(0+!</22($!&:!0+/<$'M/$'(2!
158

(0!0+<#00+2$@!!%)$+0!$8/$!'$!'6!#6+*+66!LZ<!>(2Q$!$+**!/24$8'2=!LZ<!>'**!/*>/46!L+!9(6'$'M+!LZ<!
%LQ6!6$'<F!/0(#2&@!!!
!
g8+0+!&(+6!pernicious anemia hit? Body and fundus@!!I8/$!'6!>8+0+!$8+!9/0'+$/*!<+**6!
8/M+!/#$(%LQ6!&+6$0(4'2=!$8+E;!/2&!1T!*+/&'2=!$(!/$0(98'<!=/6$0'$'6@!!!
!
I8'6!'6!"GI!>8+0+!N!94*(0'!+:+0$6!'$6!/))+<$@!!H pylori affects the pylorus and antrum@!!
1$!&+6$0(46!$8+!E#<(6/;!*+/&'2=!$(!/$0(98'<!=/6$0'$'6!()!$8+!94*(0#6!/2&!/2$0#E@!!I8'6!'6!
>8+0+!</2<+06!/0+@!!K(6$!</2<+06!/0+!/*(2=!$8+!lesser curvature of the pylorus and
antrum!?+:/<$!6/E+!9*/<+!>8+0+!=/6$0'<!#*<+06!/0+B@!!I8+!N!94*(0'!*'M+!'2!/!E#<(#6!L/00'+0!
/2&!$8+0+)(0+!'6!90($+<$+&@!!MCC stomach cancer = H pylori@!!N!94*(0'!</2!/*6(!</#6+!
E/*'=2/2$!*4E98(E/6!()!$8+!6$(E/<8!?*(>!=0/&+B@!!!
!
g84!&(2Q$!>+!+M+0!L:!/!&#(&+2/*!#*<+0n!SZ<!$8+4!/0+!2+M+0!E/*'=2/2$@!!S#$!=/6$0'<!#*<+06!
8/M+!/!<8/2<+!()!L+<(E'2=!E/*'=2/2$!$8+0+)(0+!2++&!$(!L'(964!=/6$0'<!/2&!2($!&#(&+2/*!
#*<+06@!!G2*4!0+/6(2!$8+4!L:!/!=/6$0'<!#*<+0!'6!LZ<!$8+4!/0+!$04'2=!$(!0#*+!(#$!>8+$8+0!'$!'6!
</2<+0!?E/*'=2/2$B!(0!2($!7!$8+4!F2(>!'$Q6!/2!#*<+0!/2&!'$!8/6!/!PW!()!L+2'=2!E/*'=2/2$@!!
"+M+0!8/M+!$(!L:!/!&#(&+2/*!#*<+0;!6(!3#6$!*+/M+!/*(2+@!!H pylori is more commonly
assoc with duodenal PUD than gastric@!!!
!
g84!&(!4(#!=+$!E+*/2/!>'$8!#99+0!l1!L*++&6n!\99+0!l1!C!/24$8'2=!$8/$!'6!/!L*++&!)0(E!$8+!
*'=/E+2$#E!()!$0'+$c!7!>8+0+!$8+!&#(&+2#E!8'$6!$8+!3+3#2#E!/2&!#9@!!g84!'6!'$!L*/<Fn!%<'&!
/<$6!(2!NL!/2&!<(2M+0$6!'$!$(!8+E/$'2@!!N+E/$'2!'6!L*/<F!9'=E+2$;!*+/&'2=!$(!E+*/2/@!!I8'6!'6!
'E9!$(!F2(>;!LZ<!')!4(#!8/M+!L*/<F!$/004!6$((*6;!/2&!'$6!reW!<8/2<+!$8/$!'6!/2!#99+0!l1!
L*++&;!/2&!')!4(#!9*/4!(&&6;!'$!'6!90(L!/!&#(&+2/!#*<+0!?M6@!/!=/6$0'<!#*<+0B@!Y(;!NL!'6!
<(2M+0$+&!L4!/<'&!$(!8+E/$'2;!>8'<8!'6!/!L*/<F!9'=E+2$@ k(E'$'2=!()!<())++!=0(#2&!E/$+0'/*!
C!L*((&!<*($6!/<$+&!#9(2!L4!/<'&!/2&!<8/2=+6!$(!8+E/$'2@!!!
!
[:/E9*+-!!J$;!/2!+:+<#$'M+!#2&+0!=0+/$!6$0+66;!/2&!6#&&+2!(26+$!()!6+M+0+!+9'=/6$0'<!9/'2!
$8/$!0/&'/$+6!'2$(!$8+!*+)$!68(#*&+0@!!T'06$!6$+9!'2!>(0F!#9n!!T*/$!9*/$+!()!$8+!/L&(E+2U!6++!/'0!
#2&+0!&'/980/=E@!!G&&6n!_#(&+2/*!#*<+0@!!g84!&'&!8+!8/M+!68(#*&+0!9/'2n!%'0!=($!(#$;!
6+$$*+&!#2&+0!$8+!&'/980/=E;!'00'$/$+&!2+0M+!s^!?980+2'<B;!/2&!=($!0+)+00+&!9/'2!$(!$8+!
&+0E/$(E+!?>8'<8!'6!$8+!6/E+!&+0E/$(E+6B!
!
D. Rhinitis Plastica: Adenocarcinoma of the stomach!
g'$8!6'=2+$!0'2=!<+**6@!![:/E9*+-!!eH!4Z(!)+E/*+!>'$8!>+'=8$!*(66!/2&!+9'=/6$0'<!&'6$0+66@!!Y8+!
8/&!/2!#99+0!=/6$0('2$+6$'2/*!6+0'+6;!2($+&!$8/$!6$(E/<8!&'&!2($!E(M+!?2(!9+0'6$/*6'6B;!/2&!
$8+2!68+!&'+&@!!_:n!R8'2'$'6!9*/6$'</!7!<+**6!$8/$!/0+!'2M/&'2=!$8+!>/**!()!$8+!+2$'0+!6$(E/<8;!
</**+&!signet ring cells!?>8'<8!/0+!6$/'2+&!>'$8!E#<(</02'2+!<+**6;!/0+!9'2F!7!6'=2+$!<+**6!
/0+!*'F+!/!&'/E(2&!0'2=;!/2&!$8+!&'/E(2&!8/6!L++2!9#68+&!$(!$8+!9+0'98+04B@!!I8+!E#<(#6!'6!
'26'&+;!E/F'2=!$8+!<+**!*((F!+E9$4;!/2&!9#68'2=!$8+!2#<*+#6!$(!$8+!6'&+!?3#6$!*'F+!)/$$4!
<8/2=+!()!$8+!*'M+0B@!!N(>+M+0;!$8+6+!/0+!E/*'=2/2$!2+(9*/6$'<!=*/2&#*/0!<+**6;!/2&!/0+!
<8/0/<$+0'6$'<!()!08'2'$'6!9*/6$'</!$49+!()!=/6$0'<!/&+2(</0<'2(E/@!!!
!
K'6<(2<+9$'(2-!Krukenberg tumor!'6!2($!/!$#E(0!$8/$!'6!6++&'2=!(#$!$(!$8+!(M/04@!!I8'6!
$#E(0!'6!&#+!$(!8+E/$(=+2(#6!690+/&!$(!$8+!(M/04@!!I8+0+!'6!2(!6#<8!$8'2=!/6!/!6'=2+$!0'2=!
</0<'2(E/!()!$8+!(M/04!?$8+0+!'6!2(!90'E/04!</2<+0!()!$8+!(M/04!$8/$!*((F6!*'F+!$8'6B@!!The
signet ring cells came from stomach cancer that has metastasize to ovaries =
Krukenberg tumor@!!!
159

!
K(6$!/0+!#*<+0/$'M+!$#E(06!'2!$8+!*+66+0!<#0M/$#0+!()!$8+!94*(0#6!/2&!/2$0#E@!!X+/$8+0!L($$*+!
6$(E/<8!7!M+04!8/0&!&#+!$(!/**!()!$8+!</2<+0!<+**6!/2&!$8+!)'L0(#6!0+69(26+!$(!'$@!!
!
l/6$0'<!</2<+0!'6!&+<*'2'2=!'2!\YU!($8+0!<(#2$0'+6!'$!'6!/!90'E/04!</2<+0!d!f/9/2;!LZ<!6E(F+&!
90(&#<$6@!!G$8+0!+$82'<!</2<+06-!2/6(98/042=+/*!</0<'2(E/!C!<8'2/U!6$(E/<8!</2<+0!/2&!
NIXk!,!C!f/9/2U!S#0F'$$6!*4E98(E/!C!%)0'</@!
!
1)!$8+0+!>/6!/!2(2$+2&+0!E/66!'2!*+)$!6#90/<*/M'<#*/0!/0+/!/2&!9$!>'$8!+9'=/6$0'<!&'6$0+66!(2+!
>++F!/=(!7!&:n!K+$/6$/$'<!=/6$0'<!/&+2(</0<'2(E/@!!.+0M'</*!</2<+0!</2!/*6(!E+$/6$/6'c+!
8+0+@!!!X+)$!6#90/<*/M'<#*/0!2(&+!&0/'26!/L&(E'2/*!(0=/26U!$8+0+)(0+!9/2<0+/$'<!</2<+06!L#$!
E(6$*4!$8+!6$(E/<8!</2<+06!E+$/6$/6'c+!$8+0+@!!I8+!0'=8$!6#90/<*/M'<#*/0!2(&+!E+$6!/0+!
)0(E!*#2=!</2<+0@!!!!
!
V. Malabsorption
K+/26!L/&!/L6(09$'(2!()!+M+04$8'2=-!)/$6;!</0L6;!/2&!90($+'26@!!_'/=2(6'6!9('2$!()!M'+>!>+!*((F!)(0!
'2<0+/6+&!)/$!'2!$8+!6$((*!C!6$+/$(008+/!C!6<0++2'2=!$+6$!)(0!E/*/L6(09$'(2@!
!
A. Fat Digestion:
,B!"++&!*'9/6+6!$(!L0+/F!&(>2!)/$!'2$(!H!E(2(=*4<+0'&+6!/2&!T%Q6;!6(!4(#!2++&!/!)#2<$'(2'2=!
9/2<0+/6@!
!
HB!"++&!M'**'!()!$8+!6E/**!'2$+6$'2+!LZ<!')!>+!&'&2Q$;!$8+!6E/**!'2$+6$'2+!>(#*&!8/M+!$(!L+!/!
E'*+!*(2=@!!k'**'!'2<0+/6+!$8+!(M+0/**!/L6(09$'M+!6#0)/<+!>'$8(#$!'2<0+/6'2=!$8+!*+2=$8@!!Y(;!')!
4(#!&(2Q$!8/M+!$8+E;!4(#!&+<0+/6+!$8+!/L6(09$'M+!6#0)/<+;!/2&!>'**!*(6+!$8+!E(2(=*4<+0'&+6!
/2&!T%Q6@!!I8+0+)(0+;!4(#!2++&!/!)#2<$'(2'2=!Y1!>'$8!M'**'@!
!
PB!"++&!L'*+!6/*$6!$(!+E#*6')4!$8+!)/$!/2&!L0+/F!'$!&(>2!$(!E'<+**+6!?$'24!9/0$'<*+6!$8/$!/0+!,!E'<0(2!
'2!&'/E+$+0B!/2&!<84E*(E'<0(26@!![E#*6')4'2=!/=+2$6!/0+!E/24!$'E+6!'2!&'68>/68+06!LZ<!2++&!$(!=+$!
)/$!())!9*/$+6@!!T/$!>'**!<(E+!$(!$8+!6#0)/<+!/2&!L0+/F!#9!'2$(!E'<+**+6;!>8'<8!/0+!+/6'+0!$(!/L6(0L@!!!
!
Y(;!2++&!)#2<$'(2'2=!9/2<0+/6;!L'*+!6/*$6;!6E/**!'2$+6$'2+!$8/$!8/6!M'**'!'2!(0&+0!$(!0+/L6(0L!
)/$@!
!
Bile salts /0+!E/&+!'2!$8+!*'M+0!)0(E!<8(*+6$+0(*@!!.8(*+6$+0(*!</22($!L+!&+=0/&+&U!'$!+'$8+0!
6(*#L'*'c+&!'2!L'*+!?$8+0+)(0+!0#2!$8+!0'6F!()!<8(*+6$+0(*!6$(2+6B!(0!'6!<(2M+0$+&!$(!L'*+!/<'&6@!!
./22($!L0+/F!&(>2!<8(*+6$+0(*@!!|!
!
S'*+!6/*$!&+)'<'+2<4!'6!6++2!'2-!!/B!*'M+0!&cU!LB!/24$8'2=!$8/$!(L6$0#<$6!L'*+!)*(>!>'**!90(&#<+!
L'*+!6/*$!&+)U!<B!L/<$+0'/*!(M+0=0(>$8!</2!+/$!/2&!L0+/F&(>2!L'*+U!&B!$+0E'2/*!'*+/*!&c;!+:@!
.0(82Q6!&c!</22($!0+<4<*+U!/2&!+B!.8(*+6$40/E'2+-!0+6'26!7!#6+&!)(0!$0+/$E+2$!()!
849+0*'9'&+E'/;!</2!90(&#<+!L'*+!6/*$!&+)@!!I8'6!'6!$8+!KG%!()!0+6'26;!L4!L'2&'2=!/2&!$8+2!
+:<0+$'2=!$8+E;!LZ<!')!4(#!/0+!2($!0+<4<*'2=!$8+E;!4(#!>'**!E/F+!E(0+@!!g8/$Q6!8/99+2'2=!'2!
$8+!*'M+0n!\90+=#*/$'(2!()!X_X!0+<+9$(06!642$8+6'6;!LZ<!2++&!$(!E/F+!E(0+!L'*+!6/*$6;!
$8+0+)(0+!2++&!$(!6#<F!E(0+!(#$!()!$8+!L*((&!/2&!>'**!E/F+!E(0+!X_X!0+<+9$(06@!!I8+6+!
&0#=6!>'**!+M+2$#/**4!$/F+!E(0+!<8(*+6$+0(*!(#$!()!$8+!L*((&!/2&!*(>+0!'$;!6(!4(#!</2!E/F+!
E(0+!L'*+!6/*$6@!!1$!/*6(!$/F+6!&0#=6!>'$8!'$;!6(!'$Q6!2($!=((&!)(0!9+(9*+!$/F'2=!E+&6;!LZ<!4(#!
>'**!*(6+!$8+6+!E+&6!'2!$8+!6$((*;!/*(2=!>'$8!L'*+!6/*$6@!!!
!
160

_cQ6-!6<0++2'2=!$+6$!'6!*((F'2=!)(0!)/$!'2!6$((*!?6$+/$(008+/B!7!*+$Q6!6/4!'$!'6!9(6'$'M+@!!Y(;!>+!
8/M+!$(!)'=#0+!>8'<8!')!$8+!P!/0+/6!'6!$8+!</#6+!()!$8+!E/*/L6(09$'(2!7!9/2<0+/$'<!&+);!L'*+!
6/*$!&+);!(0!6(E+$8'2=!>0(2=!>'$8!$8+!6E/**!L(>+*!?K.B@!
!
B. Celiac Dz (sprue)
J'<!()!6E/**!L(>+*!*+6'(2!/2&!/!6F'2!c'$!$8/$!8/6!/2!/66(<'/$'(2!>'$8!'$@!!I8'6!'6!<+*'/<!&c!
?/#$('EE#2+!&cB;!/2&!$8+!6F'2!c'$!'6!dermatitis herpetiformis@!!Celiac dz is an
autoimmune dz against gluten wheat, esp. gliadin@!!1$!'6!M+04!<(EE(2!/2&!'6!$8+!K..!
()!E/*/L6(09$'(2!'2!$8'6!<(#2$04@!!Y(;!>8+2!4(#!+/$!>8+/$!90(&#<$6;!$8+!=*#$+2!'6!0+/L6(0L+&!
'2$(!$8+!M'**'!/2&!$8+0+!/0+!%LQ6!/=/'26$!=*'/&'2;!/2&!*+/&6!$(!&+6$0#<$'(2!()!$8+!M'**'!?3#6$!*'F+!
%LQ6!/=/'26$!9/0'+$/*!<+**6!(0!'2$0'26'<!)/<$(06;!>8'<8!&+6$0(4!+M+04$8'2=!/0(#2&!'$B@!Y(;!$8+!
%LQ6!/$$/<F!=*#$+2!$8/$!8/6!3#6$!L++2!0+/L6(0L+&!L4!$8+!)((&;!>8'<8!>'**!</#6+!&+6$0#<$'(2!()!
$8+!M'**#6@!%2&!$8+0+!/0+!2(!M'**'!8+0+!7!'$!'6!)*/$U!L*#2$'2=!()!M'**#6!7!6(!4(#!/0+!2($!/L*+!$(!
0+/L6(0L!)/$;!90($+'26;!(0!</0L6@!!I8+0+!'6!2(!M'**#6!6#0)/<+@!!!I8+!=*/2&6!#2&+02+/$8!/0+!)'2+;!
8(>+M+0@!!I8+!M'**'!/0+!/L6+2$@!!I8+0+!'6!/!100% chance of dermatitis herpetiformis
association with underlying celiac dz. Dermatitis herpetiformis is an autoimmune
dz, and it is a vesicular lesion of the skin 7*((F6!*'F+!8+09+6!()!$8+!6F'2@!!I8+4!>'**!68(>!
9'<!()!/!&+0E/$'$'6!8+09+$')(0E'6;!/2&!>'**!/6F!>8/$!$8+!</#6+!()!&'/008+/!'6n!%LQ6!/=/'26$!
=*#$+2!?=*'/&'2B@!
161

C. Whipples dz
%2!'2)+<$'(2!()!$8+!6E/**!'2)+<$'(2!&#+!$(!/2!(0=/2'6E!$8/$!4(#!</22($!=0/E!6$/'2@!!I@!
>8'99+*''!(2*4!6++2!>'$8![KU!</22($!L+!<#*$#0+&@!!Y++!)*/$!L*#2$+&!M'**'!/2&!)(/E4!
E/<0(98/=+6!?*((F!*'F+!"'+E/22!9'<!L#LL*4!E/<0(98/=+6U!</2!/*6(!L+!)0(E!/2!N1k!iOj!LZ<!
'$!*((F6!*'F+!g8'99*+Q6;!L#$!'62Q$B@!!I8+!E/<0(98/=+6!8/M+!&'6$'2<$'M+!J%Yd9(6'$'M+!6$/'26@!
!
HIV positive pt!/2&!/<'&!)/6$!6$/'2!7!9$!>'$8!8+*9+0!I!<+**!<(#2$!()!,VV@!!!N/M+!/2!/<'&!)/6$!
6$/'2!>'$8!$8+!)(/E4!E/<0(98/=+6!7!due to MAI!?$8'6!'6!E(0+!<(EE(2!$8/$!ISB;!/2&!can
cause Whipple like dz with malabsorption@!!!
!
g8'99*+Q6;!L+'2=!/2!'2)+<$'(2;!8/6!646$+E'<!6'=26!/2&!64E9$(E6-!)+M+0;!*4E98/&+2(9/$84;!
9(*4/0$80'$'6;!=+2+0/*'c+&!9/'2@!!1$Q6!/2!'2)+<$'(2!$8+0+)(0+!</2!L+!$0+/$+&!>'$8!/2$'L'($'<6@!!!
!
Y(;!$8+0+!/0+!2 dzs that cause malabsorption: celiac dz and Whipples dz@!!G$8+0!&cQ6!
/0+!&cQ6!()!$8+!9/2<0+/6!7!chronic pancreatitis (MC in alcoholics!7!H!0+/6(26!)(0!
E/*/L6(09$'(2!'2!/*<(8(*'<6!7!/!*'9/6+!&+)!0+*/$+&!$(!<80(2'<!9/2<0+/$'$'6;!(0!L'*+!6/*$!&+)!&#+!
$(!<'008(6'6;!(0!L($8!'2!/2!/*<(8(*'<B@!
!
D. Diarrhea
S+6$!>/4!$(!<*/66')4!'6!$(!6#L&'M'&+!'2$(!P!$49+6-!!
,@!!12M/6'M+-!!L/<$+0'/!'2M/&+6!
H@!!Y+<0+$(04-!!$8+!L/<$+0'/!90(&#<+6!$(:'26!/2&!$8/$!>'**!6$'E#*/$+!<%KJ!?(0!($8+0!
E+<8/2'6E6B!</#6'2=!$8+!6E/**!L(>+*!$(!6+<0+$+!6E/**!/E(#2$6!()!1YGIG"1.!)*#'&;!>8'<8!
'6!"/.*@!
P@!!G6E($'<-!*/<$/6+!&+)'<'+2<4@!!%*6(!90(&#<+&!L4!*/:/$'M+6;!/2&!($8+0!'2L(02!+00(06!()!
E+$/L(*'6E@!!!
Y+<0+$(04!/2&!(6E($'<!&'/008+/6!/0+!8'=8!M(*#E+!&'/008+/6!/2&!4(#!=(!)0+D#+2$*4;!>8+0+/6!
'2M/6'M+!&'/008+/!'6!/!6E/**!M(*#E+!&'/008+/@!!!S+6$Z<8+/9+6$!$+6$!$(!=+$!'2!/!9$!>'$8!&'/008+/!
C!)+</*!6E+/0!)(0!*+#F(<4$+6@!!1)!$8+0+!/0+!"GI!/24!2+#$0(98'*!&(2Q$!>(004!L+</#6+!2($!
'2M/6'M+@!!1)!$8+0+!/0+!'2)*/EE/$(04!<+**6!$8+2!4(#!E#6$!&(!)+</*!6E+/0!$+6$!)(0!
</E94*(L/<$+0!(0!68'=+**/@!!!
!
/B!G6E($'<!&'/008+/!?)'$6!'2!>'$8!(6E($'<!>/$+0!E(M+E+2$B!'6!>8+2!$8+0+!'6!6(E+!(6E($'</**4!
/<$'M+!6#L6$/2<+!'2!$8+!L(>+*!*#E+2!$8/$!'6!6#<F'2=!>/$+0!(#$!()!$8+!L(>+*;!</#6'2=!/!8'=8!
M(*#E+;!849($(2'<!*(66!()!)*#'&@!![:/E9*+-!!*/<$/6+!&+)@!C!L0#68!L(0&+0!(0!&'6/<<8/0'&/6+!
&+)'<'+2<4;!/!L0#68!L(0&+0!+2c4E+@!!12!/!<*/66'<!</6+!L#$!$8+4!>'**!2($!$+**!4(#!'$Q6!/!*/<$/6+!
&+);!'26$+/&!>'**!$+**!4(#!'$Q6!/!&'6/<<8/0'&/6+!&+)!(0!+M+2!/!L0#68!L(0&+0!+2c4E+!&+)@!!Y(!')!
4(#Q0+!*/<$/6+!&+);!'$!E+/26!$8/$!/24!&/'04!90(&#<$6!>8'<8!<(2$/'26!*/<$(6+!?>8'<8!L0+/F6!
&(>2!'2$(!=*#<(6+!/2&!=/*/<$(6+B!</2Q$!L+!'2&'=+6$+&@!!Y(!'$!>'**!=(!$(!$8+!<(*(2;!/2&!/<$!/6!
&+66+0$6!$(!$8+!/2/+0(L'<!L/<$+0'/!>8'<8!>'**!+/$!$8+!*/<$(6+!/2&!90(&#<+6!84&0(=+2!=/6;!
/2&!($8+0!=/6+6;!/2&!/<'&6;!/2&!=+$!/<'&'<!6$((*6@!!I8+!84&0(=+2!=/6+6!</#6+6!$8+!L*(/$'2=;!
&'6$+2$'(2;!/2&!'2<0+&'L*+!+:9*(6'M+!&'/008+/@!
!
LB!Y+<0+$(04!&'/008+/-!$>(!$8'2=6!$(!F2(>;!k'L0'(!<8(*+0/+!/2&![I[.!?$0/M+*+0Q6!&'/008+/B@!!
I8+6+!/0+!2($!'2M/6'M+!&'/008+/;!$8+0+)(0+!>8+2!4(#!&(!/!L(>+*!L'(964!$8+0+!>'**!2($!L+!(2+!
'($/!()!'2)*/EE/$'(2;!'$Q6!9+0)+<$*4!2(0E/*@!!1$Q6!9#0+*4!/!$(:'2!$8/$!/<$'M/$+6!/!9#E9!+'$8+0!
<%KJ!?k'L0'(B!(0!6(E+!($8+0!9#E9-!=#/24*/$+!<4<*/6+!?[@!<(*'B@!!I0+/$E+2$-!!>8+2!4(#!='M+!
)*#'&!0+9*/<+E+2$!$(!9/$'+2$6!>'$8!M@!<8(*+0/+;!4(#!2++&!$(!='M+!=*#<(6+!/*(2=!>'$8!$8+!)*#'&6@!!
162

I8'6!'6!LZ<!4(#!2++&!=*#<(6+!$(!<(d$0/269(0$!"/!$8/$!>/6!'2!$8+!)*#'&6@!!Y'&+!2($+-!!"++&!$(!
F2(>!$8+!($8+0![@!<(*'!0+*/$+&!$(:'26-!![N[.-!G,e`-NÙ![1[kU!/2&![/==[.@!!!
!
<B!12M/6'M+!&'/008+/-!!$8+!K.!'2!\Y!'6!</#6+&!L4!</E94*(L/<$+0!3+3#2';!/2&!68'=+**/!'6!/!<*(6+!
6+<(2&@!!.*/66'<!</6+-!!/!9+06(2!>'$8!*(>!M'2+?nB!&'/008+/;!>'$8!6(E+!L*((&!'2!'$;!/2&!(2!
=0/E!6$/'2!$8+0+!>+0+!<(EE/!68/9+&!(0!Yd68/9+&!(0=/2'6E6!$8/$Q6!</E94*(L/<$+0!3+3#2'@!!
S($8!()!$8+6+!(0=/2'6E6!</2!90(&#<+!96+#&(E+EL0/2+6@!!I8+0+)(0+!/**!96+#&(E+EL0/2+6!
&(+6!2($!2+<+66/0'*4!E+/2!4(#!>'**!6++!.@!&'))'<'*+@!
!
&B!J/0/6'$+6!$8/$!</#6+6!&'/008+/-!!
Giardia-!!(>*!+4+6!$8/$!E(M+@!!I8'6!'6!$8+!K..!()!&'/008+/!&#+!$(!/!9/0/6'$+!'2!$8+!\Y@!!
I0+/$E+2$-!E+$0(2'&/c(*+@!!
Cryptosporidium parvi-!K..!()!%1_Y!&'/008+/!'6!/!9/0$'/**4!/<'&d)/6$!(0=/2'6E@!!1$!
6$'<F6!$(!$8+!>/**!()!$8+!<(*(2@!!.*/66'<!</6+-!!$8+0+!'6!/!9$!$8/$!8/6!%1_Y!/2&!8/6!
&'/008+/;!/2&!>8+2!$8+4!6$/'2!'$;!$8+0+!/0+!((<46$6!$8/$!/0+!9/0$'/**4!/<'&d)/6$@!!1$!>'**!
F'**!')!4(#!/0+!'EE#2(<(E90(E'6+&@!!I8+!$0+/$E+2$!'6!/*E(6$!>(0$8*+66@!1$!<(E+6!/$!
$8+!+2&!>8+2!$8+!8+*9+0!Id<+**6!/0+!2+/0!eV!(0!è;!/2&!$8/$Q6!>8+2!/**!$8+!(0=/2'6E6!
$8/$!>'**!F'**!4(#-!K%1;!<049$(69(0'&'#E;!$(:(9*/6E(6'6;!/2&!.Kk!/**!<(E+6!'2!/$!$8+!
+2&@!!J@!</0'2''!<(E+6!'2!/0(#2&!HVV!8+*9+0!Id<+**6@!
Clostridium difficile:!I8'6!'6!/2!/#$(964!9'<!()!/2!(*&+0!>(E/2!>8(!>/6!'2!$8+!8(69'$/*!
>'$8!92+#E(2'/;!/2&!68+!&+M+*(9+&!&'/008+/@!!g8/$!>/6!)(#2&!(2!/#$(964n!!g+**;!'$!
'6!6/)+!$(!6/4!$8/$!')!68+!8/&!92+#E(2'/;!$8+2!68+!>/6!$/F'2=!/2$'L'($'<6@!!Y(!$8'6!'6!
pseudomembranous colitis, caused by!clostridium difficile@!!I8'6!(<<#06!>8+2!
$/F'2=!/2$'L'($'<6!$8/$!>'9+!())!$8+!=((&!(0=/2'6E6;!*+/M'2=!L+8'2&!<@!&'))'<'*+@!!
[M+04L(&4!8/6!<@!&'))'<'*+!'2!$8+'0!6$((*6;!L#$![@!<(*';!+2$+0(L/<$+0!)0/='*'6!/0+!F++9'2=!
'$!'2!<8+<F@!!S#$!>8+2!$/F'2=!/2$'L'($'<6!6#<8!/6!/E9'<'**'2!?K.B;!<*'2&(E4<'2!?H2&!K.B!
)(0!/!9+0'(&!()!$'E+;!4(#!F2(<F!())!$8+!=((&!=#46;!='M'2=!<@!&'))'<'*+!/!<8/2<+!$(!
90(*')+0/$+!/2&!E/F+!$(:'26!$8/$!&/E/=+!$8+!6#9+0)'<'/*!*/4+06!()!$8+!<(*(2@!!I8+!
L/<$+0'/!&(+62Q$!'2M/&+;!'$Q6!$8+!$(:'26!$8/$!&(@!!I8'6!'6!/2/*(=(#6!$(!<@!&'98$8+0'/;!
>8'<8!/*6(!8/6!/!$(:'2!$8/$!&/E/=+6!/2&!90(&#<+6!96+#&(E+EL0/2+6!L#$!$8+!
(0=/2'6E!&(+6!2($!'2M/&+@!!I8+!0'L(64*/$'(2!$8'2=;!/2&!$8+![*(2=/$'(2!)/<$(0!H!?[TdH!
/**(>6!)(0!90($+'2!+*(2=/$'(2B!/0+!E+66+&!#9;!$8+0+)(0+!</22($!+*(2=/$+!90($+'26@!!
I8+!)'06$!6$+9!'2!E/2/=+E+2$!'6!$(!&(!/!$(:'2!/66/4!()!6$((*6;!2($!=0/E!6$/'2!LZ<!
$8+0+!/0+!*($6!()!=0/E!6$/'2!(0=/2'6E6!'2!$8+!6$((*6;!2($!L*((&!<#*$#0+!LZ<!'$Q6!2($!'2!
$8+!L*((&@!!The screening test of choice is toxin assay of stool!!I8+!$0+/$E+2$!
'6!$(!='M+!E+$0(2'&/c(*+;!#6+&!$(!='M+!M/2<(E4<'2!LZ<!<@!&'))'<'*+!L+</E+!0+6'6$/2$!$(!
'$@!!K+$0(2'&/c(*+!'$6+*)!</2!90(&#<+!96+#&(E+EL0/2(#6!<(*'$'6!L#$!4(#!$/F+!$8/$!
<8/2<+@!
VI. Diseases of the Small Intestine
A. Small bowel obstruction-!!Y++!<*/66'<!6$+9!*/&&+0!/99+/0/2<+!()!/'0d)*#'&!*+M+*6-!/'0;!)*#'&;!
/'0;!)*#'&!?6$+9!*/&&+0!/99+/0/2<+B@!!g8+2!4(#!8/M+!/!8(**(>!M'6<(#6!$8/$!9+0'6$/*6'6;!4(#!=+$!
/!<+0$/'2!<8/0/<$+0'6$'</**4!9/'2;!</**+&!COLIC pain@!!1$!'62Q$!*'F+!/!<0/E94!9/'2!>'$8!2(!
9/'2)0++!'2$+0M/*6U!<(*'<F4!9/'2!'6!>8+2!4(#!8/M+!9/'2;!/!9/'2)0++!'2$+0M/*;!9/'2;!/2&!$8+2!/!
9/'2)0++!'2$+0M/*@!!I8+!'2$+0M/*6!/0+!2($!<(26'6$+2$;!6(E+$'E+6!4(#!8/M+!/!,e!E'2!9/'2)0++!
'2$+0M/*;!/2&!($8+0!$'E+6!')!E/4!L+!*(2=+0!(0!68(0$+0@!!I8'6!'6!<(*'<F4!9/'2U!'$!E+/26!IGI%X!
163

6E/**!L(>+*!(L6$0#<$'(2@!!S4!$8+!>/4;!$8+!L'*+!&#<$!&(+6!2($!8/M+!9+0'6$/*6'6;!$8+0+)(0+!4(#!
&(!2($!=+$!<(*'<F4!9/'2;!/2&!'26$+/&!4(#!=+$!<0/E94!9/'2@!!b(#!8/M+!$(!8/M+!9+0'6$/*6'6!$(!
=+$!<(*'<F4!9/'2;!'$!8/6!$(!E(M+@!!%2&!>8/$Q6!'$!&('2=!'6!$04'2=!$(!E(M+!/=/'26$!$8/$!
(L6$0#<$'(2!/2&!$8/$Q6!</#6'2=!$8+!9/'2@!!SZ<!4(#!</22($!9+06$/*6+!4(#!=+$!6$/=2/$'(2!()!$8+!
)((&!90(:'E/*!$(!>8+0+M+0!$8+!(L6$0#<$'(2!'6;!/2&!=+$!/'0d)*#'&!*+M+*6@!_'6$/*!$(!$8+!/0+/!()!
(L6$0#<$'(2!$8+0+!'6!2(!/'0@!!12!(L6$0#<$'(2;!$8+0+!/0+!$>(!$8'2=6!$8/$!</2!8/99+2-!
constipation or obstipation@!!.(26$'9/$'(2!'6!>8+0+!4(#!8/M+!/!90(L*+E!>'$8!6$((*'2=;!
>8'<8!&(+6!2($!2+<+66/0'*4!E+/2!(L6$0#<$'(2@!!GL6$'9/$'(2!E+/26!$8/$!2($!(2*4!&(!4(#!8/M+!
<(26$'9/$'(2!4(#!/*6(!8/M+!/!90(L*+E!9/66'2=!=/6;!$8/$!E+/26!4(#!8/M+!<(E9*+$+!
(L6$0#<$'(2@!!Y(!4(#!8/M+!$(!/6F!$8+!9$!>8+$8+0!$8+4!8/M+!9/66+&!/24!6$((*6!(0!=/6@!!!!MCC
of obstruction: adhesions from previous surgeries. !Y*'&+-!!$8(6+!/0+!>/$+0E+*(2!9'$6;!
>'$8!/!2/00(>!*#E+2@!!S#$!')!$8+!</6+!0+/&!$8/$!$8'6!9$!&'&!2($!8/M+!9+0M'(#6!6#0=+0'+6!/2&!
8/&!<(*'<F4!9/'2;!$8'6!'6!&#+!$(!$8+!L(>+*!L+'2=!$0/99+&!'2!$8+!indirect inguinal hernia.
[:/E9*+-!!$8+0+!>/6!/!>+'=8$!*')$+0!>8(!&+M+*(9+&!<(*'<F4!9/'2!'2!$8+!RXp!/0+/;!8/&!2(!
90+M'(#6!6#0=+04;!$8+!E(6$!*'F+*4!</#6+!'6!'2&'0+<$!'2=#'2/*!8+02'/@!!g+'=8$!*')$+06!()$+2!$'E+6!
<0+/$+!'2&'0+<$!'2=#'2/*!8+02'/6@!
!
Side note-!$8+0+!>/6!/!9'<!()!Downs syndrome F'&@!!I0'6(E4!H,!?/L2(0E/*!2#EL+0!()!
<80(E(6(E+6B!'6!&#+!$(!2(2&'63#2<$'(2!?#2+D#/*!6+9/0/$'(2!&#0'2=!$8+!)'06$!6$/=+!()!E+'(6'6!1B!L#$!
2($!/**!&(>2Q6!8/M+!$0'6(E4!H,@!!S#$!')!$8+!F'&!8/&!2(0E/*!â!<80(E(6(E+6;!$8'6!'6!&#+!$(!
Robertsonian translocation@!!12!$8'6!</6+;!$8+4!>(#*&!8/M+!â!<80(E(6(E+6!L#$!(2!(2+!()!$8(6+!
<80(E(6(E+6!H,;!>'**!L+!/2($8+0!<80(E(6(E+!/$$/<8+&!$(!'$@!!I8+4!>'**!8/M+!$80++!)#2<$'(2/*!
<80(E(6(E+!H,@!!I8+!$>(!l1!&'6+/6+6!$8/$!/0+!K.Q*4!6++2!'2!_(>2Q6!/0+!duodenal atresia!?&(#L*+!
L#LL*+!6'=2B!/2&!Hirschsprung dz@!!!
!
B. Hirschsprung dz: $8+!2+0M+6!/0+!$8+0+!L#$!$8+!=/2=*'(2'<!<+**6!/0+!E'66'2=@!!Y(;!>8/$!
8/99+26!')!'$Q6!E'66'2=!'2!$8+!0+<$#E;!$8+!6$((*6!</22($!=+$!L4;!+M+2!>8+2!$8+0+!'6!/2!
(9+2'2=;!LZ<!$8+0+!'6!2(!9+0'6$/*6'6@!!Y(!$8+!6$((*6!3#6$!6$/4!$8+0+@!!Y(;!$8+!&'*/$'(2!()!$8+!
90(:'E/*!<(*(2!8/6!=/2=*'(2'<!<+**6;!/2&!$8+0+!9+0'6$/*6'6!(<<#00'2=!/2&!4(#!</2Q$!=+$!$8+!
6$((*6!$80#!$8+!0+<$/*!/0+/@!!Y(!$8'6!E+/26!$8/$!$8+!0+<$/*!/E9#**/!8/6!2(!6$((*6!'2!'$@!!!
[:/E9*+-!!')!4(#!8/M+!/!<8'*&!$8/$!&'&2Q$!9/66!$8+!E+<(2'#E!'2!H^!8(#06!/2&!/!0+<$/*!+:/E!
>/6!9+0)(0E+&@!!1)!$8+0+!>/6!NO stools that came out on exam it means
Hirschsprung dz.!!1)!(2!+:/E;!$8+0+!>/6!6$((*6!(2!$8+!)'2=+0;!'$!E+/26!$'=8$!698'2<$+0@!!!
This is a dz of the colon.!
C.!!Intussusception: E(6$!(<<#0!'2!<8'*&0+2;!/2&!'$Q6!>8+2!$8+!$+0E'2/*!'*+#E!'2$#66#6<+9$6!
=(+6!'2$(!$8+!<+<#E@!!I8+0+!>'**!L+!<(*'<F4!9/'2!LZ<!4(#!/0+!(L6$0#<$'2=;!/2&!2($!(2*4!$8/$;!
4(#!/0+!<(E90(E'6'2=!L*((&!)*(>;!6(!4(#!=+$!$8+!L*++&'2=@!!I8+4!>'**!6/4-!/!H!4Z(!F'&;!>'$8!
<(*'<F4!9/'2!/2&!L*((&4!6$((*6@!!I8+4!E'=8$!>/4!$8+0+!'6!/2!(L*(2=!E/66!'2!$8+!R\p@!!12!
6(E+!F'&6;!'$!69(2$/2+(#6*4!<(E+6!(#$;!L#$!')!2($;!$8+2!$8+!0/&'(*(='6$6!>'**!&(!L/0'#E!
+2+E/;!/2&!9#$!/!*'$$*+!90+66#0+!$8+0+;!/2&!8+!0+M+0$6!'$@!!Y(!4(#!=+$!<(E9*+$+!L(>+*!
(L6$0#<$'(2!/2&!'2)/0<$'(26@!
!
D.!!Volvulus:!I>'6$'2=!()!$8+!<(*(2!/0(#2&!$8+!E+6+2$+04!LZ<!$8+0+Q6!$((!E#<8!()!'$!</#6'2=!
<(E9*+$+!(L6$0#<$'(2!/2&!'2)0/<$'(26!&#+!$(!<(E90(E'6'2=!L*((&!)*(>@!!!!
!
E.!!Gallstone ileus!#6#/**4!6++2!'2!(*&+0!9+(9*+;!E(0+!>(E+2;!/2&!8/M+!6'=26!()!<(*'<F4!9/'2;!
/2&!(L6$0#<$'(2@!!I8+!=/**L*/&&+0!6$(2+!)/**6!$80#!$8+!)'6$#*/!/2&!6+$$*+6!'2$(!$8+!'*+(<+</*!
M/*M+!/2&!</#6+6!(L6$0#<$'(2@!!Y++!/!)*/$!9*/2+!()!$8+!/L&(E+2!$8/$!90(&#<+&!/'0!'2!$8+!
164

L'*'/04!$0++@!!S((E;!$8+0+Q6!4(#0!_:@!!I8+0+!'6!/!)'6$#*/!$8/$!'6!<(EE#2'</$'2=!$8+!=/**L*/&&+0!
>'$8!$8+!6E/**!L(>+*!$8+0+)(0+!/'0!</2!=+$!'2!$8+!6E/**!L(>+*!/2&!$8+!L'*'/04!$0++@!!Air in the
biliary tree with colicky pain is gallstone ileus. Dz of gallbladder.!
F. Meconium Ileus = cystic fibrosis
!
VII: Diseases of the Colon
A. Vascular diseases of the colon:
1. Ischemic Bowel Dz:
I8+!6E/**!L(>+*!E(0+!<(EE(2*4!'2)0/<$6!$8/2!$8+!*/0=+!L(>+*;!LZ<!'$!8/6!(2*4!(2+!L*((&!
6#99*4@!!I8+!+2$'0+!6E/**!L(>+*;!$8+!/6<+2&'2=!<(*(2;!/2&!$8+!$0/26M+06+!<(*(2!/0+!/**!
6#99*'+&!L4!$8+!YK%!?6#9+0'(0!E+6+2$+0'<!/0$+04B@!!Y(;!>8/$!'6!$8+!E/'2!&'))!'2!/!6E/**!
L(>+*!'2)/0<$!M6@!/2!'6<8+E'<!#*<+0!</#6'2=!L*((&4!&'/008+/!'2!$8+!69*+2'<!)*+:#0+n!I8+!
&'))+0+2<+!'2!J0+6+2$/$'(2@!!I8+4!L($8!</2!8/M+!L*((&4!&'/008+/@!N(>+M+0;!$8+!small
bowel infarction!>'**!_1TT\Y[!/L&(E'2/*!9/'2!?/**!(M+0!7!2($!(2+!69+<')'<!/0+/B@!!12!
ischemic colitis;!'$!>'**!9('2$!$(!69+<')'<!/0+/!(2!0'=8$!6'&+!()!/L&(E+2@!!I8'6!
&'))+0+2$'/$+6!L$>2!/!6E/**!L(>+*!'2)/0<$!)0(E!/!6E/**!'2)/0<$!'2!$8+!<(*(2!?</2!9'29('2$!
/0+/B@!
!
2. Angiodysplasia
H2&!K..!Hematochezia;!>'$8!&'M+0$'<#*(6'6!L+'2=!s,@!!1$Q6!'2!$8+!<+<#E!LZ<!*/>!()!
X/9*/<+!?>/**!6$0+66!/2&!0/&'#6B@!!I8+!&'/E+$+0!()!$8+!<+<#E!'6!L'==+0!$8/2!/24!($8+0!
9/0$!()!$8+!<(*(2@!!SZ<!$8+!&'/E+$+0!'6!=0+/$+0;!$8+!>/**!6$0+66!'6!=0+/$+0@!!I8+0+)(0+;!
9#$$'2=!6$0+66!(2!$8+!M+66+*6!'2!$8+!>/**!()!$8+!<+<#E;!'$!/<$#/**4!9#**6!$8+E!/9/0$!/2&!
90(&#<+6!$+*/2='+<$/6'/6@!!%6!/!0+6#*$;!'$!90+&'69(6+6!$(!/2='(&469*/6'/!LZ<!'2<0+/6+&!>/**!
6$0+66@!!1)!(2+!()!$8+E!0#9$#0+6!$(!$8+!6#0)/<+;!4(#!</2!+2&!#9!>'$8!6'=2')'</2$!L*++&@!!%!
M+04!<(EE(2!</#6+!()!N+E/$(<8+c'/!'2!(*&+0!9+(9*+@!!Y(;!')!&'M+0$'<#*(6'6!'6!0#*+&!(#$;!
/2='(&469*/6'/!'6!90(L/L*4!'$@!!!
!
B. Meckels Diverticulum/ Small Intestine Dz:
1. Rule of 2s:!!HW!()!9(9Q2U!H!'2<8+6!)0(E!$+0E'2/*!'*+#EU!H!)$!)0(E!$8+!'*'(<+</*!M/*M+U!H!
<E!'2!*+2=$8U!H!4Z(!(0!4(#2=+0U!/2&!HW!()!</0<'2('&!$#E(06!(<<#0!'2!K@_@!
!
K.!<(E9*'</$'(2!C!L*++&'2=@!!SZ<!'$!'6!/!&'M+0$'<#*#E;!'$!</2!L+!'2)*/E+&;!/2&!*+/&6!$(!
&'M+0$'<#*'$'6@!![:/E9*+-!!hematemisis, pain in RLQ area, melana!7&:n!K+<F+*Q6!?'2M(*M+&!
E+*/2/!%"_!8+E/$+E'6'6!7!&+)'2'$+*4!2($!\.!(0!.0(82Q6B@!!!
!
[:/E9*+-!!2+>L(02!>'$8!/!6'2#6!/2&!#EL'*'<#6!>/6!&0/'2'2=!9((9!7&:n!J+06'6$+2$!M'$+**'2+!
&#<$!?6/E+!/6!E+<F+*Q6!7!6(E+$'E+6!'$!'6!(9+2!/**!$8+!>/4!$80(#=8;!$8+0+)(0+!$8+0+!'6!/!
<(EE#2'</$'(2!L+$>++2!$8+!6E/**!L(>+*!/2&!#EL'*'<#6;!6(!)+<+6!<(E'2=!(#$!()!#EL'*'<#6;!
>8'<8!'6!9+06'6$+2<+!()!$8+!M'$+**'2+!&#<$@!!1)!4(#!8/M+!#0'2+!<(E'2=!(#$!()!$8+!M'$+**'2+!&#<$;!
$8'6!'6!9+06'6$+2<+!()!$8+!#0/<#6@!!Y(;!feces=vitelline duct, urine = uracus@!!
!
C. Sigmoid Colon
K.!*(</$'(2!)(0!</2<+0!'2!$8+!+2$'0+!l1!$0/<$!C!6'=E('&!<(*(2!
K.!*(</$'(2!)(0!9(*496!'2!$8+!+2$'0+!l1!$0/<$!C!6'=E('&!<(*(2!
165

K.!*(</$'(2!)(0!&'M+0$'<#*/!'2!$8+!+2$'0+!l1!$0/<$!C!6'=E('&!<(*(2!
!
I8+!/0+/!()!>+/F2+66!'6!>8+0+!$8+!L*((&!M+66+*6!9+2+$0/$+!$8+!M/*M+@!!I8+!E#<(6/!/2&!
6#LE#<(6/!>'**!8+02'/$+!0'=8$!2+:$!$(!$8+!M+66+*@!!I8'6!'6!M+04!L/&!]2+:$!&((0!2+'=8L(0j@!!
g8+2!)+<+6!/0+!6$#<F!?)+</*'$8B;!</2!+0(&+!$8/$!M+66+*;!/2&!</2!6++!>84!diverticulosis is
the MCC of Hematochezia massive lower GI bleed@!!I8+6+!+:$+2&!(#$6'&+!()!$8+!
*#E+2;!>8'<8!'6!&'M+0$'<#*(6'6@!!1)!4(#!6++!9(*496!'2!$8+!*#E+2;!&(!2($!<(2)#6+!>'$8!9(*49(6'6!
7!polyps go INTO the lumen;!2($!(#$@!!
!
D. Diverticulosis
MC complication = diverticulitisU!8/6!K%"b!<(E9*'</$'(26@!!!
Diverticulitis!C!X+)$!6'&+!/99+2&'<'$'6!?/99+2&'<'$'6!&:-!RXp!9/'2;!K<S#02+4Q6!9$;!0+L(#2&!
$+2&+02+66;!)+M+0;!/2&!2+#$0(98'*'<!*+#F(<4$(6'6B!7!$8'6!'6!$8+!6/E+!90+6+2$/$'(2!'2!
&'M+0$'<#*'$'6B;!L#$!&'M+0$'<#*'$'6!(<<#06!'2!$8+!XXp!/0+/;!'2!/2!+*&+0*4!9+06(2@!!MCC fistulas
communications in the GI = diverticulosis.!!g'$8!/!)'6$#*/;!$8+0+!'6!<(EE#2'</$'(2!
L+$>++2!H!8(**(>!(0=/26@!!I8+!MC fistulas are colovesicle fistulas;!>8'<8!'6!/!)'6$#*/!
L+$>++2!$8+!<(*(2!/2&!$8+!L*/&&+0;!*+/&'2=!$(!neumaturia air in the urine@!!MCC of
colovesicle fistula is diverticular dz@!!I8+4!</2!0#9$#0+;!/2&!$8+!0#9$#0+!</2!</#6+!
9+0'$(2'$'6@!
!
VIII. Inflammatory Bowel Dz: Crohns and UC
.0(82Q6!'2M(*M+&!$8+!$+0E'2/*!'*+#E!tVW!()!$8+!$'E+@!!Y(E+$'E+6!'$!3#6$!'2M(*M+6!$8+!$+0E'2/*!
'*+#E;!6(E+$'E+6!'$!'2M(*M+6!$8+!$+0E'2/*!'*+#E!%"_!$8+!<(*(2;!/2&!6(E+$'E+6!'$!3#6$!'2M(*M+6!
$8+!<(*(2@!!.0(82Q6!*'F+6!$8+!%"\Y;!\.!*'F+6!$8+!R[.I\K!?$8+4!8/M+!/!90+)+0+2<+!)(0!>8'<8!9/0$!
()!$8+!*(>+0!9/0$!$8+4!*'F+B@!!.0(82Q6!*'F+6!$(!90(&#<+!)'6$#*/6!/2&!)'66#0+6!()!$8+!/2#6U!\.!*'F+6!
$8+!0+<$#E;!90(&#<'2=!L*((&4!&'/008+/@!!.0(82Q6!3#E96!/0(#2&;!$0/26E#0/*;!2(2</6+/$'2=!
=0/2#*(E/6@!!\.!&(+62Q$!3#E9U!'$!6$/46!'2!<(2$'2#'$4;!/2&!'2M(*M+6!$8+!E#<(6/Z6#LE#<(6/@!Dx
of Crohns is simple ie ileocecal valve, ascending colon, terminal ileum there is a
transmural inflammation with a very narrow lumen therefore the presentation will
be colicky, RLQ pain, with diarrhea in young person@!!Nothing!except Crohns
produces colicky pain in the RLQ in a young person!!!1)!'6!/!P0&!>(0*&!<(#2$4;!>8/$!'6!'$n!
IS!?E@!L(M'6B@!!12!$8'6!<(#2$04;!')!>+!=+$!'2$+6$'2/*!IS!)0(E!6>/**(>'2=!'$!/2&!'$!>'**!L+!K!@IL@!!12!
$8'0&!>(0*&!<(#2$0'+6;!'$!90(&#<+6!90+6+2$/$'(2!6/E+!/6!.0(82Q6U!$8'6!(<<#06!LZ<!$8+4!&(!2($!8/M+!
9/6$+#0'c/$'(2U!K@!L(M'6!'6!$8+!K..U!$8'6!'6!>8+0+!9/4+0Q6!9/$<8+6!/0+@!!String sign!7!(2!L/0'#E!
6$#&4;!*((F6!*'F+!/!6$0'2=!7!6++!$8/$!'$!'6!$0/26E#0/*!/2&!$8/$!'$!'6!6+=E+2$/*@!!I8+!90(:'E/*!M/*M+!
'6!&'*/$+&!7!8/M+!$(!9#68!6$((*!$80(#=8!$8/$!L#$!4(#!</2Q$@!!Y++!<(LL*+6$(2+6!/2&!#*<+0/$'(2!'2!
.0(82Q6!&c@!!X'2+/0!#*<+06!/0+!/9$8#6!#*<+06. Non caseating granuloma is characteristic of
UC@!!UC always begins in the rectum;!</2!6$/4!$8+0+;!(0!</2!E(M+!#9!'2!<(2$'2#'$4!/2&!
'2M(*M+&!$8+!>8(*+!<(*(2;!L#$!'$!2+M+0!'2M(*M+6!$8+!$+0E'2/*!'*+#E@!1$!'6!'2M(*M+6!$8+!>8(*+!<(*(2;!
'$!'6!</**+&!9/2<(*'$'6;!/2&!$8'6!8/6!$8+!8'=8+6$!'2<'&+2<+!()!</2<+0@!!Y(;!$8+!E(0+!'2M(*M+E+2$!
/2&!=0+/$+0!&#0/$'(2!C!=0+/$+0!<8/2<+!()!</2<+0!0+*/$+&!$(!\.@!!J6+#&(9(*496!7!6++!#*<+0/$+&!
E#<(6/!/2&!6#LE#<(6/@!!J6+#&(9(*496!/0+!0+6'&#/*!9(*496!$8/$!/0+!'2)*/E+&;!'$!'6!'2)*/E+&!
L*((&4!E#<(6/@!![M+04$8'2=!'6!#*<+0/$+&!());!/2&!4(#!6++!$8+!6#LE#<(6/!()!$8+!<(*(2@!!\.!8/6!
$8+!8'=8+6$!'2<'&+2<+!>'$8!</2<+0;!NX%!SH`!/2F*4(6'6!69(2&4*'$'6;!/2&!'6!$8+!K..!()!6<*+0(6'2=!
9+0'<8(*/2='$'6!?6<*+0(6'6Z)'L0(6'6!/0(#2&!<(EE(2!L'*+!&#<$;!90(&#<'2=!(L6$0#<$'M+!3/#2&'<+!/2&!
8'=8!'2<'&+2<+!()!<8(*/2='(</0<'2(E/B@!!52(>!$8+!&'))!'2!\.!M6@!.0(82Q6@!
!
IX. Tumors of the Colon Polyps
166

MC polyp in entire GI = hyperplastic polyp!7!'$!'6!/!*'$$*+!2#LL'2!7!/F/!8+E/0$(E/6!
?$8+0+)(0+!2($!2+(9*/6$'<B;!#6#/**4!'2!6'=E('&!<(*(2@!
!
Tubular adenoma-!*((F6!*'F+!/!6$0/>L+004!(2!6$'<F;!$8+0+)(0+!8/6!/!6$/*F!>'$8!6$0/>L+004;!
>8'<8!'6!$8+!90+<#06(0!*+6'(2!)(0!<(*(2!</2<+0@!
Juvenile Polyp-!Y*'&+-!<(E'2=!(#$!()!<8'*&Q6!L#$$!7!F'&!>'$8!9(*49!'2!0+<$#EU!all juvenile
polyps located in the rectum and are hamartomas (no precancerous).!!!
!
X+$6!6/4!'$!'6!/2!/&#*$!/2&!$8+!9(*49!'6!6$'<F'2=!(#$!?/!0+&&'68!E/66B!7!&:n!Internal
hemorrhoids@!!Rule: internal hemorrhoids bleed, external hemorrhoids
thrombose@!!I8+0+)(0+;!>8+2!4(#!8/M+!L*((&!<(/$'2=!$8+!6$((*;!'$!'6!'2$+02/*!8+E(008('&@!!
12$+02/*!8+E(008('&6!/0+!"GI!9/'2)#*;!L#$!$8+4!&(!90(*/96+@!
%&#*$!>'$8!6(E+$8'2=!0+&&'68!6$'<F'2=!(#$!()!$8+'0!L#$$!C!90(*/96+&!'2$+02/*!8+E(008('&@!!
Internal hemorrhoids bleed and painless, while external thrombose and are
painful.!!!
Sessile Polyp (villous adenoma)!7!*((F6!*'F+!$8+!M'**(#6!6#0)/<+!()!$8+!6E/**!'2$+6$'2+!
?8+2<+!2/E+!M'**(#6!/&+2(E/BU!$8+6+!/0+!*'*!)'2=+0d*'F+!+:<0+26+6!()!$8+!6E/**!'2$+6$'2+;!
8+2<+!$8+!2/E+!M'**(#6!/&+2(E/@!!These have the greatest malignant potential, and
are usually in the rectal sigmoid. !SZ<!$8+4!/0+!M'**(#6Z)'2=+0!*'F+!$8+4!8/M+!/!*($!()!
E#<(#6!<(/$'2=!$8+!6$((*U!E#<(#6!6+<0+$'2=!M'**(#6@!!I8+4!8/M+!/!eVW!<8/2<+!()!L+<(E'2=!
E/*'=2/2$@!!Y(;!$#L#*/0!/&+2(E/6!/0+!90+<#06(06!)(0!</2<+0!?6'c+!&+$+0E'2+6!E/*'=2/2$!
9($+2$'/*!7!')!$8+4!/0+!/L(M+!H!6(2(E+$+06;!$8+4!/0+!M+04!&/2=+0(#6B!/2&!M'**(#6!/&+2(E/6!
*+/&!$(!</2<+0;!$((@!!!
Familial polyposis!7!2++&!$(!8/M+!(M+0!,VV!9(*496!$(!8/M+!)/E'*'/*!9(*49(6'6@!!!I8'6!&c!'6!
/#$(6(E/*!&(E'2/2$;!#6+6!%J.!6#990+66(0!=+2+;!0/6;!/2&!9ePU!%J.!'6!$8+!E/3(0!(2+@!!!g'**!
/*>/46!=+$!</2<+0!'2!$8+E;!#6#/**4!L+$>++2!Ped^V@!!I8+0+)(0+;!>'**!2++&!$(!90(984*/<$'</**4!
0+E(M+!$8+!L(>+*@!!I8+!/#$(6(E/*!&(E'2/2$!&c!'6!)/E(#6!)(0!*/$+!E/2')+6$/$'(26;!
9+2+$0/2<+;!/2&!M/0'/L*+!+:90+66'M'$4!?/6!/0+!/**!($8+0!%_!&cQ6B@!!I8'6!E+/26!$8/$!$8+4!>'**!
2($!L+!L(02!>'$8!9(*496!/$!L'0$8!?$8+4!6$/0$!&+M+*(9'2=!L$>2!$8+!/=+6!()!,VdHVU!'2!%_J5_;!
$8+4!&(!!2($!8/M+!<46$6!/0+!L'0$8;!$8+4!6$/0$!&+M+*(9'2=!L$>2!,VdHVU!'2!N#2$'2=$(2Q6!<8(0+/;!
&(!2($!8/M+!<8(0+/!/$!L'0$8;!L#$!/0(#2&!Ped^V!4+/06;!/2&!$8+4!8/M+!*/$+!E/2')+6$/$'(26@!
!
Affected colon has polyps and brain tumors = Turcot syndrome!?*'F+!$#0L/2B!7!
$8+0+)(0+;!4(#!8/M+!/!9(*49(6'6!642&0(E+!>'$8!L0/'2!$#E(0U!$8'6!&c!'6!/#$(!0+<!?2($!
&(E'2/2$B@!!!
Gardners syndrome-!N/M+!E#*$'9*+!9(*496!'2!$8+0+;!9*#6!Lr!6/*$!$'66#+!$#E(06-!&+6E('&6!
/2&!(6$+(E/6!'2!$8+!3/>@!
!
X. Carcinoid Tumors
%*(2=!>'$8!/#9#$!$#E(06@!!%**!</0<'2('&!$#E(06!/0+!E/*'=2/2$;!L#$!8/M+!*(>!=0/&+!9($+2$'/*@!!%!
*($!()!'$!&+9+2&6!(2!$8+'0!6'c+!/2&!')!$8+4!/0+!=('2=!$(!E+$6@!!_+9+2&6!(2!$8+'0!6'c+!'2!
6(2(E+$+06!7!')!$8+4!/0+!=0+/$+0!$8/2!H!6(2(E+$+06!$8+4!8/M+!$8+!/L'*'$4!$(!E+$6@!MC location
for carcinoid tumor = tip of the appendix!7!8/M+!/!L0'=8$!4+**(>!<(*(0;!L#$!$8+4!are
NEVER the cause of carcinoid syndrome!7!>84n!SZ<!$8+!$'9!()!$8+!/99+2&':!>'**!2+M+0!L+!
=0+/$+0!$8/2!H!6(2(E+$+06@!!Y(;!>8+0+!'6!$8+!MC location of carcinoid tumor that CAN be
associated with carcinoid syndrome? Terminal Ileum they are always greater than
167

2 sonometers@!!g8/$!&(!/**!</0<'2('&!$#E(06!E/F+n!Serotonin@!!SZ<!$8+!/99+2&':!/2&!
$+0E'2/*!'*+#E!/0+!&0/'2+&!L4!$8+!9(0$/*!M+'2;!$8+!6+0($(2'2!E/&+!=(+6!$(!$8+!9(0$/*!M+'2;!=(+6!
$(!$8+!8+9/$(<4$+;!'6!E+$/L(*'c+&!'2$(!e!84&0(:4/<$(/<$'$'<!?nB!/<'&!/2&!'6!9++Q&!(#$U!$8+0+)(0+!'$!
'6!2($!'2!$8+!L*((&6$0+/E@!!I8+0+)(0+;!$8+0+!/0+!2(!6'=26!()!)*#68'2=!/2&!&'/008+/!LZ<!$8+0+!'6!2(!
<(2$/<$!>'$8!$8+!646$+E'<!<'0<#*/$'(26@!!N(>+M+0;!')!4(#!E+$6!$(!$8+!*'M+0;!$8+2!$8(6+!E+$/6$/$'<!
2(&#*+6!$8/$!/0+!E/F'2=!6+0($(2'2!</2!&#E9!6(E+!()!'$!'2$(!$8+!8+9/$'<!M+'2!$0'L#$/0'+6@!!I8'6!
&(+6!8/M+!/<<+66!$(!$8+!646$+E'<!<'0<#*/$'(2!LZ<!=(+6!$(!1k.!$(!R'=8$!6'&+!8+/0$;!/2&!$8'6!'6!>84!
4(#!=+$!0'=8$!6'&+&!*+6'(26!7!iTIPS = tricuspid insuff and pulmonic stenosis@!!Serotonin!
'6!/!M/6(&'*/$(0!'2!6(E+!</6+6;!L#$!/!M/6(<(26$0'<$(0!'2!($8+0!</6+6@!!N(>+M+0;!'2!$+0E6!()!
6+0($(2'2!642&0(E+;!'$Q6!/!M/6(&'*/$(0!that causes flushing (which is the MC symptom of
carcinoid), followed by diarrhea (2nd MC).!!1)!'$!8/6!/<<+66!$(!646$+E'<!<'0<#*/$'(2;!'$!8/6!
8'=8!*+M+*6!()!e!84&0(:4/<+$(/<'$'<!?nB!/<'&;!>8'<8!'6!$8+!6<0++2'2=!$+6$!()!<8('<+!LZ<!'$!'6!$8+!
E+$/L(*'$+!()!6+0($(2'2@!!Y(;!b/c making and LOSING a lot of serotonin, what aa can be
deficient? Tryptophan is def, therefore the vitamin Niacin is def, therefore can have
pellagra. You using up all the Tryptophan and making serotonin instead of niacin.
!
XI. Colon cancer
"+#0(6+<0+$(04!=0/2#*+6!(2![K!7!<(*(2!</2<+0U!left side obstructs, right side bleeds@!!!
!
I8'6!'6!+/64!$(!#2&+06$/2&!LZ<!$8+!*+)$!<(*(2!8/6!/!6E/**+0!&'/E+$+0!$8/2!$8+!0'=8$@!!Y(;!>8+2!
$8+!</2<+0!&+M+*(96!'2!the left colon!/2&!>/2$6!$(!)(0E!/!9(*49;!'$!=(+6!/0(#2&!7!annular
(napkin ring);!/2&!90(&#<+6!<(26$0'<$'(2@!!G9+2!L(>+*!'2!*+)$!<(*(2;!6++!(2+!+&=+!()!$8+!
</2<+0!(2!+/<8!6'&+!()!$8+!L(>+*!/2&!L(>+*!'6!<(26$0'<$+&!7!8/M+!6'=26!()!(L6$0#<$'(2!?*+)$!6'&+!
(L6$0#<$6;!0'=8$!6'&+!L*++&6B@!!!
!
12!$8+!right colon;!LZ<!()!$8+0+!'6!/!L'==+0!&'/E+$+0U!'$!8/6!/!L'==+0!<8/2<+!()!=('2=!(#$!/2&!
)(0E'2=!/!9(*49@!!I8+0+)(0+;!'$!'6!6'$$'2=!'2!$8+!6$((*;!*+/&'2=!$(!/!L*++&!?$8+0+)(0+!*+)$!6'&+!
(L6$0#<$6;!0'=8$!6'&+!L*++&6B@!!!
!
Y(;!>8'<8!'6!6'&+!'6!E(0+!*'F+*4!$(!8/M+!T+!&+)n!R'=8$!6'&+&!*+6'(2@!!!
g8'<8!'6!E(0+!*'F+*4!$(!8/M+!/*$+0/$'(2!'2!L(>+*!8/L'$6!?<(26$'9/$'(2Z&'/008+/Bn!X+)$!6'&+&@!!!
Tumor marker for colon cancer = CEA (carcinoembryonic AgB@!!"($!#6+&!$(!&:!<(*(2!
</2<+0;!L#$!#6+&!$(!)(**(>!'$!)(0!R[G..\RR[".[@!!K..!0+*/$+6!$(!&'+$!?*/<F!()!)'L+0!'2!6$((*!7!
$8+0+)(0+;!E(0+!)'L+0!4(#!8/M+;!$8+!*+66!<8/2<+!()!<(*(2!</2<+0!LZ<!4(#!/0+!=+$$'2=!0'&!()!
*'9(<(*'<!/<'&B@!!%=+!'6!/*6(!/!0'6F!)/<$(0!?9$6!(M+0!eVBU!6E(F'2=!'6!/!0'6F!)/<$(0!$8/$!'6!/66(<!>'$8!
<(*(2!</2<+0@!!J(*49(6'6!<(*'!642&0(E+6!/*6(!8/M+!/2!/66(<'/$'(2!?)/E'*'/*!9(*49(6'6;!l/0&2+0Q6!
642&0(E+;!$#0<($Q6!642&0(E+B!!
"GI!J+#$c!f+=8+06;!849+09*/6$'<!9(*496;!(0!3#M+2'*+!9(*496B@!
!
XII. Diseases of the Appendix: Appendicitis
!
.(M+0+&!>'$8!9#6U!K..!/99+2&'<'$'6!'2!/&#*$6!C!)+</*'$8!C!'E9/<$+&!6$((*@!!Y(!>8+2!4(#!'E9/<$!
6$((*!'$!90+66+6!(2!$8+!6'&+6!()!$8+!/99+2&':;!/2&!*+/&6!$(!'6<8+E'/;!$8+2!=+$!/!L0+/F&(>2!()!
$8+!E#<(6/;![@!<(*'!=+$6!'2!$8+0+!/2&!/<#$+!/99+2&'<'$'6!(<<#06@!!This is the SAME mech for
diverticulitis ?$8+!&'M+0$'<#*/0!6/<6!/*6(!=+$!)+</*'$86!'2!$8+E!/2&!$8+!6/E+!+:/<$!$8'2=!8/99+26!
168

7!$8+!9/$8(=+2+6'6!()!/<#$+!&'M+0$'<#*'$'6!/2&!/<#$+!/99+2&'<'$'6!'6!+:/<$*4!$8+!6/E+B@!!Y(;!
)+</*'$8;!'6<8+E'/!/*(2=!$8+!>/**;!'2)*/EE/$'(2;![!<(*'@!!
!
%2($8+0!/2/*(=4-!/<#$+!<8(*+<46$'$'6!7!+:<+9$!'$!'6!2($!/!)+</*'$8;!L#$!'6!/!6$(2+!'2!$8+!<46$'<!&#<$!
9#68+6!(2!$8+!6'&+;!*+/&6!$(!'6<8+E'/;!/<#$+!<8(*+<46$'$'6;![!<(*'.!!Y(;!$8+0+!'6!/!<(2<+9$!$8+0+!7!
we have acute cholecystitis, diverticulitis, and appendicitis all related to something
obstructing the lumen, causing mucosal damage, and E coli inflammation@!!12!/<#$+!
<8(*+<46$'$'6!'$Q6!/!6$(2+;!>8'*+!/<#$+!/99+2&'<'$'6!/2&!&'M+0$'<#*'$'6!'6!&#+!$(!/!)+</*'$8@!!!
!
g8/$!$8+!MCC of appendicitis in children? Measles and/or adenovirus infection@!!I8+2;!
/<#$+!/99+2&'<'$'6!(<<#06!LZ<!$8+0+!'6!*4E98('&!$'66#+!'2!$8+!/99+2&':@!!g'$8!E+/6*+6!(0!
/&+2(M'0#6!'2)+<$'(2;!=+$!hyperplasia of lymphoid tissue in the appendix, and can
obstruct the lumen and set up inflammation for mucosal injury and leads to acute
appendicitis@!!Y(, in children, it usually follows a viral infection@!!%6!(99(6+&!$(!/&#*$6;!
>8+0+!'$!'6!&#+!$(!)+</*'$8@!!!
169

CHAPTER 10. LIVER
I. Bilirubin metabolism:
!
K(6$!()!$8+!L'*'0#L'2!'2!(#0!L*((&!'6!#2<(23#=/$+&!/2&!&+0'M+&!)0(E!$8+!RS.Q6!>8+2!$8+4!/0+!(*&;!
98/=(<4$(6+&!/2&!&+6$0(4+&@!!\2<(23!L'*'0#L'2!'6!$8+!+2&!90(&#<$;!=(+6!$(!$8+!L*((&6$0+/E!/2&!
L'2&6!>'$8!/*L#E'2;!=(+6!$(!$8+!*'M+0!/2&!'6!$/F+2!#9@!!K/3(0'$4!()!L'*'0#L'2!'6!)0(E!L0+/F&(>2!()!
RS.Q6!?rrWB;!>8'<8!'6!/**!#2<(23@!!"(2+!()!$8'6!'6!'2!$8+!#0'2+!LZ<!'$!'6!*'9'&!6(*#L*+@!!Y(;!'$!=+$6!
$/F+2!#9!L4!$8+!*'M+0!/2&!'6!<(23#=/$+&@!!%24!$'E+!$8+!<4$(<80(E+!9êV!<(23#=/$+6!L'*'0#L'2;!(0!
E+$/L(*'c+6!/24!&0#=;!'$!0+2&+06!'$!>/$+0!6(*#L*+@!!Y(;!>+!8/M+!/!*'9'&!6(*#L*+!#2<(23#=/$+&!
L'*'0#L'2!'6!<(2M+0$+&!$(!<(23#=/$+&!L'*'0#L'2!?&'0+<$!L'*'0#L'2B;!>8'<8!'6!>/$+0!6(*#L*+@!!G2+!()!$8+!
9#09(6+6!()!$8+!*'M+0!'6!$(!0+2&+0!*'9'&!6(*#L*+!&0#=6!>/$+0!6(*#L*+;!6(!4(#!</2!9++!$8+E!(#$@!!
Y(;!>+!<(23#=/$+!'$!/2&!8/M+!>/$+0!6(*#L*+!L'*'0#L'2@!!G2<+!L'*'0#L'2!'6!$/F+2!#9!L4!$8+!*'M+0;!'$!'6!
2+M+0!<*(6+!$(!/!M+66+*@!!Y(;!$8+0+!'6!2(!>/4!'$!</2!=+$!'2$(!/!M/6<#*/0!<8/22+*!?(2<+!'$!'6!$/F+2!
#9!L4!$8+!*'M+0B@!!Y(;!')!&'0+<$!<(23#=/$+&!L'*'0#L'2!'6!'2!(#0!#0'2+;!$8'6!'6!LZ<!6(E+$8'2=!8/99+2+&!
?+'$8+0!'2!$8+!*'M+0!(0!L'*+!&#<$B!$(!8/M+!</#6+&!'$!$(!=+$!$8+0+!LZ<!'$!68(#*&2Q$!8/M+!/<<+66!$(!(#0!
L*((&!6$0+/E@!!Y(;!'$!'6!$/F+2!#9!'2!$8+!*'M+0;!<(23#=/$+&;!/2&!9#E9+&!'2$(!$8+!L'*+!&#<$#*+6U!
>8'<8!=(!'2$(!$8+!$0'/&;!=(+6!#9!$8+!<(EE(2!L'*+!&#<$;!6(E+!'6!6$(0+&!'2!$8+!lS!/2&!=(+6!'2$(!
$8+!6E/**!'2$+6$'2+!$80(#=8!$8+!<(EE(2!L'*+!&#<$@!!I8+0+)(0+;!L'*+!<(2$/'26!<(23#=/$+&!L'*'0#L'2@!!
1$6!/*6(!<(2$/'26!L'*+!6/*$6;!<8(*+6$+0(*!/2&!+6$0(=+2;!L#$!8/6!<(23#=/$+&!L'*'0#L'2!$8/$!>+!>'**!=+$!
0'&!()@!!Y(;!$8'6!<(23#=/$+&!L'*'0#L'2!$/F+6!/!*(2=!$0'9!&(>2!$(!$8+!<(*(2!/2&!$8+!L/<$+0'/*!8/M+!
L++2!>/'$'2=!)(0!$8+!<(23#=/$+&!L'*'0#L'2!/2&!>'**!L0+/F!'$!&(>2!L/<F!'2$(!#2<(23#=/$+&!L'*'0#L'2@!!
I8+2;!'$!<(2$'2#+6!$(!L0+/F!'$!&(>2@!!I8+!L/<$+0'/!L0+/F6!'$!&(>2!$(!6$+0<(L'*'2(=+2!?>8/$!'$!
#6+&!$(!L+!</**+&B@!!Y$+0<(L'*'2(=+2!(:'&'c+6!$(!6$+0<(L'*'2!90(&#<+6!$8+!<(*(0!()!6$((*@!!I8'6!$+0E!
'6!2(!*(2=+0!#6+&@!!"(>;!'$!'6!</**+&!#0(L'*'2(=+2!?>8'<8!E/F+6!$8+!<(*(0!()!$8+!9'=E+2$B@!!1$!'6!
+/6'+0!$(!#2&+06$/2&!$8+!<(2<+9$@!!Y(;!the unconjugated bilinogen is broken down to
urobilinogen@!!%**!9(09840'26!/0+!<(*(0*+66!>8+2!$8+4!/0+!'2!/2!]d(=+2Q!<(E9(#2&U!8(>+M+0;!
>8+2!4(#!(:'&'c+!$8+E;!$8+4!8/M+!<(*(0@!!Y(;!urobilinogen, when it becomes oxidized in
the stool becomes urobilin, which is the color of stool@!!%!6E/**!9(0$'(2!()!#0(L'*'2(=+2!'6!
0+/L6(0L+&!(#$!()!$8+!<(*(2@!!K(6$!()!'$!=(+6!L/<F!$(!$8+!*'M+0@!!%!*'$$*+!()!'$!=(+6!$(!$8+!F'&2+4!
/2&!+2&6!#9!'2!$8+!#0'2+;!>8+0+!'$!=+$!(:'&'c+&!'2$(!#0(L'*'2@!!I8'6!'6!$8+!</#6+!()!$8+!<(*(0!()!
#0'2+@!!Y(, the same pigment that colors stool is responsible for coloring urine@!!g+!
>+0+!$/#=8$!$8/$!6$+0<(L'*'2(=+2!'6!'2!$8+!6$((*!/2&!#0(L'*'2(=+2!'6!'2!$8+!#0'2+U!8(>+M+0;!6$+0<(!
C!#0(;!6(!$8+!6/E+!<(E9(#2&!'6!0+69(26'L*+!)(0!<(*(0!<8/2=+!'2!)+<+6!/2&!#0'2+@!!I8+4!/0+!2($!
&'))!9'=E+2$6;!$8+4!/0+!$8+!6/E+@!!!Y(;!')!4(#!8/M+!(L6$0#<$+&!L'*+!)*(>!?'2!$8+!*'M+0!(0!.S_B;!
>8/$!68(#*&!$8+!<(*(0!()!$8+!6$((*!L+n!X'=8$!<(*(0+&!7!LZ<!$8+!#0(L'*'2(=+2!>(#*&!2($!8/M+!
/<<+66!$(!$8+!6$((*!$(!<(*(0!'$@!!%*6(;!>(#*&!2($!8/M+!#0(L'*'2(=+2!'2!$8+!#0'2+@!I8'6!*+/&6!$(!
3/#2&'<+@!
!
II. Jaundice
I(!</*<#*/$+!3/#2&'<+;!$8+4!$/F+!$8+!$($/*!L'*'0#L'2!/2&!)'2&!(#$!$8+!9+0<+2$/=+!()!L'*'0#L'2!$8/$!'6!
<(23#=/$+&!?&'0+<$!L'*'0#L'2B@!![:/E9*+-!$($/*!'6!,V;!<(23!C!e;!$8+0+)(0+!<(23!L'*'0#L'2!C!eVW@!!!
Y(;!$8+4!6#L&'M'&+!3/#2&'<+!'2$(!P!$49+6!7!<(23#=/$+&!L'*'0#L'2!*+66!$8/2!HVW!?$8+0+)(0+!E(6$!()!
'$!'6!#2<(23#=/$+&B;!!
L$>2!HVdeVW!?$8+0+)(0+!6(E+!'6!<(23!/2&!#2<(23B;!/2&!
!=0+/$+0!$8/2!eVW!?E(6$!()!'$!'6!<(23#=/$+&!L'*'0#L'2B@!!1$6!/*6(!E+/26!$8/$!4(#!8/M+!(L6$0#<$'(2@!!!
!
1)!'$!'6!under 20%;!$8'6!primary unconjugated hyperbilirubinemia@!!Y(!>8/$!</2!'2<0+/6+!
#2<(23!L'*'0#L'2n!Hemolytic anemias, spherocytosis, SCDz, ABO hemolytic dz of the
170

newborn, Rh hemolytic dz of the newborn, physiologic jaundice of the newborn!?LZ<!
$8+4!</22($!<(23#=/$+!'$B@!!Y(;!$8+0+!'6!'2<0+/6+&!#2<(23#=/$+&!L'*'0#L'2!LZ<!L0+/F'2=!&(>2!E(0+!
RS.Q6;!8/M+!90(L*+E6!>'$8!<(23#=/$'2=!+2c4E+6!7!+'$8+0!$((!'EE/$#0+!(0!$8+4!/0+!E'66'2=!
+2c4E+6!?Craigler Najjar syndromeB@!!Y(;!>+!/0+!+'$8+0!E/F'2=!$((!E#<8!LZ<!>+!/0+!
L0+/F'2=!&(>2!$((!E/24!RS.Q6!(0!>+!8/M+!/!90(L*+E!>'$8!<(23#=/$'2=!+2c4E+6!7!>8'<8!'6!*'$$*+!
L/L'+6!>'$8!9846'(*(='<!3/#2&'<+!&c!()!$8+!2+>L(02;!(0!0/0+!&cQ6!>8+0+!>+!/0+!&+)'<'+2$!'2!$8+!
+2c4E+!?.0/'=*+0!"/33/0B@!!!
!
I8+!&cQ6!btwn 20- 50%!/0+!8+9/$'$'6@!!Hepatitis!C!'2)*/EE/$'(2!()!$8+!*'M+0!?2($!3#6$!6(E+!()!
'$;!/**!()!'$B@!!Y(;!LZ<!'$Q6!/!6'<F!*'M+0;!'$!&(+62Q$!>/2$!$(!$/F+!#9!$8+!#2<(23#=/$+&!L'*'0#L'2@!!
\2<(23!!*'M+0!L#'*&6!#9!L+8'2&!$8+!*'M+0@!!12)*/EE/$'(2!'2!$8+!*'M+0!>'**!E/4L+!&+6$0(4!$8+!
/0<8'$+<$#0+!'2!$8+!*'M+0!/2&!L0+/F!(9+2!L'*+!&#<$6!$8/$!8/M+!<(23!L'*'0#L'2!'2!$8+E@!!!"(>;!LZ<!
4(#!8/M+!&'60#9$+&!$8+!/0<8'$+<$#0+;!$8+0+!'6!/!9(66'L'*'$4!()!>/$+0!6(*#L*+!L'*'0#L'2!$(!=+$!'2$(!
$8+!L*((&!6$0+/E!?LZ<!$8+0+!'6!2+<0(6'6!()!*'M+0!<+**6!/2&!L'*+!&#<$6!7!6(!4(#!>'**!=+$!<(23#=/$+&!
L'*'0#L'2!'2!$8+0+;!$((B!d!!*+/&'2=!$(!HVdeVW@!!I8'6!includes all the hepatitis (including
alcoholicB@!!
!
1)!'$!'6!greater than 50%;!$8'6!'6!/!"G!SR%1"[R!7!'$!'6!<*+/0*4!/2!obstruction of bile@!!g+!
8/M+!'2$0/8+9/$'<!(L6$0#<$'(2!?intrahepatic cholestasisB;!E+/2'2=!$8/$!4(#!/0+!L*(<F'2=!L'*+!
)*(>!'2!$8+!*'M+0!?$0'/&!'6!L*(<F+&B@!!%*6(!8/M+!extrahepatic cholestasis!?(#$6'&+!()!$8+!*'M+0B@!!
I8+0+!'6!(2*4!(2+!$8'2=!(#$6'&+!$8+!*'M+0!$8/$!</2!*+/&!$(!$8'6!7!CBD (common bile duct)@!!
I8+0+)(0+;!6(E+$8'2=!'6!(L6$0#<$'2=!$8/$!7!/!6$(2+!'2!$8+!<(EE(2!L'*+!&#<$!$8/$!</E+!)0(E!$8+!
lS!?9*/4!(&&6B@!!./2!/*6(!8/M+!</0<'2(E/!()!$8+!8+/&!()!$8+!9/2<0+/6!7!LZ<!&#<$6!=(!$80(#=8!
$8+!8+/&!()!$8+!9/2<0+/6@!!%6!/!0+6#*$;!4(#!8/M+!<(E9*+$+!L'*+!&#<$!(L6$0#<$'(2@!!Y(;!$8+0+!'6!
'2$0/8+9/$'<!<8(*+6$/6'6!/2&!+:$0/8+9/$'<!<8(*+6$/6'6@!!Y(;!>8/$!>'**!8/99+2!'6!*'F+!>/$+0!L+8'2&!
/!&/E@!!!1)!4(#!L*(<F!L'*+!)*(>;!'$!>'**!L/<F!#9!7!>8+0+!&(+6!'$!L/<F!#9n!S/<F6!#9!$(!>8+0+!'$!>/6!
E/&+!?$8+!*'M+0!<+**6!7!0+E+EL+0!$8'6!'6!/2!+:<+66!()!<(23#=/$+&;!&'0+<$!L'*'0#L'2B@!!12!$8+!*'M+0!
<+**6;!'$!L#LL*+6!(#$6'&+;!/2&!8/6!/<<+66!$(!$8+!6'2#6('&6!/2&!2(>!'6!'2!$8+!L*((&!6$0+/E@!!Y(;!
$8+!90+&(E'2/2$!)/<$(0!'2!$8+!L*((&!6$0+/E!'6!CONJUGATED bilirubin;!>8'<8!'6!>/$+0!6(*#L*+@!!
Y(;!>'**!have very dark yellow urine and the stool will be LIGHT colored. !I8'6!<(EL(!7!
high conj bilirubin, bilirubin in the urine!?N%Y!$(!L+!<(23#=/$+&!LZ<!'$Q6!'2!$8+!#0'2+!/2&!
$8+0+)(0+!>/$+0!6(*#L*+B;!and!light colored stools = OBSTRUCTION!?2($8'2=!+*6+!</2!&(!
$8'6;!/2&!'$!'6!+'$8+0!'2$0/8+9/$'<!(0!+:$0/8+9/$'<B@!!!
A. Congenital Unconjugated hyperbilirubinemias
1. Gilberts syndrome
Y++2!')!4(#!)/6$!)(0!(M+0!H^!806!/2&!=+$!3/#2&'<+;!%_;!Lr!?$8+0+)(0+!&(!2($!2++&!/!L:B@!!
Mech: prob in taking up bilirubin and prob in conjugating bilirubin;!$8+0+)(0+!'$!
'6!predominantly an unconjugated hyperbilirubinemia@!!Y(;!')!4(#!>/2$!$(!6++!')!9$!
8/6!'$;!&(!H^!80!)/6$'2=!$+6$@!Y(;!=+$!L/6+*'2+!L'*'0#L'2!>8+2!$8+4!/0+!2($!3/#2&'<+&!/2&!
&(2Q$!+/$!)(0!H^!806!/2&!<(E+!L/<F@!!g8+2!$8+4!<(E+!L/<F!$8+4!/0+!3/#2&'<+&@!!X+$Q6!6/4!
$8+!L/6+*'2+!'6!,;!/2&!4(#!&(#L*+!$8+!L/6+*'2+!/)$+0!H^!806;!9$!8/6!l'*L+0$Q6!642&0(E+@!!
[:@!9$!<(E+6!L/<F!/)$+0!)/6$'2=!$+6$!/2&!'6!H@e@!!!
!
2nd MCC jaundice = Gilberts syndrome (MC = hep A).![:@!0+6'&+2$!$8/$!=+$6!
3/#2&'<+;!L#$!&'&2Q$!8/M+!2++&*+!6$'<F!C!8+!8/6!l'*L+0$Q6!&c!LZ<!>/6!)/6$'2=!?+2c4E+!
*+M+*6!/0+!2(0E/*;!8'=8!#2<(23!L'*'0#L'2!*+M+*6B@!!R:n!"($8'2=!!
2. Craigler Najjar
!
171

B. Congenital Conjugated hyperbilirubinemias
Dubin Johnson; Rotor syndromes-!!l+2+$'<!&cQ6!'2M(*M'2=!90(L!=+$$'2=!0'&!()!.G"f!
L'*'0#L'2!'2!$8+!L'*+!&#<$6@!!Y(;!$8'6!'6!predominantly a conj hyperbilirubinemia@!!12!
_#L*'2!f(826(2;!8/M+!/!L*/<F!<(*(0+&!9'=E+2$!$8/$!L#'*&6!'2!$8+!*'M+0!/2&!=+$!L*/<F!*'M+0@!
!
III. Liver Function Test (LFTs)
!
g8/$!/0+!transaminases!#6+&!)(0n!I8+4!/0+!indices of liver cell necrosis!?8+9/$'$'6B@!!%YI!
?YlGIB!/2&!%XI!?YlJIBU!ALT!'6!E(0+!69+<')'<!LZ<!'$!'6!(2*4!)(#2&!'2!$8+!*'M+0U!AST '6!'2!E#6<*+;!
RS.Q6!/2&!*'M+0@!!
!
I8+0+)(0+;!')!4(#!8/M+!/!viral hepatitis;!>'$8!E/66'M+!*'M+0!<+**!2+<0(6'6;!>8'<8!>(#*&!L+!$8+!
90+&(E'2/2$!$0/26/E'2/6+6!+*+M/$+&n!ALT@!![:-!!HeVV!%XI!/2&!HHVV!%YI@!!Y(!%XI!>'**!L+!$8+!
E/'2!*'M+0!<+**!+2c4E+!elevated in diffuse liver cell necrosis@!!!
!
12!alcoholic hepatitis;!$8'6!'6!2($!>8/$!8/99+26@!!I8+0+!'6!/!0+/6(2-!AST!'6!90+6+2$!'2!$8+!E'$(!
()!8+9/$(<4$+6@!!%XI!'6!2($!7!'$Q6!'2!$8+!<4$(6(*@!!%*<(8(*!'6!/!E'$(!9('6(2!?0+E+EL+0!$8/$!'$!
#2<(#9*+6B@!!%YI!'6!90+&(E'2/2$*4!'2!E'$(;!/2&!>8+2!9$!8/6!/*<(8(*'<!8+9;!AST is higher than
ALT!?)(0=+$!$8+!H-,!0+*/$'(268'9B@!!I8+0+)(0+;!')!4(#!6++!%YI!8'=8+0!$8/2!%XI;!$8'6!'6!&#+!$(!
/*<(8(*'<!*'M+0!&c@!!.(#*&!L+!)/$$4!<8/2=+;!/*<(8(*'<!<'008(6'6;!/2&!/*<(8(*'<!8+9/$'$'6@!!1)!'$Q6!k1R%X!
8+9/$'$'6;!%XI!'6!L'==+0!$8/2!%YI@!!!
!
Y(;!>8/$!/0+!$8+!+2c4E+6!()!GSYIR\.I1G"!?obstruction of bile ductsBn!Alkaline
phosphatase and Gamma glutamyl transferase@!!I0/26/E'2/6+6!>'**!/*6(!L+!#9;!L#$!2($!$(!
$8+!6/E+!&+=0++@!!l/EE/!=*#$/E4*!$0/26)+0/6+!'6!*(</$+&!'2!$8+!Y[R@!!g8+2!$8+!Y[R!'6!0+MQ&!
#9;!'$!#2&+0=(+6!849+09*/6'/!?'+!&#+!$(!&0#=6-!/*<(8(*;!L/0L6;!0')/E9'2;!/2&!98+24$('2BU!4(#!2($!
(2*4!'2<0+/6+!$8+!E+$/L(*'6E!()!$8+!&0#=;!L#$!/*6(!'2<0+/6+!$8+!642$8+6'6!()!=/EE/!=*#$/E4*!
$0/26)+0/6+@!!Y(;!>8/$!>(#*&!$8+!<*/66'<!$8'2=!4(#!>(#*&!6++!'2!/24!alcoholic liver dz?
AST>ALT, along with INCREASED gamma glutamyl transferase@!!I8+0+!'6!/!90(L*+E-!/*F!
98(6!'6!'2!($8+0!$8'2=6!($8+0!$8/2!$8+!*'M+0!7!'2!L(2+!?(6$+(9*/6$'<!/<$'M'$4B;!9*/<+2$/@!!Y(;!8(>!
>'**!4(#!F2(>!>8+0+!$8+!/*F!98(6!<(E+6!)0(E!?'+!')!'$Q6!)0(E!L'*+!&#<$!(L6$0#<$'(2!M6@!($8+0!
$8'2=6Bn!X((F!/$!gamma glutamyl transferase b/c its specific for the liver!?6(;!')!/*F!98(6!
#9;!*((F!/$!=/EE/!=*#$/E4*!$0/26)+0/6+mB@!!If the gamma glutamyl transferase IS
elevated along with alk phos, this is BILE DUCT OBSTRUCTION.!!!
!
Albumin protime = marker of severity of liver damage@!!1$!'6!E/&+!'2!$8+!*'M+0;!$8+0+)(0+!
')!4(#!8/M+!6+M+0+!*'M+0!&c!?'+!<'008(6'6B;!'$!>'**!L+!&+<0+/6+&@!![M+2!L+$$+0!$8/2!$8/$!'6!
90($80(EL'2!$'E+!LZ<!<(/=#*/$'(2!)/<$(06!/0+!E/&+!$8+0+!?E(6$!/0+!E/&+!$8+0+!7!MgT!'6!2($;!
8(>+M+0B@!!Y(;!')!4(#!8/M+!*'M+0!&/E/=+;!$8+!90(&#<$'(2!()!<(/=#*/$'(2!)/<$(06!>'**!L+!&+<0+/6+&;!
/2&!JI!>'**!L+!90(*(2=+&!?'2<0+/6+&B@!!Y(;!albumin levels and PT are the 2 best tests for
liver severity (PT is a little better than albuminB@!!!
!
I8+0+!'6!(2*4!(2+!/#$(%L!$8/$!'6!'E9(0$/2$-!anti mito Abs in primary biliary cirrhosis.!!!
!
Tumor markers:!alpha feto protein is a marker for hepatocellular carcinoma@!!./2!/*6(!
#6+!alpha-1 antitrypsin!LZ<!'$!'6!E/&+!'2!$8+!*'M+0!?'$!'6!increased!'2!8+9/$(<+**#*/0!
</0<'2(E/B@!!!
!
172

1)!4(#!8/M+!)0/<$'(2/$'(2!()!L'*'0#L'2!?*+66!$8/2!HVW;!HVdeVW;!/2&!eVO!WB;!</2!6$/0$!&Z&U!$8+2!
='M+!$0/26/E'2/6+!*+M+*6!7!6++!8(>!'$!<(00+*/$+6!>'$8!*'M+0!&c-!$0/26/E'2/6+6!<(00+*/$+!>'$8!M'0/*!
8+9!/2&!<(23!L'*'0#L'2!()!HVdeV;!(0!(L6$0#<$'M+!*'M+0!&c!?/*F!98(6;!=/EE/!=*#$B!/2&!<(23!L'*'0#L'2!
(M+0!eVW@!!!
IV. Viral Hepatitis
A. MC on hepatitis:
K.!8+9!C!%!?)(**(>+&!L4!S;!.;!_;![!7!'2!$8/$!(0&+0B!
%!/2&![!C!)+</*!(0/*U!/**!$8+!($8+06!/0+!$0/26E'$$+&!9/0+2$/**4!
N+9!%!C!"(!<80(2'<!</00'+0!6$/$+!
N+9![!C!90(&#<+6!/!<80(2'<!</00'+0!6$/$+!(2*4!')!4(#!/0+!90+=2/2$;!*+/&'2=!$(!<80(2'<!*'M+0!&c!
N+9!_!C!R+D#'0+6!N+9!S!$(!'2)+<$'(2!
N+9!%!C!_/4</0+!<+2$+06!?$8+0+)(0+!68(#*&!=+$!M/<<'2+!$(!90+M+2$U!(#$L0+/F6!</2!(<<#0!'2!
&/4</0+!<+2$+06B!
N+9!%!C!f/'*!!
N+9!S!C!1k_%!
N+9!.!C!J(6$!$0/26)#6'(2!N+9/$'$'6!!
N+9!S!C!K.!'2)+<$'(2!L4!/<<'&+2$/*!2++&*+!6$'<F!!
B. Serology:
HAV-!/2$'!%!1=KC!8/M+!8+9!%U!/2$'!%!1=l!C!8/&!'$!/2&!>(2Q$!=+$!'$!/=/'2!
HCV-!/2$'!.!1=l!%LQ6!/0+!"GI!90($+<$'M+!/2&!E+/2!$8/$!4(#!8/M+!$8+!&cU!$8+0+!/0+!2(!
F2(>2!90($+<$'M+!%LQ6!
HDV-!?6/E+!/6!N.kB!7!/2$'!_!1=l!C!8/M+!$8+!&c;!/2&!2(!F2(>2!%LQ6!>'**!8+*9!<#0+U!')!4(#!
/0+!/2$'d_!1=l!9(6'$'M+!'$!E+/26!4(#!8/M+!$8+!/<$'M+!&c!2(>!!
!
Y(;!(2*4!90($+<$'M+!%LQ6!/0+!N%k;!NSk!?6#0)/<+!%LB;!/2&!N[k@!
!
Hep B (HBV)
First marker that comes up is surface Ag (HBsAg)@!!1$!<(E+6!#9!/L(#$!,!E(2$8!
/)$+0!4(#!8/M+!$8+!'2)+<$'(2@!!b(#!&(2Q$!F2(>!4(#!8/M+!'$!/2&!/0+!/64E9$(E/$'<@!!I8+!
+2c4E+!6$#&'+6!/0+!2(0E/*@!!I8+!2+:$!$8'2=!$8/$!<(E+6!#9!'6!$8+!L/&!=#46-!E Ag
(HBeAg) and HBV DNA;!b/c!these are only ones that are infective@!!I8+2!$8+!
)'06$!%L!<(E+6!#9!/!*'*!/)$+0!$8+!_"%!/2&![!%=;!>8'<8!'6!core Ab IgM (Anti-HBc) ?$8'6!
'6!+:9+<$+&!LZ<!$8+!)'06$!%L!/=/'26$!/<#$+!'2)*/EE/$'(2!'6!1=KB@!!I8+!E/3(0'$4!()!9+(9*+!
>'$8!N+9!S!0+<(M+0!?/L(#$!rVWBU!$8(6+!>'$8!N1kO!2+M+0!0+<(M+0!/2&!>'**!8/M+!<80(2'<!
</6+6!LZ<!$8+4!8/M+!2(!'EE#2+!0+69(26+!$(!F2(<F!'$!())@!!1)!4(#!&(!0+<(M+0!$8+ first!
things to go away are E Ag (HBeAg) and HBV DNA.!!I8+!last of the Ags that
goes away is surface Ag (HBsAg)@!!Y(;!6#0)/<+!%=!'6!$8+!)'06$!$(!<(E+!/2&!$8+!*/6$!$(!
*+/M+!?*'F+!/!i8(#6+!>'$8'2!/!8(#6+j!7!*((F!/$!$8+!<8/0$!/2&!>'**!6++!$8/$!Y!%=!'6!$8+!L'=!
8(#6+!/2&![!%=!/2&!NSk!_"%!/0+!$8+!*'*!8(#6+6!#2&+0 L'=!8(#6+B@!!12!($8+0!>(0&6;!'$!'6!
1KJGYY1SX[!$(!L+![!%=!9(6'$'M+!/2&!Y!%=!2+=/$'M+!?E Ag and DNA come up after S
Ag and leave beforeB@!!!
Surface Ab!&(+62Q$!<(E+!#9!#2$'*!/L(#$!,!E(2$8!/)$+0!S Ag!'6!=(2+;!6(!$8+0+!'6!$8'6!
=/9;!>8'<8!'6!/!]window!>'$8!2($8'2=!+*+M/$+&!?(2*4!8/6!(2+!%L!$8+0+U!Y!%=;![!%=;!NSk!
_"%!/0+!/**!=(2+;!/2&!Y!%L!2($!$8+0+!4+$B@!!Y(;!8(>!&(!4(#!F2(>!$8+!9$!N%_!N+9!Sn!
.(0+!1=K!&(+62Q$!*+/M+!7!'$!6$/46!$8+0+!/2&!L+<(E+6!1=l!(M+0!$'E+@!!Y(;!$8+!E/0F+0!)(0!
$8/$!window period!>8+2!/**!$8+!L/&!=#46!/0+!=(2+!/2&!6#0)/<+!%L!8/62Q$!/00'M+&!4+$;!
173

'6!core Ab IgM ?>8'<8!$+**6!4(#!$8/$!4(#!N%_!N+9!S!/2&!/0+!'2!$8+!90(<+66!()!
0+<(M+04B@!!I8+0+!'6!2(!>/4!4(#!/0+!'2)+<$+&!&#0'2=!$8'6!9+0'(&!7!>84n!SZ<![!%=!/2&!NSk!
_"%!/0+!2($!$8+0+@!!I8+0+)(0+;!4(#!/0+!2($!'2)+<$'M+!7!'$!3#6$!E+/26!$8/$!4(#!N%_!N+9!S!
/2&!/0+!'2!$8+!90(<+66!()!0+<(M+0'2=@!!YOU ARE NOT INFECTIVE!7!$8'6!'6!L+$>++2!$8+!
e$8!/2&!a$8!E(2$8@!!!
!
Y(;!')!4(#!8/&!N+9!S;!$8+0+!68(#*&!L+!H!%LQ6!$8/$!4(#!8/M+-!core Ab IgG and surface
Ab IgG@!
!
1)!4(#!8/M+!L++2!vaccinated;!</22($!8/M+!/24$8'2=!LZ<!4(#!8/&!4+/6$!E/F+!6#0)/<+!%=;!
>8'<8!'6!>8/$!$8+!M/<<'2+!<(26'6$6!()@!I8+!(2*4!L/&!%L!4(#!</2!=+$!)0(E!'23+<$'2=!6#0)/<+!
%=!'6!%LQ6!/=/'26$!'$@!!Y(;!(2*4!%L!4(#!>'**!8/M+!')!4(#!>+0+!M/<<'2/$+&!'6!Surface Ab@!!
"GI!<(0+!%L!1=l!LZ<!>+0+!2($!'23+<$+&!>'$8!$8/$@!!.(0+!%L!'6!2($!/!90($+<$'M+!%L@!!
C. Chronic hepatitis!'6!/!&+)'2'$'(2-!iHow long have you had!surface Ag? If its more
than 6 months;!4(#!8/M+!<80(2'<!N+9!S@!!Y(;!/0+!4(#!'2)+<$'M+!(0!2($n!7!/0+!4(#!/2!
'2)+<$'M+!</00'+0!(0!8+/*$84!</00'+0n!!b(#!/#$(E/$'</**4!F2(>!')!4(#!/0+!/2!infective chronic
carrier if you have HBV DNA@!!I8'6!E+/26!$8/$!4(#!/0+!/!9/$'+2$!>'$8!<80(2'<!N+9!S!$8/$!
'6!'2)+<$'M+@!!Y(;!4(#Q0+!/!>/*F'2=!8/c/0&;!/2&!4(#0!'2$'E/$+!<(2$/<$6!2++&!$(!L+!'EE#2'c+&!
LZ<!$8+!&c!</2!L+!$0/26E'$$+&!6+:#/**4!$(!$8(6+!9+(9*+;!(0!L4!1k!?1k_%Q6B@!!If you are
negative for E Ag and HBV DNA but are surface Ag positive, then it makes you a
healthy carrier!?$8'6!&(+6!2($!E+/2!4(#!/0+!8+/*$84!7!4(#!/0+!6$'**!/!<80(2'<!</00'+0!()!
N+9!SB@!!1)!4(#!/0+!/!8+/*$84!</00'+0;!8(>+M+0;!$8+!<8/2<+6!()!0+<(M+04!/0+!+:<+**+2$!LZ<!'2!
/L(#$!(2+!4+/0;!Y!%=!>'**!&'6/99+/0!/2&!Y!%L!>'**!<(E+!#9@!!g'**!/*6(!8/M+!<(0+!%L!1=l!/$!
$8'6!$'E+!7!$8'6!E+/26!$8/$!4(#!8/M+!/!=((&!<8/2<+!()!$($/*!0+<(M+04@!!%*6(!8/M+!a good
chance of recovery with E Ag b/c pt is a candidate for Alpha IFN therapy (DOC).
Never give corticosteroids to any chronic viral infections.
!
D. Review:
g8/$!>+!+:9+<$!'2!/<#$+!8+9/$'$'6!S!?>8/$!>(#*&!$8+!E/0F+06!L+Bn!!Y!%=;![!%=;!NSk!_"%;!
/2&!<(0+!1=K!
g8/$!')!$8+!9$!'6!'2!$8+!>'2&(>!9+0'(&n!.(0+!1=K!
g8/$!')!8/&!N+9!S;!L#$!8/M+!0+<(M+0+&!)0(E!'$n!.(0+!%L!1=l!/2&!6#0)/<+!%L!1=l!!
g8/$!')!9$!>/6!M/<<'2/$+&!?>8/$!'6!$8+!G"Xb!$8'2=!4(#!68(#*&!8/M+Bn!Y#0)/<+!%L!1=l!
g8/$!')!4(#!8/M+!/$!$8+!+2&!()!a!E(2$86!Y!%=;!<(0+!1=K;!>'$8!+M+04$8'2=!+*6+!2+=n!N+/*$84!
</00'+0!
g8/$!')!4(#!8/M+!/)$+0!a!E(2$86!6#0)/<+!%=;![!%=;!NSk!_"%!/2&!<(0+!%L!1=Kn!12)+<$'M+!
</00'+0@!!!
!
V. Inflammatory Liver Disorders
A. Amebiasis: Entamoeba histolytica
G0=/2'6E!'6!0+6'6$/2$!$(!/<'&!7!6>/**(>!'$!/2&!>'**!2($!&'+!'2!90+6+2<+!()!/<'&@!!1$!+:d<46$6!'2!
$8+!<+<#E;!>'$8'2!/2!/*F/*'2+!+2M'0(2E+2$@!!N/6!/!<8+E'</*!$8/$!</2!&0'**!/!8(*+!$80(#=8!$8+!
E#<(6/;!*+/&'2=!$(!)*/6F!68/9+&!#*<+06;!/2&!*+/&6!$(!bloody diarrhea@!!\2)(0$#2/$+*4;!LZ<!
$8+!<+<#E!'6!&0/'2+&!L4!$8+!9(0$/*!M+'2;!/2&!'6!)(0E'2=!/2!#*<+0;!$8+0+!'6!/!<8/2<+!$8/$!'$!</2!
&0'**!/2&!8(*+;!=+$!'2$(!$8+!9(0$/*!M+'2!$0'L#$/04!/2&!=+$!$(!$8+!0'=8$!*(L+!()!$8+!*'M+0;!>8+0+!'$!
>'**!90(&#<+!/2!/L6<+66@!!1$!>'**!6$/0$!&'66(*M'2=!$8+!*'M+0!7!8+2<+!$+0E!/2<8(M4!9/6$+!/L6<+66!
LZ<!'$!*((F6!*'F+!/2<8(M4!9/6$+!?/!L0(>2'68!*'D#'&B@!!1)!'$!>/2$6!$(;!'$!</2!&0'**!/!8(*+!$80(#=8!
$8+!0'=8$!&'/980/=E;!=(!$(!$8+!*#2=6;!/2&!90(&#<+!/2!+))#6'(2;!/2&!=(!/24>8+0+!'$!>/2$6!'2!
174

$8+!646$+E'<!<'0<#*/$'(2!7!L0/'2@!!R:!7!E+$0(2'&/c(*+@!!!Trophozoites!?6*'&+B!>'$8!0+&!
9/0$'<*+6!'2!$8+E;!>8'<8!/0+!RS.Q6@!!!I8+!(2*4!90($(c(/!$8/$!</2!98/=(<4$(6+!'6!Entamoeba
histolytica (no other amoeba can phagocytose RBCsB!7!$8'6!'6!/!M+04!<8/0/<$+0'6$'<!
)'2&'2=@!!K+$0(2'&/c(*+!'6!#6+&!'2!$8+!$0+/$E+2$!()!='/0&'/6'6;![2$/E(+L/!8'6$(*4$'</;!
M/='2(6'6;!<!&'));!/2&!$0'<8'2(6'6@!
B. Hydatid dz
!
,@!!_+)'2'$'M+!M6@!'2$+0E+&'/$+!8(6$!
Definitive!host C!6+:#/**4!/<$'M+!>(0E6!$8/$!8/M+!$8+!/L'*'$4!$(!E/$+!/2&!*/4!+==6@!!
Intermediate host!C!(2*4!8/M+!$8+!*/0M/*!)(0EU!&(!2($!8/M+!6+:#/**4!/<$'M+!/&#*$6@!!!
I8+6+!/0+!$8+!6$/=+6-!%&#*$;!+==;!*/0M/@!!%&#*$!*/46!+==6;!/2&!$8+!+==6!&+M+*(9!'2$(!
*/0M/@!!1)!4(#!8/M+!$8+!*/0M/!)(0E!'2!4(#;!'$!>'**!6$/4!$8+0+!LZ<!$8/$!'$Q6!$8+!+2&!6$/=+!
)(0E@!!1)!4(#!8/M+!$8+!+==!)(0E;!'$!>'**!&+M+*(9!'2$(!/!*/0M/;!L#$!$8+!*/0M/!</2Q$!=(!
/24>8+0+!+*6+@!!1)!4(#!8/M+!$8+!/&#*$!)(0E!'2!4(#;!'$!>'**!='M+!/2!+==;!>8'<8!<8/2=+6!$(!
*/0M/@!!X/0M/!)(0E!</22($!=(!/24>8+0+!7!'$!'6!$8+!+2&!6$/=+!)(0E@!
!
Sheep herders dz (gonococcus vermicularis or unilicularis (?))!
I8+!68++9!&(=!+/$6!6(E+!68++9!E+/$!?$8+0+!/0+!*/0M/*!)(0E6!'2!$8+!68++9U!$8+0+)(0+;!$8+!
68++9!'6!$8+!'2$+0E+&'/$+!8(6$B@!!_(=!+/$6!68++9;!/2&!8/6!*/0M/!'2!$8+!&(=@!!I8+!*/0M/!)(0E!
&+M+*(96!'2$(!/2!/&#*$!>'$8'2!$8+!&(=;!/2&!$8+!&(=!L+<(E+6!$8+!&+)'2'$'M+!8(6$@!!I8+!&(=!
8/6!6+:#/**4!/<$'M+!>(0E6!'26'&+!'$!/2&!$8+!>(0E6!*/4!+==6!>'$8'2!$8+!&(=@!!_(=!'6!9+$$+&;!
=+$6!+==6!(2!$8+'0!8/2&!/2&!'2$(!9$6!)((&;!>8'<8!'6!+/$+2@!!Y(;!2(>;!$8+!9$!8/6!$8+!+==;!
>8'<8!&+M+*(96!'2!$8+!*/0M/!?</22($!=(!/24!)/0$8+0!LZ<!*/0M/*!)(0E!'6!+2&!6$/=+B;!/2&!$8+!9$!
?8#E/2B!L+<(E+6!$8+!'2$+0E+&'/$+!8(6$@!!Y(;!$8+!68++9!'6!/2!'2$+0E+&'/$+!8(6$;!$8+!&(=!'6!
$8+!&+)'2'$'M+!8(6$!/2&!$8+!68++9!8+0&+0!'6!/2!'2$+0E+&'/$+!8(6$@!!_(!2($!>/2$!$(!0#9$#0+!
$8+6+!<46$6;!LZ<!')!$8+!)*#'&!=+$6!'2$(!$8+!/L&(E'2/*!</M'$4;!*+/&6!$(!/2/984*/<$'<!68(<F@!!!
!
C. T. solium (pig tapeworm)

!
b(#!=(!$(!/!L/0L+<#+!/2&!+/$!#2&+0<((F+&!9(0F!?*/0M/!'2!$8+!9'=!E+/$;!>8'<8!'6!+/$+2B@!!I8+!
*/0M/!&+M+*(9!'2$(!$8+!/&#*$!)(0E!>'$8'2!$8+!9$!?6(;!$8+0+!'6!/!6+:#/**4!/<$'M+!>(0E!'26'&+B@!!
Y(;!9$!L+<(E+6!&+)'2'$'M+!8(6$;!>8'*+!$8+!9'=!>/6!$8+!'2$+0E+&'/$+!8(6$@!!"(>!4(#!8/M+!/!
)/E'*4!E+EL+0!$8/$!'6!/!&+)'2'$'M+!8(6$!?8/6!6+:#/**4!/<$'M+!>(0E6!'26'&+!$8+EB!7!*+$6!6/4!
$8'6!)/E'*4!E+EL+0!'6!E/F'2=!6/*/&!$8/$!2'=8$;!/2&!&'&2Q$!>/68!$8+'0!8/2&6;!6(!6(E+!()!$8+!
+==6!=($!'2$(!$8+!6/*/&@!!I8+!9$!+/$6!$8+!6/*/&!>'$8!$8+!+==6!'2!'$@!!g8/$!'6!$8+!+==!=('2=!$(!
)(0E!'26'&+!E+n!X/0M/@!!g8/$!'6!$8'6!</**+&!<46$(<+0<'@!!_(!$8+4!)(0E!/&#*$6n!"(;!6$(96!$8+0+@!!
I8+0+)(0+;!9$!8/6!<46$(<+0<(6'6@!!g8/$!/0+!$8+!larvae going to do? They like the eye
and the brain (where they form a cyst in the brain, calcify and lead to seizure
activity for the rest of the pts life)@!!Y(;!'2!$8'6!&c;!$8+!9$!</2!8/M+!$>(!)(0E6!()!'$@!!1)!9$!
/$+!$8+!'2)+<$+&!9'=;!$8+4!</2!L+!$8+!&+)'2'$'M+!8(6$@!!1)!4(#!=+$!$8+!+==!'2!4(#0!E(#$8;!4(#!
L+<(E+!/2!'2$+0E+&'/$+!8(6$;!/2&!$8+!+==!</2!L+<(E+!*/0M/;!>8'<8!>'**!=(!(2!$(!
<46$(<+0<(6'6@!!Y(!$8+!*/0M/+!)(0E!'6!$8+!&/2=+0(#6!)(0E!'2!I@!6(*'#E@!
!
?K.!YZ[!()!</$/0/<$6!C!=*#<(<(0$'<('&6B!
VI. Nutmeg Liver
!
K..!C!RNT!
175

I80(EL#6!'2!9(0$/*!M+'2!>'**!"GI!*+/&!$(!2#$E+=!*'M+0!L+</#6+!9(0$/*!M+'2!'6!L+)(0+!+E9$4'2=!
'2$(!$8+!*'M+0@!g(#*&!4(#!8/M+!/6<'$+6n!b+6@!!J(0$/*!NI"n!b+6@!!k/0'<+6n!b+6@!!S#$!'6!*'M+0!L'=!
/2&!<(2=+6$+&n!"(@!
I80(EL#6!'2!8+9/$'<!M+'2-!'6!</**+&!S#&&!.8'/0'!642&0(E+!?K..!9(*4<4$8+E'/!R#L'M+0/;!H2&!K..!
C!L'0$8!<(2$0(*!9'**6B@!!g(#*&!4(#!8/M+!/!2#$E+=!*'M+0n!b+6!7!8+9/$'<!M+'2!+E9$'+6!$8+!*'M+0@!!
b(#!=+$!/!8#=+!*'M+0;!/2&!'6!/!6#0='</*!+E+0=+2<4!/2&!&'+!,VVW!()!$8+!$'E+!')!4(#!&(2Q$!8/M+!
6#0=+04@!!!
Y(;!$8+6+!/0+!90+Z9(6$!8+9/$'<!$80(EL(6+6!(Prehepatic = portal vein, posthepatic =
hepatic vein).
VII. Alcoholic liver dz!
MC manifestation is fatty change!(steatosis)@!!SZ<!/*<(8(*!E+$/L(*'6E;!8/M+!"%_NQ6;!
/<+$/$+;!/2&!/<+$4*!.(%@!!"%_NQ6!E+66!>'$8!940#M/$+!/2&!<(2M+0$!'$!'2$(!*/<$/$+!*+/&'2=!$(!
)/6$'2=!849(=*4<+E'/;!/2&!E+$/L(*'<!/<'&(6'6@!!%<+$4*!.(%!</2!E/F+!T%Q6!/2&!=*4<+0(*!P!
98(698/$+!/2&!Il!/2&!)/$$4!<8/2=+;!(0!</2!L+!<(2M+0$+&!'2$(!F+$(2+!L(&'+6;!>8'<8!</#6+6!/2!
'2<0+/6+&!/2'(2!=/9-!E+$/L(*'<!/<'&(6'6@!!T/$$4!<8/2=+!'6!0+M+06'L*+!')!$8+!/*<(8(*'<!6$(96!
&0'2F'2=@!!!
!
Alcoholic hepatitis!'6!M+04!L/&U!</2!8/M+!8+9/$'<!+2<+98/*(9/$84;!/6<'$+6;!+$<@!!%*<(8(*'<!8+9!
'6!&'))!)0(E!)/$$4!<8/2=+!LZ<!$8+0+!'6!)+M+0;!2+#$0(98'*'<!*+#F(<4$(6'6;!M+04!8'=8!%YIu%XI;!/2&!
=/EE/!=*#$/E4*!$0/26)+0/6+!'6!#9@!!b(#Q0+!L'=!$'E+!6'<F!/2&!')!4(#!&(!2($!6$(9!&0'2F'2=!4(#!>'**!
&'+@!!1$!'6!M+04!6+0'(#6!646$+E'<!&c@!!1)!9$!8(69'$/*'c+&!)(0!/*<(8(*'<!8+9;!'6!0+*+/6+&!/2&!$/F+6!
/*<(8(*;!$8+4!>'**!&'+@!!Y++!Mallory bodies!?#L'D#'2/$+&!F+0/$'2!E'<0()'*/E+2$6B@!I(:'<!
<(E9(#2&!$8/$!</#6+6!<'008(6'6!'6!/<+$/*&+84&+!L(#2&!$(!/!90($+'2;!2($!/<+$/*&+84&+!L4!'$6+*)@!!
1$(!<+**!2(0E/**4!'6!$8+!<+**!$8/$!6$(0+6!k'$!%@!!12!/2!/*<(8(*'<!$8+!/<+$/*&+84&+!90($+'2!<(E9*+:!
6$'E#*/$+6!$8+!1$(!<+**!$(!E/F+!)'L0(#6!$'66#+!/2&!<(**/=+2@!!I8+!1$(!<+**;!>8'<8!'6!0+69(26'L*+!)(0!
6$(0'2=!M'$!%;!'6!2(>!9#$$'2=!&(>2!<(**/=+2!$'66#+!/2&!'6!0+69(26'L*+!)(0!</#6'2=!)'L0(6'6@!!T'L0(#6!
$'66#+!'6!/!L'=!9/0$!()!/*<(8(*'<!$'66#+!&c@!
!
VIII. Cholestasis
Cholestasis!C!(L6$0#<$'(2!$(!L'*+!)*(>;!&#+!$(!/!6$(2+!'2!$8+!.S_@!![:-!8/M+!/!<8(*+6$+0(*!6$(2+!
>'$8!/!&++9!=0++2!<(*(0+&!*'M+0@!S'*+!'6!L*(<F+&;!>8'<8!8/6!<(23!L'*'0#L'2!'2!'$!/2&!'6!L/<F+&!#9!
'2$(!$8+!*'M+0@!!I8+!<(23!L'*'0#L'2!>'**!+M+2$#/**4!0+)*#:!'2$(!$8+!6'2#6('&6;!/2&!*+/&6!$(!L'*'0#L'2!'2!
$8+!#0'2+!/2&!*'=8$!<(*(0!6$((*6;!>'$8!"G!#0(L'*'2(=+2!'2!$8+!#0'2+@!!I8+!4+**(>!#0'2+!'6!&#+!$(!
>/$+0!6(*#L*+!<(23!L'*'0#L'2!'2!$8+!#0'2+@!!g8/$!+2c4E+6!/0+!+*+M/$+&n!%*F!98(6!/2&!=/EE/!
=*#$/E4*!$0/26)+0/6+@!!g8/$!'6!$8+!E+<8!)(0!=+$$'2=!0'&!()!<8(*+6$+0(*n!S'*+@!!Y(;!4(#!0+)*#:!
<8(*+6$+0(*;!L'*'0#L'2!/2&!L'*+!6/*$6!?$8+4!/0+!/**!0+<4<*+&B@!!g(#*&!'$!6#090'6+!4(#!$8/$!$8+4!8/M+!
849+0<8(*+6$+0(*+E'/;!$((n!"(!LZ<!'$!'6!0+<4<*+&@!!I8+!L'*+!6/*$6!&+9(6'$!'2!$8+!6F'2;!*+/&'2=!$(!
'$<8'2=@!!!
176

2 other causes of cholestasis:
S'*+!&#<$!0/&'</*;!6#00(#2&+&!L4!)'L0(#6!$'66#+;!L*((&4!&'/008+/!>'$8!XXp!<0/E94!9/'2;!3/#2&'<+!7!
>8/$!'6!$8+!1S_cn!UC!
.(EE(2!L'*+!&#<$!6#00(#2&+&!L4!)'L0(#6!$'66#+!7!&:n!Primary sclerosing cholangitis@!!
K..!90'E/04!6<*+0(6'2=!<8(*/2='$'6!C!UC!
g8/$!</2<+0!</2!&+M+*(9!LZ<!'$!'2M(*M+6!$8+!L'*+!&#<$n!Cholangiocarcinoma ?K..!'2!$8'6!
<(#2$04;!'2!P0&!>(0*&!<(#2$0'+6;!'$!'6!&#+!$(!.*(2(0<8'6!6'2+26'6!7!.8'2+6+!*'M+0!)*#F+B@!
!
IX. Primary Biliary cirrhosis
eV!4Z(!>(E/2!>'$8!=+2+0/*'c+&!'$<8'2=;!)'2&!+2*/0=+&!*'M+0!(2!J[;!2(0E/*!L'*'0#L'2!?2(!3/#2&'<+B;!
/*F!98(6!/2&!=/EE/!=*#$/E4*!$0/26)+0/6+!/0+!8#=+!?(L6$0#<$'M+!$49+!()!+2c4E+6B;!
$0/26/E'2/6+6!/0+!+*+M/$+&!7!&:n!!J0'E/04!L'*'/04!<'008(6'6;!>8'<8!'6!an autoimmune dz that
leads to granulomatous destruction of the bile ducts in the portal triad 7!>84!&(+62Q$!
68+!8/M+!3/#2&'<+n!X+$Q6!6/4!4(#!8/M+!,!E'**'(2!$0'/&6;!8/M+!$8+!&c!/2&!F2(<F!())!HeV;VVV!()!
$8+E@!!Y$'**!8/M+!èW!$8/$!</2!8/2&*+!$8+!L'*'0#L'2!*(/&@!!P!4+/06!*/$+0;!(2*4!8/M+!eVW!?eVV;VVV!
&+6$0(4+&B@!!Y$'**!2(!3/#2&'<+;!+M+2$#/**4;!E(0+!F2(<F+&!())!/2&!=+$!3/#2&'<+!>/4!&(>2!$8+!*'2+@!!
Y(;!$8+!0+/6(2!>84!9$!>(2Q$!=+$!3/#2&'<+!'6!LZ<!9$!8/6!/!0+6+0M+!$8/$!</2!8/2&*+!$8+!L'*'0#L'2@!!
I8+0+)(0+;!$8+0+!'6!2(!0+/6(2!$(!8/M+!3/#2&'<+!+/0*4!/2&!'$!<(E+6!*/$+@!!g8/$!'6!$8+!%L!$(!(0&+0!
'2!$8'6!9$n Anti-mitochondrial!antibodies ?/2$'E'<0(6(E/*!C!8/68'E($(Q6B@!
!
X. Drug effects
S'0$8!<(2$0(*!?G.JB!/2&!/2/L(*'<!6$+0('&!8/M+!$8+!6/E+!+))+<$!(2!$8+!*'M+0@!!The OCP and
anabolic steroids both produce intrahepatic cholestasis@!![:@!>$!*')$+0!?/66#E+!8+Q(2!
6$+0('&6B!&+M+*(96!3/#2&'<+;!/2&!M'0/*!6+0(*(=4!'6!2+=/$'M+;!8'=8!/*F!98(6!/2&!=/EE/!=*#$/E4*!C!
&#+!$(!6$+0('&6!?2($!8+9/$'$'6B@!!G2+!()!$8+!K..Q6!3/#2&'<+!'2!90+=2/2<4!'6!Lr!'2$0/8+9/$'<!
<8(*+6$/6'6@!I8'6!'6!LZ<!()!$8+!+6$0(=+2!&#0'2=!90+=2/2<4;!>8'<8!90(&#<+6!'2$0/8+9/$'<!
<8(*+6$/6'6@!!R:n!_+*'M+0!L/L4!?=(+6!/>/4!/)$+0!&+*'M+0'2=!L/L4B@!!X+$6!6/4!>(E/2!$/F+6!G.J!
/2&!=+$6!3/#2&'<+U!>8+2!68+!L+<(E+!90+=2/2$;!68+!>'**!&+M+*(9!3/#2&'<+;!$((!LZ<!()!$8+!
+6$0(=+2!+))+<$@!!Y(;!'2$0/8+9/$'<!<8(*+6$/6'6!'6!/!2(0E/*!<(E9*'</$'(2!()!G.JQ6!/2&!/2/L(*'<!
6$+0('&6@!!Both of these drugs also!predispose to a b9 liver tumor, called liver cell
adenoma aka hepatic adenoma@!!1$!8/6!/!2/6$4!8/L'$!7!it likes to rupture, leading to
intraperitoneal hemorrhage (which can kill you). [:/E9*+- >$!*')$+0!?/66#E+!8+Q6!(2!
/2/L(*'<!6$+0('&6B!>8(!'6!*')$'2=!/2&!6#&&+2*4!L+<(E+6!849($+26'M+!/2&!<(**/96+6@!!T'2&!
/L2(0E/*!*'M+0Z</M'$4!7!>8/$!'6!E(6$!*'F+*4!</#6+n!R#9$#0+&!*'M+0!<+**!/&+2(E/!LZ<!9$!'6!(2!
/2/L(*'<!6$+0('&6@!!So, OCPs and anabolic steroids have 2 similar effects: both can
produce b9 intrahepatic cholestasis (which goes away if you stop the drug) and liver
cell adenoma which is susceptible to rupture.!!T(0!>(E+2;!')!$8+4!/0+!(2!L'0$8!<(2$0(*;!
$8+2!=+$!())!'$!$(!=+$!90+=2/2$!7!*+$Q6!6/4!$8+4!8/M+!/!*'M+0!<+**!/&+2(E/!$8+4!&'&!2($!F2(>!
/L(#$!?$8/$!&+M+*(9+&!>'$8!G.J!#6+B;!$8+2!=+$!90+=2/2$;!$8+2!=+$!/2!'2$0/9+0'$(2+/*!
8+E(008/=+;!/2&!$8+2!>8/$!'6!&Z&n!R#9$#0+&!+<$(9'<!90+=2/2<4!(0!0#9$#0+!'2$0/9+0'$(2+/*!
8+E(008/=+@!!Y$+9!H-!!90+=2/2$!>(E+2!8/M+!$8+!$+2&+2<4!$(!8/M+!69*+2'<!/0$+04!/2+#046E!C!
0#9$#0+@!!!!
XI. Hemochromatosis
!
[:/E9*+- hyperpigmented pt adult that is diffusely hyperpigmented and has
diabetes (type I diabetic) = bronze diabetes = hemochromatosis = Fe overload, auto
rec, reabsorb too much Fe.!N+E(6'&+0(6'6!'6!/<D#'0+&!'0(2!(M+0*(/&!L4!L+'2=!/2!/*<(8(*'<@!!
10(2!6#99*+E+2$6!/0+!<(2$0/'2&'</$+&!'2!$8+!+*&+0*4!LZ<!'$!>'**!<0+/$+!8+E(6'&+0(6'6!/2&!8/M+!
'0(2!(M+0*(/&@!!S/<F!$(!8+E(<80(E/$(6'6-!!'$Q6!/2!/#$(6(E/*!0+<+66'M+!&c!/2&!>8/$!8/99+26!'6!
177

$8/$!'26$+/&!()!0+/L6(0L'2=!,Vd,eW!()!'0(2!)0(E!)((&6;!4(#!/0+!/L6(0L'2=!,VVW!()!'0(2@!I/0=+$!
(0=/2!'6!$8+!*'M+0@!!g8+2+M+0!T+!'6!/L6(0L+&!'2$(!<+**6;!'$!90(&#<+6!84&0(:4*!)0++!0/&'</*6@!!Y(;!
$8+!T+!&(+62Q$!&/E/=+!/24$8'2=;!'$Q6!$8+!)0++!0/&'</*6!?$8+!84&0(:4*!)0++!0/&'</*6!7T+2$(2!0:2B@!!
1)!4(#!/0+!&/E/='2=!*'M+0!<+**6;!>'**!*+/&!$(!)'L0(6'6!/2&!<'008(6'6@!!They ALL have cirrhosis in
Fe overload;!either by hemosiderosis or hemochromatosis.!!12!<'008(6'6;!4(#!6++!*'M+0!
>'$8!L0(>2'68!9'=E+2$;!J0#66'/2!L*#+!6$/'2!?$(!6++!T+B;!/2&!/!k[Rb!N1lN!'2<'&+2<+!()!
8+9/$(<+**#*/0!</0<'2(E/@!!./2!/*6(!=(!+*6+>8+0+79/2<0+/67$8+0+)(0+!</2!8/M+![hG<0'2+!/2&!
["_G<0'2+!&46)#2<$'(2;!*+/&'2=!$(!E/*/L6(09$'(2@!!_+6$0#<$'(2!()!'6*+$!<+**6!*+/&6!$(!M+04!L0'$$*+!
$49+!1!&'/L+$+6@!%*6(!&+9(6'$6!'2!6F'2!/2&!*+/&!$(!849+09'=E+2$/$'(2!?L0(2c+!*((FB@!!I8'6!'6!/!
<(EL(!()!T+!&+9(6'$'2=!$8+0+!/2&!L4!6$'E#*/$'2=!E+*/2(<4$+6;!$8+0+)(0+!$8+0+!'6!T+!
9'=E+2$/$'(2!/2&!E+*/2'2@!!./2!=(!'2$(!3('2$6!/2&!*+/&!$(!9(*4/0$80'$'6;!</2!=(!$(!9'$#'$/04;!
*+/&'2=!$(!849(9'$#'$/0'6E;!</2!=(!$(!8+/0$!/2&!90(&#<+!0+6$0'<$'M+!</0&'(E4(9/$84@!!N(>!4(#!&(!
screen for iron overload? Serum ferritin. Serum Fe = high. Excess Fe stores,
therefore decreased syn of transferrin. The TIBC is decreased. % sat is increased,
serum ferritin is increased. Rx? Phlebotomy@!!_(!2($!#6+!<8+*/$'(2!$8+0/94@!!I8+4!
9#09(6+*4!E/F+!4(#!T+!&+)@!I8'6!&c!'6!$8+!2+:$!$(!$8+!E(6$!<(EE(2!/#$(6(E/*!0+<!&c@!!
Hemosiderosis = ACQUIRED Fe overload from alcohol.!
!
XII. Wilsons dz
!
Kayser Fleischer ring!7!L0(>2!0'2=!/0(#2&!<(02+/@!!g8/$!'6!&+=+2+0/$'(2!</**+&n!
Hepatolenticular degeneration@!!Pt with abnormal movement (chorea) disorder,
dementia, and cirrhosis. Auto recessive. Defect in ridding Cu in bile; so, the Cu
builds up and accumulates in the liver.!!k+04!$(:'<@!Y(;!(M+0!/!9+0'(&!()!E(2$86!$(!4+/06;!
4(#!=(!)0(E!<80(2'<!/<$'M+!8+9/$'$'6!$(!<'008(6'6@!!g8+2!4(#!=+$!/!$($/*!.#!*+M+*;!>8/$!&(+6!'$!
'2<*#&+n!T0++!.#!/2&!L'2&'2=!90($+'2!)(0!.#@!!The binding protein is called ceruloplasmin.!!
Y(;!6(E+!.#!'6!/$$/<8+&!$(!<+0#*(9*/6E'2@!!Y(;!$8+!$($/*!.#!E+/6#0+&!'2<*#&+6!L(#2&!/2&!)0++@!!
reW!()!/!2(0E/*!$($/*!.#!*+M+*!'6!0+*/$+&!$(!.#!/$$/<8+&!$(!<+0#*(9*/6E'2@!!Y(;!E(6$!()!$8+!$($/*!
.#!*+M+*!'6!L(#2&!$(!<+0#*(9*/6E'2;!2($!$8+!.#!$8/$!'6!)0++@!!So, 95% in a normal person the
total copper is Cu that is bound and inactive to ceruloplasmin.!!Y(;!'6!<+0#*(9*/6E'2!/!
90($+'2n!b+6@!!Y(;!>'$8!<'008(6'6;!/0+!4(#!642$8+6'c'2=!<+0#*(9*/6E'2n!"(@!!I8+0+)(0+;!$8+0+!'6!/!
&+<0+/6+!()!L'2&'2=!90($+'2!)(0!.#@!!Y(;!free cu increased. So, the total Cu level is
decreased (b/c less ceruloplasmin), but the free Cu is increased (more unbound).!!
R:n!J."/E'2+!?.#!L'2&+0B@!!X+2$'<#*/0!2#<*+#6!E+66+&!#9!?</#&/$+!2#<*+#6!'2!N_B!
XIII. Cirrhosis
!
"+M+0!)(</*;!/*>/46!&'))#6+@!!I8+!L#E96!/**!(M+0!'$!/0+!</**+&!0+=+2+0/$'M+!2(&#*+6@!!52(>!$8/$!
*'M+0!$'66#+!'6!6$/L*+;!$8+0+)(0+!'$Q6!#6#/**4!'2!$8+!l(!98/6+;!/2&!6(E+$8'2=!8/6!$(!6$'E#*/$+!'$!$(!
=(!'2$(!$8+!<+**!<4<*+!$(!&'M'&+@!!I8+!*'M+0!8/6!/2!/E/c'2=!0+=+2+0/$'M+!</9/<'$4@!!R+=+2+0/$'(2!()!
*'M+0!<+**6!/0+!8+9/$(<4$+6!>'$8!2(!$0'/&;!2(!<+2$0/*!M+'2;!/2&!2(!6'2#6('&6@!!Just wall to wall
hepatocytes which are worthless@!!S#E96!/0+!0+=+2+0/$'M+!2(&#*+6;!2(!$0'/&U!$8+0+!/0+!3#6$!
>/**!$(!>/**!8+9/$(<4$+6!6#00(#2&+&!L4!)'L0(#6!$'66#+@!!Y$/0$6!())!/6!E'<0(2(&#*/0!?*+66!$8+2!P!
EEB!/2&!+2&6!#9!E/<0(2(&#*/0!?(M+0!P!EEB@!!Y(;!8/M+!*'M+0;!L#$!<+**6!2($!>(0F'2=@!!N(>!'6!/!
9(0$/*!M+'2!=(22/!L+!/L*+!$(!+E9$4!'2$(!$8+!*'M+0!>8+2!$8+0+!/0+!2(!6'2#6('&Z$0'/&6n!1$Q6!/!
90(L*+E!7!9(0$/*!NI"@!!
!
Complications-!J'$$'2=!+&+E/;!/6<'$+6;!+6(98/=+/*!M/0'<+6;!/2&!E+$/L(*'<!90(L6!?cannot
metabolize estrogen;!*+/&6!$(!=42+<(E/6$'/B@!!./22($!*((F!/$!=42+<(E/6$'/;!8/M+!$(!)++*!'$@!!!
178

Side effects of problems of estrogen metabolism-!!Y'&+!2($+-!!I8+0+!/0+!P!$'E+6!'2!/!
*')+$'E+!>8+0+!E/*+6!</2!&+M+*(9!=42+<(E/6$'/@!!,@!"+>L(026!E/*+6!8/M+!L((L6!LZ<!
+6$0(=+2!)0(E!E(EU!2+>L(02!='0*6!>'$8!9+0'(&6!LZ<!+6$0(=+2!)0(E;!$8+2!&0(9!());!*+/&6!$(!
L*++&'2=@!!H@!K/*+6!/*6(!=+$!L((L6!'2!$++26!?9#L+0$4B@!!P@!K/*+6!/*6(!=+$!L((L6!>8+2!$8+4!
$#02!(*&!LZ<!$+6$(6$+0(2+!=(+6!&(>2!/2&!+6$0(=+2!=(+6!&(>2;!*+/&'2=!$(!=42+<(E/6$'/!7!6(;!
=+$!L((L6!?=42+<(E/6$'/B!$80++!$'E+6!$80(#=8(#$!*')+;!/2&!$8'6!'6!2(0E/*@!![:/E9*+- ,P!4Z(!
#2'*/$+0/*!6#L/*M+(*/0!E/66;!>8/$!'6!E/2/=+E+2$n!X+/M+!'$!/*(2+@!!l42+<(E/6$'/!'6!2($!
/*>/46!L'*/$+0/*;!'$!'6!#6#/**4!#2'*/$+0/*@!!g(E+2!8/M+!&'))!6'c+!L0+/6$6!LZ<!+/<8!L0+/6$!8/6!
&'))+0+2$!6#6<+9$'L'*'$4!$(!+6$0(=+2;!90(=+6$+0(2+;!/2&!90(*/<$'2@!!K+2!&(!2($!8/M+!L0+/6$!
$'66#+;!$8+0+)(0+!E(0+!*'F+*4!$8/$!(2+!>'**!+2*/0=+;!$8+!($8+0!>'**!2($@!!J/*E+0!+04$8+E/!
?0+*/$+&!$(!+6$0(=+2B;!69'&+0!/2='(E/;!M'$!&+)Q6;!&#9/$0(2Q6!<(2$0/<$#0+!'2!9/*E!?)'L0(E/$(6'6!
7!'2<0+/6+&!)'L0(#6!$'66#+!/0(#2&!$8+!$+2&(2!68+/$86;!</#6'2=!)'2=+06!$(!<('*!'2;!<(EE(2*4!
/66(<!>'$8!/*<(8(*'<6B!7!$8+6+!/0+!/**!+6$0(=+2!/L2(0E/*'$'+6@!!!
!
.(E9*'</$'(2!()!%6<'$+6!7!/&#*$!>'$8!/6<'$+6!7!69(2$/2+(#6!9+0'$(2'$'6!&#+!$(![!<(*'@!!.8'*&!>'$8!
2+980($'<!642&0(E+!/2&!=+$!/6<'$+6!/2&!69(2$/2+(#6!9+0'$(2'$'6;!>8/$!'6!$8+!(0=/2'6En!Y$0+9!
92+#E(2'/+@!!Y(;!/&#*$6!>'$8!/6<'$+6!/2&!69(2$/2+(#6!9+0'$(2'$'6!C![!<(*';!>8'*+!F'&!>'$8!/6<'$+6!
/2&!69(2$/2+(#6!9+0'$(2'$'6!C!Y$0+9!92+#E(2'/+@!
!
XIV. Hepatocellular carcinoma
!
"(&#*/0'$4U!./2<+0!'2!8+9!M+'2!$0'L#$/04!?'+B@!!I8'6!</2<+0!/*E(6$!/*>/46!&+M+*(96!'2!$8+!
L/<F=0(#2&!()!<'008(6'6@!!1$!'6!M+04!0/0+!)(0!8+9/$(<+**#*/0!</0<'2(E/!$(!&+M+*(9!>'$8(#$!<'008(6'6!
90+6+2$@!!Y'2<+!/*<(8(*!'6!$8+!K..Q6!<'008(6'6;!'6!'$!/*6(!$8+!K..!()!</2<+0n!"G@!!MCCs
hepatocellular carcinoma = pigment cirrhosis: hemochromatosis; hepatitis B and C.
I8'6!</2<+0!</2!90(&#<+!+<$(9'<!8(0E(2+6!7![JG!?*+/&6!$(!H2&/04!9(*4<4$8+E'/B;!'26#*'2!*'F+!lT!
?*+/&6!$(!849(=*4<+E'/B@!!I#E(0!E/0F+0-!/*98/!)+$(!90($+'2@!![:/E9*+- 9$!>'$8!#2&+0*4'2=!
<'008(6'6;!/2&!'6!6$/L*+@!!S#$!6#&&+2*4!$8+!9$!L+='26!$(!*(6+!>$!/2&!/6<'$+6!'6!=+$$'2=!>(06+@!!_(!/!
9+0'$(2+/*!$/9!/2&!'$!'6!8+E(008/='<!?&(!2($!/66#E+!'$!'6!$0/#E/$'<!)0(E!$8+!2++&*+;!#2*+66!$8+4!
6/4!'$B@!!!1)!$8+0+!'6!L*((&!'2!$8+!/<'&'<!)*#'&!'$!'6!9/$8(*(='<!L*++&'2=@!!Y(;!this hx (wt loss,
beginning to deteriorate suddenly, blood in acidic fluid). Know it is hepatocellular
carcinoma, but will ask what test do you do? Alpha feto protein. K/24!$#E(06!'2!
*'M+0!C!E+$6;!90(L!)0(E!*#2=U!*+$6!6/4!'$Q6!/!2(26E(F+0;!>8/$!'6!$8+!90'E/04!</2<+0n!.(*(2!
</2<+0;!LZ<!8+!'6!/!2(26E(F+0;!$8+0+)(0+!'$!>(2Q$!L+!)0(E!/!90'E/04!*#2=!</2<+0;!6(!$8+!H2&!K..!
'6!<(*(2!</2<+0!/2&!'$!&(+62Q$!8/M+!/!8'=8!/66(<'/$'(2!>'$8!6E(F'2=@!
!
R+E+EL+0!$8+!H2&!E(6$!<(EE(2!</#6+-!+:/E9*+!()!/!6E/**!L(>+*!(L6$0#<$'(2;!$8+!K..!'6!
/&8+6'(2!)0(E!90+M'(#6!6#0=+04;!L#$!')!$8+!9$!&'&!2($!8/M+!/24!6#0=+0'+6!$8+2!'$Q6!&#+!$(!'2&'0+<$!
'2=#'2/*!8+02'/@!
!
GALLBLADDER DZ
!
I. Ask about pathogenesis of stone too much cholesterol in bile or too little bile salts.
b(#!>'**!8/M+!/!6#9+06/$#0/$+&!6$(2+!>'$8!<8(*+6$+0(*!7!>'**!=+$!cholesterol stone (MC stone).
179

G0;!$((!*'$$*+!L'*+!6/*$6;!L($8!*+/&!$(!6$(2+6@!!%24$8'2=!$8/$!</#6+6!L'*+!6/*$!&+)!?<'008(6'6;!(L6$0#<$'(2;!
.8(*+6$40/E'2+;!.0(82Q6!&cB!</2!*+/&!$(!=/**6$(2+6!LZ<!$((!*'*!L'*+!6/*$6@!
!
II. Pigment stones!
!
b+**(>!6$(2+6!?F2(>!$8+4!/0+!2($!<8(*+6$+0(*!6$(2+6B!7!He!4Z(!)+E/*+;!R\p!<0/E94!9/'2;!)+M+0;!
9('2$!$+2&+02+66;!2+#$0(98'*'<!*+#F(<4$(6'6;!6$(2+6!0+M+/*+&!(2!#*$0/6(#2&@!!.S.!68(>+&!/!E'*&!
2(0E(<4$'<!/2+E'/!/2&!/!<(00+<$+&!0+$'<#*(<4$+!<$!()!tW@!!Y9*+2(E+=/*4!(2!J[!/2&!)/E'*4!8:!()!
69*+2+<$(E4@!Dx? Congenital spherocytosisU!LZ<!68+!8/6!L++2!8+E(*4c'2=!RS.Q6!/**!8+0!*')+;!
68+!9#$6!/!*($!()!L'*'0#L'2!'2$(!<(23!L'*'0#L'2!/2&!$8+0+)(0+!8/6!6#9+06/$#0/$+&!L'*+!>'$8!L'*'0#L'2;!
/2&!)(0E6!Ca bilirubinate stones that are jet black@!!Y++2!>'$8!#*$0/6(#2&@!!!
! !
g8/$!'6!$8+!screening test of choice!)(0!6$(2+6n!\*$0/6(#2&@!!Y<0++2'2=!$+6$!()!<8('<+!)(0!
/24$8'2=!'2!$8+!9/2<0+/6!C!.I!7!0+/6(2!>84!'6!LZ<!L(>+*!(M+0*'+6!9/2<0+/6!/2&!E+66+6!#9!
#*$0/6(#2&;!$8+0+)(0+!2($!/6!6+26'$'M+@!!%*>/46!9#$!.I!)(0!9/2<0+/6U!lS!C!#*$0/6(#2&!?</2!$+**!
&'/E+$+0!()!.S_!$(!$+**!')!$8+0+!'6!/!6$(2+!'2!'$B@!
!
180

PANCREAS
!
I. Cystic Fibrosis
.46$'<!)'L0(6'6!7!=0(>$8!/*$+0/$'(2!LZ<!E#<(#6!'2!&#<$6!()!$8+!9/2<0+/6@!!Y++!atrophy!LZ<!L*(<F!
*#E+2!()!+:(<0'2+!&#<$6;!/2&!90+66#0+!=(+6!L/<F!$(!$8+!=*/2&6!/2&!$8/$!90+66#0+!/$0(98'+6!$8+!
=*/2&6;!leading to malabsorption@!!./2!<46$'<!)'L0(6'6!/*6(!*+/&!$(!&'/L+$+6n!b+6!7!LZ<!
+M+2$#/**4!)'L0(6+!())!$8+!'6*+$!<+**6;!*+/&'2=!$(!type I diabetes;!$((@!!!
Molecular bio-!<Q6(E+!`!>'$8!P!2#<*+($'&+!&+*+$'(2;!/2&!$8(6+!P!2#<*+($'&+6!<(&+6!)(0!
98+24*/*/2'2+@!!Y(;!4(#!/0+!def of phenylalanine in the cystic fibrosis transmembrane
regulator protein (CFTR).!!Y(;!/**!'$6!E'66'2=!'6!98+24*/*/2'2+@!!K(6$!$8'2=6;!/)$+0!$8+4!/0+!
E/&+!'2!$8+!0'L(6(E+!'2!$8+!R[R;!8/M+!9(6$$0/26*/$'(2/*!E(&')'</$'(26!'2!$8+!l(*='!/99/0/$#6;!
>8'<8!'6!>8+0+!$8+!0+/*!&+)+<$!'6@!!The real problem is when it gets to the Golgi
apparatus its supposed to be modified and secreted to the cell surface. It ends up
being degraded in the cell, and you end up having the CFTR.!!Y(;!$8+!90(L!'6!'2!$8+!l(*='!
/99/0/$#6!7!'$!6<0+>6!'$!#9;!/2&!2+M+0!E/F+6!'$!$(!$8+!6#0)/<+;!$8+0+)(0+!8/6!2(!)#2<$'(2@!!!
!
Y(;!>8/$!&(+6!'$!&(n!!In the sweat glands, normally, it would reabsorb Na and Cl out of
the sweat gland. B/c they are def in this, they are losing salt, which is the basis of
the sweat test.!!P!4Z(!F'&;!)/'*#0+!$(!$80'M+;!<80(2'<!&'/008+/;!0+69!'2)+<$'(2;!E(E!6$/$+6!$8/$!
$8+!L/L4!$/6$+Q6!6/*$4!>8+2!68+!F'66+6!$8+!L/L4@!!I8'6!'6!$8+!='M+!/>/4!)(0!.T;!LZ<!$8+4!*(6+!
<(26'&+0/L*+!6/*$!/2&!L+<(E+!6/*$!&+9*+$+&!>8+2!$8+4!/0+!(M+08+/$+&@!!g84!/0+!/**!$8+!
6+<0+$'(26!6(!$8'<F!'2!$8+!*#2=6;!9/2<0+/6;!/2&!L'*+!&#<$6n!.TIR!0+=#*/$(0!7!>8/$!&(+6!'$!&(n!7!
12!lungs;!2++&!$(!8/M+!6/*$!/2&!6+<0+$'(26!'2!$8+!*#E+26!()!$8+!0+69!$0/<$!$(!F++9!'$!M'6<(#6!?$(!
F++9!'$!2'<+!/2&!*((6+BU!')!4(#!/0+!E'66'2=!.TIR;!"/!'6!0+/L6(0L+&!G\I!()!$8+!6+<0+$'(26!'2!$8+!
/'0>/4!?$8+0+)(0+!/!*'*!&+84&0/$+&B@!!%2&;!<8*(0'&+!</22($!L+!9#E9+&!'2$(!$8+!*#E+2!()!$8+!
/'0>/4!7!6(!4(#!/0+!$/F'2=!/>/4!$8+!H!'E9!'2=0+&'+2$6!>'$8!$8'6!9#E9-!$/F'2=!"/!(#$!/2&!2($!
9#$$'2=!.*!'2@!I8+0+)(0+!$8+6+!6+<0+$'(26!/0+!$8'<F!*'F+!<(2<0+$+@!!I8+!6/E+!'6!$0#+!)(0!6+<0+$'(26!
'2!$8+!9/2<0+/6!?"/!9#E9+&!(#$!/2&!.*!2($!9#$!'2B@!MCC death = pseudomonas
aeruginosa. Fertility-!>8/$!'6!<8/2<+!()!E/*+!>'$8!<46$'<!)'L0(6'6!8/M'2=!<8'*&0+2n!VdeW!?E(6$!
/0+!'2)+0$'*+BU!)(0!)+E/*+6;!$8+4!</2!=+$!90+=2/2$;!L#$!(2*4!8/M+!PVW!<8/2<+!()!=+$$'2=!
90+=2/2$@!!I8+!90(L*+E!'6!$8/$!$8+!<+0M'</*!E#<(#6!'6!/6!$8'<F!/6!<(2<0+$+!/2&!$8+0+)(0+!$8+!
69+0E!</22($!9+2+$0/$+;!/2&!$8/$!'6!(2+!()!$8+!0+/6(26!>84!$8+4!/0+!'2)+0$'*+!
!
II. Acute pancreatitis
!
K.!&#+!$(!/*<(8(*U!H2&!K..!C!6$(2+!</#=8$!'2!/<<+66(04!&#<$6!()!$8+!9/2<0+/6@!!%E4*/6+!'6!
+*+M/$+&@!.8/0/<$+0'6$'<!9/'2-!Epigastric pain with radiation into the back!?LZ<!'$Q6!/!
0+$0(9+0'$(2+/*!(0=/2B@!!!
!
N/M+!/2!8:!()!/<#$+!9/2<0+/$'$'6U!/)$+0!,V!&/46;!8/M+!/!E/66!'2!$8+!/L&(E+2!/2&!$8+4!/6F!>8/$!
&(!4(#!&(n!.I!7!>8/$!'6!'$n!Pancreatic pseudocyst!d!/!*($!()!)*#'&!/<<#E#*/$+6!/0(#2&!/2!
'2)*/E+&!9/2<0+/6!/2&!)(0E6!/!)/*6+!</96#*+!/2&!8/6!/!9($+2$'/*!$(!0#9$#0+!?2($!=((&!$(!8/M+!
/E4*/6+!'2!9+0'$(2+/*!</M'$4B@!
!
R\p!>'$8!&46$0(98'<!</*<')'</$'(2!?&($6!(2!:d0/4BU!>8/$!&(!4(#!$8'2F!'$!'6n!Pancreatitis. !16!'$!
/<#$+!(0!<80(2'<n!Chronic!LZ<!$8+0+!/0+!6(!E/24@!!16!$8'6!9$!*'F+*4!$(!L+!/2!/*<(8(*'<n!b+6@!!g8/$!
+*6+!>(#*&!4(#!+:9+<$!7!'+!>8'<8!()!$8+!)(**(>'2=!4(#!+:9+<$n!7!Y$+/$(008+/!?(2+!()!$8+!</#6+6!
()!E/*/L6(09$'(2!7!2++&!+2c4E+6B;!(0!E/4!6/4!4(#!8/M+!L'*+!6/*$!&+)!?2(;!LZ<!9/2<0+/6!8/6!
181

2($8'2=!$(!&(!>'$8!L'*+!6/*$6B;!8+E(008/='<!&'/$8+6'6!?4+6;!k'$!5!&+)!0+*/$+&!$(!E/*/L6(09$'(2B;!
+$<A!
!
Carcinoma of the head of the pancreas MCC = smoker, 2nd MCC = chronic
pancreatitis, painless jaundice (mainly conjugated bilirubin), light colored stools,
palpable GB (Courvoisiers sign). .!6'=2!7!9+0E/2+2$*4!'2&+2$'2=!$8+!&#(&+2#E;!&(!L/0'#E!
6$#&4;!/*6(!/!6'=2!()!9/2<0+/$'<!</2<+0@!!!
!
Acute pancreatitis with inflammation@!!g8/$!>'**!$8/$!&(!$(!9+0'6$/*6'6!()!$8/$!&#(&+2#E!
2+:$!$(!'$n!N(>!&(+6!$8+!L(>+*!0+/<$!$(!$8+!90+6+2<+!()!'2)*/EE/$'(2!2+:$!$(!'$n!It stops
peristalsing!?2($!$80(#=8!$8+!+2$'0+!L(>+*;!3#6$!$8+0+B@!!1)!$8'6!'6!$0#+;!$8+0+!>(#*&!3#6$!L+!/'0!'2!
$8+!/0+/!'$!&(+62Q$!9+0'6$/*6+6!7!>8/$!'6!$8'6!</**+&n!Sentinel sign!?6+2$'2+*!'6!6(E+(2+!$8/$!'6!
6#99(6+&!$(!F++9!>/$<8B!7!F++9!>/$<8!()!>8/$n!12)*/EE/$'(2!?6(;!the sentinel sign keeps
watch of inflammationBU!$8+!<*/66'<!/0+/!'6!$8+!9/2<0+/6@!!I8'6!is called localized ileus
(ileus, by definition is lack of peristalsis). Whenever the bowel lacks peristalsis, will
see air accumulate and will get distension. g8/$!')!4(#!8/M+!/!6+=E+2$!()!L(>+*!$8/$!'6!
&'6$+2&+&!'2!$8+!RXpn!N/6!$(!L+!'2)*/EE/$'(2;!$8+!<+<#E!'6!'2!$8+!RXp!/2&!/99+2&':!<(#*&!L+!
$8+!0+/6(2@!!Y(;!/99+2&'<'$'6!90(&#<'2=!6+2$'2+*Q6!6'=2@!!
!
!
!
!
182

CHAPTER 11: KIDNEY
!
I. Cast 7!!
E(*&!()!>8/$+M+0!'6!=('2=!(2!'2!$8+!2+980(2Z$#L#*+@!!1$!'6!/!90($+'2!$8/$!'6!<(2=+/*'2=!/0(#2&!
>8/$+M+0!'6!90+6+2$!'2!$8+!$#L#*+!/$!$8/$!$'E+U!$8+0+!'6!/!E(*&!E/&+;!/2&!'6!9/66+&!'2$(!$8+!#0'2+!
/2&!>+!</2!6++!'$!#2&+0!$8+!E'<0(6<(9+@!!This is imp b/c now we do not have to do a renal
bx of the renal tubules b/c the cast will tell you what is going on@!![:/E9*+-!!')!4(#!8/M+!
=*(E+0#*(2+980'$'6!?'2)*/EE/$'(2!()!$8+!=*(E+0#*#6B;!4(#!8/M+!&/E/=+&!$8+!</9'**/0'+6!/2&!=+$!
8+E/$#0'/;!6(!$8+!RS.Q6!/0+!'2!$8+!2+980(2!/2&!$0/99+&!'2!$8+!</6$;!/2&!>'**!8/M+!/2!RS.!</6$!$8/$!
$+**6!4(#!$8+0+!'6!/!=*(E+0#*(2+980'$'6!(<<#00'2=@!![:/E9*+-!!g'$8!0+2/*!$#L#*+!2+<0(6'6;!$8+!$#L#*+6!
/0+!6*(#=8'2=!())!>'$8!<(/=#*/$'(2!2+<0(6'6@!!I8'6!>'**!)(0E!/!</6$!/2&!'6!</**+&!0+2/*!$#L#*/0!</6$;!
/2&!>'**!$+**!4(#!$8+0+!'6!0+2/*!$#L#*/0!2+<0(6'6@!![:/E9*+-!!E/2Z>(E/2!>'$8!/<#$+!94+*(2+980'$'6!
>'$8!2+#$0(98'*6!'2M/&'2=!$8+!'2$+06$'$'#E!/2&!$8+!$#L#*+6;!$8+0+!/0+!</6$!()!2+#$0(98'*6!?gS.!</6$6B;!
$+**'2=!E+!$8+0+!'6!'2)+<$'(2!()!$8+!F'&2+4@!![:/E9*+-!!69'**'2=!*'9'&!'2!#0'2+!'2!2+980($'<!642&0(E+!
/2&!)(0E!</6$!()!)/$!/2&!/!)/$$4!</6$!$8/$!4(#!</2!6++!/2&!9(*/0'c+!'2!$8+!#0'2+@!!!
!
II. Urinalysis
The first thing that disappears in renal failure is the ability of the kidney to
concentrate urine@!!I8'6!(<<#06!L+)(0+!.0ZS\"!$8'2F!/L(#$!'2<0+/6'2=;!(0!+M+2!8/M'2=!0+2/*!
$#L#*/0!</6$6@!![:/E9*+-!!$/F'2=!#0'2+!'2!$8+!E(02'2=!/2&!&('2=!$8+!69+<')'<!=0/M'$4!()!$8+!#0'2+!
/2&!6++'2=!>8/$!'$!'6@!!SZ<;!specific gravity can tell you if it is concentrated or dilute
urine.!!1)!$8+!69+<')'<!=0/M'$4!'6!=0+/$+0!$8/2!,@VHP;!$8'6!E+/26!$8/$!$8+!9$!'6!<(2<+2$0/$'2=!#0'2+!
/2&!$8/$!$8+!F'&2+46!/0+!%SYGX\I[Xb!"GRK%X!?$8'6!'6!/!.N[%J!$+6$B@!![:/E9*+-!!*+$Q6!6/4!1!&'&!
/!69+<')'<!=0/M'$4!()!#0'2+!(M+02'=8$!/2&!'$!'6!,@V,V!7!$8'6!'6!M+04!849($(2'<!#0'2+;!/2&!'$!E+/26!
$8/$!$8+!9$!<(#*&!2($!<(2<+2$0/$+;!/2&!$8/$!$8+!9$!'6!'2!0+2/*!)/'*#0+@!!?S\"Z.0!>'**!2($!8+*9!
&+$+0E'2+!$8'6B@!!I8+!#0'2+!$8/$!68(#*&!L+!<(2<+2$0/$+&!'6!)0(E!/!9$!$8/$!'6!6*++9'2=!(M+02'=8$@!!!
!
Hyaline cast cast of a protein; mostly b9/harmless!?/**!($8+0!</6$6!8/M+!9/$8(*(='</*!
6'=2')'</2<+B@!!!
III. Crystals:
Uric acid crystal!7!*((F6!*'F+!/!6$/0U!9N!()!$8+!#0'2+!8/6!$(!L+!/<'&'<!$(!)(0E!/!#0'<!/<'&!<046$/*@!!
J$!>'$8!=(#$!7!>/2$!$(!6$(9!<046$/*6!)0(E!)(0E'2=;!/2&!4(#!F2(>!$8+4!)(0E!'2!*(>!9N;!>8/$!&(!
4(#!>/2$!$(!&(!>'$8!$8+!#0'2+n!%*F/*'2'c+!'$@!!N(>!</2!4(#!&(!$8/$n!./0L(2'<!%28'&0/6+!'28'L'$(0!
?/<+$/c(*/E'&+B@!!S4!L*(<F'2=!L'</0L(2/$+!0+<*/E/$'(2!>'**!/*F/*'2'c+!$8+!#0'2+;!/2&!90+M+2$!
6$(2+6!)0(E!)(0E'2=@!!Y(;!6'E9*+!E/2'9#*/$'(2!()!$8+!9N!</2!90+M+2$!#0/$+!2+980(9/$84@!!!
Calcium Oxalate crystal!7!*((F!*'F+!$8+!L/<F!()!/2!+2M+*(9+U!>84!'6!$8'6!'E9!$(!F2(>n!
[:/E9*+-!6$0++$!9+06(2!<(E+6!'2;!6$#9#0(#6;!8/6!'2<0+/6+&!/2'(2!=/9!E+$/L(*'<!/<'&(6'6@!_(!/!
#0'2/*46'6;!/2&!6++!L#2<8!()!</*<'#E!(:/*/$+!6$(2+6!7!>8/$!&'&!8+!&0'2Fn![$84*+2+!=*4<(*@!!g8/$!
'6!$8+!MC stone we pass? Ca oxalate@!!Y(!')!4(#!8/M+!/!./!G:/*/$+!6$(2+;!4(#!>'**!8/M+!
<046$/*6!/66(<'/$+&!>'$8!'$@!
Horse kidney!73('2+&!/$!$8+'0!*(>+0!9(*+6@!!g'**!/6F!>8/$!'6!0+6$0'<$'2=!$8+!E(M+E+2$!()!$8+!
F'&2+4n!1K%!7!'$!$0/96!$8+!F'&2+4@!!!
IV. Cystic dz of the kidney!7!!
!
A. Infantile polycystic kidney dz;!!
183

>8'<8!'6!/#$(!0+<+66'M+U!$8+0+)(0+!'$!'6!90+6+2$!/$!L'0$8@!!_(!4(#!$8'2F!$8'6!L/L4!'6!#0'2/$'2=n!
"(;!$8+0+)(0+!8/6!(*'=(84&0/E2'(6!?&+<0+/6+&!/E2'($'<!)*#'&B@!!Y(;!L/L4!'6!'2!/2!/E2'($'<!
6/<;!>'$8!8/0&*4!/24!/E2'($'<!)*#'&!/0(#2&!'$;!/2&!$8+0+)(0+!8/M+!E/*)(0E/$'(2!&#+!$(!
90+66#0+@!!X((F!/$!$8+!2(6+!/2&!+/06U!$8'6!'6!called Potters face, which is a sign of
oligohydramnios in polycystic kidney dz: flattened nose, low-set ears, and
recessed chin)@!!I8'6!<8'*&!>/62Q$!/L*+!$(!L0+/$8;!/2&!>8+2!'$!$0'+&!$(!L0+/$8;!'$!<(#*&2Q$U!
$8+!*#2=6!/0+!849(9*/6$'<!7!$8+4!2+M+0!)#**4!&+M+*(9+&!LZ<!$8+!F'&!<(#*&2Q$!)'**!$8+E!#9@!!
I8+6+!<46$6!/0+!/*6(!6++2!'2!$8+!9/2<0+/6;!$8+!*'M+0!/2&!3#6$!'2<(E9/$'L*+!>'$8!*')+@!!!
!
B. Adult polycystic kidney disease:!APKDz
Y(E+!/#$(6(E/*!&(E'2/2$!&c!68(>!J+2+$0/2<+!7!8/M+!$8+!/L2(0E/*'$4!>8+2!$8+4!*((F!
)(0!'$!(2!$8+!=+2+;!L#$!&(!2($!+:90+66!'$@!?6(!4(#!8/M+!$8+!=+2+$'<!/L2(0E/*'$4;!L#$!8/M+!
2+M+0!+:90+66+&!'$!'2!4(#0!*')+B@!!I8/$Q6!$8+!=((&!2+>6!7!$8+!L/&!2+>6!'6!$8/$!4(#!</2!
$0/26E'$!'$!$(!4(#0!<8'*&;!$8+0+)(0+!'$!'6!&'))'<#*$!$(!0+<(=2'c+!(2!$8+!9+&'=0++@!![:/E9*+!()!
9+2+$0/2<+-!!)/E'*'/*!9(*49(6'6!C!,VVW!9+2+$0/2<+!7!')!4(#!8/M+!$8+!=+2+;!4(#!8/M+!$8+!
&c@!![:/E9*+!()!'2<(E9*+$+!9+2+$0/2<+-!!E/0)/2!7!/L2(0E/*'$4!(2!<Q6(E+!,e;!2(0E/*!
9/0+2$6;!$8+4!&(!2($!+:90+66!$8+!=+2+;!L#$!9/66+&!(2!$(!<8'*&!?$8'6!'6!'2<(E9*+$+!
9+2+$0/2<+B@!!%J5_c!'6!/2($8+0!+:/E9*+!()!'2<(E9*+$+!9+2+$0/2<+@!
!
Y(;!%J5_c!'6!/2!/#$(6(E/*!&(E'2/2$!&c!$8/$!'6!2($!90+6+2$!/$!L'0$8!LZ<!%_!&c!8/M+!delayed
manifestations@!!Y++!<46$6!L4!,Vd,H!4+/06!()!/=+;!/*>/46!=+$!HTN which will then!
predisposes 2 types of bleeds-!?,B!Charcot-Bouchard aneurysms!?/!L*((&!<*($B!/2&!
?HB!6++!L*((&!/**!(M+0!$8+!L0/'2;!&#+!$(!6#L/0/<82('&!8+E(008/=+;!$8+0+)(0+!$8+!L*((&!'6!&#+!
$(!rupture berry aneurysm@!!Subarachnoid hemorrhage!C!i>(06$!8+/&/<8+!()!E4!
*')+j;!L*((&!'2!6#L/0/<82('&!69/<+@!!!
!
MVP (mitral valve prolapse)-!![:/E9*+-!!8:!()!NI";!/L2(0E/*'$4!()!#*$0/6(#2&!'2!$8+!
0+2/*!9+*M'6;!/2&!8/&!<*'<F!E#0E#0!?$8+0+)(0+!KkJB!7!&:n!%J5_c@!!I8+0+!'6!/!8'=8!/66(<!()!
KkJ!>'$8!$8'6@!!!
!
Diverticulosis!/*6(!8/6!/!8'=8!'2<'&+2<+@![:/E9*+-!!9$!>'$8!NI";!/L2(0E/*'$4!(2!#*$0/6(#2&!
'2!0+2/*!/0+/;!*(6$!aVV!E*6!()!L*((&!/**!()!/!6#&&+2;!*+/&'2=!$(!8+E/$(<8+c'/!?K..!
8+E/$(<8+c'/!C!&'M+0$'<#*(6'6B@!
!
184

V. Glomerular stuff
!
A. Nomenclature of the Kidney dz:
-itis = type III HPY therefore its an immunologic dz (glomerulonephritis)
[:/E9*+-!!X'9('&!2+980(6'6!7!&(+6!$8/$!8/M+!$49+!111n!"(!!
[:/E9*+-!!T(</*!6+=E+2$/*!=*(E+0#*/0!6<*+0(6'6n!"(!
[:/E9*+-!!_'/L+$'<!=*(E+0#*(6<*+0(6'6n!"(@!
[:/E9*+-!!1=%!=*(E+0#*(2+980'$'6;!&'))#6+!E+EL0/2(#6!=*(E+0#*(2+980'$'6n!b+6!
!
g8+2!>+!6/4!]&'))#6+Q;!$8'6!E+/26!$8/$![k[Rb!=*(E+0#*#6!8/6!6(E+$8'2=!>0(2=!>'$8!'$!(2!
0+2/*!L:@!!g8/$!'6!])(</*Qn!2($!/**!=*(E+0#*'!'2M(*M+&@!!!
g8/$!')!&c!'6!)(</*!/2&!&c!'2!$8+!=*(E+0#*#6!'6!)(</*n!N/M+!/!90(L*+E!7!$8'6!'6!</**+&!T(</*!
Y+=E+2$/*!l*(E+0#*#6!
g8/$!&(+6!90(*')+0/$'M+!E+/2n!N/M+!*($6!()!$8+E@!Y(;!4(#!8/M+!E/24!2#<*+'@!1)!/**!$8+!
=*(E+0#*'!8/M+!/!*($!()!2#<*+';!$8'6!'6!&'))#6+!90(*')+0/$'M+!=*(E+0#*(2+980'$'6!
1)!4(#!3#6$!6++!$8'<F!E+EL0/2+6;!'$6!E+EL0/2(#6!=*(E+0#*(2+980'$'6!
1)!4(#!6++!L($8!'2<0+/6+&!<+**!/2&!$8'<F+2+&!E+EL0/2+n!K+EL0/2(90(*')+0/$'M+!
=*(E+0#*(2+980'$'6!
!
B. Anatomy/schematic
!
I8+!(0&+0!'6-!!L*((&;!+2&($8+*'/*!<+**6!()!$8+!</9'**/0'+6;!#2&+02+/$8!$8+0+!'6!/!SK;!/2&!$8+2!
$8+!M'6<+0/*!+9'$8+*'/*!<+**6!?*((F6!*'F+!)++$!C!9(&(<4$+6U!>8'<8!8/M+!69/<+6!'2!L+$>++2!$8+E!
</**+&!6*'$!9(0+6B!$8/$!*'2+!$8+!L(>E/2Q6!</96#*+@!!g8(!makes/synthesizes the GBM?
Visceral epithelial cells (podocytes)@!!g8/$!F++96!%*L#E'2!(#$!()!$8+!#0'2+!2(0E/**4n!
Y$0(2=!2+=/$'M+!<8/0=+!()!$8+!SK@!!g8(!'6!0+69(26'L*+!)(0!6$0(2=!idi()!$8+!SKn!%!GAG
called heparan sulfate, which has a strong neg charge.!!1)!>+!'EE#2(*(='</**4!
&/E/=+!$8+!M'6<+0/*!+9'$8+*'/*!<+**;!>8/$!&(!>+!/#$(E/$'</**4!/*6(!&/E/=+n!I8+!SK;!>8'<8!
E+/26!4(#Q0+!=(22/!69'**!/!*($!()!90($+'2!'2!$8+!#0'2+;!>8'<8!E+/26!4(#!9($+2$'/**4!</2!8/M+!
2+980($'<!642&0(E+!')!4(#!69'**!uP@e!=0/E6!'2!H^!806B@!
!
C. Test on Renal Bx
Stains!7!0(#$'2+!N!}![!8+E($(:4*'2!6$/'26;!6'*M+0!6$/'26@!!Immunofluorescent!6$/'2!7!
9/$$+02!</2!L+!*'2+/0!(0!=0/2#*/0!?/F/!*#E94!L#E94B;!>8'<8!/0+!$8+!(2*4!H!9/$$+026@!!!I8+6+!
9/$$+026!/0+!'EE#2+!<(E9*+:+6!(0!9/$$+026Z%LQ6!$8/$!$8+4!/0+!&+$+<$'2=@!!I/F+!L:;!/2&!8/M+!
%LQ6!>'$8!/!)*#(0+6<+2$!$/=!(2!$8+E@!!1+!>/2$!$(!6++!1=%!'2!$8+!=*(E+0#*#6!/2&!8/M+!/2$'!1=%!
%LQ6!>'$8!/!)*#(0+6<+2$!$/=!7!')!$8+0+!/0+!/24;!'$!>'**!/$$/<8!$(!'$!/2&!E/F+!/!)*#(0+6<+2$!$/=@!!
I8+0+!/0+!/*6(!$/=6!)(0!1=l;!.P;!)'L0'2(=+2!7!6(!</2!=+$!/2!'&+/!()!>8/$Q6!'2!$8+!=*(E+0#*#6!
/2&!/2!'&+/!()!>8/$!9/$$+02!'$!'6!'2!?'+!*'2+/0!M6@!*#E94!L#E94!=0/2#*/0!9/$$+02B@!!1$!&(+62Q$!
$+**!#6!>8+0+!$8+6+!$8'2=6!/0+;!'$!3#6$!$+**6!#6!$8/$!$8+4!/0+!$8+0+@!!g8/$!$+**6!#6!>8+0+!
'EE#2+!&+9(6'$6!/2&!'EE#2+!<(E9*+:+6!/0+!*(</$+&!/0+!EM@!!Y(;!>+!&(!6$/'26;!
)*#(0+6<+2<+;!/2&![K@!N(>!</2!>+!$+**!$8/$!$8+!9(&(<4$+6!/0+!)#6+&n!./2!(2*4!$+**!L4![K!LZ<!
'$6!6(!6E/**@!!!
VI. Difference between Ab recognition vs. immune complexes!
!
_+$+<$!>'$8!%L!>8'<8!8/M+!H!%=!0+<(=2'$'(2!6'$+6!(2!$8+!%L@!!Goodpasture syndrome is an
IgG anti BM Abs.!!Y(;!$8+4!=+$!'2!$8+!L*((&!$8+4!=+$!'2$(!$8+!=*(E+0#*/0!</9'**/04!/2&!/0+!
&'0+<$+&!/=/'26$!$8+!SK@!!g8+0+M+0!$8+0+!>/6!/!69($!(2!$8+!SK!4(#!>'**!6++!/2!1=l!%L@!!I8+0+!
>(#*&2Q$!L+!(2+!69($!(2!$8+!SK!>'$8(#$!1=l@!!Y(;!>8/$!')!>+!&(!/!)*#(0+6<+2$!$/=!)(0!1=l!
185

(M+0*4'2=!$8+!=*(E+0#*#6!7!>8/$!>(#*&!4(#!6++n!g(#*&!6++!(#$*'2+6!()!/**!$8+!SKQ6!()!$8+!+2$'0+!
=*(E+0#*#6@!!1$!'6!*'2+/0@!!!
MCC linear pattern on immunufluorescence = Goodpastures.!!!
!
Immune complexes!7!%=!>'$8!%L!/$$/<8+&!/2&!'6!<'0<#*/$'2=!'2!$8+!L*((&6$0+/E;!8+2<+!AgAb complex!7!'+!lupus = immune complex dz: Ag = DNA, Ab = anti-DNA!7!$8+4!/$$/<8!
$(!+Z(!/2&!)*(/$!/0(#2&!/2&!&+9(6'$!'2!<+0$/'2!9*/<+6U!'2!$8'6!</6+!'$!>'**!&+9(6'$!'2!$8+!=*(E+0#*/0!
</9'**/04U!type III HPY (b/c immune complex).!!SZ<!$8+4!/0+!'EE#2+!<(E9*+:+6;!$8+4!/0+!
*/0=+0!$8/2!'2&'M'&#/*!%LQ6!LZ<!$8+4!/0+!%=!/2&!%L!/$$/<8+&!$(=+$8+0!7!$8+0+)(0+!$8+4!/0+!L'==+0;!
8/M+!&'))!6(*#L'*'$'+6;!8/M+!&'))!<8/0=+6!7!$8+4!>(2Q$!)'$!2'<+!/2&!2+/$!'2!$8+!=*(E+0#*#6@!!Y(;!
&+9+2&'2=!(2!$8+!6'c+!/2&!<8/0=+!>'**!&+9+2&!(2!>8+0+!$8+4!*(</$+!$8+E6+*M+6@!!1+!')!$((!L'=;!
>'**!*(</$+!#2&+0!$8+!+2&($8+*'/*!2#<*+#6@!!Y(;!$8'6!>(#*&!L+!</**+&!/!6#L+2&($8+*'/*!E+EL0/2+!7!
$8+4!/0+!6(!L'=!$8/$!$8+4!)'$!#2&+0!/!9(&(<4$+!?$8+4!</22($!=+$!$80(#=8!$8+!SKB@!X#9#6!'6!*'F+!
$8'6;!$((!7!$8+4!</22($!=+$!9/66+&!$8+!SK!/2&!8/2=(#$!#2&+0!$8+!+2&($8+*'/*!<+**6@!!Post strep
GM bacterial Ag with Ab against (immune complex), which is very small, and very
soluble. They can go all the way past the BM and deposit under the epithelial side
this is a subepithelial deposit@!Y(;!8(>!&(!4(#!)'2&!(#$!>8+0+!$8+!&+9(6'$6!/0+n!./22($!6++!
>'$8!'EE#2#)*#(0+6<+2<+;!L#$!>'**!L+!/L*+!$(!6++!>'$8![K!LZ<!$8+4!/0+!+*+<$0(2!&+26+!?E+/2'2=!
$8/$!$8+4!'2<0+/6+!$8+!&+26'$4!>8+0+M+0!$8+4!/0+B@!!Y(;!'EE#2+!<(E9*+:+6!8/M+!&'))!6(*#L'*'$'+6;!
&'))!<8/0=+6;!/2&!0/2&(E*4!=(!#2&+02+/$8!$8+!+2&($8+*'#E;!#2&+0!$8+!6#L+9'$8+*'/*!6#0)/<+U!
$8+4!>'**!2($!8/M+!/!2'<+!6E(($8!*'2+/0!9/$$+02!*'F+!/2$'!L/6+E+2$!E+EL0/2+!%LQ6@!![:/E9*+-!!
dz that isnt linear (so its not Goodpastures) it could be any immune complex dz
lupus, post strep, IgA glomerulonephritis. ./2!=+$!/!8'2$!()!>8/$!$8+!&c!'6;!&+9+2&'2=!(2!
>8/$!'6!'2!$8+0+!7!'+!>8/$!'6!$8+!only glomerular nephritis that you can only dx with
immunufluorescence? IgA glomerulonephritis@!!SZ<!')!4(#!/0+!=(22/!</**!'$!=*(E+0#*/0!
2+980'$'6;!$8'6!E+/26!$8/$!$8+0+!'6!2(!1=l!'2!$8+0+;!L#$!1=%@!!Y(;!$8+!(2*4!>/4!$(!/<<#0/$+*4!&:!
1=%!=*(E+0#*(2+980'$'6!'6!$(!90(M+!$8/$!'$!'6!1=%!/2&!2($8'2=!+*6+@!!Granular/lumpy bumpy
pattern when you see this, what does it mean? Immunocomplex type III dz;
remember anti BMs and anti BM Abs against the BM is not a type III, but a type II.
Whereas, immune complexes are type III.
186

VII. Nephritic vs. Nephrotic Glomerulonephritis
There are 2 types of glomerulonephritis: nephritic or nephrotic!?</22($!L+!L($8!/$!6/E+!
$'E+U!8(>+M+0;!'$!</2!6$/0$!(#$!2+980'$'<!/2&!L+<(E+!2+980($'<B!
!
A. Nephritic Syndrome:
!
Has unique cast!$8/$!'6!0+&;!/2&!*((F6!*'F+!L'<(2</M+!&'6F!7!RBC casts!?#2'D#+!$(!
2+980'$'<!&cQ6BU!LZ<!4(#!8/M+!'2)*/EE/$'(2!4(#!>'**!69'**!90($+'2;!L#$!2($!=0+/$+0!$8/2!P@e!
=0/E6!'2!/!H^!80!9+0'(&!?LZ<!')!'$!&'&;!'$!>(#*&!L+!2+980($'<B!7!6(!'$!'6!E'*&!$(!E(&+0/$+!
90($+'2#0'/@!!b(#!/0+!69'**'2=!90($+'2;!L#$!2($!$(!$8+!6/E+!*+M+*!/6!2+980($'<;!$8+0+)(0+!will
not!8/M+!9'$$'2=!+&+E/;!/6<'$+6;!+$<A!1)!/0+!'2)*/E'2=!$8+!=*(E+0#*#6;!>'**!4(#!8/M+!(*'=#0'/n!
b+6!7!/**!$8+!=*(E+0#*/0!</9'**/0'+6!8/M+!6>(**+2!#9;!lTR!>(#*&!&+<0+/6+;!/2&!$8'6!>(#*&!
*+/&!$(!(*'=#0'/@!!%0+!4(#!&+<0+/6'2=!$8+!/L6(09$'(2!(0!2($!)'*$+0'2=!"/n!4+6@!!Y(!&(+6!$8+!"/!
L#'*&!#9n!b+6!7!$8+0+)(0+!0#2!$8+!0'6F!()!NI"@!!So, classically what you see in nephritic
dzs is hematuria, RBCs casts, oliguria, HTN, and mild/moderate proteinuria (this
is the definition)
!
B. Nephrotic Syndrome:
!
N/6!/!&'))+0+2$!</6$!?fatty castB;!have greater than 3.5 grams of protein in a 24 hr
urine sample. Will also have pitting edema.
Y(;!')!4(#!6$/0$+&!(#$!2+980'$'<!?RS.!</6$6;!E'*&ZE(&+0/$+!90($+'2#0'/B!/2&!/**!()!/!6#&&+2!4(#!
6$/0$!6++'2=!9'$$'2=!+&+E/;!6$/0$!6++'2=!(M+0!P@e!=0/E6!()!90($+'2!'2!$8+!#0'2+!(M+0!H^!806;!/2&!
)/$$4!</6$6!7!$8+2!2+980'$'<!8/6!L+<(E+!2+980($'<@!
VIII. Nephritic Syndromes
A. Proliferative Glomerulonephritis
%**!$8+!=*(E+0#*'!/0+!&'))#6+;!$((!E/24!2#<*+'!
!
B. Post strep GN
!
[:/E9*+-!6</0*+$!)+M+0!H!>++F6!/=(;!90+6+2$6!>'$8!8+E/$#0'/;!RS.!</6$6;!E'*&!$(!E(&+0/$+!
90($+'2#0'/;!NJ;!9+0'(0L'$/*!9#))'2+66@!![K-!*#E+2!()!</9'**/04;!L#E9!(2!*#E+2!'6!+2&($8+*'/*!
<+**;!#2&+02+/$8!'6!SK!?=0/4'68B;!/2&!+9'$8+*'/*!<+**6!#2&+0@!!N/6!L(#*&+06!$8/$!/0+!&+26+0!
$8/2!$8+!2(0E/*!=*(E+0#*/0!SK!7!$8+6+!/0+!'EE#2+!<(E9*+:+6@!!12!$8'6!</6+;!'$!$8+!L/<$+0'/!
'6!$8+!%=d%L!'EE#2+!<(E9*+:+6@!!g8'<8!6'&+!/0+!$8+4!<*(6+0!$(n!.*(6+0!$(!+9'$8+*'/*!6'&+;!
$8+0+)(0+!$8+4!/0+!6#L+9'$8+*'/*!&+9(6'$6!7!8+2<+!9(6$!6$0+9!lK"@!
!
C. Lupus GN
!
[:/E9*+-!Pe!4Z(!)+E/*+!>'$8!iOj!6+0#E!%"%!>'$8!/!0'E!9/$$+02!?E+/2'2=!4(#!8/M+!/2$'!_"%!
%LQ6!90+6+2$B@!!Lupus almost always involves the kidney.!!I8+0+!/0+!a!$49+6;!/2&!$8+!
important one to know is type IV;!>8'<8!'6!/!diffuse proliferative
glomerulonephritis,!>8'<8!'6!$8+!K.!(M+0/**!(2+!6++2!'2!X#9#6@!!N/6!E/24!2#<*+';!
$8+0+)(0+!90(*')+0/$'M+U!8/6!>'0+!*((96@!!?(0'+2$!$(![KB!&+9(6'$6!'2!SK!/0+!/2$'!_"%!&+9(6'$6@!!
g(#*&!4(#!/=0++!$8/$!$8+4!/0+!'2!$8+!+2&($8+*'/*!<+**n!b+6@!Y(!>8/$!'6!$8'6!*(</$'(2n!
Y#L+2&($8+*'/*!&+9(6'$6@!!J(&(<4$+6!>'$8!6*'$!9(0+6!'2!L$>2!/0+!2($!)#6+&!LZ<!')!$8+4!>+0+;!'$!
187

>(#*&!L+!2+980($'<!642&0(E+@!!%*6(!6++!*#E+2;!+2&($8+*'/*!<+**6!/2&!&+9(6'$6@!!1EE#2+!
<(E9*+:+6!/0+!6(!L'=!$8+4!</2Q$!=+$!$80(#=8!$8+!SK@!!!
!
D. Crescentic GN
!
l*(E+0#*#6!6#00(#2&+&!L4!90(*')+0/$'2=!<+**6!$8/$!/0+!9/0'+$/*!<+**6!LZ<!2($!'2!$8+!=*(E+0#*#6;!
/2&!8/6!<0+6<+2$!68/9+;!8+2<+!$8+!2/E+!<0+6<+2$'<!=*(E+0#*/0!2+980'$'6@!I8'6!'6!$8+!WORST
glomerular nephritis to have b/c in 3 months; pts will go into acute renal failure
and die unless pt is on dialysis@!!K/24!&cQ6!8/M+!/!<0+6<+2$'<!=*(E+0#*(2+980'$'6;!L#$!$8+!
(2*4!(2+!1!2++&!$(!F2(>!'6!Goodpastures; this is a NEPHRITIC dz; this dz has
crescentic glomerulonephritis on bx (therefore a BAD dx).!!!
!
IX. Nephrotic Syndromes:
!
J$!>'$8!</6$6!?)/$$4!</6$6B;!9(*/0'c+&!69+<'E+2!>'$8!E/*$+6+!<0(66!7!$8'6!'6!<8(*+6$+0(*!'2!$8+!
#0'2+@!!g8+2!<8(*+6$+0(*!'6!9(*/0'c+&;!'$!*((F6!*'F+!/!E/*$+6+!<0(66@!!These fatty casts are
pathonognomic for nephrotic syndrome. l0+/$+0!$8/2!P@!e!=0/E6!90($+'2!)(0!H^!806;!)/$$4!
</6$6!'2!$8+!#0'2+;!/6<'$+6;!9'$$'2=!+&+E/;!0'6F!()!69(2$/2+(#6!9+0'$(2'$'6!')!4(#!/0+!/!<8'*&@!!
G0=/2'6En!Y$0+9!92+#E(2'/!'2!F'&6;![!<(*'!'2!/&#*$6@!!!
A. Lipoid nephrosis aka Minimal Change Dz:
[:/E9*+-![K!()!t!4Z(!L(4!$8/$!8/&!/2!\R1!(2+!>++F!/=(;!/2&!2(>!'6!/**!6>(**+2;!8/6!9'$$'2=!
+&+E/!$80(#=8(#$!L(&4!?/2/6/0</B!/2&!/6<'$+6;!2(0E(d$+26'M+;!2(!NI"U!6/>!2($8'2=!(2!
0+2/*!L:U!L#$!$8+2!&'&!/![K!7!6++!RS.!'2!=*(E+0#*/0!</9'**/04!*#E+2@!Y(;!6++!+2&($8+*'/*!
<+**6;!6++!SK!?>'$8(#$!+*+<$0(2!&+26+!&+9(6'$6B;!9(&(<4$+6!?)#6+&B!7!fusion of podocytes
is ALWAYS seen in any cause of nephrotic syndrome. K/*$+6+!<0(66+6!'2!#0'2+@!!_:n!
Lipoid nephrosis. %**!9$!>'$8!2+980($'<!642&0(E+!8/M+!849+0<8(*+6$+0+E'/@!!Y'2<+!$8+4!
8/M+!=*(E+0#*/0!&c!/2&!6(E+!()!$8+!<8(*+6$+0(*!</2!=+$!'2$(!$8+!#0'2+;!6(E+!</2!)(0E!</6$6!
'2!$8+!#0'2+@!!%F/!E'2'E/*!<8/2=+!&c@!!g84!'6!$8'6!8/99+2'2=n!N/6!*(6$!2+=!<8/0=+!'2!lSK;!
$8+0+)(0+!/*L#E'2!</2!=+$!$80(#=8@!!I8+6+!9$6!8/M+!/!6+*+<$!90($+'2#0'/!7!$8+!(2*4!90($+'2!'2!
$8+6+!9$Q6!#0'2+!'6!/*L#E'2;!/2&!'$!'6!=0+/$+0!$8/2!P@e!=0/E6!9+0!H^!806@!!R:!7!<(0$'<(6$+0('&6!
?#6#/**4!=(+6!/>/4!'2!,!4+/0!2+M+0!$(!<(E+!L/<F!/=/'2B@!!I8+!MCC nephrotic syndrome
in kids. !
B. Focal Segmental Glomerulosclerosis
!
[:/E9*+-!pt that is HIV +,!9'$$'2=!+&+E/!7!$8+0+)(0+!*((F!/$!#0'2+!/2&!2($+!$8/$!'6!
=0+/$+0!$8/2!P@e!=0/E6!(M+0!H^!806@!!N/6!)/$$4!</6$6!'2!#0'2+!/2&!8/6!NI"@!!_(!L:;!/2&!
/*0+/&4!F2(>!>8/$!4(#!/0+!=(22/!6++!LZ<!'$!$8+!MCC nephrotic syndrome in AIDs pt@!!
G2!L:;!6(E+!()!$8+!=*(E+0#*'!/0+!/L2(0E/*!/2&!($8+06!/0+!2(0E/*;!L#$!(2*4!/!9/0$!()!$8+!
=*(E+0#*#6!'6!E+66+&!#9@!!I8+0+)(0+;!'$!'6!)(</*!6+=E+2$/*@!!SZ<!$8+!0+2/*!L:!>'$8![K!/2&!
'EE#2()*#(0+2<+!&'&!"GI!68(>!&+9(6'$6;!$8+0+)(0+!'$Q6!=*(E+0#*(6<*+0(6'6@!Y(;!$8'6!'6!</**+&!
)(</*!6+=E+2$/*!=*(E+0#*(6<*+0(6'6@!!I8'6!'6!the MC lesion in AIDs pts and IVDAs@!!"+:$!
$(!0/9'&*4!90(=0+66'M+!<0+<+2$0'<!=*(E+0#*(2+980'$'6;!$8'6!'6!$8+!2+:$!>(06+!=*(E+0#*/0!&c@!!!
C. Diffuse membranous glomerulonephritis
!
[:/E9*+-!/&#*$!>'$8!9'$$'2=!+&+E/;!(M+0!P@e!=0/E!9+0!H^!406;!)/$$4!</6$6@!!_(!/!L:!/2&!6++!
2($!E/24!]&($6Q!$8+0+)(0+!2($!/!90(*')+0/$'M+!&c@!!N(>+M+0!$8+!SK!'6!$8'<F+0@!!_:n!Diffuse
membranous glomerulonephritis = MCC nephrotic syndrome in adults@!!I8'6!'6!
188

6#L+9'$8+*'/*!&+9(6'$@!!Epimembranous spikes spike like lesion on the outside of
GBM seen with silver stain C!&'))#6+!E+EL0/2(#6!=*(E+0#*(2+980'$'6!?(2*4!(2+!$8/$!
*((F6!*'F+!$8/$B@!!
!
K/24!$8'2=6!</2!</#6+!$8'6!?&0#=6;!</2<+0;!2($8'2=;!'2)+<$'(26BU!6(E+!$8+!&0#=6!'2<*#&+!
"Y%1_6;!N+9!S;!</9$(90'*!?F'2=!()!$0+/$E+2$!()!&'/L+$'<!2+980(9/$84!/2&!8+/0$!)/'*#0+B;!
E/*/0'/;!6498'*'6;!<(*(2!</2<+0!?'EE#2+!<(E9*+:!'6!/2$'d.[%!%LQ6B@!![M+2$#/**4!*+/&6!$(!0+2/*!
)/'*#0+!/2&!</2!&'+!#2*+66!4(#!=+$!/!0+2/*!$0/269*/2$!
!
D. Type I and II Membranoproliferative Glomerulonephritis
(ends in -itis therefore it is type III HPY immune complex!)
!
,@!!I49+!1!8/6!/!0+*/$'(268'9!>'$8!N+9!.!7!8(>!&(!4(#!0+E+EL+0n!K+EL0/2(#6!C!N+9!S!
?/*6(!0+E+EL+0!$8+!M/6<#*'$'6!7!J(*4/0$+0'$'6!"(&(6/B;!K+EL0/2(90(*')+0/$'M+!C!N+9!.!
?/*6(!0+E+EL+0!<04(=*(L'2+E'/B@!!!
Y(;!type I is a subendothelial deposit that produces nephrotic syndrome@!!!
!
H@!!I49+!11!'6!*+66!<(EE(2;!/2&!8/6!/2!%#$(!%L!/=/'26$!.P;!</**+&!.P!2+980'$'<!)/<$(0@!!1$!
</#6+6!.P!<(2M+0$/6+!$(!L+<(E+!(M+0/<$'M+!/2&!'6!<(26$/2$*4!L0+/F'2=!<(E9*+E+2$!
&(>2@!!Y(;!$8+!*(>+6$!<(E9*+E+2$!*+M+*6!4(#!>'**!6++!'6!'2!$49+!11!=*(E+0#*/0!2+980'$'6!7!
$8'6!'6!</**+&!&+26+!&+9(6'$!&c!LZ<!$8+!+2$'0+!SK!/2!'EE#2+!<(E9*+:@!
!
tram tracks!7!E+6/2='/*!<+**!?6$0#<$#0/*!<(E9(2+2$!()!$8+!=*(E+0#*/0!</9'**/04B!7!$8+!
E+6/2='/*!<+**!'6!+:$+2&'2=!'$6+*)!L+$>++2!$8+!SK!/2&!$8+!+2&($8+*'/*!<+**;!E/F'2=!'$!*((F!*'F+!
/!$0/E!$0/<FU!6(;!'$Q6!/!E+6/2='/*!90(<+66!L$>2!$8+!SK!/2&!+2&($8+*'/*!<+**!7!$0/E!$0/<F!
K+EL0/2(90(*')+0/$'M+!&c!
E. Diabetic Glomerulosclerosis!
!
.*/66'<!6'=2-!L'=!0(#2&!L/**6!(2!N!/2&![!6$/'2@!!g8+2!$8+0+!'6!+:<+66!0+&!'2!$8+!<+**;!$8'2F!
hyaline arteriolosclerosisU!$8'6!'6!/!6E/**!M+66+*!&c!()!&'/L+$+6!/2&!NI"@!!I8+!M+04!)'06$!
M+66+*!$8/$!'6!84/*'2'c+&!'6!$8+!+))+0+2$!/0$+0'(*+@!!X+$Q6!6/4!'$!'6!84/*'2'c+&@!!Y(;!LZ<!$8+!*#E+2!
'6!2/00(>!'2!$8+!+))+0+2$!/0$+0'(*+;!$8+!lTR!>'**!'2<0+/6+@!!Y(;!>8/$!'6!$8+!.0!<*+/0/2<+n!
12<0+/6+&@!!Y(;!'2!+/0*4!&'/L+$'<!2+980(9/$84;!$8+0+!'6!/2!increased GFR and Cr
clearance@!!g84n!SZ<!$8+!+))+0+2$!/0$+0'(*+!'6!84/*'2'c+&!/2&!(L6$0#<$+&@!!16!$8'6!L/&n!b+6!7!
/6!/!0+6#*$!$8+!=*(E+0#*#6!>'**!$/F+!/!9(#2&'2=!)(0!$8+!2+:$!$+2!4+/06!7!*+/&'2=!'23#04!</**+&!
849+0)'*$0/$'(2!&/E/=+@!g8/$!'6!$8+!90(<+66!>8+0+!=*#<(6+!/$$/<8+6!$(!/2!//!'2!/!90($+'2Bn!
"(2+2c4E/$'<!=*4<(64*/$'(2@!!X+$6!6/4!$8'6!'6!/*6(!=('2=!(2!LZ<!$8+!9$!'6!2($!>/$<8'2=!8'E6+*)!
$((!>+**;!$8+0+)(0+!we are nonenzymatically glycosylating the GBM@!!g8/$!>(#*&!
8/99+2!>8+2!4(#!=*4<(64*/$+!/!SK!7!>8/$!'6!'$!9+0E+/L*+!$(n!J0($+'2@!!Y(;!8/M+!/**!$8'6!
90+66#0+!(2!$8+!=*(E+0#*/0!</9'**/04!LZ<!$8+!+))+0+2$!/0$+0'(*+!/2&!/*6(!2(2+2c4E/$'</**4!
=*4<(64*/$'2=!$8+!lSK;!6(!'$6!9+0E+/L*+!$(!90($+'2@!Y(;!$(26!()!90($+'2!=('2=!'2$(!$8+!#0'2+@!!
g8+2!4(#!'2'$'/**4!6$/0$!6++'2=!'$;!'6!</**+&!microalbuminuria.!!g'**!$8+!6$/2&/0&!&'96$'<F!)(0!
90($+'2!&+$+<$!$8/$n!"(@!!I8+0+!/0+!69+<'/*!&'96$'<F6!$8/$!/0+!/M/'*/L*+!$(!&+$+<$!$8'6!7!</**+&!
E'<0(/*L#E'2#0'/!&'96$'<F6@!!Y(;!>8/$!&(+6!'$!E+/2!>8+2!4(#0!&'/L+$'<!9$!8/6!/!iOj!&'96$'<F!
)(0!E'<0(/*L#E'2#0'/n!Have to give pt ACE inhibitor!LZ<!4(#!>/2$!$(!6$(9!90(=0+66'(2!()!
$8'6@!!N(>!>'**!'$!>(0Fn!%))+0+2$!/0$+0'(*+!'6!<(2$0(**+&!L4!Jl[HU!$8+!+))+0+2$!/0$+0'(*+!'6!
<(2$0(**+&!L4!%I!11!?>8'<8!<(26$0'<$6!'$B@!!Y(;!>8+2!4(#!='M+!/2!%.[!'28'L'$(0;!>8/$!8/99+26!
$(!%I!11!*+M+*n!1$!&+<0+/6+6@!!Y(;!LZ<!%I!11!&+<0+/6+&;!4(#!$/F+!())!$8+!M/6(<(26$0'<$'M+!
+*+E+2$!'$!8/6!(2!'$@!![M+2!$8(#=8!'$!>/6!84/*'2'c+&;!'$!>'**!(9+2!$8+2!*#E+2;!$/F'2=!90+66#0+!
189

())!$8+!=*(E+0#*#6;!/2&!&+<0+/6+!$8+!)'*$0/$'(2!0/$+@!!Y(;!$8+!<(26$/2$!9(#2&'2=!(2!$8+!
=*(E+0#*#6!'6!$/F+2!/>/4@!!"++&!$(!=+$!=*4<(64*/$+&!NL!?NL%,<B!#2&+0!aW;!L#$!$8+!%.[!
'28'L'$(0!</2$!&(!'$!/**;!6(!E#6$!8/M+!9+0)+<$!=*4<+E'<!<(2$0(*;!($8+0>'6+!>'**!=(!'2$(!<80(2'<!
0+2/*!&c@!!1)!$8+4!</2!&(!$8'6;!$8+!%.[!inhibitor will prevent the dz. The ACE inhibitor
also helps HTN@!!J'2F!6$#))!'6!$49+!1k!<(**/=+2!'2!$8+!E+6/2='#E@!!1$!L#'*&6!#9;!+c!$(!6++!
L'=!<'0<*+!?L'=!L/**6Z=(*)!L/**6Z.80'6$E/6!L/**6B!/F/!5'EE+*6$'+*dg'*6(2!2(&#*+6!7!$8'6!'6!
2(&#*/0!=*(E+0#*/0!6<*+0(6'6@!
!
F. Amyloid
X'F+!$(!&+9(6'$!'2!$8+!F'&2+46@!!1$6!/!69+<'/*!90($+'2@!!Stain with Congo red, and after
you polarize it, it has a (granny smith) apple green birefringence@!!X'=8$!=0++2!'6!
>8/$!$8+!/E4*('&!'6!6#99(6+&!$(!*((F!*'F+!>8+2!4(#!9(*/0'c+!'$!>'$8!/!.(2=(!R+&!6$/'2@!!
%E4*('&!/2&!&'/L+$'<!=*(E+0#*/0!6<*+0(6'6!/0+!2+980($'<!642&0(E+6@!!!
!
190

G. Summary nephrotic:
X'9('&!6<*+0(6'6!C!K..!2+980($'<!'2!F'&6!
T(</*!6+=E+2$/*!=*(E+0#*(6<*+0(6'6!C!1k_%Q6;!%1_6!
_'))#6+!K+EL0/2(#6!=*(E+0#*(2+980'$'6!C!K.!'2!/&#*$6!
I49+!1!/2&!11!K+EL0/2(90(*')+0/$'M+!=*(E+0#*(2+980'$'6!C!$49+!1!>'$8!8+9!.!0+*/$'(268'9;!
$49+!11!>'$8!/#$(%L!/=/'26$!.P!?*(>+6$!<(E9*+E+2$!*+M+*6!6++2B!
_'/L+$'<!2+980(9/$84!
%E4*('&!!
!
X. Combo of Nephritic and Nephrotic Syndrome
A. IgA Glomerulonephritis (burgers dz)
!
1=%!=*(E+0#*(2+980'$'6!'6!/!k%R1%"I!()!N+2(<8!Y<8(2*+'2!9#09#0/!LZ<!'$!'6!/2!'EE#2+!
<(E9*+:!&c;!/2$'!1=%!%L6!?6(!'6!N+2(<8!Y<8(2*+'2!7!9/*9/L*+!9#09#0/!'2!L#$$(<F6!()!*+=6;!
9(*4/0$80'$'6;!l1!L*++&;!8+E/$#0'/!?RS.!</6$6BB!
!
G2!'EE#2()*#(0+2<+;!+M+04$8'2=!68(>6!#9!'2!$8+!E+6/2='#E@!![:/E9*+-!!'2!kids;!90+6+2$6!
>'$8!+9'6(&+6!()!=0(66!8+E/$#0'/;!=(+6!/>/4;!<(E+6!L/<F!/!)+>!4+/06!*/$+0U!'2!adults;!
90+6+2$6!>'$8!+9'6(&'<!L(#$!()!E'<0(6<(9'<!8+E/$#0'/@!!Y(;!8/M+!/!*'*!8+E/$#0'/;!=(+6!/>/4;!
/2&!<(E+6!/=/'2@!X'*!90($+'2#0'/;!2(!NI"@!!g8+2!'$!6$/0$6!=+$$'2=!>(06+!?,V!4+/06!*/$+0B;!
$8/$Q6!>8+2!'$!>'**!L+!L/&!?6(!'$6!2($!LrB@!!It is the MC of all glomerulonephritis and is
type III HPY.
!
XI. BUN/Cr Prerenal Azotemia
!
./2!6+9/0/$+!90+0+2/*!/c($+E'/!M6@!0+2/*!)/'*#0+!
BUN!C!L*((&!#0+/!2'$0(=+2!/2&!Cr!C!+2&!90(&#<$!()!<0+/$'2+!E+$/L(*'6E@!!\0+/!</2!L+!
)'*$+0+&!/2&!0+/L6(0L+&!'2!$8+!90(:!$#L#*+!?6(!'$6!2($!/!9+0)+<$!<*+/0/2<+!6#L6$/2<+BU!.0!'6!
(2*4!)'*$+0+&!'2!$8+!F'&2+4!/2&!'6!0+/L6(0L+&!(0!6+<0+$+&@!!?*2#*'2!<*+/0/2<+!'6!L+$$+0B@!!If you
take the normal BUN level (10), and normal Cr level (1mg/dL), will have the
normal ratio of 10:1.!!!
!
g8+2!4(#!8/M+!prerenal azotemia;!$8+0+!'6!/2!'2<0+/6+!'2!S\"!?$8'6!'6!>8/$!/c($+E'/!
E+/26B@!!J0+!C!L+)(0+;!$8+0+)(0+!$8+0+!'6!6(E+$8'2=!>0(2=!]L+)(0+Q!$8+!F'&2+4!7!'2!($8+0!
>(0&6;!$8+0+!'6!2($8'2=!>0(2=!>'$8!$8+!F'&2+4;!L#$!$8+!.G!'6!&+<0+/6+&!?)0(E!/24!</#6+!d!'+!
.NT;!K1;!849(M(*+E'/;!</0&'(E4(9/$84;!+$<B@!!Anything that decreases CO will lead to
prerenal azotemia b/c the GFR will decrease.!!1)!4(#!8/M+!*+66!0+2/*!L*((&!)*(>;!4(#!
>'**!)'*$+0!*+66!/2&!$8+!lTR!>'**!&+<0+/6+@!!Y(;!>8+2!'$!&+<0+/6+6;!'$!='M+6!$8+!90(:!$#L#*+!
E(0+!$'E+!$(!0+/L6(0L!*'$$*+!L'$!E(0+!#0+/!$8/2!2(0E/*@!!Y(;!$8+0+!'6!'2<0+/6+!90(:!$#L#*+!
0+/L6(09$'(2!()!#0+/@!!g8/$!/L(#$!.0n!g+!F2(>!$8/$!'$!'6!2($!0+/L6(0L+&;!L#$!4(#!&(!8/M+!$(!
=+$!0'&!()!'$!$80(#=8!$8+!F'&2+46@!!Y(;!+M+2!$8(#=8!'$!'6!2($!0+/L6(0L+&;!$8+!lTR!'6!
&+<0+/6+&;!$8+0+!'6!/!L/<F!#9!()!.0!/2&!>'**!2($!L+!/L*+!$(!<*+/0!'$!/6!)/6$@!I8+0+)(0+;!$8+0+!
>'**!L+!/2!'2<0+/6+!'2!6+0#E!.0@!!I8+0+!'6!*'$$*+!E(0+!()!/2!'2<0+/6+!'6!#0+/!LZ<!'$!'6!L+'2=!
0+/L6(0L+&!$8/2!>'$8!.0@!!Y(;!$8+0+!'6!/!&'690(9(0$'(2/$+!'2<0+/6+!()!S\"Z.0@!!%**!4(#!8/M+!$(!
0+E+EL+0!'6!,e-,@!!Y(;!greater than a 15:1 BUN/Cr = prerenal azotemia.!!!
!
[:/E9*+-!$8+!9$!8/6!.NT;!S\"!'6!tV!/2&!.0!'6!H@!!Y(;!L($8!/0+!+*+M/$+&;!L#$!$8+!S\"Z.0!0/$'(!
'6!^V-,;!'2&'</$'2=!$8/$!'$!'6!90+0+2/*!/c($+E'/;!/2&!$8+!9$!&(+6!"GI!8/M+!%I"@!!!
191

!
X+$6!6/4!9$!$0#*4!8/6!renal failure 7!oliguria, renal tubular casts, acute renal failure@!
I8'6 will affect the BUN/Cr EQUALLY!LZ<!6(E+$8'2=!'6!>0(2=!>'$8!$8+!F'&2+4;!$8+0+)(0+!
$8+!6/E+!+))+<$!(2!$8+!S\"!'6!$8+!6/E+!(2!.0@!!T(0!L($8;!#0+/!8/6!$(!L+!)'*$+0+&!(#$!()!$8+!
F'&2+4!/2&!'$!8/6!)/'*+&!7!L($8!'2<0+/6+&!90(9(0$'(2/$+!$(!+/<8!($8+0!LZ<!L($8!8/M+!$8+!6/E+!
90(L*+E!/2&!F'&2+4!'6!6<0+>+&!#9U!</22($!=+$!0'&!()!#0+/;!</2Q$!=+$!0'&!()!<0+/$'2'2+;!6(!$8+4!
'2<0+/6+!'2!90(9(0$'(2!$(!+/<8!($8+0!LZ<!$8+!#0+/!'6!2($!L+'2=!0+/L6(0L+&!/24E(0+!LZ<!$8+!
F'&2+4!'6!'2!68(<F@![:/E9*+-!S\"!C!tV;!.0!C!t;!$8+0+)(0+!$8+!S\"Z.0!0/$'(!'6!,V-,;!/2&!9$!'6!
'2!0+2/*!)/'*#0+@!Y(;!+M+2!$8(#=8!$8+!,V-,!'6!E/'2$/'2+&;!6$'**!8/M+!0+2/*!)/'*#0+!LZ<!'$!8/6!
'2<0+/6+&!6(!E#<8@!!If the ratio is 15:1, it is prerenal azotemia; if it is increased and
still 10:1, its renal failure.!
!
XII. Acute Renal Failure
A. Acute Tubular Necrosis:
MCC = Ischemic Acute Tubular Necrosis!7!$8'6!'6!>8/$!4(#!>(004!/L(#$!$8+!E(6$!>8+2!
$8+!CO decreases, pt develops oliguria@!!g8+2!/!9$Q6!.G!&+<0+/6+6;!/2&!8/M+!90+0+2/*!
/c($+E'/;!4(#!8/M+!/!&+<0+/6+!'2!lTR;!>8'<8!'6!/2($8+0!</#6+!()!$8+!(*'=#0'/@!!Y(;!&+<0+/6+!
'2!.G!/2&!(*'=#0'/!'6!k[Rb!S%_;!/2&!6$/0$!$(!6++!S\"Z.0!=(!#9!7!2++&!$(!F2(>!')!'$6!90+0+2/*!
/c($+E'/;!(0!0+2/*!/c($+E'/!7!$(!&'6$'2=#'68;!=+$!/!S\"Z.0@!!1$!'$6!,e-,;!'$6!6$'**!90+0+2/*@!!S#$!
'$!</2!90(=0+66!$(!0+2/*!)/'*#0+!7!'6<8+E'<!/<#$+!$#L#*/0!2+<0(6'6@!!MCC ischemic acute
tubular necrosis = not treating prerenal azotemia.!So, ischemic ATN is the worst
the get and the BUN/Cr ratio will be normal, but increased in values (ie 80/8)!
!
Coagulation necrosis: Y*(#=86!());!L*(<F6!*#E+2!/2&!<(2$0'L#$+6!$(!(*'=#0'/;!/2&!6++!

</6$6!'2!$8+!#0'2+@!!I8+!</6$6!/0+!0+2/*!$#L#*+!</6$6@!!Y(;!combo of renal tubular casts,
oliguria, BUN/Cr of 10:1 = ATN@!!!
g84!&(+6!$8'6!8/M+!6#<8!/!L/&!90(=2(6'6n!g8+2!9$!8/6!'6<8+E'<!2+<0(6'6;!2($!(2*4!/0+!4(#!
F'**'2=!$8+!$#L#*/0!<+**6;!L#$!$8+!SK!/*6(!=+$6!&/E/=+&;!6(!$8+!6$0#<$#0/*!'2$+=0'$4!()!$8+!
$#L#*+!'6!L+'2=!$/F+2!/>/4;!>8'<8!'6!2($!=((&@!!g8+2!4(#!8/M+!*'M+0!&/E/=+;!/2&!&/E/=+!
*'M+0!<+**6;!/2&!$8+!<+**6!0+=+2+0/$+;!$8+!<+**6!/0+!2($!0+=+2+0/$'2=!6'2#6('&6!/2&!$0'/&6;!L#$!
(2*4!$8+E6+*M+6@!1)!$8+!SK!'62Q$!$8+0+;!/2&!$8+!9/$'+2$!8/6!0+<(M+0+&!)0(E!%I"!(0!'6!'2!$8+!
90(<+66!()!&('2=!$8/$;!</2!4(#!0+=+2+0/$+!/!$#L#*/0!<+**!>'$8(#$!/!SKn!"(@!!Y(;!$8+!E(0+!
2+<0(6'6;!$8+!E(0+!SK!/0+!&+6$0(4+&;!$8+!>(06+!$8+!90(=2(6'6!LZ<!</22($!0+=+2+0/$+!/2&!
</22($!=+$!L/<F!2(0E/*!)#2<$'(2@!!I8'6!'6!>84!'$!'6!6#<8!/!L/&!&c@!!There are 2 parts of
the nephron that are most susceptible to ischemia what are they? Straight
portion of the prox tubule and thick ascending limb of the medullary segment
(where the Na/K/2 Cl co-transport pump is). I8+6+!$>(!9/0$6!#2&+0=(!<(/=#*/$'(2!
2+<0(6'6!/2&!6*(#=8'2=!())@!!Y(;!>'**!6++!$8+6+!)/**!())!'2!$8+!90(:'E/*!$#L#*+!/2&!/*6(!'2!$8+!
$8'<F!/6<+2&'2=!*'EL!()!$8+!E+&#**/04!6+=E+2$@!!!
!
B. Nephrotoxic ATN:
l+2$/E4<'2;!%lQ6@!!1)!$8+4!/0+!2+980($(:'<;!>8/$!'6!$8+!)'06$!$8'2=!$8+4!>'**!)'*$+0+&!)0(E!$8+!
=*(E+0#*#6n!J0(:'E/*!$#L#*+@!!Y(;!nephrotoxic tubular necrosis related to drugs
involves the proximal tubule@!!%2&;!$8+!SK!0+E/'26!'2$/<$U!$8+0+)(0+!$8+!90(=2(6'6!()!
2+980($(:'<'$4!'6!>/4!L+$$+0!)(0!H!0+/6(26-!(2*4!/))+<$'2=!$8+!90(:'E/*!$#L#*+6!/2&!2($!
/))+<$'2=!$8+!SK@!!I8+!MCC nephrotoxicity = AGs (2nd MCC = intravenous
192

pyelograms)@!!g8/$!'6!lTR!'2!tV!4Z(n!1$!'6!&+<0+/6+&!7!$8+!.0!'6!^!E*6ZE'2U!>8'<8!'6!
2(0E/*!'2!(*&+0!9+(9*+@!!.0!<*+/0/2<+!&+<0+/6+6!/*(2=!>'$8!lTR!/6!$8+4!=+$!(*&+0U!6(;!')!4(#!
/0+!='M'2=!/!&0#=!>'$8(#$!2+980($(:'<'$4!$8+!6/E+!&(6+!/6!/!4(#2=!9+06(2;!4(#!>'**!L+!F'**'2=!
$8+!(*&+0!9+06(2@!!I8'6!'6!(LM'(#6*4!(<<#00'2=!LZ<!%lQ6!/0+!$8+!K..!%I"!/2&!&(<$(06!/0+!2($!
&+<0+/6'2=!$8+!&(6+!()!$8+!&0#=!$(!&+<0+/6+!2+980($(:'<'$4@!
!
XIV. Tubular and Interstitial Disorders of the Kidney
A. Acute Pyelonephritis:
N(>!&(!4(#!6+9/0/$+!'$!)0(E!/!*(>+0!\I1n!k+04!+/6'*4@!!J4+*(2+980'$'6!'6!6++2!E(0+!'2!
>(E+2!LZ<!()!$8+'0!68(0$!#0+$80/@!!Acute pyelonephritis is a systemic infection and is
an infection of the kidney proper. N(>!&(+6!'$!=+$!'2$(!$8+!F'&2+4n!%$!$8+!#0+$(M+6'<#*/0!
3#2<;!$8+!E#6<*+!6D#++c+6!6(!$8+0+!'6!2(!0+)*#:!()!#0'2+!)0(E!$8+!L*/&&+0!'2$(!$8+!#0+$+0@!
I8'6!'6!$0#+!'2!2(0E/*!9+(9*+@!!N(>+M+0;!2($!/**!9+(9*+!8/M+!/!2(0E/*!M+6'<(#0+$+0/*!3#2<$'(2@!!
Y(;!>8/$!8/99+26!'2!/!9$!>'$8!/!L*/&&+0!'2)+<$'(2!/2&!$8+!3#2<$'(2!'6!'2<(E9+$+2$;!'$!*+/&6!$(!
vesicouretal reflux;!/2&!$8+!'2)+<$+&!#0'2+!0+)*#:+6!#9!'2$(!#0+$+06;!/2&!*+/&6!$(!/6<+2&'2=!
'2)+<$'(2!$8/$!=(+6!/**!$8+!>/4!#9!$(!$8+!F'&2+46@!!Y(;!$8+4!>'**!/6F!4(#;!what is the mech
of ALL UTIs? (urethritis, cystitis, pelvitis, or pyelonephritis) due to ascending
infection from the beginning of the urethra.!![M+04!>(E/2!?8/6!2($8'2=!$(!&(!>'$8!
<*+/2*'2+66B!8/6!$8+!6/E+![!<(*'!6+0($49+!'2!8+0!6$((*!/$!$8+!'2$0(#$#6!()!$8+!#0+$80/!/2&!8+0!
M/='2/@!!Y(;!>'$8!$0/#E/!(0!<+0$/'2!6+0($49+6!()![!<(*';!'$!</2!/6<+2&!#9!$8+!#0+$80/!'2$(!$8+!
L*/&&+0@!1)!$8+!9$!8/6!/2!'2<(E9+$+2$!#0+$(M+6'<#*/0!3#2<;!#9!$8+!#0+$+06!'2$(!$8+!F'&2+46@!!
Y(;!/**!\I1Q6!/0+!/6<+2&'2=!)0(E!$8+!L+='22'2=!()!$8+!#0+$80/!(2!#9@!
!
g'$8!acute cholecystitis, have painful urination (dysuria), increased frequency,
suprapubic pain, NO fever, no flank pain, NO WBC casts (with neutrophils in
them) why? B/c the WBC casts develop in the renal tubules; they do not
develop in the ureter or the bladder; they develop in the kidney in the tubule.!!!
So, fever, flank pain, and WBC casts = ACUTE PYELONEPHRITIS. Y(;!'$6!/2!
ascending infection due to incompetent vesicouretal junc@!!I8'6!#6#/**4!68(>6!#9!'2!
2+>L(02!='0*6!?/2&!>'**!L+!/!90(L!)(0!0+6$!()!*'M+6B@!!!
!
[:/E9*+-!F'&2+4!>'$8!>8'$+!69($6!C!/L6<+66+6!6++2!'2!94+*(2+980'$'6@!!1)!4(#!8/M+!<(26$/2$!
/<#$+!/$$/<F6!()!94+*(2+980'$'6;!</2!L+<(E+!<80(2'<@!!I8+0+)(0+!8/M+!'2<0+/6+&!0'6F!()!NI"!
/2&!0+2/*!)/'*#0+@!!!
B. Chronic Pyelonephritis
!
[:/E9*+-!6</00+&!F'&2+4!?(2!<(0$+:B;!L*#2$'2=!()!$8+!</*4<+6!?(<<#06!#2&+0!$8+!6</0B;!6++2!
(2!'2$0/M+2(#6!94+*(=0/E6!7!&:n!.NRG"1.!94+*(2+980'$'6@!Y(;!blunting of the calyces =
CHRONIC pyelonephritis.
!
C. Acute Drug-induced interstitial nephritis
!
./2!drugs!90(&#<+!/!2+980'$'6!'2M(*M'2=!$8+!'2$+06$'$'#E!/2&!$#L#*+6n!b+6!7!</2!L+!/<#$+!
/2&!<80(2'<!/2&!+c!$(!&'/=2(6+@!!g84n!SZ<!>'**!8/M+ )+M+0;!/2&!&+M+*(9!/!0/68@!!Fever +
Rash!?(LM'(#6*4!&#+!$(!&0#=;!LZ<!6$/0$+&!/)$+0!$/F'2=!$8+!&0#=B;!oliguria;!eosinophiliuria!
?eosinophils in the urine pathognomonicB@!!I8'6!'6!</**+&!acute drug induced
interstitial nephritis@!!I8'6!'6!E(0+!/2&!E(0+!<(EE(2;!/2&!'6!/!M+04!<(EE(2!</#6+!()!
193

<80(2'<!0+2/*!)/'*#0+@!!Y(;!9#$!9$!(2!&0#=;!=+$!)+M+0;!0/68;!(*'=#0'/!C!&'6</0&Z6$(9!&0#=!?2+M+0!
='M+!/=/'2B!7!$8'6!'6!/!<(EL(!()!$49+!1!/2&!1k!NJb@!
!
Analgesic nephropathy!
[:/E9*+-!&'6<(*(0/$'(2!'2!0+2/*!E+&#**/;!9/*+!'2)/0<$;!0+2/*!9/9'**/!6*(#=8+&!())!7!0'2=+&!
6'=2+&U!/2&!(2!94+*(=0/E6!$8+0+!>'**!L+!2($8'2=!$8+0+!3#6$!/2!+E9$4!69/<+@!!_:n!Analgesic
nephropathy@!I8'6!from combo of acetaminophen and aspirin over a long period of
time.!!Acetaminophen!'6!90(&#<'2=!)0++!0/&'</*6@!!SZ<!()!$8+!9((0!<'0<#*/$'(2!'2!$8+!
E+&#**/;!$8+0+!'6!)0++!0/&'</*!&/E/=+!(2!$8+!$#L#*/0!<+**6!()!$8+!E+&#**/@!!Aspirin!>'**!L*(<F!
Jl[H!?/!M/6(&'*/$(0B;!$8+0+)(0+!/2='($+26'2!11!?/!M/6(<(26$0'<$(0B!'6!'2!<8/0=+!()!$8+!0+2/*!
L*((&!)*(>@!!k/6(<(26$0'<$(0!()!$8+!+))+0+2$!/0$+0'(*+@!!I8+!9+0'$#L#*/0!</9'**/0'+6!/0'6+!)0(E!
$8+!+))+0+2$!/0$+0'(*+@!!Y(;!>'$8!M/6(<(26$0'<$'(2!()!$8+!+))+0+2$!/0$+0'(*+;!9$!'6!/))+<$'2=!
9+0'$#L#*/0!</9'**/0'+6!=('2=!/0(#2&!<(**+<$'2=!$#L#*+6!/2&!0+2/*!E+&#**/@!!Y(;!'6!$8/$!
90(&#<'2=!'6<8+E'/n!b+6@!!Y(;!9$!has free radical damage and ischemia leading to
analgesic nephropathy@!!I8'6!'6!>84!$8+!0+2/*!9/9'**/!2+<0(6+6;!6*(#=86!());!/2&!*+/&6!$(!
renal!papillary!necrosis@!!Y(;!aspirin and acetaminophen toxicity. Diabetic
nephropathy (b/c causes ischemia), acute pyelonephritis (b/c abscess
formation), SCDz and trait, can all lead to analgesic nephropathy.
!
194

XV. Chronic renal Failure
Definition: Pt has BUN/Cr ratio 10:1 for more than 3 months@!!1)!L($8!F'&2+46!)/'*+&-!>'**!
2($!L+!/L*+!$(!+:<0+$+!$8+!$8'2=6!>+!2(0E/**4!=+$!0'&!()!?6(!$8(6+!things will build up 7!'+!
6/*$BU![JG!90(&#<$'(2!>'**!&+<0+/6+;!*+/&'2=!$(!normocytic anemia with a corrected
reticulocyte ct of less than 2%@!!g'**!2($!L+!/L*+!$(!=+$!0'&!()!(0=/2'<!/<'&6;!*+/&'2=!$(!
metabolic acidosis;!'2<0+/6+&!/2'(2!=/9@!!g'$8!E+$/L(*'<!/<'&(6'6;!L(2+6!$04!$(!L#))+0!/**!$8+!
/<'&@!!SZ<!$8+!L(2+6!/0+!L#))+0'2=!$8+!+:$0/!N!'(2;!L(2+!&c!</2!&+M+*(9;!*+/&'2=!$(!
osteoporosis@!!I8+!90(:!$#L#*+6!/0+!E+66+&!#9!'2!$8+!0+2/*!$#L#*+6;!/2&!,d/*98/!84&0(:4*/6+!
>'**!&+<0+/6+!?$8'6!0+69(26'L*+!'6!84&0(:4*/$'2=!k'$!_BU!6(;!>'$8!0+2/*!)/'*#0+!>'**!/*6(!8/M+!
hypovitaminosis D!?M'$!_!&+)B@!!I8'6!E+/26!$8/$!$8+0+!>'**!L+!hypocalcemia!/2&!
hypophosphatemia;!*+/&'2=!$(!osteomalacia@!!Y(;!$8+0+!/0+!$>(!L(2+!&cQ6!7!(6$+(9(0(6'6!
?LZ<!L#))+0'2=!/2&!>+/0'2=!/>/4!L(2+!E/$0':B!/2&!(6$+(E/*/<'/U!/*6(;!JIN!'6!0+/<$'2=!$(!<80(2'<!
849(</*<+E'/!/2&!*+/&6!$(!secondary hyperparathyroidism!?/*6(!/))+<$6!$8+!L(2+B@!!I8+!
L#2Z.0!0/$'(!'6!tVZt@!Y(;!')!4(#!F2(>!2(0E/*!0+2/*!)#2<!4(#!F2(>!>8/$!8/99+26@!
!
XVI. Other Problems related to kidneys:
!
[:/E9*+-!9$!8/6!+66+2$'/*!NI"!(M+0!,V!406;!/2&!9$!'6!2($!<(E9*'/2$!>'$8!E+&'</$'(2!7!F'&2+4!
>'$8!<(LL*+6$(2+!/99+/0/2<+!C!nephrosclerosis@!!\2&+0*4'2=!&c!</#6'2=!'$-!84/*'2+!
/0$+0'(*(6<*+0(6'6!LZ<!$8+0+!'6!&+<0+/6+&!L*((&!)*(>;!$#L#*/0!/$0(984;!=*(E+0#*'!/0+!)'L0(6'2=!());!
0+2/*!)#2<$'(2!'6!=('2=!&(>2;!/2&!*+/&6!$(!0+2/*!)/'*#0+@!!!
!
[:/E9*+-!*+$6!6/4!$8+!9$!>/F+6!#9!>'$8!/!L'=!8+/&/<8+!/2&!L*#004!M'6'(2@!J$!'6!=+$$'2=!&'cc4;!
=(+6!$(!&0;!/2&!90+66#0+!'6!H^VZ,^V;!'2!$8+!0+$'2/;!&#&+!8/6!9/9'**(+&+E/!>'$8!)*/E+!
8+E(008/=+6!/2&!8/0&!/2&!6()$!+:#&/$+6;!=0/&+!^!849+0$+26'M+!0+$'2(9/$84;!S\"Z.0!/0+!tVZt!7!
dx? Malignant HTN!?/F/!)*+/!L'$$+2!F'&2+4!7!9+$+<8'/!M'6'L*+!(2!6#0)/<+!()!F'&2+4!7!6++!M+66+*!
<8/2=+6!'+!849+09*/6$'<!/0$+0'(*(6<*+0(6'6;!/2&!$8+!SkQ6!/0+!0#9$#0'2=;!*+/&'2=!$(!9+$+<8'/*!*+6'(26!
(2!$8+!<(0$+:!7!</**+&!)*+/!L'$$+2!F'&2+4B@!!I8'6!'6!/**!4(#!8/M+!$(!F2(>@!!I8+4!</2!/*6(!/6F!Rx:
IV nitroprusside to get the BP down@!!Y(;!$8+4!8/M+!."Y!+&+E/!>'$8!9/9'**(+&+E/;!/2&!')!
$8+!SJ!'62Q$!*(>+0+&;!$8+4!/0+!=(22/!&'+@!!
!
[:/E9*+-!F'&2+4!>'$8!/L2(0E/*!/0+/6!$8/$!/0+!9/*+!/2&!&+90+66+&!7!6(;!')!4(#!$/F+!/!6+<$'(2!
$80(#=8!(2+!()!$8+6+;!/2&!4(#!6++!/2!'00+=#*/0!'00+=#*/0!9#*6+;!>'**!6++!9/*+!'2)/0<$'(2!>'$8!
<(/=#*/$'(2!2+<0(6'6!LZ<!>8/$!4(#!/0+!*((F'2=!/$!/0+!infarcts@!!100+=#*/0!'00+=#*/0!9#*6+!'6!)0(E!
/$0'/*!)'L;!/2&!/$0'/*!)'L!'6!E(6$!&/2=+0(#6!)(0!embolization@!!Y(;!$8+6+!'2)/0<$6!/0+!)0(E!
multiple emboli;!*+/&'2=!$(!E#*$'9*+ 9/*+!'2)/0<$6!()!$8+!F'&2+4@!!I8'6!'6!"GI!94+*(2+980'$'6!LZ<!
8/6!E'<0(/L<+66+6!
!
[:/E9*+-!/$0(984!&#+!$(!&'*/$/$'(2!()!$8+!0+2/*!9+*M'6;!*+/&'2=!$(!hydronephrosis@!
Y(;!')!4(#!8/M+!84&0(2+980(6'6!/2&!'2<0+/6+&!90+66#0+!90+66'2=!(2!$8+!<(0$+:!/2&!E+&#**/;!
>8/$!8/99+26!$(!$8/$n!Get ischemia and atrophy which is called compression atrophy.!!!
I8'6!'6!M+04!6'E'*/0!$(!<46$'<!)'L0(6'6!&#<$6!)'**+&!>'$8!E#<(#6!7!$8+!90+66#0+!'6!'E9/<$+&!L/<F!$(!
$8+!=*/2&6;!/2&!$8+4!#2&+0=(!<(E90+66'(2!/$0(984@!!.(0$+:!/2&!E+&#**/!/0+!M+04!$8'2;!/*(2=!
>'$8!M+04!&'*/$+&!0+2/*!9+*M'<+6@!!MCC = stone!
!
[:/E9*+-!staghorn calculus urine pH is alkaline and smells like ammonia; therefore,
there must be a urease producer, and this is Proteus. B/c it is a urease producer,
$8+4!L0+/F!#0+/!&(>2!$(!/EE(2'/;!/2&!=+$!/2!/*F/*'2+!9N@!!I8'6!'6!>84!/!staghorn calculus is
195
Mg ammonium phosphate;!/2&!(2*4!&+M+*(96!'2!'2)+<$'(26!'2!9$6!$8/$!8/M+!#0+/6+!90(&#<+06@!!
[!<(*'!/0+!2($!#0+/6+!90(&#<+0!/2&!90($+#6!69+<'+6!/0+!/2&!$8+4!90+&'69(6+!$(!$8+6+!6$(2+6@!!_(!
2($!9/66!$8+6+!6$(2+6!?$((!L'=B;!$8+0+)(0+!2++&!$(!+:$0/<$!$8+6+!?6#0=+04B@!!Y(;!urease
producer, alkaline pH, ammonia smell to the urine.
XVII. Tumors of the kidney

!
1)!4(#!6++!/!E/66!'2!/!F'&2+4;!/2&!'$6!/2!/&#*$;!'$!'6!/!renal!adenocarcinoma@!1)!'$Q6!/!F'&;!'$Q6!
/!g'*EQ6!$#E(0@!!Y(;!')!4(#!6++!/!E/66!'2!$8+!F'&2+4;!'$6!90(L!2($!E+$6!?LZ<!2($!E/24!$8'2=6!=(!
$8+0+B;!'$6!2($!Lr;!9'<F!</2<+0@!!!!!!!
!
So, adult = renal adenocarcinoma, kid = Wilms tumor; they derived from the
proximal tubule and the MCC = smoking; they make lot of ectopic hormones: EPO,
parathyroid hormone (leads to hypercalcemia), invade the renal vein.
Cells are clear, full of glycogen.
!
[:/E9*+-!)*/2F!E/66!'2!<8'*&;!NI"!C!g'*E6!$#E(0U!NI"!(<<#06!LZ<!'$Q6!E/F'2=!0+2'2U!#6#/**4!
#2'*/$+0/*@!N'6$(*(=4-!</2<+0!>8+0+!9$!'6!&#9*'</$'2=!+EL04(=+2+6'6!()!/!F'&2+4!7!+M+04$8'2=!'6!
90'E'$'M+@!!./2!6++!08/L&(E4L*/6$6U!*'F+6!$(!E+$6!$(!*#2=!
1)!AD, from csome 11, and have 2 classic findings: aniridia (absent iris), and
hemihypertrophy of an extremity (one extremity is bigger than another) this is a
sign that the wilms tumor has a genetic basis.
J/9'**/04!*+6'(2!'2!$8+!L*/&&+0!C!$0/26'$'(2/*!<+**!</0<'2(E/!?I..B!
g8/$!'6!$8+!K..!$0/26'$'(2/*!<+**!</0<'2(E/!()!$8+!L*/&&+0n!YE(F'2=!
_4+!#6+!$(!*((Fn!%2'*'2+!&4+U!>8/$!'6!<8+E($8+0/94!/=+2$!#6+&!$(!R:!g+=+2+0Q6n!
.4<*(98(698/E'&+@!!g8/$!/0+!$8+!<(E9*'</$'(26!()!.4<*(98(698/E'&+n!N+E(008/='<!<46$'$'6!/2&!
$0/26'$'(2/*!<+**!</0<'2(E/@!
N(>!&(!4(#!90+M+2$!$8'6n!K+62/@!
XVIII. Urinary Tract Infection!!!
!
K.!#0'2+!/L2(0E/*'$4!6++2!'2!$8+!*/L!!
!
[:/E9*+-!/00(>!9('2$'2=!$(!2+#$0(98'*6!'2!#0'2+U!RS.Q6!'2!'$;!$((;!L/<$+0'/!7![!<(*'!?9*/4!(&&6B@!!
Y(;!see neutrophils, RBCs and bacteria. The dipstick will pick up all three of these
things.
+ dipstick for blood due to RBCs@!!N+E/$#0'/!'6!M+04!)0+D#+2$!/2&!6(E+$'E+6!/!*($!()!
L*((&!<(E+6!(#$!?hemorrhagic!cystitisB!/2&!E(6$!()!$8+!$'E+!'$6!E coli;!L#$!6(E+$'E+6!'$!</2!
L+!)0(E!/&+2(M'0#6@!!!
!
%*6(;!$8+!dipstick has leukocyte esterase!/2&!'$Q6!E+/6#0'2=!$8+!+2c4E+!'2!$8+!*+#F(<4$+@!!!
196

!
K(6$!#0'2/04!9/$8(=+26!/0+!2'$0/$+!0+&#<+06;!E+/2'2=!$8/$!$8+4!<(2M+0$!2'$0/$+!$(!2'$0'$+@!!G2!/!
dipstick, they have a section for nitrites@!!SZ<![!<(*'!'6!/!2'$0/$+!0+&#<+0;!$8+0+!68(#*&!L+!
2'$0'$+6!'2!$8+!#0'2+;!>8'<8!/0+!&'96$'<F!iOj!)(0!$8/$@!!
!
Y(;!4(#!8/M+!/!9$;!>(E/2!(0!E/2;!>8(!8/6!&46#0'/;!'2<0+/6+&!)0+D#+2<4;!6#90/9#L'<!9/'2!/2&!
8/M+!/!#0'2+!6+&'E+2$!()!2+#$0(98'*6;!RS.Q6;!L/<$+0'/!(0!&'96$'<F!)'2&'2=6!()!8+E/$#0'/;!*+#F(<4$+!
+6$+0/6+!9(6;!2'$0/$+!iOj = UTI!
!
Is it lower or upper? If the pt has fever, flank pain, WBC casts its upper, if none of
these things are present, its lower.
!
[:/E9*+: 9$!>'$8!&46#0'/;!'2<0+/6+&!)0+D#+2<4;!2+#$0(98'*6!'2!$8+!#0'2+;!)+>!RS.Q6;!2(!L/<$+0'/;!
iOj!*+#F(<4$+!+6$+0/6+;!#0'2+!<#*$#0+!'6!2+=;!/2&!6+:#/**4!/<$'M+!9+06(2;!&:n Chlamydia
normal urine cultures do not pick up Chlamydia trachomatis. It is the MC STD.!!12!
E+2;!</**+&!2(269+<')'<!#0+$80'$'6;!'2!>(E/2!'$6!</**+&!/<#$+!#0+$80/*!642&0(E+@!!g+!/*6(!#6+!$8+!
$+0E!</**+&!6$+0'*+!94#0'/@!!g+!&(2Q$!8/M+!L/<$+0'/!90+6+2$;!L#$!&(!8/M+!2+#$0(98'*!90+6+2$@!!G2!
0(#$'2+!6$((*!<#*$#0+;!'$6!2+=@!!Y(;!one cause of sterile pyuria is Chlamydia infection and
the other one is TB.!
!
MC organ that military TB goes to = kidney, therefore will have TB in the urine, and
it will be sterile b/c urine cultures do not pick up. So, remember Chlamydia and TB
as causes of sterile pyuria.
Day 4 Last part
%#&'(!)'*+!st!R+2/*!H!
Penis
!
[EL04(-!>8/$!'6!$8+!+EL04(*(=4!()!hypospadiasn!G9+2'2=!(2!$8+!#2&+06#0)/<+!?4(#!9++!/2&!'$!
=(+6!(2!4(#0!68(+6B!7!)/'*#0+!()!<*(6#0+!()!#0+$80/*!)(*&!
Epispadiasn!G9+2'2=!(2!#99+0!6#0)/<+!?9++!/2&!=(+6!'2!)/<+BU!&+)+<$!'2!=+2'$/*!$#L+0<*+!
!
Peyronies dz: *'F+!_#9#4$0+2Q6!<(2$0/<$#0+!
Priapism!7!9+0E/2+2$!+0+<$'(2;!6++2!<(EE(2*4!'2!Y._c!L<!()!$8+!RS.Q6!/2&!6'<F*+!<+**6!$0/99+&!'2!
$8+!M/6<#*/0!<8/22+*6@!!!
!
MC cancer of the penis!C!squamous!L<!*/<F!()!<'0<#E<'6'(2@!!1$!'6!E(0+!<(EE(2*4!6++2!'2!/2!
#2<'0<#E6<0'L+&!9$!7!$8+4!#6#/**4!&(!2($!<*+/2!?9((0!84='+2+B!90+&'69(6+6!7!$8+!smegma is
carcinogenic.
!
Testicle
!
.049$(0<8'&!$+6$'6!7!$+6$'<*+!&(+62Q$!>/2$!$(!<(E+!&(>2@!I8+0+!/0+!$>(!98/6+6!'2!$8+!&+<+2$!()!/!
$+6$'<*+-!$0/26/L&(E'2/*!E'=0/$'(2!&(>2!$(!'2=#'2/*!</2/*@!!K1T!'6!0+69(26'L*+!)(0!$8'6@!!I8+!6+<(2&!
9/0$!()!$8+!$0'9!'6!/2&0(=+2!&+9+2&+2$@!!I8'6!'2<*#&+6!$+6$(6$+0(2+!/2&!&'84&0($+6$(6$+0(2+@!!Y(;!$8+!
)'06$!98/6+!'6!)0(E!K1T!/2&!$8+!6+<(2&!98/6+!'6!/2&0(=+2!&+9+2&+2$@!!"++&!$+6$'<*+!&(>2!L4!$>(!
4+/06!()!/=+!L<!')!2($;!8/6!/!0'6F!()!6+E'2(E/6@!!Y$'**!/$!0'6F!')!4(#!=+$!'$!&(>2@!!X+$6!6/4!4(#!>+2$!
'2;!/2&!'$!*((F!/$0(98'<!/2&!($8+0!$+6$'<*+!*((F6!2(0E/*;!8/M+!$(!$/F+!2(0E/*!(2+!(#$;!$((!L<!'$!'6!/*6(!
/$!0'6F@!!Y(;!E#6$!8/M+!$+6$+6!+:/E'2+6!$(!E/F+!6#0+!4(#!&(2Q$!8/M+!/!6+E'2(E/@!!!
197

!
Analogy-!'2!$#02+06;!$8+4!/0+!'2)+0$'*+!/2&!8/M+!E+2(9/#6+!L+)(0+!E+2/0<8+;!L<!L4!$>(!4+/06!()!
/=+6;!$8+4!8/M+!2(!)(**'<*+6!'2!$8+'0!(M/0'+6;!/2&!$8'6!'6!</**+&!/!6$0+/F!=(2/&@!I8'6!'6!/2!(M/04!
>'$8(#$!/24!)(**'<*+6@!!I8'6!'6!/2/*/=(#6!$(!<049$(0<8'&!$+6$+6-!3#6$!*'F+!$8+!<049$(0<8'&!$+6$+6!
90+&'69(6+6!$(!6+E'2(E/6!?>8'<8!'6!/!=+0E!<+**!$#E(0B;!6(!&(+6!$8+!6$0+/F!=(2/&!90+&'69(6+!$(!/!
=+0E!<+**!$#E(0!7!8(>+M+0;!&(!2($!</**!$8+E!6+E'2(E/6!'2!>(E+2;!L#$!dysgerminomas@!!Y(;!'2!
9$6!&:Q&!>'$8!I#02+0Q6!642&0(E+;!$8+4!6#0='</**4!0+E(M+!L($8!(M/0'+6!L<!()!$8+!=0+/$!0'6F@!!I8+4!
&(2Q$!F++9!$8+E!'2!$8+0+!L<!*+/&!$(!</2<+0@!
!
Orchitis!7!E#E96!
!
Epididymitis!7!*+66!$8/2!Pe!C!"!=(2(008+/Z<8*/E4&'/;!=0+/$+0!$8/2!Pe!C!96+#&(E(2/6!
!
Varicocele!7!(2!*+)$!6'&+!L<!69+0E/$'<!M+'2!<(22+<$+&!$(!*+)$!0+2/*!M+'2;!>8+0/6!$8+!69+0E/$'<!M+'2!
(2!$8+!0'=8$!'6!<(22+<$+&!$(!$8+!1k.U!L<!()!$8'6;!$8+!90+66#0+6!'2<0+/6+;!/2&!/!M/0'<(<+*+!(2!$8+!*+)$;!
*+/&6!$(!'2<0+/6+&!8+/$!/2&!'6!(2+!()!$8+!E(6$!<(EE(2!</#6+6!()!'2)+0$'*'$4!7!'+!>8/$!>(#*&!8/99+2!
')!4(#!L*(<F+&!$8+!*+)$!0+2/*!M+'2n!g(#*&!&+M+*(9!/!M/0'<(<+*+@!!Y(;!')!4(#!L*(<F!$8+!*+)$!0+2/*!M+'2;!
4(#!>'**!'2<0+/6+!$8+!90+66#0+!'2!$8+!69+0E/$'<!M+'2!/2&!>'**!*+/&!$(!/!M/0'<(<+*+@!!!
!
Torsion!7!69+0E/$'<!<(0&!$>'6$'2=U!>8+2!$8+0+!'6!/!$(06'(2!()!$8+!69+0E/$'<!<(0&;!'$!68(0$+26!'$@!!
I8'6!E+/26!$8/$!$8+!$+6$'<*+!>'**!=(!#9!'2$(!$8+!'2=#'2/*!</2/*@!I8'6!'6!9/'2)#*@!!b(#!>'**!*(6+!4(#0!
<0+E/6$+0'<!0+)*+:!?'2!2(0E/*!E/*+;!')!4(#!6</$<8!$8+!6<0($#E;!'$!>'**!<(2$0/<$;!>8'<8!'6!*(6$!'2!$(06'(2!
()!$8+!$+6$'<*+B@!
!
Hydrocele!7!9+06'6$+2<+!!()!$#2'</!M/='2/*'6U!>8+2!4(#!8/M+!!L'=!6<0($#E;!4(#!&(2Q$!F2(>!>8+$8+0!
'$6!L'=!L<!$8+0+!'6!)*#'&!'2!'$;!(0!'$6!L'=!L<!$8+0+!'6!/!$+6$'<*+!'2!'$@!Y(;!>8/$!&(!4(#!&(n!I0/26'**#E'2/$+@!!
1)!'$!$0/26'**#E'2/$+6;!'$!'6!84&0(<+*+@!!1)!'$!&(+62Q$!'$6!</2<+0@!!&Z&!)(0!9/'2*+66!+2*/0=+E+2$!()!$+6$'<*+!
-!</2<+0;!</2<+0;!</2<+0mm!?>84!$8+4!&(2Q$!+M+2!&(!L:;!3#6$!0+E(M+B!
!
Seminoma!7!K.!?L+6$!90(=2(6'6BU!8#=+!<+**6!>'$8!*4E98(<4<$'<!'2)'*$0/$+@!!I8+4!/0+!$8+!
<(#2$+09/0$!()!/!>(E/2Q6!&46=+0E'2(E/@!!I8+6+!>'**!E+*$!>'$8!0/&'/$'(2;!have little beta hcGU!
E+$!$(!9/0/(0$'<!*4E98!2(&+6!7!>84n!S<!$8+4!</E+!)0(E!$8+!/L&(E+2;!/2&!$8/$Q6!>8+0+!$8+4!>'**!
=(@!!!
!
MC testicular tumor in child? Yolk sac tumorU!$#E(0!E/0F+0n!%*98/!)+$(!90($+'2!
!
What is worst testicular cancer? choriocarcinoma !2($!$8+!6/E+!90(=2(6'6!()!/!=+6$/$'(2/**4!
&+0'M+&!<8(0'(</0<'2E/!'2!/!>(E/2!7!4(#Q0+!&+/&!
[:/E9*+--!He!4(!E/*+!>'$8!#2'*/$+0/*!=42+<(E/6$'/!/2&!&4692+/@!!.8+6$!:0/4!0+M+/*6!E#*$'9*+!
2(&#*/0!E/66+6!'2!$8+!*#2=@!Y(;!=42+<(E/6$'/!/2&!E+$6!&c;!d!>8/$!'6!$8+!90'E/04!</2<+0n!$+6$'<*+!7!
<8(0'(</0<'2(E/@!Y(#0<+!()!=42+<(E/6$'/-!BHCG is like LH, and therefore it stimulates
progesterone in the male, which increases duct growth and breast tissue and leads to
gynecomastia
[:/E9*+--!6/E+!6<+2/0'(;!L#$!(*&+0!E/2!7!>'**!*+/&!$(!E/*'=2/2$!*4E98(E/!
Y(;!(*&+0!9$6!=+$!E/*'=2/2$!*4E98(E/!?2($!/6!90'E/04!&c;!L#$!)0(E!E+$6BU!$8+!$+6$+6!E+$6!/!*($!;!
+69!'2!*+#F+E'/!/2&!*4E98(E/6!
!
Summary:
198

g(06$!C!<8(0'(</<'2(E/!
K.!C!Y+E'2(E/!
K.!'2!F'&6!C!4(*F!6/<!$#E(0!
K.!'2!(*&!C!E+$6!E/*'=2/2$!*4E98(E/!
!
Prostate
!
N49+09*/6'/!(<<#06!'2!$8+!9+0'#0+$80/*!9(0$'(2!()!$8+!90(6$/$+!=*/2&@!!I8'6!'6!>84!4(#!=+$!&0'LL*'2=!
/2&!#0'2/04!0+$+2$'(2!/6!$8+!E(6$!<(EE(2!64E9$(E@!!J0(6$/$+!</2<+0!'6!'2!$8+!9+0'98+04!()!$8+!
90(6$/$+!=*/2&!>'$8'2!$8+!9+0'98+04!()!4(#0!)'2=+0@!!Y(;!>8+2!4(#!90+66!(2!'$;!4(#!)++*!8/0&2+66@!!!
[:/E9*+!è!4(!E/2!>'$8!#0'2/04!0+$+2$'(2!/2&!L*/&&+0!'6!#9!$8+!#EL'*'<#6!/2&!8/6!&0'LL*'2=!7!>8/$!
'6!$8+!E(6$!*'F+*4!</#6+n!"GI!90(6$/$+!</2<+0!7!>84n!S<!)(0!90(6$/$+!</2<+0!$(!&(!$8/$;!'$!8/6!$(!
'2M/&+!/**!$8+!>/4!$80(#=8!$8+!90(6$/$+!=*/2&!$(!$8+!#0+$80/ZL*/&&+0!2+<F@!!I8'6!'6!90(6$/$+!
NbJ[RJX%Y1%!L<!'$!'6!/*0+/&4!/0(#2&!$8+!#0+$80/;!/2&!$8'6!'6!$8+!K..;!2($!</2<+0@!!g8/$!E/*+!
8(0E(2+!'6!$($/**4!0+69(26'L*+!)(0!90(6$/$+n!_'84&0($+6$(6$+0(2+!7!'2!+EL04(=+2+6'6;!$8'6!8(0E(2+!
)#6+6!$8+!*/L'/!!$(!)(0E!/!6<($0#E;!+:$+2&6!$8+!<*'$(0'6!$(!)(0E!/!9+2'6!/2&!E/F+6!/!90(6$/$+!=*/2&@!!
Y(;!90(6$/$+!NJb!/2&!</2<+0!/0+!"GI!$+6$(6$+0(2+!&+9!</2<+06;!L#$!&'84&0($+6$+0(2+!&+9!</2<+06@!!
1)!4(#!#6+!/!e!/*98/!0+&#<$/6+!'28'L'$(0;!$8/$!>'**!'2<0+/6+!$+6$(6$+0(2+@!!I8'6!&0#=!>'**!&+<0+/6+!
_1Nb_RGI[YIGYI[RG"[!
K.!</2<+0!'2!E+2!C!90(6$/$+!</2<+0!
J0(&#<+6!(6$+(L*/6$'<!E+$6@!
!
Day 5
%#&'(!)'*+!s,!l42,!
!
Hirsutism and Virilization
N'06#$'6E!C!'2<0+/6+&!8/'0!'2!2(0E/*!8/'0!L+/0'2=!/0+/6!
k'0'*'c/$'(2!C!8'06$#'6E;!9*#6!E/*+!6+<(2&/04!6+:#/*!<8/0/<$+0'6$'<6!?c'$6;!/<2+;!&++9+0!M('<+B;!
<*'$(0(E+=/*4!?9/$8(=2(E(2'<B!
!
I+6$(6$+0(2+!'6!90+&(E'2/2$*4!642$8+6'c+&!'2!$8+!(M/04@!!K(6$!$+6$(6$+0(2+!'2!/!>(E/2!'6!)0(E!$8+!
(M/04@!!!
!
_N[%!6#*)/$+!'6!reW!)0(E!/&0+2/*6;!/2&!'6!/2!/2&0(=+2@!!I8+0+)(0+;!')!/!9$!8/6!8'06$#'6E;!8/M+!$(!
=+$!$>(!$+6$6!7!=+$!/!$+6$(6$+0(2+!*+M+*!7!8/M+!$(!)0/<$'(2/$+!'$!L<!6(E+$'E+6!$8+!$($/*!</2!L+!
2(0E/*;!L#$!$8+!)0++!$+6$!</2!L+!'2<0+/6+&;!/2&!4(#!=+$!/!_N[%!6#*)/$+!$+6$@!!Y(;!')!$+6$+$+0(2+!'6!
90+&(E'2/2$*4!+*+M/$+&;!'$!'6!<(E'2=!)0(E!$8+!(M/04!/2&!')!_N[%!'6!+*+M/$+&;!'$!'6!<(E'2=!)0(E!$8+!
/&0+2/*6@!
!
1)!'$!'6!/&0+2/*!(0='2;!'$!<(26'6$6!()!84&0(:4*/6+!&+)!?/&0(=+2'$/*!642&0(E+B;!.#68'2=6;!+$<@@!
N'06$#'6E!)0(E!$8+!(M/0'+6!'6!/!<(EE(2!98+2(E+2(2@!
Y(;!>8+2!4(#!/0+!+M/*#/$'2=!8'06#$'6E;!*((F!/$!_N[%!!*+M+*6!?/&0+2/*!(0'='2B!/2&!$+6$(6$+0(2+!
*+M+*6?(M/0'/2!(0'='2B@!!!
G2+!()!$8+!<(EE(2!</#6+6!()!(M/0'/2!(0'='2!/0+!9(*4<46$'<!(M/0'/2!642&0(E+@!
!
Polycystic ovarian syndrome
MCC hirstuism = polycystic ovarian syndrome (or idiopathic)
199

?%*6(!&#+!$(!6$0(E/*!849+09*/6'/!7!6$0(E/!()!$8+!(M/04!</2!E/F+!$+6$(6$+0(2+;!(0!$#E(06!($8+06!
(M/04B!
!
I8'6!&c!'6!/!849($8/*/E'<d9'$!/L2(0E/*'$4!>8+0+!TYN!'6!6#990+66+&!/2&!XN!'6!'2<0+/6+&@!!1)!4(#!
F2(>!>8/$!XN!&(+6;!'$!E/F+6!$8+!9/$8(9846!+/64@!!12!/!>(E/2;!XN!'6!0+69(26'L*+!)(0!642$8+6'6!()!
$8+</!'2$+02/!?>8'<8!'6!/0(#2&!$8+!&+M+*(9'2=!)(**'<*+B@!!_#0'2=!$8+!90(*')+0/$'M+!98/6+!()!$8+!<4<*+;!
>8/$!'6!90+&(E'2/2$*4!L+'2=!642$8+6'c+&!'6!$8+!,`!F+$(!6$+0('&6!_N[%!/2&!/2&0(6$+2+&'(2+@!!I8+!
/2&0(6$+2+&'(2+!'6!<(2M+0$+&!L4!(:4&(0+&#<$/6+!'2$(!$+6$(6$+0(2+@!!I8+2;!$8+!$+6$!=(+6!/<0(66!$8+!
E+EL0/2+!()!$8+!&+M+*(9'2=!)(**'<*+!'2$(!$8+!=0/2#*(6/!<+**6;!>8+0+!$8+0+!'6!/0(E/$/6+@!!TYN!'6!9#$!
'2!$8+0+@!!I8+2;!$8+!/0(E/$/6+!'2!$8+!=0/2#*(6/!<+**!<(2M+0$6!$+6$!'2$(!+6$0(&'(*!/2&!$8'6!'6!>8+0+!$8+!
>(E/2!=+$6!8+0!+6$0/&'(*!?)0(E!$8+!/0(E/$'c/$'(2!90(<+66B@!!XN!'6!0+69(26'L*+!)(0!642$8+6'6!()!,`!
F+$(!6$+0('&6!/2&!$+6$(6$+0(2+!'2!$8+!(M/0'+6@!!I8'6!'6!>84!>+!>'**!6++!8'06$#'6E!'2!/!>(E/2!>'$8!
9(*4<46$'<!(M/0'/2!642&0(E+!?L<!'2<0+/6+!()!,`!F+$(6$+0('&6;!_N[%;!/2&0(6$+2&'(2+;!/2&!
$+6$(6$+0(2+B@!!GL+6'$4!'6!/!<(EE(2!<(00+*/$'(2!>'$8!$8'6!&c@!I8'6!E/F+6!6+26+!L<!+:<+66!/&'9(6+!C!
E(0+!/0(E/$/6+;!6(!$8+!6+:!8(0E(2+6!$+6$!/2&!/2&0(6$+2+&'(2+!</2!L+!<(2M+0$+&!$(!+6$0(=+26!'2!
$8+6+!9$6@!!%2&0(6$+2+&'(2+!'6!/0(E/$'c+&!'2$(!+6$0(2+!?/!>+/F!+6$0(=+2B@!!I+6$(6$+0(2+!'6!
/0(E/$'c+&!'2$(!+6$0/&'(*;!>8'<8!'6!/!6$0(2=!+6$0(=+2@!!Y(;!>+!8/M+!/!9/0/&(:!7!8/M+!/!>(E/2!>'$8!
6'=26!()!+:<+66!/2&0(=+26!?8'06#$'6E;!/<2+!7!2($!6'=26!()!M'0#*'c/$'(2B@!!%$!$8+!6/E+!$'E+;!$8+6+!/0+!
L+'2=!<(2M+0$+&!$(!+6$0(=+26!6(!>'**!8/M+!+2&(E+$0'/*!849+09*/6'/!/2&!$8+0+)(0+!8/M+!/!0'6F!()!
+2&(E+$0'/*!</0'<'2(E/@!!Y(;!$8+0+!'6!/!<(EL(!()!'2<0+/6+&!/2&0(=+26!/2&!'2<0+/6+&!+6$0(=+26@!!1$!
'6!$8+!'2<0+/6+&!+6$0(=+26!$8/$!</#6+6!6#990+66'(2!()!TYN!M'/!2+=/$'M+!)++&L/<F;!>8'*+!$8+0+!'6!/!
JGY1I1k[!)++&L/<F!(2!XN@!!Y(;!L<!'2<0+/6+&!+6$0(=+26;!9$!'6!<(26$/2$*4!6#990+66'2=!TYN!/2&!
<(26$/2$*4!'2<0+/6'2=!XN;!6(!$8+!<4<*+!0+9+/$6!'$6+*)@!!Y(;!4(#!</2!L0+/F!$8+!<4<*+!>'$8!/2!G.J!L<!$8+!
90(=+6$'2!'2!'$!>'**!L*(<F!XN@!!Y(;!>84!&(!$8+4!8/M+!<46$6n!T#2<$'(26!()!TYN!'6!$(!90+9/0+!$8+!)(**'<*+@!!
%*6(;!$8+4!'2<0+/6+!$8+!/0(E/$/6+!/<$'M'$4@!!1)!$8+!TYN!'6!<(26$/2$*4!6#990+66+&;!$8+!)(**'<*+!
&+=+2+0/$+6!/2&!*+/M+6!L+8'2&!/!<46$'<!69/<+6!>8+0+!$8+!)(**'<*+!#6+&!$(!L+@!!Y(;!9$!8/6!JGXb<4$'<!
(M/0'/2!642&0(E+!0+*/$+&!$(!<80(2'<!TYN!6#990+66'(2@!!./2!)++*!$8+6+!L4!9+*M'<!+:/E!/2&!6++2!>'$8!
#*$0/6(#2&@!!!
!
Menstrual dysfunction
Dysmenorrhea!C!9/'2)#*!E+26+6!?90'E/04!/2&!6+<(2&/04!7!K..!90'E/04!'6!$((!E#<8!JlT!7!/!Jl!
$8/$!'2<0+/6+6!<(2$0/<$'(2!()!$8+!#$+0'2+!E#6<#*/$#0+@!!I8+!K.!6+<(2&/04!</#6+!'6!+2&(E+$0'(6'6B@!!!
I8+0+!/0+!/*6(!90(L*+E6!>'$8!&46)#2<$'(2/*!#$+0'2+!L*++&'2=!7!$8'6!'6!"GI!/!L*++&'2=!/L2(0E/*'$4!
0+*/$+&!$(!/!L*++&'2=Z(0=/2'<!</#6+@!!Y(;!'2!($8+0!>(0&6;!'$!'6!2($!L*++&'2=!)0(E!/2!+2&(E+$0'/*!
9(*49;!'$6!2($!L*++&'2=!)0(E!/!</2<+0U!$8'6!$49+!()!L*++&'2=!'6!/!8(0E(2+!'EL/*/2<+!$8/$!</#6+6!
/L2(0E/*'$4!'2!L*++&'2=@!!!
K..!/L2(0E/*!L*++&'2=!'2!4(#2=!*/&4!)0(E!E+2/0<8+!$(!HV!406!()!/=+!C!/2(M#*/$(04!L*++&'2=@!!Y(;!
')!/!4(#2=!*/&4!'6!L*++&'2=;!$8/$!'6!$8+!#6#/*!</#6+@!!
g8/$!'6!(<<#00'2=n!I8+0+!'6!/!9+06'6$+2$!+6$0(=+2!6$'E#*/$'(2!$8/$!'6!(<<#00'2=!(2!$8+!E#<(6/;!/2&!
2($!+2(#=8!90(=+6$+0(2+!6$'E#*/$'(2@!!Y(;!$8+4!&+M+*(9!/!*'*!849+09*/6'/;!$8+0+!'6!/!L#'*&!#9!()!
E#<(6/!/6!$8+!E(2$8!90(=0+66+6;!/2&!$8+2!+M+2$#/**4!$8+!6$0(E/!6*(#=86!())!/2&!*+/&6!$(!
6'=2')'</2$!L*++&'2=@!!Y(;!'$6!E/'2*4!/2!+6$0(=+2!90'E+&!#$+0#6;!>'$8(#$!$8+!+))+<$!()!90(=+6$+0(2+!
/2&!$8+4!&(!2($!(M#*/$+!0+*/$+&!$(!$8'6@!!I8'6!'6!$8+!K..@!!!
!
!
!
Amenorrhoea
!
200

J0'E/04!/E+2(008+/!/2&!6+<(2&/04!/E+2(008+/!
g8+2!4(#!$8'2F!/E+2(008+/;!'$!</2!L+!/!90(L!>'$8!$8+!849($8/*/E#6Z9'$#'$/04@!!12!($8+0!>(0&6;!'6!
$8+!849($8/*/E#6!9#$$'2=!(#$!l2RN!(0!2($n!16!$8+!9'$!9#$$'2=!(#$!TYNZXN!(0!2($n!Y(;!'6!'$!/!
849($8/*/E'<d9'$!/L2(0E/*'$4n!16!'$!/2!(M/0'/2!90(Ln!K/4L+!$8+!(M/04!'6!2($!E/F'2=!+2(#=8!
+6$0(=+2@!16!'$6!/2!+2&!(0=/2!90(Ln!!
I8'6!'6!/2/$(E'</**4!0+*/$+&!7!E/4L+!68+!&(+62Q$!8/M+!/!M/='2/!d!Rokitansky-Kuster-Hauser
syndrome;!(0!E/4L+!68+!8/6!/2!'E9+0)(0/$+!84E+2!7!68+Q6!L++2!8/M'2=!9+0'(&6!/**!/*(2=;!/2&!8/6!
L*((&!L#'*$!#9!L+8'2&!'$;!(0!<+0M'</*!6$+2(6'6!?_[Y!+:9(6#0+B!7!$8+6+!/0+!/**!/2/$(E'</*!0+/6(26!)(0!
$8+!/E+2(008+/@!
!!!
Ashermans syndrome!7!6+<(2&/04!/E+2(008+/;!>(E/2!8/6!0+9+/$+&!&'*/$/$'(2!/2&!
<#0($(68+6?nB;!>8+0+!$8+!6$0/$#E!L/6/*'6!'6!6<0/9+&!/>/4U!8/M+!$(!*+/M+!6(E+$8'2=!L+8'2&!)0(E!
>8'<8!4(#!</2!90(*')+0/$+!+2&(E+$0'/*!E#<(6/!7!')!4(#!6<0/9+!/**!$8+!>/4!&(>2!$8+!$8+!E#6<*+;!>'**!
2($!L+!/L*+!$(!E+26$0#/$+!/=/'2;!/2&!>'**!6</0!+M+04$8'2=!());!*+/&'2=!$(!/2!'2)+0$'*+!>(E/2@!!!
!
Y(;!/E+2(008+/!'6!90'E/04!(0!6+<(2&/04!-!849($8/*/E'<d9'$!90(L*+E;!(M/0'/2!90(L;!(0!+2&!(0=/2!
90(L@!!TYN!/2&!XN!*+M+*6!8+*9!'2!&'6$'2=#'68'2=!$8(6+!P@!!
!1)!9$!8/6!849($8/*/E'<d9'$!90(L;!>8/$!>(#*&!TYN!/2&!XN!L+n!X(>@!!!
1)!8/&!/!90'E/04!(M/0'/2!90(L*+E;!>8/$!>(#*&!$8+4!L+n!N'=8@!!
!1)!4(#!8/M+!/2!+2&!(0=/2!&+)+<$;!>8/$!>(#*&!TYN!/2&!XN!*+M+*6!L+n!"(0E/*@!!!
g8/$!'6!$8+!)'06$!6$+9!'2!$8+!>(0F#9!()!/24!</6+!()!/E+2(008+/n!J0+=2/2<4!$+6$@!
!
Turners syndrome:
J0'E/04!</#6+!()!/E+2(008+/;!>+LL+&!2+<F;!)+E/*+6!
K/3(0'$4!/0+!hG;!$8+0+)(0+!&(!2($!8/M+!/!L/00!L(&4@!!_+)+<$6!'2!*4E98/$'<6@!!./2!E/F+!&:!/$!L'0$8!
M'/!J[!7!6++!6>+**'2=!()!8/2&!/2&!)++$!?*4E98+&+E/B!C!$#02+06!
g+LL+&!2+<F!'6!&#+!$(!*4E98/$'<!/L2(0E/*'$'+6!7!=+$!<46$'<!84=0(E/6;!>8'<8!/0+!&'*/$+&!*4E98/$'<6!
'2!$8+!2+<F!/0+/!/2&!)'**!>'$8!*4E98/$'<!)*#'&!/2&!6$0+$<8!$8+!6F'2!7!L<!$8+4!6$0+$<8!$8+!6F'2;!*((F6!
*'F+!>+LL'2=@!!N/M+!90+&#<$/*!<(/0<$/$'(26@!!_(!2($!8/M+!KR@!!6(E+!</6+6!/0+!E(6/'<6!7!hGhh!/2&!
$8+0+!'6!/!0+E($+!9(66'L'*'$4!$8/$!$8+4!E/4!L+!)+0$'*+@!!I8+0+!/0+!/*6(!hGhbQ6!$8/$!/0+!E(6/'<Q6@!!8/M+!
E+2(9/#6+!L^!E+2/0<8+@!!%**!()!$8+0+!)(**'<*+6!/0+!=(2+!L4!$8+!/=+!()!H;!/2&!$8'6!'6!$8+!6$0+/F!
(M/0'+6!?=(2/&B@!!I8+0+)(0+;!$8+4!/0+!6#6<+9$'L*+!$(!&46=+0E'2(E/6!?6+E'2(E/6!/0+!'2!E/*+6!/0+!
/2/*(=(#6B@!!!
!
Uterine Disorders
Adenomyosis!7!=*/2&6!/2&!6$0(E/!>'$8'2!$8+!E4(E+$0'#E!7M+04!<(EE(2!</#6+!()!
&46E+2(008+/*;!&46940#2'/;!E+2(00/='/8;!846$+0+<$(E4U!&(+6!"GI!90+&'69(6+!$(!</2<+0@!!
!
Endometriosis 7!)#2<$'(2'2=!=*/2&6!/2&!6$0(E/!(#$6'&+!$8+!#$+0#6!?E4(E+$0'#E!'6!1"Y1_[BU!K.!
*(</$'(2!C!(M/04;!</#6+6!L*++&'2=!'2!$8+!(M/04!7!6++!<8(<(*/$+!<46$!?+2&(E+$0(E/Q6!d!2($!</2<+0;!
3#6$!+2&(E+$0'(6'6!()!$8+!(M/04B;!$#L+;!'2!9(#<8!()!_(#=*/6!!
!
[:/E9*+-!=((&!D#+6$'(2!$(!/6F!')!9$!8/6!+2&(E+$0'(6'6-!i_(+6!'$!8#0$!>8+2!4(#!&+)+</$+!n!b+6@!!N(>!
/L(#$!>8+2!4(#0!9+0'(&!=(+6!/>/4nj!"(;!'$!=(+6!/>/4!7!$8'6!'6!+2&(E+$0'(6'6!L<!$8+0+!'6!L*++&'2=!'2!
$8+!0+<$/*!9(#<8!()!$8+!9(#<8!()!_(#=*/6!?$8+0+!'6!+2&(E+$0+(6'6!$8+0+B@!!I8+!0+<$#E!'6!)'**+&!>'$8!
6$((*6;!/2&!6$0+<8+6!$8+!9(#<8!()!_(#=*/6;!*+/&'2=!$(!9/'2@!!Y(;!9/'2!(2!&+)+</$'(2!&#0'2=!$8+!9+0'(&!
*+/&6!$(!+2&(E+$0'(6'6@!!!
!
201

Endometrial Hyperplasia
T0(E!#2(99(6+&!+6$0(=+2@!!%*>/46!&/2=+0(#6!$(!8/M+!#2(99(6+&!+6$0(=+2;!E+/2'2=!2(!
90(=+6$+0(2+!+))+<$;!L<!$8+2!9$!0#26!0'6F!)(0!+2&(E+$0'/*!</2<+0@!
K..!+2&(E+$0'/*!</2<+0!C!+2&(E+$0'/*!NJb!&#+!$(!#2(99(6+&!+6$0(=+2!
!
J(#<8!()!_(#=*/6!</2!<(**+<$!6++&'2=!)0(E!(M/0'/2!</2<+0;!9#6!)0(E!J1_;!#2<*($$+&!L*((&!)0(E!
0#9$#0+&!+<$(9'<!90+=2/2<4!
?*(>!9/0$!()!/!>(E/2Q6!9+*M'6!'2<*#&+6-!M/='2/;!<+0M'</*!(6;!#$+0#6;!L*/&&+0B!
!
Endometrial cancer:
[/0*4!M6!*/$+!E+2/0<8+!7!+/0*4!'6!>(06+!L<!*(2=+0!$'E+!)(0!+6$0(=+2!$(!<'0<#*/$+!!
[/0*4!M6!X/$+!E+2(9/#6+!7!*/$+!'6!>(06+!L<!E(0+!+6$0(=+2!+:9(6#0+!
GL+6+!M6!2($!(L+6+!7!(L+6+!L<!$8+!+6$0(=+2!)/<$(0!'2!/&'9(6+!?E(0+!/0(E/$/6+B;!$8+0+)(0+;!(L+6+!
>(E/2!/0+!E(0+!6#6<+9$'L*+!$(!</2<+06!0+*/$+&!$(!+6$0(=+2!d!L0+/6$!</2<+0;!+2&(E+$0'/*!</2<+0;!
(M/0'/2!</2<+0!
I49+!11!&'/L+$'<6!/0+!/$!'2<0+/6+&!0'6F!L<!tVW!()!$49+!11!9$6!/0+!(L+6+!?6(;!$8+!(L+6'$4!'6!$8+!</#6+!
()!'2<0+/6+&!0'6F!()!+2&(E+$0'/*!</2<+0B@!
!
Cancer and age brackets
ê!C!<+0M'</*!
ee!C!+2&(E+$0'/*!
ae!C!(M/0'/2!
ee!4(;!9(6$E+2(9/#6/*!'6!>8+2!4(#!#6#/**4!6++!+2&(E+$0'/*!</0<'2(E/@!!%24!>(E/2!$8/$!8/6!L++2!
'2!E+2(9/#6+!)(0!(M+0!,!40;!/2&!$8+2!8/6!0+L*++&'2=!8/6!+2&(E+$0'/*!</2<+0!#2$'*!90(M+2!($8+0>'6+@!!!
,6$!6$+9!'2!E/2/=+E+2$n![2&(E+$0'/*!S:!!
!
Leiomyoma!7!K.!Lr!$#E(0!'2!/!>(E/2!
X+'(E4(6/0<(E/!7!E'$(6'6!90(LU!K.!6/0<(E/!()!$8+!#$+0#6U!L'=!L#*F4!$#E(06!?/6!/0+!/**!6/0<(E/6BU!
*+'(E4(E/!'6!"GI!/!90+<#06(0!)(0!*+'(E4(6/0<(E/@!!!
!
[:/E9*+-!4(#2=!>(E/2!6#&&+2!(26+$!()!6+M+0+!*(>+0!/L&(E'2/*!9/'2!7!must do a pregnancy
(look at beta HCG level) test to rule out ectopic pregnancy.
!
Ovarian masses
Y#0)/<+!&+0'M+&!7!&+0'M+&!)0(E!$8+!6#0)/<+!()!$8+!(M/04!
l+0E!<+**!$49+6!d!&46=+0E'2(E/6!?E+2!8/M+!$8+6+;!$((B!
Y+:!<8(0&!6$0(E/*!$#E(06!7!E/F+!+6$0(=+26!?'+!=0/2#*(6/!<+**!$#E(06!d!$8+0+)(0+!</2!8/M+!
849+0+6$0'2'6E!>8'<8!*+/&6!$(!L*++&'2=!/2&!+2&(!</0<'2(E/6B;!6(E+!E/F+!/2&0(=+26!?6+0$(*'!*+4&'=!
<+**!$#E(06!()!$8+!(M/04!7!/66(<!>'$8!M'0#*'c/$'(2!/2&!8'06$#'6EB@!!!
?E/*+6!3#6$!8/M+!=+0E!<+**!$#E(06B!
!
Follicular cyst
MCC of ovarian mass in a young woman = follicular cyst
T(**'<*+!$8/$!0#9$#0+&;!2($!2+(9*/6$'<;!/<<#E#*/$+6!)*#'&!/2&!*+/&6!$(!9+0'$(2'$'6@!!1$!'6!L/&!')!'$6!(2!
$8+!0'=8$!6'&+!L<!'$!</2!L+!+'$8+0!0#9$#0+&!)(**'<#*/0!<46$;!/99+&'<'$#6;!+<$(9'<!90+=2/2<4!?0#9$#0+&B;!
J1_U!*((F!/$!>'$8!#*$0/6(#2&!!
!
202

\2&+0!Pe!4(;!E(6$!(M/0'/2!E/66+6!/0+!Lr!
GM+0!Pe!4(;!E(6$!(M/0'/2!E/66+6!8/M+!/!=0+/$+0!9($+2$'/*!()!L+'2=!E/*'=2/2$@!!!
!
Surfaced derived!?(M+0/**!K.B!
K.!6#0)/<+&!&+0'M+&!C!6+0(#6!<46$/&+2(E/!?SrBU!6+0(#6!<46$/&+2(</0<'2(E/!?E/*'=2/2$B!
!?$8+6+!/0+!$8+!K.!(M+0/**!Lr!/2&!E/*'=2/2$!(M/0'/2!$#E(06B!
I8+6+!/0+!/*6(!$8+!K.!$8/$!/0+!L'*/$+0/*;!/2&!$8+!<46$/&+2(</0<'2(E/!8/6!96(EE(E/!L(&'+6!?L*#'68!
<(*(0+&!7!&#+!$(!/9(9$(6'6;!&+6$0#<$'(2!()!$8+!$#E(0!<+**!/2&!0+9*/<+E+2$!>'$8!&46$0(98'<!
</*<')'</$'(2B@!%*6(!6++2!'2!9/9'**/04!</0<'2(E/!()!$8+!$840('&!/2&!'2!E+2'2='(E/Q6!
[:/E9*+--!ae!4(;!L'*/$+0/*!(M/0'/2!+2*/0=+E+2$!?0+E+E!$8+4!$+2&!$(!/0'6+!/$!$8'6!/=+B!
%24!>(E/2!$8/$!'6!(M+0!ee!/2&!8/6!9/*9/L*+!(M/0'+6!'6!</2<+0!#2$'*!90(M+2!($8+0>'6+!L<!/!
9(6$E+2(9/#6/*!>(E/2!68(#*&!L+!8/M+!(M/0'+6!$8/$!/0+!/$0(984'2=@!!!
[:/E9*+--!aH!4(!>(E/2!>'$8!(M/0'/2!E/66!(2!$8+!0'=8$!7!/*0+/&4!F2(>!'$6!L/&!L<!68(#*&2Q$!8/M+!/!
9/*9/L*+!(M/04@!
Cystic teratoma
I(($8;!6+L/<+(#6!=*/2&6;!</0$'*/=+;!6F'2;!$840('&;;!
K.!(M+0/**!=+0E!<+**!$#E(0;!#6#/**4!Sr!
1)!'$!'6!E/F'2=!$840('&;!'$!'6!</**+&!6$0#E/!(M/04!
!
Sex chord stromal tumors
K.!C!)'L0(E/6!?SrB!
K+'=6!642&0(E+-!(M/0'/2!)'L0(E/;!/6<'$+6;!/2&!0'=8$!6'&+!9*+#0/*!+))#6'(2!7!=(+6!/>/4!>8+2!4(#!
$/F+!$8+!(M/04!(#$@!
l0/2#*(6/!<+**!$#E(0!()!(M/04-!*(>!=0/&+!E/*'=2/2$!$#E(0U!>8/$!&(+6!$8+!=0/2#*(6/!<+**!2(0E/**4!
&(n!1$!/0(E/$'c+6!/2&0(=+26!/2&!+6$0(=+26;!6(!/!=0/2#*(6/!<+**!$#E(0!'6!E(0+!$8/2!*'F+*4!/2!
+6$0(=+2!90(&#<'2=!$#E(0@!!!
Y'=2+$!0'2=!<+**6!7!'6!$8'6!/!90'E/04!</2<+0;!(0!E+$6!)0(E!/2($8+0!6'$+n!Y'$+!'6!)0(E!6$(E/<8!7!</**+&!
/!F0#F+2L#0=!$#E(0U there is NO primary ovarian cancer that has signet ring cells.
!
Gestational Disorders
Placenta
.8(0'(2'<!M'**#6!7!(#$6'&+!*/4+0!C!642<4$'($0(98(L*/6$;!<*+/0!<+**6!#2&+0!$8+!(#$6'&+!*/4+0!C!
<4$($0(98(L*/6$U!>8'<8!'6!E/F'2=!8(0E(2+6n!Y42<4$'($0(98(L*/6$@!!
!
g8/$!8(0E(2+6!'6!'$!E/F'2=n!Sd8<l!/2&!N#E/2!J*/<+2$/*!X/<$(=+2!?NJXB!7!=0(>$8!8(0E(2+!()!
90+=2/2<4@!!N/6!E4:(E/$(#6!6$0(E/@!!k+66+*6!<(/*+6<+!'2$(!#EL'*'</*!M+'2;!>8'<8!8/6!$8+!8'=8+6$!
(H!<(2$+2$@!
!
Neoplasms of chorionic villus:
Hydatidiform mole!7!</2!L+!<(E9*+$+!?â;!hh;!L($8!h!<Q6(E+6!<(E+!)0(E!)/$8+0!7!</**+&!
/2&0(=+2+6'6B!(0!9/0$'/*!?$0'9*('&;!ar!<Q6(E+6;!</2!8/M+!/!)+$#6!90+6+2$B!
I8+!<(E9*+$+!E(*+6!8/M+!/!=0+/$+0!90(9+26'$4!$(!E(M'2=!(2!$(!<8(0'(</0<'2(E/@!!!
!
Causes of choriocarcinoma:
,eW!()!<8(0'(</0'<2(E/6!/0+!)0(E!90++:'6$'2=!84/&')(0E!E(*+!
HeW!)0(E!69(2$/2+(#6!/L(0$'(2!
203

HeW!)0(E!2(0E/*!90+=2/2<4!
N4/$'&')(0E!E(*+6!/0+!Lr!$#E(06!()!$8+!<8(0'(2'<!M'**#6U!<8(0'(</0<'2(E/6!/0+!/!E/*'=2/2<4!()!$8+!
$0(98(L*/6$'<!$'66#+!?&(!2($!6++!<8(0'(2'<!M'**'B@!!X(M+6!$(!=(!$(!$8+!*#2=6!/2&!0+69(2&6!>+**!$(!
<8+E($8+0/94!?</2!+M+2!=(!/>/4!'2!$8+!90+6+2<+!()!E+$6B!
!
Breast
!
J'<$#0+!/!6<8+E/$'<!>'$8!2'99*+;!*/<$')+0(#6!&#<$;!E/3(0!&#<$6;!$+0E'2/*!*(L#*+6!?>8+0+!E'*F!'6!E/&+B;!
/2&!$8+!6$0(E/!
"'99*+!C!J/=+$6!&c!()!$8+!L0+/6$!
X/<$')+0(#6!&#<$!C!12$0/&#<$/*!9/9'**(E/!?K..!()!L*((&4!2'99*+!&'6<8/0=+!()!>(E/2!#2&+0!eVB!7!Lr!
9/9'**/04!$#E(0;!')!4(#!90+66!(2!'$;!L*((&!>'**!<(E+!(#$!()!$8+!/0+(*/!
K/3(0!&#<$6!C!>8+0+!E(6$!()!$8+!</2<+06!/0'6+!)0(E!7!'2M/6'M+!&#<$/*!</2<+06;!E+&#**/04!
</0<'2(E/6;!E#<'2(#6!</0<'2(E/6!
I+0E'2/*!*(L#*+6!?>8+0+!E'*F!'6!E/&+B!7!K.!$#E(0!C!*(L#*/0!</02'<(E/;!'6!)/E(#6!L+!S1X%I[R%X!
?6(;!*(L#*/0!$#E(06!/0+!$(!$8+!L0+/6$!/6!6+0(#6!$#E(06!/0+!$(!$8+!(M/04!'2!$+0E6!()!$8+'0!
L'*/$$+0/**'$4BU!mammography doesnt pic up lobular cancers. !
!
MCC of mass in breast of woman under 50 = fibrocystic change
MCC of mass in breast of woman over 50 = cancer: '2)'*$0/$'2=!&#<$/*!</0<'2(E/!?2($!
'2$0/&#<$/*!7!$8'6!E+/26!$8/$!>+!/0+!2($!9'<F'2=!#9!$8+!</2<+0!+/0*4!+2(#=8!L4!E/EE(=0/984!/2&!
9'<F'2=!#9!'2!$8+!'2$0/&#<$/*!98/6+;!/2&!(#0!$+<82'D#+6!/0+!'26+26'$'M+!7!6(!>+!/0+!E'66'2=!$8+!
&#<$/*!6$/=+!/2&!>+!/0+!9'<F'2=!#9!$8+!</2<+0!>8+2!'$!8/6!'2M/&+&!7!$(!9'<F!#9!+/0*4;!2++&!$(!=+$!/$!
eEE!(0!*+66B@!
Y(;!')!$8+4!/0+!'2$0/&#<$/*;!8/6!/!=((&!90(=2(6'6!
!
[:/E9*+-!Pe!4(!>(E/2!>'$8!E(M/L*+!E/66!'2!L0+/6$!$8/$!=+$6!L'==+0!/6!$8+!<4<*+!90(=0+66+6!C!
)'L0(/&+2(E/!!!
I8+6+!/0+!$8+!E(6$!<(EE(26!'2!$+0E6!()!/=+!/2&!*(</$'(2!
!
Y*'&+-!fibrocystic change 7!<46$6;!*#E94!L#E94!'2!L0+/6$;!E(0+!9/'2)#*!/6!$8+!<4<*+!90(=0+66+6!L<!
$8+4!/0+!8(0E(2+!6+26'$'M+!
[:/E9*+--!&#<$/*!849+09*/6'/!7!</22($!6++U!90+<#06(0!*+6'(2!)(0!</2<+0!$8/$!/0+!+6$0(=+2!6+26'$'M+!
+9'$8+*'/*!<+**6!'2!$8+!&#<$6!!?3#6$!*'F+!$8+!+2&(E+$0'/*!=*/2&6!/0+!+6$0(=+2!6+26'$'M+;!$8+!=*/2&6!*'2'2=!
$8+!&#<$6!/0+!+6$0(=+2!6+26'$'M+B@!
!
Sclerosing adenosis!7!'2!$+0E'2/*!*(L#*+6;!Lr!9/0$!()!)'L0(<46$'<!<8/2=+!?6++!<46$6B!
!
Fibroadenoma
MC tumor that moves around in the breast in a woman under 35 = fibroadenoma!7!'6!$8+!
2+(9*/6$'<!<(E9(2+2$6!$8+!=*/2&6!(0!$8+!6$0(E/n!1$Q6!$8+!6$0(E/!7!/6!'$!=0(>6;!'$!<(E90+66+6!$8+!
&#<$6$+E6;!6(!$8+4!8/M+!6*'$!*'F+!69/<+6U!M+04!<(EE(2@!![M+2!')!4(#!F2(>!'$Q6!/!)'L0(/&+2(E/;!6$'**!
=+$!/!L:!
!
Breast Cancer
Y*'&+-!N(>!&(!4(#!F2(>!'$6!L0+/6$!</2<+0n!2'99*+!'6!8/0&!/6!/!0(<F!7!>8+2!L0+/6$!</2<+06!'2M/&+!
$8+!6$0(E/;!$8+4!+*'<'$!/!)'L0(L*/6$'<!/2&!+*/6$'<6!$'66#+!0+69(26+;!E/F'2=!'$!8/0&!7!$8'6!'6!=((&!L<!'$!
204

E/F+6!'$!9/*9/L*+@!!This is why a woman over 50, that has a painless palpable mass, its
cancer.!!!
!
If its painful and under 50, its rarely cancer (fat necrosis, fibrocystic change).!!Y(;!$8+!
E/='<!>(0&!'6!9/'2*+66@!!!
!
G#$+0!D#/&0/2$6!()!$8+!L0+/6$!/0+!$8+!K.!6'$+6!L<!$8'6!'6!>8+0+!E(6$!()!$8+!L0+/6$!$'66#+!'6@!!
I8+0+)(0+;!$8'6!>(#*&!L+!$8+!K.!6'$+!)(0!L0+/6$!</2<+0@!!I8+!H2&!K.!6'$+!'6!/0(#2&!$8+!/0+(*/@!!!
!
Y*'&+-!2'99*+!L+'2=!6#<F+&!'2;!>8'$'68!E/66;!6$+**/$+!?<*/66'<!)(0!'2M/6'M+!</2<+0BU!(2!E/EE(=0/984;!
6++!&+26'$4!>'$8!69'<#*+6!<(E'2=!(#$!/2&!8/6!</*<')'+&@!!I8'6!'6!8'=8*4!90+&'<$'M+!)(0!</2<+0@!!g8/$!'6!
$8+!)'06$!6$+9!'2!E/2/=+E+2$!()!/!9/*9/L*+!E/66n!T"%!7!L<!</2!E/F+!/!&:!/2&!$+**!')!'$6!6(*'&!(0!
<46$'<!?$8'6!'6!/*6(!$8+!)'06$!6$+9!'2!E/2/=+E+2$!()!<(*&!2(&#*+!'2!$840('&;!2($!#*$0/6(#2&B@!
!
Y*'&+-!'2$0/&#<$/*!</2<+0!7!2+$*'F+!/00/2=+E+2$;!</**+&!<(E+&(</0<'2(E/;!3#2F!$8/$!<(E+6!(#$!?*'F+!
</6+(#6!2+<0(6'6BU!8/6!+0LdH!(2<(=+2+!?/==0+66'M+!</2<+06B@!
!
Y*'&+-!'2M/6'M+!</2<+0;!6++!$#E(0!<+**6!'2M/&'2=!6$0(E/U!6++!12&'/2!)'*'2=!7!6'=2!()!'2M/6'M+!*(L#*/0!
</2<+0U!6++2!E(0+!()$+2!'2!'2)'*$0/$'2=!&#<$/*!</0<'2(E/!
!
Y*'&+-!+<c+E/$(#6!&c!/0(#2&!$8+!2'99*+!C!9/=+$6!&c!()!$8+!L0+/6$!7!0/68!/0(#2&!2'99*+!7!</2<+0!()!
$8+!&#<$!$8/$!8/6!690+/&!$(!$8+!6F'2!!
!
Y*'&+-!'2)*/EE/$(04!</0<'2(E/!7!>(06$;!0+&;!&'E9*+&!6F'2!L<!$8+!*4E98/$'<6!/0+!9*#==+&!>'$8!</2<+0!
#2&+02+/$8!/2&!$8+!*4E98/$'<!)*#'&!*+/F+&!(#$;!L#$!$8+!*'=/E+2$6!/0+!6$'**!/$$/<8+&;!L#$!'2<0+/6'2=!
$8+!)*#'&!'2!$8+!'2$+06$'#E;!/2&!/6!'$!+:9/2&6!(#$;!'$!&'E9*+6!7!9Q&(+#!(0/2=+!7!6(;!'2)*/EE/$(04!
</0<'2(E/!*((F6!*'F+!$8/$!L<!'$6!*4E98/$'<!)'**+&!>'$8!$#E(0;!/2&!'6!$8+!>(06$!()!$8+!>(06$@!
!
Y*'&+-!*(L#*/0!</0<'2(E/!7!K.!</2<+0!()!$8+!$+0E'2/*!</2<+0!?/$!$8+!+2&!()!$8+!&#<$6BU!'$!'6!)/E(#6!
)(0!L'*/$+0/*'$4!
!
Y*'&+-!*4E98+&+E/!'6!/!>(E/2!$8/$!'6!9(6$0/&'</*!E/6+<$+<$(E4U!>8+2!4(#!/0+!&('2=!/!E(&')'+&!
0/&'</*!E/6$+<$(E4;!>8/$!/0+!4(#!0+E(M'2=n!I8+!+2$'0+!L0+/6$!'2<*#&'2=!/!2'99*+;!*+/M'2=!L+8'2&!
9+<!E/3(0;!/:'**/04!0+6+<$'(2;!/2&!$/F'2=!9+<!E'2(0@!!K.!<(E9*'</$'(2!C!>'2=+&!6</9#*/!?L<!<#$!$8+!
*(2=!$8(0/<'<!2+0M+B!
!
The lumpectomy!0+E(M+6!$8+!#2&+0*4'2=!$#E(0!>'$8!/!=((&!L(0&+0!()!2(0E/*!$'66#+!/0(#2&!'$;!
$/F+!!/!)+>!2(&+6!)0(E!$8+!/:'**/!?L<!8/M+!$(!#6+!)(0!6$/='2=!L<!$8+4!=(!$(!*(>+0!/:'**/04!)'06$B;!/2&!
$8+2!4(#!&(!0/&'/$'(2!()!$8+!L0+/6$!?=((&!)(0!L0+/6$!<(26+0M/$'(2!7!6/E+!90(=2(6'6!/6!E/6$+<$(E4B!
[:/E9*+--![R%dJR%!C!+6$0(=+2!0+<+9$(0Z90(=+6$+0(2+!0+<+9$(0!/66/4!7!>8/$!&(+6!'$!E+/2n!
R+*/$'(268'9!L+$>2!+6$0(=+2!/2&!'$6!0+<+9$(0!642$8+6'6@!!Y(;!')!4(#!/0+!'2!/!0+90(&#<$'M+!9+0'(&!()!
4(#0!*')+!>8+2!+6$0(=+2!'6!/L#2&/2$;!$8+!0+<+9$(06!>'**!L+!&(>20+=#*/$+&@!!I8'6!'6!>84!'2!>(E+2!
$8/$!/0+!4(#2=;!'2!$8+!0+90(&#<$'M+!9+0'(&!()!$8+'0!*')+;!8/M+!L0+/6$!</2<+0!/2&!/0+![RJR%!2+=/$'M+!
L<!$8'6!'6!>8/$!>+!>(#*&!+:9+<$!L<!+6$0(=+2!>(#*&!&(>2!0+=#*/$+!0+<+9$(0!642$8+6'6@!!g8+0+/6;!')!
4(#!/0+!9(6$E+2(9/#6/*;!'$!*+/&6!$(!#9!0+=#*/$'(2!()!$8+!0+<+9$(06!/2&!$8(6+!>(E+2!/0+![RJR%!
9(6'$'M+@!!S#$!>8/$!&(+6!$8'6!E+/2n!1$!E+/26!$8/$!$8+!$#E(0!'6!0+69(2&'2=!$(!+6$0(=+2!/2&!2++&!$(!
$/F+!/>/4!$8/$!+6$0(=+2!/))+<$!L<!'$!'6!)++&'2=!$8+!$#E(0@!!N(>!</2!4(#!$/F+!'$!/>/4n!I/E(:')+2!7!
$8'6!'6!>+/F!+6$0(=+2;!6(!'$!8((F6!'2$(!$8+!0+<+9$(0!()!L0+/6$!$#E(06;!6(!')!$8+0+!'6!/24!*+)$!L+8'2&;!
205

2(0E/*!+6$0(=+2!'2!/!>(E/2!</2Q$!=+$!'2$(!'$!/2&!>(2Q$!L+!/L*+!$(!)++&!$8+!$#E(0@!!Y(;!'$Q6!/!L*(<F+0!
()!$8+!0+<+9$(0@!!!
!
.(E9*'</$'(26n!K+2(9/#6/*!$49+!64E9$(E6U!/*6(;!'$!'6!/2!+6$0(=+2!6(!4(#!8/M+!$8+!0'6F!()!
+2&(E+$0'/*!</2<+0@!!%!L+2+)'$!'2!$8+!9(6$E+2(9/#6/*!6$/$+!>'$8!/2![R%!JR%!9(6!>(E/2!'6!$8/$!'$!
&(+6!90+M+2$!(6$+(9(0(6'6@!Y(;!</22($!='M+!+6$0(=+2!$(!/!>(E/2!$8/$!'6![R%!JR%!9(6;!L#$!'6!/!
</2&'&/$+!)(0!$/E(:!/2&!>'**!90(*(2=!0+<#00+2<+@!!!
!
%#&'(!)'*+!_/4e!sH!l42H!?>0(2=!$'$*+B'$!'6![2&(<!
!
Ch 22: Endocrine Disorders
!
Primary vs Secondary vs Tertiary
N/68'E($(6!C!&+6$0#<$'(2!()!$8+!$840('&!=*/2&!C!JR1K%Rb!849($840('&'6E!?$8+!=*/2&!6<0+>6!#9!$8+!
8(0E(2+B!
N49(9'$#'$/0'6E!/2&!849($840('&'6E!C!Y[.G"_%Rb!849($840('&'6E!?2(!IYN!$(!6$'E#*/$+B!
N49($8/*/E'<!_c!C!Y/0<('&(6'6!&+6$0(4'2=!IRN-!I[RI1%Rb!?2(!IRNB!
!
[:/E9*+-!/&+2(E/!(2!9/0/$840('&!90(&#<'2=!JIN!*+/&'2=!$(!849+0</*<+E'/!C!90'E/04!
849+09/0/$840('&'6E!
!
[:/E9*+-!8/M+!849(</*<+E'/ZM'$!_!&+);!/2&!/6F+&!$8+!9/0/$840('&!$(!#2&+0=(!849+09*/6'/;!$8/$!'6!
</**+&!Y[.G"_%Rb!849+09/0/$840('&'6E!
!
[:/E9*+-!>8/$!')!/)$+0!/!*(2=!$'E+!JIN!F++96!L+'2=!E/&+!C!$+0$'/04!849+09/0/$8040('&'6E!?0/0+B!
!
Overactivity vs underactivity of glands
!
Stimulation test-!')!9$!8/6!#2&+0/<$'M+!=*/2&;!>(#*&!#6+!6$'E#*/$'(2!$+6$!$(!6++!')!$8+!=*/2&!'6!
>(0F'2=@!
!!
Supression test-!')!9$!8/6!(M+0/<$'M+!=*/2&;!>(#*&!#6+!6#990+66'(2!$+6$!$(!6++!')!=*/2&!>'**!6$(9!
>(0F'2=@!
!
K(6$!()!$8+!$'E+;!$8'2=6!$8/$!</#6+!(M+0/<$'M'$4;!>+!.%""GI!6#990+66!$8+E@!!!
!
I8+0+!/0+!H!+:<+9$'(26!>8+0+!>+!6#990+66!$8+E;!/2&!$8+4!&+/*!>'$8!(M+0/<$'M'$4!'2!$8+!9'$#'$/04!
=*/2&!!
!
7!,Bprolactinoma!!</2!L+!6#990+66+&!L<!'$!</2!90+M+2$!$8+!$#E(0!)0(E!E/F'2=!90(*/<$'2U!
L0(E(<0'9$'2+!6#990+66+6!'$!?&(9/E'2+!/2/*(=!7!2(0E/**4;!>(E+2!&(!2($!8/M+!=/*/<$(008+/!L<!$8+4!
/0+!0+*+/6'2=!&(9/E'2+;!>8'<8!'6!'28'L'$'2=!90(*/<$'2!?$8+0+)(0+!&(9/E'2+!'6!/2!'28'L'$(04!6#L6$/2<+!
7!L0(E(<0'9$'2+!'6!/*6(!#6+&!)(0!$0+/$'2=!9/0F'26(2Q6!L<!L0(E(<0'9$'2+!'6!/!&(9/E'2+!/2/*(=!?>8'<8!
'6!>8/$!'6!E'66'2=!'2!9/0F'26(26!&cB!
!
HB Pituitary Cushings-!Lr!$#E(0!'2!$8+!9'$'#'$/04!$8/$!'6!E/F'2=!%.IN!7!4(#!.%"!6#990+66!'$!>'$8!
/!8'=8!&(6+!()!&+:/E+$8/6(2+@!!I8+6+!/0+!$8+!(2*4!$>(!+:<+9$'(26!)(0!/!$#E(0!E/F'2=!$((!E#<8!
6$#))@!!!
206

?I8+0+!'6!2(!>/4!$(!6#990+66!/!9/0/$840('&!/&+2(E/!E/F'2=!JIN;!(0!/2!/&0+2/*!/&+E(2/!E/F'2=!
<(0$'6(*;!(0!/!/2!/&0+2/*!$#E(0!)0(E!642$8+6'c'2=!/*&(6$+0(2+!7!$8+6+!/0+!%\IG"GKG\YB!
!
[:/E9*+-!9$!>'$8!849(<(0$'6(*'6E!7!*+$6!&(!/2!%.IN!6$'E#*/$'(2!$+6$!7!>'**!8/2=!#9!/2!1k!&0'9!/2&!
9#$!'2!6(E+!%.INU!!<(**+<$'2=!#0'2+!)(0!,`!84&0(:4<(0$'<('&6!?E+$/L(*'<!+2&!90(&#<$!()!<(0$'6(*B!/2&!
2($8'2=!8/99+26!7!6(!>8/$!'6!$8+!849(<(0$'6(*!&#+!$(n!%&&'6(2!&c!7!=*/2&!>/6!&+6$0(4+&!7!
$8+0+)(0+;!+M+2!')!4(#!F++9!6$'E#*/$'2=!'$;!4(#!>'**!2($!L+!E/F'2=!<(0$'6(*@!!
!!
[:/E9*+-!X+$Q6!6/4!/)$+0!/!)+>!&/46!4(#!6++!'2!/2!'2<0+/6+!'2!,`!84&0(:4<(0$'<('&6;!$8+2!>8/$!'6!$8+!
</#6+!()!849(<(0$'6(*'6En!N49(9'$#'$/0'6E!7!'2!($8+0!>(0&6;!'$Q6!/$0(98'<!L<!'$6!2($!L+'2=!6$'E#*/$+&!
L4!%.IN;!L#$!>8+2!4(#!=/M+!'$!%.IN!(M+0!/!9+0'(&!()!$'E+;!'$!>/6!/L*+!$(!0+=/'2!'$6!)#2<$'(2@!!Y(;!
>'$8!$8/$!6'2=*+!$+6$;!4(#!/0+!/L*+!$(!)'2&!</#6+!()!849(<(0$'6/*'6E@!!!
!
./2!/*6(!*((F!/$!8(0E(2/*!*+M+*6!7!'+!%&&'6(2Q6!</#6'2=!849(<(0$'6/*'6E;!>8/$!>(#*&!%.IN!L+n!N'=8U!
')!4(#!8/M+!849(9'$#'$/0'6E!</#6'2=!849(<(0$'6/*'6E;!>8/$!>(#*&!%.IN!L+n!X(>!
!
Hypopituitarism
MCC in adults = nonfunctioning pituitary adenoma ?>'$8'2!6+**/!$#0<'</!7!'2!$8+!698+2('&!
L(2+;!8+2<+!6#0=+04!'6!$0/2698+2('&/*!6#0=+04;!>8+0+!$8+!+:9/2&+&!6+**/!$#0<'</!'6B@!
J'$!%&+2(E/!7!#6#/**4!2(2)#2<$'(2'2=!/2&!&+6$0(46!$8+!2(0E/*!9'$#'$/04!(M+0!$'E+!/6!'$!=0(>6;!
*+/&'2=!$(!849(9'$#'$/0'6E@!
!
Sheehans (postpartum necrosis)
[:/E9*+--!8/M+!/!90+=2/2$!>(E/2;!8/6!/L0#9$'(!9*/<+2$/!/2&!=(+6!'2!$(!849(M(*+E'<!68(<F;!L#$!
=+$!(#$U!&('2=!)'2+!/2&!L0+/6$!)+/&'2=!L/L4!/$!8(E+;!L#$!6#&&+2$*4!6$(96!L0+/6$!E'*F!90(&#<$'(2!7!
&:n!J(6$9/0$#E!2+<0(6'6!7!$8+0+)(0+!68+!8/6!'2)/0<$+&!8+0!9'$#'$/04!?<(/=#*/$'(2!2+<0(6'6B;!/2&!$8'6!
'6!0+6'&#/*!9'$'#/$/04!
(This is not liquefactive necrosis bc the pituitary is not part of the brain).
K+<8!'6!'6<8+E'/!/2&!<(/=#*/$'(2!2+<0(6'6@!!J0+=2/2$!>(E/2!8/M+!/!9'$#'$/04!=*/2&!$>(!$'E+6!$8+!
2(0E/*!6'c+@!!J0(*/<$'2!'6!L+'2=!642$8+6'c+&!7!L#$!/!90+=2/2$!>(E/2!&(+6!2($!8/M+!=/*/$(008+/!L<!
$8+!+6$0(=+2!/2&!90(=+6$+0(2+!'28'L'$!0+*+/6+@!!Y(;!$8+!E(E+2$!4(#!='M+!L'0$8;!$8+!'28'L'$(04!+))+<$!
'6!0+*+/6+&!/2&!6$/0$!8/M'2=!=/*/<$(008+/@!I8'6!'6!$8+!H2&!K..!849(9'$!'2!/&#*$@!
!
MC in kids = craniopharnygioma
R/$8F+Q6!9(#<8!(0'='2!7!$8'6!'6!9/0$!()!$8+!+EL04(*(='</*!&+M+*(9E+2$!()!$8+!9'$#'$/04!=*/2&!7!9'+<+6!
()!'$!0+E/'2!/2&!</2!L+<(E+!2+(9*/6$'</**4!$0/26)(0E+&!'2$(!/!<0/2'(98/04='(E/@!!1$6!2($!/!
E/*'=2/2$!$#E(0;!L#$!/!Lr!$#E(0!'2!/!L/&!9*/<+@!!1$!'6!K.!6#90/d6+**/0!7!?/L(M+!$8+!6+**/B!7!/2&!'$!
=(+6!&(>2!/2&!&+6$0(46!$8+!9'$#'$/04;!L#$!*'F+6!$(!=(!)(0>/0&!/2&!L#E96!'2$(!(9$'<!<8'/6E;!*+/&'2=!
$(!bitemporal hemianopsia;!*+/&'2=!$(!M'6#/*!)'+*&!&+)+<$@!
[:/E9*+--!<8'*&!>'$8!8+/&/<8+6!/2&!M'6#/*!)'+*&!&+)+<$!7!&(!/!6<8+E/$'<!()!'$!/2&!>'**!/6F!>8/$!$8+!
</#6+!'6!7!<0/2'(98/042='(E/!7!$#E(0!()!0/$8F+Q6!9(#<8!(0'='2@!!!
!
Growth Hormone
g8+2!4(#!8/M+!/!$#E(0!$8/$!'6!+:9/2&'2=!'2!$8+!6+**/!$#0<'</;!&'))+0+2$!0+*+/6'2=!)/<$(06!?8(0E(2+6B!
&+<0+/6+!'2!/!<+0$/'2!6#<<+66'(2@!!I8+!)'06$!$8'2=!$8/$!'6!&+6$0(4+&!'6!=(2/&($0(9'2@!!Y(;!'2!/!>(E/2;!
>8/$!>(#*&!8/99+2n!Y8+!>(#*&!8/M+!/E+2(008+/!?6+<(2&/04!/E+2(008+/B@!!g8/$!')!1!>+0+!/!E/2!
?>8/$!'6!$8+!/2/*(=(#6!<(2&'$'(2Bn!!1E9($+2<+U!'E9($+2<+!'6!$(!/!E/*+!/6!/E+2(008+/!'6!$(!/!
207

)+E/*+@!!1E9($+2<+!C!)/'*#0+!$(!6#6$/'2!/2!+0+<$'(2!&#0'2=!/$$+E9$+&!'2$+0<(#06+@!!I8+!2+:$!$8'2=!
$8/$!=(+6!'6!=0(>$8!8(0E(2+!?>8'<8!8/6!H!)#2<$'(26-!,B!increases aa uptake!/2&!HB!involved in
gluconeogenesis ?8(0E(2+!$8/$!90(&#<+6!L(2+!/2&!$'66#+!=0(>$8!'6!'26#*'2!*'F+!=0(>$8!)/<$(0d,;!
>8'<8!'6!90+6+2$!'2!$8+!*'M+0!7!/F/!6(E/$(E+&'26U!6(;!lN!0+*+/6+!>'**!6$'E#*/$+!$8+!*'M+0!$(!0+*+/6+!
1lTd,!$(!</#6+!=0(>$8!()!L(2+6!*'2+/0*4!/2&!6()$!$'66#+BU!!/2!/&#*$!>'$8!$8+!*(66!()!=0(>$8!8(0E(2+!
>'**!2($!=+$!6E/**+0;!L#$!>'**!8/M+!$8+!+))+<$6!()!*/<F!()!=0(>$8!8(0E(2+-!>'**!6$/0$!$(!*(6+!E#6<*+!
E/66!/2&!>'**!8/M+!)/6$'2=!849(=*4<+E'/!L<!lN!'6!2(0E/**4!=*#<(2+(=+2'<@!!Y(;!'$6!2($!$8+0+!/2&!2($!
<(2$0'L#$'2=!'6!)#2<!$(!=*#<(=2=+(=+2+6'6;!*+/&'2=!$(!849(=*4<+E'/@!!g8/$!>(#*&!4(#!6++!'2!/!<8'*&n!
J'$#'$/04!_>/0)'6E@!!g(#*&!6++!hypoplasia!?'2<(E9*+$+!&+M+*(9E+2$!()!6(E+$8'2=B@!!Y(;!9'$!
&>/0)'6'E!'6!/2!'2<(E9*+$+*4!&+M+*(9+&!<8'*&;!L#$!+M+04$8'2=!*((F6!2(0E/*@!!g8/$!'6!$8+!L+6$!
6$'E#*/$'(2!$+6$!$(!6++!')!4(#!/0+!lN!(0!1lTd,!&+)+<'+2$n!Y*++9@!!b(#!=0(>!>8+2!4(#!6*++9!7!+:/<$*4!
/$!e!/E!?$8/$Q6!>8+2!lN!<(E+6!(#$B@!!Y(;!$8+!L+6$!$+6$!'6!6*++9'2=;!$8+2!<8+<F'2=!L*((&!/$!e!/E!?')!
'$!'62Q$!4(#0!&+)B@g84!'6!8'6$'&'2+!/2&!/0='2'2+!&+)'<'+2$n!!I8+4!/0+!+66+2$'/*!$(!2(0E/*!=0(>$8!()!/!
<8'*&!L<!$8+4!6$'E#*/$+!=0(>$8!8(0E(2+@!!I8+6+!/0+!L/6'<!//Q6@!!I8'6!'6!>84!>$!*')$+06!L#4!/0=Z8'6!
6#99*+E+2$6@!!Y(;!L+6$!$+6$!'6!6*++9;!)(**(>+&!L4!E+/6#0'2=!/0=!/2&!8'6!*+M+*6@!!I8+!$8'0&!8(0E(2+!
$(!=(!'6!IYN;!>8'<8!*+/&6!$(!849($840('&'6E!?$8+0+)(0+!*(>!IYN!/2&!*(>!I^!7!<(*&!'2$(*+0/2<+;!
L0'$$*+!8/'0;!)/$'=#+;!&+*/4+&!0+)*+:+6B@!!I8+!2+:$!$8'2=!$8/$!=(+6!'6!%.IN!;!*+/&'2=!$(!
849(<(0$'6/*'6E@!g'**!L+!)/$'=#+!>'**!/!*(>!<(0$'6(*!*+M+*@!!g'**!/*6(!*+/&!$(!849(=*4<+E'/!L<!<(0$'6(*!'6!
=*#<(2+(=+2'<@!!I8/$!*/6$!$8'2=!$(!*(6+!'6!90(*/<$'2@!
!
Diabetes Insipidus
.+2$0/*!?*/<F'2=!%_NB!M6!"+980(=+2'<!?F'&2+4!&(+62Q$!0+69(2&!$(!%_NB!
!
.+2$0/*-!(2+!()!$8+!<(EE(2!</#6+6!'6!</0!/<<'&+2$;!*+/&'2=!$(!8+/&!$0/#E/@!!I8+!8+/&!'6!68')$+&!
/2&!6$/*F!'6!6+M+0+&@!!G2+!()!$8+!)'06$!$8'2=6!$8/$!=(+6!'6!%_N!L<!'$!'6!E/&+!'2!$8+!6#90/(9'$'<!
9/0/M+2$0'<#*/0!2#<*+#6!()!$8+!849($8/*/E#6@!!12!$8+!6/E+!2+0M+!'$!'6!E/&+!'2;!'$!=(+6!&(>2!$8+!
6$/*F!/2&!'6!6$(0+&!'2!$8+!JGYI[R1GR!9'$#'$/04@!!Y(;!')!4(#!6+M+0!$8/$!6$/*F;!4(#!6+M+0!$8+!<(22+<$'(2!
/2&!*+/&6!$(!%_N!&+)@!!!%*6(!&+)!'2!/**!$8+!0+*+/6'2=!)/<$(06!$8/$!/0+!E/&+!'2!$8+!849($8/*/E#6!$8/$!
6$'E#*/$+!$8+!9'$#'$/04;!*+/&'2=!$(!849(9'$#'$/0'6E!?+M+2$#/**4!7!L#$!'2'$'/**4!>'**!8/M+!6Z6!()!_1!C!
9(*4#0+/!/2&!$80'6$B@!!!
!
"+980(=+2'<-!8/M+!%_N;!L#$!&(+62Q$!>(0F!(2!$8+!<(**+<$'2=!$#L#*+!$(!E/F+!'$!9+0E+/L*+!$(!)0++!
>/$+0@!!G$8+0!9(*4#0+/Q6!?_K!7!E+<8!C!(6E($'<!&'#0+6'6;!9(*4&'9'6'/!7!E+<8!C!&0'2F!$((!E#<8!>/$+0!
?964<8(*(='</*!90(L*+EB;!849+0</*<+E'/!*+/&6!$(!9(*4#0+/B@!
.(26$/2$*4!&'*#$'2=;!L#$!>'**!2+M+0!L+!/L*+!$(!<(2<+2$0/$+!#0'2+U!Y1%_N!'6!$8+!+:/<$!(99(6'$+;!>8+0+!
%_N!'6!/*>/46!$8+0+;!/2&!>'**!<(26$/2$*4!<(2<+2$0/$'2=;!/2&!>'**!2($!L+!/L*+!$(!&'*#$+@!!12!_1;!
<(26$/2$*4!&'*#$'2=!#0'2+;!*(6'2=!)0++!>/$+0;!/2&!>'**!2+M+0!L+!/L*+!$(!<(2<+2$0/$+!$8+!#0'2+@!!Y(;!4(#!
/0+!*(6'2=!/**!$8+!>/$+0;!/2&!6+0#E!"/!>'**!=(!#9;!<(00+*/$'2=!>'$8!/2!'2<0+/6+&!9*/6E/!(6E(*/*'$4!
?L<!E(6$!()!9*/6E/!(6E(*/*'$4!'6!"/B@!
!!!
To test: restrict water!7!'2!!/!2(0E/*!9+06(2;!')!4(#!0+6$0'<$!>/$+0;!$8+!9*/6E/!(6E(*/*'$4!>'**!=(!
#9!$(!HrH!?$8+!#99+0!*'E'$!()!2(0E/*!)(0!$8+!(6E(*/*'$4B;!èV!#0'2+!(6E(*/*'$4!!d!>8/$!&(+6!$8/$!
E+/2n!J$!'6!<(2<+2$0/$'2=!$8+!#0'2+@!!Y(;!')!4(#!/0+!&+90'M'2=!/!2(0E/*!9$!()!>/$+0;!'$!68(#*&!
<(2<+2$0/$+!$8+!#0'2+U!>/$+0!'6!L+'2=!0+$/'2+&!=+$!'2$(!$8+![.T!$(!=+$!$8+!6+0#E!"/!'2$(!2(0E/*!
0/2=+@!!
!
[:/E9*+-!9$!0+6$0'<$+&!>/$+0!/2&!8/M+!/!P,r!/2&!P,H!9*/6E/!(6E(*/*'$4!?>8'<8!'6!+*+M/$+&B@!!Y(;!
$8+4!8/M+!849+02/$0+E'/@!!1)!4(#!*((F!/$!#0'2+!(6E(*/*'$4;!'$!'6!,,V!/2&!rt@!!Y(!4(#!F2(>!$8/$!8/M+!
208

_1@!!Y(;!8(>!&(!4(#!&'6$'2=#'68!<+2$0/*!)0(E!2+980(=+2'<n!l'M+!$8+E!%_N!?/F/!M/6(90+66'2B@!!Y(;!
4(#!='M+!'$!$(!$8+E!/2&!6++!>8/$!8/99+26!$(!#0'2+!(6E(*/*'$4@!
If it increases greater that 50% from the baseline: then its central.!!!
It its less than 50% its nephrogenic.!!Y(;!=/M+!%_N!$(!)'06$!=#4!/2&!'$!#0'2+!(6E(*/*'$4!<8/2=+!
$(!eeV;!'2&'</$'2=!$8/$!8+!8/6!<+2$0/*!_1@!!T(0!$8+!6+<(2&!9$;!%_N!>/6!='M+2;!L#$!(2*4!/!*'*!'2<0+/6+!
'2!#0'2+!(6E/*/*'$4;!'2&'</$+&!2+980(=+2'<!_1@!!!
!
Acromegaly
g8/$!'6!<8+/9+6$!>/4!)(0!6<0++2'2=!)(0!/<0(E+=/*4n!%6F!)(0!/2!(*&!9'<!()!$8+!9$!,V!4+/06!/=(@!!
l'=/2$'6E!'2!F'&!L<!+9'9846+6!8/M+2Q$!)#6+&;!$8+0+)(0+!/2!+:<+66!'2!lN!/2&!1lTd,!*+/&!$(!/2!
'2<0+/6+!'2!*'2+/0!=0(>$8@!!S/&!&c!L<!</2!&'+!)0(E!</0&'(E4(9/$84@!!Y(;!$8+4!8/M+!+:<+66!lN!/2&!
+:<+66!1lTd,@!!Y(;!>8/$!')!4(#Q0+!/2!/&#*$!>'$8!/<0(E+=/*4n!g'**!2($!=+$!$/**+0!L<!$8+!+9'9846+6!8/M+!
)#6+&;!L#$!L(2+6!>'**!=0(>!>'&+0@!!G2+!()!$8+!L(2+6!'2!$8+!8+/&!$8/$!&(+6!$8/$!'6!$8+!)0(2$/*!L(2+6;!
6(!$8+4!6$'<F!(#$@!!Y(;!=+$!/!=(0'**/!*'F+!'2<0+/6+!'2!$8+!)0(2$/*!*(L+!?L<!'$!'2<0+/6+6!6'c+!()!$8+!
6'2#6+6B;!6(!$8+!8/$!6'c+!>'**!'2<0+/6+@!!!b(#0!8/2&6!=+$!L'==+0;!)++$!=+$!L'==+0;!/2&!+M+04!(0=/2!'2!
$8+!L(&4!=+$6!L'==+0@!!%*6(;!4(#!90(&#<+!/!</0&'(E4(9/$84;!>8'<8!*+/&6!$(!&+/$8@!!!
!
Galactorrhea/Prolactinoma
!
K+2!&(!2($!=+$!=/*/<$(008+/!L<!>+!&(2Q$!8/M+!+2(#=8!$+0E'2/*!*(L#*+6!$(!E/F+!$8+!E'*F@!!Y(;!')!/!
E/*+!8/6!/!90(*/<$'2(E/;!&(!2($!+:9+<$!8'E!$(!8/M+!=/*/<$(008+/@!!I8'6!8/6!E/24!</#6+6@!!g8+2!
>(E/2!<(E+6!'2!>'$8!'$;!E/F+!6#0+!4(#!/6F!>8/$!&0#=!$8+4!/0+!(2!d!L<!$8+0+!/0+!E/24!&0#=6!$8/$!
</2!6$'E#*/$+!90(*/<$'2!642$8+6'6@!!!
!
[:/E9*+--!G.JQ6;!84&0/*/c'2+;!./!<8/22+*!L*(<F+06;!964<8($0(9'<!&0#=6@!!J0'E/04!849($840('&'6E!</2!
/*6(!L+!/!</#6+;!$8+0+)(0+!=+$!/!IYN!*+M+*@!!g84n!S<!')!4(#!8/M+!8/68'E($(Q6;!2($!(2*4!'6!IYN!
'2<0+/6+&;!L#$!4(#!/*6(!8/M+!'2<0+/6+&!IRN@!!IRN!'6!#6+&!/6!/!6$'E#*/$'(2!$+6$!)(0!90(*/<$'2@!!Y(;!
4(#!E#6$!0#*+!(#$!849($840('&'6E!'2!/!>(E/2!>'$8!=/*/<$(008+/!?6(!'2!$8'6!</6+;!$8+0+!'6!2($8'2=!
>0(2=!>'$8!$8+!9'$#'$/04;!L#$!$8+!$840('&;!*+/&'2=!$(!=/*/<$(008+/B@!So, must r/o hypothyroidism@!!!
!
1)!/**!$8'6!'6!0#*+&!(#$!/2&!9$!8/6!8'=8!90(*/<$'2!*+M+*;!&:!'6!90(*/<$'2(E/!?/24!$'E+!$8+0+!'6!/!
90(*/<$'2!*+M+*!(M+0!HVV!'$!'6!/*>/46!/!90(*/<$'2(E/B@!!g8+2!9$6!8/M+!90(*/<$'2(E/;!>84!&(!$8+4!
&+M+*(9!/E+2(008+/n!S<!90(*/<$'2!8/6!/!2+=/$'M+!)++&L/<F!(2!l2RN@!!Y(;!$8'6!'6!/!<8+/9!L'0$8!
<(2$0(*!9'**!)(0!$8+!)'06$!$80++!E(2$86!/)$+0!90+=2/2<4!L<!E(E!'6!L0+/6$!)++&'2=;!/2&!$8+!8'=8!
90(*/<$'2!*+M+*6!/0+!)++&'2=!L/<F!(2!$8+!9'$#'$/04!(2!l2RN@!
!
Thyroid
I840('&!6$#&'+6!7!&(!"GI!8/M+!$(!F2(>!0+6'2!IP!#9$/F+!/2&!I^!'2&+:+6U!P!$8'2=6!2++&!$(!F2(>-!I^;!
IYN;!1!,P,!#9$/F+!!
1)!IYN!'6!2(0E/*;!$8+!$840('&!'6!2(0E/*@!!1)!IYN!'6!&+<0+/6+&;!9$!8/6!849+0$840('&'6E!(0!
849(9'$#'$/0'6E@!!1)!IYN!'6!'2<0+/6+&;!8/M+!8'=8!90'E/04!849($840('&'6E@!!!
!
I840('&!L'2&'2=!=*(L#*'2!'6!$8+!L'2&'2=!90($+'2!)(0!$840('&!8(0E(2+!
!
g8/$!'6!$8+!L'2&'2=!90($+'2!)(0~!
<(0$'6(*n!I0/26<(0$'2U!!
</*<'#En!%*L#E'2U!!
209

T+n!I0/26)+00'2U!!
.#n!.+0#*(9*/6E'2U!>8/$!W!()!L'2&'2=!6'$+6!(<<#9'+&n!PVWB@!
!
P!()!r!L'2&'2=!6'$+6!(2!ISl!/0+!(<<#9'+&!L4!$840('&!8(0E(2+@!!!
!
T0++!I^!*+M+*@!!g8+2!>+!E+/6#0+!$($/*!I^!*+M+*;!$8+0+!'6!)0++!I^!/2&!L(#2&!I^@!!I8+!)0++!I^!'6!$8+!
9/0$!$8/$!'6!E+$/L(*'</**4!/<$'M+!/2&!'6!<(2M+0$+&!$(!IP@!!I8'6!9/0$!'6!&('2=!/**!$8+!>(0F!?$8/$!9/0$!
$8/$!'6!L(#2&!'6!2($B@!
!
g8/$!8/99+26!')!4(#!/0+!(2!/2!G.J!>'$8!/2!'2<0+/6+!()!+6$0(=+2n!ISl!/2&!$0/26<(0$'2!'2<0+/6+@!!
Y(;!'2<0+/6+&!642!ISl;!/2&!'6!'EE+&'/$+*4!,ZP!(<<#9'+&!?r!6'$+6!(2!ISl;!/2&!,ZP!(<<#9'+&!L4!I^;!
6(!$8/$!'6!P!I^Q6B@!!S<!+M+04$8'2=!'6!'2!+D#'*'L0'#E;!$8+!$840('&!6+26+6!$8/$!'$!*(6$!P!I^Q6!/2&!0+9*/<+6!
$8+E!'EE+&'/$+$*4@!!Y(;!8/6!$8+!TR[[!I^!/*$+0+&n!"(@!!Y(!>8/$!'6!$8+!IYNn!"(0E/*@!!g8/$!'6!$8+!
I^n!12<0+/6+&!?L#$!$8+!)0++!8(0E(2+!*+M+*!/2&!IYN!2($!/*$+0+&B@!!Y(;!/2!'2<0+/6+!I^!>'$8!/!2(0E/*!
IYN!E+/26!$8+!9$!'6!(2!+6$0(=+26@!!I8'6!'6!$0#+!)(0!/24!>(E/2!(2!+6$0(=+2!(0!/24!90+=2/2$!
>(E+2@!!Y(;!$8+!$($/*!I^!'6!+*+M/$+&!L<!'2<0+/6+&!ISl!?2($!L+!'2<0+/6+&!)0++!8(0E(2+!*+M+*B!/2&!'$!
/#$(E/$'</**4!8/6!P!6'$+6!(<<#9'+&!L4!I^B@!Y/E+!'6!$0#+!)(0!<(0$'6(*!7!')!9$!'6!90+=2/2$!(0!(2!G.J;!
<(0$'6(*!'6!+*+M/$+&!L#$!&(!2($!8/M+!6'=26!()!<#68'2=6@!g84n!S<!$0/26<(0$'2!'6!'2<0+/6+&!L<!+6$0(=+2!
'2<0+/6'2=!$8+!642$8+6'6!()!'$;!6(!$8+0+!'6!E(0+!<(0$'6(*!L(#2&!$(!'$;!L#$!$8+!)0++!<(0$'6(*!*+M+*6!/0+!
6$'**!2(0E/*@!!!
!
[:/E9*+--!')!)(($L/**!9*/4+0Z>$!*')$+0;!/66#E+!9$!'6!(2!/2/L(*'<6@!!I8+4!>(0F!$8+!(99(6'$+@!!%2/L(*'<6!
L0+/F!&(>2!90($+'26!$8/$!4(#!2(0E/**4!>(#*&!#6+!)(0!($8+0!$8'2=6!$(!L#'*&!#9!/2&!9#$!$8+E!'2$(!
E#6<*+@!I8+!90($+'26!'$!*'F+6!$(!=(!/)$+0!'6!L'2&'2=!90($+'26@!!Y(;!>8+2!$8+4!/0+!(2!/2/L(*'<6;!$840('&!
L'2&'2=!=*(L#*'2!'6!&+<0+/6+&!L<!$8+!//Q6!$8/$!4(#!>(#*&!8/M+!#6+&!$(!E/F+!$8+!L'2&'2=!90($+'2!/0+!
'26$+/&!#$'*'c+&!$(!E/F+!E#6<*+6!6$0(2=+0@!!Y(;!$8+4!>(2Q$!>(0F!')!4(#!/0+!2($!>(0F'2=!//!
6#99*+E+2$6@!!
!
[:/E9*+-!9$!(2!/2/L(*'<6;!6(!*+66!ISl!L+'2=!642$8+6'c+!L<!90($+'26!L+'2=!#6+&!+*6+>8+0+!?E#6<*+6B@!!
I8+!6/E+!2#EL+0!()!6'$+!/0+!(<<#9'+&;!L#$!E'66'2=!ISl@!!Y(;!)0++!I^!'6!$8+!6/E+;!L#$!E'66'2=!ISl@!!
Y(;!')!/!9+06(2!8/6!/!*(>!I^!>'$8!/!IYN;!$8+4!/0+!(2!/2/L(*'<!6$+0('&6@!!1)!/!>(E/2!8/6!/!8'=8!I^!
/2&!/!2(0E/*!IYN;!>8/$!'6!68+!(2n![6$0(=+2@!!1)!/!9+06(2!8/6!8'=8!I^!/2&!*(>!IYN;!>8/$!&(!$8+4!
8/M+n!N49+0$840('&'6E@!!1)!9$!8/6!*(>!I^!/2&!'2<0+/6+&!IYN;!>8/$!&(!$8+4!8/M+n!Primary
hypothyroidism@!_(!2($!2++&!0+6'2!IP!#9$/F+!$(!E/F+!$8+6+!&:Q6@!
!
I 131 uptake '6!/!0/&'(/<$'M+!$+6$!?0+E+EL+0!$8/$!$840('&!8(0E(2+!'6!$40(6'2+!>'$8!'(&'2+!(2!'$B@!!
?g8/$!/0+!($8+0!$8'2=6!'2M(*M+&!>'$8!$40(6'2+n!K+*/2'2;!$40(6'2+!$40(6'2/6+;!&(9/E'2+!7!=(+6!'2$(!
$8+!=(*='!/99/0/$#6!/2&!L+<(E+6!E+*/2'2;!98+24*/*/2'2+;!&(9/E'2+;!&(9/;!"[;!+9'!
?</$+<8(*/E'2+6B;!')!4(#!9#$!'(&'&+6!(2!$40(6'2+!4(#!8/M+!$840('&!8(0E(2+B@!!Y(;!>'$8!
849+0$840('&'6E!?'+!=0/M+6B;!$840('&!=*/2&!>'**!L+!E/F'2=!E(0+!$840('&!8(0E(2+@!!g(#*&!>+!2++&!
E(0+!'(&'&+!$(!&(!$8'6n!b+6@!!Y(;!')!4(#!=/M+!/!9$!0/&'(/<$'M+!'(&'&+;!>'**!$8+0+!L+!'2<0+/6+&!#9$/F+!
()!0/&'(/<$'M+!'(&'&+!'2!$8/$!(M+0/<$'M+!=*/2&n!b+6@!!Y(;!>'**!8/M+!'2<0+/6+&!1,P,!#9$/F+@!!g8/$!')!1!
>+0+!$/F'2=!+:<+66!$840('&!8(0E(2+!$(!*(6+!>+'=8$!7!>8/$!>(#*&!$8/$!&(!$(!E4!IYN!*+M+*n!Y#990+66!
'$@!!Y(;!>8+2!$8/$!9$!'6!$/F'2=!$((!E#<8!8(0E(2+;!$8+!=*/2&!8/6!/$0(98'+&@!!Y(;!')!4(#!8/M+!/!
0/&'(/<$'M+!1!,P,;!>(#*&!$8+0+!L+!/2!'2<0+/6+&!#9$/F+n!"(!L<!'6!8/6!/$0(98'+&@!Y(;!0/&'(/<$'M+!1!,P,!
'6!$8+!E/'2!>/4!$(!&'6$'2=#'68!>8+$8+0!/!9+06(2!8/6!$0#+!+M'&+2<+!()!849+0$840('&'6E!?lX%"_!'6!
E/F'2=!$((!E#<8!$840('&!8(0E(2+B!M6!6(E+(2+!$8/$!'6!6#00+9$'$'(#6*4Z9#09(6+*4Z#2F2(>'2=*4!$/F'2=!
$((!E#<8!$840('&!8(0E(2+!/2&!90(&#<'2=!849+0$840('&'6E@!!1!,P,!'6!$8+!L+6$!$+6$!$(!&'6$'2=#'68!
210

$8+6+!$>(!$49+6!()!849+0$840('&'6E@!!Y(;!')!'$6!'2<0+/6+&;!9$!8/6!=0/M+6!?=*/2&!'6!#6'2=!'$BU!')!'$6!
&+<0+/6+&;!9$!'6!$/F'2=!$840('&!8(0E(2+@!!!
[:/E9*+--!9$!)0(E!>$!*(66!<*'2'<!7!$8+4!/0+!$/F'2=!$840('&!8(0E(2+;!6(!$8+4!>'**!*(6+!>$!/$!$8+!
+:9+26+!()!849+0$840('&'6E!
!
Y*'&+-!E'&*'2+!<46$!7!&:n!Thyroglossal cyst. R+E+EL+0!$8/$!$8+!$840('&!=*/2&!>/6!(0'='2/**4!/$!$8+!
L/6+!()!$8+!$(2=#+!/2&!E'=0/$+6!&(>2!$8+!E'&*'2+!$(!$8+!<#00+2$!*(</$'(2@!!!
!
Y*'&+-!<46$!'2!/2(*/$+0/*!9(0$'(2!()!2+<F!7!&:n!S0/2<8'(<*+)$!<46$!
?F2(>!/**!L0/2<8'(<*+)$!&+0'M/$'M+6!7!+69!$8+!(2+!'2!$8+!8+/&!/0+/B@!
!
Thyroiditis!?'2)*/EE/$'(2!()!$8+!$840('&B!
I8+!(2*4!'E9!(2+!'6!8/68'E($(Q6!!
!
Graves Dz!7!+:(98/*E(6!Unique to Graves Dz!7!+:<+66!l%lQ6!&+9(6'$+&!'2!(0L'$/*!)/$;!/2&!
9#68'2=!$8+!+4+!(#$!?9/$8(2(E(=2'<!)(0!=0/M+6BU!/9/$8+$'<!=0/M+6!
GX_!9+(9*+!>'$8!=0/M+6!&c!8/M+!8+/0$!90(L!>'$8!/$0'/*!)'L@!!I8+4!=+$!8+/0$!E/2')+6$/$'(26@!!Y(;!/24!
9$!>'$8!/$0'/*!)'L;!E#6$!=+$!/!IYN!*+M+*!$(!0#*+!(#$!=0/M+6@!
!
s/s hyperthyroidism:
!
8+/$!'2$(*+0/2<;!6'2#6!$/<84;!/$0'/*!)'L;!L0'6F!0+)*+:+6;!&'/008+/;!646$(*'<!NI";!849+0</*<+E'/;!
'2<0+/6+&!L(2+!$#02(M+0!?/**!64E9$(E6!/0+!/&0+2+0='<!7!$8+4!/0+!/**!</$+<8(*/E'2+!$8'2=6!7!>84n!
I^!'2<0+/6+6!$8+!642$8+6'6!()!L+$/!0+<+9$(06!?</$+<8(*/E'2+6!/0+!<(#6'26!()!I840('&!8(0E(2+!/2&!
$8+4!>(0F!$(=+$8+0@!!%**!$8+!64E9$(E6!/0+!/&0+2+0='<@!!g8/$!'6!$8+!1"1I1%X!R:!()!=0/M+6n!S+$/!
L*(<F+06!?L*(<F'2=!/&0+2+0='<!0+69(26+;!$8+2!='M+!JI\!$(!6$(9!$8+!=*/2&!)0(E!E/F'2=!'$!7!</2!6$(9!
/**!$8+!64E9$(E6!>'$8!L+$/!L*(<F+0!+:<+9$!(2+!7!6>+/$'2=B!!
6(;!$840('&!6$#&'+6!(2!=0/M+6!9$-!I^!'6!8'=8;!IYN!'6!*(>;!1!,P,!'6!N1lN!
!
%#&'(!T'*+!_/4e!sP![2&(<!
!
In hyperthyroidism,!>/2$!$(!/*>/46!*((F!/$!$8+!)/<+!/2&!>'**!6++!9+0'(0L'$/*!9#))'2+66;!>8'<8!'6!
6++2!/!*($!L<!()!l%lQ6!?/*6(!'2!M(</*!<(0&6;!*+/&'2=!$(!8(/06+2+66;!$'L'/*!/0+/!*+/&'2=!$(!2(29'$$'2=!
+&+E/B!!
!
Mitral Valve Prolapse!/*6(!8/6!/2!'2<0+/6+!'2!l%l6!L<!&+0E/$/2!6#*)/$+!'6!0+69(26'L*+!)(0!</#6'2=!
+:<+66!/2&!0+&#&+2<4!()!$8+!M/*M+B@!!%*6(!6++2!'2!N/68'E($(6@!!l0/M+6!'6!&#+!$(!1=l!%L!/=/'26$!IYN!
0+<+9$(0;!</#6'2=!'$!$(!642$8+6'c+!$((!E#<8@!!g8/$!$49+!()!NJb!0:2!'6!$8'6n!I49+!11!?%L!/=/'26$!$8+!
0+<+9$(0BU!Kl!'6!/*6(!$49+!11!NJb!?8/M+!%L!/=/'26$!0+<+9$(0!>8'<8!'6!&+6$0(4'2=!$8+!0+<+9$(0B@!!12!
8/68'E($(Q6!$840('&'$'6;!$8+4!/*6(!8/M+!/2!1=l!/=/'26$!$8+!0+<+9$(0;!+:<+9$!'26$+/&!()!/<$'M/$'2=!$8+!
=*/2&;!'$!!'28'L'$6!'$@!!Y(;!'2!N/68'E($(Q6!/2&!l0/M+6;!$8+6+!/0+!L($8!/#$('EE#2+!&cQ6!L#$!/$!(99(6'$+!
+2&6!()!$8+!69+<$0#E@!!G2+!/6!6$'E#*/$(04!1=l!>8'*+!$8+!($8+0!8/6!/2!'28'L'L'$(04!(2+@!!Y(;!/2!
(M+0*4'2=!64E9$(E!$8/$!$8+4!L($8!8/M+!'6!90+$'L'/*!E4:+&+E/!/2&!l%l!&+9(6'$'(2@!!g8+0+!&(!4(#!
6++!/!&+<0+/6+!'2!l%lQ6!?'+!E+$/L(*'6E!()!l%lQ6Bn!X46(6(E/*!6$(0/=+!&c6!7!N#0*+06;!N#2$+06!7!2++&!
*46(6(E/*!+2c4E+6!)(0!L0+/F'2=!&(>2!&+0E/$/2!6#*)/$+;!+$<A!
!
s/s hypothyroidism
!
211

>+/F2+66!?K.B!L<!/**!9$6!>'$8!849($840('&'6E!8/M+!90(:'E/*!E#6<*+!E4(9/$84;!6(!$8+4!</22($!=+$!
#9!(#$!()!<8/'06!;!6+0#E!.5Q6!/0+!+*+M/$+&@!!%*6(!8/M+!L0'$$*+!8/'0;!<(#06+!6F'2;!6*(>!E+2$/$'(2;!
9+0'(0L'$/*!9#))'2+66;!&+*/4+&!0+)*+:;!&'/6$(*'<!NI"!
!
Y*'&+-!!L:!()!$840('&!=*/2&!'2!N/68'E($(6Q6!7!2(!)(**'<*+;!L#$!&(!6++!=+0E'2/*!)(**'<*+!L<!$8+0+!'6!
/#$('EE#2+!&+6$0#<$'(2!()!$8+!=*/2&@!!I8+0+!/0+!<4$($(:'<!I!<+**6!$8/$!&+6$0(4'2=!'$;!/2&!/0+!
642$8+6'c'2=!%LQ6!?1=l!%L6;!8+2<+!4(#!6++!$8+!=+0E'2/*!)(**'<*+6B;!/2&!$8+0+)(0+!*((F6!*'F+!/!*4E98!
2(&+B@!!g'**!6++!/!*(>!I^;!8'=8!IYN;!*(>!1!,P,!?2($!2+<+66/04!$(!&(!$8'6!$+6$B@!
!
[:/E9*+-!9$!(2!+6$0(=+2!7!>8/$!>'**!8/99+2!$(!I^n!12<0+/6+!IYNn!"(0E/*!?2(!2++&!)(0!1!,P,!7!$8'6!
'6!L/&!L<!L/L'+6!$840('&!>(#*&!$/F+!'$!#9!/2&!'$6!$840('&!>(#*&!$/F+!'$!#9!/2&!*+/&6!$(!<0+$'2'6EB!
$840('&!8(0E(2+!'6!0+69(26'L*+!)(0!L0/'2!=0(>$8!'2!$8+!)'06$!4+/0;!6(!'$!'E9!$(!&(!$840('&!8(0E(2+!
6<0++26!$(!/M('&!<0+$'2'6E!?>'**!L+!6+M+0*4!KR!L<!L0/'2!&+9+2&6!(2!$840('&!8(0E(2+!)(0!
&+M+*(9E+2$B@!!!
!
[:/E9*+-!l0/M+Q6!&c!7!I^!8'=8;!IYN;!*(>;!1!,P,!8'=8!
!
[:/E9*+-!9$!(2!/2/L(*'<!6$+0('&6!7!I^!*(>;!IYN!2(0E/*!
!
[:/E9*+-!N/68'E($(6!7!I^!*(>;!IYN!8'=8;!1!,P,!*(>!
!
[:/E9*+-!)/<$'$'(#6!?$/F'2=!$((!E#<8!$840('&!8(0E(2+!/2&!8/M+!849+0$840('&'6EB!7!I^!8'=8;!IYN!
*(>;!1!,P,!*(>!?E/'2!)/<$(0!$8/$!&'6$'2=#'68+6!)0(E!=0/M+6B!
!
Goiter
%24$'E+!$840('&!'6!L'=@!!X($6!<46$6@!!
MCC goiter = Iodine def
K(6$!()$+2!&#+!$(!*(>!'(&'&+!*+M+*6;!6(!$8+4!8/M+!849($840('&'6E!(0!L(0&+0*'2+!849($840('&'6E;!6(!
$8+!=*/2&6!/0+!=+$$'2=!0+MQ&!#9;!I^!=(+6!#9!/2&!IYN!=(+6!&(>2!?6(!IYN!>'**!L+!6$'E#*/$'2=!'$;!$8+2!
2($;!$8+2!'$!'6;!+$<@@B@!!
R:!()!<8('<+!7!$840(:'2+!
Y(E+$'E+6!8/M+!/!2(&#*+!7!2(&#*+6!$8/$!&+M+*(9!'2!$8+!$840('&!=*/2&!=+$!8+E(008/=+&@!!I8+0+!'6!
6#&&+2!'2<0+/6+!'2!8+E(008/=+!&#+!$(!<46$@!!_:!>'$8!T"%@!I8+2;!='M+!$840('&!8(0E(2+!/2&!E/24!
$'E+6!$8+6+!$8'2=6!>'**!=+$!6E/**+0@!!!
12!$8'6!<(#2$04;!>+!'(&'2'c+!6/*$;!6(!&(2Q$!6++!E#<8@!!N(>+M+0;!6(E+!9*/<+6!9+(9*+!8/M+!'(&'2+!9((0!
&'+$6!7!'+!l0+/$!X/F+6!'2!.8'</=(!/0+/;!S0'$/'2U!>8+2!$8+4!=+$!=0/M+6!&c;!&#+!$(!'2<0+/6+!'2!IP!L<!
$8+4!/0+!'(&'&+!&+)!/2&!&(!2($!8/M+!+2(#=8!'(&'2+@!!!
!
Cold nodule vs Hot Nodule
K+/26!')!2(&#*+!'6!$/F'2=!#9!1!,P,!(0!2($@!!1)!'$!&(+6!2($;!$8+0+!'6!/2!/0+/!()!*#<+2<4;!/2&!$8+0+)(0+!
<(*&@!!1)!'$!'6!8($;!$8+0+!>'**!L+!/!L*/<F!&($@!g84n!S<!')!$8+!2(&#*+!'6!/#$(2(E(#6*4!E/F'2=!$840('&!
8(0E(2+;!>8/$!'6!$8+!IYNn!_+<0+/6+&@!!1)!$8+!IYN!'6!&+<0+/6+&;!>(#*&!$8/$!6#990+66!$8+!2(0E/*!
9(0$'(2!()!$8+!$840('&n!b+6;!6(!'$!#2&+0=(!/$0(984!/2&!2($!$/F+!'$!#9;!*+/&'2=!$(!L*/<F!&($!?>(#*&2Q$!
6++!/24$8'2=!+*6+B@!!g8/$!'6!<8/2<+!$8/$!/!<(*&!2(&#*+!'6!E/*'=2/2$!'2!/!>(E/2n!,edHVW@!!K(6$!
<(*&!2(&#*+6!'2!/2!(*&+0!>(E/2!/0+!L+2'=2@!!K(6$!/0+!<46$6@!!%!6E/**!W!'6!)(**'<#*/0!/&+2(E/@!!%24!
<(*&!2(&#*+!'2!/!K%"!'6!</2<+0!#2$'*!90(M+2!($8+0>'6+@!!%24!<(*&!2(&#*+!'2!/!<8'*&!'6!</2<+0!#2$'*!
90(M+2!($8+0>'6+@!!%24!J[RYG"!$8/$!8/6!L++2!+:9(6+&!$(!0/&'/$'(2!/2&!8/6!/!<(*&!2(&#*+!8/6!
.%".[R!?9/9'**/04!</0<'2(E/!()!$8+!$840('&!7!0/&'/$'(2!+:9(6#0+!'2!8+/&Z2+<F!/0+/B@!!!
!
212

Cancers of the thyroid
"++&!$(!L:!?</22($!$+**!')!E/*'=2/2$!3#6$!L4!*((F'2=!/$!'$B!7!$8'6!'6!$0#+!)(0!)(**'<#*/0!/&+2(E/;!
6(E+$8'2=!Lr;!E#*$'2(&#*/0!=('$+0@!!_(2+!>'$8!T"%@!!!
,@ Papillary cancer!>(#*&!68(>!#9!>'$8!/!<(*&!2(&#*+;!/2&!8/6!Psammoma bodies.!!
J/9'**/04!</0<'2(E/6!E+$6!$(!<+0M'</*!*4E98!2(&+6!2+:$!$(!$8+E@!!I8+4!<(EE(2*4!&(!$8'6;!
/2&!8/M+!/!=((&!90(=2(6'6@!!I8'6!'6!$8+!(2*4!/66(<!>'$8!0/&'/$'(2@!!%22'+!(098/2!2#<*+'@!!!
H@ Follicular cancer!7!H2&!K.!$49+;!'2M/&+6!M+66+*6@!!_(!2($!=(!$(!*4E98!2(&+6@!!Y90+/&!
8+E/$(=+2(#6*4;!$8+0+)(0+!()$+2!=(!$(!*#2=6!/2&!L(2+@!!!
P@ Medullary carcinoma!7!6(E+!</6+6!/0+!69(0/&'<!/2&!($8+0!</6+6!8/M+!%_!0+*/$'(268'9U!
/66(<!>'$8!K["!642&0(E+6!?E#*$'9*+!+2&(<0'2+!2+(9*/6'/!1;!11/;!!11LB!!J'2F!6$/'2!7!6$/'2!>'$8!
<(2=(!0+&!/2&!6++!9(*/0'c+&!/99*+!=0++2!L'0+)0'2=+2<+!C!/E4*('&!%!?>8'<8!</E+!)0(E!
</*<'$(2'2BU!>8/$!'6!$8+!$#E(0!E/0F+0n!./*<'$(2'2!?>8'<8!'6!$8+!6<0++2'2=!$+6$!()!<8('<+B!
!
[:/E9*+-!>8+0+!>(#*&!$8+!</2<+0!L+!*(</$+&!'2!$8+!L(&4!>8+0+!$8+!$#E(0!E/0F+0!'6!<(2M+0$+&!'2$(!
/E4*('&n!Medullary carcinoma of the thyroid!
!
MEN I!7!9'$!$#E(0;!9/0/$840('&!/&+2(E/;!9/2<0+/$'<!$#E(0!?#6#/**4!q(*'2=+0![**'6(2;!*+/&'2=!$(!
9+9$'<!#*<+0B@!
MEN IIa 7!E+&#**/04!</0<'2(E/;!9'$#'$/04!;!98+(<80(E(<4$(E/!
MEN IIb!7!E+&#**/04!</0<'2(E/;!98+(<80(E(<4$(E/;!E#<(6/*!2+#0(E/!!!
N(>!&(!4(#!6<0++2n!R+$!90($((2<(=+2+!?#2'D#+!$(!<(&'2=!)(0!0+<+9$(06!'2!$8'6!642&0(E+B@!!!
!
Prognosis (best to worst): Papillary>Follicular>Medullary
PARATHYROID GLAND
!
J$!</2!8/M+!$+$/24!>'$8!/!2(0E/*!$($/*!./@!!./!'6!L(#2&!/2&!)0++!7!'$Q6!$8+!)0++!./!$8/$!'6!
E+$/L(*'</**4!/<$'M+!?>8'<8!'6!$0#+!)(0!%"b!8(0E(2+!7!$8+!9/0$!$8/$!'6!L(#2&!'6!$($/**4!E+$/L(*'</**4!
'2/<$'M+B@!!Y(;!>8(!&(+6!./!'2$+0/<$!>'$8n!JIN!
!
Y(;!')!./!'6!*(>;!$8+!JIN!'6!8'=8;!/2&!')!./!'6!8'=8;!JIN!'6!*(>@!!R(#=8*4!,ZP!()!$8+!L'2&'2=!6'$+6!'2!
/*L#E'2!/0+!(<<#9'+&!L4!./@!!Y(;!'2!($8+0!>(0&6;!0(#=8*4!^VW!()!$8+!$($/*!./!'6!L(#2&!$(!/*L#E'2@!!
^`W!'6!'(2'c+&!./!)*(/$'2=!/0(#2&!/2&!$8+!0+6$!'6!98(698/$+!/2&!6#*)/$+6@!!I8+!'(2'c+&!./!'6!$8+!
E+$/L(**'</*4!/<$'M+!)(0E@!!K..!(M+0/**!()!849(</*<+E'/!C!849(/*L#E'2+E'/@!!N/M+!*(>!/*L#E'2!
*+M+*;!$8+0+)(0+!&+<0+/6+&!*+M+*;!/2&!*+66!()!/*L#E'2!L'2&6!./@!!Y(;!L+)(0+!4(#!*((F!/$!JIN!*+M+*6;!
*((F!/$!/*L#E'2!*+M+*6!7!')!$8/$!'6!*(>;!$8'6!'6!$8+!</#6+!()!849(</*<+E'/@!!I8'6!'6!2($!/))+<$'2=!$8+!
)0++!8(0E(2+!*+M+*;!3#6$!$8/$!/*L#E'2!'6!&+<0+/6+&@!!I8'6!$8+!6/E+!/6!ISl!L+'2=!&+<0+/6+&;!*+/&'2=!
$(!&+<0+/6+&!I^@!!!
!
Alkalosis (resp or metabolic):!8/M+!&+<0+/6+&!N!'(26;!/2&!9N!'6!'2<0+/6+&@!!g8/$!/0+!$8+!/<'&'<!
//Q6n!l*#$/E/$+;!%69/0$/$+@!!g84!/0+!$8+4!/<'&'<n!N/M+!.GGN!=0(#96!?/6!(99(6+&!$(!L/6'<!//Q6!;!
>8'<8!8/M+!E(0+!L/6'<!"N!=0(#96B@!!
I8+!0+/6(2!>84!/*L#E'2!'6!6#<8!/!=0+/$!L'2&+0!()!./!'6!L<!'$!8/6!$8+!E(6$!2+=/$'M+!<8/0=+6!'2!$8+!
L(&4;!L<!'$!8/6!$8+!E(6$!/<'&'<!//Q6!'2!'$@!Y(;!')!4(#!8/M+!/2!/*F/*($'<!6$/$+!$8+!.GGN!=0(#96!L+<(E+!
.GG!idi!=0(#96@!!S<!')!4(#!8/M+!*+66!N!'(26;!'$6!.GGjdi@!!Y(;!/*L#E'2!8/6!KGR[!()!/!2+=/$'M+!<8/0=+!
'2!/2!/*F/*($'<!6$/$+;!>8'<8!E+/26!'$!</2!L'2&!E(0+!./@!!Y(;!>8+0+!&(+6!'$!=+$!'$!)0(En!1(2'c+&!)0++!
./!?6(!/!L#2<8!()!'(2'c+&!)0++!./!L'2&6!$(!$8+!$8+!/*L#E'2B@!!N(>+M+0;!>+!8/M+!"GI!/*$+0+&!$8+!
$($/*;!3#6$!$((F!'$@!!1$!&(+62Q$!/))+<$!$8+!$($/*;!L#$!'$!_G[Y!&+<0+/6+!$8+!'(2'c+&!./!*+M+*;!*+/&'2=!$(!
I[I%"b@!Y(;!$($/*!'6!$8+!6/E+;!L#$!$8+!'(2'c+&!*+M+*!8/6!&+<0+/6+&@!!g8/$!'6!$8+!E+<8!()!$+$/24n!
213

N/M+!$80+68(*&!)(0!$8+!%J!L+)(0+!$8+!2+0M+!'6!6$'E#*/$+&@!!I8+2!4(#!8/M+!/!0+6$'2=!E+EL0/2+!
9($+2$'/*@!!Y(;!/!&+<0+/6+&!'(2'c+&!./!*+M+*!>'**!*(>+0!$8+!$80+68(*&!)(0!/<$'M/$'2=!$8+!2+0M+!/2&!
E#6<*+@!!1)!'$6!daV!)(0!2(0E/*!$80+68(*&@!!J$!'6!9/0$'/**4!&+9(*/0'c+&;!$8+0+)(0+!&(+62Q$!$/F+!/!*($!$(!
/<$'M/$+!$8+!E#6<*+!(0!$8+!2+0M+!?>8'<8!'6!$8+!E+<8!()!$+$/24B!7!6(!4(#!/0+!*(>+0'2=!$8+!$80+68(*&@!!
12!849+0</*<+E'/;!$8+!(99(6'$+!(<<#06!/2&!4(#!/0+!'2<0+/6'2=!$8+!$80+68(*&;!6(!'$!$/F+6!E(0+!'(2'c+&!
./!$(!/<$'M/$+!$8+!2+0M+@!!!
!
JIN!(2!4!/:'6!/2&!./!'2!:!/:'6!7!8$!()!6D#/0+!C!JIN!/2&!>'&$8!C!./!
Low serum Ca, low PTH = primary hypoparathyroidism !
MCC = previous thyroid surgery
!
[:/E9*+-!9$!=(+6!'2!$(!0+E(M+!$840('&!</2<+0!?$8+6+!&/46!$8+4!/#$($0/29*/2$!'$!$(!$8+!/0EB!
[:/E9*+-!2+>L(02!>'$8!<4/2(6'6;!'00'$/L*+!/2&!:0/4!()!<8+6$!68(>6!2($!/2$+0'(0E+&'/6$'2#E!68/&(>!
7!&:n!_'l+(0=+!7!849(9/0/$840('&'6E!/2&!2(!$84E#6!
!
[:/E9*+-!low Ca, high PTH = secondary hypoparathyrodism 7!6(!>8/$+M+0!'6!</#6'2=!$8+!
849(</*<+E'/!'6!</#6'2=!/!<(E9+26/$(04!'2<0+/6+!'2!JIN!?</**+&!6+<(2&/04!849(9/0/$840(&'6E!7!$8+!
K..!()!$8'6!'6!0+2/*!)/'*#0+!L<!$8+6+!9$6!8/M+!849(M'$/E'2(6'6!_;!>8'<8!&+<0+/6+6!./!/2&!'2<0+/6+6!
JINB@!!Y(;!/24!&+<0+/6+!'2!./!>'$8!</#6+!/!<(E9+26/$(04!'2<0+/6+!'2!JIN@!!!
!
[:/E9*+-!high Ca, high PTH = primary hyperparathyroidism C!=*/2&!'6!2($!(L+4'2=!2+=/$'M+!
)++&L/<F@!!I8'6!'6!K..!849+0</*<+E'/!'6!/!<(EE#2'$4U!!
1)!9$!'6!'2!/!8(69'$/*;!K..!849+0</*<+E'/!C!E+$6!$(!L(2+!?E/*'=2/2<4!'2&#<+&B@!!K(6$!849+0</*<+E'/!
9$6!/0+!/6E9$(E/$'<U!')!$8+4!%R[!64E9$(E/$'<;!$8+4!8/M+!6$(2+6!?./!6$(2+6;!>8'<8!'6!$8+!K.!
64E9$(E/$'<!90+6+2$/$'(2!)(0!849+0</*<+E'/B@!!!
X/L6-!'2<0+/6+&!./;!'2<0+/6+&!JIN;!*(>!98(698/$+!?2(0E/**4!JIN!'2<0+/6+6!./!0+/L6(09$'(2!/2&!
&+<0+/6+&!98(98(0#6!0+/L6(09$'(2B@!%*E(6$!/*>/46!(M+0!eV!4(!
!
[:/E9*+- high Ca, low PTH = all other causes except primary hyperparathyroidism. K.!
&#+!$(!E/*'=2/2<4@!!./2!JIN!*'F+!9+9$'&+!</#6+!849+0./n!b+6!?6(!')!4(#!E+/6#0+!JIN!'$!>'**!L+!
2(0E/*B@!!YD#/E(#6!<+**!()!$8+!*#2=;!0+2/*!/&+2(</<'2(E/;!(0!E+$6!$(!L(2+!?L0+/F'2=!L(2+!&(>2B;!
6/0<('&6'6!?*+/&'2=!$(!849+0</*<+E'/B;!E#*$'9*+!E4+*(E/!?*+/&'2=!$(!849+0</*<+E'/B!/**!>'**!8/M+!
XGg!JIN@!!Y(;!>8/$!'6!$8+!+cQ+6$!>/4!$(!&+$+0E'2+!849+0./!'2!/!9$n!JIN!*+M+*!
?')!'$6!8'=8;!'$6!90'E/04!849+09/0/$840('&'6EU!')!'$6!*(>;!'$6!/**!$8+!</#6+6!7!'+!E/*'=2/2<4B@!!!
!
ADRENAL GLAND
Cushing Syndrome
J\RJX[!6$0'/+;!(L+6'$4;!$8'2!+:$0+E'$'+6!
K..!C!9$!(2!*(2=!$+0E!6$+0('&!$8+0/94!?'+!9$6!>'$8!0+2/*!$0/269*/2$6;!9$!(2!'EE#2(6#990+66/2$;!
X#9#6B!
!
1)!$8'6!'6!+:<*#&+&;!2++&!$(!$8'2F!()!P!6(#0<+6-!9'$#'$/04!.#68'2=6;!/&0+2/*!.#68'2=6;!+<$(9'<!
.#68'2=6@!g8'<8!()!$8+!$80++!>'**!8/M+!$8+!8'=8+6$!%.IN!*+M+*6n![<$(9'<!?6E/**!<+**!</0<'2(E/B@!!
g8'<8!>(#*&!8/M+!$8+!*(>+6$!%.IN!*+M+*6n!%&0+2/*@!!g84n!S<!'$6!E/F'2=!<(0$'6(*;!>8'<8!>(#*&!
6#990+66!$8+!%.IN@!!J'$!.#68'2=6!'6!#6#/**4!/!Lr!$#E(0!E/F'2=!%.IN@!!!
!
214

I8+0+!/0+!H!=((&!6<0++2'2=!$+6$6!)(0!.#68'2=6!?>8+2!4(#!8/M+!+:<*#&+&!$8+!)/<$!$8/$!$8+4!/0+!2($!
(2!6$+0('&6B@!!I8+!6<0++2'2=!$+6$6!/0+-!H^!80!#0'2+!$+6$!)(0!)0++!<(0$'6(*@!!I8'6!'6!*((F'2=!)(0!<(0$'6(*!'2!
$8+!#0'2+;!2($!/$$/<8+&!$(!/24!90($+'2!?6(!'$Q6!)0++B@!!1$!E#6$!E+/2!$8/$!4(#!8/M+!/!*($!()!+:<+66!()!'$!
$(!8/M+!$8/$!E#<8!()!'$!'2!4(#0!#0'2+@!!I8'6!'6!$8+!S[YI!6<0++2'2=!$+6$!)(0!.#68'2=6@!!I8'6!$+6$!
&'6$'2=#'68+6!.#68'2=Q6!642&0(E+!)0(E!.#68'2=('&!(L+6'$4@!!!
!
[:/E9*+-!6++!(L+6+!9$!>'$8!.#68'2=Q6!64E9$(E6!/2&!4(#!$8'2F!$8+4!8/M+!.#68'2=6U!8(>+M+0;!=+$!/!
H^!80!#0'2+!<(0$'6(*!$+6$!/2&!'$Q6!2(0E/*@!!1)!'$Q6!'2<0+/6+&;!$8+4!$0#*4!8/M+!.#68'2=6!7!'2!($8+0!>(0&6;!
$8+4!8/M+!rrW!6+26!/2&!69+<')'<'$4@!!!
!
I8+4!>'**!/6F!/L(#$!dexmeth suppression test!?*(>!M6!8'=8!&(6+B@!!g8/$!'6!&+:/E+$8/6(2+n!1$Q6!
/!<(0$'6(*!/2/*(=@!!1)!4(#!='M+!&+:/E+$8/6(2+!$(!/!2(0E/*!9+06(2;!'$!>'**!6#990+66!%.IN@!!1)!4(#!
6#990+66!%.IN;!$8+!<(0$'6(*!*+M+*6!>'$8!L+!*(>;!'2&'</$'2=!$8+!<(0$'6(*!*+M+*6!/0+!6#990+66'L*+@!!Y(;!
>8/$!8/99+26!>8+2!4(#!='M+!/!XGg!&(6+!()!&+:/E+$8/6(2+!'2!/!9$!>'$8!.#68'2=6!7!>'**!4(#!
6#990+66!$8+'0!<(0$'6(*n!"(@!Y(;!4(#!6++!!/!*/<F!()!6#990+66'(2@!!I8+0+)(0+!9$!8/6!<#68'2=Q6@!!
N(>+M+0!$8+!XGg!&(6+!3#6$!$+**6!4(#!9$!8/6!.#68'2=6;!2($!>8/$!F'2&!$8+4!8/M+;!6(!'$!3#6$!/!
6<0++2'2=!$+6$!?')!4(#!&'&!/!H^!80!<(0$'6(*!#0'2+!*+M+*;!'$!>(#*&!L+!9(6'$'M+B@!!R+E+EL+0!$8/$!$8+0+!/0+!
$>(!+2&(<0'2+!&cQ6!$8/$!4(#!.%"!6#990+66!7!J1I\1I%Rb!.#68'2=6!/2&!90(*/<$'2(E/@!!Y(;!')!4(#!='M+!
8'=8!&(6+!()!&+:/E+$8/6(2+;!4(#!/0+!/L*+!$(!6#990+66!$8+!%.IN!0+*+/6+!L4!$8+!9'$#'$/04!/2&!
<(0$'6(*!=(+6!&(>2@!!1$!>'**!2($!L+!6#990+66+&!'2!/&0+2/*!/2&!+<$(9'<!.#68'2=6!?6E/**!<+**B@!
zR+/&!*/6$!6+2$+2<+!')!4(#!=+$!/!*(2=!D#+6$'(2{!
!
[:/E9*+-!)(0!(2+!()!$8+6+;!$8+4!>'**!&+6<0'L+!.#68'2=6;!/2&!/6F!/L(#$!&+:E+$8!6#990+66'(2!7!)'06$!
$8'2=!$(!&(!'6!*((F!/$!8'=8!&(6+!6#990+66'(2!7!')!'$6!6#990+66+&;!'$6!/#$(E/$'</**4!9'$#'$/04!<#68'2=6!
?2($!/!8/0&!D#+6$'(2mB!
!
Y(;!>84!&(!$8+!9$6!*((F!*'F+!$8'6n!J$!8/6!849+0<(0$'6(*'6E;!>8'<8!'6!=*#<(2+(=+2'<@!!Y(;!2++&!
6#L6$0/$+6!)(0!=*#<(2+(=+2+6'6!7!E/'2!6#L6$0/$+!'6!//!)0(E!E#6<*+6@!!g8+0+!/0+!$8+!E#6<*+6!
*(</$+&n!%0E6!/2&!*+=6!7!6(!9$!>'**!=+$!/!L0+/F!&(>2!()!E#6<*+!'2!$8+!+:$0+E'$'+6;!>8'<8!'6!>84!$8+4!
8/M+!$8'2!/0E6!/2&!$8'2!*+=6@!!!I8+2!>'**!=+$!/*/2'2+!$0/26/E'2/$+&!/2&!=+$!940#M/$+@!!Y(;!>'**!
/*>/46!8/M+!$8'2!/0E6!/2&!+:$0+E'$'+6@!S<!'$!'6!=*#<(2+(=+2'<;!>8/$!>'**!$8+!=*#<(6+!L+n!N'=8@!!g8/$!
&(+6!$8/$!&(!$(!'26#*'2!0+*+/6+n!12<0+/6+6!'$@!!g8/$!&(+6!'26#*'2!&(!$(!)/$n!12<0+/6+6!)/$!6$(0/=+@!!
g8/$!9/0$!()!$8+!L(&4!8/M+!$8+!E(6$!/&'9(6+n!T/<+!/2&!$0#2F@!!Y(;!4(#!/0+!=+$$'2=!/2!'2<0+/6+!'2!
&+9(6'$'(2!()!Il!'2!$8+!)/<+!/2&!$0#2F!/2&!L/<F@!!Y(;!$8+!$8'2!+:$0+E'$'+6!'6!&#+!$(!L0+/F'2=!&(>2!
E#6<*+!)(0!//Q6!'2!=*#<(2+(=+2+6'6@!!I8+!E((2!)/<'+6;!L#))/*(!8#E9!/2&!$0#2</*!(L+6'$4!'6!&#+!$(!
'2<0+/6+!'2!'26#*'2!/2&!)/$!&+9(6'$'(2@!!I8+!6$0+$<8!E/0F6!/0+!&#+!$(!(L+6'$4;!/2&!$8+4!/0+!9#09*+!L<!
<(0$'6(*!&+<0+/6+6!<(**/=+2!642$8+6'6@!!g'**!=+$!6$0#<$#0/**4!>+/F+0!<(**/=+2@!!1$6!*'F+!9#09#0/!>'$8'2!
$8+!6$0+$<8!E/0F!?*'F+!6+2'*+!9#09#0/B@!!S0+/F!&(>2!$8+!M+66+*6!L<!'2<0+/6+!'2!<(0$'6(*@!!!
!
[:/E9*+- Trousseaus sign!7!6'=2!()!$+$/24U!$8'6!9$!8/6!NI";!849+02/$0+E'/;!849(F/*+E'/;!/2&!
E+$/L(*'<!/*F/*(6'6!7!&:n!J0'E/04!/*&(6$+0(2'6E@!!?8/M+!$+$/24!L<!/*F/*(6'6!7!2+=!<8/0=+6!(2!
/*L#E'2!/0+!'2<0+/6+&;!/2&!'(2'2c+&!./!*+M+*!&+<0+/6+6B@!!%F/!.(22Q6!642&0(E+!
!
Adrenal Medulla tumors
MC in adults = pheochromocytoma (Lr;!NI"B!?6(;!/&#*$;!NI";!$#E(0!'2!/&0+2/*!E+&#**/!C!
98+(BU!8/M+!#26$/L*+!NI"!7!/2:'+$4;!6>+/$!/!*($U!=+$!/!H^!80!#0'2+!$+6$!)(0!kK%!/2&!E+$+2+980'2+!
?$8+6+!/0+!E+$/L(*'<!+2&90(&#<$6!()!"[!/2![9'!?6(;!/2:'(#6;!6>+/$'2=;!NI"B@!!%0+!$8+0+!/66(<!>'$8!
98+(<80(E(<4$(E/n!b+6!7!K["!11/!/2&!K["!11L;!2+#0()'L0(E/$(6'6!?'+!9$!>'$8!2+#0()'L0(E/$(6'6!
>'$8!NI"!7!>8/$!$+6$!4(#!=+$n!kK%!/2&!E+$/2+980'2+!H^!80!#0'2+;!L<!8'=8!/66(<!>'$8!98+(B@!
215

K.!'2!F'&6!C!2+#0(L*/6$(E/!?K%X1l"%"IB!
S($8!()!$8+6+!/0+!)0(E!0+2/*!E+&#**/;!L($8!/0+!2+#0/*!<0+6$!(0'='2;!L($8!90(&#<+!NI"@!!J8+(!C!
/&#*$6!U!2+#0(!d!F'&6!!!!!!!
!
Waterhouse Friderichsen Syndrome
"@!E+2'='$'&'6!
[:/E9*+--!,H!4(;!=0/E!idi!&'9*(<<(<#6;!8'=8!)+M+0;!2#<8/*!0'='&'$4;!69'2/*!$/9!)(#2&!2+#$0(98'*6!/2&!
=0/E!idi;!F'&!$8+2!]<0/68+&Q!7!6$/0$+&!$(!=+$!9+$+<8'/*!*+6'(26!/**!(M+0!$8+!L(&4;!849(M(*+E'<!68(<F;!
&'+&;!(2!/#$(964!L($8!/&0+2/*!=*/2&6!/0+!8+E(008/=+&!7!_:n!!g/$+08(#6+!T0+'&0'<F6(2!
MCC meningitis from 1 month to 18 yrs of age = N meningitidis.!!1$!'6!$8+!G"Xb!E+2'2='$'6!
>'$8!9+$+<8'/*!*+6'(26!?/2&!$8+4!/*>/46!E+2$'(2!$8'6B@!
!!
Y(;!')!$8+4!='M+!E+2'2='$'6!/2&!9+$+<8'/;!F2(>!'6!"!E+2'2='$'6@!!1)!$8+4!/0+!849(M(*+E'<;!$8+4!
8+E(008/=+&!$8+'0!/&0+2/*6!/2&!>+2$!'2$(!849M(*+E'<!68(<F;!/*6(;!$8+4!8/M+!2(!<(0$'6(*!(0!
E'2+0/*(<(0$'<('&6@!!!
!
Cause of hypocortisolism that is chronic = Addisons dz
K..!%&&'6(26!C!/#$('EE#2+!&+6$0#<$'(2!()!$8+!=*/2&!?#6+&!$(!L+!IS!&#+!$(!/#$('EE#2+!
&+6$0#<$'(2B@!!I8+!+2$'0+!/&0+2/*!<(0$+:!'6!&+6$0(4+&;!$8+0+)(0+!$8+!E'2+0/*(<(0$'<('&6!/2&!
=*#<(<(0$'<('&6!/0+!*(>@!!Y(;!$8+0+!'6!*(>!<(0$'6(*!>'$8!N1lN!%.IN@!!g8/$!&(+6!$8/$!&(!$(!
E+*/2(<4$+6n!12<0+/6+6!$8+E;!*+/&'2=!$(!849'=E+2$/$'(2!'2!$8+!E(#$8!/2&!+*6+>8+0+@!!I8+0+!'6!"G!
/*&(6$+0(2+@!!I8+0+!/0+!H!9#E96!?"/Z5!9#E9!/2&!90($(2Z5!9#E9B@!!%0+!4(#!=(22/!*(6+!"/n!b+6!7!
>8'<8!>'**!*+/&!$(!849(2/$0+E'/!/2&!NbJ[RF/*+E'/!?9+/F+&!I!>/M+6B@!!!g'**!4(#!L+!/L*+!$(!=+$!0'&!
()!$8+!90($(26!'2!$8+!#0'2+n!"(!7!$8+0+)(0+!>'**!8/M+!E+$/L(*'<!/<'&(6'6@!!Y(;!4(#!8/M+!
849(2/$0+E'/;!849+0F/*+E'/;!E+$/L(*'<!/<'&(6'6;!849+09'=E+2$/$'(2@!
!
[:/E9*+-!/EL'=#(#6!=+2+$/*'/!7!>8/$!'6!)'06$!6$+9!'2!E/2/=+E+2$n!.Q6(E+!/2/*46'6!7!8/M+!$(!)'2&!
(#$!>8/$!$8+!=+2+$'<!6+:!'6@!!1$Q6!hh@!!Y(;!9$!8/6!/EL'=#(#6!=+2+$/*'/;!)+E/*+;!98+2($49'</**4!</22($!
$+**;!so its female pseudohermaphrotide !?9*/4!(&&6B!7!/&0+2(=+2'$/*!642&0(E+!&#+!$(!21
hydroxylase def.
!
,`!84&0(:4*/6+!'6!0+69(26'L*+!)(0!,`!F+$(6$+0'(&6!?'2<*#&+!_N[%;!/2&0(6$+2+&'(2+;!/2&!/0+!>+/F!
/2&0(=+26B@!!%2&0(6$+2+&'(2+!</2!L+!<(2M+0$+&!'2$(!$+6$(6$+0(2+!/2&!$+6$(6$+0(2+!'2$(!
&'84&0($+6$(6$+0(2+@!!!
!
,`!84&0(:4<(0$'<('&6!/0+!,,!&+(:4<(0$'6(*!/2&!<(0$'6(*!
So, if you have an increase in 17 hydroxycorticoids, this is an increase in 11
deoxycortisol and cortisol
If you have an increase in 17 ketosteroids, (17, KS) its an increase in DHEA and
androstenedione.
When you have an enzyme def, things prox to the block increase and things distal to the
block decrease
With 21 hydroxylase def,!&+<0+/6+!E'2+0/*<(0$'<('&6!/2&!=*#<(<(0$'(<('&6!/2&!'2<0+/6+!
/2&0(=+26;!*+/&!$(!/EL'=#(#6!=+2+$/*'/!?+:<+66!/2&0(=+26B;!*(6+!6/*$;!8'=8!%.IN;!$8+0+)(0+!
849+09'=E+2$+&!
216

With 11 hydroxylase def!7!&+<0+/6+&!<(0$'6(*;!&+<0+/6+&!/*&(6$;!L#$!'2<0+/6+&!,,!
&+(:4<(0$'<(6$+0(2+!?>+/F!E'2+0/*<(0'<('&B;!'2<0+/6+&!,`!84&0(:4Q6!/2&!,`!F+$(6!7!*'*!='0*!>'**!8/M+!
/EL'=#(#6!=+2'$/*'/;!*'*!L(4!>'**!8/M+!90+<(<'(#6!9#L+0$4!?+:<+66!/2&0(=+26B;!NI"!
17 hydroxylase def!7!2(!/2&0(=+26;!'2<0+/6+&!'2!E'2+0/*(<(0$'<('&6!?NI"B;!6(!')!'$Q6!/!*'*!L(4!8+!
>(2Q$!8/M+!$+6$!/2&!>'**!*((F!*'F+!/!)+E/*+!L<!2(!&+M+*(9E+2$!?2(!+:$+02/*!=+2'$/*'/!L<!2(!,`!F+$(Q6;!
$+6$;!(0!&'84&0($+6$B@!12!/!*'*!='0*!7!68+!>'**!L+!#2&+0&+M(9+&@!
!
Islet cell tumors
G2*4!H!$(!F2(>-!126#*'2(E/6!/2&!q[!642&0(E+!
q[-!E/F'2=!$((!E#<8!=/6$0'2;!*+/&6!$(!9+9$'<!#*<+06!
126#*'2(E/-!'6!9$!'23+<$'2=!(0!&(!$8+4!0+/**4!8/M+!'26#*'2(E/n!
g8+2!4(#!L0+/F!90('26#*'2!&(>2!'2$(!'26#*'2;!4(#!0+*+/6+!.!9+9$'&+;!6(!)(0!+M+04!'26#*'2!E(*+<#*+!
$8/$!'6!0+*+/6+&;!$8+0+!'6!.!9+9$'&+!$8/$!'6!0+*+/6+&!>'$8!'$@!Y(;!')!4(#!'23+<$!8#E/2!'26#*'2!'2$(!
4(#06+*);!/2&!90(&#<+!/!*(>!=*#<(6+!*+M+*!/2&!.!9+9$'&+!>'**!L+!Y\JJR[YY[_@!!!
1)!4(#!8/M+!/!'6*+$!<+**!$#E(0;!=*#<(6+!>'**!L+!*(>;!'26#*'2!>'**!L+!8'=8!/2&!.!9+9$'&+!>'**!L+!
1".R[%Y[_@!
[:/E9*+-!9$6!$8/$!8/M+!/<<+66!$(!'26#*'2!=+$!$8'6!?_06;!2#06+6;!98/0E/<'6$6B!
!
%#&'(!)'*+!_/4e!s^!K#6<#*(6F+*+$/*!
!
Diabetes Mellitus
Type 1
%L6(*#$+!'26#*'2!&+)'<'+2<4!!
217

%2$'L(&'+6!/=/'26$!'6*+$!<+**6!
_5%!
NX%!0+*/$'(268'9!
126#*'2!#6+&!?/*>/46B!
!
Type 2
T/E'*4!8'6$(04!()!&'/L+$+6!
GL+6'$4!
%E4*('&!'2!'6*+$!<+**6!
N49+0(6E(*/0!2(2dF+$($'<!<(E/!
126#*'2!#6+&!>8+2!+M+2$#/**4!9$!=+$!0+6'6$/2$!$(!YT\!
!
J%INGl["[Y1Y-!H!E+<8/2'6E6-!
!
,B!Osmotic Damage
!
I'66#+!8/6!$(!8/M+!/*&(6+!0+&#<$/6+-!(2*4!H!8/M+!$8+E-!
'B!X+26;!=*#<(6+!6(0L'$(*;!(6E($'<!0+/<$'M+;!/L6(0L6!>/$+0!'2$(!$8+!*+26!
!
R+$'2/*!M+66+*6!'2!*+26!=+$!>+/F;!$8+2!&+6$0(4+&!&#+!$(!E'<0(/L6+66+6!/2&!</2!0#9$#0+!/2&!*+/&!$(!
L*'2&2+66@!
!
''B!Y<>/22!.+**6-!K..!</#6+!()!9+0'98+0/*!2+#0(9/$84!'6!_'/L+$+6-!K[.N-!(6E($'<!&/E/=+!
!
HB!Non-enzymatic Glycosylation
R+2&+06!$8+!SK!9+0E+/L*+!$(!90($+'26-!N4/*'2+!/0$+0'(*(6<*(0(6'6;!&'/L+$'<!2+980(98/$84!
!
NL%,<-!*(2=!$+0E!<(2$0(*!()!_K@!
!
Y*'&+-!R+$'2/!'2!/!&'/L+$'<dE'<0(/2+#046E6!?0+&!&($6B!
!
Y*'&+-!R+$'2/!'2!/!&'/L+$'<d2+(M/6<#*/0'c/$'(2!
!
[:/E9*+-!eV!40!(*&;!L*#004!M'6'(2U!=+$6!/!90+6<0'9$'(2!)0(E!/!(9$(E+$0'6$;!2+>!=*/66+6;!(2+!E(2$8!*/$+0;!
L*#004!M'6'(2!/=/'2@!l+$6!2+>!90+6<0;!(2+!E$8!*/$+0;!L*#004!M'6'(2!/=/'2@!_:-!_'/L+$+6@!
l*#<(6+!'6!L+'2=!<(2M+0$+&!$(!6(0L'$(*d>/$+0!'6!=('2=!'2!/2&!<8/2='2=!$8+!0+)0/<$'M+!'2&+:@!.*/66'<!
D#+6$'(2@!N%k[!$(!=+$!/!T%YI1"l!SXGG_!lX\.GY[@
!
X/L-!T/6$'2=!=*#<(6+!u,Ha!E=Z&*!(2!$>(!6+9/0/$+!(<</6'(26@!
!
[:/E9*+-!S+8!Y<!*'2F-!I8+!TSY!*+M+*!8/6!L++2!&+<0+/6+&!)0(E!,^V!E=Z&*!$(!,Ha!E=Z&*@!16!$8'6!
'2<0+/6'2=!$8+!69+<')'<'$4!(0!$8+!6+26'$'M'$4!()!$8+!$+6$n!
%-!N1lN!Y+26'$'M'$4@!S4!L0'2='2=!'$!*(>+0!'+!<*(6+0!$(!$8+!2(0E/*!0/2=+;!4(#!/0+!=('2=!$(!L+!/L*+!$(!9'<F!
#9!E(0+!9+(9*+!>'$8!&'/L+$+6@!g8+2!'$!>/6!,^V;!'$!>/6!8'=8!69-!$(!+*'E'2/$+!)/*6+!9(6'$'M+6@!Y(!'$!>/6!
#2+D#'M(</**4!/!&'/L+$'<!')!'$!>/6!u!,^V@!
!
l*#<(6+!$(*+0/2<+!$+6$;!&(2Q$!>(004!/L(#$!'$@!
218

!
Gestational Diabetes
_+)-!g(E/2!>8(!&'&!2($!8/M+!&'/L+$+6;!L#$!/)$+0!L+<(E'2=!90+=2/2$!&+M+*(96!&'/L+$+6@!
!
R'6F!)/<$(06!)(0!L/L4-!!
R_Y;!90+E/$#0+!&+*'M+04!
!
g(E+2!>'$8!l_;!/0+!/$!/!8'=8+0!0'6F!)(0!&+M+*(9'2=!&'/L+$+6!*/$+0!(2@!
!
%E4*('&!'2!S+$/!'6*+$6-!I49+!H!
!
%2$'L(&'+6!/=/'26$!'6*+$6U!'2)*/EE/$'(2-!I49+,!!
?.(:/<F'+!M'0#6!'E9*'</$+&B!
!
NX%!<(00+*/$'(2-!HLA DR3 and DR4=Type 1;!90(9+26'$4!)(0!&+M+*(9'2=!I49+!,;!')!<+0$/'2!
+2M'0(2E+2$/*!)/<$(0!<(E+6!'2!6#<8!/6!'2)+<$'(2-!.(:6/<F'+;!E#E96;![Sk!
!
NX%SH`-!%2F4*(6'2=!Y9(2&4*'$'6!
[2M!)/<$(06-!!
.8*/E4&+/*!12)+<$'(2!
\*<+0/$'M+!.(*'$'6;!
Y8'=+**(6'6!
J6(0'/6'6!
!
Musculoskeletal System
"++&!$(!'&+2$')4!<046$/*6!'2!642(M'/*!)*#'&!
!
Gout
Pseudogout
R8(EL('&!<046$/*6!'2!642(M'/*!)*#'&CC96+#&(=(#$!
!
S#$!J6+#&(=(#$!<(#*&!/*6(!8/M+!2++&*+d68/9+&!<046$/*6!?*'F+!$8(6+!()!E(2(d6(&'#E!#0/$+!'2!l(#$B!
>8'<8!E/F+6!__!&'))'<#*$@!Y(!4(#!#6+!/!69+<'/*!)'*$+0!$(!E/F+!$8+!>8(*+!6*'&+!0+&!/2&!$8+2!$8+!<046$/*6!
/0+!E/&+!$(!*((F!4+**(>!(0!L*#+@!
!
g8+2!$8+!<(*(0!()!$8+!<046$/*6!'6!4+**(>!>8+2!$8+!9*/2+!()!)'*$+0!'6!9/0/**+*!$(!$8+!/2/*4c+0C!Negatively
birefringent =GOUT
!
[/6$!>+6$!&'0+<$'(2-!<(*(0!'6!L*#+!/2&!9/0/**+*!$(!/2/*4c+0CPositively birefringent = PSEUDOGOUT
?</*<'#E!940(98(698/$+B!
!
Arthritis
Osteoarthritis
J0(=0+66'M+!>+/0'2=!&(>2!()!/0$'<#*/0!</0$'*/=+!
219

!
Y(E+$'E+6!*+/&6!$(!0+/<$'(2!$(!'23#04-!YJ\R!)(0E/$'(2~/$!$8+!E/0='2!()!$8+!3('2$C!N+L+0&+2Q6!2(&+-!
(6$+(984$+!'2!$8+!3('2$!
!
"($+!$8+!+2*/0=+E+2$!()!$8+!_1J!?N+L+0&+26!2(&+6B!/2&!J1J!3('2$6!?S(#<8/0&6!2(&+6B;!+2*/0=+E+2$6!
0+90+6+2$!(6$+(984$+6@!
!
Rheumatoid Arthritis
12)*/EE/$(04!3('2$!&cU!+2*/0=+&!K.J!3('2$6!
R8!)/<$(0!6+$6!#9!$8+!'2)*/EE/$'(2-!1=K!%L!/=/'26$!1=l@!1=l!'6!'2!642(M'/*!)*#'&@!1=Kd1=l!)(0E!
<(E9*+:+6;!/<$'M/$+!$8+!<(E9*+E+2$!646$+E;!&/E/=+!$8+!3('2$;!642(M'/*!)*#'&!=+$6!'2)*/E+&;!6$/0$6!
=0(>'2=!/2&!=0(>'2=;!6$/0$6!=0(>'2=!(M+0!$8+!/0$'<#*/0!</0$'*/=+C!J%""\YU!849+09*/6$'<!642(M'/*!)*#'&@!
?&'))+0+2$!)0(E!I(98#6B!
!
f('2$6!</2!=+$!)':+&;!/2&!/2F4*(6+&!/2&!</22($!E(M+@!!
_(2Q$!=+$!)':'2=!()!$8+!3('2$!'2!G%@!
1)!08+#E/$('&6!&(2Q$!F++9!E(M'2=!$8+'0!3('2$6;!/2&!')!'$!'6!2($!<(2$0(**+&!#6'2=!/2$'d'2)*/EE/$(04!&0#=6!
$8+2!+M+2$#/**4!$8+4!</22($!E(M+!'$!/$!/**@!
!
Y*'&+-!R8+#E/$('&!2(&#*+6@!./2!L+!6++2!'2!R8+#E/$'<!)+M+0!/6!>+**@!
!
[:/E9*+-!(*&+0!9$!8/M'2=!$0(#L*+!+/$'2=!/2&!6>/**(>'2=!<0/<F+06;!)++*6!*'F+!$8+0+!'6!6/2&!'2!E4!+4+!/**!
$8+!$'E+@!G2!+:/E'2/$'(2-!+4+6!/2&!E(#$8!/0+!&04@!_:n!Sjograns Syndrome. J$!>'$8!R%!/2&!/#$(d
'EE#2+!&+6$0#<$'(2!()!*/<0'E/*!=*/2&6;!6/*'M/04!=*/2&6@!5+0/$(<(23#2<$'M'$'6!6'<</!
!
R8+#E/$('&!2(&#*+6!'2!*#2=!O!92+#E(<(2'(6'6CC./9*/2!Y42&0(E+!
!
I0+/$E+2$!()!R%C!K+$8($0+:/$+!
!
[:/E9*+-!J$!>'$8!R%;!&+M+*(96!/!E/<0(<4$'<!/2+E'/!>'$8!849+06+=E+2$+&!2+#$0(98'*6;!2+#0(!+:/E!'6!
2(0E/*;!'2$+06$'$'/*!)'L0(6'6!'2!*#2=@!g8/$!'6!$8+!&0#=n!K+$8($0+:/$+!
!
Gout = podagra
S'=!$(+;!#6#/**4!)'06$!(2+!$(!L+!'2M(*M+&U!#6#/**4!/$!2'=8$@!
K(2(6(&'#E!#0/$+!<046$/*6!/0+!90+<'9'$/$+&!/2&!$/F+2!#9!L4!$8+!2+#$0(98'*6!$8/$!98/=(<4$(6+!'$!/2&!
0+*+/6+!<8+E'</*6~'2)*/EE/$(04!0+/<$'(2@!
!
_(2Q$!&+)'2+!l(#$!L/6+&!(2!\0'<!/<'&!*+M+*@!![*+M/$+&!#0'<!/<'&!&(+6!2($!2+<+66/0'*4!*+/&!$(!=(#$@!%L(#$!
HeW!()!9+(9*+!E'=8$!8/M+!+*+M/$+&!#0'<!/<'&@!
!
_:-!N%Y!$(!L+!L4!90+6+2<+!()!#0'<!/<'&!<046$/*6!'2!$8+!3('2$@!!
!
I0+/$E+2$-!12&(E+$8/<'2!$(!<(2$0(*!'2)*/EE/$'(2@!
!
./#6+-!(M+0!90(&#<$'(2!?R:C/**(9#0'2(*-!L*(<F6!h/2$8'2+!(:'&/6+B!(0!#2&+0!+:<0+$'(2!()!#0'<!/<'&!
?urVW!()!</6+6B!R:C#0'<(6#0'<!&0#=6!*'F+!90(L+2+<'&!/2&!Y#*)'2940/c(2+!
220

!
Chronic Gout = tophus: &+9(6'$'(2!()!E(2(6(&'#E!#0/$+!'2!6()$!$'66#+~E/**+(*#6!
k+04!&'6/L*'2=!/6!'$!+0(&+6!$8+!3('2$@!!
R:C!/**(9#0'2(*!
!
Y*'&+-!I(98#6!$8/$!>/6!9(*/0'c+&!68(>'2=!KY\!<046$/*6!
!
Y*'&+-!hd0/4!()!&'='$!68(>'2=!+0(6'(2!L4!$(98#6!
!
Genetics of Gout:
!
K#*$')/<$(0'/*!'28+0'$/2<+!
!
%kG1_!0+&!E+/$6!?)#**!()!9#0'2+6B!
%kG1_!%*<(8(*@!K+<8/2'6E-!
!
K+$/L(*'<!/<'&(6'6-!#0'<!/<'&!8/6!$(!<(E9+$+!>'$8!($8+0!/<'&6!)(0!+:<0+$'(2!'2!90(:'E/*!$#L#*+@!%*<(8(*!
'2<0+/6+6!/**!$8+!*/<$'<!/<'&;!/2&!L+$/!84&0(:4*!L#$40'<!/<'&6@!Y(!/**!$8+6+!/<'&6!<(E9+$+!/2&!>'2!/=/'26$!
#0'<!/<'&;!/2&!=+$!+:<0+$+&@!\0'<!/<'&!F++96!>/'$'2=!/2&!>/'$'2=U!/2&!L#'*&6!#9!/2&!</#6+6!=(#$@!
!
Ankylosing spondylitis (AS)
NX%SH`!/66(<'/$'(2!
!
Y*'&+-!"($+!/2$+0'(0!)*+:'(2!>8'<8!()$+2!0+6#*$6!'2!0+6$0'<$'M+!*#2=!&'6+/6+@!N#2<8+&!(M+0;!0+6$0'<$6!
E(M+E+2$!()!<8+6$!</M'$4;!L*((&!=/6!/L2(0E/*'$'+6;!!
!
HV!40!(*&;!E(02'2=!>8+2!8+!>(F+!#9;!6#&&+2!9/'2!'2!6/<0(d*#EL/0!0+='(2@!12)*/EE/$(04!0+/<$'(2!6++2!
(2!hd0/4;!/6!$8+!&/4!90(=0+66+6!9/'2!&+<0+/6+6@![M+2$#/**4;!$8+!'2)*/EE/$'(2!690+/&6!$(!$8+!M+0$+L0/*!
<(*#E2;!/2&!'$!)#6+6CCjS/EL((!69'2+j!
!
%*6(!&+M+*(9-!\M+'$'6;!%(0$'$'6;!'0'&(<4<*'$'6;!L*#004!M'6'(2;!+M+2$#/**4!=(!L*'2&@!
!
[:/E9*+-!l+2+$'<!&c!>8+0+!&+=+2+0/$'M+!/0$80'$'6!'2!M+0$!<(*;!(2!/#$(964;!L*/<F!</0$'*/=+U!#0'2+!(2!
+:9(6#0+!$(!/'0!$#026!L*/<F@!Alkoptonuria
%#$!0+<;!8(E(=+2$'6'<!/<'&!(:'&/6+!+2c4E+!&+)
Y*'&+-!HV!40!(*&;!&46#0'/;!'2<0+/6+&!)0+D;!#0'2/*46'6C!*+#<(<4$+!+6$+0/6+!9(6'$'M+;!6$+0'*+!94#0'/dd6+:#/**4!
/<$'M+;!8/&!2(2d69+<')'<!#0+$80'$'6;!<(23#2<$'M'$'6;!>/6!$0+/$+&@!1$!>/6!.8*/E4&'/!$0/<8(E/$'6!
<(23#2<$'M'$'6;!L#$!(2+!>++F!*/$+0;!=($!6$+0'*+!<(23#2<$'M'$'6!/2&!$+2&(2'$'6!'2!%<8'**+6!$+2&(2@!!
!
Y(!9/$'+2$!>'$8!2(2d'2)+<$'(#6!<(23#2<$'M'$'6;!90+M'(#6*4!8/&!.8*/E4&'/!$0/<8(E/$'6!'2)+<$'(2!/2&!$8+2!
&+M+*(9+&!<(23#2<$'M'$'6!/2&!/0$80'$'6!?NX%!SH`!9(6'$'M+B-!Reiter's syndrome!!
!
Another Env trigger in HLAB27 positive pt: \*<+0/$'M+!.(*'$'6!
!
221

Septic arthritis due to disseminated gonococcemia!
"($+!$8+!8($!F2++!/2&!$8+!9#6$#*+!(2!$8+!>0'6$;!(2!/69'0/$'2=-!=0/E!2+=/$'M+!&'9*(<(<<'!
!
YI_C!Y+:#/**4!I0/26E'$$+&!_'6+/6+!
!
YCY42(M'$'6C3('2$6!
IC!I+2(642(M'$'6C!3('2$6!'2!8/2&6!/2&!)++$!
_C!_+0E/$'$'6C9#6$#*+6!
!
K..!()!6+9$'<!/0$80'$'6!'2!\YC!l(2(008(+/!
T(0!'$!$(!L+<(E+!&'66+E'2/$+&;!2++&!$(!L+!&+)'<'+2$!'2!$8+!)'2/*!9/$8>/4!()!.(E9*+E+2$!646$+E-!C5C9 ?6(E+!6/4!.ad.rB!
!
Y*'&+-!"($+!$8+!1:(&+6!$'<F!?M+<$(0!()!S(00+*'/!L#0=&(0)+0'!/2&!S/L+6'/!E'<0($'B;!2($+!$8+!+04$8+E/$(#6!
0/68!'2!$8+!L($$(E!6<0++2!d!$8+!$'<F!L'$+!'6!'2!$8+!<+2$+0!()!$8+!0/68!/2&!$8+!0/68!+:$+2&6!(#$!'2!
<(2<+2$0'<!<'0<*+6!)0(E!$8/$!9('2$;!$8+!0/68!'6!</**+&!erythema chronicum migrans!?9+LL*+!$80(>2!'2!
>/$+0B!J/$8(=2(E(2'<!()!Lyme's disease
!
[/0*4!)(0E!R:-!$+$0/<4<*'2+!
!
Chronic Lymes Disease:!%9/0$!)0(E!&'6/L*'2=!3('2$!&'6+/6+-!E4(</0&'$'6!9*#6!L'*/$+0/*!S+**Q6!9/*64-!
."!k11!'2M(*M+&!O!9$!>'**!8/M+!S/L+6'(6'6!
!
1&'(9/$8'<-!'6!#6#/**4!\2'*/$+0/*!S+**Q6!J/*64C!N+09+6!Y'E9*+:!
!
%L(M+!J$!&+M+*(96!N+E(*4$'<!/2+E'/;!>8/$!&'&!8+!6++!'2!8'6!9+0'98+0/*!L*((&!6E+/0n!S/L+6'/!E'<0($'!
?0'2=!)(0E!6'E'*/0!$(!J*/6E(&'#E!)/*<'9/0#EB!
!
Remember: the Ixodes tick has the reservoir for Borrelia burgdorferi (white tailed deer
that has Babesia microti) AND Babesia microti '2$0/d+04$80(<4$'<!9/0/6'$+!
!
R:-!.+)$0'/:(2+!
!
Bone Disorders
Osteogenesis imperfecta!
Y*'&+-!5'&!>'$8!/2!+4+L/**;!L*#+!6<*+0/-!%_!&'6(0&+0!>'$8!&+)+<$!'2!642$8+6'6!()!$49+!1!<(**/=+2;!2($+!$8+!
L*#+!6<*+0/d!*(66!()!<(**/=+2!'2!6<*+0/!/**(>6!L*#'68!<(*(0!()!<8(0('&/*!M+66+*6!$(!68'2+!$80(#=8-!
Osteogenesis imperfecta ?"GI!)(0+'=2!L(&4mB!iL0'$$*+!L(2+!&'6+/6+j!</2$!L0+/F!L(2+!&(>2!
!
p#+6$'(2-!>8/$Q6!$8+!&+)+<$n!_+)+<$'M+!642$8+6'6!()!$49+!,!<(**/=+2!
!
p#+6$'(2-!>8/$Q6!$8+!E+<8/2'6E!()!&+M+*(9E+2$!()!L*#+!6<*+0/n!!
.(**/=+2!'2!6<*+0/;!$49+!,!'6!&+)+<$'M+;!6(!'$!'6!6(!$8'2;!6(!4(#!</2!6++!$8+!#2&+0*4'2=!<8(0('&/*!M+'26!
$8/$!='M+6!$8+!L*#+!<(*(0@!
222

!
Osteopetrosis = marble bone disease
_+)+<$!'2!$((!E#<8!L(2+-!&+)+<$!'2!(6$+(<*/6$6!
!
Osteoporosis
Y*'&+-!_+<0+/6+&!>'&$8!()!'2$+0!M+0$+L0/*!</0$'*/=+@!"($+!$8+!<(**/96+!()!$8+!M+0$+L0/!&#+!$(!*(66!()!
L(2+!E/66-!9/$'+2$6!*(6+!E(0+!L(2+!$8/2!'6!0+9*/<+&!
!
Y*'&+-!_(>/=+0Q6!N#E9!
!
K+<8-!J(6$E+2(9/#6/*!(6$+(9(0(6'6!'6!&#+!$(!$8+!*(66!()!$8+!'28'L'$(04!+))+<$!()!+6$0(=+2!(2!$8+!
0+*+/6+!()!'2$+0*+#F'2!,!)0(E!(6$+(L*/6$6U!2($!+2(#=8!+6$0(=+2!$(!6$(9!$8+!/<$'M'$4!()!12$+0*+#F'2d,!
?(6$+(<*/6$!/<$'M/$'2=!)/<$(0B!)0(E!L0+/F'2=!4(#0!L(2+!&(>2@!
!
G6$+(9(0(6'6-!GM+0/**!0+&#<$'(2!'2!L(2+!E/66@!S($8!E'2+0/*!%"_!(0=/2'<!<(E9(2+2$@!gNGX[!E/66!()!
L(2+!'6!0+&#<+&@!
!
G6$+(E/*/<'/-!_+<0+/6+&!E'2+0/*'c/$'(2!()!L(2+-!(0=/2'<!9/0$!()!L(2+!'6!2(0E/*@!./0$'*/=+!'6!(F;!
(6$+('&!'6!(FU!'$6!2($!=+$$'2=!E'2+0/*'c+&!
!
_:!()!(6$+(9(0(6'6-!_#/*!L+/E!%L6(09$'(E+$04-!&+26'$4!()!$8+!L(2+!'2!>8(*+!L(&4!'6!E+/6#0+&@!"(2!
'2M/6'M+;!M+04!+/64@!
!
MC fracture: compression fracture-!*(6+!6$/$#0+;!!
2nd MC fracture-!.(**+Q6!)0/<$#0+!()!&'6$/*!0/&'#6@!
!
p#+6$'(2-!16!6>'EE'2=!/!=((&!+:+0<'6+!)(0!90+M+2$'2=!(6$+(9(0(6'6-!"G@!S+</#6+!2(!6$0+66!(2!L(2+6@!
1$!'6!=0+/$!+:+0<'6+!)(0!/+0(L'<6@!S#$!'$!&(+6!2($!90+M+2$!(6$+(9(0(6'6@!g/*F'2=!'6!=((&@!g+'=8$!L+/0'2=!
'6!+M+2!L+$$+0!$8/2!>/*F'2=m!g/*F!>'$8!_#EL+**6m!l+$!/+0(L'<6!/2&!'2<!'2!L(2+!E/66m!
N%k[!$(!6$0+66!L(2+!$(!L#'*&!'$!#9@!
!
[:/E9*+-!12!69/<+;!*/<F!()!=0/M'$4!/2&!/6$0(2/#$6!/0+!='M+2!L'698(698(2/$+6;!k'$!_!/2&!</*<'#E!$(!=+$!
L(2+!&+26'$4!L/<F-!L+</#6+!6+0'(#6!90(L!()!(6$+(9(0(6'6!'2!69/<+@!
!
I'9-!0+90(&#<$'M+!>(E+2!2++&!$(-!
,B![:+0<'6+!
HB!,eVV!E=!()!./!+M+04&/4!
PB!^VVdtVV!#2'$6!()!k'$!_!
^B!k'$!9'**!$8/$!<(2$/'26!10(2!
!
Bone Tumors
Exostosis (osteochondroma)!!
"($+!$8+!</0$'*/='2(#6!</9!(2!$8+!6#0)/<+!()!$8+!L(2+@!I8'6!</#6+6!/!90($#L+0/2<+!()!$8+!L(2+@!I8'6!'6!
$8+!E(6$!<(EE(2!L+2'=2!L(2+!$#E(0@!!
!
Chondrosarcoma of the hip
MC malignant one
223
Osteogenic sarcoma!!
Y*'&+-!"($+!E+$/9846+/*!(0'='2!()!$8+!</2<+0!/2&!+:$+26'(2!'2$(!$8+!E#6<*+;!2($+!$8+!69*'2$+0!()!
9+0'(6$+#E!$8/$!'6!+*+M/$+&!>8'<8!>(#*&!<(00+69(2&!$(!.(&E/26!$0'/2=*+!
!
Y*'&+-!hd0/4!()!90(:'E/*!8#E+0#6!68(>'2=!$8+!6#2L#06$!/99+/0/2<+!()!(6$+(=+2'<!6/0<(E/!$8/$!'6!
+:$+2&'2=!'2$(!$8+!E#6<*+;!(6$+(=+2'<!'E9*'+6!$8/$!$8+!</2<+0!'6!E/F'2=!L(2+!
!
%&(*+6<+2$;!6#2!L#06$!/99;!<(&E/26!$0'/2=*+;!F2++!/0+/CCG6$+(=+2'<!Y/0<(E+!
!
Suppressor Gene relationship: RL!6#990+66(0!.80(E(6(E+!,P!
!
Muscular Disorders
Duchennes Muscular Dystrophy
l(>+0Q6!E/2+#M+0!
[*+M/$+&!Y+0#E!.5;!%L6+2<+!()!&46$0(98'2!90($+'2!
!
Y+:!*'2F+&!0+<+66'M+;!E'66'2=!_46$0(98'2!=+2+!
!
k/0'/2$-!S+<F+0Q6!&46$0(984-!E/F+!&46$0(98'2!L#$!'$!'6!&+)+<$'M+!
!
%2/*(=4-!/*)/!,!/2$'$0496'2!&+)-!K..!()!N..!'2!<8'*&0+2!
%&#*$6!=+$!9/2/<'2/0!+E9846+E/-!E/24!&'))!6#L!$49+6!()!/*)/!,!/2$'d$0496'2-!!
!
,B!%L6+2$!/*)/!,!/2$'d$0496'2-!=+$!9/2!/<'2/0!+E9846+E/@!
!
HB!%*)/!,!/2$'d$0496'2!'6!90+6+2$!L#$!'$!</22($!=+$!G\I!()!$8+!8+9/$(<4$+6-!6(!=+$!N..!
!
%#&'(!)'*+!_/4!e!se!YF'2!
Myotonic dystrophy - MC adult dystrophy, AD
I0'9*+$!0+9+/$!&c!7!0+9+$'$'(2!()!$0'd2$Q6!?$8+0+!/0+!^!&cQ6!>'$8!$8'6!/L2(0E/*'$4!7!N_;!T0/='*+!h!7!8/M+!
E/<0(0<8'&'6E!?L'=!$+6$+6!'2!/&(*+6<+2$6B;!T0'+&0'<8Q6!/$/:'/;!K4($(2'<!&46$0(984B@!!!
!
12!)#$#0+!=+2+0/$'(26;!&c!=+$6!>(06+!7!/2$'<'9/$'(2@!!I8+0+)(0+;!</2!/2$'<'9/$+!$8/$!'2!)#$#0+!&cQ6!'$!>'**!
=+$!>(06+@!!T(0!+/<8!=+2+0/$'(2;!$8+0+!/0+!E(0+!$0'9*+$!0+9+/$6!/&&+&!(2;!*+/&'2=!$(!/!E(0+!&+)+<$'M+!
90($+'2!/2&!$8+!&c!=+$6!>(06+!/2&!>(06+@!
!!!
[:/E9*+-!=+2+$'<!<(#26+*(0!$+**'2=!<(#9*+!$8/$!$8+4!8/M+!/!&c;!>8+0+!')!/0+!$(!8/M+!<8'*&0+2;!$8+!&c!>'**!
L+!)/$/*!'2!$8+'0!<8'*&0+2@!!I8+!<(#9*+!&'&2Q$!*'6$+2!$(!$8+'0!<(#26+*+0;!8/&!/!<8'*&!/2&!$8+!<8'*&!&'+&!(2*4!
/)$+0!,!E(2$8@!!g8/$!>/6!'$!/2&!>8/$!'6!$8'6-!/2!'+!$0'9*+$!0+9+/$!&'6(0&+0!?/2$'<'9/$'(2B!K#6<*+!
>+/F2+66!'2!)/<+!?6(!E(#$8!'6!&0((9+&!(9+2B@!!
!!
[:/E9*+-!9$!>'$8!)/'*#0+!$(!0+*+/6+!=0'9!(2!=(*)!6$'<F!?(0!>8+2!68/F'2=!8/2&B!7!$8+4!</22($!0+*/:!$8+'0!
E#6<*+!=0'9;!&'/L+$+6;!</0&'/<!/L2(0E/*'$4!
!
224

Myasthenia Gravis
%#$(%L!/=/'26$!%<8!0+<+9$(0!7!'$Q6!/2!1=l!%L;!$8+0+)(0+!'6!/2![:/E9*+-!()!$49+!11!NJb;!*'F+!l0/M+Q6;!
>8'<8!'6!/2!1=l!%L!/=/'26$!$8+!0+<+9$(0!?L4!&+)'2'$'(2;!$8'6!E/F+6!'$!$49+!11B@!!g8+$8+0!4(#!&+6$0(4!$8+!
0+<+9$(0!(0!3#6$!L*(<F!'$!'6!'00+*+M/2$@!!%<8!</22($!8((F!'2$(!'$!/2&!$8+0+)(0+!$8+0+!'6!E#6<*+!>++F2+66@!!
I8+!)'06$!E#6<*+6!/0+!$8+!*'&6;!>8'<8!*+/&6!$(!*'&!*/=@!!I8+4!/*6(!=+$!&(#L*+!M'6'(2!L<!E#6<*+6!()!$8+!+4+!
/0+!E+66+&!#9;!*+/&'2=!$(!&'9*(9'/@!![M+2$#/**4;!$8+4!=+$!&4698/='/!)(0!6(*'&6!/2&!*'D#'&6!?=+$6!6$#<F!'2!
#99+0!+6(98/=#6;!L<!$8'6!'6!>8+0+!$8+0+!'6!YIR1%I[_!E#6<*+B@!![M+2$#/**4!E#6<*+!&c!90+M/'*6!
$80(#=8(#$@!
T++*!+2+0='c+&!'2!$8+!E(02'2=!/2&!)++*!$'0+&!/$!2'=8$@!!I+26'*(2!$+6$!9(6'$'M+@!./2!&'+@!!!
!
R:!'6!/<+$4*<8(*'2+6$0/6+!'28'L'$(06@!!S4!='M'2=!/2!'28'L'$(0;!L*(<F!$8+!L0+/F&(>2!()!%<8!/2&!L#'*&!#9!
%<8@!!g'$8!)+>!0+<+9$(06!4(#!8/M+!'2!$8+0+;!$8+0+!'6!/!*/0=+0!<8/2<+!()!8((F'2=!#9!$(!$8+!0+<+9$(06!/2&!
9$!&(+6!>+**@!N(>+M+0;!+M+2$#/**4;!2(!0+<+9$(06!$8+0+!/2&!'$!&(+62Q$!E/$$+0!8(>!E#<8!%<8!'6!$8+0+;!6(!
9$!'6!6<0+>+&@!!I8+2;!8+0!(2*4!(9$'(2!'6!/!$84E+<$(E4@!!!
!
I8+!$84E#6!'6!'2!$8+!/2$+0'(0!E+&'/6$'E#2@!!I0'<F!D#+6$'(2-!$8+4!</2!/6F;!>8/$!'6!$8+!9/$8(*(=4n!I8+4!
</2!&+6<0'L+!Kl!/2&!/6F;!>8/$!&(!4(#!+:9+<$!$(!6++!'2!$8+!E+&'/6$'2#En!_(!"GI!9#$!$84E(E/@!!I8'6!
'6!/!E/*'=2/2<4!()!$8+!$84E#6!/2&!&(+6!(<<#0!'2!,edHVW!()!</6+6;!L#$!'62Q$!$8+!K.!9/$8(*(=4!6++2!'2!
$8+!$84E#6!'2!/!9$!>'$8!Kl@!!Y++!=+0E'2/*!)(**'<*+6!'2!$8+!$84E#6!?0+E+EL+0;!$8'6!I!<+**!<(#2$04;!2($!S!
<+**!<(#2$04;!6(!'$6!/L2(0E/*!$(!8/M+!=+0E'2/*!)(**'<*+6!8+0+B!7!$8+4!/0+!$8+!(2+6!E/F'2=!$8+!%L!</#6'2=!
$8+!Kl@!!Y(;!L4!&('2=!/!$84E+<$(E4!)(0!R:;!4(#!/0+!0+E(M'2=!$8+!%L!90(&#<'2=!$'66#+@!!,ZP!9$6!=+$!/!
<(E9*+$+!<#0+@!!,ZP!=+$!/!9/0$'/*!<#0+;!/2&!,ZP!&'+!L<!$8+4!>/'$+&!$((!*(2=!)(0!$84E+<$(E4!/2&!R:!/2&!
&'&2Q$!8/M+!0+<+9$(06;!/24>/4@!!Y(;!S!<+**!849+09*/6'/!'6!$8+!K.!$8'2=!4(#!6++;!2($!$84E(E/@!!I8'6!
>8+0+!$8+!%L!'6!L+'2=!E/&+@!!!
!
!
Lupus
S#$$+0)*4!&'6$0'L#$'(2!(2!$8+!)/<+!?E/*/0!0/68B!
G)!/**!$8+!/#$('EE#2+!&cQ6!$8'6!(2+!'6!$8+!E(6$!*'F+*4!(2+!$(!8/M+!/!iOj!%"%!?rrW!6+26'$'M'$4B@!!I8+!
%LQ6!4(#!>/2$!$(!(0&+0!$(!90(M+!$8/$!'$6!*#9#6!/0+!/2$'dYE'$8!%L!?>8'<8!8/6!/!,VVW!69+<;!$8+0+)(0+!2(!
)/*6+!9(6!7!$8+0+)(0+!,VVW!JJkB!)(0!*#9#6;!E+/2'2=!$8/$!')!4(#!$+6$!iOj!)(0!$8'6!%L;!4(#!8/M+!X#9#6@!
I8+!($8+0!%L!'6!/2$'!7&6_"%!7!$8'6!2($!(2*4!'2&'</$+6!$8/$!4(#!8/M+!*#9#6;!L#$!/*6(!$8/$!4(#!8/M+!
51_"[b!&c@!!I8/$!8/6!/!rtW!69+<;!$((@!!Y(;!$8+6+!/0+!$>(!=((&!%LQ6!$(!<(2)'0E!*#9#6@!!K(02'2=!
6$'))2+66!'6!90+6+2$!'2!*#9#6!?6'E#*/$+6!R8!/0$80'$'6Z98($(98(L'/B;!0/68;!9+0'</0&'$'6U!X[!<+**!90+9!7!%2$'!7!
_"%!%LQ6!/0+!98/=(<4$(6+&!L4!2+#$0(98'*6;!/2&!$8+4!8/M+!/*$+0+&!_"%@!"($!69+<')'<!)(0!*#9#6!?>/6$+!()!
$'E+B@!
!
Progressive Systemic Sclerosis/CREST
I'=8$!)/<+;!$+*/2='+<$/6'/;!R/42/#&6;!&4698/='/!?6(*'&6!/2&!*'D#'&6B;!&46$0(98'<!</*<')'</$'(2;!
6<*+0(&/<$*4U!')!F'&2+46!'2M(*M+&;!'$!'6!90(=0+66'M+!646$+E'<!6<*+0(6'6;!"GI!.R[YI!?&(+62Q$!'2M(*M+&!
F'&2+46B@!!!
!
Dermatomyositis
R/<((2!+4+6;!+*+M/$+&!6+0#E!.5;!0/68!(M+0!$8+!J1J!?=(#$0+2Q!9/$<8+6B;!8'=8+6$!/66(<!>'$8!#2&+0*4'2=!
</2<+0@!
!
Sjogrens syndrome
225

%66(<!>'$8!08!/0$80'$'6;!/#$('EE#2+!7!%LQ6!&+6$0(4!6/*'M/04!=*/2&6!*+/&'2=!$(!&04!E(#$8;!*/<0'E/*!
=*/2&6!*+/&'2=!$(!&04!+4+6@!
[:/E9*+-!L:!()!*(>+0!*'9!>8'<8!'6!/!<(2)'0E/$(04!$+6$!7!'$6!*((F'2=!$(!6++!')!$8+0+!'6!&+6$0#<$'(2!()!$8+!
E'2(0!6/*'M/04!=*/2&6!7!6++!*4E98(<4$+6!?>8'<8!'6!<(2)'0E/$(04!&:B@!!%LQ6!/0+!/2$'dYY/!?/F/!/2$'dR(B!
/2&!/2$'dYYL!?/F/!/2$'dX/B!?YY!C!Y3(=0+2Q6!642&0(E+B@!!!
%2$'d0(!</2!/*6(!L+!'2!*#9#6!9$6;!/2&!</2!<0(66!$8+!9*/<+2$/!/2&!&'60#9$6!$8+!L/L4Q6!<(2&#<$'(2!646$+E!
?*+/&6!$(!<(E9*+$+!8+/0$!L*(<FB@!
!
!
!
Skin
!
Basal cell carcinoma ?#99+0!*'9B!
Squamous cell carcinoma!?*(>+0!*'9B!
!
Psoriasis 7!6'*M+04!*+6'(2!$8/$!'6!0+&!/2&!0/'6+&@!!./2!'2M(*M+!$8+!8/2&6;!6</*9!7!9$6!$8'2F!$8+4!8/M+!
&/2&0#))!?/F/!6+L(00+'<!&+0E/$'$'6!7!)0(E!E/*/6+c'/!)#0)#0/B;!L#$!$8+4!0+/**4!8/M+!96(0'/6'6@!!G2!L*/<F!
9+06(2!>(2Q$!6++!0+&!*+6'(2;!>'**!6++!6'*M+0!(2+@!!R/68!/$!90+66#0+!9('2$6!7!+69!$8+!+*L(>@!!!
!
Atopic dermatitis!7!<8'*&!>'$8!/**+0='<!&'/$8+6'6!6$/0$6!&cU!8/M+!+<c+E/!?/F/!/$(9'<!&+0E/$'$'6BU!$49+!1!
NJb@!!!
!
Contact dermatitis 7!'+!$(!E+$/*!?2'<F+*BU!$49+!1k!NJb!
[:/E9*+-!9/$8(9846!'6!+D#/*/2$!$(!>8/$n!iOj!JJ_;!L<!L($8!/0+!$49+!1k!NJb!
!
Seborrheic Dermatitis
_#+!$(!K/*/66+c'/!)#0)#0!?/!)#2=#6B!
1.!9$!?'+!%1_6B!
I8'6!'6!/!90+%1_6!*+6'(2!
!
Tinea capitis
[:/E9*+-!9$!>'$8!L/*&!69($!(2!8+/&;!)*#(#0+6<+6!/2&!6++2!>'$8!L*/<F!*'=8$!L*/<F*'=8$!?\kd%!*'=8$B!
./2!</#6+!I'2+/!</9'$'6!(now Trichophyton tonsurans is MCC)
S<!$8+!)#2=#6!'2M(*M+6!$8+!'22+0!9(0$'(2!()!$8+!68/)$;!$8+0+!/0+!2(!)*#(0+6<+2$!E+$/L(*'$+6;!/2&!'6!
Wood light negative!
!
%**!$8+!($8+0!6#9+0)'<'/*!&+0E/$(984$+!'2)+<$'(26!'2<*#&'2= Tinea corporis!?0'2=!>(0EB!
[:/E9*+-!0+&!(#$+0!+&=+!/2&!<*+/0!<+2$+0;!>8/$!'6!)'06$!6$+9!'2!>(0F#9n!Y<0/9+!(#$6'&+!/2&!&(!5GN!
90+9;!/2&!6++!8498/+!/2&!4+/6$!)(0E6@!!All other superficial dermatophyte infections (except
Tinea capitis) are due to trychophyton rubra. g8/$!'6!$8+!<(*(0!/0(#2&!I'2+/!</9'$'6n!R+&!?C!
0#L0/B!?8(>!$(!0+E+EL+0!'$B@!
!
Molluscum contagiosum
Y/2&4!*'F+!E/$+0'/*!'2!<0/$+0;!<8'*&0+2;!6+*)!'2(<#*/$+!
J(:M'0#6!E/F+6!$8+6+!?_"%!M'0#6B!
k(*</2(!<0/$+0!*((F;!>'$8!6/2&4!6$#))!'2!'$!
!
Pityriasis Rosea
226

[:/E9*+-!0/68!(2!L#$$!7!2(2!90#0'$'<!0/68;!"G"!1"T[.I1G\YU!(L*(2=!*((F'2=!>'$8!0+&!(2!(#$6'&+!/2&!
9/*+!'2!E'&&*+@!!b(#!$8'2F!$8'6!'6!I!<(09(0'6;!L#$!'$6!(L*(2=!?/2&!2($!<'0<#*/0B@!!_(!/!5GN!90+9;!)'2&!
2($8'2=U!$8+2!9#$!$(9'</*!6$+0('&6!/2&!&(+62Q$!=(!/>/4U!P!&/46!*/$+0!<(E+6!L/<F!>'$8!0/68!'2!$8+!*'2+!()!
*/2=+0!'2!.80'6$E/6!$0++!*'F+!&'6$0'L#$'(2U!2($!/2!'2)+<$'(#6!&c;!like a herald rash; not a fungus!
!
Dysplastic Nevus syndrome
[:/E9*+-!90+<#06(0!*+6'(2!)(0!E/*'=2/2$!E+*/2(E/U!')!4(#!8/M+!(M+0!,VV!2+M'!/**!(M+0!L(&4;!4(#!8/M+!
&469*/6$'<!2+M#6!642&0(E+!
k+04!<(EE(2!
K#6$!=(!$(!&+0E/$(*(='6$!(2<+!/!4+/0!L<!2++&!$(!*((F!/$!&469*/6$'<!2+M'@!
.(#*&!L+!/!90+<#06(0!*+6'(2!)(0!E/*'=2/2$!E+*/2(E/@!!!
!
4 diff types of malignant melanoma
g8/$!'6!)'06$!6$+9!'2!E/2/=+E+2$n![:<'6'(2!
[:/E9*+-!6#9+0)'<'/*!690+/&'2=!E/*'=2/2$!E+*/2(E/!?K.B!
[:/E9*+-!(2!)/<+!()!(*&+0!9$!7!X+2$'=(!E/*'=2/!E+*/2(E/U!'00+=#*/0!L(0&+0;!<(02!<(*(0+&;!X[%YI!*'F+*4!
$(!E+$!()!/**!E/*'=2/2$!E+*/2(E/6@!!!
[:/E9*+-!L*/<F!9(9Q2!&(!2($!=+$!E/*'=2/2$!E+*/2(E/6!L<!$8+!L*/<F!9'=E+2$!'2!$8+!6F'2!90+M+2$6!\k!
*'=8$!&/E/=+!/2&!90(9+26'$4!)(0!</2<+0@!!8(>+M+0;!$8+0+!'6!(2+!$49+!()!</2<+0!$8+4!E/*'=2/2$!
E+*/2(E/!$8+4!.%"!=+$-!!
L*/<F!9$!>'$8!&4692+/;!(2!:0/4!)'2&!E#*$'9*+!E+$6!/**!(M+0!L(&4@!!S:!'6!&(2+!/2&!9$!8/6!E/*'=2/2$!
E+*/2(E/;!>8'<8!9/0$!()!$8+!L(&4!>(#*&!4(#!+:/E'2+!$(!)'2&!$8+!90'E/04!&cn!\2&+0!$8+!2/'*6;!9/*E6!
(0!6(*+!()!$8+!)++$!7!$8'6!'6!%<0(*+2$'='2(#6!E/*'=2/2$!E+*/2(E/!!?]/<0(Q!E+/26!+&=+!()Z$'9!()B!7!$8'6!'6!
$8+!KGYI!%llR[YY1k[!()!/**!$8+!E+*/2(E/6@!!I8'6!8/6!2($8'2=!$(!&(!>'$8!0/&'/$'(2@!!J/=+$6!&c!*((F6!
6'E'*/0!
!
[:/E9*+-!"(&#*/0!E/*'=2/2$!E+*/2(E/!7!/*6(!M+04!/==0+66'M+@!!!
!
The most important thing affecting prognosis is depth of invasion!?F+4!$(!90(=2(6'6!7!E/='<!s!
'6!@à!EEB@!!1)!'$6!*+66!$8/2!@à;!'$6!2($!=(22/!E+$@!
!
Toxins
H!9('6(2(#6!69'&+06!7!!
Black widow
N/6!/!2+#0($(:'2!7!</#6+6!69/6E!()!$8+!E#6<*+6!'2!$8+!#99+0!$8'=86!/2&!/L&(E+2!6(!6$0(2=!'$6!/*E(6$!
*'F+!$+$/2#6U!9/'2!E#6<*+!<(2$0/<$'(26;!+69!'2!$8+!/L&(E+2@!!I8+0+!'6!/2!/2$'M+2(E;!9/'2)#*!L'$+!
!
[:/E9*+-!9+06(2!>+2$!&(>2!'2$(!$8+'0!<+**/0;!*')$+&!L(:+6;!)+*$!68/09!90'<F!(2!)'2=+0;!/2&!&+M+*(9+&!
<(2$0/<$#0+6!(M+0!/!9+0'(&!()!806!7!&#+!$(!L*/<F!>'&(>!L'$+@!
!
Brown recluse spider!?/F/!M'(*'2!69'&+0B!
J/'2*+66!L'$+;!8/6!/!2+<0($(:'2;!*+/&'2=!$(!#*<+0!
Y(;!2+#0($(:'2!)(0!L*/<F!>'&(>;!2+<0($(:'2!)(0!L0(>2!0+<*(#6!
!
Where is receptors to androgens? Sebaceous glands ?$8'6!'6!>84!E+2!=+$!E(0+!c'$6!$8/2!>(E/2!
7!$+6$(6$+0(2+!>'**!0+*+/6+!*'9'&!0'<8!E/$+0'/*!>8'<8!=+$6!'2$(!$8+!8/'0!)(**'<*+@!!I8+2;!')!4(#!8/M+!
90(90'(2#E!/<2+'!?/2/+0(L+B!'$!8/6!*'9/6+6!$8/$!L0+/F&(>2!)/$!)0(E!$8+!6+L/<+(#6!=*/2&!/2&!90(&#<+6!
T%Q6!$8/$!'00'$/$+!$8+!)(**'<*+!/2&!+2&!#9!>'$8!/<2+@!!Y(;!E+2!E(0+!*'F+*4!$(!=+$!'$!L<!$8+4!8/M+!/<2+!
227

1$!/**!(<<#06!'2!$8+!+0+<$(0!9'*'!E#6<*+!()!$8+!6F'2@!!
Y(;!$8+0+!/0+!/2&0(=+2!0+<+9$(06!6+L/<+(#6!=*/2&6!/2&!+0+<$(0!9'*'!E#6<*+@!!!
!
Drug used to prevent hirsutism? Spironolactone ?6/E+!&0#=!#6+&!$(!L*(<F!/*&(6$+0(2+BU!$8'6!
&0#=!'6!=((&!L<!'$!L*(<F6!/2&0(=+2!0+<+9$(06!/2&!$8+0+)(0+!90+M+2$6!8'06#$'6E@!!./2!/*6(!*+/&!$(!
=42+<(E/6$'/@!
!
CNS
!
Y9'2/*!)*#'&!7!&+0'M+6!)0(E!<8(0('&!9*+:#6!'2!$8+!M+2$0'<*+6@!!12!$8+!*/$+0/*;!P0&!/2&!^$8!M+2$0'<*+6@!!1$6!/2!
#*$0/)'*$0/$+!()!9*/6E/@!!g8/$!'6!$8+!&'))+0+2<+!'2!6+0#E!/2&!69'2/*!)*#'&n!g/4!E(0+!90($+'2!'2!69'2/*!
)*#'&!L<!'$Q6!/2!#*$0/)'*$0/$+@!!.+**n!N/0&*4!/24!<+**6!'2!69'2/*!)*#'&!?2(2+B@!l*#<(6+n!X(>+0!'2!69'2/*!)*#'&!7!
/L(#$!aVW!()!>8/$!'$!'6!'2!6+0#E!?')!$8+!69'2/*!)*#'&!=*#<(6+!*+M+*!>+0+!*(>;!$8+2!6(E+$8'2=!'6!'2!$8+0+!
#$'*'c'2=!'$!)(0!+2+0=4!6#<8!/6!L/<$+0'/!(0!)#2=#6!(0!</2<+0!<+**6B@!!16!$8+0+!/24$8'2=!KGR[!'2!69'2/*!)*#'&!
$8/2!6+0#En!.8*(0'&+!?>/4!8'=8+0!'2!69'2/*!)*#'&!$8/2!6+0#EB!d!!/0(#2&!,HV@!!I8+6+!/0+!'E9!L<!$8+0+!
/0+!'23#0'+6!$(!$8+!8+/&@!
!
[:/E9*+-!L/6+L/**!$8/$!8'$6!$8+!+4+!'2!/2!(0L'$/*!L*(>(#$!)0/<$#0+!7!</2!9($+2$'/**4!L0+/F!<0'L0')(0E!
9*/$+;!*+/&'2=!$(!&0'99'2=!)*#'&!(#$;!>8'<8!<(#*&!L+!62($;!6+0#E;!(0!69'2/*!)*#'&@!!!Y(;!'$6!'E9!$(!F2(>!
&'))Q6!L$>2!$8+!$>(@!
!
[:/E9*+-!>/<F+&!'2!$8+!8+/&!7!)*#'&!(#$!()!+/0!?($(008+/B;!8+E(008/=+!*+/&6!$(!L/$$*+!6'=2@!!I8'6!'6!/!
)0/<$#0+!()!$8+!L/6'*/0!9*/$+!/2&!$8+0+!'6!69'2/*!)*#'&!$8+0+@!!!
!
K(6$!()!$8+!)*#'&!<(E+6!(#$!$8+!/D#+&#<$!()!64*M'#6!7!>8'<8!'6!$8+!K..!()!84&0(<+98/*#6!'2!<8'*&0+2!L<!
'$!=+$6!L*(<F+&!())!#2$'*!4(#!=+$!/!L#'*&!#9!()!69'2/*!)*#'&!'2!$8+!P0&!M+2$!/2&!*/$+0/*!M+2$;!>8'<8!'6!/!
2/00(>!/0+/!/2&!*+/&6!$(!84&0(<+98/*#6@!!I8+2;!'$!<(E+6!$(!$8+!)(#0$8!M+2$!/2&!2++&6!$(!=+$!(#$!L<!'$!
2++&6!$(!=+$!'2$(!$8+!6#L/0/<82('&!69/<+@!!Y(;!'$!=(+6!$80(#=8!$8+!)(0/E+2!()!X#6<8F/!/2&!K/=+2&'+;!
6(!)*#'&!=(+6!(#$@!!!
!
_#0/!E+/26!6$0(2=!7!'$Q6!$'=8$*4!/&8+0+2$!$(!$8+!9+0'(6$+#E@!!Y(;!>8+2!9$!8/6!+9'&#0/*!8+E/$(E/!
?L*((&!<*($!L+$>2!L(2+!/2&!&#0/B@!!I8+!(2*4!90+66#0+!$8/$!</2!69*'$!$8+!9+0'(6$+#E!/>/4!)0(E!&#0/!'6!
/0$+0'/*!90+66#0+@!!Y(;!this is the one when the middle mengial artery ruptures;!/2&!</2!L+!
&(2+!>'$8!/0$+0'/*!90+66#0+!?2($!M+2(#6B@!!!
!
1$!=+$6!'2$(!$8+!6#L/0/<82('&!69/<+!?$(!90($+<$!#6!7!/!<#68'(2!/=/'26$!&/E/=+B@!!l+$!0'&!()!69'2/*!)*'#&!
'2!/0/<8(2('&!=0/2#*/$'(2@!!z%!$#E(0!</2!/0'6+!)0(E!$8+!/0/<82('&!=0/2#*/$'(26!7!E+2'2='(E/@{!!1$!
=(+6!$80(#=8!$8+!/0/<82('&!=0/2#*/$'(26;!?$8+0+!/0+!"G!XbKJN%I1.Y!1"!SR%1"B!/2&!$8+!&#0/*!6'2#6+6!
/2&!<(2=*(E+0/$+!'2$(!$8+!3#=#*/0!M+'2;!>8'<8!'6!+E9$'+&!'2$(!$8+!0'=8$!6'&+!()!$8+!8+/0$@!!!
!
Y(;!>8+2!4(#!&(!/!M/*6/*M/!/2&!$8+!2+<F!M+'26!&'6$+2&;!$8/$!90+66#0+!$0/26E'$6!/**!$8+!>/4!L/<F!$(!$8+!
&#0/*!6'2#6+6;!$(!$8+!/0/<82('&!=0/2#*/$'(26!$80(#=8!$8+!69'2/*!)*#'&!;!/2&!0'=8$!&(>2!$8+!$8+!2++&*+!'2!
$8+!6#L/0/<82('&!69/<+!/$!X^!/2&!$8+!90+66#0+!=(+6!#9@!!I8'6!'6!</**+&!D#/F+26!6$+9!E/2+#M+0@!!1$!'6!/!
=0+/$!$+6$!)(0!>8+2!4(#!/0+!&('2=!/!69'2/*!$/9!$(!6++!')!$8+!+2$'0+!6#L/0/<82('&!69/<+!'6!9/$+2$@!!1)!4(#!
&(2Q$!6++!$8/$!E/2(E+$+0!=(!#9;!$8+0+!'6!6(E+$8'2=!L*(<F'2=!$8+!69'2/*!)*#'&!E(0+!90(:'E/**4@!!!
[:/E9*+-!>8+2!4(#!>$!*')$;!4(#!68(#*&2Q$!8(*&!4(#0!L0+/$8!L<!$8+!90+66#0+!/0+!8#=+!/2&!/2&!*+/&!$(!/!
8+02'/$+&!&'6F@!!!
!
228

Tentorium Cerebelli
`VW!()!L0/'2!$#E(06!'2!/&#*$6!/0+!6#90/$+2$(0'/*!?'2M(*M+!<+0+L0/*!<(0$+:B!
`VW!()!L0/'2!$#E(06!'2!F'&6!/0+!'2)0/$+2$(0'/*!?<+0+L+**/0;!<46$'<!/6$0(<4$(E/;!E+&#**(L*/6$(E/B!
!
Hydrocephalus
.(EE#2'</$'2=!M6!"(2<(EE#2'</$'2=!
.(EE#2'</$'(2!()!69'2/*!)*#'&!'2!M+2$0'<*+6!>'$8!6#L/0<82('&!69/<+@!
!
Noncommunicating
K.!
Y(E+$8'2=!'6!90+M+2$'2=!69'2/*!)*#'&!'2!$8+!M+2$0'<*+6!)0(E!=+$$'2=!'2$(!$8+!6#L/0/<82('&!69/<+!
MCC = stenosed Aqueduct of Sylvius
G0!6(E+$8'2=!=('2=!'2!$8+!^$8!M+2$;!+9+2&4E(E/!'2!F'&6!>'**!L*(<F!'$!());!(0!E+2'2='$'6!'2!L/6+!()!L0/'2!
?ISB;!*+/&6!$(!6</0!$'66#+!L<!L*(<F6!)(0/E+2!()!E/=+2&'+!/2&!*#6<8F/@!!!
!
Communicating
Y$'**!<(EE#2'</$'2=;!L#$!6$'**!/!L#'*&!#9!()!90+66#0+@!!G2+!</#6+!<(#*&!L+!$#E(0!()!<8(0('&!9*+:#6!
?9/9'**/04!*((F'2=B@!!Y(;!')!4(#!8/M+!/!$#E(0!$8+0+;!4(#!8/M+!/!=0+/$+0!#*$0/)'*$0/$+!()!9*/6E/!/2&!>(#*&!
L+!E/F'2=!E(0+!9*/6E/@!!%*6(;!>(#*&!L+!E/F'2=!E(0+!69'2/*!)*#'&@!!I8+0+!>(#*&!6$'**!L+!/!
<(EE#2'</$'(2!>'$8!8+0+;!L#$!$8+!90+66#0+!>(#*&!L#'*&!#9!L<!E/F'2=!E(0+!$8/2!4(#!<(EE(2*4!&(@!!!
K(0+!<(EE(2*4;!>8/$!')!4(#!8/M+!/!6#L/0/<82('&!L*++&!(0!E+2'2='$'6n!I8+2!9$!8/6!6</00+&!())!
/0/<82('&!=0/2#*/$'(26!/2&!8/M+!2(!>/4!()!&0/'2'2=!'$!(#$@!!Y(;!6$'**!8/M+!/!<(EE#2'</$'(2;!L#$!</22($!
=+$!0'&!()!'$!?K.B@!!!
!
Arnold Chiari Malformation
[:/E9*+-!9#**!&(>2!69'2/*!<(0&@!!I8'6!>(#*&!L0'2=!$8+!E+&#**/!'2$(!$8+!<+0M'</*!0+='(2!/2&!E/4L+!/!*'*!
9/0$!()!$8+!<+0+L+**#E@!!X+/&6!$(!84&0(<+98/*#6!/2&!9*/$4L/6'/!?)*/$$+2'2=!()!$8+!L/6+!()!$8+!6F#**B!
!
Dandy walker syndrome
.+0+L+**/0!M+0E'6!'6!2($!&+M+*(9+&!
!
Herniation
g84!>(#*&!>+!8+02'/$+!'2!$8+!L0/'2n!S<!$8+0+!'6!<+0+L0/*!+&+E/!/2&!2(!($8+0!9*/<+!$(!=(@!!I8+!)/E(#6!
(2+6!/0+!$(26'**/0!8+02'/$'(2!$80(#=8!$8+!)(0/E+2!E/=2#E@!!?)0(E!$8+!<+0+L+**#EB!7!<+0+L+**/0!
8+02'/$'(2!7!8/6!L++2!6D#++c+&!'2$(!$8+!)(0/E+2!E/=2#E;!/2&!8/6!<(26$0'<$'(2@!!./2!</#6+!'EE+&'/$+!
&+/$8@!
\2</*!8+02'/$'(2!7!E+&'/*!9(0$'(2!()!$8+!$+E9(0/*!*(L+!8+02'/$+6!$80(#=8!$8+!$+2$(0'#E!<+0+L+**'!/2&!
90+66'2=!/=/'26$!E'&L0/'2;!*+/&6!$(!8+E(008/=+!?&#0+$Q6!8+E(008/=+B@!!%*6(!/2!(<#*(E($(0!2+0M+!$8/$!
'6!=(22/!L+!<(E90+66+&@!!Y(;!$8'6!>'**!*+/&!$(!(9$8/*(E(9*+='/!?XRaYG^;!PB;!6(!+M+04$8'2=!'22+0M/$+&!
L4!."!111!'6!9/0/*4c+&@!!g'$8!(<#*(E($(0!2+0M+!9/*64;!'$!'6!&(>2!/2&!(#$@!!?&(>2!/2&!'2!'6!."!^!9/*64!7!
')!."!a!'6!9/0/*4c+&;!>'**!*((F!<0(66!+4+&B@!!X((F!/$!9#9'*@!
!
[:/E9*+-!KR1!()!(0'L'$;!2/E+!E#6<*+6!
J/0/64E9/$8+$'<!<(26$0'<$!$8+!9#9'*!?2(0E/**4B!;!64E9/$8+$'<6!&'*/$+!?2(0E/**4B!
Y(;!')!4(#!E+66!#9!$8+!9/0/64E9/$8+$'<6;!>8'<8!2(0E/**4!<(26$0'<$;!'$!>'**!*+/&!$(!E4&0'/6'6@!!!
I8+!)'06$!6'=2!()!#2</*!8+02'/$'(2!'6!E4&0'/6'6!()!9#9'*!(2!6'&+!()!8+02'/$'(2!?6(!'$!&'*/$+6!(2!$8/$!6'&+B@!!
%*6(;!9(6$+0'(0!<+0+L0/*!/0$+04!</2!=+$!L*(<F+&!>'$8!#2</*!8+02'/$'(2;!*+/&'2=!$(!9(6$!*(L+!'2)/0<$'(2@!!!
Know brainstem and CNs and how it related to herniation
229

!
Papilledema
%24!</#6+!()!'2<0+/6+&!'2<0/2'/*!90+66#0+!
k'$!%!$(:!
X+/&!9('6(2'2=!7!&+*$/d/E'2(*+M#*'2'<!/<'&!7!*+/&6!$(!'2<0+/6+&!9+0E+/L'*'$4!
!
%#&'(!)'*+!_/4e!sa!."Y!
!
Hydrocephalus
K..!C!6$+2(6'6!()!$8+!/D#+&#<$!()!64*M'#6!
"(2<(EE#2'</$'2=@!!!
l+$!84&0(<+98/*#6!L<!$8+!6#$#0+6!8/M+!2($!)#6+&!
')!4(#!E'66!84&0(<+98/*#6!'2!/&#*$!/2&!6#$#0+6!8/M+!)#6+&;!>'**!*+/&!$(!&'*/$/$'(2!()!$8+!M+2$0'<*+6!/2&!
+M+2$#/**4!(M+0!4+/06;!$8+!90+66#0+!>'**!$#02!L/<F!$(!2(0E/*!L<!$8+!'2<0+/6+&!90+66#0+6!F++9!$8+!
<8(0('&!9*+:#6!)0(E!E/F'2=!6(!E#<8!!
_+E+2$'/;!/$/:'/;!#0'2/04!'2<(2$'2+2<+@!!
%F/!2(0E/*!90+66#0+!84&0(<+98/*#6!?L<!90+66#0+6!2(0E/*'c+B!
!
Tuberous Sclerosis
AD
N/E/0$(E/6!?2(2+(9*/6$'<!90(*')+0/$'(2!()!$8'2=6B!!
k+2$0'<*+6!8/M+!L#E96!</**+&!$#L+0<*+6!7!>8'<8!/0+!8/E/0$(E/6!>8'<8!8/M+!90(*')+0/$'(2!()!/6$0(<4$+6@!!
I8+4!90(&#<+!8/E/0$(E/6!$8/$!L#*=+!'2$(!$8+!M+2$0'<*+;!</**+&!</2&*+!6$'<F!&0'99'2=@!!N+E/0$(E/6!()!
$8+!F'&2+4!</**+&!/2='(E4(*'9(E/6;!KR;!</0&'/<!$#E(06!?08/L&(E4(E/6B;!68/=0++2!9/$<8+6;!/0+/6!()!
849(9'=E+2$/$'(2;!>((&6!*'=8$!68'2+!(#$!
!
!
Anencephaly
g(06$!()!2+#0/*!$#L+!&+)+<$6!
%L6+2$!L0/'2!
!
Vertebral arch defects
Spina bifida occulta!7!$#)$6!()!8/'0!<(E+!(#$;!M+0$!/0<8+6!&(!2($!$(#<8;!2(!E+2'2=+6!<(E+!
Meningoceole!7!E+2'2=+6!<(E+!(#$!
Meningomylocele!7!L($8!E+2'2=+6!/2&!69'2/*!<(0&!<(E+!(#$!
N'=8!/*98/!)+$(!90($+'2!*+M+*6!'2!L*((&!()!E($8+0U!&+<0+/6+&!'2!&(>26!642&0(E+!
N/M+!$(!L+!(2!)(*/$+!$(!90+M+2$!2+#0/*!$#L+!&+)+<$6!?2+#0/*!$#L+!)'2'68+&!)(0E'2=!L4!PV!&/46;!6(!E/F+!
6#0+!68+!'6!(2!)(*/$+!')!68+!'6!$04'2=!$(!=+$!90+=2/2$B@!!!
!
Neurofibromatosis
%*L0'=8$!642&0(E+!?90+<(<'(#6!9#L+0$4;!</)x!/#!*/'$;!L(2+!c'$6B!
Y$#0=+!>+L+0!
./)x!/#!*/'$!?<())++!<(*(0+&!2(2!0/'6+&!*+6'(26B!69($;!9*+:')(0E!2+#0()'L0(E/6;!849+09'=E+2$/$'(2!'2!
$8+!/:'**/!?/:'**/04!)0+<F*'2=B;!2+#0()'L0(E/6!
%_!;!$8+0+)(0+!*/$+!E/2')+6$/$'(26!?+69!)(0!2+#0()'L0(E/$(6'6B;!9+2+$0/2<+;!M/0'/L*+!+:90+66'M'$4!?4(#!
/0+!+:90+66'2=!$8+!&c;!L#$!&'))!*+M+*6!()!8(>!6+M+0+!$8+!&c!'6B!
[:/E9*+-!9$!>'$8!HTN!/2&!9'<;!>8/$!$+6$!>(#*&!4(#!=+$n!R+*/$'(268'9!()!2+#0()'L0(E/!>'$8!
98+(<80(E(<4$(E/;!$8+0+)(0+!=+$!/!H^!80!#0'2+!)(0!kK%!/2&!E+$/2+980'2+@!!!
230

!
Acoustic schwannoma
[:/E9*+-!9$!>'$8!6+26(0'2+0#/*!8+/0'2'2=!*(66!7!Lr!$#E(0!()!Y<8>/22!<+**6!/0(#2&!."!t!
!
Meningiomas
G9$'<!2+0M+!=*'(E/6!
!
Syringomyelia
[:/E9*+-!9$!$8/$!>(0F6!'2!)/<$(04!/2&!(2+!()!>(0F+06!6/46!4(#!/0+!L#02'2=!4(#0!8/2&!/2&!9$!&'&2Q$!
2($'<+!$8'6;!(2!+:/E!*(66!()!E#6<#*/$#0+!?*(66!()!XK"B!'2!'2$0'26'<!E#6<*+6!()!$8+!8/2&;!*(66!()!9/'2!/2&!
$+E9!'2!</9+!*'F+!&'6$0'L#$'(2!/<0(66!L/<F@!
./2Q$!)++*!9/'2!?2($!%XY!7!'2!%XY;!)'06$!9*/<+!()!&+M+*(9E+2$!()!*(66!()!E#6<*+6!'6!8+0+;!6(!&(2Q$!
<(2)#6+U!L#$!%XY!'6!\K"!/2&!XK"!*(66;!J\R[!KGIGR!;!6(!')!9$!8/6!9/'2;!'+;!$8'6!'6!6+26(04!/2&!2($!
%XYB!!
S'=!<46$'<!</M'$4!F2(<F'2=!())!69'2($8/*/E'<!F2(<F'2=!())!9/'2!/2&!$+E9@!!</2!F2(<F!())!$8+!
<(0$'<(69'2/*!$0/<$!/2&!/2$+0'(0!8(02!<+**6;!6(!'$!>'**!L+!/!.GKSG!()!6+26(04!%"_!E($(0!*(66!)(0!
640'2='(E4+*'/@!!!
!
Infections
!
Meningitis vs encephalitis
K+2'2='$'6!7!'2)*/EE/$'(2!()!E+2'2=+6!/2&!2#<8/*!0'='&'$4U!')!4(#!E(M+!4(#0!8+/&!(0!+:$+2&!4(#0!F2++;!
4(#!>'**!6$0+$<8!$8+!E+2'=+6;!*+/&'2=!$(!9/'2!?6$0+$<8'2=!'2)*/E+&!E+2'2=+6B@!!!
[2<+98/*'$'6!7!6*++9'2=!6'<F2+66!7!$8+4!/0+!/*>/46!6*++9'2=!/2&!&0(>64U!$8+4!8/M+!E+2$/*!6$/$#6!
/L2(0E/*'$'+6!?2($!2#<8/*!0'='&'$4B!
!
J#6!/$!$8+!L/6+!()!$8+!L0/'2!7!</2!9(66'L*4!L*(<F!*#68F/!/2&!E/3+2&'+;!*+/&'2=!$(!(L6$0#<$'M+!
84&0(<+98/*4!/2&!2(2<(EE#2'</$'2=!
g8+2!4(#!R:!E+2'2='$'6;!#6+!6$+0('&6!/2&!%L6@!!>84n!Y$+0('&6!90+M+2$!6</0!$'66#+!)(0E/$'(2!/2&!
<(E9*'</$'(26!$8/$!/0'6+!>'$8!'$!?'+!84&0(<+98/*#6B@!!!
I8'6!'6!6$/2&/0&!IS!E+2'2='$'6!R:!?IS!'2!L0/'2!</#6+6!M/6<#*'$'6!/2&!6</00'2=B!
_+/)2+66!'6!/!<(E9*'</$'(2!()!E+2'2='$'6@!
!
!
Rabies
[:/E9*+--!E+2'2='$'6;!<+0+L0/*!/L<+66;!R/L'+6!?K..!'2!Y$/$+6!C!6F#2F6;!&(=6!'2!P0&!>(0*&B!!
"+=0'!L(&'+6!?9+0F'23+!<+**!'2<*#6'(2B!
!
CMV
J+0'M+2$0'<#*/0!</*'<')'</$'(26!
[:/E9*+-!6+<$'(2!()!F'&!?L0/'2B!!!d!6++!>8'$+!6$#))!=('2=!/0(#2&!M+2$0'<*+6!
K.!<(2=+2$/*!'2)+<$'(2!C!.Kk!
g8/$!L(&4!)*#'&!'6!L+6$!$(!<#*$#0+!)0(En!\0'2+!
!
Meningitis
g8/$!'6!K.!E+2'2='$'6Z6+9'6!'2!)'06$!E(2$8!()!*')+n!l0(#9!S!6$0+9!7!6$0+9!/=/*/<$/+!7!L<!E/24!>(E+2!
8/M+!$8'6!(0=/2'6E!'2!$8+'0!M/='2/;!6(!$8+4!/0+!</00'+06@!!J0+E/$#0+!0#9$#0+&!E+EL0/2+6!*+$6!$8+!
(0=/2'6E!=+$!#9;!=+$!/2!<8(0'(/E2'(2'$'6!/2&!'2$(!$8+!L*((&6$0+/E@!!!
231

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!
g8/$!)((&!68(#*&!90+=2/2$!>(E+2!/M('&n!Y()$!<8++6+6!?'+!)+$/!<8++6+;!L#$!*'6$+0'/!'6!90+6+2$B@!!!
K.!'2!,!E(2$8!7!,t!4(!C!"!E+2'2='$'&+6!
?2($!N!'2)*#+2c/!L<!M/<<'2/$'(2B!
K.!'2!,tO!C!Y$0+9!92!
[:/E9*+-!eH!4(!E/2;!2#<8/*!0'='&'$4;!$/9!68(>6!'2<0+/6+&!90($+'2;!'2<0+/6+&!2+#$0(98'*6!/2&!&+<0+/6+&!
=*#<(6+!7!&:n!Y$0+9!92@!>8/$!'6!$8+!=0/E!6$/'2n!l0/E!O!&'9*(<<#6!
!
Cryptococcus
12&'/!'2F!7!6++!2/00(>!L/6+&!L#&!)(0!.049$(<(<<#6!
g8(!&(!4(#!$8'2F!$8'6!'6!'2n!1.Q&!9$6!
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K..!E+2'2='$'6!'2!%1_6!9$6n!.049$(<(<<#6!
!
Mucormycosis
12!)0(2$/*!*(L+;!$8+0+)(0+!)0(E!/!&'/L+$'<!'2!F+$(/<'&(6'6!
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[:/E9*+-!69+<'/*!6$/'2!(2!%1_6!9$!>'$8!._!^!<$!()!eV;!.I!68(>+&!69/<+!(<<#94'2=!*+6'(2!
_:n!Toxoplasmosis !
!
[:/E9*+-!9'=!8+0&+0;!/2&!*(2=!$'E+!90(L*+E!>'$8!)(</*!+9'*+9$'<!6+'c#0+6!?&'*/$'2=!$8+0/94B!7!E#*$'9*+!
</*<')'+&!/2&!<46$'<!*+6'(26!'2!L0/'2!7!&:n!Cysticercosis!
!
[:/E9*+-!f/<(L!.0#+$c)+*$&6!)0(E!90'(26!?E/&!<(>B!7!>8(!'6!E(6$!*'F+*4!$(!=+$n!"+#0(9/$8(*(='6$6;!
2+#0(6#0=+(26;!L++);!*+$$#<+!)0(E!%0'c(2/!?<(>!E/2#0+!(2!'$B!
!
!
Traumatic lesions!!
Epidural hematoma!?/L(M+!&#0/B!7!8'$!'2!8+/&!E'&&*+!E+2'2=+/*!7!8/M+!$(!)0/<$#0+!L(2+!?#2&+0!
/0$+0'/*!90+66#0+6;!</2!6+9/0/$+!&#0/!)0(E!9+0'(6$+#EB@!g8+2!4(#!=+$!eV!E*6!()!L*((&;!4(#!=+$!#2</*!
8+02'/$'(2!/2&!&'+@!!1+!=+$!8'E;!6/4!$8+4!/0+!(F;!a!806!*/$+0!+9'&#0/*!8+E/$(E/!/2&!&+/$8!
!
Subdural hematoma!7!0#9$#0+!()!L0'&='2=!M+'26!L+$>2!&#0/!/2&!/0/<8(2('&!E+EL0/2+@!!1)!4(#!8/M+!
<+0+L0/*!/$0(984;!$8+2!$8+!69/<+!L>$2!$8+!&#0/!/2&!/0/<82('&!E+EL0/2+6!'6!L'==+0@!S0'&='2=!M+'26!
&/2=*'2=;!L0+/F!/2&!=+$!/!8+E/$(E/@!!T*#<$#/$'2=!*+M+*6!()!<(26<'(#62+66@!!X+)$!#2$0+/$+&!*+/&!$(!
&+E+2$'/@!!_(!.I!$(!0Z(!+9'!/2&!6#L&#0/*!8+E/$(E/!?/*6(!)(0!6$0(F+6!7!')!'$6!!/!8+E(008/='<!6$0(F+B!
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Strokes
Y*'&+-!S0/'2-!(2+!6'&+!'6!L'==+0@!!%$8+0(6<*+0($'<!6$0(F+U!9/*+!'2)/0<$!()!L0/'2@!!%$!L')#0</$'(2;!$8+0+!'6!/2!
/$8+0(6<*+0($'<!9*/D#+!/2&!$80(EL#6@!!"(!L*((&!)*(>!$(!L0/'2!/2&!'$!'2)0/<$+&;!6$/0$6!L0+/F'2=!&(>2;!2(!
0+9+0)#6'(2;!6(!'$!0+E/'26!/!9/*+!'2)/0<$@!!1)!$8+!$80(EL#6!&'&!L0+/F!/9/0$;!/2&!0+9+0)#66+!$8+!L0/'2;!$8+!
L*((&!'2!$8+!=(+6!'2$(!$8+!/0+/!()!'2)/0<$'(2!/2&!'6!</**+&!/!8+E(008/='<!'2)/0<$@!!N(>+M+0;!$8'6!#6#/**4!
&(+62Q$!(<<#0!/2&!!9/*+!'2)/0<$6!E(0+!<(EE(2@!!1)!2(!L*((&;!/2&!$8+0+!'6!'2)/0<$'(2;!9$!'6!/!</2&'&/$+!
)(0!8+9/0'2!$8+0/94@!!GM+0!$'E+;!')!9$!6#0M'M+6;!+2&6!#9!>'$8!<46$'<!69/<+!>8+0+!$8+0+!>/6!'2)/0<$'(2!
/2&!$8'6!'6!</**+&!*'D#+)/<$'M+!2+<0(6'6dd9/*+!'2)/0<$;!*'D#+)/<$'M+!2+<0(6'6@!
232

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()!$8+!8+/0$@!I8+!M+66+*!'$!/*>/46!=(+6!$(!'6!E'&&*+!<+0+L0/*!/0$+04@!!1$!=+$6!'2$(!$8+!.'0<*+!()!g'**'6!/2&!
'2$(!$8+!E'&&*+!<+0+L0/*@!!1)!4(#!+EL(*'c+!&(>2;!>'**!=(!'2$(!$8+!6#9+0'(0!E+6+2$+0'<!
I8+!0+/6(2!'$!'6!8+E(008/='<!'6!L<!9$!>'**!=+$!L0+/F&(>2!()!)'L0'2(*4$'<!646$+E!()!$8+!+EL(*#6!/2&!*+/&6!
$(!0+9+0)#6'(2@!!126$+/&!()!L+'2=!/!9/*+!'2)/0<$;!'$Q6!/!8+E(008/='<!'2)/0<$@!!Y(;!L($8!/!/$8+0(6<*+0($'<!
6$0(F+!/2&!8+E(008/='<!6$0(F+!/0+!L($8!'2)/0<$6!7!(2+!'6!9/*+!/2&!$8+!($8+0!'6!8+E(008/='<@!!!
!
Y*'&+-!HTN;!90+66#0+6!</#6+!*+2$'<#*(6$0'/$+!M+66+*6!$(!<(E+!#9!/2&!6#99*4!$8'6!/0+/!()!$8+!L0/'2@!!
_+0'M+!)0(E!$8+!E'&&*+!<+0+L0/*!/2+#046E6;!</**+&!.8/0<($!S(#<8/0&!/2+#046E!/2&!'$!0#9$#0+6;!*+/&'2=!
$(!='/2$!8+E/$(E/!/2&!L*((&!<*($@!N(00'L*+!90(=2(6'6@!!!
Y(;!+EL(*'<!6$0(F+!=(+6!$(!6#0)/<+!()!$8+!L0/'2!/2&!')!'$Q6!'2!$8+!L/6/*!=/2=*'/;!its always an
intracebral bleed from HTN.
!
[:/E9*+-!subarachnoid hemorrhage!E(6$*4!&#+!$(!0#9$#0+!<(2=+2'$/*!L+004!/2+#046E@!!K.!/$!$8+!
3#2<$'(2!/2$!<(EE!L0/2<8!()!/2$!<+0+L0/*!/0$+04!
X+66!<(EE(2!</#6+!()!Y%N-!!
AV malformation
Y$#0=+!g+L+0!7!(2!6/E+!6'&+!/6!6F'2!*+6'(2!()!$8+!)/<+;!$8+0+!'6!/2!%k!E/*)(0E/$'(2!
!
Lacunar infarcts!7!6E/**!/0+/6!(2!$8+!L0/'2U!#2#6#/*!L<!$8+4!8'$!/0+/6!()!$8+!L0/'2@!!_+9+2&'2=!(2!
>8+0+!'2!$8+!'2$+02/*!</96#*+;!</2!8/M+!/!9#0+!E($(0!6$0(F+!(0!9#0+!6+26(04@!K.!&#+!$(!NI"!
!
Multiple Sclerosis (MS)
MC demyelinating Dz (autoimmune) MS
Slide:&+E4*'2/$+&-!>8'$+!E/$$+0!8/6!E4+*'2!'$;!=0+4!&(+62Q$@!!1)!4(#!/0+!&+6$0(4'2=!>8'$+!E/$$+0;!$8+2!
4(#Q**!6++!=0+4!#2&+02+/$8@!!Plaques of MS@!!!
!
H!>/46!$(!&+E4*'2/$+!!
,B!F2(<F!())!<+**!$8/$!E/F+6!E4+*'2!'2!$8+!L0/'2!?(*'=(&+2&0(<4$+6!'2!L0/'2;!6<8>/22!<+**!'2!J"YB!7!
M'0#6+6!&(!$8'6!7!6#L/<#$+!6<*+0(6'6;!90(=0+66'M+!E#*$')(</*!*+#F(+2<+98/*(9/$84;!NJk!7!$8+4!/))+<$!$8+!
(*'=(&+2&0(<4$+U!!
!
HB!</2!/*6(!8/M+!%LQ6!/=/'26$!E4+*'2!/2&!2($!$8+!(*'=(&+2&0(<4$+;!>8'<8!'6!KY!9/0+6$8+6'/6!!
"46$/=E#6;!/$/:'/;!(9$'<!2+#0'$'6!>'$8!L*#004!M'6'(2!?MCC of Optic Neuritis= MS!L<!&+E4*'2/$'(2!()!
(9$'<!2+0M+B!
!
Internuclear opthalmaplegia!?&+E4*'2/$'(2!()!KXTB!d!9/$8(=2(E(2'<!
Spinal tap will show increased protein, normal glucose, increase lymphs!
!
!
Hydrocephalus Ex Vacuo
Y+M+0+!/$0(984!()!L0/'2!/2&!M+2$0'<*+6!*((F!L'==+0!$8/2!$8+4!68(#*&!L+!
_+E+2$'/!
!
Alzheimers Dz
233

.*/66'<!*+6'(2-!6+2'*+!9*/D#+;!2+#0'$Q6;!/E4*('&!?S+$/mmB!7!6(!L+$/!/E4*('&!'6!$(:'<!/2&!$8+!E(0+!4(#!
8/M+!$8+!E(0+!$(:'<!7!9/$8(=2(E(2'<!()!/*c8+'E+06;!(2!<Q6(E+!H,;!$8+0+)(0+!6++2!'2!&(>2Q6;!2+#0()'L!
$/2=*+6!?'2!/24!&+E+2$'/!/2&!N_B!
%*c!7!90(L6!'2!8'=+0!*+M+*6!7!&+E+2$'/!!
G2*4!>/4!$(!&:!'6!/#$(964!?<(2)'0E/$'(2B!7!6++!6+2'*+!9*/D#+6!
!
Parkinsons Dz
R+6$'2=!$0+E(0!
234

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B. Steps involved in Acute inflammation ?$8'6!$8+!2(0E/*!6+D#+2<+!'2!/<#$+!'2)*/EE/$'(2B:!!

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B. Four kinds of shock-!!

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Increase in bicarb = increase pH = metabolic alkalosis

Increase pCO2 = decrease pH = respiratory acidosis

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B. Steps involved in Acute inflammation ?$8'6!$8+!2(0E/!6+D#+2<+!'2!/<#$+!'2)/EE/$'(2B:!!