ALGORITHMS

usman saeed
1. Cardiovascular system 8
Factors associated with poor outcome after witnessed out-of-hospital sudden cardiac arrest 8
Lifestyle interventions for HTN 8
Acute ST-elevation MI 9
Wide complex tachycardia 9
Abdominal aortic aneurysm screening 10
Pretest probability for coronary artery disease 10
Evaluation of chest pain 10
Evaluation of chest pain in ER 11
Pretest probability for pulmonary embolism 11
Suspected pulmonary embolism 12
Management of symptomatic sinus bradycardia 13
Diagnosis of anaphylaxis 13
Approach to adult cardiac arrest 14
Adult cardiac arrest management 14
CHA2DS2-VASc score for thromboembolic risk in nonvalvular atrial fibrillation 15
Management of Acute decompensated heart failure 16
Management of hypertriglyceridemia 16
Diagnostic approach to aortic dissection 17
Management of adult tachycardia 18
Pharmacological rate control of atrial fibrillation 19
Management of hypertrophic cardiomyopathy 19
Diagnosis of HTN 20
Cardiorenal syndrome 20
Neonatal cyanosis 21
Routine newborn care 21
Stenotic valve replacement indications 22
Blunt chest trauma management 22
Evaluation of suspected abdominal aortic aneurysm 23
Evaluation of suspected acute coronary syndrome 23
Cardiac risk evaluation for a noncardiac surgery 24
Valvular heart disease management before noncardiac surgery 24
Ankle-brachial index 25

2. Renal 25
Causes gross hematuria 25
Pathogenesis of nephrotic syndrome 26
Workup for AGMA 26
Mechanism of hypovolemic hyponatremia 27

1
 Refeeding syndrome 27
Differential diagnosis of metabolic alkalosis 28
Evaluation of hyponatremia 28
Evaluation of AKI 29
Evaluation of hematuria in children 29
Hypernatremia 30
Kidney stones 31
UTI due to vesicoureteral reflux 32
Evaluation of red urine 32
Labs in persistent vomiting 33
Potter sequence 33
Renal osteodystrophy 34
Management of ureteral stones 35

3. Respiratory and critical care 36

Asthma evaluation 36
Treatment of asthma 36
Treatment plan for COPD 37
Effects of Positive pressure ventilation in cardiogenic edema 37
Evaluation of solitary pulmonary nodule 38
Pulmonary function testing 38
Evaluation of chronic cough 39
Differentials of hyponatremia 39
Acetazolamide for High altitude sickness 40
Pulmonary embolism 40
Diagnostic strategy in suspected pulmonary embolism 41
Suspected pulmonary embolism 42
O2 induced co2 retention in COPD 42
Arterial blood gas 43
CURB-65 criteria for CAP management 43
ARDS : initial ventilator settings 44
Mediastinal masses 45
Management of parapneumonic effusion 45
Parapneumonic effusions 45
Management of drowning 46
Management of hemoptysis 47

4. Hematology and oncology 48

Transfusion reactions timeline 48
Cold vs warm agglutinins 48

2
 Evaluation of elevated PT & PTT 49
Evaluation of anemia 49
Transfusion reactions 50
Iron studies in anemia 50
Cancer pain management 51
Common pediatric causes of pancytopenia 51
Electrophoresis in SCD 52
Thalassemia 52
Neonatal jaundice 52
Common causes of anemia in infants 53
Transfusion reactions 53
Palpable breast mass 54
Management of lower extremity proximal DVT 54

5. Gastrointestinal system 55
Hep B infection 55
Evaluation of elevated alk phos 55
GERD 56
d-xylose test 56
Management of variceal bleeding 57
Hyperbilirubinemia in adults 58
Colon cancer screening 58
Management of ascites 59
Evaluation of dysphagia 60
Lactation failure jaundice vs breast milk jaunice 60
Food protein induced allergic protocollitis 61
Foreign body ingestion 62
Differentials of regurgitation and vomiting in infants 62
Lab abnormalities in persistent vomiting 63
Approach to neonatal cholestasis 64
Straining in infants 64
Timeline of infant nutrition 65
Evaluation of bilious emesis 65
HUS 66
Bariatric surgery 66
Blunt abdominal trauma 66
Variceal bleeding 67
Staging evaluation of rectal adenocarcinoma 67
Solid liver masses 67

3
 C diff infection management 68
Approach to hyperbilirubinemia in adults 68
Age based occult GI bleed testing 69
Staging of gastric adenocarcinoma 69
Gastrinoma evaluation 70
Appendicitis 70
Ascitic fluid characteristics 71
Postoperative fever 71

6. Endocrinology 72
Management of hyperprolactinemia 72
Hypoglycemia associated sympathetic failure 73
Evaluation of suspected hyperaldosteronism 73
Exercise induced hypoglycemia 74
Evaluation of suspected acromegaly 74
Differentials of hypercalcemia 75
Approach to hypocalcemia 75
Hyperthyroid bone 76
Evaluation of suspected hyperthyroidism 76
Treatment of choice in hyperthyroidism 77
Management of diabetic kidney 77
Thyroid nodule evaluation 78
DMT2 treatment 78
Postpartum thyroiditis 79
Water deprivation test 79
Adreanal insufficiency diagnosis 80
Hypokalemia and hypertension 80
Hypertriglyceridemia 81
Management of diabetic ketoacidosis 81
Evaluation of precocious puberty 82
Non classic CAH 82
Classic CAH 83
Infant of a diabetic mother 84
Refeeding syndrome 85
Evaluation of gynecomastia 86
Management of hyperprolactinoma 87

7. Reproductive system 88
Malignant testicular tumors 88
Breast cyst management 88

4
 Management of cryptorchidism 89
Primary amenorrhea evaluation 89

8. Rheumatology and sports 91

Nerves 91
RA vs osteoarthritis 91
Non-traumatic back pain management 92
Joint fluid 92
Rheumatoid arthritis 93
Muscle weaknesses 93
Differentials of heel pain 94
Common causes of shoulder pain 94
Neuropathic arthropathy 95
Ottawa ankle rules 95
Management of osteoarthritis 96

9. Neurology 97
Timeline of stroke 97
Parkinsons and MDD 97
Initial management of stroke 98
Management of ischemic stroke 98
Gait disorders 99
Management of carotid atherosclerotic disease 100
Assessment of delirium 100
Bells palsy 101
Management of hospital delirium 101
Idiopathic Intracranial HTN 102
Antipsychotics adverse effects 102
Initial workup of cognitive decline 103
Brain death diagnosis 104
Management of generalized convulsive status epilepticus 104
CSF analysis 105
Indications of dialysis 105
Aphasia 106
Microcephaly evaluation 106
Complications of ventriculoperitoneal shunt 107
Bladder dysfunction in children 108

10. Infectious diseases 109

Vaccine for adults 109

5
 Immunization in HIV patients 109
Screening for STIs 110
Treatment of CAP 111
CDC immunization schedule 111
Influenza vaccination and treatment 112
Diarrhea in AIDS patients 112
Evaluation of pharyngitis 113
Bacterial meningitis 113
Dysphagia in AIDS 114
Treatment of syphilis 114
PEP in animal bite 115
Foodborne illness 115
Airborne precautions 116
Evaluation of suspected ventilator associated pneumonia 116

11. ENT 117

Management of peritonsillar abscess 117

12. Ophthalmology 118

Management of corneal abrasion 118

13. Dermatology 119

Childhood vascular lesions 119
Treatment of acne vulgaris 119
Benign childhood rashes 120
Skin conditions and associated diseases 120
Staging of pressure ulcers 122
Drug induced acne 122

14. OBGYN 123

Beta hCG in pregnancy 123
Site of production: 123
Structure 123
Function 123
Pregnancy test: 123
Ultrasound findings 124
HSV in pregnancy 125
Management of CIN 3 125
Pulmonary edema in preeclampsia 126
Management of PPROM 126
Cervical cancer screening 127
1st trimester screening 127

6
Second trimester quadruple screen 128
Treatment of menopause 128
Management of endometriosis 129
Prenatal diabetes screening 130
Management of suspected ectopic pregnancy 131
Fetal heart rate monitoring 131
Intrapartum fetal heart rate monitoring 132
Postmenopausal bleeding 133
Management of postpartum uterine atony 133
Secondary amenorrhea 134
Suspected idiopathic intracranial hypertension 135
Suspected cerebral vein thrombosis 135
Risk based ovarian cancer screening 136
Breast discharge evaluation 136
Management of hydatidiform mole 137
Normal labor 137
Functional hypothalamic amenorrhea 138
Preterm labor management 138
Preterm birth management 139
Premenopausal adnexal mass evaluation 139
Postmenopausal adnexal mass evaluation 140
Management of breast pain 140
Secondary amenorrhea and AUB evaluation 141
Management of migraines in pregnancy 141
Evaluation of polyurea 142

7
 1. Cardiovascular system
Medicine
Factors associated with poor outcome after witnessed out-of-hospital
sudden cardiac arrest
Factors associated with poor outcome after witnessed out-of-hospital sudden cardiac
arrest
• Time elapsed prior to effective resuscitation (delayed bystander CPR, delayed
defibrillation)

• Initial rhythm of pulseless electrical activity or asystole

• Prolonged CPR (>5 min)
• Absence of vital signs
• Advanced age
• History of cardiac disease
• ≥2 Chronic illnesses
• Persistent coma after CPR
• Need for intubation or vasopressors
• Pneumonia or renal failure after CPR
• Sepsis, cerebrovascular accident, or class III or IV heart failure

CPR = cardiopulmonary resuscitation.

Lifestyle interventions for HTN

Lifestyle interventions for hypertension
Modification Recommended plan Approximate ↓

systolic BP (mm
Hg)
DASH diet Diet high in fruits & vegetables & low in saturated 11
& total fats
Weight loss Reduction of BMI to <25 kg/m2 6 per 10-kg loss
Aerobic exercise 30 minutes/day for 5+ days/week 7
Dietary sodium <1.5-2.3 g/day (response varies) 5-8
Alcohol ≤2 drinks/day in men, ≤1 drink/day in women 5
limitation
DASH = Dietary Approaches to Stop Hypertension.

8
Acute ST-elevation MI

Wide complex tachycardia

9
Abdominal aortic aneurysm screening
Screening: abdominal aortic aneurysm
Patient • Men
population • Age 65-75

Risk factor • Any smoking history

indication
Test • One-time abdominal duplex
ultrasonography

Pretest probability for coronary artery disease

Pretest probability of coronary artery disease
Low (<10%) • Asymptomatic people of all ages
• Atypical chest pain in women age <50

Intermediate (20%-80%) • Atypical angina in men of all ages

• Atypical angina in women age ≥50
• Typical angina in women age 30-50

High (>90%) • Typical angina in men age ≥40

• Typical angina in women age ≥60

Evaluation of chest pain

10
Evaluation of chest pain in ER

Pretest probability for pulmonary embolism

Modified Wells criteria for pretest probability
of pulmonary embolism
+3 points • Clinical signs of DVT
• Alternate diagnosis less likely than PE

+1.5 points • Previous PE or DVT

• Heart rate >100
• Recent surgery or immobilization

+1 point • Hemoptysis
• Cancer

Total score • ≤4 = PE unlikely

• >4 = PE likely

DVT = deep vein thrombosis; PE = pulmonary embolism.

11
Suspected pulmonary embolism

12
Management of symptomatic sinus bradycardia

Diagnosis of anaphylaxis
Diagnostic criteria for anaphylaxis
Anaphylaxis is likely if there is rapid symptom onset & any 1 of the following criteria:
1 Skin/mucosa involvement (eg, hives, lip/tongue swelling) & either hypotension
or respiratory distress
2 Involvement of ≥2 organ systems after exposure to a likely allergen

• Skin/mucosa (eg, hives, lip/tongue swelling)

• Respiratory (eg, wheezing, stridor, dyspnea)
• Cardiovascular (eg, hypotension, tachycardia, syncope)
• Gastrointestinal (eg, abdominal pain, vomiting, diarrhea)

3 Hypotension after exposure to a known allergen

13
Approach to adult cardiac arrest

Adult cardiac arrest management

14
CHA2DS2-VASc score for thromboembolic risk in nonvalvular atrial
fibrillation
CHA2DS2-VASc score for thromboembolic risk in nonvalvular atrial fibrillation
Risk criteria Points
C Congestive heart failure 1
H Hypertension 1
A2 Age ≥75* 2
D Diabetes mellitus 1
S2 Stroke or TIA 2
V Vascular disease (eg, PAD, prior MI) 1
A Age 65-74* 1
Sc Sex category female** 1
Maximum score 9
Total score Generalized Antithrombotic
Male Female stroke risk therapy
0 0 Low None
1 2 Moderate None or oral anticoagulant
≥2 ≥3 High Oral anticoagulant
*Patients are assigned to 1 of the 2 age categories.

**Different cutoffs are used for males & females because female sex is considered a risk
modifier that adds to the CHA2DS2-VASc score only if other (nonsex) risk factors are
present.

MI = myocardial infarction; PAD = peripheral artery disease; TIA = transient ischemic

attack.

15
Management of Acute decompensated heart failure

Management of hypertriglyceridemia
Treatment of hypertriglyceridemia
Triglycerides 150-499 mg/dL 500-999 mg/dL ≥1,000 mg/dL
General • Limit dietary sugar/tight
measures glycemic control in
diabetes
• Limit saturated fat
• Regular aerobic exercise
• Weight loss of 5%-10%
of body weight
• Treat with statins based
on ASCVD risk

Specific • Limit alcohol • Abstain from • Abstain from

measures intake alcohol alcohol
• Ω-3 acids if high • Ω-3 acids or • Fibrates to
risk of ASCVD fibrates, reduce
depending on pancreatitis risk
ASCVD risk

ASCVD = atherosclerotic cardiovascular disease; Ω-3 acids = omega-3 fatty acids.

16
Diagnostic approach to aortic dissection

17
Management of adult tachycardia

18
Pharmacological rate control of atrial fibrillation

Management of hypertrophic cardiomyopathy

19
Diagnosis of HTN

Cardiorenal syndrome

20
Paedriatrics
Neonatal cyanosis

Routine newborn care

Routine newborn care
Preventive • Intramuscular vitamin K
• Erythromycin eye ointment
• Hepatitis B vaccine

Screening • Newborn screen (metabolic/genetic disorders)

• Hyperbilirubinemia
• Hearing screen
• Pre- & post-ductal pulse oximetry (congenital heart disease)
• Hypoglycemia (select populations)

21
Surgery
Stenotic valve replacement indications
Valve replacement in aortic stenosis
Severe AS criteria • Aortic jet velocity ≥4.0 m/sec, or
• Mean transvalvular pressure gradient ≥40 mm
Hg
• Valve area usually ≤1.0 cm2 but not required

Indications for valve Severe AS & ≥1 of the following:

replacement
• Onset of symptoms (eg, angina, syncope)
• Left ventricular ejection fraction <50%
• Undergoing other cardiac surgery (eg, CABG)

AS = aortic stenosis; CABG = coronary artery bypass grafting.

Blunt chest trauma management

22
Evaluation of suspected abdominal aortic aneurysm

Evaluation of suspected acute coronary syndrome

23
Cardiac risk evaluation for a noncardiac surgery
Revised Cardiac Risk Index (RCRI)
(cardiovascular risk of noncardiac surgery)
6 risk predictors • High-risk surgery (eg, vascular, intrathoracic)
• Ischemic heart disease
• History of congestive heart failure
• History of cerebrovascular disease (stroke or TIA)
• Diabetes mellitus treated with insulin
• Preoperative creatinine >2 mg/dL

Risk of cardiac death, • 0-1 factor: low risk*

nonfatal cardiac arrest, • ≥2 factors: elevated risk
or nonfatal MI
*RCRI score of 0-1 originally reported as ≤1% and still accepted as low risk. Slightly
higher
event rates of later studies probably due to using troponins (↑ sensitivity) and
including
additional outcomes (eg, all-cause mortality).

MI = myocardial infarction; TIA = transient ischemic attack.

Valvular heart disease management before noncardiac surgery

24
Ankle-brachial index
Ankle-brachial index
ABI = SBP of dorsalis pedis or posterior tibial artery ÷ SBP of brachial artery
≤0.9 Diagnostic of peripheral artery disease
0.91-1.3 Normal
>1.3 Suggests calcified & uncompressible vessels*
*Other testing should be considered.

ABI = ankle-brachial index; SBP = systolic blood pressure.

2. Renal
Medicine
Causes gross hematuria

25
Pathogenesis of nephrotic syndrome

Workup for AGMA

26
Mechanism of hypovolemic hyponatremia

Refeeding syndrome

27
Differential diagnosis of metabolic alkalosis

Evaluation of hyponatremia

28
Evaluation of AKI

Paedriatrics
Evaluation of hematuria in children

29
Hypernatremia

30
Kidney stones

31
UTI due to vesicoureteral reflux

Evaluation of red urine

32
Labs in persistent vomiting

Potter sequence

33
Surgery
Renal osteodystrophy

34
Management of ureteral stones

35
3. Respiratory and critical care
Medicine
Asthma evaluation

Treatment of asthma

36
Treatment plan for COPD

Effects of Positive pressure ventilation in cardiogenic edema

37
Evaluation of solitary pulmonary nodule

Pulmonary function testing

38
Evaluation of chronic cough

Differentials of hyponatremia
Hyponatremia
Serum ECV Urine findings Cause
osmolality
Low Hypovolemic UNa <40 mEq/L • Nonrenal salt loss (eg, vomiting,
(<275 diarrhea, dehydration)
mOsm/kg)
UNa >40 mEq/L • Renal salt loss (eg, diuretics,
primary adrenal insufficiency)

Euvolemic UOsm <100 • Psychogenic polydipsia

mOsm/kg • Beer potomania

UOsm >100 • SIADH (rule out hypothyroidism,

mOsm/kg & UNa secondary adrenal insufficiency)
>40 mEq/L
Hypervolemic Variable • CHF, hepatic failure, nephrotic
syndrome

Normal Variable • Pseudohyponatremia (eg,

paraproteinemia,
hyperlipidemia)

High • Hyperglycemia
(>295 • Exogenous solutes (eg,
mOsm/kg) mannitol)

CHF = congestive heart failure; ECV = extracellular volume; SIADH = syndrome of

inappropriate antidiuretic hormone; UNa = urine sodium; UOsm = urine osmolality.

39
Acetazolamide for High altitude sickness

Pulmonary embolism

40
Diagnostic strategy in suspected pulmonary embolism

Modified Wells criteria for pretest probability

of pulmonary embolism
+3 points • Clinical signs of DVT
• Alternate diagnosis less likely than PE

+1.5 points • Previous PE or DVT

• Heart rate >100
• Recent surgery or immobilization

+1 point • Hemoptysis
• Cancer

Total score ≤4 = PE unlikely

>4 = PE likely
DVT = deep venous thrombosis; PE = pulmonary embolism.

41
Suspected pulmonary embolism

O2 induced co2 retention in COPD

42
Arterial blood gas

CURB-65 criteria for CAP management

Community-acquired pneumonia
Setting Recommended therapy

43
Outpatient • Healthy patients
o Amoxicillin or doxycycline
• Comorbid conditions (eg, diabetes, malignancy)
o Fluoroquinolone or beta-lactam + macrolide

Inpatient • Fluoroquinolone
(non-ICU)
OR

• Beta-lactam + macrolide

Inpatient • Beta-lactam + macrolide

(ICU)
OR. Beta-lactam + fluoroquinolone

ARDS : initial ventilator settings

Pediatrics

44
Mediastinal masses

Management of parapneumonic effusion

Parapneumonic effusions
Parapneumonic effusions
Uncomplicated Complicated
Etiology Sterile exudate in pleural Bacterial invasion of pleural
space space
Radiologic Small to moderate & free Moderate to large, free
appearance flowing flowing
or loculated

45
 Pleural fluid • pH ≥7.2 • pH <7.2
characteristics • Glucose ≥60 mg/dL • Glucose <60 mg/dL
• WBCs ≤50,000/mm3 • WBCs >50,000/mm3
• LDH ≤1,000 units/L • LDH >1,000 units/L

Pleural fluid Negative Positive or negative*

Gram stain & culture
Treatment Antibiotics Antibiotics & drainage
*Gram stain & culture are often falsely negative due to low bacterial count. Both are
typically positive in empyema, which represents advanced progression of a complicated
effusion.

LDH = lactate dehydrogenase; WBC = white blood cell.

Surgery
Management of drowning

46
Management of hemoptysis

47
 4. Hematology and oncology
Medicine
Transfusion reactions timeline

Cold vs warm agglutinins

48
Evaluation of elevated PT & PTT

Evaluation of anemia

49
Transfusion reactions
Transfusion reactions associated with hypotension
Reaction Onset* Cause Clinical features
Anaphylaxis Seconds to Recipient anti- • Shock,
minutes IgA antibodies angioedema/urticaria
& respiratory distress

Transfusion- Minutes to Donor • Respiratory distress

related acute hours antileukocyte & noncardiogenic
lung injury antibodies pulmonary edema
• Bilateral pulmonary
infiltrates

Acute hemolysis Minutes to ABO • Fever, flank pain,

hours incompatibility hemoglobinuria &
DIC

Bacterial sepsis Minutes to Bacterial • Fever, chills, septic

hours contamination shock & DIC
of donor product
*Time after transfusion initiation.

DIC = disseminated intravascular coagulation.

Iron studies in anemia

Iron studies in microcytic anemia
Cause MCV Iron TIBC Ferritin Transferrin
saturation

(Iron/TIBC)
Iron deficiency ↓ ↓ ↑ ↓ ↓
Thalassemia ↓↓ ↑ ↓ ↑ ↑↑
Anemia of chronic disease Normal/↓ ↓ ↓ Normal/↑ Normal/↓
(inflammation)
MCV = mean corpuscular volume; TIBC = total iron binding capacity.

50
Cancer pain management

Pediatrics
Common pediatric causes of pancytopenia

51
Electrophoresis in SCD
Electrophoresis patterns in sickle cell syndromes
HbA HbA2 HbF HbS HbC
Normal ++++ + + None None
Sickle cell trait +++ + + +++ None
Sickle cell anemia (SCA) None + + ++++ None
SCA on hydroxyurea None + ++ +++ None
Hemoglobin SC disease None + + +++ +++

Thalassemia
Alpha thalassemia
Genotype Disorder Clinical features
1 gene loss Alpha thalassemia minima Asymptomatic, silent carrier
(αα/α−)
2 gene loss Alpha thalassemia minor Mild microcytic anemia
(αα/−−) or (α−/α−)
3 gene loss Hemoglobin H disease Chronic hemolytic anemia
(α−/−−)
4 gene loss Hydrops fetalis, High-output cardiac failure,
(−−/−−) hemoglobin Barts anasarca, death in utero

Neonatal jaundice

52
Common causes of anemia in infants

Surgery
Transfusion reactions
Transfusion reactions associated with hypotension
Reaction Onset* Cause Clinical features
Anaphylaxis Seconds to Recipient anti- • Shock,
minutes IgA antibodies angioedema/urticaria
& respiratory distress

Transfusion- Minutes to Donor • Respiratory distress

related acute hours antileukocyte & noncardiogenic
lung injury antibodies pulmonary edema
• Bilateral pulmonary
infiltrates

Acute hemolysis Minutes to ABO • Fever, flank pain,

hours incompatibility hemoglobinuria &
DIC

Bacterial sepsis Minutes to Bacterial • Fever, chills, septic

hours contamination shock & DIC
of donor product
*Time after transfusion initiation.

DIC = disseminated intravascular coagulation.

53
Palpable breast mass

Management of lower extremity proximal DVT

54
 5. Gastrointestinal system
Medicine
Hep B infection

Evaluation of elevated alk phos

55
GERD

d-xylose test

56
Management of variceal bleeding

57
Hyperbilirubinemia in adults

Colon cancer screening

Colon cancer screening
Patients at • Start at age 45:
average risk o Colonoscopy every 10 years
o gFOBT or FIT every year
o FIT-DNA every 1-3 years
o CT colonography every 5 years

o Flexible sigmoidoscopy every 5 years (or every

10 years with annual FIT)

Patients with FDR with CRC or • Colonoscopy at age 40 (or 10 years prior to age
high-risk adenomatous polyp* of diagnosis in FDR, whichever comes first)
• Repeat every 5 years (every 10 years if FDR
diagnosed at age >60)

Patients with ulcerative colitis • Start screening 8-10 years after diagnosis
• Colonoscopy every 1-3 years

*Adenomatous polyp ≥10 mm, high-grade dysplasia, villous elements (for example).

58
CRC = colorectal cancer; FDR = first-degree relative; FIT = fecal immunochemical test;
FIT-DNA = multitarget stool DNA test; gFOBT = guaiac-based fecal occult blood test.

Management of ascites

59
Evaluation of dysphagia

Pediatrics
Lactation failure jaundice vs breast milk jaunice
Lactation failure jaundice vs breast milk jaundice
Diagnosis Timing Pathophysiology Clinical features
Lactation Age <1 Insufficient intake of breast • Suboptimal
failure week milk: breastfeeding
jaundice • Signs of
• ↓ Bilirubin dehydration
elimination
• ↑ Enterohepatic
circulation

Breast milk Age >1 ↑ β-glucuronidase in • Adequate

jaundice week breast milk: breastfeeding
• Well-hydrated
(peaks at • ↑ Deconjugation of
2 weeks) intestinal bilirubin

60
 • ↑ Enterohepatic
circulation

Food protein induced allergic protocollitis

61
Foreign body ingestion

Differentials of regurgitation and vomiting in infants

Differential diagnosis of

regurgitation & vomiting in infants

Diagnosis Clinical features Management
Gastroesophageal • Physiologic • Reassurance
reflux o Asymptomatic • Positioning
o "Happy spitter" therapy

• Pathologic (GERD)
o Failure to thrive
o Significant • Thickened feeds
irritability • Antacid therapy
o Sandifer • If severe,
syndrome esophageal pH
probe monitoring
& upper
endoscopy

62
 Milk protein • Regurgitation/vomiting • Elimination of
allergy • Eczema dairy & soy protein
• Bloody stools from diet

Pyloric stenosis • Projectile nonbilious • Abdominal

vomiting ultrasound
• Olive-shaped • Pyloromyotomy
abdominal mass
• Dehydration, weight
loss

Lab abnormalities in persistent vomiting

63
Approach to neonatal cholestasis

Straining in infants

64
Timeline of infant nutrition

Evaluation of bilious emesis

65
HUS

Surgery
Bariatric surgery
Preparation for bariatric surgery
Indications • BMI ≥40 kg/m2
• BMI ≥35 kg/m2 with serious comorbidity (eg, T2DM, hypertension,
OSA)
• BMI ≥30 kg/m2 with resistant T2DM or metabolic syndrome

Intake • Review previous attempts at weight loss, diet, exercise habits

assessment • Review psychiatric history, coping skills, readiness to change
• Review risk for cardiac (eg, CAD) and pulmonary (eg, OSA) disease

CAD = coronary artery disease; OSA = obstructive sleep apnea; T2DM = type 2 diabetes
mellitus.

Blunt abdominal trauma

66
Variceal bleeding

Staging evaluation of rectal adenocarcinoma

Staging evaluation for rectal adenocarcinoma
Tumor markers Carcinoembryonic antigen
Imaging CT scan: chest, abdomen, pelvis
Endoscopy/direct visualization Colonoscopy

Solid liver masses

Solid liver masses
Focal nodular hyperplasia • Associated with anomalous arteries
• Arterial flow & central scar on imaging

Hepatic adenoma • Women on long-term oral contraceptives

• Possible hemorrhage or malignant transformation

Regenerative nodules • Acute or chronic liver injury (eg, cirrhosis)

Hepatocellular carcinoma • Systemic symptoms

• Chronic hepatitis or cirrhosis
• Elevated ɑ fetoprotein

Liver metastasis • Single/multiple lesions

• Known extrahepatic malignancy

67
C diff infection management

Approach to hyperbilirubinemia in adults

68
Age based occult GI bleed testing

Staging of gastric adenocarcinoma

69
Gastrinoma evaluation

Appendicitis

70
Ascitic fluid characteristics
Ascites fluid characteristics
Color • Bloody: trauma, malignancy, TB (rarely)
• Milky: chylous
• Turbid: possible infection
• Straw color: likely more benign causes

Neutrophils • ≥250/mm3: peritonitis (secondary or spontaneous bacterial)

Total • ≥2.5 g/dL (high-protein ascites)

protein o CHF, constrictive pericarditis, peritoneal carcinomatosis, TB,
Budd-Chiari syndrome, fungal
• <2.5 g/dL (low-protein ascites)
o Cirrhosis, nephrotic syndrome

SAAG • ≥1.1 g/dL (indicates portal hypertension)

o Cardiac ascites, cirrhosis, Budd-Chiari syndrome
• <1.1 g/dL (absence of portal hypertension)
o TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic
syndrome

CHF = congestive heart failure; SAAG = serum-ascites albumin gradient; TB =

tuberculosis.

Postoperative fever

71
 6. Endocrinology
Medicine
Management of hyperprolactinemia

72
Hypoglycemia associated sympathetic failure

Evaluation of suspected hyperaldosteronism

73
Exercise induced hypoglycemia

Evaluation of suspected acromegaly

74
Differentials of hypercalcemia

Approach to hypocalcemia

75
Hyperthyroid bone

Evaluation of suspected hyperthyroidism

76
Treatment of choice in hyperthyroidism

Management of diabetic kidney

77
Thyroid nodule evaluation

DMT2 treatment

78
Postpartum thyroiditis

Water deprivation test

79
Adreanal insufficiency diagnosis

Hypokalemia and hypertension

80
Hypertriglyceridemia

Management of diabetic ketoacidosis

Management of diabetic ketoacidosis
IV fluids • Rapid infusion of 0.9% normal saline
• Add dextrose 5% when serum glucose is ≤200 mg/dL

Insulin • Start continuous IV insulin infusion; hold if K <3.3 mEq/L

• Switch to SQ (basal bolus) insulin for the following: able to eat,
glucose <200 mg/dL, anion gap <12 mEq/L & serum HCO3− ≥15
mEq/L
• Overlap SQ & IV insulin by 1-2 hr

Potassium • Add IV K if serum K+ <5.3 mEq/L; hold if ≥5.3 mEq/L

• Nearly all patients' K+ depleted, even with hyperkalemia

Bicarbonate • Consider for patients with pH ≤6.9

Phosphate • Consider for serum phosphate <1.0 mg/dL, cardiac dysfunction, or

respiratory depression
• Monitor serum calcium frequently

IV = intravenous; SQ = subcutaneous.

81
Pediatrics
Evaluation of precocious puberty

Non classic CAH

This patient's early onset of secondary sexual characteristics, advanced bone age, and low LH
level are suggestive of peripheral precocious puberty, likely nonclassic congenital adrenal
hyperplasia (CAH) secondary to 21-hydroxylase (CYP21A2) deficiency. Similar to classic
CAH, the 21-hydroxylase deficiency impairs the conversion of 17-hydroxyprogesterone to
11-deoxycortisol; 17-hydroxyprogesterone is shunted toward adrenal androgen
overproduction (ie, precocious puberty). However, in patients with nonclassic CAH,
sufficient glucocorticoid and mineralocorticoid levels are maintained; therefore, patients have
normal electrolytes (no salt wasting).

82
Classic CAH
Classic congenital adrenal hyperplasia
Pathogenesis • Autosomal recessive
• 21-Hydroxylase deficiency

Clinical • Ambiguous genitalia in girls

presentation • Salt-wasting syndrome*
o Affects most girls & boys
o Hypotension, dehydration &
vomiting

Laboratory • ↓ Sodium, ↑ potassium, ↓ glucose

findings • ↑ 17-Hydroxyprogesterone

Treatment • Glucocorticoids &

mineralocorticoids
• High-salt diet
• Psychosocial support

83
*Clinical symptoms & electrolyte abnormalities develop at
age 1-2 weeks.

Infant of a diabetic mother

84
Refeeding syndrome

85
Evaluation of gynecomastia

86
Surgery
Management of hyperprolactinoma

87
 7. Reproductive system
Malignant testicular tumors
Malignant testicular neoplasms
Germ Seminoma • Retain features of spermatogenesis
cell • β-hCG, AFP usually negative
(95%)
Nonseminoma • ≥1 partially differentiated cells: yolk sac, embryonal
carcinoma, teratoma, and/or choriocarcinoma
• β-hCG, AFP usually positive

Stromal Leydig • Often produces excessive estrogen (gynecomastia) or

(5%) testosterone (acne)
• Can cause precocious puberty

Sertoli • Rare
• Occasionally associated with excessive estrogen
secretion (eg, gynecomastia)

AFP = alpha-fetoprotein.

Breast cyst management

88
Management of cryptorchidism

Primary amenorrhea evaluation

89
90
 8. Rheumatology and sports
Medicine
Nerves

RA vs osteoarthritis
Osteoarthritis vs rheumatoid arthritis
Osteoarthritis Rheumatoid arthritis
Age of onset >40; increases with age 40-60; often younger
Joint involvement • Knees & hips • MCP joint
• DIP joint • PIP joint
• First CMC joint • Wrists

Morning stiffness None/brief Prolonged

Systemic Absent • Fever
symptoms • Fatigue
• Weight loss

Examination • Hard, bony enlargement of • Soft/spongy, warm

joints joints

X-ray • Narrowed joint space • Periarticular erosions

• Osteophytes

CMC = carpometacarpal; DIP = distal interphalangeal; MCP = metacarpophalangeal; PIP

= proximal interphalangeal.

91
Non-traumatic back pain management

Joint fluid
Joint fluid characteristics
Normal Noninflammatory Inflammatory Septic joint

(eg, OA) (eg, crystals,

RA)
Appearance Clear Clear Translucent or Opaque

opaque
WBCs <200 200-2,000 2,000-100,000 50,000-150,000
3
(mm )
PMNs <25% 25% Often >50% >80%-90%
OA = osteoarthritis; PMNs = polymorphonuclear leukocytes; RA = rheumatoid
arthritis; WBCs = white blood cells.

92
Rheumatoid arthritis

Muscle weaknesses

93
Surgery
Differentials of heel pain
Differential diagnosis of heel pain
Plantar • Maximal pain on first stepping out of bed
fasciitis
• Pain & tenderness at medial plantar heel, worse with toe
dorsiflexion

Achilles • Posterior pain

tendinopathy • Swelling & tenderness 2-6 cm proximal to tendon insertion

Calcaneal stress • Pain that is worse with activity

fracture • Pain reproduced by medial-lateral squeezing of the
calcaneus

Tarsal tunnel • Pain, paresthesia & numbness on the sole of the foot
syndrome • Percussion tenderness over the posterior tibial nerve in
the tarsal tunnel

Common causes of shoulder pain

Common causes of shoulder pain
Rotator cuff impingement or • Pain with abduction, external rotation
tendinopathy • Subacromial tenderness
• Normal range of motion with positive
impingement tests (eg, Neer, Hawkins)

Rotator cuff tear • Similar to rotator cuff tendinopathy

• Weakness with abduction & external rotation
• Age >40

Adhesive capsulitis • Decreased passive & active range of motion

(frozen shoulder) • Stiffness ± pain

Biceps tendinopathy • Anterior shoulder pain

or rupture • Pain with lifting, carrying, or overhead reaching
• Weakness (less common)

Glenohumeral osteoarthritis • Uncommon & usually caused by trauma

• Gradual onset of anterior or deep shoulder pain
• Decreased active & passive abduction &
external rotation

94
Neuropathic arthropathy

Ottawa ankle rules

95
Management of osteoarthritis

96
 9. Neurology
Medicine
Timeline of stroke

Parkinsons and MDD

97
Initial management of stroke

Management of ischemic stroke

98
Gait disorders
Gait disorders
Type of gait Description Associated signs Causes
Cerebellar Ataxic: Dysdiadochokinesia, • Cerebellar
Staggering, wide- dysmetria, nystagmus, degeneration
based Romberg sign • Stroke
• Drug/alcohol
intoxication
• Vitamin B12
deficiency

Gait apraxia Magnetic Dementia, incontinence, • Frontal lobe

(frontal gait) (freezing): frontal lobe signs degeneration
• Normal
Start & turn pressure
hesitation hydrocephalus

Parkinsonian Short steps, Bradykinesia, resting • Parkinson

shuffling tremor, postural disease
instability, decreased arm
swing
Steppage Footdrop, Distal sensory loss & • Motor
excessive hip & weakness neuropathy
knee flexion while
walking, slapping
quality, falls
Vestibular Unsteady, falling Normal sensation, • Acute
to one side reflexes & motor labyrinthitis
strength; nausea, vertigo • Ménière disease

99
Management of carotid atherosclerotic disease

Assessment of delirium

100
Bells palsy

Management of hospital delirium

Management of hospital delirium
• Reduce noise, improve room lighting, open window blinds during the day &
avoid frequent room changes
• Constant observation by a familiar person at the bedside, preferably a family
member
• Nonpharmacologic sleep aids for insomnia
• Early mobilization & minimal use of physical restraints
• Visual & hearing aids when appropriate
• Early volume repletion for dehydrated patients
• Adequate pain control
• Aggressive chronic disease management (eg, diabetes, COPD)
• Reduce polypharmacy
• Monitor & treat for metabolic disturbances, infections & drug toxicity

COPD = chronic obstructive pulmonary disease.

101
Idiopathic Intracranial HTN

Antipsychotics adverse effects

Antipsychotic extrapyramidal effects Pharmacotherapy*
Acute • Sudden, sustained • Benztropine
dystonia contraction of the neck, • Diphenhydramine
mouth, tongue & eye
muscles

Akathisia • Subjective restlessness, • Beta blocker (propranolol)

inability to sit still • Benzodiazepine
(lorazepam)
• Benztropine

Parkinsonism • Gradual-onset tremor, • Benztropine

rigidity & bradykinesia • Amantadine

Tardive • Gradual onset after • Valbenazine

dyskinesia prolonged therapy (>6 • Deutetrabenazine
months): dyskinesia of the
mouth, face, trunk &
extremities

102
*
Management may include reducing the dose or switching to another antipsychotic,
depending on the clinical scenario.

Initial workup of cognitive decline

Initial workup of suspected cognitive impairment
Cognitive • MMSE (score <24/30 suggestive of MCI/dementia)
testing • Montreal Cognitive Assessment (score <26/30)
• Mini-Cog (abnormal 3-word recall &/or clock-drawing test)

Laboratory • Routine: CBC, vitamin B12, TSH, CMP

testing
• Selective (specific risk factors): folate, syphilis, vitamin D level
• Atypical (early onset): CSF

Imaging • Routine: CT scan or MRI of the brain

• Atypical: EEG

CBC = complete blood count; CMP = complete metabolic panel; CSF = cerebrospinal
fluid; EEG = electroencephalogram; MCI = mild cognitive impairment; MMSE =
Mini-Mental State Examination.

103
Brain death diagnosis

Management of generalized convulsive status epilepticus

104
CSF analysis
Cerebrospinal fluid analysis
Diagnosis WBC count Glucose Protein
3
(mm ) (mg/dL) (mg/dL)
Normal 0-5 40-70 <40
Bacterial >1,000 <40 >250
meningitis
Tuberculous 100-500 <45 100-500
meningitis
Viral meningitis 10-500 40-70 <150
Guillain-Barré 0-5 40-70 45-1,000
syndrome
WBC = white blood cell.

Indications of dialysis
Indications for urgent dialysis (AEIOU)
Acidosis • Metabolic acidosis
o pH <7.1 refractory to medical therapy

Electrolyte • Symptomatic hyperkalemia

abnormalities o ECG changes or ventricular arrhythmias
• Severe hyperkalemia
o Potassium >6.5 mEq/L refractory to medical
therapy

Ingestion • Toxic alcohols (methanol, ethylene glycol)

• Salicylate
• Lithium
• Sodium valproate, carbamazepine

Overload • Volume overload refractory to diuretics

Uremia • Symptomatic:
o Encephalopathy
o Pericarditis
o Bleeding

105
Aphasia

Pediatrics
Microcephaly evaluation

106
Complications of ventriculoperitoneal shunt

107
Bladder dysfunction in children

108
 10. Infectious diseases
Vaccine for adults
Vaccines for adults with HIV
Vaccine Indications
HAV • All patients without documented
immunity to HAV

HBV • All patients without documented

immunity to HBV

HPV • All patients age 11-26

Influenza • Inactivated vaccine annually

Meningococcus • All patients

(serogroups A, C, W, Y)
Pneumococcus • Pneumococcal conjugate vaccine once
• Pneumococcal polysaccharide vaccine 8
weeks later, 5 years later & at age 65

Varicella-zoster • Varicella (live): patients born after 1979

without evidence of immunity*
• Recombinant zoster: all patients age ≥50

*Live vaccines (eg, MMR, varicella) contraindicated if CD4 <200/mm3.

HAV = hepatitis A virus; HBV = hepatitis B virus; HPV = human

papillomavirus; MMR = measles, mumps & rubella.

Immunization in HIV patients

Opportunistic infections in HIV
Infection CD4 cell count Prophylaxis
Pneumocystis • <200/mm3 OR Trimethoprim-sulfamethoxazole
jirovecii • Oropharyngeal
candidiasis OR Alternate therapies:
• History of PCP infection
• Dapsone
• Atovaquone
• Pentamidine

Toxoplasma <100/mm3 & positive IgG Trimethoprim-sulfamethoxazole

gondii antibody

109
 Alternate therapies:

• Dapsone plus pyrimethamine

plus leucovorin
• Atovaquone ± pyrimethamine
plus leucovorin

Histoplasma <150/mm3 & endemic area Itraconazole

capsulatum
VZV Close contact with person with VariZIG or IVIG administered within
chickenpox or shingles & no 4 days of exposure
history of prior disease or
negative antibody to VZV
IVIG = intravenous immune globulin; PCP = Pneumocystis jirovecii
pneumonia; VariZIG = human varicella immune globulin; VZV = varicella-zoster
virus.

Screening for STIs

Sexually transmitted infection screening*
All patients • Neisseria gonorrhoeae (eg, NAAT)
• Chlamydia trachomatis (eg, NAAT)
• Syphilis (eg, RPR)
• HIV (eg, 4th-generation antigen/antibody)

Additional testing for • Women only: Trichomonas vaginalis (eg, wet mount)
certain populations • Herpes simplex virus screening (eg, serology) only
when history of characteristic lesions

*For patients with active sexually transmitted infection or those who request
screening.

NAAT = nucleic acid amplification testing; RPR = rapid plasma reagin.

110
Treatment of CAP

CDC immunization schedule

111
Influenza vaccination and treatment
Distinguishing features of common upper respiratory illnesses
Viral upper respiratory Influenza Streptococcal
syndrome pharyngitis
Onset of Slow, stepwise, Abrupt & often Variable
symptoms migratory, or evolving dramatic
Upper Rhinorrhea, coryza, Usually mild Predominantly
respiratory sneezing, mild pharyngeal symptoms
symptoms pharyngitis
Systemic Usually mild Prominent with Variable with possible
symptoms possible high fever, fever & myalgias
myalgias, headache
Examination Nasal edema with Variable but often Pharyngeal erythema,
findings normal or slightly unremarkable tonsillar hypertrophy
erythematous pharynx & exudates, tender
cervical lymph nodes

Diarrhea in AIDS patients

Common causes of diarrhea in patients with AIDS
Organism CD4 count Symptoms
3
Cryptosporidium <180/mm • Severe watery diarrhea
• Low-grade fever
• Weight loss

Microsporidium/Isosporidium <100/mm3 • Watery diarrhea

• Crampy abdominal pain
• Weight loss
• Fever is rare

Mycobacterium avium complex <50/mm3 • Watery diarrhea

• High fever (>39 C [102.2 F])
• Weight loss

Cytomegalovirus <50/mm3 • Frequent, small-volume diarrhea

• Hematochezia
• Abdominal pain
• Low-grade fever
• Weight loss

112
Evaluation of pharyngitis

Bacterial meningitis
Bacterial meningitis
Risk group Common organisms Empiric antibiotics
Streptococcus Vancomycin + 3rd-
pneumoniae, Neisseria generation
Age 2-50 meningitidis cephalosporin
Age >50 S pneumoniae, N Vancomycin + ampicillin
meningitidis, Listeria + 3rd-generation
cephalosporin
S pneumoniae, N Vancomycin + ampicillin
meningitidis, Listeria, + cefepime
Immunocompromised gram-negative rods
Neurosurgery/penetrating Gram-negative rods, Vancomycin + cefepime
skull trauma MRSA, coagulase-negative
staphylococci
• 3rd-generation cephalosporins: ceftriaxone or cefotaxime
• Alternatives to cefepime: ceftazidime or meropenem
• Alternative to ampicillin: trimethoprim-sulfamethoxazole for Listeria

MRSA = methicillin-resistant Staphylococcus aureus.

113
Dysphagia in AIDS

Treatment of syphilis
Syphilis treatment
Stage First line Alternate
Primary (chancre) Penicillin G IM × 1 Doxycycline × 14 days
Secondary (diffuse rash)
Early latent (asymptomatic)*
Late latent (asymptomatic)* Penicillin G IM × 3 Doxycycline × 28 days
Tertiary (eg, CV, gummata)
Neurosyphilis Penicillin G IV × 10- Ceftriaxone IV × 14 days**
(eg, meningitis, ocular) 14 days
*Early latent = asymptomatic with infection <1 year; Late latent = asymptomatic with
unknown duration of infection or infection >1 year.

**Penicillin desensitization followed by IV penicillin is preferred for those with penicillin

allergy who have neurosyphilis; ceftriaxone can be used in those unable to be
desensitized.

CV = cardiovascular; IM = intramuscular; IV = intravenous.

114
PEP in animal bite

Foodborne illness

115
Airborne precautions
Airborne precautions
Indications • Tuberculosis
• Varicella* (cxhickenpox)
• Herpes zoster** (shingles)
• Rubeola (measles)

Components • N95 respirator or powered air-purifying respirator

• Negative-pressure isolation room with
high-efficiency particulate air filter
• As needed if contact with body fluid is anticipated:
clean gloves, disposable gown, goggles/face shield

*Only when uncrusted lesions are present; contact precautions also

required.
**Only in disseminated disease or immunocompromised clients; contact
precautions also required.

Evaluation of suspected ventilator associated pneumonia

116
 11. ENT
Management of peritonsillar abscess

117
 12. Ophthalmology
Management of corneal abrasion

118
 13. Dermatology
Childhood vascular lesions

Treatment of acne vulgaris

119
Benign childhood rashes
Benign neonatal rashes
Diagnosis Onset Clinical features Management/resolution
Erythema • Birth to • Pustules with • Observation
toxicum age 3 erythematous • Resolves within a
neonatorum days base on trunk & week
proximal
extremities

Milia • Birth • Firm, white • Observation

papules on face • Resolves within a
month

Miliaria • Any • Erythematous, • Avoid overheating

rubra age, papular rash on (eg, cool
but not occluded & environment,
present intertriginous thin/cotton
at birth areas clothing)
• If severe, topical
corticosteroid

Neonatal • Birth • Nonerythematous • Observation

pustular pustules → • Pustules resolve
melanosis evolve into within days
hyperpigmented • Hyperpigmentation
macules with may last months
collarette of scale
• Diffuse, may
involve palms &
soles

Neonatal • Around • Erythematous • Observation

cephalic age 3 papules & • Resolves in weeks
pustulosis weeks pustules on face to months
& scalp only • If severe, topical
corticosteroid or
ketoconazole

Skin conditions and associated diseases

Skin conditions & associated diseases
Skin conditions Associated conditions
• Acanthosis nigricans • Insulin resistance

120
 • Gastrointestinal
malignancy

• Multiple skin tags • Insulin resistance

• Pregnancy
• Crohn disease (perianal)

• Porphyria cutanea tarda • Hepatitis C

• Cutaneous leukocytoclastic vasculitis
(palpable pupura) secondary
to cryoglobulinemia

• Dermatitis herpetiformis • Celiac disease

• Sudden-onset, severe psoriasis • HIV infection

• Recurrent herpes zoster
• Disseminated molluscum contagiosum

• Severe seborrheic dermatitis • HIV infection

• Parkinson disease

• Explosive onset multiple, itchy • Gastrointestinal

seborrheic keratoses malignancy

• Pyoderma gangrenosum • Inflammatory bowel

disease

121
Staging of pressure ulcers

Drug induced acne

122
 14. OBGYN
Beta hCG in pregnancy
Human chorionic gonadotropin (hCG)
Site of production:
placental syncytiotrophoblast
Structure
α-subunit: common to hCG, FSH, LH, and TSH
β-subunit: specific to the placenta (pregnancy tests measure the β-hCG levels)
Function
Maintenance of the corpus luteum during the first 8–10 weeks of pregnancy (LH has
a similar function)
Luteal-placental shift: levels decrease after corpus luteum involution (placenta starts
synthesizing its own estriol and progesterone)
Pregnancy test:
measurement of human chorionic gonadotropin (β-hCG)
Urine β-hCG test (e.g., home pregnancy test)
Qualitative test (less sensitive than serum pregnancy test)
β-hCG can be detected in urine 14 days after fertilization
Serum β-hCG test
Quantitative test (high sensitivity)
Detectable 6–9 days (on average) after fertilization

123
Ultrasound findings
Ultrasound findings in normal pregnancy (abdominal or transvaginal) [6]

Confirms pregnancy
At 5 weeks of pregnancy: detection of the gestational sac (corresponds with a serum
β-HCG level of 1500–2000 mIU/mL)
At 5–6 weeks of pregnancy: detection of the yolk sac
At 6–7 weeks of pregnancy: detection of the fetal pole and cardiac activity
with transvaginal ultrasound
At 10–12 weeks of pregnancy: detection of fetal heartbeat with doppler ultrasound
At 18–20 weeks of pregnancy: fetal movements
See POCUS for early pregnancy for more details.
Gestational age and estimated date of delivery
Naegele rule: used to calculate the expected date of delivery (due date)
First day of the last menstrual period + 7 days + 1 year - 3 months
Inaccurate if:
The date of the last menstrual period is uncertain or unknown
The patient has irregular menstruation cycles
The patient conceived while taking contraceptive pills
Ultrasonography
More accurate than Naegele rule
Measurement of the crown-rump length (CRL) in the first trimester
Measurement of biparietal diameter , fetal femoral length , and abdominal
circumference in the second and third trimesters (can be used for
determining gestational age starting at 13 weeks) [7]
Symphysis fundal height: the length from the top of the uterus to the top of
the pubic symphysis
Used to assess fetal growth and development from approx. 20 weeks' gestation
onwards
Development is approx. 1 cm/week after 20 weeks
Correlates with gestational age

124
HSV in pregnancy

Management of CIN 3

125
Pulmonary edema in preeclampsia

Management of PPROM

126
Cervical cancer screening
Cervical cancer screening
Age <21 • No screening

Age 21-29 • Cytology every 3 years

Age 30-65 • Cytology every 3 years

OR

• Cytology plus HPV testing every 5 years

OR

• Primary HPV testing every 5 years

Age >65 • No screening if negative prior screens & low risk

Hysterectomy • No screening if negative prior screens & low risk

(with cervix removed)
HIV • Onset of sexual intercourse or time of HIV diagnosis
(whichever is first)
• Annually until ≥3 normal results, then routine testing

Immunosuppressed • Onset of sexual intercourse

(eg, SLE, organ • Annual Pap test with HPV cotesting
transplant)
HPV = human papillomavirus; SLE = systemic lupus erythematosus.

1st trimester screening

127
Second trimester quadruple screen
Second-trimester quadruple screening
Diagnosis MSAFP β-hCG Estriol Inhibin A
Trisomy 18 ↓ ↓ ↓ Normal
Trisomy 21 ↓ ↑ ↓ ↑
Neural tube or abdominal wall defect ↑ Normal Normal Normal
MSAFP = maternal serum α-fetoprotein.

Treatment of menopause

128
Management of endometriosis

129
Prenatal diabetes screening

130
Management of suspected ectopic pregnancy

Fetal heart rate monitoring

131
Intrapartum fetal heart rate monitoring
Fetal heart rate tracing patterns
Category I Requires all the following criteria:

• Baseline 110-160/min
• Moderate variability (6-25/min)
• No late/variable decelerations
• ± Early decelerations
• ± Accelerations

Category II • Not category I or III (indeterminate pattern)

Category III ≥1 of the following characteristics:

• Absent variability + recurrent late decelerations

• Absent variability + recurrent variable decelerations
• Absent variability + bradycardia
• Sinusoidal pattern

132
Postmenopausal bleeding

Management of postpartum uterine atony

133
Secondary amenorrhea

134
Suspected idiopathic intracranial hypertension

Suspected cerebral vein thrombosis

135
Risk based ovarian cancer screening

Breast discharge evaluation

136
Management of hydatidiform mole

Normal labor

137
Functional hypothalamic amenorrhea

Preterm labor management

138
Preterm birth management

Premenopausal adnexal mass evaluation

139
Postmenopausal adnexal mass evaluation

Management of breast pain

140
Secondary amenorrhea and AUB evaluation

Management of migraines in pregnancy

141
Evaluation of polyurea

142