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Mind Maps for Medical Students
Clinical Specialties
K30033_C000.indd 1 28/02/17 2:09 pm
iii
Olivia Smith BSc (Hons), MSc (Dist)
Mind Maps for Medical Students
Clinical Specialties
The Hull York Medical SchoolHull and York, UK
K30033_C000.indd 3 28/02/17 2:09 pm
CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2017 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
International Standard Book Number-13: 978-1-4987-8219-7 (Paperback)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, n either the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the p atient’s medical history, r elevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For p ermission to p hotocopy o r use ma terial el ectronically f rom this w ork, please access www.copyright.com (http://www.copyright.com/) or c ontact the C opyright C learance C enter, I nc. (CCC), 222 R osewood Dr ive, Da nvers, MA 0192 3, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com
K30033_C000.indd 4 28/02/17 2:09 pm
v
Dedication vi
Foreword vii
Preface viii
Abbreviations ix
Chapter 1 Psychiatry 1Chapter 2 Obstetrics 33Chapter 3 Gynaecology 71Chapter 4 Paediatrics 103Chapter 5 Ophthalmology 157Chapter 6 Ear, nose and throat 171Chapter 7 Dermatology 183Chapter 8 Orthopaedics 219
Appendix 1 Useful diagnostic classifications 253Appendix 2 Useful websites 254Index 257
Contents
Please note due to the layout of the maps and tables, some pages within chapters
have been left intentionally blank
K30033_C000.indd 5 28/02/17 2:09 pm
vi
For my father and mother.This book is dedicated to my parents who have been the greatest influence in my life.
For all your unceasing encouragement, love and support I am forever grateful.
Dedication
K30033_C000.indd 6 28/02/17 2:09 pm
vii
Medical students and trainees are faced with a huge volume of facts and knowledge that they must learn, assimilate and understand how to apply. Many hours are spent pouring over text books, online resources, lecture notes and papers. This tsunami of information is often hard to make sense of and the essentials difficult to remember.
Mind maps have become a popular way to help people understand complex interconnected concepts and information. Diagrams are used to visually organise information and show relationships among pieces of the whole. Despite technological advances, when it comes to efficient learning, simple methods, such as that used by Olivia Smith in MindMaps forMedicalStudents:ClinicalSpecialities, can be highly effective.
Mind maps can take a lot of time to create. In this compact volume Olivia Smith, a senior medical student, has helped to do this for readers across eight core clinical specialities essential to the study of medicine. This is a sequel to her successful first book, Mind Maps for Medical Students, which distills a wide range of knowledge according to body systems. Both books organize a large amount of material in a logical, concise and conceptually appealing way to aid learning. By doing so it complements, but does not replace, more exhaustive sources and will also allow readers to position and contextualize new evidence as it emerges, so adding to their knowledge base.
It can be used by medical students, junior doctors and other health care professionals as a brief overview to introduce an area, for intense periods of revision and as an aide-mémoire. I hope this will encourage learners to develop their own mind maps in these or other areas and inspire other medical students to write.
Professor Trevor A Sheldon DSc, FMedSciDean, Hull York Medical School, UK
Foreword
K30033_C000.indd 7 28/02/17 2:09 pm
viii
This book serves as a companion to MindMapsforMedicalStudents. It aims to cover succinctly the main topics in clinical specialties that students and junior doctors are expected to be familiar with. It is a distillation of knowledge that aims to complement larger texts rather than replace them by presenting key facts in a digestible format. Each topic is presented in a logical manner following a design that may be utilized in OSCE assessments covering definitions, causes and investigations as well as treatments and complications. This will aid readers with their revision and consolidation of knowledge prior to examinations.
Wishing you all the very best in your examinations and future careers.
Olivia Smith BSc (Hons), MSc (Dist)Final year medical student, The Hull York Medical School, UK.
Preface
K30033_C000.indd 8 28/02/17 2:09 pm
ix
Abbreviations
ACE angiotensin converting enzyme
ACE-III Addenbrooke’s Cognitive Examination
ACL anterior cruciate ligamentADHD attention deficit hyperactivity
disorderADLs activities of daily livingAIDS acquired immunodeficiency
syndromeALL acute lymphoblastic leukaemiaALT alanine aminotransferaseANCA antineutrophil cytoplasmic
antibodyAP anteroposteriorAPP amyloid precursor proteinARPKD autosomal recessive polycystic
kidney diseaseASD atrial septal defectASO antistreptolysin O AST aspartate aminotransferaseBBPV benign paroxysmal positional
vertigoBMI body mass indexBP blood pressureBUN blood urea nitrogenCADASIL cerebral autosomal
dominant arteriopathy with subcortical infarcts and leukoencephalopathy
CBT cognitive behavioural therapyCF cystic fibrosisCFTR cystic fibrosis transmembrane
conductance regulatorCJD Creutzfeldt–Jakob diseaseCMV cytomegalovirusCOCP combined oral contraceptive
pillCOPD chronic obstructive pulmonary
disease
CRP C-reactive proteinCT computed tomographyCTG cardiotocographyDDH developmental dysplasia of
the hipDIC disseminated intravascular
coagulationDKA diabetic ketoacidosisDLQI Dermatology Life Quality
IndexDM diabetes mellitusDMARD disease modifying
antirheumatic drugDSM-5 Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition
DVT deep venous thrombosisECG electrocardiogram/
electrocardiographyECHO echocardiogramECT electroconvulsive therapyEEG electroencephalogramELISA enzyme linked
immunosorbent assayEPSE extrapyramidal side effectsESR erythrocyte sedimentation
rateFBC full blood countFEV1/FVC forced expiratory volume in
1 second/fixed vital capacityFGFR3 fibroblast growth factor
receptor 3FIGO Fédération Internationale de
Gynécologie et d’ObstétriqueFSH follicle-stimulating hormoneGABA gamma-aminobutyric acidGAD-7 Generalized Anxiety Disorder
(Assessment)GFR glomerular filtration rateGGT gamma glutamyltransferase
K30033_C000.indd 9 28/02/17 2:09 pm
x
GI gastrointestinalGnRH gonadotropin releasing
hormoneHAART highly active anti-retroviral
therapyHADS Hospital Anxiety and
Depression ScalehCG human chorionic gonadotropinHELLP haemolysis, elevated liver
enzymes, low platelet count (syndrome)
HHV human herpesvirusHIV human immunodeficiency virusHPA hypothalamic–pituitary–
adrenal (axis)HPV human papillomavirusHRT hormone replacement therapyHSP Henoch–Schönlein purpuraHSV herpes simplex virus5-HT 5-hydroxytryptamine
(receptors)HUS haemolytic uraemic syndromeIBD inflammatory bowel diseaseICD-10 International Statistical
Classification of Diseases and Related Health Problems, 10th Revision
IL interleukinIM intramuscularIOP intraocular pressureIUD intrauterine deviceIUGR intrauterine growth
restriction IUS intrauterine systemIV intravenousIVF in-vitro fertilizationLABA long-acting beta agonistLCHAD long-chain 3-hydroxyl-
coenzyme A dehydrogenase
LDH lactase dehydrogenaseLFTs liver function testsLH leutinizing hormoneLP lumbar punctureMAO-B monoamine oxidase type B
(inhibitor)MAOI monoamine oxidase inhibitorMCV mean corpuscular volumeMMR measles, mumps, rubellaMND motor neurone diseaseMRI magnetic resonance imagingNAAT nucleic acid amplification testNEC necrotizing enterocolitisNICE National Institute for Health
and Care ExcellenceNICU Neonatal Intensive Care UnitNMS neuroleptic malignant
syndromeNNRTI non-nucleoside reverse
transcriptase inhibitorsNRI noradrenaline reuptake
inhibitorNSAID non-steroidal anti-
inflammatory drugNTD neural tube defectOA osteoarthritisOCD obsessive compulsive disorderPAS pulmonary artery stenosisPASI Psoriasis Area and Severity
IndexPCL posterior cruciate ligamentPCOS polycystic ovary syndromePCR polymerase chain reactionPDA patent ductus arteriosusPEFR peak expiratory flow ratePET positron emission tomographyPHQ-9 Patient Health QuestionnairePID pelvic inflammatory diseasePOP progesterone only pill
Abbreviations
K30033_C000.indd 10 28/02/17 2:09 pm
xi
PPH post-partum haemorrhagePTSD post-traumatic stress
disorderPUVA psoralen + ultraviolet
(A spectrum) light RA rheumatoid arthritisRAST radioallergosorbent testRBC red blood cellRIMA reversible inhibitor of
monoamine oxidase ARMI Risk of Malignancy IndexRUQ right upper quadrantSABA short-acting beta agonistSFH symphysis–fundal heightSHBG sex hormone binding globulinSJS Stevens–Johnson syndrome SNRI serotonin noradrenaline
re-uptake inhibitorSPECT single-photon emission
computed tomographySSRI selective serotonin re-uptake
inhibitorSTI sexually transmitted infectionSUDEP sudden unexplained death in
epilepsy
SUFE slipped upper femoral epiphysis
TB tuberculosisTCA tricyclic antidepressantTEN toxic epidermal necrolysisTNM tumour/nodes/metastases
(staging system)TFTs thyroid function testsTOP termination of pregnancyTSH thyroid stimulating hormoneU&E urine and electrolytesuE3 oestriolUMN upper motor neuronUSS ultrasound scanUTI urinary tract infectionVDRL Venereal Disease Research
Laboratory (test)VEGF vascular endothelial growth
factorVMA/ (urinary) vanillyl mandellic pHVA acid/plasma homovanillic acidVSD ventricular septal defectVZV varicella zoster virus WCC white cell countWHO World Health Organization
Abbreviations
K30033_C000.indd 11 28/02/17 2:09 pm
MAP
1.1
D
epre
ssio
n
2
TABL
E 1.
1 Tr
eatm
ent
of
dep
ress
ion
4
TABL
E 1.
2 A
nti
dep
ress
ants
6
MAP
1.2
A
nxi
ety
8
MAP
1.3
O
bse
ssiv
e co
mp
uls
ive
dis
ord
er (
OC
D)
10
TABL
E 1.
3 A
nxi
oly
tics
an
d h
ypn
oti
cs
12
MAP
1.4
Sc
hiz
op
hre
nia
14
TABL
E 1.
4 A
nti
psy
cho
tics
16
MAP
1.5
B
ipo
lar
dis
ord
er
18
TABL
E 1.
5 P
erso
nal
ity
dis
ord
ers
20
MAP
1.6
A
no
rexi
a n
ervo
sa
22
MAP
1.7
B
ulim
ia n
ervo
sa
24
MAP
1.8
Att
enti
on
defi
cit
hyp
erac
tivi
ty
dis
ord
er (
AD
HD
)
26
TABL
E 1.
6 D
emen
tia
28
Chap
ter O
ne P
sych
iatr
y
Psyc
hiat
ry1
K30033_C001.indd 1 28/02/17 11:02 am
Psyc
hiat
ry2
Map
1.1
. D
epre
ssio
n
Clas
sifi
cati
on
Mild
(4–5
sym
ptom
s)M
oder
ate
(6–7
sym
ptom
s)
Seve
re (8
–10
sym
ptom
s)U
nabl
e to
com
plet
e da
ily ta
sks
Real
diff
icul
ty in
com
plet
ing
daily
task
sCa
n co
ntin
ue w
ith d
aily
task
s+
/– s
omat
ic s
ympt
oms
+/–
som
atic
sym
ptom
s
+/–
psy
chot
ic s
ympt
oms
Pres
enta
tion
Som
atic
or
psyc
hoti
c sy
mpt
oms
Sym
ptom
sTh
ese
may
be
split
into
thre
e br
oad
cate
gorie
s: co
re s
ympt
oms,
nega
tive
thin
king
and
som
atic
sym
ptom
s:Co
re s
ympt
oms:
dep
ress
ed m
ood,
ane
rgia
, anh
edon
ia.
Neg
ativ
e th
inki
ng: t
houg
hts
of g
uilt,
low
sel
f est
eem
, tho
ught
s of
sui
cide
and
dea
th, p
oor c
once
ntra
tion.
Som
atic
sym
ptom
s: d
ecre
ased
wei
ght (
incr
ease
d w
eigh
t see
n in
aty
pica
l dep
ress
ion)
, sle
ep d
istu
rban
ce w
ith e
arly
mor
ning
wak
ing,
de
crea
sed
libid
o, c
onst
ipat
ion,
psy
chom
otor
reta
rdat
ion
or a
gita
tion.
Thes
e s
ympt
oms
may
be
used
to c
lass
ify d
epre
ssio
n as
mild
, mod
erat
e or
sev
ere:
Psyc
hotic
sym
ptom
s ar
e m
ood
cong
ruen
t or i
ncon
grue
nt:
Moo
d co
ngru
ent:
• De
lusi
ons:
of p
over
ty, g
uilt,
pun
ishm
ent;
if th
e pa
tient
hol
ds th
e de
lusi
on th
at th
ey a
re d
ead,
then
this
is k
now
n as
Cot
ard’
s sy
ndro
me.
• Ha
lluci
natio
ns:
Au
dito
ry: u
sual
ly d
erog
ator
y vo
ices
.
Olfa
ctor
y: ro
ttin
g fru
it/fle
sh.
Vi
sual
: tor
men
tors
.
Moo
d in
cong
ruen
t: th
ough
t ins
ertio
n or
with
draw
al.
Trea
tmen
tDe
pend
s on
the
clas
sific
atio
n of
dep
ress
ion.
It
incl
udes
psy
chol
ogic
al th
erap
ies
such
as
CBT,
antid
epre
ssan
ts a
nd E
CT (s
ee Ta
ble
1.1,
p. 4
)
Inve
stig
atio
nsEn
sure
that
the
patie
nt is
real
ly s
uffe
ring
from
dep
ress
ion
and
not a
nor
gani
c di
sord
er. T
his
invo
lves
taki
ng a
car
eful
his
tory
from
the
patie
ntan
d th
e us
e of
que
stio
nnai
res
such
as
HADS
, PHQ
-9, G
AD-7
follo
wed
by
inve
stig
atio
ns d
epen
ding
on
patie
nt p
rese
ntat
ion.
Alw
ays
asse
ss s
uici
de ri
sk.
• Ba
selin
e bl
oods
: FBC
, U&
E, L
FTs
(incl
udin
g G
GT
and
MCV
for
al
coho
l mis
use)
, TFT
s (h
ypot
hyro
idis
m m
ay c
ause
low
moo
d),E
SR,
gl
ucos
e, c
alci
um, v
itam
in B
12 a
nd fo
late
leve
ls.•
Spec
ific
test
s ar
e on
ly u
sed
if in
dica
ted
by h
isto
ry a
nd e
xam
inat
ion
(e
.g. u
rine
for t
oxic
olog
y, de
xam
etha
sone
sup
pres
sion
test
, syp
hilis
se
rolo
gy e
tc).
• Ra
diol
ogy:
CT
or M
RI m
ay b
e in
dica
ted
in s
ome
case
s.
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tics,
neur
ohor
mo-
nal a
nd p
sych
osoc
ial f
acto
rs. A
few
exa
mpl
es a
re g
iven
bel
ow:
• G
enet
ic: f
amily
his
tory
of d
epre
ssio
n.•
Neu
roho
rmon
al: t
he m
onoa
min
e hy
poth
esis
of d
epre
ssio
n is
pop
ular
,
whi
ch s
ugge
sts
that
ther
e ar
e lo
w le
vels
of s
erot
onin
, nor
adre
nalin
e
and
dopa
min
e in
the
brai
n. O
ther
theo
ries
incl
ude
the
sugg
estio
n of
in
crea
sed
cort
isol
leve
ls.•
Psyc
hoso
cial
: adv
erse
life
eve
nts
and
nega
tive
child
hood
exp
erie
nces
su
ch a
s ab
use,
the
loss
of a
par
ent a
nd b
ully
ing.
Chr
onic
phy
sica
l
illne
ss, u
nem
ploy
men
t and
the
lack
of a
con
fidin
g re
latio
nshi
p ar
e
linke
d to
incr
ease
d ra
tes
of d
epre
ssio
n.
Wha
t is
dep
ress
ion?
This
is a
con
ditio
n of
per
vasi
ve lo
w m
ood.
It is
dia
gnos
ed u
sing
the
ICD-
10 o
r the
DSM
-5 a
nd th
e fo
llow
ing
crite
ria n
eed
to b
e fu
lfille
d:
1. S
ympt
oms
mus
t be
pres
ent f
or a
t lea
st 2
wee
ks w
ith a
cha
nge
from
n
orm
al m
ood
and
at le
ast t
wo
to th
ree
core
sym
ptom
s.2.
Cha
nge
in m
ood
mus
t not
be
seco
ndar
y to
dru
g or
alc
ohol
mis
use,
a
med
ical
con
ditio
n or
an
adve
rse
life
even
t suc
h as
ber
eave
men
t.3.
The
re m
ust b
e im
pairm
ent o
f soc
ial f
unct
ioni
ng.
MA
P 1.
1. D
epre
ssio
n
K30033_C001.indd 2 28/02/17 11:02 am
Psyc
hiat
ry3
Map
1.1
. D
epre
ssio
n
Clas
sifi
cati
on
Mild
(4–5
sym
ptom
s)M
oder
ate
(6–7
sym
ptom
s)
Seve
re (8
–10
sym
ptom
s)U
nabl
e to
com
plet
e da
ily ta
sks
Real
diff
icul
ty in
com
plet
ing
daily
task
sCa
n co
ntin
ue w
ith d
aily
task
s+
/– s
omat
ic s
ympt
oms
+/–
som
atic
sym
ptom
s
+/–
psy
chot
ic s
ympt
oms
Pres
enta
tion
Som
atic
or
psyc
hoti
c sy
mpt
oms
Sym
ptom
sTh
ese
may
be
split
into
thre
e br
oad
cate
gorie
s: co
re s
ympt
oms,
nega
tive
thin
king
and
som
atic
sym
ptom
s:Co
re s
ympt
oms:
dep
ress
ed m
ood,
ane
rgia
, anh
edon
ia.
Neg
ativ
e th
inki
ng: t
houg
hts
of g
uilt,
low
sel
f est
eem
, tho
ught
s of
sui
cide
and
dea
th, p
oor c
once
ntra
tion.
Som
atic
sym
ptom
s: d
ecre
ased
wei
ght (
incr
ease
d w
eigh
t see
n in
aty
pica
l dep
ress
ion)
, sle
ep d
istu
rban
ce w
ith e
arly
mor
ning
wak
ing,
de
crea
sed
libid
o, c
onst
ipat
ion,
psy
chom
otor
reta
rdat
ion
or a
gita
tion.
Thes
e s
ympt
oms
may
be
used
to c
lass
ify d
epre
ssio
n as
mild
, mod
erat
e or
sev
ere:
Psyc
hotic
sym
ptom
s ar
e m
ood
cong
ruen
t or i
ncon
grue
nt:
Moo
d co
ngru
ent:
• De
lusi
ons:
of p
over
ty, g
uilt,
pun
ishm
ent;
if th
e pa
tient
hol
ds th
e de
lusi
on th
at th
ey a
re d
ead,
then
this
is k
now
n as
Cot
ard’
s sy
ndro
me.
• Ha
lluci
natio
ns:
Au
dito
ry: u
sual
ly d
erog
ator
y vo
ices
.
Olfa
ctor
y: ro
ttin
g fru
it/fle
sh.
Vi
sual
: tor
men
tors
.
Moo
d in
cong
ruen
t: th
ough
t ins
ertio
n or
with
draw
al.
Trea
tmen
tDe
pend
s on
the
clas
sific
atio
n of
dep
ress
ion.
It
incl
udes
psy
chol
ogic
al th
erap
ies
such
as
CBT,
antid
epre
ssan
ts a
nd E
CT (s
ee Ta
ble
1.1,
p. 4
)
Inve
stig
atio
nsEn
sure
that
the
patie
nt is
real
ly s
uffe
ring
from
dep
ress
ion
and
not a
nor
gani
c di
sord
er. T
his
invo
lves
taki
ng a
car
eful
his
tory
from
the
patie
ntan
d th
e us
e of
que
stio
nnai
res
such
as
HADS
, PHQ
-9, G
AD-7
follo
wed
by
inve
stig
atio
ns d
epen
ding
on
patie
nt p
rese
ntat
ion.
Alw
ays
asse
ss s
uici
de ri
sk.
• Ba
selin
e bl
oods
: FBC
, U&
E, L
FTs
(incl
udin
g G
GT
and
MCV
for
al
coho
l mis
use)
, TFT
s (h
ypot
hyro
idis
m m
ay c
ause
low
moo
d),E
SR,
gl
ucos
e, c
alci
um, v
itam
in B
12 a
nd fo
late
leve
ls.•
Spec
ific
test
s ar
e on
ly u
sed
if in
dica
ted
by h
isto
ry a
nd e
xam
inat
ion
(e
.g. u
rine
for t
oxic
olog
y, de
xam
etha
sone
sup
pres
sion
test
, syp
hilis
se
rolo
gy e
tc).
• Ra
diol
ogy:
CT
or M
RI m
ay b
e in
dica
ted
in s
ome
case
s.
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tics,
neur
ohor
mo-
nal a
nd p
sych
osoc
ial f
acto
rs. A
few
exa
mpl
es a
re g
iven
bel
ow:
• G
enet
ic: f
amily
his
tory
of d
epre
ssio
n.•
Neu
roho
rmon
al: t
he m
onoa
min
e hy
poth
esis
of d
epre
ssio
n is
pop
ular
,
whi
ch s
ugge
sts
that
ther
e ar
e lo
w le
vels
of s
erot
onin
, nor
adre
nalin
e
and
dopa
min
e in
the
brai
n. O
ther
theo
ries
incl
ude
the
sugg
estio
n of
in
crea
sed
cort
isol
leve
ls.•
Psyc
hoso
cial
: adv
erse
life
eve
nts
and
nega
tive
child
hood
exp
erie
nces
su
ch a
s ab
use,
the
loss
of a
par
ent a
nd b
ully
ing.
Chr
onic
phy
sica
l
illne
ss, u
nem
ploy
men
t and
the
lack
of a
con
fidin
g re
latio
nshi
p ar
e
linke
d to
incr
ease
d ra
tes
of d
epre
ssio
n.
Wha
t is
dep
ress
ion?
This
is a
con
ditio
n of
per
vasi
ve lo
w m
ood.
It is
dia
gnos
ed u
sing
the
ICD-
10 o
r the
DSM
-5 a
nd th
e fo
llow
ing
crite
ria n
eed
to b
e fu
lfille
d:
1. S
ympt
oms
mus
t be
pres
ent f
or a
t lea
st 2
wee
ks w
ith a
cha
nge
from
n
orm
al m
ood
and
at le
ast t
wo
to th
ree
core
sym
ptom
s.2.
Cha
nge
in m
ood
mus
t not
be
seco
ndar
y to
dru
g or
alc
ohol
mis
use,
a
med
ical
con
ditio
n or
an
adve
rse
life
even
t suc
h as
ber
eave
men
t.3.
The
re m
ust b
e im
pairm
ent o
f soc
ial f
unct
ioni
ng.
MA
P 1.
1. D
epre
ssio
n
K30033_C001.indd 3 28/02/17 11:02 am
Psyc
hiat
ry4
Tabl
e 1.
1. T
reat
men
t o
f d
epre
ssio
n
TABL
E 1.
1. T
reat
men
t of
dep
ress
ion.
Tre
atm
ent
depe
nds
on t
he c
lass
ifica
tion
of
depr
essi
on.
Clas
sifi
cati
on o
f de
pres
sion
M
etho
d of
tre
atm
ent
Mild
Cons
erva
tive
the
rapy
This
is a
‘wat
chfu
l wai
ting’
app
roac
h an
d in
volv
es:
• An
exe
rcis
e re
gim
e: th
e cu
rren
t rec
omm
enda
tions
are
thre
e tim
es a
wee
k fo
r 45
min
utes
last
ing
10–1
2 w
eeks
• Al
coho
l and
life
styl
e ad
vice
• Sl
eep
hygi
ene
• G
uide
d se
lf he
lp
Mod
erat
e –
seve
re
Cons
erva
tive
the
rapy
:
• An
exe
rcis
e re
gim
e as
abo
ve•
Psyc
holo
gica
l the
rapi
es (e
.g. c
ogni
tive
beha
viou
ral t
hera
py [C
BT],
whi
ch c
halle
nges
the
patie
nt’s
thou
ghts
and
fe
elin
gs in
ord
er to
cha
nge
them
), co
unse
lling
, int
erpe
rson
al p
sych
othe
rapy
, dyn
amic
ther
apy
Med
ical
the
rapy
:
• An
tidep
ress
ants
(see
Tabl
e 1.
2, p
. 6).
Mos
t pat
ient
s ar
e st
arte
d on
an
SSRI
firs
t lin
e•
If th
is in
itial
ther
apy
does
not
wor
k, p
atie
nts
may
be
switc
hed
to a
ltern
ativ
e an
tidep
ress
ants
, hav
e th
eir t
hera
py
augm
ente
d w
ith a
ntip
sych
otic
or a
ntie
pile
ptic
med
icat
ion
by a
spe
cial
ist o
r be
refe
rred
for E
CT (u
sual
ly 6
–12
sess
ions
, tw
ice
wee
kly)
. The
pat
hway
follo
wed
dep
ends
on
NIC
E an
d lo
cal g
uida
nce
K30033_C001.indd 4 28/02/17 11:02 am
Psyc
hiat
ry6
TABL
E 1.
2. A
ntid
epre
ssan
ts.
Clas
s of
ant
idep
ress
ant
Exam
ples
Use
sSi
de e
ffec
ts
Sele
ctiv
e se
roto
nin
reup
take
in
hibi
tors
(SSR
Is)
Cita
lopr
amSe
rtra
line
(ofte
n us
ed in
thos
e w
ho
have
pre
viou
sly
had
a m
yoca
rdia
l in
farc
tion)
Fluo
xetin
e (h
as a
long
hal
f-life
)Pa
roxe
tine
DO
BS:
Dep
ress
ion
OCD
Bulim
ia
Soci
al p
hobi
as
• G
I ups
et•
Sexu
al d
ysfu
nctio
n•
Hypo
natr
aem
ia in
the
elde
rly
• Di
scon
tinui
ty s
yndr
ome:
shi
verin
g, a
nxie
ty, h
eada
che,
na
usea
, diz
zine
ss•
Sero
toni
n sy
ndro
me:
mus
cle
rigid
ity, s
eizu
res,
card
iova
scul
ar c
olla
pse,
hyp
erth
erm
ia. T
reat
ser
oton
in
synd
rom
e w
ith c
ypro
hept
adin
e (a
5-H
T 2A re
cept
or
anta
goni
st)
Tric
yclic
ant
idep
ress
ants
(T
CAs)
Amitr
ipty
line
Imip
ram
ine
Clom
ipra
min
e
DO
BS:
Dep
ress
ion
OCD
(clo
mip
ram
ine)
Bed
wet
ting
(imip
ram
ine)
Som
etim
es n
euro
path
ic
pain
(am
itrip
tylin
e)
• Li
nked
to re
cept
or b
lock
ade:
α 1 a
ntag
onis
t: po
stur
al h
ypot
ensi
on
Antim
usca
rinic
: dry
mou
th, u
rinar
y re
tent
ion,
co
nstip
atio
n, b
lurr
ed v
isio
n
Antih
ista
min
ergi
c: w
eigh
t gai
n, d
row
sine
ss•
Toxi
city
= th
e 3C
s:Co
nvul
sion
sCo
ma
Card
ioto
xici
ty
Sero
toni
n no
radr
enal
ine
reup
take
inhi
bito
rs (S
NRI
s)Ve
nlaf
axin
eDu
loxe
tine
Depr
essi
onG
ener
aliz
ed a
nxie
ty d
isor
-de
r (ve
nlaf
axin
e)Pe
riphe
ral n
euro
path
y (d
ulox
etin
e)
• In
crea
sed
bloo
d pr
essu
re•
Nau
sea
• Se
datio
n
Tabl
e 1.
2. A
nti
dep
ress
ants
K30033_C001.indd 6 28/02/17 11:02 am
Psyc
hiat
ry7
Tabl
e 1.
2. A
nti
dep
ress
ants
Mon
oam
ine
oxid
ase
inhi
bito
rs (M
AOIs
)Se
legi
line
Moc
lobe
mid
e (re
vers
ible
inhi
bito
r of
mon
oam
ine
oxid
ase
A [R
IMA]
)
HA
D:
Hyp
ocho
ndria
sis
Anx
iety
Dep
ress
ion
Sele
gilin
e is
a M
AO-B
in
hibi
tor t
hat i
s lic
ense
d fo
r use
in P
arki
nson
’s di
seas
e
• An
timus
carin
ic: d
ry m
outh
, urin
ary
rete
ntio
n,
cons
tipat
ion,
blu
rred
vis
ion
• Th
e Ch
eese
Rea
ctio
n –
hype
rten
sive
cris
is th
at o
ccur
s w
ith in
gest
ion
of ty
ram
ine
cont
aini
ng s
ubst
ance
s (e
.g. c
hees
e, p
ickl
ed h
errin
g, s
oybe
an p
rodu
cts,
etc.
)
α 2 ant
agon
ist
Mirt
azap
ine
Depr
essi
onPT
SD•
Incr
ease
d ap
petit
e an
d w
eigh
t •
Dry
mou
th•
Seda
tion
Nor
adre
nalin
e re
upta
ke
inhi
bito
rs (N
RIs)
Rebo
xetin
eDA
P:D
epre
ssio
nA
DHD
Pani
c di
sord
er
• An
timus
carin
ic: d
ry m
outh
, urin
ary
rete
ntio
n,
cons
tipat
ion,
blu
rred
vis
ion
• An
tihis
tam
iner
gic:
wei
ght g
ain,
dro
wsi
ness
Tetr
acyc
lics
Map
rotil
ine
Depr
essi
on•
Seda
tion
• Po
stur
al h
ypot
ensi
on
K30033_C001.indd 7 28/02/17 11:02 am
Psyc
hiat
ry8
Map
1.2
. A
nxi
ety
Wha
t is
anx
iety
?An
xiet
y is
a n
orm
al e
mot
ion
that
like
ly h
as b
een
expe
rienc
ed b
ym
ost o
f us
durin
g ou
r liv
es. H
owev
er, w
hen
anxi
ety
is s
uch
that
itin
terfe
res
with
dai
ly fu
nctio
ning
and
per
form
ance
, it i
s co
nsid
ered
to b
e pa
thol
ogic
al. T
his
rela
tions
hip
is c
alle
d Ye
rkes
–Dod
son
law
.
Anxi
ety
may
be
clas
sifie
d in
to m
any
diffe
rent
sub
grou
ps:
Org
anic
cau
ses:
• Hy
pert
hyro
idis
m.
• Hy
pogl
ycae
mia
.•
Phae
ochr
omoc
ytom
a.•
Cere
bral
trau
ma.
• Te
mpo
ral l
obe
epile
psy.
Psyc
hiat
ric
caus
es:
• An
xiet
y di
sord
ers:
Phob
ic d
isor
ders
(e.g
. ago
raph
obia
).
N
on-s
ituat
iona
l dis
orde
rs (e
.g. g
ener
aliz
ed a
nxie
ty
di
sord
er [a
tria
d of
app
rehe
nsio
n, m
otor
tens
ion
and
auto
nom
ic o
vera
ctiv
ity]).
Reac
tion
to s
tres
sful
eve
nts
(e.g
. PTS
D).
OCD
(see
Map
1.3
, p. 1
0).
• Se
cond
ary
to d
epre
ssio
n or
psy
chos
is.•
Seco
ndar
y to
a m
edic
al c
ondi
tion.
• Se
cond
ary
to p
sych
oativ
e su
bsta
nce
abus
e (e
.g. a
lcoh
ol in
take
or
with
draw
al, a
mph
etam
ines
, ben
zodi
azep
ine
with
draw
al).
Sym
ptom
sTh
ese
may
be
gene
raliz
ed o
r par
oxys
mal
.
Rem
embe
r as
PAN
ICS:
P –
Palp
itatio
ns, p
ins
& n
eedl
esA
– A
bdom
inal
dis
com
fort
N –
Nau
sea
and
vom
iting
I –
Inte
nse
fear
of d
ying
(ang
or a
nim
us)
C –
Ches
t pai
n, c
hoki
ngS
– S
wea
ting,
sw
allo
win
g di
fficu
lty (g
lobu
s hy
ster
icus
), sh
ortn
ess
of
bre
ath
Thes
e sy
mpt
oms
may
occ
ur a
t diff
eren
t tim
es a
nd o
f var
ying
inte
nsity
dep
endi
ng o
n th
e un
derly
ing
diso
rder
(e.g
. if a
patie
nt h
ad a
soc
ial p
hobi
a, th
en a
n ex
cess
ive
anxi
ous
resp
onse
wou
ld o
nly
occu
r on
a sp
ecifi
c so
cial
situ
atio
n su
chas
del
iver
ing
a sp
eech
).
Trea
tmen
tDe
pend
s on
the
type
of a
nxie
ty d
isor
der
diag
nose
d, b
ut c
onsi
sts
of p
sych
olog
ical
and
phar
mac
olog
ical
ther
apy.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Be
havi
oura
l the
rapy
suc
h as
gra
ded
ex
posu
re.
• Ps
ycho
dyna
mic
ther
apy.
Phar
mac
olog
ical
the
rapy
:•
Antid
epre
ssan
ts (s
ee Ta
ble
1.2,
p. 6
).•
Anxi
olyt
ics
(see
Tabl
e 1.
3, p
. 12)
.
Inve
stig
atio
nsTh
ere
is n
o sp
ecifi
c in
vest
igat
ion
for a
nxie
tydi
sord
ers,
but i
t is
vita
l to
excl
ude
an o
rgan
icca
use.
The
refo
re, p
erfo
rm in
itial
inve
stig
atio
ns:
• Bl
oods
– F
BC, U
&E,
TFT
s, gl
ucos
e, c
alci
um
leve
ls.•
ECG.
• To
xico
logy
repo
rt if
indi
cate
d.•
Urin
ary
VMA/
pHVA
if in
dica
ted
(for
ph
aeoc
hrom
ocyt
oma)
.
Caus
es
The
gene
tic/
biol
ogic
al m
odel
:•
Inhe
rited
dis
orde
r – m
any
patie
nts
have
a
first
-deg
ree
fam
ily re
lativ
e w
ith th
e di
sord
er.
• Ab
norm
al re
cept
ors
in th
e 5-
HT, n
orad
rena
line
an
d G
ABA
syst
ems.
The
soci
al/p
sych
olog
ical
mod
el:
• Re
spon
se to
str
essf
ul li
fe e
vent
s.•
A ps
ycho
logi
cally
sus
cept
ible
pat
ient
may
m
isin
terp
ret a
nor
mal
bod
y st
imul
us.
MAP
1.2
. Anx
iety
K30033_C001.indd 8 28/02/17 11:02 am
Psyc
hiat
ry9
Map
1.2
. A
nxi
ety
Wha
t is
anx
iety
?An
xiet
y is
a n
orm
al e
mot
ion
that
like
ly h
as b
een
expe
rienc
ed b
ym
ost o
f us
durin
g ou
r liv
es. H
owev
er, w
hen
anxi
ety
is s
uch
that
itin
terfe
res
with
dai
ly fu
nctio
ning
and
per
form
ance
, it i
s co
nsid
ered
to b
e pa
thol
ogic
al. T
his
rela
tions
hip
is c
alle
d Ye
rkes
–Dod
son
law
.
Anxi
ety
may
be
clas
sifie
d in
to m
any
diffe
rent
sub
grou
ps:
Org
anic
cau
ses:
• Hy
pert
hyro
idis
m.
• Hy
pogl
ycae
mia
.•
Phae
ochr
omoc
ytom
a.•
Cere
bral
trau
ma.
• Te
mpo
ral l
obe
epile
psy.
Psyc
hiat
ric
caus
es:
• An
xiet
y di
sord
ers:
Phob
ic d
isor
ders
(e.g
. ago
raph
obia
).
N
on-s
ituat
iona
l dis
orde
rs (e
.g. g
ener
aliz
ed a
nxie
ty
di
sord
er [a
tria
d of
app
rehe
nsio
n, m
otor
tens
ion
and
auto
nom
ic o
vera
ctiv
ity]).
Reac
tion
to s
tres
sful
eve
nts
(e.g
. PTS
D).
OCD
(see
Map
1.3
, p. 1
0).
• Se
cond
ary
to d
epre
ssio
n or
psy
chos
is.•
Seco
ndar
y to
a m
edic
al c
ondi
tion.
• Se
cond
ary
to p
sych
oativ
e su
bsta
nce
abus
e (e
.g. a
lcoh
ol in
take
or
with
draw
al, a
mph
etam
ines
, ben
zodi
azep
ine
with
draw
al).
Sym
ptom
sTh
ese
may
be
gene
raliz
ed o
r par
oxys
mal
.
Rem
embe
r as
PAN
ICS:
P –
Palp
itatio
ns, p
ins
& n
eedl
esA
– A
bdom
inal
dis
com
fort
N –
Nau
sea
and
vom
iting
I –
Inte
nse
fear
of d
ying
(ang
or a
nim
us)
C –
Ches
t pai
n, c
hoki
ngS
– S
wea
ting,
sw
allo
win
g di
fficu
lty (g
lobu
s hy
ster
icus
), sh
ortn
ess
of
bre
ath
Thes
e sy
mpt
oms
may
occ
ur a
t diff
eren
t tim
es a
nd o
f var
ying
inte
nsity
dep
endi
ng o
n th
e un
derly
ing
diso
rder
(e.g
. if a
patie
nt h
ad a
soc
ial p
hobi
a, th
en a
n ex
cess
ive
anxi
ous
resp
onse
wou
ld o
nly
occu
r on
a sp
ecifi
c so
cial
situ
atio
n su
chas
del
iver
ing
a sp
eech
).
Trea
tmen
tDe
pend
s on
the
type
of a
nxie
ty d
isor
der
diag
nose
d, b
ut c
onsi
sts
of p
sych
olog
ical
and
phar
mac
olog
ical
ther
apy.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Be
havi
oura
l the
rapy
suc
h as
gra
ded
ex
posu
re.
• Ps
ycho
dyna
mic
ther
apy.
Phar
mac
olog
ical
the
rapy
:•
Antid
epre
ssan
ts (s
ee Ta
ble
1.2,
p. 6
).•
Anxi
olyt
ics
(see
Tabl
e 1.
3, p
. 12)
.
Inve
stig
atio
nsTh
ere
is n
o sp
ecifi
c in
vest
igat
ion
for a
nxie
tydi
sord
ers,
but i
t is
vita
l to
excl
ude
an o
rgan
icca
use.
The
refo
re, p
erfo
rm in
itial
inve
stig
atio
ns:
• Bl
oods
– F
BC, U
&E,
TFT
s, gl
ucos
e, c
alci
um
leve
ls.•
ECG.
• To
xico
logy
repo
rt if
indi
cate
d.•
Urin
ary
VMA/
pHVA
if in
dica
ted
(for
ph
aeoc
hrom
ocyt
oma)
.
Caus
es
The
gene
tic/
biol
ogic
al m
odel
:•
Inhe
rited
dis
orde
r – m
any
patie
nts
have
a
first
-deg
ree
fam
ily re
lativ
e w
ith th
e di
sord
er.
• Ab
norm
al re
cept
ors
in th
e 5-
HT, n
orad
rena
line
an
d G
ABA
syst
ems.
The
soci
al/p
sych
olog
ical
mod
el:
• Re
spon
se to
str
essf
ul li
fe e
vent
s.•
A ps
ycho
logi
cally
sus
cept
ible
pat
ient
may
m
isin
terp
ret a
nor
mal
bod
y st
imul
us.
MAP
1.2
. Anx
iety
K30033_C001.indd 9 28/02/17 11:02 am
Psyc
hiat
ry10
Map
1.3
. O
bse
ssiv
e co
mp
uls
ive
dis
ord
er (
OC
D)
Wha
t is
OCD
?O
CD is
a p
sych
iatr
ic d
isor
der c
hara
cter
ized
by
obse
ssiv
e th
ough
ts, r
umin
atio
ns a
nd c
ompu
lsiv
e rit
uals.
It a
ffect
s m
en a
nd w
omen
equ
ally.
The
mea
n ag
e of
ons
et is
20 y
ears
.
The
cond
ition
is a
ssoc
iate
d w
ith a
nank
astic
pe
rson
ality
dis
orde
r, G
illes
de
la To
uret
te s
yndr
ome,
de
pres
sion
and
, les
s co
mm
only,
sch
izop
hren
ia a
nd b
asal
ga
nglia
dis
orde
rs.
Trea
tmen
t
Psyc
holo
gica
l the
rapy
:•
CBT.
• Re
spon
se p
reve
ntio
n.•
Thou
ght s
topp
ing.
• Co
gniti
ve m
odel
ling.
Phar
mac
olog
ical
the
rapy
:•
Antid
epre
ssan
ts (s
ee Ta
ble
1.2,
p. 6
), pa
rtic
ular
ly
cl
omip
ram
ine,
whi
ch h
as s
tron
g an
ti-ob
sess
iona
l
actio
ns•
Anxi
olyt
ics
(see
Tabl
e 1.
3, p
. 12)
.•
Busp
irone
is u
sed
if m
arke
d an
xiet
y pr
esen
t.
Psyc
hosu
rgic
al:
• Th
is is
rare
and
onl
y co
nsid
ered
for i
ntra
ctab
le c
ases
.
Exam
ples
incl
ude
ster
eota
ctic
cin
gulo
tom
y or
ytt
rium
ra
dioa
ctiv
e im
plan
ts.
Inve
stig
atio
nsTh
ere
is n
o sp
ecifi
c te
st fo
r OCD
.(S
ee M
ap 1
.2, p
. 8, f
or te
sts
requ
ired
to ru
leou
t org
anic
cau
ses
of a
nxie
ty a
nd o
ther
type
sof
anx
iety
dis
orde
r.)
Caus
es•
Gen
etic
fact
ors:
3–7%
of s
uffe
rers
hav
e
a fir
st-d
egre
e re
lativ
e w
ith th
e co
nditi
on.
• Dy
sreg
ulat
ion/
hype
rsen
sitiv
ity o
f 5-H
T
rece
ptor
s.•
Hype
ract
ive
orbi
tofro
ntal
lobe
.•
Basa
l gan
glia
dys
func
tion:
Dysf
unct
iona
l str
iatu
m.
Smal
ler c
auda
te n
ucle
us.
Sym
ptom
sO
bses
sive
thou
ghts
, com
puls
ions
, im
puls
es,
rum
inat
ions
and
ritu
als.
Th
e IC
D-10
hig
hlig
hts
six
feat
ures
that
ar
e hi
ghly
sug
gest
ive
of th
e di
sord
er:
1. O
bses
sion
s an
d co
mpu
lsio
ns th
at h
ave
be
en p
rese
nt fo
r at l
east
2 w
eeks
.2.
The
obs
essi
ons
and
com
puls
ions
dec
reas
e
the
patie
nt’s
func
tion.
3. T
he p
atie
nt is
aw
are
that
thes
e th
ough
ts
are
gene
rate
d fro
m th
eir o
wn
min
d.4.
The
se th
ough
ts a
re u
nple
asan
tly re
petit
ive.
5. A
t lea
st o
ne o
f the
se th
ough
ts is
not
re
sist
ed.
6. T
he c
ompu
lsio
ns a
nd ri
tual
s pe
rform
ed a
re
not,
in th
emse
lves
, ple
asur
able
for t
he
patie
nt.
MAP
1.3
. Obs
essi
ve c
ompu
lsiv
e di
sord
er (O
CD)
K30033_C001.indd 10 28/02/17 11:02 am
Psyc
hiat
ry11
Map
1.3
. O
bse
ssiv
e co
mp
uls
ive
dis
ord
er (
OC
D)
Wha
t is
OCD
?O
CD is
a p
sych
iatr
ic d
isor
der c
hara
cter
ized
by
obse
ssiv
e th
ough
ts, r
umin
atio
ns a
nd c
ompu
lsiv
e rit
uals.
It a
ffect
s m
en a
nd w
omen
equ
ally.
The
mea
n ag
e of
ons
et is
20 y
ears
.
The
cond
ition
is a
ssoc
iate
d w
ith a
nank
astic
pe
rson
ality
dis
orde
r, G
illes
de
la To
uret
te s
yndr
ome,
de
pres
sion
and
, les
s co
mm
only,
sch
izop
hren
ia a
nd b
asal
ga
nglia
dis
orde
rs.
Trea
tmen
t
Psyc
holo
gica
l the
rapy
:•
CBT.
• Re
spon
se p
reve
ntio
n.•
Thou
ght s
topp
ing.
• Co
gniti
ve m
odel
ling.
Phar
mac
olog
ical
the
rapy
:•
Antid
epre
ssan
ts (s
ee Ta
ble
1.2,
p. 6
), pa
rtic
ular
ly
cl
omip
ram
ine,
whi
ch h
as s
tron
g an
ti-ob
sess
iona
l
actio
ns•
Anxi
olyt
ics
(see
Tabl
e 1.
3, p
. 12)
.•
Busp
irone
is u
sed
if m
arke
d an
xiet
y pr
esen
t.
Psyc
hosu
rgic
al:
• Th
is is
rare
and
onl
y co
nsid
ered
for i
ntra
ctab
le c
ases
.
Exam
ples
incl
ude
ster
eota
ctic
cin
gulo
tom
y or
ytt
rium
ra
dioa
ctiv
e im
plan
ts.
Inve
stig
atio
nsTh
ere
is n
o sp
ecifi
c te
st fo
r OCD
.(S
ee M
ap 1
.2, p
. 8, f
or te
sts
requ
ired
to ru
leou
t org
anic
cau
ses
of a
nxie
ty a
nd o
ther
type
sof
anx
iety
dis
orde
r.)
Caus
es•
Gen
etic
fact
ors:
3–7%
of s
uffe
rers
hav
e
a fir
st-d
egre
e re
lativ
e w
ith th
e co
nditi
on.
• Dy
sreg
ulat
ion/
hype
rsen
sitiv
ity o
f 5-H
T
rece
ptor
s.•
Hype
ract
ive
orbi
tofro
ntal
lobe
.•
Basa
l gan
glia
dys
func
tion:
Dysf
unct
iona
l str
iatu
m.
Smal
ler c
auda
te n
ucle
us.
Sym
ptom
sO
bses
sive
thou
ghts
, com
puls
ions
, im
puls
es,
rum
inat
ions
and
ritu
als.
Th
e IC
D-10
hig
hlig
hts
six
feat
ures
that
ar
e hi
ghly
sug
gest
ive
of th
e di
sord
er:
1. O
bses
sion
s an
d co
mpu
lsio
ns th
at h
ave
be
en p
rese
nt fo
r at l
east
2 w
eeks
.2.
The
obs
essi
ons
and
com
puls
ions
dec
reas
e
the
patie
nt’s
func
tion.
3. T
he p
atie
nt is
aw
are
that
thes
e th
ough
ts
are
gene
rate
d fro
m th
eir o
wn
min
d.4.
The
se th
ough
ts a
re u
nple
asan
tly re
petit
ive.
5. A
t lea
st o
ne o
f the
se th
ough
ts is
not
re
sist
ed.
6. T
he c
ompu
lsio
ns a
nd ri
tual
s pe
rform
ed a
re
not,
in th
emse
lves
, ple
asur
able
for t
he
patie
nt.
MAP
1.3
. Obs
essi
ve c
ompu
lsiv
e di
sord
er (O
CD)
K30033_C001.indd 11 28/02/17 11:02 am
Psyc
hiat
ry12
Tabl
e 1.
3. A
nxi
oly
tics
an
d h
ypn
oti
cs
TABL
E 1.
3. A
nxio
lyti
cs a
nd h
ypno
tics
.
Dru
g na
me
Mec
hani
sm o
f ac
tion
Use
sSi
de e
ffec
ts
Busp
irone
5-HT
1A p
artia
l ago
nist
Gen
eral
ized
anx
iety
dis
orde
r•
Nau
sea
and
vom
iting
• Di
zzin
ess
• He
adac
he•
Blur
red
visi
on
Amob
arbi
tal
Incr
ease
s th
e in
hibi
tory
act
ion
of G
ABA
by b
indi
ng to
the
barb
itura
te b
indi
ng s
ite o
n th
e G
ABA A r
ecep
tor.
Incr
ease
d in
flux
of C
l- ion
s
Seve
re in
som
nia
• De
pend
ence
•
With
draw
al s
ympt
oms
• Da
ytim
e se
datio
n•
Card
iore
spira
tory
dep
ress
ion
• Dr
ug in
tera
ctio
ns s
ince
it in
duce
s p4
50 s
yste
m
Zolp
idem
Bind
s to
the
benz
odia
zepi
ne
bind
ing
site
on
the
GAB
A A rec
epto
rIn
som
nia
• De
pend
ence
• To
lera
nce
• Se
datio
n•
Drow
sine
ss•
Dizz
ines
s
Diaz
epam
Incr
ease
s th
e in
hibi
tory
act
ion
of G
ABA
by b
indi
ng to
the
benz
odia
zepi
ne b
indi
ng s
ite o
n th
e G
ABA
rece
ptor
. Inc
reas
ed in
flux
of
Cl- i
ons
Anxi
ety
Inso
mni
aSt
atus
epi
lept
icus
• De
pend
ence
• To
lera
nce
• Ca
rdio
resp
irato
ry d
epre
ssio
n •
Drow
sine
ss•
Seda
tion
Flum
azen
ilCo
mpe
tes
at th
e be
nzod
iaze
pine
bi
ndin
g si
te. I
t is
ther
efor
e an
an
tago
nist
to th
e ac
tions
of
zolp
idem
and
dia
zepa
m
Benz
odia
zepi
ne o
verd
ose
• Pa
lpita
tions
• In
som
nia
• Co
nvul
sion
• An
xiet
y
K30033_C001.indd 12 28/02/17 11:02 am
Psyc
hiat
ry14
Caus
esTh
e ex
act c
ause
of s
chiz
ophr
enia
is u
nkno
wn
but t
here
are
man
y th
eorie
s:1.
The
dop
amin
e hy
poth
esis
– d
opam
iner
gic
ov
er a
ctiv
ity.
2. S
erot
oner
gic
over
activ
ity –
due
to th
e
supe
riorit
y of
clo
zapi
ne in
trea
ting
tr
eatm
ent r
esis
tant
sch
izop
hren
ia.
3. G
enet
ics
– hi
gher
inci
denc
e in
thos
e w
ith a
fa
mily
his
tory
. Ass
ocia
tion
with
the
DISC
1
gene
(Dis
rupt
ed In
SCh
izop
hren
ia).
4. D
rug
abus
e –
part
icul
arly
can
nabi
s us
e at
an
ea
rly a
ge.
5. G
roup
A p
erso
nalit
y di
sord
er.
6. I
llnes
s du
ring
preg
nanc
y.7.
Win
ter b
irths
.8.
Adv
erse
life
eve
nts.
Wha
t is
sch
izop
hren
ia?
This
is a
chr
onic
psy
chia
tric
dis
orde
r in
whi
ch
the
patie
nt e
xper
ienc
es d
isto
rted
real
ity. I
t af
fect
s m
en a
nd w
omen
equ
ally,
alth
ough
the
form
er te
nd to
hav
e an
ear
lier o
nset
. The
co
nditi
on is
ass
ocia
ted
with
a h
ighe
r sui
cide
ra
te th
an th
e ge
nera
l pop
ulat
ion
(10–
15%
).
Sym
ptom
sTh
e IC
D-10
sug
gest
s th
at s
ympt
oms
need
to b
e pr
esen
t for
at l
east
1 m
onth
.
Thes
e sy
mpt
oms
may
be
desc
ribed
as
Schn
eide
r’s fi
rst r
ank
sym
ptom
s (re
mem
ber a
s TA
P2) o
r, m
ore
broa
dly,
as p
ositi
ve a
nd n
egat
ive
sym
ptom
s.
Schn
eide
r’s fi
rst
rank
sym
ptom
s:•
T –
Thou
ght d
isor
der –
thou
ght i
nser
tion,
with
draw
al, b
road
cast
ing.
Thi
s m
ay
in
terfe
re w
ith s
peec
h, le
adin
g to
neol
ogis
ms,
thou
ght s
topp
ing
and
knig
ht’s
mov
e th
inki
ng.
• A
– A
udito
ry h
allu
cina
tions
– th
ough
t ech
o,
ru
nnin
g co
mm
enta
ry.
• P
– Pa
ssiv
ity p
heno
men
on –
bel
ief t
hat b
ody
is c
ontr
olle
d by
an
exte
rnal
age
ncy.
• P
– de
lusi
onal
Per
cept
ions
– th
inki
ng a
n
ev
eryd
ay o
bjec
t has
a s
peci
fic m
eani
ng
fo
r the
pat
ient
.
Posi
tive
sym
ptom
s:•
Thou
ght d
isor
der –
thou
ght i
nser
tion,
w
ithdr
awal
, bro
adca
stin
g.•
Delu
sion
s.•
Idea
s of
refe
renc
e.
• Ha
lluci
natio
ns.
• Pa
ssiv
ity p
heno
men
a.
Neg
ativ
e sy
mpt
oms
(ABC
P):
• A
logi
a.•
Anh
edon
ia.
• A
volit
ion.
• B
lunt
ing
of a
ffect
.•
Cat
aton
ia.
• P
over
ty o
f ide
atio
n.
Inve
stig
atio
nsTh
ere
is n
o sp
ecifi
c in
vest
igat
ion
for s
chiz
ophr
e-ni
a. It
is a
clin
ical
dia
gnos
is b
ut it
is v
ital t
o ru
le
out o
ther
cau
ses
of p
sych
osis,
suc
h as
dru
g-in
duce
d ps
ycho
sis,
and
to p
erfo
rm a
risk
as
sess
men
t. M
oreo
ver,
base
line
bloo
ds s
houl
d be
pe
rform
ed a
s w
ell a
s an
ECG
due
to th
e po
ssib
le
side
effe
cts
of a
ntip
sych
otic
med
icat
ion.
Trea
tmen
tDe
pend
s on
whe
ther
it is
an
urge
nt o
r non
-urg
ent s
ituat
ion.
Fol
low
you
r loc
al g
uide
lines
.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
inte
rven
tion
– pr
ogno
sis
is w
orse
in fa
mili
es w
ith h
igh
expr
esse
d em
otio
n.•
Art t
hera
py.
• Li
aise
with
soc
ial w
orke
r reg
ardi
ng h
ousi
ng d
iffic
ultie
s an
d em
ploy
men
t.
Phar
mac
olog
ical
the
rapy
:•
Antip
sych
otic
s (s
ee Ta
ble
1.4,
p. 1
6).
MAP
1.4
. Sch
izop
hren
ia
Map
1.4
. Sc
hiz
op
hre
nia
K30033_C001.indd 14 28/02/17 11:02 am
Psyc
hiat
ry15
Map
1.4
. Sc
hiz
op
hre
nia
Caus
esTh
e ex
act c
ause
of s
chiz
ophr
enia
is u
nkno
wn
but t
here
are
man
y th
eorie
s:1.
The
dop
amin
e hy
poth
esis
– d
opam
iner
gic
ov
er a
ctiv
ity.
2. S
erot
oner
gic
over
activ
ity –
due
to th
e
supe
riorit
y of
clo
zapi
ne in
trea
ting
tr
eatm
ent r
esis
tant
sch
izop
hren
ia.
3. G
enet
ics
– hi
gher
inci
denc
e in
thos
e w
ith a
fa
mily
his
tory
. Ass
ocia
tion
with
the
DISC
1
gene
(Dis
rupt
ed In
SCh
izop
hren
ia).
4. D
rug
abus
e –
part
icul
arly
can
nabi
s us
e at
an
ea
rly a
ge.
5. G
roup
A p
erso
nalit
y di
sord
er.
6. I
llnes
s du
ring
preg
nanc
y.7.
Win
ter b
irths
.8.
Adv
erse
life
eve
nts.
Wha
t is
sch
izop
hren
ia?
This
is a
chr
onic
psy
chia
tric
dis
orde
r in
whi
ch
the
patie
nt e
xper
ienc
es d
isto
rted
real
ity. I
t af
fect
s m
en a
nd w
omen
equ
ally,
alth
ough
the
form
er te
nd to
hav
e an
ear
lier o
nset
. The
co
nditi
on is
ass
ocia
ted
with
a h
ighe
r sui
cide
ra
te th
an th
e ge
nera
l pop
ulat
ion
(10–
15%
).
Sym
ptom
sTh
e IC
D-10
sug
gest
s th
at s
ympt
oms
need
to b
e pr
esen
t for
at l
east
1 m
onth
.
Thes
e sy
mpt
oms
may
be
desc
ribed
as
Schn
eide
r’s fi
rst r
ank
sym
ptom
s (re
mem
ber a
s TA
P2) o
r, m
ore
broa
dly,
as p
ositi
ve a
nd n
egat
ive
sym
ptom
s.
Schn
eide
r’s fi
rst
rank
sym
ptom
s:•
T –
Thou
ght d
isor
der –
thou
ght i
nser
tion,
with
draw
al, b
road
cast
ing.
Thi
s m
ay
in
terfe
re w
ith s
peec
h, le
adin
g to
neol
ogis
ms,
thou
ght s
topp
ing
and
knig
ht’s
mov
e th
inki
ng.
• A
– A
udito
ry h
allu
cina
tions
– th
ough
t ech
o,
ru
nnin
g co
mm
enta
ry.
• P
– Pa
ssiv
ity p
heno
men
on –
bel
ief t
hat b
ody
is c
ontr
olle
d by
an
exte
rnal
age
ncy.
• P
– de
lusi
onal
Per
cept
ions
– th
inki
ng a
n
ev
eryd
ay o
bjec
t has
a s
peci
fic m
eani
ng
fo
r the
pat
ient
.
Posi
tive
sym
ptom
s:•
Thou
ght d
isor
der –
thou
ght i
nser
tion,
w
ithdr
awal
, bro
adca
stin
g.•
Delu
sion
s.•
Idea
s of
refe
renc
e.
• Ha
lluci
natio
ns.
• Pa
ssiv
ity p
heno
men
a.
Neg
ativ
e sy
mpt
oms
(ABC
P):
• A
logi
a.•
Anh
edon
ia.
• A
volit
ion.
• B
lunt
ing
of a
ffect
.•
Cat
aton
ia.
• P
over
ty o
f ide
atio
n.
Inve
stig
atio
nsTh
ere
is n
o sp
ecifi
c in
vest
igat
ion
for s
chiz
ophr
e-ni
a. It
is a
clin
ical
dia
gnos
is b
ut it
is v
ital t
o ru
le
out o
ther
cau
ses
of p
sych
osis,
suc
h as
dru
g-in
duce
d ps
ycho
sis,
and
to p
erfo
rm a
risk
as
sess
men
t. M
oreo
ver,
base
line
bloo
ds s
houl
d be
pe
rform
ed a
s w
ell a
s an
ECG
due
to th
e po
ssib
le
side
effe
cts
of a
ntip
sych
otic
med
icat
ion.
Trea
tmen
tDe
pend
s on
whe
ther
it is
an
urge
nt o
r non
-urg
ent s
ituat
ion.
Fol
low
you
r loc
al g
uide
lines
.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
inte
rven
tion
– pr
ogno
sis
is w
orse
in fa
mili
es w
ith h
igh
expr
esse
d em
otio
n.•
Art t
hera
py.
• Li
aise
with
soc
ial w
orke
r reg
ardi
ng h
ousi
ng d
iffic
ultie
s an
d em
ploy
men
t.
Phar
mac
olog
ical
the
rapy
:•
Antip
sych
otic
s (s
ee Ta
ble
1.4,
p. 1
6).
MAP
1.4
. Sch
izop
hren
ia
K30033_C001.indd 15 28/02/17 11:02 am
Psyc
hiat
ry16
Tabl
e 1.
4. A
nti
psy
cho
tics
TABL
E 1.
4. A
ntip
sych
otic
s.
Clas
sifi
cati
onEx
ampl
esM
echa
nism
of
acti
onU
ses
Side
eff
ects
Typi
cal
Halo
perid
olCh
lorp
rom
azin
eTh
iorid
azin
e
Bloc
k D 2 r
ecep
tors
, th
ereb
y in
crea
sing
co
ncen
trat
ion
of
cAM
P 1
Schi
zoph
reni
aPs
ycho
sis
Man
iaTo
uret
te’s
synd
rom
e
Antip
sych
otic
med
icat
ions
blo
ck s
ever
al re
cept
ors,
whi
ch re
sults
in a
n ar
ray
of s
ide
effe
cts:
• D 2 r
ecep
tors
affe
ct s
ever
al p
athw
ays:
Tu
bero
infu
ndib
ular
pat
hway
: gal
acto
rrho
ea, a
men
orrh
oea,
hy
perp
rola
ctin
aem
ia
N
igro
stria
tal p
athw
ay: e
xtra
pyra
mid
al s
ide
effe
cts
(EPS
E).
Rem
embe
r as
TRA
P:T
– Ta
rdiv
e dy
skin
esia
R
– Re
stle
ss lo
wer
lim
bs (a
kath
esia
)A
– A
cute
dys
toni
aP
– Pa
rkin
soni
sms
M
esoc
ortic
al p
athw
ay: i
ncre
ases
neg
ativ
e sy
mpt
oms
(see
Map
1.
4, p
. 14)
.
Mes
olim
bic
path
way
: dec
reas
es p
ositi
ve s
ympt
oms
(see
Map
1.
4, p
. 14)
.•
α 1 ant
agon
ist:
post
ural
hyp
oten
sion
• An
timus
carin
ic: d
ry m
outh
, urin
ary
rete
ntio
n, c
onst
ipat
ion,
blu
rred
vi
sion
• An
tihis
tam
iner
gic:
wei
ght g
ain,
dro
wsi
ness
• N
euro
lept
ic m
alig
nant
syn
drom
e (N
MS)
– th
is is
a li
fe-t
hrea
teni
ng
reac
tion
that
may
be
caus
ed b
y an
adv
erse
reac
tion
to a
ntip
sych
otic
dr
ugs.
Sym
ptom
s of
NM
S in
clud
e: fe
ver,
mus
cle
rigid
ity, a
ltere
d m
enta
l sta
tus
and
auto
nom
ic d
ysfu
nctio
n
K30033_C001.indd 16 28/02/17 11:02 am
Psyc
hiat
ry17At
ypic
al
Ola
nzap
ine
Cloz
apin
eQ
uetia
pine
Risp
erid
one
Arip
ipra
zole
Bloc
k D 2 r
ecep
tors
th
ereb
y in
crea
sing
co
ncen
trat
ion
of
cAM
P 1 rec
epto
rs,
but a
re a
lso
effe
ctiv
e in
bl
ocki
ng 5
-HT 2,
α 1 an
d H 1 r
ecep
tors
Schi
zoph
reni
a O
lanz
apin
e m
ay a
lso
be u
sed
for a
nxie
ty
diso
rder
s, O
CD, m
ania
, de
pres
sion
and
To
uret
te’s
synd
rom
e
• Si
de e
ffect
s ar
e th
e sa
me
as th
ose
liste
d fo
r typ
ical
age
nts;
how
ever
, th
ere
are
far f
ewer
EPS
E an
d an
ticho
liner
gic
side
effe
cts,
whi
ch is
w
hy a
typi
cal a
gent
s ar
e pr
efer
red
to th
e ol
der,
typi
cal m
edic
atio
ns.
• Sp
ecifi
c si
de e
ffect
s:
Cloz
apin
e (u
sed
in tr
eatm
ent r
esis
tant
sch
izop
hren
ia):
agra
nulo
cyto
sis
O
lanz
apin
e: w
eigh
t gai
n
Moo
d st
abili
zer
Lith
ium
U
nkno
wn.
Tho
ught
to
act
in a
sim
ilar
way
to o
ther
sin
gle
char
ged
catio
ns
by in
terfe
ring
with
mem
bran
e io
n tr
ansp
ort
mec
hani
sms
Bipo
lar d
isor
der
Man
ia•
Com
mon
: tre
mor
, dia
rrho
ea, i
ncre
ased
app
etite
• Th
ose
that
requ
ire b
lood
test
mon
itorin
g: n
ephr
ogen
ic d
iabe
tes
insi
pidu
s, hy
poth
yroi
dism
• In
ove
rdos
e: c
onvu
lsio
ns, c
oma,
dea
th•
Tera
toge
nic:
Ebs
tein
’s ab
norm
ality
• Sp
ecia
l poi
nts:
narr
ow th
erap
eutic
inde
x. M
onito
r ser
um li
thiu
m
conc
entr
atio
n
Tabl
e 1.
4. A
nti
psy
cho
tics
K30033_C001.indd 17 28/02/17 11:02 am
Psyc
hiat
ry18
Map
1.5
. B
ipo
lar
dis
ord
er
Wha
t is
bip
olar
dis
orde
r?M
ajor
dep
ress
ion
alon
gsid
e at
leas
t one
man
ic
(bip
olar
I) o
r one
hyp
oman
ic (b
ipol
ar II
) epi
sode
ch
arac
teriz
es th
is d
isor
der.
Patie
nts
will
ev
entu
ally
suf
fer f
rom
dep
ress
ive
sym
ptom
s. In
so
me
way
s th
is d
isor
der m
ay b
e vi
ewed
as
a cy
clic
al in
terc
hang
ing
betw
een
elev
ated
and
low
moo
d w
here
the
patie
nt is
func
tiona
lly n
orm
al
betw
een
epis
odes
.
M
en a
nd w
omen
are
equ
ally
affe
cted
.
MA
P 1.
5. B
ipo
lar
dis
ord
er
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tic, n
euro
horm
onal
, neu
roan
atom
ical
and
psyc
hoso
cial
fact
ors.
A fe
w e
xam
ples
are
giv
enbe
low
:G
enet
ic: f
amily
his
tory
bip
olar
dis
orde
r.Po
ssib
le in
volv
emen
t of c
hrom
osom
es 6
q an
d8q
21.
Neu
roho
rmon
al: t
he m
onoa
min
e hy
poth
esis.
Neu
roan
atom
ical
: inc
reas
ed s
ize
of la
tera
lve
ntric
les,
abno
rmal
HPA
axi
s.Ps
ycho
soci
al: a
dver
se li
fe e
vent
s an
d ne
gativ
ech
ildho
od e
xper
ienc
es s
uch
as a
buse
, PTS
D.
Trea
tmen
tDe
pend
s on
whe
ther
it is
an
urge
nt o
rno
n-ur
gent
situ
atio
n. F
ollo
w y
our l
ocal
guid
elin
es.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy.
• Li
aise
with
soc
ial w
orke
r reg
ardi
ng h
ousi
ng
diffi
culti
es a
nd e
mpl
oym
ent.
Phar
mac
olog
ical
the
rapy
:•
Antip
sych
otic
s an
d m
ood
stab
ilize
rs (s
ee
Tabl
e 1.
4, p
. 16)
.•
Antie
pile
ptic
med
icat
ions
are
als
o us
ed
eith
er in
depe
nden
tly o
r in
com
bina
tion
with
lit
hium
.
Inve
stig
atio
ns•
Ther
e is
no
spec
ific
inve
stig
atio
n fo
r bip
olar
di
sord
er. I
t is
a cl
inic
al d
iagn
osis
but
it is
vi
tal t
o ru
le o
ut o
ther
cau
ses
of p
sych
osis,
su
ch a
s dr
ug-in
duce
d ps
ycho
sis,
as w
ell a
s
orga
nic
moo
d di
sord
ers
and
to p
erfo
rm a
ris
k as
sess
men
t. M
oreo
ver,
base
line
bloo
ds
shou
ld b
e pe
rform
ed a
s w
ell a
s an
ECG
due
to
the
poss
ible
affe
cts
of a
ntip
sych
otic
m
edic
atio
n. (N
ote:
QTc
pro
long
atio
n m
ay
occu
r with
all
antip
sych
otic
s.)•
Inve
stig
atio
ns a
s fo
r dep
ress
ion
(see
Map
1.
1, p
. 2).
Type
s of
bip
olar
dis
orde
r
Type
sKe
y fe
atur
es
Bipo
lar I
Bipo
lar I
I
Rapi
d cy
clin
g
Cycl
othy
mia
• At
leas
t one
man
ic
epis
ode
last
ing
>1
wee
k.•
Usu
ally
cou
pled
with
pe
riods
of d
epre
ssio
n,
but s
ome
patie
nts
may
on
ly h
ave
man
ic e
piso
des.
• >
1 ep
isod
e of
sev
ere
de
pres
sion
, but
onl
y
coup
led
with
hyp
oman
ia.
• >
4 m
ood
swin
gs w
ithin
a
year
.
• M
ood
swin
gs th
at a
re n
ot
as s
ever
e as
thos
e in
bipo
lar d
isor
der.
Follo
ws
a
cycl
ic p
atte
rn th
at m
ay
last
for l
onge
r per
iods
.
Sym
ptom
s•
Thos
e of
dep
ress
ion
(see
Map
1.1
, p. 2
).•
Thos
e of
man
ia: t
hese
sym
ptom
s m
ust b
e
pres
ent f
or a
t lea
st 1
wee
k. R
emem
ber a
s
DIG
FA
ST:
D
– D
istr
actib
ility
I
– Irr
espo
nsib
le b
ehav
iour
(e.g
. hed
onis
tic
beha
viou
r with
out c
onsi
derin
g th
e
con
sequ
ence
s su
ch a
s bo
rrow
ing
or
spen
ding
vas
t sum
s of
mon
ey a
nd
hav
ing
unpr
otec
ted
sexu
al in
terc
ours
e)
G –
Gra
ndio
sity
with
del
usio
ns o
f
po
wer
/wea
lth
F –
Flig
ht o
f ide
as
A –
Act
ivity
incr
ease
s
S –
Sle
ep d
ecre
ases
T
– T
alka
tiven
ess
K30033_C001.indd 18 28/02/17 11:02 am
Psyc
hiat
ry19
Map
1.5
. B
ipo
lar
dis
ord
er
Wha
t is
bip
olar
dis
orde
r?M
ajor
dep
ress
ion
alon
gsid
e at
leas
t one
man
ic
(bip
olar
I) o
r one
hyp
oman
ic (b
ipol
ar II
) epi
sode
ch
arac
teriz
es th
is d
isor
der.
Patie
nts
will
ev
entu
ally
suf
fer f
rom
dep
ress
ive
sym
ptom
s. In
so
me
way
s th
is d
isor
der m
ay b
e vi
ewed
as
a cy
clic
al in
terc
hang
ing
betw
een
elev
ated
and
low
moo
d w
here
the
patie
nt is
func
tiona
lly n
orm
al
betw
een
epis
odes
.
M
en a
nd w
omen
are
equ
ally
affe
cted
.
MA
P 1.
5. B
ipo
lar
dis
ord
er
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tic, n
euro
horm
onal
, neu
roan
atom
ical
and
psyc
hoso
cial
fact
ors.
A fe
w e
xam
ples
are
giv
enbe
low
:G
enet
ic: f
amily
his
tory
bip
olar
dis
orde
r.Po
ssib
le in
volv
emen
t of c
hrom
osom
es 6
q an
d8q
21.
Neu
roho
rmon
al: t
he m
onoa
min
e hy
poth
esis.
Neu
roan
atom
ical
: inc
reas
ed s
ize
of la
tera
lve
ntric
les,
abno
rmal
HPA
axi
s.Ps
ycho
soci
al: a
dver
se li
fe e
vent
s an
d ne
gativ
ech
ildho
od e
xper
ienc
es s
uch
as a
buse
, PTS
D.
Trea
tmen
tDe
pend
s on
whe
ther
it is
an
urge
nt o
rno
n-ur
gent
situ
atio
n. F
ollo
w y
our l
ocal
guid
elin
es.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy.
• Li
aise
with
soc
ial w
orke
r reg
ardi
ng h
ousi
ng
diffi
culti
es a
nd e
mpl
oym
ent.
Phar
mac
olog
ical
the
rapy
:•
Antip
sych
otic
s an
d m
ood
stab
ilize
rs (s
ee
Tabl
e 1.
4, p
. 16)
.•
Antie
pile
ptic
med
icat
ions
are
als
o us
ed
eith
er in
depe
nden
tly o
r in
com
bina
tion
with
lit
hium
.
Inve
stig
atio
ns•
Ther
e is
no
spec
ific
inve
stig
atio
n fo
r bip
olar
di
sord
er. I
t is
a cl
inic
al d
iagn
osis
but
it is
vi
tal t
o ru
le o
ut o
ther
cau
ses
of p
sych
osis,
su
ch a
s dr
ug-in
duce
d ps
ycho
sis,
as w
ell a
s
orga
nic
moo
d di
sord
ers
and
to p
erfo
rm a
ris
k as
sess
men
t. M
oreo
ver,
base
line
bloo
ds
shou
ld b
e pe
rform
ed a
s w
ell a
s an
ECG
due
to
the
poss
ible
affe
cts
of a
ntip
sych
otic
m
edic
atio
n. (N
ote:
QTc
pro
long
atio
n m
ay
occu
r with
all
antip
sych
otic
s.)•
Inve
stig
atio
ns a
s fo
r dep
ress
ion
(see
Map
1.
1, p
. 2).
Type
s of
bip
olar
dis
orde
r
Type
sKe
y fe
atur
es
Bipo
lar I
Bipo
lar I
I
Rapi
d cy
clin
g
Cycl
othy
mia
• At
leas
t one
man
ic
epis
ode
last
ing
>1
wee
k.•
Usu
ally
cou
pled
with
pe
riods
of d
epre
ssio
n,
but s
ome
patie
nts
may
on
ly h
ave
man
ic e
piso
des.
• >
1 ep
isod
e of
sev
ere
de
pres
sion
, but
onl
y
coup
led
with
hyp
oman
ia.
• >
4 m
ood
swin
gs w
ithin
a
year
.
• M
ood
swin
gs th
at a
re n
ot
as s
ever
e as
thos
e in
bipo
lar d
isor
der.
Follo
ws
a
cycl
ic p
atte
rn th
at m
ay
last
for l
onge
r per
iods
.
Sym
ptom
s•
Thos
e of
dep
ress
ion
(see
Map
1.1
, p. 2
).•
Thos
e of
man
ia: t
hese
sym
ptom
s m
ust b
e
pres
ent f
or a
t lea
st 1
wee
k. R
emem
ber a
s
DIG
FA
ST:
D
– D
istr
actib
ility
I
– Irr
espo
nsib
le b
ehav
iour
(e.g
. hed
onis
tic
beha
viou
r with
out c
onsi
derin
g th
e
con
sequ
ence
s su
ch a
s bo
rrow
ing
or
spen
ding
vas
t sum
s of
mon
ey a
nd
hav
ing
unpr
otec
ted
sexu
al in
terc
ours
e)
G –
Gra
ndio
sity
with
del
usio
ns o
f
po
wer
/wea
lth
F –
Flig
ht o
f ide
as
A –
Act
ivity
incr
ease
s
S –
Sle
ep d
ecre
ases
T
– T
alka
tiven
ess
K30033_C001.indd 19 28/02/17 11:02 am
Psyc
hiat
ry20
Tabl
e 1.
5. P
erso
nal
ity
dis
ord
ers
TABL
E 1.
5. P
erso
nalit
y di
sord
ers.
The
se a
re p
erva
sive
dif
ficu
ltie
s in
per
sona
lity
that
impa
ct u
pon
a pa
tien
t's
soci
al
func
tion
ing
in a
det
rim
enta
l way
. The
y ar
e in
cred
ibly
dif
ficu
lt t
o tr
eat
and
ofte
n re
quir
e ye
ars
of p
sych
othe
rapy
.
Clus
ter
Gen
eral
cha
ract
eris
tics
Spec
ific
subt
ypes
AO
dd e
ccen
tric
beh
avio
urDo
not
form
mea
ning
ful r
elat
ions
hips
Psyc
hosi
s is
not
pre
sent
1. P
aran
oid:
Susp
icio
usDe
fenc
e m
echa
nism
: pro
ject
ion
2. S
chiz
oid:
Soci
al w
ithdr
awal
/like
s so
cial
isol
atio
n 3.
Sch
izot
ypal
:Ec
cent
ric b
ehav
iour
and
bel
iefs
‘Mag
ical
thin
king
’
BTh
e em
otio
nal c
lust
erAs
soci
ated
with
moo
d di
sord
ers
Asso
ciat
ed w
ith s
ubst
ance
abu
se
1. A
ntis
ocia
l:Af
fect
s m
ales
mor
e th
an fe
mal
esCr
imin
al b
ehav
iour
and
dis
rega
rd fo
r oth
er m
embe
rs o
f soc
iety
2.
Bor
derl
ine:
Affe
cts
fem
ales
mor
e th
an m
ales
Asso
ciat
ed w
ith d
epre
ssio
nAs
soci
ated
with
del
iber
ate
self
harm
Feel
ings
of e
mpt
ines
sU
nsta
ble
inte
rper
sona
l rel
atio
nshi
psBl
ack
and
whi
te th
inki
ngIm
puls
ive
beha
viou
rDe
fenc
e m
echa
nism
: spl
ittin
g3.
His
trio
nic:
Atte
ntio
n se
ekin
g, v
ery
flirt
atio
us fe
mal
eSe
xual
ly p
rovo
cativ
e
K30033_C001.indd 20 28/02/17 11:02 am
Psyc
hiat
ry21
Tabl
e 1.
5. P
erso
nal
ity
dis
ord
ers
4. N
arci
ssis
tic:
Af
fect
s m
ales
mor
e th
an fe
mal
esG
rand
iose
del
usio
nsLa
ck o
f em
path
yLo
ves
adm
iratio
n an
d lo
athe
s cr
itici
sm
CTh
e an
xiou
s cl
uste
rAs
soci
ated
with
anx
iety
dis
orde
rs1.
Avo
idan
t:Ve
ry s
ensi
tive
to re
ject
ion
Avoi
ds s
ocia
l situ
atio
ns2.
Ana
nkas
tic:
Asso
ciat
ed w
ith O
CDPe
rfect
ioni
st p
erso
nalit
ies
3. D
epen
dent
: Lo
w s
elf e
stee
m‘C
lingy
’
K30033_C001.indd 21 28/02/17 11:02 am
Psyc
hiat
ry22
Map
1.6
. A
no
rexi
a n
ervo
sa
Sym
ptom
s•
Exce
ssiv
e w
eigh
t los
s.•
Wea
knes
s an
d fa
tigue
.•
Cold
per
iphe
ries.
• Br
adyc
ardi
a.•
Hypo
tens
ion.
• Am
enor
rhoe
a.•
Thin
lanu
go h
air o
ver f
ace
and
body
.•
Inab
ility
to p
erfo
rm s
quat
test
.•
Co-m
orbi
d de
pres
sion
/OCD
.
Sign
s•
Sig
ns o
f ind
uced
pur
ging
:
Ru
ssel
l’s s
ign.
Toot
h en
amel
that
is p
itted
/ero
ded.
Enla
rged
par
otid
gla
nds.
• S
igns
of e
lect
roly
te im
bala
nce:
Card
iac
arrh
ythm
ias.
Trea
tmen
tPs
ycho
educ
atio
n co
ncer
ning
wei
ght a
ndnu
triti
on.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy.
• In
terp
erso
nal t
hera
py.
• Ps
ycho
dyna
mic
ther
apy.
Phar
mac
olog
ical
the
rapy
:•
Corr
ectio
n of
ele
ctro
lyte
imba
lanc
e.•
Rest
ore
heal
thy
wei
ght.
• Pr
escr
ibe
mea
ls th
at a
re n
utrit
iona
lly
appr
opria
te.
Urg
ent s
ituat
ions
may
requ
ire re
feed
ing
unde
r the
Men
tal H
ealth
Act
.
Com
plic
atio
ns•
Deat
h.•
Endo
crin
e dy
sfun
ctio
n
(e.g
. am
enor
rhoe
a).
• M
etab
olic
alk
alos
is –
from
exc
essi
ve
vo
miti
ng.
• M
etab
olic
aci
dosi
s –
from
laxa
tive
abus
e.•
Card
iac
com
plic
atio
ns (e
.g. a
rrhy
thm
ias
and
QT
prol
onga
tion
that
may
lead
to
sudd
en d
eath
).•
Refe
edin
g sy
ndro
me
– re
sults
in
hypo
phos
phat
aem
ia, w
hich
can
lead
to
rhab
dom
yoly
sis,
arrh
ythm
ias,
resp
irato
ry
fa
ilure
, con
vuls
ions
, com
a an
d de
ath.
• El
ectr
olyt
e ab
norm
aliti
es –
hyp
okal
ae-
m
ia, h
ypon
atra
emia
, hyp
ogly
caem
ia,
hy
poca
lcae
mia
, hyp
erch
oles
tero
laem
ia.
• An
aem
ia.
• Pr
oxim
al m
yopa
thy.
Wha
t is
ano
rexi
a ne
rvos
a?Th
is is
an
eatin
g di
sord
er th
at is
char
acte
rized
by
ICD-
10 b
y fo
ur k
ey p
oint
s:1.
BM
I <17
.5.
2. S
elf–
indu
ced
wei
ght l
oss.
3. A
mor
bid
fear
of f
atne
ss.
4. E
ndoc
rine
dysf
unct
ion
(e.g
. am
enor
rhoe
a).
This
con
ditio
n af
fect
s fe
mal
es 1
0–20
tim
es
mor
e th
an m
ales
. It i
s as
soci
ated
with
soc
ial
clas
ses
I and
II a
s w
ell a
s ce
rtai
n pr
ofes
sion
s (e
.g. m
odel
s an
d da
ncer
s).
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tics,
neur
ohor
mon
al a
ndps
ycho
soci
al fa
ctor
s. A
few
exa
mpl
es a
regi
ven
belo
w:
• G
enet
ic: f
amily
his
tory
of a
nore
xia
ne
rvos
a.•
Neu
roho
rmon
al: a
bnor
mal
ities
in
sero
toni
n m
etab
olis
m.
• Ps
ycho
soci
al: a
dver
se li
fe e
vent
s,
perfe
ctio
nist
per
sona
litie
s, hi
gh
achi
evin
g fa
mili
es, m
edia
exp
ecta
tions
of
thin
ness
rela
ting
to th
e id
eal f
emal
e
form
.
Inve
stig
atio
nsCl
inic
al a
sses
smen
t: ov
eral
l clin
ical
as
sess
men
t inc
ludi
ng th
e us
e of
tool
s su
chas
the
SCO
FF q
uest
ionn
aire
:S
– Ha
ve y
ou e
ver m
ade
your
self
Sick
b
ecau
se y
ou a
re u
ncom
fort
ably
full?
C –
Do y
ou fe
el th
at y
ou h
ave
lost
Con
trol
o
ver h
ow m
uch
you
eat?
O –
Hav
e yo
u lo
st O
ne s
tone
in a
3 m
onth
p
erio
d?F
– Do
you
bel
ieve
you
rsel
f to
be F
at w
hen
o
ther
s sa
y yo
u ar
e th
in?
F –
Does
Foo
d do
min
ate
your
life
?
• BM
I = w
eigh
t (kg
)/hei
ght (
m)2 .
• Bl
oods
– F
BC, U
&E,
LFT
s, TF
Ts, g
luco
se,
ca
lciu
m le
vels.
• EC
G.•
Bloo
d pr
essu
re.
• To
xico
logy
repo
rt if
indi
cate
d.
MAP
1.6
. Ano
rexi
a ne
rvos
a
K30033_C001.indd 22 28/02/17 11:02 am
Psyc
hiat
ry23
Map
1.6
. A
no
rexi
a n
ervo
sa
Sym
ptom
s•
Exce
ssiv
e w
eigh
t los
s.•
Wea
knes
s an
d fa
tigue
.•
Cold
per
iphe
ries.
• Br
adyc
ardi
a.•
Hypo
tens
ion.
• Am
enor
rhoe
a.•
Thin
lanu
go h
air o
ver f
ace
and
body
.•
Inab
ility
to p
erfo
rm s
quat
test
.•
Co-m
orbi
d de
pres
sion
/OCD
.
Sign
s•
Sig
ns o
f ind
uced
pur
ging
:
Ru
ssel
l’s s
ign.
Toot
h en
amel
that
is p
itted
/ero
ded.
Enla
rged
par
otid
gla
nds.
• S
igns
of e
lect
roly
te im
bala
nce:
Card
iac
arrh
ythm
ias.
Trea
tmen
tPs
ycho
educ
atio
n co
ncer
ning
wei
ght a
ndnu
triti
on.
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy.
• In
terp
erso
nal t
hera
py.
• Ps
ycho
dyna
mic
ther
apy.
Phar
mac
olog
ical
the
rapy
:•
Corr
ectio
n of
ele
ctro
lyte
imba
lanc
e.•
Rest
ore
heal
thy
wei
ght.
• Pr
escr
ibe
mea
ls th
at a
re n
utrit
iona
lly
appr
opria
te.
Urg
ent s
ituat
ions
may
requ
ire re
feed
ing
unde
r the
Men
tal H
ealth
Act
.
Com
plic
atio
ns•
Deat
h.•
Endo
crin
e dy
sfun
ctio
n
(e.g
. am
enor
rhoe
a).
• M
etab
olic
alk
alos
is –
from
exc
essi
ve
vo
miti
ng.
• M
etab
olic
aci
dosi
s –
from
laxa
tive
abus
e.•
Card
iac
com
plic
atio
ns (e
.g. a
rrhy
thm
ias
and
QT
prol
onga
tion
that
may
lead
to
sudd
en d
eath
).•
Refe
edin
g sy
ndro
me
– re
sults
in
hypo
phos
phat
aem
ia, w
hich
can
lead
to
rhab
dom
yoly
sis,
arrh
ythm
ias,
resp
irato
ry
fa
ilure
, con
vuls
ions
, com
a an
d de
ath.
• El
ectr
olyt
e ab
norm
aliti
es –
hyp
okal
ae-
m
ia, h
ypon
atra
emia
, hyp
ogly
caem
ia,
hy
poca
lcae
mia
, hyp
erch
oles
tero
laem
ia.
• An
aem
ia.
• Pr
oxim
al m
yopa
thy.
Wha
t is
ano
rexi
a ne
rvos
a?Th
is is
an
eatin
g di
sord
er th
at is
char
acte
rized
by
ICD-
10 b
y fo
ur k
ey p
oint
s:1.
BM
I <17
.5.
2. S
elf–
indu
ced
wei
ght l
oss.
3. A
mor
bid
fear
of f
atne
ss.
4. E
ndoc
rine
dysf
unct
ion
(e.g
. am
enor
rhoe
a).
This
con
ditio
n af
fect
s fe
mal
es 1
0–20
tim
es
mor
e th
an m
ales
. It i
s as
soci
ated
with
soc
ial
clas
ses
I and
II a
s w
ell a
s ce
rtai
n pr
ofes
sion
s (e
.g. m
odel
s an
d da
ncer
s).
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tics,
neur
ohor
mon
al a
ndps
ycho
soci
al fa
ctor
s. A
few
exa
mpl
es a
regi
ven
belo
w:
• G
enet
ic: f
amily
his
tory
of a
nore
xia
ne
rvos
a.•
Neu
roho
rmon
al: a
bnor
mal
ities
in
sero
toni
n m
etab
olis
m.
• Ps
ycho
soci
al: a
dver
se li
fe e
vent
s,
perfe
ctio
nist
per
sona
litie
s, hi
gh
achi
evin
g fa
mili
es, m
edia
exp
ecta
tions
of
thin
ness
rela
ting
to th
e id
eal f
emal
e
form
.
Inve
stig
atio
nsCl
inic
al a
sses
smen
t: ov
eral
l clin
ical
as
sess
men
t inc
ludi
ng th
e us
e of
tool
s su
chas
the
SCO
FF q
uest
ionn
aire
:S
– Ha
ve y
ou e
ver m
ade
your
self
Sick
b
ecau
se y
ou a
re u
ncom
fort
ably
full?
C –
Do y
ou fe
el th
at y
ou h
ave
lost
Con
trol
o
ver h
ow m
uch
you
eat?
O –
Hav
e yo
u lo
st O
ne s
tone
in a
3 m
onth
p
erio
d?F
– Do
you
bel
ieve
you
rsel
f to
be F
at w
hen
o
ther
s sa
y yo
u ar
e th
in?
F –
Does
Foo
d do
min
ate
your
life
?
• BM
I = w
eigh
t (kg
)/hei
ght (
m)2 .
• Bl
oods
– F
BC, U
&E,
LFT
s, TF
Ts, g
luco
se,
ca
lciu
m le
vels.
• EC
G.•
Bloo
d pr
essu
re.
• To
xico
logy
repo
rt if
indi
cate
d.
MAP
1.6
. Ano
rexi
a ne
rvos
a
K30033_C001.indd 23 28/02/17 11:02 am
Psyc
hiat
ry24
Map
1.7
. B
ulim
ia n
ervo
sa
Sym
ptom
s•
Rem
embe
r tha
t pat
ient
s m
ay a
ctua
lly b
e
over
wei
ght d
ue to
bin
ge e
atin
g be
havi
our.
• Co
-mor
bid
depr
essi
on/O
CD.
Sign
s•
Sign
s of
indu
ced
purg
ing:
Russ
ell’s
sig
n.
To
oth
enam
el th
at is
pitt
ed/e
rode
d.
En
larg
ed p
arot
id g
land
s.
O
esop
hage
al te
ars.
• Si
gns
of e
lect
roly
te im
bala
nce:
Card
iac
arrh
ythm
ias.
Hypo
kala
emia
is a
ssoc
iate
d w
ith v
omiti
ng
as
wel
l as
laxa
tive
abus
e.
Trea
tmen
t
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy.
• In
terp
erso
nal t
hera
py.
• Ps
ycho
dyna
mic
ther
apy.
Phar
mac
olog
ical
the
rapy
:•
Corr
ectio
n of
ele
ctro
lyte
imba
lanc
e.•
Antid
epre
ssan
ts s
uch
as T
CAs
and
SSRI
s ha
ve
been
sho
wn
to d
ecre
ase
purg
ativ
e be
havi
our.
Urg
ent s
ituat
ions
are
less
com
mon
than
for
anor
exia
ner
vosa
sin
ce p
atie
nts
are
ofte
n of
no
rmal
wei
ght.
MAP
1.7
. Bul
imia
ner
vosa
Wha
t is
bul
imia
ner
vosa
?Th
is is
an
eatin
g di
sord
er th
at is
char
acte
rized
by
ICD-
10 b
y th
ree
key
poin
ts:
1. P
atie
nt e
ngag
es in
bin
ge e
atin
g.2.
The
re is
evi
denc
e of
pur
gativ
e be
havi
our
(e
.g. v
omiti
ng to
cou
nter
act t
he e
ffect
s of
bi
nge
eatin
g an
d in
crea
sed
wei
ght).
3. A
mor
bid
fear
of f
atne
ss.
Caus
esTh
e ca
use
of b
ulim
ia is
unc
lear
, but
it is
thou
ght
to b
e du
e to
com
plex
inte
ract
ions
bet
wee
n ge
netic
, neu
roho
rmon
al a
nd p
sych
osoc
ial f
acto
rs.
A fe
w e
xam
ples
are
giv
en b
elow
.
Gen
etic
: fam
ily h
isto
ry o
f bul
imia
ner
vosa
.
Neu
roho
rmon
al: t
heor
ies
invo
lvin
g al
tera
tion
of
sero
toni
n an
d no
radr
enal
ine
exis
t.
Psyc
hoso
cial
: adv
erse
life
eve
nts,
perfe
ctio
nist
pe
rson
aliti
es, p
ast d
ietin
g be
havi
our,
anor
exia
ne
rvos
a, p
erso
nalit
y di
sord
ers
part
icul
arly
bo
rder
line
patie
nts,
low
sel
f est
eem
and
de
pres
sion
.
Inve
stig
atio
nsLi
ke a
nore
xia
nerv
osa,
ther
e is
no
spec
ific
unde
rlyin
g te
st fo
r bul
imia
ner
vosa
. How
ever
, it i
s im
port
ant t
o ru
le o
ut o
rgan
ic c
ause
s of
wei
ght
gain
and
wei
ght l
oss
as w
ell a
s pe
rform
ing
a ps
ychi
atric
eva
luat
ion.
It is
impo
rtan
t to
perfo
rm
the
inve
stig
atio
ns li
sted
bel
ow, p
artic
ular
ly U
&E,
si
nce
elec
trol
yte
dist
urba
nces
are
com
mon
with
pu
rgat
ive
beha
viou
r.•
BMI =
wei
ght (
kg)/h
eigh
t (m
)2 .•
Bloo
ds –
FBC
, U&
E, L
FTs,
TFTs
, glu
cose
, cal
cium
le
vels.
• EC
G.•
Bloo
d pr
essu
re.
• To
xico
logy
repo
rt if
indi
cate
d.
K30033_C001.indd 24 28/02/17 11:02 am
Psyc
hiat
ry25
Map
1.7
. B
ulim
ia n
ervo
sa
Sym
ptom
s•
Rem
embe
r tha
t pat
ient
s m
ay a
ctua
lly b
e
over
wei
ght d
ue to
bin
ge e
atin
g be
havi
our.
• Co
-mor
bid
depr
essi
on/O
CD.
Sign
s•
Sign
s of
indu
ced
purg
ing:
Russ
ell’s
sig
n.
To
oth
enam
el th
at is
pitt
ed/e
rode
d.
En
larg
ed p
arot
id g
land
s.
O
esop
hage
al te
ars.
• Si
gns
of e
lect
roly
te im
bala
nce:
Card
iac
arrh
ythm
ias.
Hypo
kala
emia
is a
ssoc
iate
d w
ith v
omiti
ng
as
wel
l as
laxa
tive
abus
e.
Trea
tmen
t
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy.
• In
terp
erso
nal t
hera
py.
• Ps
ycho
dyna
mic
ther
apy.
Phar
mac
olog
ical
the
rapy
:•
Corr
ectio
n of
ele
ctro
lyte
imba
lanc
e.•
Antid
epre
ssan
ts s
uch
as T
CAs
and
SSRI
s ha
ve
been
sho
wn
to d
ecre
ase
purg
ativ
e be
havi
our.
Urg
ent s
ituat
ions
are
less
com
mon
than
for
anor
exia
ner
vosa
sin
ce p
atie
nts
are
ofte
n of
no
rmal
wei
ght.
MAP
1.7
. Bul
imia
ner
vosa
Wha
t is
bul
imia
ner
vosa
?Th
is is
an
eatin
g di
sord
er th
at is
char
acte
rized
by
ICD-
10 b
y th
ree
key
poin
ts:
1. P
atie
nt e
ngag
es in
bin
ge e
atin
g.2.
The
re is
evi
denc
e of
pur
gativ
e be
havi
our
(e
.g. v
omiti
ng to
cou
nter
act t
he e
ffect
s of
bi
nge
eatin
g an
d in
crea
sed
wei
ght).
3. A
mor
bid
fear
of f
atne
ss.
Caus
esTh
e ca
use
of b
ulim
ia is
unc
lear
, but
it is
thou
ght
to b
e du
e to
com
plex
inte
ract
ions
bet
wee
n ge
netic
, neu
roho
rmon
al a
nd p
sych
osoc
ial f
acto
rs.
A fe
w e
xam
ples
are
giv
en b
elow
.
Gen
etic
: fam
ily h
isto
ry o
f bul
imia
ner
vosa
.
Neu
roho
rmon
al: t
heor
ies
invo
lvin
g al
tera
tion
of
sero
toni
n an
d no
radr
enal
ine
exis
t.
Psyc
hoso
cial
: adv
erse
life
eve
nts,
perfe
ctio
nist
pe
rson
aliti
es, p
ast d
ietin
g be
havi
our,
anor
exia
ne
rvos
a, p
erso
nalit
y di
sord
ers
part
icul
arly
bo
rder
line
patie
nts,
low
sel
f est
eem
and
de
pres
sion
.
Inve
stig
atio
nsLi
ke a
nore
xia
nerv
osa,
ther
e is
no
spec
ific
unde
rlyin
g te
st fo
r bul
imia
ner
vosa
. How
ever
, it i
s im
port
ant t
o ru
le o
ut o
rgan
ic c
ause
s of
wei
ght
gain
and
wei
ght l
oss
as w
ell a
s pe
rform
ing
a ps
ychi
atric
eva
luat
ion.
It is
impo
rtan
t to
perfo
rm
the
inve
stig
atio
ns li
sted
bel
ow, p
artic
ular
ly U
&E,
si
nce
elec
trol
yte
dist
urba
nces
are
com
mon
with
pu
rgat
ive
beha
viou
r.•
BMI =
wei
ght (
kg)/h
eigh
t (m
)2 .•
Bloo
ds –
FBC
, U&
E, L
FTs,
TFTs
, glu
cose
, cal
cium
le
vels.
• EC
G.•
Bloo
d pr
essu
re.
• To
xico
logy
repo
rt if
indi
cate
d.
K30033_C001.indd 25 28/02/17 11:02 am
Psyc
hiat
ry26
Map
1.8
. A
tten
tio
n d
efici
t h
yper
acti
ve d
iso
rder
(A
DH
D)
Sym
ptom
s•
Decr
ease
d co
ncen
trat
ion.
• Po
or s
choo
l per
form
ance
.•
Forg
etfu
lnes
s.•
Hype
ract
ive
beha
viou
r.•
Inab
ility
to o
rgan
ize
task
s.•
Fidg
etin
g.•
Very
talk
ativ
e.•
Ofte
n in
terr
upts
.
Trea
tmen
t
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy
incl
udin
g pa
rent
m
anag
emen
t the
rapy
.•
Educ
atio
nal i
nter
vent
ion.
Phar
mac
olog
ical
the
rapy
:•
Met
hylp
heni
date
(Rita
lin) i
s th
e tr
eatm
ent o
f
choi
ce.
Com
plic
atio
ns•
Subs
tanc
e m
isus
e.•
Diss
ocia
l per
sona
lity
diso
rder
.•
Une
mpl
oym
ent.
• Lo
w s
elf e
stee
m.
• In
crea
sed
rate
of s
uici
de.
Wha
t is
AD
HD
?Th
is is
per
vasi
ve, d
evel
opm
enta
lly in
appr
opria
tebe
havi
our i
n w
hich
the
patie
nt la
cks
conc
entr
atio
nan
d is
hyp
erac
tive.
It is
mor
e co
mm
on in
mal
es
than
fem
ales
and
mus
t be
pres
ent i
n at
leas
t tw
o di
ffere
nt s
ettin
gs (e
.g. a
t hom
e an
d at
sch
ool).
The
sy
mpt
oms
mus
t be
pres
ent f
or a
t lea
st 6
mon
ths.
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tics,
neur
ohor
mon
al a
nd p
sych
osoc
ial f
acto
rs.
A fe
w e
xam
ples
are
giv
en b
elow
.
Gen
etic
s: p
ossi
ble
invo
lvem
ent o
f chr
omos
omes
5,
6 a
nd 1
1.
Neu
roho
rmon
al: d
ysre
gula
tion
of d
opam
ine
and
nora
dren
alin
e.
Psyc
hoso
cial
: fam
ilial
dys
func
tion,
par
enta
l st
ress
, pot
entia
lly fo
od a
dditi
ves.
Inve
stig
atio
ns•
Ther
e is
no
spec
ific
test
for A
DHD,
but
it is
im
port
ant t
o pe
rform
a fu
ll de
velo
pmen
tal,
m
edic
al a
nd fa
mili
al a
sses
smen
t as
wel
l as
ob
tain
ing
info
rmat
ion
from
the
child
’s sc
hool
co
ncer
ning
thei
r beh
avio
ur.
• Th
e Co
nner
s Co
mpr
ehen
sive
Ass
essm
ent S
cale
may
aid
initi
al a
sses
smen
t and
follo
w-u
p
appo
intm
ents
.
MAP
1.8
. Att
enti
on d
efic
it h
yper
acti
ve d
isor
der
(AD
HD
)
K30033_C001.indd 26 28/02/17 11:02 am
Psyc
hiat
ry27
Map
1.8
. A
tten
tio
n d
efici
t h
yper
acti
ve d
iso
rder
(A
DH
D)
Sym
ptom
s•
Decr
ease
d co
ncen
trat
ion.
• Po
or s
choo
l per
form
ance
.•
Forg
etfu
lnes
s.•
Hype
ract
ive
beha
viou
r.•
Inab
ility
to o
rgan
ize
task
s.•
Fidg
etin
g.•
Very
talk
ativ
e.•
Ofte
n in
terr
upts
.
Trea
tmen
t
Psyc
holo
gica
l the
rapy
:•
CBT.
• Fa
mily
focu
sed
ther
apy
incl
udin
g pa
rent
m
anag
emen
t the
rapy
.•
Educ
atio
nal i
nter
vent
ion.
Phar
mac
olog
ical
the
rapy
:•
Met
hylp
heni
date
(Rita
lin) i
s th
e tr
eatm
ent o
f
choi
ce.
Com
plic
atio
ns•
Subs
tanc
e m
isus
e.•
Diss
ocia
l per
sona
lity
diso
rder
.•
Une
mpl
oym
ent.
• Lo
w s
elf e
stee
m.
• In
crea
sed
rate
of s
uici
de.
Wha
t is
AD
HD
?Th
is is
per
vasi
ve, d
evel
opm
enta
lly in
appr
opria
tebe
havi
our i
n w
hich
the
patie
nt la
cks
conc
entr
atio
nan
d is
hyp
erac
tive.
It is
mor
e co
mm
on in
mal
es
than
fem
ales
and
mus
t be
pres
ent i
n at
leas
t tw
o di
ffere
nt s
ettin
gs (e
.g. a
t hom
e an
d at
sch
ool).
The
sy
mpt
oms
mus
t be
pres
ent f
or a
t lea
st 6
mon
ths.
Caus
esTh
e ca
use
is a
com
plic
ated
inte
ract
ion
betw
een
gene
tics,
neur
ohor
mon
al a
nd p
sych
osoc
ial f
acto
rs.
A fe
w e
xam
ples
are
giv
en b
elow
.
Gen
etic
s: p
ossi
ble
invo
lvem
ent o
f chr
omos
omes
5,
6 a
nd 1
1.
Neu
roho
rmon
al: d
ysre
gula
tion
of d
opam
ine
and
nora
dren
alin
e.
Psyc
hoso
cial
: fam
ilial
dys
func
tion,
par
enta
l st
ress
, pot
entia
lly fo
od a
dditi
ves.
Inve
stig
atio
ns•
Ther
e is
no
spec
ific
test
for A
DHD,
but
it is
im
port
ant t
o pe
rform
a fu
ll de
velo
pmen
tal,
m
edic
al a
nd fa
mili
al a
sses
smen
t as
wel
l as
ob
tain
ing
info
rmat
ion
from
the
child
’s sc
hool
co
ncer
ning
thei
r beh
avio
ur.
• Th
e Co
nner
s Co
mpr
ehen
sive
Ass
essm
ent S
cale
may
aid
initi
al a
sses
smen
t and
follo
w-u
p
appo
intm
ents
.
MAP
1.8
. Att
enti
on d
efic
it h
yper
acti
ve d
isor
der
(AD
HD
)
K30033_C001.indd 27 28/02/17 11:02 am
Psyc
hiat
ry28
Tabl
e 1.
6. D
emen
tia
TABL
E 1.
6. D
emen
tia.
Dem
enti
a is
a s
yndr
ome
of a
pro
gres
sive
glo
bal d
eclin
e in
cog
niti
ve f
unct
ion.
Type
of
dem
enti
aCa
uses
Sign
s an
d sy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Alzh
eim
er’s
dise
ase
Exac
t cau
se u
nkno
wn.
Risk
fact
ors
incl
ude:
• Do
wn’
s sy
ndro
me
due
to ↑
am
yloi
d pr
ecur
sor p
rote
in
(APP
) gen
e lo
ad•
Fam
ilial
gen
e as
soci
atio
ns:
AP
P –
chro
mos
ome
21
Pres
enili
n-1
– ch
rom
osom
e 14
Pr
esen
ilin-
2 –
chro
mos
ome
1
Apol
ipop
rote
in E
4 (A
PoE4
) alle
les
– ch
rom
osom
e 19
•
Hypo
thyr
oidi
sm•
Prev
ious
hea
d tr
aum
a•
Fam
ily h
isto
ry o
f Al
zhei
mer
’s di
seas
e
• Am
nesi
a•
Diso
rient
atio
n•
Chan
ges
in
pers
onal
ity
• De
crea
sing
sel
f car
e•
Apra
xia
• Ag
nosi
a•
Apha
sia
• Le
xial
ano
mia
• Pa
rano
id d
elus
ions
• De
pres
sion
• W
ande
ring
• Ag
gres
sion
• Se
xual
dis
inhi
bitio
n
Men
tal s
tate
exa
min
atio
n an
d m
ini-m
enta
l sta
te
exam
inat
ion
Adde
nbro
oke'
s co
gniti
ve
exam
inat
ion
(ACE
-III)
FBC,
U&
E, L
FTs,
TFTs
, CR
P, ES
R, g
luco
se,
calc
ium
, mag
nesi
um,
phos
phat
e, V
DRL,
HIV
se
rolo
gy, v
itam
in B
12
and
fola
te le
vels,
blo
od
cultu
re, E
CG, c
hest
x-r
ay,
CT, M
RI, S
PECT
Thre
e m
ain
findi
ngs
on
hist
olog
y: B
ATB
– Be
ta a
myl
oid
plaq
ues
A –
↓ A
cety
lcho
line
T –
neur
ofibr
illar
y Ta
ngle
s
• M
eman
tine
– in
hibi
ts g
luta
mat
e by
blo
ckin
g N
MDA
re
cept
ors
• Do
nepe
zil –
ac
etyl
chol
ines
tera
se
inhi
bito
r•
Riva
stig
min
e –
acet
ylch
olin
este
rase
in
hibi
tor
• Am
nesi
a•
Incr
ease
d ris
k of
in
fect
ion
• Dy
spha
gia
• U
rinar
y in
cont
inen
ce•
Incr
ease
d ris
k of
falls
K30033_C001.indd 28 28/02/17 11:02 am
Psyc
hiat
ry29
Tabl
e 1.
6. D
emen
tia
Vasc
ular
dem
entia
• Is
the
seco
nd m
ost
com
mon
cau
se o
f de
men
tia•
Caus
ed b
y in
farc
ts o
f sm
all a
nd m
ediu
m
size
d ve
ssel
s in
the
brai
n•
Gen
etic
ass
ocia
tion
with
cer
ebra
l au
toso
mal
dom
inan
t ar
terio
path
y w
ith s
ubco
rtic
al
infa
rcts
and
le
ukoe
ncep
halo
path
y (C
ADAS
IL) o
n ch
rom
osom
e 19
Follo
ws
a de
terio
ratin
g st
epw
ise
prog
ress
ion.
Th
ere
are
thre
e ty
pes:
1. V
ascu
lar d
emen
tia
follo
win
g st
roke
2. M
ulti-
infa
rct
dem
entia
follo
win
g m
ultip
le s
trok
es3.
Bin
swan
ger
dise
ase
follo
win
g m
icro
vasc
ular
infa
rcts
• Am
nesi
a•
Diso
rient
atio
n•
Chan
ges
in
pers
onal
ity
• De
crea
sing
sel
f car
e•
Depr
essi
on•
Sign
s of
UM
N le
sion
s (e
.g. b
risk
refle
xes)
• Se
izur
es
Men
tal s
tate
exa
min
atio
n an
d m
ini-m
enta
l sta
te
exam
inat
ion
Adde
nbro
oke’
s co
gniti
ve
exam
inat
ion
(ACE
-III)
FBC,
U&
E, L
FTs,
TFTs
, CR
P, ES
R, g
luco
se,
calc
ium
, mag
nesi
um,
phos
phat
e, V
DRL,
HIV
se
rolo
gy, v
itam
in B
12 a
nd
fola
te le
vels,
cho
lest
erol
le
vels,
vas
culit
is s
cree
n,
syph
ilis
sero
logy
, ECG
, ch
est x
-ray
, CT,
MRI
, SP
ECT
• Di
etar
y ad
vice
• Sm
okin
g ce
ssat
ion
• Tr
eat D
M a
nd
hype
rten
sion
• As
pirin
Sign
ifica
nt c
o-m
orbi
dity
(e
.g. c
ardi
ovas
cula
r di
seas
e an
d re
nal
dise
ase)
Cont
inue
d ov
erle
af
K30033_C001.indd 29 28/02/17 11:02 am
Psyc
hiat
ry30
Tabl
e 1.
6. D
emen
tia
TABL
E 1.
6. D
emen
tia.
Dem
enti
a is
a s
yndr
ome
of a
pro
gres
sive
glo
bal d
eclin
e in
cog
niti
ve f
unct
ion
(con
tinue
d ).
Type
of
dem
enti
aCa
uses
Sign
s an
d sy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Dem
entia
with
Lew
y bo
dies
• As
soci
ated
with
Pa
rkin
son’
s di
seas
e•
Avoi
d an
tipsy
chot
ic
drug
s in
thes
e pa
tient
s
Is a
tria
d of
:1.
Par
kins
onia
nism
–
brad
ykin
esia
, gai
t di
sord
er
2. H
allu
cina
tions
–
pred
omin
atel
y vi
sual
, us
ually
of a
nim
als
and
peop
le3.
Dis
ease
pro
cess
fo
llow
s a
fluct
uatin
g co
urse
Men
tal s
tate
exa
min
atio
n an
d m
ini-m
enta
l sta
te
exam
inat
ion
Adde
nbro
oke’
s co
gniti
ve
exam
inat
ion
(ACE
-III)
CT, M
RI, S
PECT
ApoE
gen
otyp
eLe
wy
bodi
es, u
biqu
itin
prot
eins
and
alp
ha-
synu
clei
n fo
und
on
hist
olog
y
• AV
OID
AN
TIPS
YCHO
TICS
–
caus
e hy
pers
ensi
tivity
to
neu
role
ptic
s•
Levo
dopa
may
be
use
d to
trea
t Pa
rkin
son’
s sym
ptom
s bu
t the
se m
ay
wor
sen
psyc
hotic
sy
mpt
oms
• N
euro
lept
ic
hype
rsen
sitiv
ity•
Auto
nom
ic
dysf
unct
ion
• Fl
uctu
atin
g bl
ood
pres
sure
• Ar
rhyt
hmia
s•
Urin
ary
inco
ntin
ence
• Dy
spha
gia
• In
crea
sed
risk
of fa
lls
Fron
tote
mpo
ral
dem
entia
(Pic
k’s
dise
ase)
• G
enet
ic a
ssoc
iatio
n w
ith c
hrom
osom
e 17
q21–
22 a
nd ta
u ge
ne 3
mut
atio
ns
• Am
nesi
a•
Diso
rient
atio
n•
Chan
ges
in
pers
onal
ity
• De
crea
sing
sel
f car
e•
Mut
ism
• Ec
hola
lia•
Ove
reat
ing
• Pa
rkin
soni
sm
• Di
sinh
ibiti
on
Men
tal s
tate
ex
amin
atio
n an
d m
ini-m
enta
l sta
te
exam
inat
ion
Adde
nbro
oke’
s co
gniti
ve
exam
inat
ion
(ACE
-III)
CT, M
RI, S
PECT
Curr
ently
non
e. O
nly
supp
ortiv
e tr
eatm
ent
avai
labl
e.
• In
crea
sed
risk
of fa
lls•
Incr
ease
d ris
k of
in
fect
ion
K30033_C001.indd 30 28/02/17 11:02 am
Psyc
hiat
ry31
Tabl
e 1.
6. D
emen
tia
Hist
olog
y: d
epen
ds o
n su
btyp
e:1.
Mic
rova
cuol
ar ty
pe –
m
icro
vacu
olat
ion
2. P
ick
type
–
wid
espr
ead
glio
sis,
no m
icro
vacu
olat
ion
3. M
ND
type
–
hist
olog
ical
cha
nges
lik
e M
ND
Hunt
ingt
on’s
dem
entia
• Ca
used
by
Hunt
ingt
on’s
dise
ase,
whi
ch is
an
auto
som
al d
omin
ant
diso
rder
whe
re th
ere
is a
def
ectiv
e ge
ne o
n ch
rom
osom
e 4
• Ca
uses
unc
ontr
olla
ble
chor
eifo
rm
mov
emen
ts a
nd
dem
entia
Unc
ontr
olla
ble
chor
eifo
rm m
ovem
ents
Di
agno
stic
gen
etic
te
stin
gN
o cu
re. T
reat
sym
ptom
s:•
Chor
ea –
an
atyp
ical
an
tipsy
chot
ic a
gent
• O
bses
sive
com
puls
ive
thou
ghts
and
irr
itabi
lity
– SS
RIs
• Dy
spha
gia
• In
crea
sed
risk
of fa
lls•
Incr
ease
d ris
k of
in
fect
ion
Cont
inue
d ov
erle
af
K30033_C001.indd 31 28/02/17 11:02 am
Psyc
hiat
ry32
Tabl
e 1.
6. D
emen
tia
TABL
E 1.
6. D
emen
tia.
Dem
enti
a is
a s
yndr
ome
of a
pro
gres
sive
glo
bal d
eclin
e in
cog
niti
ve f
unct
ion
(con
tinue
d ).
Type
of
dem
enti
aCa
uses
Sign
s an
d sy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Creu
tzfe
ldt–
Jako
b di
seas
e (C
JD)
• Ca
used
by
prio
ns•
Prog
ress
ive
and
with
out c
ure
• Th
ere
is a
lso
varia
nt
CJD
(vCJ
D), w
hich
ha
s an
ear
lier o
nset
of
dea
th
• Ra
pidl
y pr
ogre
ssiv
e de
men
tia (4
–5 m
onth
s)•
Amne
sia
• Di
sorie
ntat
ion
• Ch
ange
s in
pe
rson
ality
• De
pres
sion
• Ps
ycho
sis
• At
axia
• Se
izur
es
EEG
– tr
ipha
sic
spik
es
seen
LP –
for 1
4-3-
3 pr
otei
nCT
, MRI
No
cure
•
Incr
ease
d ris
k of
in
fect
ion
• Co
ma
• He
art f
ailu
re•
Resp
irato
ry fa
ilure
Oth
er c
ause
s•
HIV
• Vi
tam
in B
12 d
efici
ency
• Sy
phili
s•
Wils
on’s
dise
ase
– au
toso
mal
rece
ssiv
e co
nditi
on w
here
co
pper
acc
umul
ates
w
ithin
the
tissu
es•
Dem
entia
pug
ilist
ica
(aka
“pu
nch
drun
k”
synd
rom
e) –
see
n in
bo
xers
and
pat
ient
s w
ho s
uffe
r mul
tiple
co
ncus
sion
s
K30033_C001.indd 32 28/02/17 11:02 am
TABL
E 2.
1 U
K a
nte
nat
al b
oo
kin
g
app
oin
tmen
ts
34
TABL
E 2.
2 T
he
ph
ysio
log
y o
f la
bo
ur
37
TABL
E 2.
3 D
ysto
cia
38
MAP
2.1
P
rob
lem
s in
pre
gn
ancy
39
MAP
2.2
D
iab
etes
mel
litu
s (D
M)
in p
reg
nan
cy
40
MAP
2.3
E
pile
psy
in p
reg
nan
cy
42
MAP
2.4
P
re-e
clam
psi
a 44
MAP
2.5
L
iver
dis
ease
un
iqu
e to
p
reg
nan
cy
46
MAP
2.6
T
OR
CH
ES in
fect
ion
s 50
MAP
2.7
T
oxo
pla
smo
sis
51
MAP
2.8
R
ub
ella
52
MAP
2.9
C
yto
meg
alo
viru
s (C
MV
) 54
MAP
2.1
0 H
erp
es s
imp
lex
viru
s (H
SV)
55
MAP
2.1
1 H
um
an im
mu
no
defi
cien
cy v
iru
s (H
IV)
56
MAP
2.1
2 Sy
ph
ilis
58
MAP
2.1
3 Pl
acen
tal a
bru
pti
on
60
MAP
2.1
4 Pl
acen
ta p
raev
ia
62
MAP
2.1
5 Po
st-p
artu
m h
aem
orr
hag
e (P
PH)
64
MAP
2.1
6 R
hes
us
dis
ease
66
MAP
2.1
7 Sy
mp
hys
is p
ub
is d
ysfu
nct
ion
68
TABL
E 2.
4 B
reas
tfee
din
g
69
Chap
ter T
wo
Obs
tetr
ics
33O
bste
tric
s
K30033_C002.indd 33 28/02/17 11:15 am
34O
bste
tric
sTa
ble
2.1.
UK
an
ten
atal
bo
oki
ng
ap
po
intm
ents
TABL
E 2.
1. U
K a
nten
atal
boo
king
app
oint
men
ts. U
sefu
l web
site
tha
t su
mm
ariz
es t
he c
urre
nt p
rogr
amm
e: h
ttp:
//cpd
. sc
reen
ing.
nhs.
uk/fl
ashv
ideo
/NH
SPre
gnan
cySc
reen
ing.
mp4
.
Ges
tati
onW
hat
happ
ens
duri
ng t
he a
ppoi
ntm
ent?
8–12
wee
ksTh
is is
the
initi
al b
ooki
ng a
ppoi
ntm
ent:
• Ta
ke a
gen
eral
his
tory
enq
uirin
g ab
out p
ast m
edic
al m
ater
nal h
isto
ry a
nd m
ater
nal l
ifest
yle
fact
ors
incl
udin
g al
coho
l, sm
okin
g an
d di
et.
Also
, ask
abo
ut fo
lic a
cid
and
vita
min
D s
uppl
emen
tatio
n. S
tart
thes
e su
pple
men
ts if
they
are
not
bei
ng ta
ken
• M
easu
re b
lood
pre
ssur
e•
Perfo
rm a
urin
e di
p st
ick
and
cultu
re (f
or a
sym
ptom
atic
bac
teriu
ria)
• M
easu
re p
atie
nt’s
BMI
• Ro
utin
e bl
ood
test
s: FB
C, b
lood
gro
up, r
hesu
s st
atus
, red
blo
od c
ell a
lloan
tibod
ies
• Sc
reen
for i
nfec
tious
dis
ease
: HIV
, hep
atiti
s B,
rube
lla, s
yphi
lis
10–1
3 +
6 w
eeks
• Da
te c
onfir
min
g sc
an•
Scre
ens
for m
ultip
le p
regn
ancy
11–1
3 +
6 w
eeks
• Do
wn’
s sy
ndro
me
scre
enin
g: th
e co
mbi
ned
test
is o
ffere
d to
wom
en 1
1–14
wee
ks g
esta
tion.
Thi
s co
nsis
ts o
f the
nuc
hal t
rans
luce
ncy
scan
and
blo
od te
sts
(ser
um b
eta
hum
an c
horio
nic
gona
dotr
opin
and
ser
um p
regn
ancy
-ass
ocia
ted
plas
ma
prot
ein
A)
16 w
eeks
• Ro
utin
e bl
ood
test
: FBC
– g
ive
iron
supp
lem
enta
tion
if an
aem
ic•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
18–2
0 +
6 w
eeks
•
Feta
l ano
mal
y sc
an
25 w
eeks
O
nly
for p
rimip
arou
s m
othe
rs:
• M
easu
re s
ymph
ysis
–fun
dal h
eigh
t (SF
H)•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
K30033_C002.indd 34 28/02/17 11:15 am
35O
bste
tric
sTa
ble
2.1.
UK
an
ten
atal
bo
oki
ng
ap
po
intm
ents
28 w
eeks
• M
easu
re S
FH•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
• Ro
utin
e bl
ood
test
: FBC
– g
ive
iron
supp
lem
enta
tion
if an
aem
ic. C
heck
for a
typi
cal r
ed b
lood
cel
l allo
antib
odie
s•
Giv
e an
ti-D
prop
hyla
xis
to rh
esus
-neg
ativ
e m
othe
rs
31 w
eeks
O
nly
for p
rimip
arou
s m
othe
rs:
• M
easu
re S
FH•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
34 w
eeks
• M
easu
re S
FH•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
• G
ive
anti-
D pr
ophy
laxi
s to
rhes
us-n
egat
ive
mot
hers
• Co
unse
l mot
her a
bout
birt
hing
pla
n an
d sp
ecifi
c w
ishe
s or
con
cern
s
36 w
eeks
• M
easu
re S
FH•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
• Ex
tern
al c
epha
lic v
ersi
on fo
r bre
ech
pres
enta
tions
• Co
unse
l mot
her a
bout
bre
ast f
eedi
ng a
nd p
ost-
nata
l dep
ress
ion/
baby
blu
es
38 w
eeks
• M
easu
re S
FH•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
Cont
inue
d ov
erle
af
K30033_C002.indd 35 28/02/17 11:15 am
36O
bste
tric
sTa
ble
2.1.
UK
an
ten
atal
bo
oki
ng
ap
po
intm
ents
TABL
E 2.
1. U
K a
nten
atal
boo
king
app
oint
men
ts. U
sefu
l web
site
tha
t su
mm
ariz
es t
he c
urre
nt p
rogr
amm
e: h
ttp:
//cpd
. sc
reen
ing.
nhs.
uk/fl
ashv
ideo
/NH
SPre
gnan
cySc
reen
ing.
mp4
(con
tinue
d ).
Ges
tati
onW
hat
happ
ens
duri
ng t
he a
ppoi
ntm
ent?
40 w
eeks
• M
easu
re S
FH•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
• Co
unse
l mot
her a
bout
indu
ctio
n of
labo
ur
41 w
eeks
• M
easu
re S
FH•
Mea
sure
blo
od p
ress
ure
• Pe
rform
a u
rine
dip
stic
k an
d cu
lture
• Co
unse
l mot
her a
bout
indu
ctio
n of
labo
ur
K30033_C002.indd 36 28/02/17 11:15 am
37O
bste
tric
sTa
ble
2.2.
Th
e p
hys
iolo
gy
of
lab
ou
r
TABL
E 2.
2. T
he p
hysi
olog
y of
labo
ur. T
here
are
thr
ee s
tage
s of
labo
ur a
nd t
he s
ucce
ss o
f ea
ch s
tage
dep
ends
on
mat
erna
l, fe
tal a
nd m
echa
nica
l fac
tors
.
Stag
e of
labo
urSu
bcat
egor
ies
App
roxi
mat
e du
rati
onSp
ecifi
c in
vest
igat
ions
1. O
nset
of c
ontr
actio
ns u
ntil
full
dila
tatio
n of
the
cerv
ix1.
Lat
ent s
tage
– u
ntil
the
cerv
ix
reac
hes
4 cm
2. A
ctiv
e st
age
– fro
m 4
–10
cm
Varia
ble
Mea
sure
feta
l hea
rt ra
te u
sing
CTG
Mea
sure
mat
erna
l hea
rt ra
te, b
lood
pr
essu
re a
nd te
mpe
ratu
re
2. F
rom
full
dila
tatio
n of
the
cerv
ix u
ntil
the
deliv
ery
of
the
fetu
s
May
be
split
into
a p
assi
ve a
nd a
n ac
tive
stag
e.
The
fetu
s m
echa
nica
lly fo
llow
s a
path
way
to
be
expe
lled
from
the
uter
us.
This
pat
hway
is a
s fo
llow
s:
1. T
he h
ead
beco
mes
eng
aged
2. T
he fe
tus
desc
ends
to ‘s
tatio
n ze
ro’ (
the
leve
l of t
he is
chia
l spi
nes)
3. H
ead
flexi
on4.
Hea
d ro
tate
s in
tern
ally
5. H
ead
exte
nds
6. H
ead
rota
tes
exte
rnal
ly7.
Sho
ulde
rs a
nd b
ody
are
subs
eque
ntly
de
liver
ed
2–3
hour
s M
easu
re fe
tal h
eart
rate
usi
ng C
TGM
easu
re m
ater
nal h
eart
rate
, blo
od
pres
sure
and
tem
pera
ture
3. F
rom
del
iver
y of
the
fetu
s un
til d
eliv
ery
of th
e pl
acen
taN
ote
umbi
lical
cor
d le
ngth
enin
g 30
min
utes
M
easu
re fe
tal r
espo
nse
usin
g th
e
APG
AR s
core
Chec
k m
ater
nal v
ital s
igns
K30033_C002.indd 37 28/02/17 11:15 am
38O
bste
tric
sTa
ble
2.3.
Dys
toci
a
TABL
E 2.
3. D
ysto
cia.
In la
yman
’s t
erm
s th
is m
eans
dif
ficu
lt c
hild
birt
h. T
here
are
man
y re
ason
s w
hy c
hild
birt
h m
ay b
e di
fficu
lt a
nd t
hese
may
be
clas
sifi
ed in
to m
ater
nal c
ause
s, f
etal
cau
ses
and
mec
hani
cal c
ause
s. S
ome
exam
ples
are
pr
esen
ted
belo
w.
Mat
erna
l fac
tors
Feta
l fac
tors
Mec
hani
cal f
acto
rs
Inef
fect
ive
uter
ine
cont
ract
ion:
this
ofte
n oc
curs
in
nul
lipar
ous
wom
en w
ho h
ave
had
a pr
olon
ged
labo
ur
Mat
erna
l illn
ess
(e.g
. dia
bete
s m
ellit
us,
pre-
ecla
mps
ia, e
clam
psia
)
Prob
lem
atic
pla
cent
al im
plan
tati
on
(e.g
. pla
cent
a pr
aevi
a)
Feta
l mal
pres
enta
tion
Mac
roso
mia
: ass
ocia
ted
with
mat
erna
l dia
bete
s
Ceph
alop
elvi
c di
spro
port
ion:
ther
e ar
e fo
ur b
road
an
atom
ical
type
s of
fem
ale
pelv
is:
• G
ynec
oid
• An
droi
d•
Anth
ropo
id•
Plat
ypel
loid
Shou
lder
dys
toci
a: th
is h
as a
var
iety
of
asso
ciat
ions
suc
h as
dia
bete
s m
ellit
us, m
acro
som
ia,
smal
l mat
erna
l siz
e an
d a
past
obs
tetr
ic h
isto
ry o
f sh
ould
er d
ysto
cia.
To m
anag
e th
is p
robl
em s
ever
al
man
oeuv
res
may
be
empl
oyed
sta
rtin
g w
ith th
e M
cRob
ert’s
man
oeuv
re. O
ther
s in
clud
e th
e W
ood’
s sc
rew
pro
cedu
re a
nd th
e Za
vane
lli m
anoe
uvre
K30033_C002.indd 38 28/02/17 11:15 am
39O
bste
tric
sM
ap 2
.1.
Pro
ble
ms
in p
reg
nan
cy
Dis
orde
rs r
elat
ing
to h
igh
bloo
dpr
essu
re•
Pre-
ecla
mps
ia (s
ee M
ap 2
.4, p
. 44)
• Ec
lam
psia
Live
r di
seas
e un
ique
to
preg
nanc
y•
Hype
rem
esis
gra
vida
rum
(see
Map
2.5
, p. 4
6)•
Intr
ahep
atic
cho
lest
asis
of p
regn
ancy
(s
ee M
ap 2
.5, p
. 46)
• Ac
ute
fatt
y liv
er o
f pre
gnan
cy (s
ee M
ap
2.5,
p. 4
6)
Infe
ctio
ns•
TORC
HES
(see
Map
2.6
, p. 5
0)
Endo
crin
e di
sord
ers
• Di
abet
es m
ellit
us (s
ee M
ap 2
.2, p
. 40
)N
euro
logi
cal d
isor
ders
• Ep
ileps
y (s
ee M
ap 2
.3, p
. 42)
MAP
2.1
. Pro
blem
s in
pre
gnan
cy
K30033_C002.indd 39 28/02/17 11:15 am
40O
bste
tric
sM
ap 2
.2.
Dia
bet
es m
ellit
us
(DM
) in
pre
gn
ancy
Wha
t is
diab
etes
mel
litus
in p
regn
ancy
?Th
is is
met
abol
ic c
ondi
tion
in w
hich
the
patie
ntha
s hy
perg
lyca
emia
due
to in
sulin
inse
nsiti
vity
or d
ecre
ased
insu
lin s
ecre
tion.
Caus
esTh
ese
may
be:
Pre-
exis
ting
. The
re a
re m
any
– on
ly a
few
com
mon
cau
ses
are
liste
d he
re:
• Ty
pe 1
DM
: thi
s is
an
auto
imm
une
cond
ition
,
whi
ch re
sults
in th
e de
stru
ctio
n of
the
p
ancr
eatic
bet
a ce
lls re
sulti
ng in
no
insu
lin
pro
duct
ion.
Thi
s co
nditi
on h
as a
juve
nile
o
nset
and
is a
ssoc
iate
d w
ith H
LA-D
R3 a
nd
HLA
-DR4
. Pat
ient
s ar
e at
risk
of k
etoa
cido
sis.
• Ty
pe 2
DM
: thi
s oc
curs
whe
n pa
tient
s
gra
dual
ly b
ecom
e in
sulin
resi
stan
t or w
hen
t
he p
ancr
eatic
bet
a ce
lls fa
il to
sec
rete
e
noug
h in
sulin
, or b
oth.
It u
sual
ly h
as a
late
r
life
ons
et; h
owev
er, t
he in
cide
nce
is in
crea
sing
i
n yo
ung
popu
latio
ns d
ue to
env
ironm
enta
l
fac
tors
suc
h as
incr
easi
ng o
besi
ty a
nd
sed
enta
ry li
fest
yle.
Pat
ient
s ar
e at
risk
of
d
evel
opin
g a
hype
rosm
olar
sta
te.
• Ch
roni
c pa
ncre
atiti
s: th
is c
ondi
tion
dest
roys
b
oth
alph
a an
d be
ta p
ancr
eatic
cel
ls s
o th
at
glu
cago
n an
d in
sulin
are
no
long
er p
rodu
ced
a
nd s
ecre
ted.
Sym
ptom
s•
Gen
eral
: pol
yuria
, pol
ypha
gia,
poly
dips
ia, b
lurr
ed v
isio
n, g
lyco
suria
, sig
ns
of
mac
rova
scul
ar a
nd m
icro
vasc
ular
dis
ease
.•
Mor
e co
mm
on in
type
1 D
M: a
ceto
ne
brea
th, w
eigh
t los
s, Ku
ssm
aul
br
eath
ing,
nau
sea
and
vom
iting
.
Trea
tmen
t (g
esta
tion
al D
M s
peci
fic)
Cons
erva
tive
:•
Ensu
re th
at m
othe
r is
unde
r con
sulta
nt
led
care
.•
Ensu
re m
othe
r is
taki
ng a
hig
her d
ose
of
folic
aci
d (5
mg/
day)
due
to a
n in
crea
sed
ris
k of
neu
ral t
ube
defe
cts.
• Di
et c
ontr
ol.
• In
crea
sed
exer
cise
.
Med
ical
:•
Met
form
in.
• In
sulin
.
Inve
stig
atio
ns
Dia
gnos
tic
inve
stig
atio
ns fo
r D
M a
re:
• Fa
stin
g pl
asm
a gl
ucos
e: >
7 m
mol
/L
(12
6 m
g/dL
).•
Rand
om p
lasm
a gl
ucos
e (p
lus
DM s
ympt
oms)
:
>11
.1 m
mol
/L (2
00 m
g/dL
).•
HbA1
C: >
6.5%
.
Oth
er t
ests
incl
ude:
• Im
paire
d gl
ucos
e to
lera
nce
test
(for
bor
derli
ne
case
s):
Fast
ing
plas
ma
gluc
ose:
<7
mm
ol/L
(126
mg/
dL) a
nd a
t 2 h
ours
a le
vel o
f 7.8
–11
mm
ol/L
(140
–200
mg/
dL)
Plas
ma
gluc
ose
at 2
hou
rs: >
11.1
mm
ol/L
(>20
0 m
g/dL
)•
Impa
ired
fast
ing
gluc
ose:
Plas
ma
gluc
ose:
5.6
–6.9
mm
ol/L
(110
–126
mg/
dL).
Spec
ific
to g
esta
tion
al D
M:
• O
ral g
luco
se to
lera
nce
test
at 1
6–18
wee
ks
and
at 2
8 w
eeks
if in
itial
test
is n
orm
al.
• G
esta
tiona
l dia
bete
s m
ay b
e di
agno
sed
whe
n
the
blo
od g
luco
se le
vel i
s >
9 m
mol
/L 2
hou
rs
a
fter a
75
g or
al g
luco
se lo
ad.
Com
plic
atio
ns
Gen
eral
:•
Mac
rova
scul
ar: h
yper
tens
ion,
incr
ease
d ris
k
of s
trok
e, m
yoca
rdia
l inf
arct
ion,
dia
betic
foot
.•
Mic
rova
scul
ar: n
ephr
opat
hy, n
euro
path
y
(glo
ve a
nd s
tock
ing
dist
ribut
ion)
, ret
inop
athy
.•
Psyc
holo
gica
l: de
pres
sion
.
Feta
l:•
Neu
ral t
ube
and
card
iac
defe
cts.
• M
acro
som
ia a
nd s
houl
der d
ysto
cia.
• N
eona
tal h
ypog
lyca
emia
.
Mat
erna
l:•
DM la
ter i
n lif
e.•
Pote
ntia
lly in
stru
men
tal d
eliv
ery
or c
aesa
rean
se
ctio
n.
MAP
2.2
.D
iabe
tes
mel
litus
(DM
) in
preg
nanc
y
Ges
tati
onal
(i.e
. it d
evel
oped
dur
ing
preg
nanc
y). T
his
ofte
n no
rmal
izes
afte
r the
bab
yis
del
iver
ed b
ut m
any
wom
en g
o on
tode
velo
p DM
late
r in
life.
The
exa
ct c
ause
of
gest
atio
nal d
iabe
tes
is u
nkno
wn.
It is
ass
ocia
ted
with
man
y ris
k fa
ctor
s su
ch a
s hi
gh m
ater
nal
BMI,
ethn
ic o
rigin
with
a h
igh
prev
alen
ce in
thos
e w
ith S
outh
Asi
an a
nces
try,
a pr
evio
ushi
stor
y of
ges
tatio
nal d
iabe
tes
or a
mac
roso
mic
baby
(wei
ght >
4.5
kg).
K30033_C002.indd 40 28/02/17 11:15 am
41O
bste
tric
sM
ap 2
.2.
Dia
bet
es m
ellit
us
(DM
) in
pre
gn
ancy
Wha
t is
diab
etes
mel
litus
in p
regn
ancy
?Th
is is
met
abol
ic c
ondi
tion
in w
hich
the
patie
ntha
s hy
perg
lyca
emia
due
to in
sulin
inse
nsiti
vity
or d
ecre
ased
insu
lin s
ecre
tion.
Caus
esTh
ese
may
be:
Pre-
exis
ting
. The
re a
re m
any
– on
ly a
few
com
mon
cau
ses
are
liste
d he
re:
• Ty
pe 1
DM
: thi
s is
an
auto
imm
une
cond
ition
,
whi
ch re
sults
in th
e de
stru
ctio
n of
the
p
ancr
eatic
bet
a ce
lls re
sulti
ng in
no
insu
lin
pro
duct
ion.
Thi
s co
nditi
on h
as a
juve
nile
o
nset
and
is a
ssoc
iate
d w
ith H
LA-D
R3 a
nd
HLA
-DR4
. Pat
ient
s ar
e at
risk
of k
etoa
cido
sis.
• Ty
pe 2
DM
: thi
s oc
curs
whe
n pa
tient
s
gra
dual
ly b
ecom
e in
sulin
resi
stan
t or w
hen
t
he p
ancr
eatic
bet
a ce
lls fa
il to
sec
rete
e
noug
h in
sulin
, or b
oth.
It u
sual
ly h
as a
late
r
life
ons
et; h
owev
er, t
he in
cide
nce
is in
crea
sing
i
n yo
ung
popu
latio
ns d
ue to
env
ironm
enta
l
fac
tors
suc
h as
incr
easi
ng o
besi
ty a
nd
sed
enta
ry li
fest
yle.
Pat
ient
s ar
e at
risk
of
d
evel
opin
g a
hype
rosm
olar
sta
te.
• Ch
roni
c pa
ncre
atiti
s: th
is c
ondi
tion
dest
roys
b
oth
alph
a an
d be
ta p
ancr
eatic
cel
ls s
o th
at
glu
cago
n an
d in
sulin
are
no
long
er p
rodu
ced
a
nd s
ecre
ted.
Sym
ptom
s•
Gen
eral
: pol
yuria
, pol
ypha
gia,
poly
dips
ia, b
lurr
ed v
isio
n, g
lyco
suria
, sig
ns
of
mac
rova
scul
ar a
nd m
icro
vasc
ular
dis
ease
.•
Mor
e co
mm
on in
type
1 D
M: a
ceto
ne
brea
th, w
eigh
t los
s, Ku
ssm
aul
br
eath
ing,
nau
sea
and
vom
iting
.
Trea
tmen
t (g
esta
tion
al D
M s
peci
fic)
Cons
erva
tive
:•
Ensu
re th
at m
othe
r is
unde
r con
sulta
nt
led
care
.•
Ensu
re m
othe
r is
taki
ng a
hig
her d
ose
of
folic
aci
d (5
mg/
day)
due
to a
n in
crea
sed
ris
k of
neu
ral t
ube
defe
cts.
• Di
et c
ontr
ol.
• In
crea
sed
exer
cise
.
Med
ical
:•
Met
form
in.
• In
sulin
.
Inve
stig
atio
ns
Dia
gnos
tic
inve
stig
atio
ns fo
r D
M a
re:
• Fa
stin
g pl
asm
a gl
ucos
e: >
7 m
mol
/L
(12
6 m
g/dL
).•
Rand
om p
lasm
a gl
ucos
e (p
lus
DM s
ympt
oms)
:
>11
.1 m
mol
/L (2
00 m
g/dL
).•
HbA1
C: >
6.5%
.
Oth
er t
ests
incl
ude:
• Im
paire
d gl
ucos
e to
lera
nce
test
(for
bor
derli
ne
case
s):
Fast
ing
plas
ma
gluc
ose:
<7
mm
ol/L
(126
mg/
dL) a
nd a
t 2 h
ours
a le
vel o
f 7.8
–11
mm
ol/L
(140
–200
mg/
dL)
Plas
ma
gluc
ose
at 2
hou
rs: >
11.1
mm
ol/L
(>20
0 m
g/dL
)•
Impa
ired
fast
ing
gluc
ose:
Plas
ma
gluc
ose:
5.6
–6.9
mm
ol/L
(110
–126
mg/
dL).
Spec
ific
to g
esta
tion
al D
M:
• O
ral g
luco
se to
lera
nce
test
at 1
6–18
wee
ks
and
at 2
8 w
eeks
if in
itial
test
is n
orm
al.
• G
esta
tiona
l dia
bete
s m
ay b
e di
agno
sed
whe
n
the
blo
od g
luco
se le
vel i
s >
9 m
mol
/L 2
hou
rs
a
fter a
75
g or
al g
luco
se lo
ad.
Com
plic
atio
ns
Gen
eral
:•
Mac
rova
scul
ar: h
yper
tens
ion,
incr
ease
d ris
k
of s
trok
e, m
yoca
rdia
l inf
arct
ion,
dia
betic
foot
.•
Mic
rova
scul
ar: n
ephr
opat
hy, n
euro
path
y
(glo
ve a
nd s
tock
ing
dist
ribut
ion)
, ret
inop
athy
.•
Psyc
holo
gica
l: de
pres
sion
.
Feta
l:•
Neu
ral t
ube
and
card
iac
defe
cts.
• M
acro
som
ia a
nd s
houl
der d
ysto
cia.
• N
eona
tal h
ypog
lyca
emia
.
Mat
erna
l:•
DM la
ter i
n lif
e.•
Pote
ntia
lly in
stru
men
tal d
eliv
ery
or c
aesa
rean
se
ctio
n.
MAP
2.2
.D
iabe
tes
mel
litus
(DM
) in
preg
nanc
y
Ges
tati
onal
(i.e
. it d
evel
oped
dur
ing
preg
nanc
y). T
his
ofte
n no
rmal
izes
afte
r the
bab
yis
del
iver
ed b
ut m
any
wom
en g
o on
tode
velo
p DM
late
r in
life.
The
exa
ct c
ause
of
gest
atio
nal d
iabe
tes
is u
nkno
wn.
It is
ass
ocia
ted
with
man
y ris
k fa
ctor
s su
ch a
s hi
gh m
ater
nal
BMI,
ethn
ic o
rigin
with
a h
igh
prev
alen
ce in
thos
e w
ith S
outh
Asi
an a
nces
try,
a pr
evio
ushi
stor
y of
ges
tatio
nal d
iabe
tes
or a
mac
roso
mic
baby
(wei
ght >
4.5
kg).
K30033_C002.indd 41 28/02/17 11:15 am
42O
bste
tric
sM
ap 2
.3.
Epile
psy
in p
reg
nan
cy
Com
plic
atio
ns (p
regn
ancy
spe
cific
)
Gen
eral
:•
Inju
ries
whi
le h
avin
g se
izur
e.•
Depr
essi
on.
• An
xiet
y.•
Brai
n da
mag
e.•
Sudd
en u
nexp
lain
ed d
eath
in e
pile
psy
(
SUDE
P).
Feta
l:•
Neu
ral t
ube
defe
cts
(ass
ocia
ted
with
sod
ium
va
lpro
ate
espe
cial
ly).
• Cl
eft p
alat
e (a
ssoc
iate
d w
ith p
heny
toin
).•
Intr
aute
rine
grow
th re
stric
tion.
• De
velo
pmen
tal d
elay
.
Inve
stig
atio
nsN
ote
that
epi
leps
y w
ill o
ften
be d
iagn
osed
befo
re th
e la
dy fa
lls p
regn
ant.
How
ever
, the
fo
llow
ing
test
s ar
e us
ed to
hel
p ai
d th
edi
agno
sis
of e
pile
psy
and
iden
tify
the
caus
e.•
Bloo
ds –
FBC
, U&
E, L
FTs,
CRP,
ESR,
glu
cose
,
cal
cium
leve
ls•
Radi
olog
y –
MRI
• O
ther
– E
CG, L
P, EE
G
Wha
t is
epi
leps
y?Th
is is
a c
ondi
tion
in w
hich
the
brai
n is
affe
cted
by re
curr
ent s
eizu
res.
Caus
esSe
izur
es a
re c
ause
d by
abn
orm
al p
arox
ysm
alne
uron
al d
isch
arge
s in
the
brai
n, w
hich
are
usua
lly a
resu
lt of
som
e fo
rm o
f tra
umat
ic b
rain
inju
ry. T
hese
dis
char
ges
disp
lay
hype
rsyn
chro
niza
tion.
The
cau
ses
of e
pile
psy
may
be
broa
dly
class
ified
into
thre
e ty
pes:
1. I
diop
athi
c –
caus
e fo
r epi
leps
y is
unk
now
n.2.
Cry
ptog
enic
– c
ause
for e
pile
psy
is u
nkno
wn,
b
ut th
ere
are
sign
s th
at s
ugge
st th
at th
e
cau
se m
ay b
e lin
ked
to b
rain
inju
ry (e
.g.
p
atie
nt h
as a
utis
m o
r lea
rnin
g di
fficu
lties
).3.
Sym
ptom
atic
– c
ause
kno
wn.
Som
e ca
uses
of
sy
mpt
omat
ic e
pile
psy
incl
ude:
VIN
DIC
ATE:
V
– Va
scul
ar: h
isto
ry o
f str
oke
I
– In
fect
ion:
hist
ory
of m
enin
gitis
or m
alar
ia
N –
Neo
plas
ms:
brai
n tu
mou
r
D –
Dru
gs: a
lcoh
ol a
nd il
licit
drug
use
I
– Ia
trog
enic
: dru
g w
ithdr
awal
C
– Co
ngen
ital:
fam
ily h
isto
ry o
f epi
leps
y
A –
Aut
oim
mun
e: v
ascu
litis
T
– Tr
aum
a: h
isto
ry o
f bra
in in
jury
E
– En
docr
ine:
¯N
a+, ¯
Ca2+
, ¯ o
r g
luco
se
Trea
tmen
t (p
regn
ancy
spe
cific
)Co
ntin
uing
ant
iepi
lept
ic th
erap
y du
ring
preg
nanc
y is
adv
isab
le s
ince
the
risks
of h
avin
gse
izur
es w
hile
pre
gnan
t out
wei
gh th
e ha
rm o
fth
erap
y on
the
fetu
s.
Cons
erva
tive
:•
Ensu
re th
at m
othe
r is
unde
r con
sulta
nt
led
care
.•
Ensu
re m
othe
r is
taki
ng a
hig
her d
ose
of fo
lic
acid
(5 m
g/da
y) d
ue to
an
incr
ease
d ris
k of
ne
ural
tube
def
ects
.
Med
ical
:•
Neo
nata
l car
e –
vita
min
K in
ject
ion.
• Ca
rbam
azep
ine
is c
onsi
dere
d to
be
the
leas
t
tera
toge
nic
of th
e ol
der a
ntie
pile
ptic
age
nts.
• So
dium
val
proa
te h
as th
e st
rong
est
a
ssoc
iatio
n w
ith n
eura
l tub
e de
fect
s.
Sign
s an
d sy
mpt
oms
Thes
e de
pend
on
the
regi
on o
f the
bra
inaf
fect
ed.
• F
ront
al lo
be: J
AM
:
J –
Jack
soni
an m
arch
.
A –
pA
lsy
(pos
t-ic
tal T
odd’
s pa
lsy)
.
M –
Mot
or fe
atur
es.
• T
empo
ral l
obe:
AD
D F
AT:
A
– A
ura
that
the
epile
ptic
att
ack
will
occ
ur.
D
– D
éjà
vu.
D
– D
elus
iona
l beh
avio
ur.
F
– F
ear/p
anic
– h
ippo
cam
pal i
nvol
vem
ent.
A
– A
utom
atis
ms.
T
– Ta
ste/
smel
l – u
ncal
invo
lvem
ent.
• P
arie
tal a
nd o
ccip
ital
lobe
s:
Visu
al a
nd s
enso
ry d
istu
rban
ces
Oth
ers
incl
ude:
par
tial o
r gen
eral
ized
seiz
ures
with
or w
ithou
t con
vuls
ions
, to
ngue
biti
ng, m
igra
ines
and
dep
ress
ion.
MAP
2.3
. Epi
leps
y in
pre
gnan
cy
K30033_C002.indd 42 28/02/17 11:15 am
Com
plic
atio
ns (p
regn
ancy
spe
cific
)
Gen
eral
:•
Inju
ries
whi
le h
avin
g se
izur
e.•
Depr
essi
on.
• An
xiet
y.•
Brai
n da
mag
e.•
Sudd
en u
nexp
lain
ed d
eath
in e
pile
psy
(
SUDE
P).
Feta
l:•
Neu
ral t
ube
defe
cts
(ass
ocia
ted
with
sod
ium
va
lpro
ate
espe
cial
ly).
• Cl
eft p
alat
e (a
ssoc
iate
d w
ith p
heny
toin
).•
Intr
aute
rine
grow
th re
stric
tion.
• De
velo
pmen
tal d
elay
.
Inve
stig
atio
nsN
ote
that
epi
leps
y w
ill o
ften
be d
iagn
osed
befo
re th
e la
dy fa
lls p
regn
ant.
How
ever
, the
fo
llow
ing
test
s ar
e us
ed to
hel
p ai
d th
edi
agno
sis
of e
pile
psy
and
iden
tify
the
caus
e.•
Bloo
ds –
FBC
, U&
E, L
FTs,
CRP,
ESR,
glu
cose
,
cal
cium
leve
ls•
Radi
olog
y –
MRI
• O
ther
– E
CG, L
P, EE
G
Wha
t is
epi
leps
y?Th
is is
a c
ondi
tion
in w
hich
the
brai
n is
affe
cted
by re
curr
ent s
eizu
res.
Caus
esSe
izur
es a
re c
ause
d by
abn
orm
al p
arox
ysm
alne
uron
al d
isch
arge
s in
the
brai
n, w
hich
are
usua
lly a
resu
lt of
som
e fo
rm o
f tra
umat
ic b
rain
inju
ry. T
hese
dis
char
ges
disp
lay
hype
rsyn
chro
niza
tion.
The
cau
ses
of e
pile
psy
may
be
broa
dly
class
ified
into
thre
e ty
pes:
1. I
diop
athi
c –
caus
e fo
r epi
leps
y is
unk
now
n.2.
Cry
ptog
enic
– c
ause
for e
pile
psy
is u
nkno
wn,
b
ut th
ere
are
sign
s th
at s
ugge
st th
at th
e
cau
se m
ay b
e lin
ked
to b
rain
inju
ry (e
.g.
p
atie
nt h
as a
utis
m o
r lea
rnin
g di
fficu
lties
).3.
Sym
ptom
atic
– c
ause
kno
wn.
Som
e ca
uses
of
sy
mpt
omat
ic e
pile
psy
incl
ude:
VIN
DIC
ATE:
V
– Va
scul
ar: h
isto
ry o
f str
oke
I
– In
fect
ion:
hist
ory
of m
enin
gitis
or m
alar
ia
N –
Neo
plas
ms:
brai
n tu
mou
r
D –
Dru
gs: a
lcoh
ol a
nd il
licit
drug
use
I
– Ia
trog
enic
: dru
g w
ithdr
awal
C
– Co
ngen
ital:
fam
ily h
isto
ry o
f epi
leps
y
A –
Aut
oim
mun
e: v
ascu
litis
T
– Tr
aum
a: h
isto
ry o
f bra
in in
jury
E
– En
docr
ine:
¯N
a+, ¯
Ca2+
, ¯ o
r g
luco
se
Trea
tmen
t (p
regn
ancy
spe
cific
)Co
ntin
uing
ant
iepi
lept
ic th
erap
y du
ring
preg
nanc
y is
adv
isab
le s
ince
the
risks
of h
avin
gse
izur
es w
hile
pre
gnan
t out
wei
gh th
e ha
rm o
fth
erap
y on
the
fetu
s.
Cons
erva
tive
:•
Ensu
re th
at m
othe
r is
unde
r con
sulta
nt
led
care
.•
Ensu
re m
othe
r is
taki
ng a
hig
her d
ose
of fo
lic
acid
(5 m
g/da
y) d
ue to
an
incr
ease
d ris
k of
ne
ural
tube
def
ects
.
Med
ical
:•
Neo
nata
l car
e –
vita
min
K in
ject
ion.
• Ca
rbam
azep
ine
is c
onsi
dere
d to
be
the
leas
t
tera
toge
nic
of th
e ol
der a
ntie
pile
ptic
age
nts.
• So
dium
val
proa
te h
as th
e st
rong
est
a
ssoc
iatio
n w
ith n
eura
l tub
e de
fect
s.
Sign
s an
d sy
mpt
oms
Thes
e de
pend
on
the
regi
on o
f the
bra
inaf
fect
ed.
• F
ront
al lo
be: J
AM
:
J –
Jack
soni
an m
arch
.
A –
pA
lsy
(pos
t-ic
tal T
odd’
s pa
lsy)
.
M –
Mot
or fe
atur
es.
• T
empo
ral l
obe:
AD
D F
AT:
A
– A
ura
that
the
epile
ptic
att
ack
will
occ
ur.
D
– D
éjà
vu.
D
– D
elus
iona
l beh
avio
ur.
F
– F
ear/p
anic
– h
ippo
cam
pal i
nvol
vem
ent.
A
– A
utom
atis
ms.
T
– Ta
ste/
smel
l – u
ncal
invo
lvem
ent.
• P
arie
tal a
nd o
ccip
ital
lobe
s:
Visu
al a
nd s
enso
ry d
istu
rban
ces
Oth
ers
incl
ude:
par
tial o
r gen
eral
ized
seiz
ures
with
or w
ithou
t con
vuls
ions
, to
ngue
biti
ng, m
igra
ines
and
dep
ress
ion.
MAP
2.3
. Epi
leps
y in
pre
gnan
cy
43O
bste
tric
sM
ap 2
.3.
Epile
psy
in p
reg
nan
cy
K30033_C002.indd 43 28/02/17 11:15 am
44O
bste
tric
sM
ap 2
.4.
Pre-
ecla
mp
sia
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, U
&E,
LFT
s, gl
ucos
e
(par
ticul
arly
scr
eeni
ng fo
r HEL
LP
synd
rom
e), u
ric a
cid
leve
l.•
Mea
sure
blo
od p
ress
ure:
>14
0/90
mm
Hg.
• U
rinal
ysis
: pro
tein
uria
.•
Neu
rolo
gy e
xam
inat
ion:
hyp
erre
flexi
a, c
lonu
s.•
Fund
osco
py: p
apill
oede
ma.
Sym
ptom
s•
May
be
asym
ptom
atic
.•
Head
ache
.•
Visu
al d
istu
rban
ce.
• Ab
dom
inal
pai
n (ty
pica
lly ri
ght u
pper
q
uadr
ant o
r epi
gast
ric re
gion
).•
Nau
sea
and
vom
iting
.
Wha
t is
pre
-ecl
amps
ia?
This
is a
mul
tisys
tem
ic d
isor
der c
hara
cter
ized
by
four
fact
ors:
1. H
yper
tens
ion
>14
0/90
mm
Hg.
2. O
ccur
s af
ter 2
0 w
eeks
ges
tatio
n.3.
Pro
tein
uria
>0.
3 g/
24 h
ours
.4.
Nor
mal
izes
afte
r del
iver
y of
fetu
s.
Caus
esIt
is a
pla
cent
al d
isea
se b
ut th
e ex
act
path
ogen
esis
is in
com
plet
ely
unde
rsto
od.
Pre-
ecla
mps
ia is
, how
ever
, ass
ocia
ted
with
num
erou
s ris
k fa
ctor
s su
ch a
s:•
Extr
emes
in a
ge: <
20 o
r >40
yea
rs.
• N
ullip
arity
.•
Mul
tiple
pre
gnan
cy.
• N
ew p
artn
er.
• Pa
st h
isto
ry o
f pre
-ecl
amps
ia.
• Hi
gh m
ater
nal B
MI.
• Pr
evio
us h
yper
tens
ion.
• Pr
evio
us re
nal d
isea
se.
• Pr
evio
us D
M.
• In
terv
al b
etw
een
preg
nanc
ies
>10
yea
rs.
Trea
tmen
tDe
liver
y is
the
defin
itive
trea
tmen
t of
pre-
ecla
mps
ia b
ut o
ther
opt
ions
are
em
ploy
edw
hile
the
fetu
s de
velo
ps. F
ollo
wN
ICE/
cons
ensu
s gu
idel
ines
.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Re
gula
r blo
od p
ress
ure
mon
itorin
g.
Med
ical
:•
Labe
talo
l is
used
firs
t lin
e.•
Oth
er a
gent
s in
clud
e ni
fedi
pine
and
h
ydra
lazi
ne.
• M
agne
sium
sul
phat
e is
als
o us
ed fo
r sei
zure
pr
even
tion.
Com
plic
atio
ns
Feta
l:•
Intr
aute
rine
grow
th re
stric
tion.
• Pr
emat
ure
deliv
ery.
Mat
erna
l:•
Ecla
mps
ia.
• HE
LLP
synd
rom
e.•
Cere
bral
hae
mor
rhag
e.•
Intr
a-ab
dom
inal
hae
mor
rhag
e.
MAP
2.4
. Pre
-ecl
amps
ia
K30033_C002.indd 44 28/02/17 11:16 am
45O
bste
tric
sM
ap 2
.4.
Pre-
ecla
mp
sia
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, U
&E,
LFT
s, gl
ucos
e
(par
ticul
arly
scr
eeni
ng fo
r HEL
LP
synd
rom
e), u
ric a
cid
leve
l.•
Mea
sure
blo
od p
ress
ure:
>14
0/90
mm
Hg.
• U
rinal
ysis
: pro
tein
uria
.•
Neu
rolo
gy e
xam
inat
ion:
hyp
erre
flexi
a, c
lonu
s.•
Fund
osco
py: p
apill
oede
ma.
Sym
ptom
s•
May
be
asym
ptom
atic
.•
Head
ache
.•
Visu
al d
istu
rban
ce.
• Ab
dom
inal
pai
n (ty
pica
lly ri
ght u
pper
q
uadr
ant o
r epi
gast
ric re
gion
).•
Nau
sea
and
vom
iting
.
Wha
t is
pre
-ecl
amps
ia?
This
is a
mul
tisys
tem
ic d
isor
der c
hara
cter
ized
by
four
fact
ors:
1. H
yper
tens
ion
>14
0/90
mm
Hg.
2. O
ccur
s af
ter 2
0 w
eeks
ges
tatio
n.3.
Pro
tein
uria
>0.
3 g/
24 h
ours
.4.
Nor
mal
izes
afte
r del
iver
y of
fetu
s.
Caus
esIt
is a
pla
cent
al d
isea
se b
ut th
e ex
act
path
ogen
esis
is in
com
plet
ely
unde
rsto
od.
Pre-
ecla
mps
ia is
, how
ever
, ass
ocia
ted
with
num
erou
s ris
k fa
ctor
s su
ch a
s:•
Extr
emes
in a
ge: <
20 o
r >40
yea
rs.
• N
ullip
arity
.•
Mul
tiple
pre
gnan
cy.
• N
ew p
artn
er.
• Pa
st h
isto
ry o
f pre
-ecl
amps
ia.
• Hi
gh m
ater
nal B
MI.
• Pr
evio
us h
yper
tens
ion.
• Pr
evio
us re
nal d
isea
se.
• Pr
evio
us D
M.
• In
terv
al b
etw
een
preg
nanc
ies
>10
yea
rs.
Trea
tmen
tDe
liver
y is
the
defin
itive
trea
tmen
t of
pre-
ecla
mps
ia b
ut o
ther
opt
ions
are
em
ploy
edw
hile
the
fetu
s de
velo
ps. F
ollo
wN
ICE/
cons
ensu
s gu
idel
ines
.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Re
gula
r blo
od p
ress
ure
mon
itorin
g.
Med
ical
:•
Labe
talo
l is
used
firs
t lin
e.•
Oth
er a
gent
s in
clud
e ni
fedi
pine
and
h
ydra
lazi
ne.
• M
agne
sium
sul
phat
e is
als
o us
ed fo
r sei
zure
pr
even
tion.
Com
plic
atio
ns
Feta
l:•
Intr
aute
rine
grow
th re
stric
tion.
• Pr
emat
ure
deliv
ery.
Mat
erna
l:•
Ecla
mps
ia.
• HE
LLP
synd
rom
e.•
Cere
bral
hae
mor
rhag
e.•
Intr
a-ab
dom
inal
hae
mor
rhag
e.
MAP
2.4
. Pre
-ecl
amps
ia
K30033_C002.indd 45 28/02/17 11:16 am
46O
bste
tric
sM
ap 2
.5.
Live
r d
isea
se u
niq
ue
to p
reg
nan
cy
Hyp
erem
esis
gra
vida
rum
Wha
t is
hyp
erem
esis
gra
vida
rum
?Th
is is
a c
ompl
icat
ion
of p
regn
ancy
, whi
ch b
egin
s du
ring
the
first
trim
este
r and
usu
ally
reso
lves
by
wee
k 20
. A tr
iad
char
acte
rizes
the
cond
ition
:1.
Nau
sea
and
vom
iting
.2.
Wei
ght l
oss
(5%
or m
ore
of p
re-p
regn
ancy
bod
y w
eigh
t).3.
Deh
ydra
tion.
Caus
esTh
e ex
act c
ause
is u
nkno
wn.
Sym
ptom
s•
Nau
sea
and
vom
iting
.•
Wei
ght l
oss
(5%
or m
ore
of p
re-p
regn
ancy
bod
y w
eigh
t).•
Dehy
drat
ion
– re
sulti
ng in
ket
osis
and
con
stip
atio
n.•
Met
abol
ic im
bala
nce
– ke
tosi
s an
d th
yrot
oxic
osis.
• Hy
pero
lfact
ion.
• Pt
yalis
m.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, U
&E,
BU
N, T
FTs
(TSH
low
), LF
Ts =
AST
,
ALT
<1,
000
IU/L
, ALT
>AS
T, vi
tam
in B
leve
ls.•
Urin
alys
is.•
USS
– m
onito
r ges
tatio
n an
d ex
clud
e m
olar
pre
gnan
cy
(see
Map
3.3
, p. 7
6).
Trea
tmen
t
Med
ical
:•
IV fl
uid
resu
scita
tion.
• An
tiem
etic
s –
pyrid
oxin
e, p
rom
etha
zine
.•
Nut
ritio
nal s
uppo
rt –
thia
min
e.
Com
plic
atio
ns
Mot
her:
• W
eigh
t los
s.•
Com
plic
atio
ns o
f vom
iting
(e.g
. oes
opha
geal
rupt
ure,
re
nal d
amag
e, v
ascu
lar d
eple
tion,
Wer
nick
e’s
en
ceph
alop
athy
).
Fetu
s:•
Prem
atur
ity.
• Lo
w b
irth
wei
ght.
Intr
ahep
atic
cho
lest
asis
of p
regn
ancy
Wha
t is
intr
a-he
pati
c ch
oles
tasi
s of
pre
gnan
cy?
This
is a
reve
rsib
le h
orm
onal
ly in
fluen
ced
chol
esta
sis,
whi
chty
pica
lly p
rese
nts
durin
g th
e se
cond
trim
este
r and
con
tinue
sin
to th
e th
ird tr
imes
ter.
Caus
esTh
e ex
act c
ause
is u
nkno
wn.
Stu
dies
hav
e su
gges
ted
that
this
cond
ition
is li
nked
to in
crea
sed
horm
one
leve
ls. In
crea
sed
risk
with
mul
tiple
pre
gnan
cies
. Thi
s co
nditi
on o
ften
recu
rs in
subs
eque
nt p
regn
anci
es.
Sym
ptom
s•
Prur
itus,
typi
cally
com
men
cing
on
the
palm
s of
the
hand
s
and
sole
s of
the
feet
. Itc
hing
then
spr
eads
to th
e fa
ce a
nd
trun
k. W
orse
at n
ight
. No
rash
pre
sent
.•
Jaun
dice
.•
Stea
torr
hoea
.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, U
&E,
BU
N, L
FTs
= A
ST, A
LT <
1,00
0 IU
/L,
G
GT
norm
al, b
ile a
cid
leve
ls (h
igh)
, pro
thro
mbi
n
(nor
mal
), bi
lirub
in <
6 m
g/dL
.•
Urin
alys
is.•
USS
– m
onito
r ges
tatio
n.
Trea
tmen
t•
Med
ical
: urs
odeo
xych
olic
aci
d, a
ntih
ista
min
es.
• De
liver
y of
fetu
s (u
sual
ly a
t 37
wee
ks o
r whe
n fe
tal
di
stre
ss is
imm
inen
t).
Com
plic
atio
ns
Mot
her:
• Se
vere
pru
ritus
– in
terfe
res
with
sle
ep.
• De
rang
ed c
lott
ing
– du
e to
dec
reas
ed v
itam
in K
leve
ls.
Fetu
s:•
Feta
l dis
tres
s.•
Still
birt
h.•
Mec
oniu
m in
gest
ion/
aspi
ratio
n.
MAP
2.5
. Liv
er d
isea
se u
niqu
e to
preg
nanc
y
K30033_C002.indd 46 28/02/17 11:16 am
47O
bste
tric
sM
ap 2
.5.
Live
r d
isea
se u
niq
ue
to p
reg
nan
cy
Hyp
erem
esis
gra
vida
rum
Wha
t is
hyp
erem
esis
gra
vida
rum
?Th
is is
a c
ompl
icat
ion
of p
regn
ancy
, whi
ch b
egin
s du
ring
the
first
trim
este
r and
usu
ally
reso
lves
by
wee
k 20
. A tr
iad
char
acte
rizes
the
cond
ition
:1.
Nau
sea
and
vom
iting
.2.
Wei
ght l
oss
(5%
or m
ore
of p
re-p
regn
ancy
bod
y w
eigh
t).3.
Deh
ydra
tion.
Caus
esTh
e ex
act c
ause
is u
nkno
wn.
Sym
ptom
s•
Nau
sea
and
vom
iting
.•
Wei
ght l
oss
(5%
or m
ore
of p
re-p
regn
ancy
bod
y w
eigh
t).•
Dehy
drat
ion
– re
sulti
ng in
ket
osis
and
con
stip
atio
n.•
Met
abol
ic im
bala
nce
– ke
tosi
s an
d th
yrot
oxic
osis.
• Hy
pero
lfact
ion.
• Pt
yalis
m.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, U
&E,
BU
N, T
FTs
(TSH
low
), LF
Ts =
AST
,
ALT
<1,
000
IU/L
, ALT
>AS
T, vi
tam
in B
leve
ls.•
Urin
alys
is.•
USS
– m
onito
r ges
tatio
n an
d ex
clud
e m
olar
pre
gnan
cy
(see
Map
3.3
, p. 7
6).
Trea
tmen
t
Med
ical
:•
IV fl
uid
resu
scita
tion.
• An
tiem
etic
s –
pyrid
oxin
e, p
rom
etha
zine
.•
Nut
ritio
nal s
uppo
rt –
thia
min
e.
Com
plic
atio
ns
Mot
her:
• W
eigh
t los
s.•
Com
plic
atio
ns o
f vom
iting
(e.g
. oes
opha
geal
rupt
ure,
re
nal d
amag
e, v
ascu
lar d
eple
tion,
Wer
nick
e’s
en
ceph
alop
athy
).
Fetu
s:•
Prem
atur
ity.
• Lo
w b
irth
wei
ght.
Intr
ahep
atic
cho
lest
asis
of p
regn
ancy
Wha
t is
intr
a-he
pati
c ch
oles
tasi
s of
pre
gnan
cy?
This
is a
reve
rsib
le h
orm
onal
ly in
fluen
ced
chol
esta
sis,
whi
chty
pica
lly p
rese
nts
durin
g th
e se
cond
trim
este
r and
con
tinue
sin
to th
e th
ird tr
imes
ter.
Caus
esTh
e ex
act c
ause
is u
nkno
wn.
Stu
dies
hav
e su
gges
ted
that
this
cond
ition
is li
nked
to in
crea
sed
horm
one
leve
ls. In
crea
sed
risk
with
mul
tiple
pre
gnan
cies
. Thi
s co
nditi
on o
ften
recu
rs in
subs
eque
nt p
regn
anci
es.
Sym
ptom
s•
Prur
itus,
typi
cally
com
men
cing
on
the
palm
s of
the
hand
s
and
sole
s of
the
feet
. Itc
hing
then
spr
eads
to th
e fa
ce a
nd
trun
k. W
orse
at n
ight
. No
rash
pre
sent
.•
Jaun
dice
.•
Stea
torr
hoea
.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, U
&E,
BU
N, L
FTs
= A
ST, A
LT <
1,00
0 IU
/L,
G
GT
norm
al, b
ile a
cid
leve
ls (h
igh)
, pro
thro
mbi
n
(nor
mal
), bi
lirub
in <
6 m
g/dL
.•
Urin
alys
is.•
USS
– m
onito
r ges
tatio
n.
Trea
tmen
t•
Med
ical
: urs
odeo
xych
olic
aci
d, a
ntih
ista
min
es.
• De
liver
y of
fetu
s (u
sual
ly a
t 37
wee
ks o
r whe
n fe
tal
di
stre
ss is
imm
inen
t).
Com
plic
atio
ns
Mot
her:
• Se
vere
pru
ritus
– in
terfe
res
with
sle
ep.
• De
rang
ed c
lott
ing
– du
e to
dec
reas
ed v
itam
in K
leve
ls.
Fetu
s:•
Feta
l dis
tres
s.•
Still
birt
h.•
Mec
oniu
m in
gest
ion/
aspi
ratio
n.
MAP
2.5
. Liv
er d
isea
se u
niqu
e to
preg
nanc
y
K30033_C002.indd 47 28/02/17 11:16 am
48O
bste
tric
sM
ap 2
.5.
Live
r d
isea
se u
niq
ue
to p
reg
nan
cy
Acu
te fa
tty
liver
of p
regn
ancy
Wha
t is
acu
te fa
tty
liver
of p
regn
ancy
?Th
is is
a s
erio
us c
ompl
icat
ion
of p
regn
ancy
that
typi
cally
occ
urs
in th
e th
ird tr
imes
ter.
It is
cha
ract
eriz
ed b
y m
icro
vesi
cula
r st
eato
sis
(var
iant
form
of h
epat
ic fa
t acc
umul
atio
n) in
the
liver
. Ass
ocia
ted
with
ecl
amps
ia.
Caus
esTh
e ex
act c
ause
is u
nkno
wn.
Incr
ease
d ris
k in
wom
en w
ho h
ave
a he
tero
zygo
us lo
ng-c
hain
3-h
ydro
xyac
ylco
enzy
me
A de
hydr
ogen
ase
(LCH
AD) d
efic
ienc
y. Th
is c
ondi
tion
is th
ough
t to
be d
ue to
mito
chon
dria
l dys
func
tion.
Dys
func
tion
of th
e m
itoch
ondr
ia re
sults
in th
e dy
sfun
ctio
n of
fatt
y ac
id o
xida
tion
and,
as
such
, an
accu
mul
atio
n of
fat w
ithin
the
hepa
tocy
tes.
Exce
ss fa
t inf
iltra
tion
resu
lts in
acu
te h
epat
ic in
suffi
cien
cy.
Sym
ptom
s•
Non
-spe
cific
– le
thar
gy, n
ause
a an
d vo
miti
ng.
• Hy
pert
ensi
on.
• Ab
dom
inal
pai
n –
epig
astr
ic, R
UQ.
• Sy
mpt
oms
asso
ciat
ed w
ith: u
pper
gas
troi
ntes
tinal
hae
mor
rhag
e, a
cute
kid
ney
inju
ry, p
ancr
eatit
is, h
ypog
lyca
emia
, ful
min
ant
he
patic
failu
re.
• En
ceph
alop
athy
– a
ltere
d m
enta
l sta
tus
and
conf
usio
n.•
Jaun
dice
.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, p
late
lets
<10
0,00
0 m
m3 , f
ibrin
ogen
leve
l (lo
w),
antit
hrom
bin
III, U
&E,
BU
N, L
FTs
= A
ST,
AL
T >
300
IU/L
, pro
thro
mbi
n (in
crea
sed)
, bili
rubi
n (in
crea
sed)
, DIC
, glu
cose
leve
ls (d
ecre
ased
).•
Urin
alys
is.•
Mat
erna
l USS
– li
ver (
incr
ease
d ec
hoge
nici
ty).
• Fe
tal U
SS –
mon
itor g
esta
tion.
Trea
tmen
t
Med
ical
:•
Resu
scita
tion
– IV
flui
ds, I
V gl
ucos
e, fr
esh
froze
n pl
asm
a, c
ryop
reci
pita
te.
• De
liver
y of
fetu
s.
Surg
ical
:•
Live
r tra
nspl
ant m
ay b
e re
quire
d fo
r mot
hers
with
sev
ere
liver
failu
re, e
ncep
halo
path
y or
sev
ere
DIC.
Com
plic
atio
ns
Mot
her:
• Fu
lmin
ant h
epat
ic fa
ilure
.•
DIC.
• En
ceph
alop
athy
.•
Deat
h <
20%
.
Fetu
s:•
Feta
l mor
talit
y ~
45%
.
MAP
2.5
. Liv
er d
isea
se u
niqu
e to
pre
gnan
cy (c
ontin
ued
).
K30033_C002.indd 48 28/02/17 11:16 am
49O
bste
tric
sM
ap 2
.5.
Live
r d
isea
se u
niq
ue
to p
reg
nan
cy
Acu
te fa
tty
liver
of p
regn
ancy
Wha
t is
acu
te fa
tty
liver
of p
regn
ancy
?Th
is is
a s
erio
us c
ompl
icat
ion
of p
regn
ancy
that
typi
cally
occ
urs
in th
e th
ird tr
imes
ter.
It is
cha
ract
eriz
ed b
y m
icro
vesi
cula
r st
eato
sis
(var
iant
form
of h
epat
ic fa
t acc
umul
atio
n) in
the
liver
. Ass
ocia
ted
with
ecl
amps
ia.
Caus
esTh
e ex
act c
ause
is u
nkno
wn.
Incr
ease
d ris
k in
wom
en w
ho h
ave
a he
tero
zygo
us lo
ng-c
hain
3-h
ydro
xyac
ylco
enzy
me
A de
hydr
ogen
ase
(LCH
AD) d
efic
ienc
y. Th
is c
ondi
tion
is th
ough
t to
be d
ue to
mito
chon
dria
l dys
func
tion.
Dys
func
tion
of th
e m
itoch
ondr
ia re
sults
in th
e dy
sfun
ctio
n of
fatt
y ac
id o
xida
tion
and,
as
such
, an
accu
mul
atio
n of
fat w
ithin
the
hepa
tocy
tes.
Exce
ss fa
t inf
iltra
tion
resu
lts in
acu
te h
epat
ic in
suffi
cien
cy.
Sym
ptom
s•
Non
-spe
cific
– le
thar
gy, n
ause
a an
d vo
miti
ng.
• Hy
pert
ensi
on.
• Ab
dom
inal
pai
n –
epig
astr
ic, R
UQ.
• Sy
mpt
oms
asso
ciat
ed w
ith: u
pper
gas
troi
ntes
tinal
hae
mor
rhag
e, a
cute
kid
ney
inju
ry, p
ancr
eatit
is, h
ypog
lyca
emia
, ful
min
ant
he
patic
failu
re.
• En
ceph
alop
athy
– a
ltere
d m
enta
l sta
tus
and
conf
usio
n.•
Jaun
dice
.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s us
ing
CTG.
• Bl
oods
– F
BC, p
late
lets
<10
0,00
0 m
m3 , f
ibrin
ogen
leve
l (lo
w),
antit
hrom
bin
III, U
&E,
BU
N, L
FTs
= A
ST,
AL
T >
300
IU/L
, pro
thro
mbi
n (in
crea
sed)
, bili
rubi
n (in
crea
sed)
, DIC
, glu
cose
leve
ls (d
ecre
ased
).•
Urin
alys
is.•
Mat
erna
l USS
– li
ver (
incr
ease
d ec
hoge
nici
ty).
• Fe
tal U
SS –
mon
itor g
esta
tion.
Trea
tmen
t
Med
ical
:•
Resu
scita
tion
– IV
flui
ds, I
V gl
ucos
e, fr
esh
froze
n pl
asm
a, c
ryop
reci
pita
te.
• De
liver
y of
fetu
s.
Surg
ical
:•
Live
r tra
nspl
ant m
ay b
e re
quire
d fo
r mot
hers
with
sev
ere
liver
failu
re, e
ncep
halo
path
y or
sev
ere
DIC.
Com
plic
atio
ns
Mot
her:
• Fu
lmin
ant h
epat
ic fa
ilure
.•
DIC.
• En
ceph
alop
athy
.•
Deat
h <
20%
.
Fetu
s:•
Feta
l mor
talit
y ~
45%
.
MAP
2.5
. Liv
er d
isea
se u
niqu
e to
pre
gnan
cy (c
ontin
ued
).
K30033_C002.indd 49 28/02/17 11:16 am
50O
bste
tric
sM
ap 2
.6.
TOR
CH
ES in
fect
ion
s
Syph
ilis
(See
Map
2.8
, p. 5
2)TO
– T
Oxo
plas
mos
isR
– R
ubel
laC
– C
MV
HE
– H
Erpe
s an
d H
IVS
– S
yphi
lis
Her
pes
sim
plex
vir
us (H
SV)
(See
Map
2.1
1, p
. 56)
Hum
an im
mun
odef
icie
ncy
viru
s (H
IV)
(See
Map
2.1
0, p
. 55)
Toxo
plas
mos
is(S
ee M
ap 2
.7, p
. 51)
Cyto
meg
alov
irus
(CM
V)(S
ee M
ap 2
.9, p
. 54)
Rube
lla(S
ee M
ap 2
.12,
p. 5
8)
MAP
2.6
. TO
RCH
ES in
fect
ions
K30033_C002.indd 50 28/02/17 11:16 am
51O
bste
tric
s
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vise
pre
gnan
t wom
en to
avo
id c
ats/
clea
ring
litte
r tra
ys.
• Do
not
allo
w p
et c
at to
sle
ep in
sam
e be
d.•
High
light
han
d hy
gien
e, e
spec
ially
if h
andl
ing
raw
mea
t.
Med
ical
:•
Feta
l:
Py
rimet
ham
ine.
Sulp
hona
mid
e.•
Mat
erna
l:
Sp
iram
ycin
.
Wha
t is
tox
opla
smos
is?
This
is a
n in
fect
ion
caus
ed b
yTo
xopl
asm
a go
ndii,
a p
roto
zoan
. Inf
ectio
n is
mor
e co
mm
on in
imm
unos
uppr
esse
d in
divi
dual
s(e
.g. H
IV, c
ance
r suf
fere
rs).
Tran
smis
sion
:•
Infe
cted
mea
t.•
Cat f
aece
s.
Sym
ptom
s•
Ofte
n as
ympt
omat
ic.
• Fl
u-lik
e sy
mpt
oms
– fa
tigue
, sor
e
thro
at, h
eada
che,
feve
r,
lym
phad
enop
athy
.
Inve
stig
atio
ns•
Bloo
d te
st: m
ater
nal
im
mun
oglo
bulin
M.
• Ra
diol
ogy:
ultr
asou
nd
scan
for f
etal
hyd
roce
phal
us.
• Am
nioc
ente
sis.
• Pe
rform
add
ition
al te
sts
(e
.g. f
or H
IV c
o-in
fect
ion
if
clin
ical
ly re
leva
nt).
Com
plic
atio
ns
Feta
l: Re
mem
ber a
s th
e 3C
s:
C
– C
ereb
ral m
anife
stat
ions
(e.g
. hyd
roce
phal
us, m
icro
ceph
aly)
.
C
– C
onvu
lsio
ns.
C –
Cho
riore
tiniti
s.M
ater
nal:
Rem
embe
r as
ABC
DE:
A
– A
bsce
ss fo
rmat
ion
(cer
ebra
l)
B –
Blu
rred
vis
ion
C
– C
onfu
sion
D
– D
iffic
ulty
bre
athi
ng (p
neum
oniti
s)
E –
Enc
epha
lom
yelit
is
MAP
2.7
. Tox
opla
smos
is
Map
2.7
. To
xop
lasm
osi
s
K30033_C002.indd 51 28/02/17 11:16 am
52O
bste
tric
sM
ap 2
.8.
Ru
bel
la
Sym
ptom
s•
Arth
ralg
ia.
• So
re th
roat
.•
Feve
r.•
Mac
ular
rash
– in
itial
ly o
n fa
ce b
ut s
prea
ds to
tors
o an
d th
en le
gs. D
urat
ion
abou
t 3 d
ays.
• O
ccip
ital l
ymph
aden
opat
hy; t
his
may
be
pa
infu
l and
cau
se d
isco
mfo
rt.
Com
plic
atio
ns
Feta
l:•
Cong
enita
l rub
ella
syn
drom
e - r
emem
ber a
s
ABC
DE:
A
– A
sm
all h
ead
(mic
roce
phal
y) a
nd lo
w b
irth
wei
ght
B
– Bl
uebe
rry
muf
fin ra
sh (e
xtra
med
ulla
ry
ha
emat
opoi
esis
)
C –
Cong
enita
l hea
rt m
alfo
rmat
ions
(PDA
, PAS
)
D –
Dea
fnes
s (s
enso
rineu
ral)
E
– Ey
e ab
norm
aliti
es (c
atar
acts
)
Mat
erna
l: as
in S
ympt
oms
box.
Trea
tmen
tTh
ere
is n
o sp
ecifi
c tr
eatm
ent f
or ru
bella
.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vise
pre
gnan
t wom
en to
avo
id k
now
n
con
tact
s w
ith ru
bella
(e.g
. kno
wn
case
s at
w
ork)
.
Med
ical
:•
Mat
erna
l:
M
MR
vacc
ine.
Wha
t is
rub
ella
?Th
is is
a s
ingl
e st
rand
ed R
NA
viru
s. It
is a
lso
know
n as
Ger
man
mea
sles
. Gre
ates
t ris
k of
in
fect
ion
and
com
plic
atio
ns is
dur
ing
the
first
few
wee
ks o
f pre
gnan
cy.
Tran
smis
sion
:•
Airb
orne
infe
ctio
n pa
ssed
thro
ugh
re
spira
tory
dro
plet
s.
Inve
stig
atio
ns•
Bloo
d te
st: m
ater
nal a
ntib
odie
s.•
Urin
alys
is: f
or v
irus
in n
eona
te.
MAP
2.8
. Rub
ella
K30033_C002.indd 52 28/02/17 11:16 am
53O
bste
tric
sM
ap 2
.8.
Ru
bel
la
Sym
ptom
s•
Arth
ralg
ia.
• So
re th
roat
.•
Feve
r.•
Mac
ular
rash
– in
itial
ly o
n fa
ce b
ut s
prea
ds to
tors
o an
d th
en le
gs. D
urat
ion
abou
t 3 d
ays.
• O
ccip
ital l
ymph
aden
opat
hy; t
his
may
be
pa
infu
l and
cau
se d
isco
mfo
rt.
Com
plic
atio
ns
Feta
l:•
Cong
enita
l rub
ella
syn
drom
e - r
emem
ber a
s
ABC
DE:
A
– A
sm
all h
ead
(mic
roce
phal
y) a
nd lo
w b
irth
wei
ght
B
– Bl
uebe
rry
muf
fin ra
sh (e
xtra
med
ulla
ry
ha
emat
opoi
esis
)
C –
Cong
enita
l hea
rt m
alfo
rmat
ions
(PDA
, PAS
)
D –
Dea
fnes
s (s
enso
rineu
ral)
E
– Ey
e ab
norm
aliti
es (c
atar
acts
)
Mat
erna
l: as
in S
ympt
oms
box.
Trea
tmen
tTh
ere
is n
o sp
ecifi
c tr
eatm
ent f
or ru
bella
.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vise
pre
gnan
t wom
en to
avo
id k
now
n
con
tact
s w
ith ru
bella
(e.g
. kno
wn
case
s at
w
ork)
.
Med
ical
:•
Mat
erna
l:
M
MR
vacc
ine.
Wha
t is
rub
ella
?Th
is is
a s
ingl
e st
rand
ed R
NA
viru
s. It
is a
lso
know
n as
Ger
man
mea
sles
. Gre
ates
t ris
k of
in
fect
ion
and
com
plic
atio
ns is
dur
ing
the
first
few
wee
ks o
f pre
gnan
cy.
Tran
smis
sion
:•
Airb
orne
infe
ctio
n pa
ssed
thro
ugh
re
spira
tory
dro
plet
s.
Inve
stig
atio
ns•
Bloo
d te
st: m
ater
nal a
ntib
odie
s.•
Urin
alys
is: f
or v
irus
in n
eona
te.
MAP
2.8
. Rub
ella
K30033_C002.indd 53 28/02/17 11:16 am
54O
bste
tric
sM
ap 2
.9.
Cyt
om
egal
ovi
rus
(CM
V)
Wha
t is
CM
V?Th
is is
an
enve
lope
d vi
rus
belo
ngin
g to
the
Herp
esvi
ridae
fam
ily.
Tran
smis
sion
:•
Airb
orne
infe
ctio
n pa
ssed
thro
ugh
resp
irato
ry
dr
ople
ts.
• Vi
a m
ater
nal g
enito
urin
ary
trac
t.
Inve
stig
atio
ns•
Bloo
d te
st: m
ater
nal a
ntib
odie
s.•
Radi
olog
y: U
SS m
ay s
how
hyp
erec
hoge
nic
bow
el.
• Hy
pere
chog
enic
bow
el is
als
o fo
und
in c
ystic
fibr
osis
and
Dow
n’s
synd
rom
e.
Sym
ptom
s•
Gen
eral
ly a
sym
ptom
atic
.
MAP
2.9
. Cyt
omeg
alov
irus
(CM
V)
Com
plic
atio
nsFe
tal:
rem
embe
r as
ABC
DE:
A –
A s
mal
l hea
d m
icro
ceph
aly)
and
low
birt
h w
eigh
tB
– Bl
indn
ess
(occ
asio
nally
)C
– Ca
uses
neo
nata
l jau
ndic
eD
– D
eafn
ess
(hig
h ris
k)E
– En
larg
ed li
ver a
nd s
plee
n
Mat
erna
l: as
in S
ympt
oms
box.
Trea
tmen
tTh
ere
is n
o sp
ecifi
c tr
eatm
ent f
or C
MV.
Th
e m
edic
atio
ns u
sed
to tr
eat C
MV
ordi
naril
y ar
ete
rato
geni
c.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Mat
erna
l:
Co
nsid
er te
rmin
atio
n of
pre
gnan
cy.
K30033_C002.indd 54 28/02/17 11:16 am
55O
bste
tric
sM
ap 2
.10.
Her
pes
sim
ple
x vi
rus
(HSV
)
Wha
t is
HSV
?Th
is is
a v
irus
belo
ngin
g to
the
Herp
esvi
ridae
fam
ily. T
here
are
man
y di
ffere
nt ty
pes
of h
erpe
svi
rus,
but t
his
min
d m
ap fo
cuse
s on
HSV
-1 a
ndHS
V-2.
Tran
smis
sion
:•
Sexu
al c
onta
ct.
• M
ucou
s m
embr
ane
cont
act (
e.g.
sal
iva)
.
Inve
stig
atio
ns•
Vira
l sw
ab.
• Vi
ral P
CR.
Sym
ptom
s•
Tend
er b
liste
r(s) t
hat o
ccur
eith
er o
n
the
lip o
r in
the
geni
tal r
egio
n. T
hese
m
ay w
eep.
• Ly
mph
aden
opat
hy.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vise
on
deliv
ery
rout
e (i.
e. c
aesa
rean
se
ctio
n is
pre
fera
ble)
.
Med
ical
:•
Mat
erna
l: ac
iclo
vir.
• Fe
tal:
acic
lovi
r.
Com
plic
atio
ns
Feta
l: re
mem
ber a
s A
BCD
E:
A
– A
sm
all h
ead
(mic
roce
phal
y)
B
– Br
ain
path
olog
y (m
enin
gitis
)
C
– Ch
orio
retin
itis
D –
Dea
th
E
– En
ceph
aliti
s
Mat
erna
l: as
in S
ympt
oms
box.
MAP
2.1
0. H
erpe
s si
mpl
ex v
irus
(HSV
)
K30033_C002.indd 55 28/02/17 11:16 am
56O
bste
tric
sM
ap 2
.11.
Hu
man
imm
un
od
efici
ency
vir
us
(HIV
)
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
dvic
e, p
lann
ed c
aesa
rean
del
iver
y, in
fant
bot
tle fe
edin
g.
Med
ical
:•
High
ly a
ctiv
e an
tiret
rovi
ral t
hera
py (H
AART
):
N
ucle
osid
e re
vers
e tr
ansc
ripta
se in
hibi
tors
(NRT
Is) (
e.g.
zid
ovud
ine
[par
ticul
arly
to re
duce
vert
ical
tran
smis
sion
]). N
ote:
Zid
ovud
ine
is th
e on
ly a
gent
sho
wn
to d
ecre
ase
perin
atal
tran
smis
sion
.
N
on-n
ucle
osid
e re
vers
e tr
ansc
ripta
se in
hibi
tors
(NN
RTIs
) (e.
g. n
evira
pine
).
Pr
otea
se in
hibi
tors
(PIs
) (e.
g. a
taza
navi
r).•
Giv
e ei
ther
:
Tw
o N
RTIs
com
bine
d w
ith o
ne N
NRT
I; or
Two
NRT
Is c
ombi
ned
with
one
PI;
or
Tw
o N
RTIs
com
bine
d w
ith o
ne in
tegr
ase
inhi
bito
r (II;
e.g
. ral
tega
vir).
Spec
ial n
otes
:•
NRT
Is c
ross
the
plac
enta
, the
NN
RTIs
nev
irapi
ne a
nd e
favi
renz
cro
ss th
e pl
acen
ta, b
ut P
Is d
o no
t
cros
s th
e pl
acen
ta e
asily
.•
Zido
vudi
ne is
giv
en in
trav
enou
sly
durin
g la
bour
.•
Neo
nata
l car
e: in
fant
zid
ovud
ine,
initi
ated
as
soon
as
poss
ible
afte
r del
iver
y an
d co
ntin
ued
until
6
wee
ks.
• He
patit
is B
co-
infe
ctio
ns: t
enof
ovir
and
lam
ivud
ine
or e
mtr
icita
bine
.
Wha
t is
HIV
?Th
is is
an
RNA
retr
oviru
s of
the
Lent
iviru
s ge
nus.
Th
is v
irus
caus
es a
cqui
red
imm
unod
efic
ienc
y sy
ndro
me
(AID
S).
Caus
eTh
ere
are
two
type
s of
HIV
:•
HIV-
1:
G
roup
M, s
ubty
pes
A to
J: p
reva
lent
in
Euro
pe, N
orth
Am
eric
a, A
ustr
alia
and
sub-
Saha
ran
Afric
a.
G
roup
O: m
ainl
y in
Cam
eroo
n.•
HIV-
2:
Pr
edom
inan
tly c
onfin
ed to
Wes
t Afri
ca.
Tran
smis
sion
• U
npro
tect
ed s
exua
l int
erco
urse
.•
Shar
ed n
eedl
es (e
.g. d
rug
user
s).
• Co
ntam
inat
ed b
lood
tran
fusi
ons.
• Ve
rtic
al tr
ansm
issi
on –
mot
her t
o ch
ild. T
he
viru
s cr
osse
s th
e pl
acen
ta a
nd is
tran
smitt
ed
th
roug
h br
east
milk
.
Com
plic
atio
ns
Feta
l:•
IUG
R.•
Still
birt
h.
Mat
erna
l:•
Pre-
ecla
mps
ia.
• In
crea
sed
risk
of in
fect
ion:
Toxo
plas
mos
is.
CMV
retin
itis.
Pneu
moc
ystic
jiro
veci
i pne
umon
ia.
Kapo
si’s
sar
com
a.
Cr
ypto
cocc
al m
enin
gitis
.
M
ycob
acte
rium
avi
um c
ompl
ex.
MAP
2.1
1. H
uman
imm
unod
efic
ienc
y vi
rus
(HIV
)
Inve
stig
atio
ns•
Enzy
me-
linke
d im
mun
osor
bent
ass
ay (E
LISA
).•
Wes
tern
blo
t tes
t.•
Imm
unof
luor
esce
nce
assa
y (IF
A).
• N
ucle
ic a
cid
test
ing.
Gen
es r
equi
red
for
vira
l rep
licat
ion
PEG
:P
– po
l: en
code
s re
vers
e tr
ansc
ripta
se a
nd
inte
gras
eE
– en
v: e
ncod
es e
nvel
ope
prot
eins
(e.g
. gp1
20)
G –
gag
: enc
odes
vira
l str
uctu
ral p
rote
ins.
K30033_C002.indd 56 28/02/17 11:16 am
57O
bste
tric
sM
ap 2
.11.
Hu
man
imm
un
od
efici
ency
vir
us
(HIV
)
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
dvic
e, p
lann
ed c
aesa
rean
del
iver
y, in
fant
bot
tle fe
edin
g.
Med
ical
:•
High
ly a
ctiv
e an
tiret
rovi
ral t
hera
py (H
AART
):
N
ucle
osid
e re
vers
e tr
ansc
ripta
se in
hibi
tors
(NRT
Is) (
e.g.
zid
ovud
ine
[par
ticul
arly
to re
duce
vert
ical
tran
smis
sion
]). N
ote:
Zid
ovud
ine
is th
e on
ly a
gent
sho
wn
to d
ecre
ase
perin
atal
tran
smis
sion
.
N
on-n
ucle
osid
e re
vers
e tr
ansc
ripta
se in
hibi
tors
(NN
RTIs
) (e.
g. n
evira
pine
).
Pr
otea
se in
hibi
tors
(PIs
) (e.
g. a
taza
navi
r).•
Giv
e ei
ther
:
Tw
o N
RTIs
com
bine
d w
ith o
ne N
NRT
I; or
Two
NRT
Is c
ombi
ned
with
one
PI;
or
Tw
o N
RTIs
com
bine
d w
ith o
ne in
tegr
ase
inhi
bito
r (II;
e.g
. ral
tega
vir).
Spec
ial n
otes
:•
NRT
Is c
ross
the
plac
enta
, the
NN
RTIs
nev
irapi
ne a
nd e
favi
renz
cro
ss th
e pl
acen
ta, b
ut P
Is d
o no
t
cros
s th
e pl
acen
ta e
asily
.•
Zido
vudi
ne is
giv
en in
trav
enou
sly
durin
g la
bour
.•
Neo
nata
l car
e: in
fant
zid
ovud
ine,
initi
ated
as
soon
as
poss
ible
afte
r del
iver
y an
d co
ntin
ued
until
6
wee
ks.
• He
patit
is B
co-
infe
ctio
ns: t
enof
ovir
and
lam
ivud
ine
or e
mtr
icita
bine
.
Wha
t is
HIV
?Th
is is
an
RNA
retr
oviru
s of
the
Lent
iviru
s ge
nus.
Th
is v
irus
caus
es a
cqui
red
imm
unod
efic
ienc
y sy
ndro
me
(AID
S).
Caus
eTh
ere
are
two
type
s of
HIV
:•
HIV-
1:
G
roup
M, s
ubty
pes
A to
J: p
reva
lent
in
Euro
pe, N
orth
Am
eric
a, A
ustr
alia
and
sub-
Saha
ran
Afric
a.
G
roup
O: m
ainl
y in
Cam
eroo
n.•
HIV-
2:
Pr
edom
inan
tly c
onfin
ed to
Wes
t Afri
ca.
Tran
smis
sion
• U
npro
tect
ed s
exua
l int
erco
urse
.•
Shar
ed n
eedl
es (e
.g. d
rug
user
s).
• Co
ntam
inat
ed b
lood
tran
fusi
ons.
• Ve
rtic
al tr
ansm
issi
on –
mot
her t
o ch
ild. T
he
viru
s cr
osse
s th
e pl
acen
ta a
nd is
tran
smitt
ed
th
roug
h br
east
milk
.
Com
plic
atio
ns
Feta
l:•
IUG
R.•
Still
birt
h.
Mat
erna
l:•
Pre-
ecla
mps
ia.
• In
crea
sed
risk
of in
fect
ion:
Toxo
plas
mos
is.
CMV
retin
itis.
Pneu
moc
ystic
jiro
veci
i pne
umon
ia.
Kapo
si’s
sar
com
a.
Cr
ypto
cocc
al m
enin
gitis
.
M
ycob
acte
rium
avi
um c
ompl
ex.
MAP
2.1
1. H
uman
imm
unod
efic
ienc
y vi
rus
(HIV
)
Inve
stig
atio
ns•
Enzy
me-
linke
d im
mun
osor
bent
ass
ay (E
LISA
).•
Wes
tern
blo
t tes
t.•
Imm
unof
luor
esce
nce
assa
y (IF
A).
• N
ucle
ic a
cid
test
ing.
Gen
es r
equi
red
for
vira
l rep
licat
ion
PEG
:P
– po
l: en
code
s re
vers
e tr
ansc
ripta
se a
nd
inte
gras
eE
– en
v: e
ncod
es e
nvel
ope
prot
eins
(e.g
. gp1
20)
G –
gag
: enc
odes
vira
l str
uctu
ral p
rote
ins.
K30033_C002.indd 57 28/02/17 11:16 am
58O
bste
tric
sM
ap 2
.12.
Syp
hili
s
Wha
t is
syp
hilis
?Th
is is
a s
exua
lly tr
ansm
itted
dis
ease
cau
sed
by
the
spiro
chae
te T
repo
nem
a pa
llidu
m.
Tran
smis
sion
:•
Sexu
al c
onta
ct.
Sym
ptom
sIn
fect
ions
occ
urs
in th
ree
stag
es:
1. C
hanc
re –
pai
nles
s.2.
Dis
sem
inat
ed d
isea
se –
rash
on
palm
s
and
sol
es.
3. C
ardi
ac a
nd n
euro
logi
cal i
nvol
vem
ent.
Inve
stig
atio
ns•
Vene
real
Dis
ease
Res
earc
h La
bora
tory
(
VDRL
) tes
t.•
Rapi
d pl
asm
a re
agin
test
.•
Fluo
resc
ent t
repo
nem
al a
ntib
ody
abso
rptio
n
tes
t (FT
A-AB
S).
• Tr
epon
ema
palli
dum
hae
mag
glut
inat
ion
test
(
TPHA
).•
Trep
onem
a pa
llidu
m p
artic
le a
gglu
tinat
ion
t
est (
TPPA
).•
Trep
onem
al e
nzym
e im
mun
oass
ay (E
IA).
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vise
on
deliv
ery
rout
e (i.
e. c
aesa
rean
sec
tion
is p
refe
rabl
e)
Med
ical
: (m
any
antib
iotic
s lis
ted
belo
w a
re c
ontr
aind
icat
ed d
urin
g pr
egna
ncy.
Cons
ult l
ocal
gui
delin
es a
nd th
e BN
F). M
othe
r may
nee
d to
co
nsid
er te
rmin
atio
n of
pre
gnan
cy.
• M
ater
nal:
Pr
ocai
ne p
enic
illin
G.
Do
xycy
clin
e.
Eryt
hrom
ycin
.
Azith
rom
ycin
.N
ote:
If p
atie
nt h
as n
euro
syph
ilis,
give
pro
phyl
actic
pre
dnis
olon
e to
avoi
d th
e Ja
risch
–Her
xhei
mer
reac
tion.
Thi
s re
actio
n m
ay o
ccur
afte
ran
tibac
teria
l tre
atm
ent,
whi
ch c
ause
s th
e de
ath
of th
e sp
iroch
aete
and
su
bseq
uent
end
otox
in re
leas
e. E
ndot
oxin
s ca
use
the
Jaris
ch–H
erxh
eim
er
reac
tion.
• F
etal
:
Peni
cilli
n.
Com
plic
atio
ns
Feta
l: A
BCD
ES:
A
– A
sm
all h
ead
(mic
roce
phal
y)
B –
Bra
in p
atho
logy
(men
ingi
tis),
Bloo
d st
aine
d na
sal d
isch
arge
C
– C
horo
iditi
s
D –
Den
tal m
alfo
rmat
ions
, Dea
fnes
s (s
enso
rineu
ral)
E
– E
nlar
ged
liver
and
spl
een
S
– S
kin
lesi
ons,
Seiz
ures
Mat
erna
l: •
Mis
carr
iage
. •
Gum
ma
form
atio
n. •
Men
ingi
tis.
• S
trok
e. •
Hea
rt v
alve
dam
age.
MA
P 2.
12. S
yph
ilis
K30033_C002.indd 58 28/02/17 11:16 am
59O
bste
tric
sM
ap 2
.12.
Syp
hili
s
Wha
t is
syp
hilis
?Th
is is
a s
exua
lly tr
ansm
itted
dis
ease
cau
sed
by
the
spiro
chae
te T
repo
nem
a pa
llidu
m.
Tran
smis
sion
:•
Sexu
al c
onta
ct.
Sym
ptom
sIn
fect
ions
occ
urs
in th
ree
stag
es:
1. C
hanc
re –
pai
nles
s.2.
Dis
sem
inat
ed d
isea
se –
rash
on
palm
s
and
sol
es.
3. C
ardi
ac a
nd n
euro
logi
cal i
nvol
vem
ent.
Inve
stig
atio
ns•
Vene
real
Dis
ease
Res
earc
h La
bora
tory
(
VDRL
) tes
t.•
Rapi
d pl
asm
a re
agin
test
.•
Fluo
resc
ent t
repo
nem
al a
ntib
ody
abso
rptio
n
tes
t (FT
A-AB
S).
• Tr
epon
ema
palli
dum
hae
mag
glut
inat
ion
test
(
TPHA
).•
Trep
onem
a pa
llidu
m p
artic
le a
gglu
tinat
ion
t
est (
TPPA
).•
Trep
onem
al e
nzym
e im
mun
oass
ay (E
IA).
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vise
on
deliv
ery
rout
e (i.
e. c
aesa
rean
sec
tion
is p
refe
rabl
e)
Med
ical
: (m
any
antib
iotic
s lis
ted
belo
w a
re c
ontr
aind
icat
ed d
urin
g pr
egna
ncy.
Cons
ult l
ocal
gui
delin
es a
nd th
e BN
F). M
othe
r may
nee
d to
co
nsid
er te
rmin
atio
n of
pre
gnan
cy.
• M
ater
nal:
Pr
ocai
ne p
enic
illin
G.
Do
xycy
clin
e.
Eryt
hrom
ycin
.
Azith
rom
ycin
.N
ote:
If p
atie
nt h
as n
euro
syph
ilis,
give
pro
phyl
actic
pre
dnis
olon
e to
avoi
d th
e Ja
risch
–Her
xhei
mer
reac
tion.
Thi
s re
actio
n m
ay o
ccur
afte
ran
tibac
teria
l tre
atm
ent,
whi
ch c
ause
s th
e de
ath
of th
e sp
iroch
aete
and
su
bseq
uent
end
otox
in re
leas
e. E
ndot
oxin
s ca
use
the
Jaris
ch–H
erxh
eim
er
reac
tion.
• F
etal
:
Peni
cilli
n.
Com
plic
atio
ns
Feta
l: A
BCD
ES:
A
– A
sm
all h
ead
(mic
roce
phal
y)
B –
Bra
in p
atho
logy
(men
ingi
tis),
Bloo
d st
aine
d na
sal d
isch
arge
C
– C
horo
iditi
s
D –
Den
tal m
alfo
rmat
ions
, Dea
fnes
s (s
enso
rineu
ral)
E
– E
nlar
ged
liver
and
spl
een
S
– S
kin
lesi
ons,
Seiz
ures
Mat
erna
l: •
Mis
carr
iage
. •
Gum
ma
form
atio
n. •
Men
ingi
tis.
• S
trok
e. •
Hea
rt v
alve
dam
age.
MA
P 2.
12. S
yph
ilis
K30033_C002.indd 59 28/02/17 11:16 am
60O
bste
tric
sM
ap 2
.13.
Pla
cen
tal a
bru
pti
on
Wha
t is
pla
cent
al a
brup
tion
?Th
is is
a c
ause
of a
ntep
artu
m h
aem
orrh
age,
whi
chm
ay b
e de
fined
as
vagi
nal b
leed
ing
that
occ
urs
at <
24w
eeks
ges
tatio
n. T
he c
ause
s of
ant
epar
tum
haem
orrh
age
may
be
rem
embe
red
as P
VC2 :
P –
Plac
enta
l abr
uptio
nP
– Pl
acen
ta p
raev
iaV
– Va
sa p
raev
iaV
– Va
gina
l inf
ectio
nC
– Ca
ncer
of t
he c
ervi
xC
– Ce
rvic
itis
Caus
esPl
acen
tal a
brup
tion
occu
rs w
hen
the
plac
enta
sepa
rate
s fro
m th
e w
all o
f the
ute
rus.
It is
subc
lass
ified
as
eith
er a
con
ceal
ed o
r rev
eale
d (m
ore
com
mon
) abr
uptio
n.
Risk
fact
ors
Rem
embe
r as
OH
PIP
S:O
– O
verd
iste
nded
ute
rus
H –
Hyp
erte
nsio
n
P –
Pre-
ecla
mps
iaI –
Int
ra-u
terin
e gr
owth
rest
rictio
nP
– Pa
st h
isto
ry o
f pla
cent
al a
brup
tion
S –
Smok
ing
hist
ory
Sym
ptom
s•
Vagi
nal b
leed
ing.
• Se
vere
abd
omin
al p
ain
out o
f kee
ping
w
ith b
lood
loss
, cou
pled
with
sig
ns o
f
sys
tem
ic s
hock
may
indi
cate
con
ceal
ed
abr
uptio
n.•
Woo
den
uter
us o
n pa
lpat
ion.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s w
ith C
TG.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave.
• Ra
diol
ogy:
USS
for p
lace
nta
prae
via.
Trea
tmen
t
Med
ical
:•
Emer
genc
y tr
eatm
ent:
adm
issi
on, c
ross
-mat
ch
and
blo
od tr
ansf
usio
n.•
Cons
ider
del
iver
y de
pend
ing
on g
esta
tion.
If
the
fetu
s is
<34
wee
ks, g
ivin
g st
eroi
ds to
the
m
othe
r will
hel
p in
duce
feta
l lun
g
dev
elop
men
t.
Com
plic
atio
ns
Feta
l:•
Deat
h•
Intr
a-ut
erin
e gr
owth
rest
rictio
n
Mat
erna
l: DA
DS:
D –
Dea
th
A
– A
cute
kid
ney
inju
ry
D
– D
isse
min
ated
intr
avas
cula
r
coag
ulat
ion
and
mul
ti-or
gan
failu
re
S
– S
hock
MAP
2.1
3. P
lace
ntal
abru
ptio
n
K30033_C002.indd 60 28/02/17 11:16 am
61O
bste
tric
sM
ap 2
.13.
Pla
cen
tal a
bru
pti
on
Wha
t is
pla
cent
al a
brup
tion
?Th
is is
a c
ause
of a
ntep
artu
m h
aem
orrh
age,
whi
chm
ay b
e de
fined
as
vagi
nal b
leed
ing
that
occ
urs
at <
24w
eeks
ges
tatio
n. T
he c
ause
s of
ant
epar
tum
haem
orrh
age
may
be
rem
embe
red
as P
VC2 :
P –
Plac
enta
l abr
uptio
nP
– Pl
acen
ta p
raev
iaV
– Va
sa p
raev
iaV
– Va
gina
l inf
ectio
nC
– Ca
ncer
of t
he c
ervi
xC
– Ce
rvic
itis
Caus
esPl
acen
tal a
brup
tion
occu
rs w
hen
the
plac
enta
sepa
rate
s fro
m th
e w
all o
f the
ute
rus.
It is
subc
lass
ified
as
eith
er a
con
ceal
ed o
r rev
eale
d (m
ore
com
mon
) abr
uptio
n.
Risk
fact
ors
Rem
embe
r as
OH
PIP
S:O
– O
verd
iste
nded
ute
rus
H –
Hyp
erte
nsio
n
P –
Pre-
ecla
mps
iaI –
Int
ra-u
terin
e gr
owth
rest
rictio
nP
– Pa
st h
isto
ry o
f pla
cent
al a
brup
tion
S –
Smok
ing
hist
ory
Sym
ptom
s•
Vagi
nal b
leed
ing.
• Se
vere
abd
omin
al p
ain
out o
f kee
ping
w
ith b
lood
loss
, cou
pled
with
sig
ns o
f
sys
tem
ic s
hock
may
indi
cate
con
ceal
ed
abr
uptio
n.•
Woo
den
uter
us o
n pa
lpat
ion.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s w
ith C
TG.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave.
• Ra
diol
ogy:
USS
for p
lace
nta
prae
via.
Trea
tmen
t
Med
ical
:•
Emer
genc
y tr
eatm
ent:
adm
issi
on, c
ross
-mat
ch
and
blo
od tr
ansf
usio
n.•
Cons
ider
del
iver
y de
pend
ing
on g
esta
tion.
If
the
fetu
s is
<34
wee
ks, g
ivin
g st
eroi
ds to
the
m
othe
r will
hel
p in
duce
feta
l lun
g
dev
elop
men
t.
Com
plic
atio
ns
Feta
l:•
Deat
h•
Intr
a-ut
erin
e gr
owth
rest
rictio
n
Mat
erna
l: DA
DS:
D –
Dea
th
A
– A
cute
kid
ney
inju
ry
D
– D
isse
min
ated
intr
avas
cula
r
coag
ulat
ion
and
mul
ti-or
gan
failu
re
S
– S
hock
MAP
2.1
3. P
lace
ntal
abru
ptio
n
K30033_C002.indd 61 28/02/17 11:16 am
62O
bste
tric
sM
ap 2
.14.
Pla
cen
ta p
raev
ia
Wha
t is
pla
cent
a pr
aevi
a?Th
is is
a ‘l
ow ly
ing
plac
enta
’ and
a c
ause
of
ante
part
um h
aem
orrh
age,
whi
ch m
ay b
e de
fined
as
vagi
nal b
leed
ing
that
occ
urs
at <
24 w
eeks
ges
tatio
n.O
ther
cau
ses
of a
ntep
artu
m h
aem
orrh
age
are
liste
d in
Map
2.1
3, p
. 60.
Pl
acen
ta p
raev
ia m
ay b
e cl
assi
fied
as e
ither
min
or o
r maj
or. T
he m
ajor
form
com
plet
ely
cove
rsth
e in
tern
al o
s, w
here
as in
the
min
or fo
rm th
ein
tern
al o
s is
onl
y pa
rtia
lly c
over
ed.
Caus
esPl
acen
ta p
raev
ia is
cau
sed
by lo
w im
plan
tatio
n of
the
embr
yo.
Risk
fact
ors
Rem
embe
r as
MU
MS:
M –
Mat
erna
l age
U –
Ute
rine
abno
rmal
ityM
– M
ultip
arity
S –
Sec
tion
(cae
sare
an)
Sym
ptom
s•
Pain
less
vag
inal
ble
edin
g.•
Abno
rmal
feta
l lie
/failu
re o
f eng
agem
ent.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s w
ith C
TG.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave.
• Ra
diol
ogy:
abd
omin
al a
nd tr
ansv
agin
al U
SS.
Trea
tmen
t
Med
ical
:•
Emer
genc
y tr
eatm
ent:
adm
issi
on, c
ross
-mat
ch
and
blo
od tr
ansf
usio
n.
• Co
nsid
er e
lect
ive
caes
area
n se
ctio
n de
pend
ing
o
n ge
stat
ion.
If th
e fe
tus
is <
34 w
eeks
, giv
ing
s
tero
ids
to th
e m
othe
r will
hel
p in
duce
feta
l lun
g
dev
elop
men
t.
Com
plic
atio
ns
Feta
l:•
Deat
h•
Prem
atur
e de
liver
y.
Mat
erna
l: •
Mas
sive
hae
mor
rhag
e an
d de
ath.
• H
yste
rect
omy.
• H
igh
risk
of p
ost-
part
um h
aem
orrh
age.
MAP
2.1
4. P
lace
nta
prae
via
K30033_C002.indd 62 28/02/17 11:16 am
63O
bste
tric
sM
ap 2
.14.
Pla
cen
ta p
raev
ia
Wha
t is
pla
cent
a pr
aevi
a?Th
is is
a ‘l
ow ly
ing
plac
enta
’ and
a c
ause
of
ante
part
um h
aem
orrh
age,
whi
ch m
ay b
e de
fined
as
vagi
nal b
leed
ing
that
occ
urs
at <
24 w
eeks
ges
tatio
n.O
ther
cau
ses
of a
ntep
artu
m h
aem
orrh
age
are
liste
d in
Map
2.1
3, p
. 60.
Pl
acen
ta p
raev
ia m
ay b
e cl
assi
fied
as e
ither
min
or o
r maj
or. T
he m
ajor
form
com
plet
ely
cove
rsth
e in
tern
al o
s, w
here
as in
the
min
or fo
rm th
ein
tern
al o
s is
onl
y pa
rtia
lly c
over
ed.
Caus
esPl
acen
ta p
raev
ia is
cau
sed
by lo
w im
plan
tatio
n of
the
embr
yo.
Risk
fact
ors
Rem
embe
r as
MU
MS:
M –
Mat
erna
l age
U –
Ute
rine
abno
rmal
ityM
– M
ultip
arity
S –
Sec
tion
(cae
sare
an)
Sym
ptom
s•
Pain
less
vag
inal
ble
edin
g.•
Abno
rmal
feta
l lie
/failu
re o
f eng
agem
ent.
Inve
stig
atio
ns•
Mon
itor f
etal
dis
tres
s w
ith C
TG.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave.
• Ra
diol
ogy:
abd
omin
al a
nd tr
ansv
agin
al U
SS.
Trea
tmen
t
Med
ical
:•
Emer
genc
y tr
eatm
ent:
adm
issi
on, c
ross
-mat
ch
and
blo
od tr
ansf
usio
n.
• Co
nsid
er e
lect
ive
caes
area
n se
ctio
n de
pend
ing
o
n ge
stat
ion.
If th
e fe
tus
is <
34 w
eeks
, giv
ing
s
tero
ids
to th
e m
othe
r will
hel
p in
duce
feta
l lun
g
dev
elop
men
t.
Com
plic
atio
ns
Feta
l:•
Deat
h•
Prem
atur
e de
liver
y.
Mat
erna
l: •
Mas
sive
hae
mor
rhag
e an
d de
ath.
• H
yste
rect
omy.
• H
igh
risk
of p
ost-
part
um h
aem
orrh
age.
MAP
2.1
4. P
lace
nta
prae
via
K30033_C002.indd 63 28/02/17 11:16 am
64O
bste
tric
sM
ap 2
.15.
Po
st-p
artu
m h
aem
orr
hag
e (P
PH)
Wha
t is
PPH
?Th
is is
ble
edin
g th
at o
ccur
s af
ter d
eliv
ery
of th
e fe
tus.
It m
ay b
e de
fined
as
prim
ary,
seco
ndar
y or
m
assi
ve d
epen
ding
on
the
amou
nt o
f blo
od lo
st a
nd th
e tim
e th
at h
as e
laps
ed p
ost d
eliv
ery.
Caus
esPr
imar
y: re
mem
ber a
s th
e 5T
s:
T
– T o
ne o
f ute
rus
lost
(mos
t com
mon
cau
se)
T –
Trau
ma
(e.g
. to
perin
eum
or u
terin
e ru
ptur
e)
T
– To
rn c
ervi
x or
vag
ina
T –
Thro
mbi
n (i.
e. b
leed
ing
diso
rder
s)
T
– Ti
ssue
(i.e
. ret
aine
d pr
oduc
ts o
f con
cept
ion)
Seco
ndar
y:•
Infe
ctio
n –
endo
met
ritis.
• Re
tain
ed p
rodu
cts
of c
once
ptio
n.
Risk
fact
ors:
rem
embe
r as
ABC
D:
A
– A
ntep
artu
m h
aem
orrh
age
B
– B
irthi
ng p
robl
ems
(i.e.
inst
rum
enta
l del
iver
y, in
duce
d la
bour
)
C –
Coa
gula
tion
diso
rder
s (e
.g. v
on W
illeb
rand
dis
ease
)
D –
Dur
atio
n of
labo
ur >
12 h
ours
Type
of
PPH
Bloo
d lo
stTi
me
elap
sed
afte
r bi
rth
Prim
ary
>50
0 m
L<
24 h
ours
Seco
ndar
y>
500
mL
>24
hou
rs to
12
wee
ksM
assi
ve>
1,50
0 m
LN
/A
Sym
ptom
sDe
pend
s on
the
caus
e of
PPH
. All
may
pres
ent w
ith s
hock
:•
Aton
ic u
teru
s: ut
erus
is e
nlar
ged.
• U
terin
e ru
ptur
e: a
bdom
inal
pai
n, v
agin
al
b
lood
loss
.•
Infe
ctio
n: ta
chyc
ardi
a, fe
ver,
abdo
min
al
p
ain,
vag
inal
blo
od lo
ss.
• Re
tain
ed c
once
ptio
n pr
oduc
ts: s
igns
of
i
nfec
tion
(see
abo
ve).
Trea
tmen
t
Emer
genc
y tr
eatm
ent:
• G
ener
ally
resu
scita
tion
man
agem
ent
in
clud
ing
an A
BCDE
app
roac
h w
ith
in
sert
ion
of tw
o w
ide
bore
can
nula
s.•
Bloo
ds: c
ross
-mat
ch a
nd b
lood
tran
sfus
ion.
• Sp
ecifi
c m
anag
emen
t dep
endi
ng o
n ca
use:
Aton
ic u
teru
s: ut
erin
e m
assa
ge.
U
terin
e ru
ptur
e: la
paro
tom
y.
Endo
met
ritis
: ant
ibio
tics
(che
ck lo
cal
g
uide
lines
).
Reta
ined
pro
duct
s of
con
cept
ion:
evac
uatio
n w
ith s
uctio
n cu
rett
e.
Inve
stig
atio
ns•
Trau
ma
ABCD
E w
ith u
rine
outp
ut
mea
sure
men
t.•
Iden
tify
caus
e (e
.g. v
agin
al e
xam
inat
ion)
.•
Mon
itor f
etal
dis
tres
s w
ith C
TG.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave.
• Ra
diol
ogy:
abd
omin
al a
nd tr
ansv
agin
al
U
SS.
Com
plic
atio
ns•
Mas
sive
hae
mor
rhag
e.•
Hyst
erec
tom
y.•
Deat
h.
MAP
2.1
5. P
ost-
part
um h
aem
orrh
age
(PPH
)
K30033_C002.indd 64 28/02/17 11:16 am
65O
bste
tric
sM
ap 2
.15.
Po
st-p
artu
m h
aem
orr
hag
e (P
PH)
Wha
t is
PPH
?Th
is is
ble
edin
g th
at o
ccur
s af
ter d
eliv
ery
of th
e fe
tus.
It m
ay b
e de
fined
as
prim
ary,
seco
ndar
y or
m
assi
ve d
epen
ding
on
the
amou
nt o
f blo
od lo
st a
nd th
e tim
e th
at h
as e
laps
ed p
ost d
eliv
ery.
Caus
esPr
imar
y: re
mem
ber a
s th
e 5T
s:
T
– To
ne o
f ute
rus
lost
(mos
t com
mon
cau
se)
T –
Trau
ma
(e.g
. to
perin
eum
or u
terin
e ru
ptur
e)
T
– To
rn c
ervi
x or
vag
ina
T –
Thro
mbi
n (i.
e. b
leed
ing
diso
rder
s)
T
– Ti
ssue
(i.e
. ret
aine
d pr
oduc
ts o
f con
cept
ion)
Seco
ndar
y:•
Infe
ctio
n –
endo
met
ritis.
• Re
tain
ed p
rodu
cts
of c
once
ptio
n.
Risk
fact
ors:
rem
embe
r as
ABC
D:
A
– A
ntep
artu
m h
aem
orrh
age
B
– B
irthi
ng p
robl
ems
(i.e.
inst
rum
enta
l del
iver
y, in
duce
d la
bour
)
C –
Coa
gula
tion
diso
rder
s (e
.g. v
on W
illeb
rand
dis
ease
)
D –
Dur
atio
n of
labo
ur >
12 h
ours
Type
of
PPH
Bloo
d lo
stTi
me
elap
sed
afte
r bi
rth
Prim
ary
>50
0 m
L<
24 h
ours
Seco
ndar
y>
500
mL
>24
hou
rs to
12
wee
ksM
assi
ve>
1,50
0 m
LN
/A
Sym
ptom
sDe
pend
s on
the
caus
e of
PPH
. All
may
pres
ent w
ith s
hock
:•
Aton
ic u
teru
s: ut
erus
is e
nlar
ged.
• U
terin
e ru
ptur
e: a
bdom
inal
pai
n, v
agin
al
b
lood
loss
.•
Infe
ctio
n: ta
chyc
ardi
a, fe
ver,
abdo
min
al
p
ain,
vag
inal
blo
od lo
ss.
• Re
tain
ed c
once
ptio
n pr
oduc
ts: s
igns
of
i
nfec
tion
(see
abo
ve).
Trea
tmen
t
Emer
genc
y tr
eatm
ent:
• G
ener
ally
resu
scita
tion
man
agem
ent
in
clud
ing
an A
BCDE
app
roac
h w
ith
in
sert
ion
of tw
o w
ide
bore
can
nula
s.•
Bloo
ds: c
ross
-mat
ch a
nd b
lood
tran
sfus
ion.
• Sp
ecifi
c m
anag
emen
t dep
endi
ng o
n ca
use:
Aton
ic u
teru
s: ut
erin
e m
assa
ge.
U
terin
e ru
ptur
e: la
paro
tom
y.
Endo
met
ritis
: ant
ibio
tics
(che
ck lo
cal
g
uide
lines
).
Reta
ined
pro
duct
s of
con
cept
ion:
evac
uatio
n w
ith s
uctio
n cu
rett
e.
Inve
stig
atio
ns•
Trau
ma
ABCD
E w
ith u
rine
outp
ut
mea
sure
men
t.•
Iden
tify
caus
e (e
.g. v
agin
al e
xam
inat
ion)
.•
Mon
itor f
etal
dis
tres
s w
ith C
TG.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave.
• Ra
diol
ogy:
abd
omin
al a
nd tr
ansv
agin
al
U
SS.
Com
plic
atio
ns•
Mas
sive
hae
mor
rhag
e.•
Hyst
erec
tom
y.•
Deat
h.
MAP
2.1
5. P
ost-
part
um h
aem
orrh
age
(PPH
)
K30033_C002.indd 65 28/02/17 11:16 am
66O
bste
tric
sM
ap 2
.16.
Rh
esu
s d
isea
se
Wha
t is
rhe
sus
dise
ase?
This
dis
ease
is o
ne c
ause
of h
aem
olyt
ic d
isea
seof
the
new
born
. Ant
ibod
ies
from
arh
esus
-neg
ativ
e m
othe
r des
troy
feta
l blo
odce
lls, r
esul
ting
in h
aem
olyt
ic d
isea
se.
Caus
esRh
esus
dis
ease
occ
urs
as a
dire
ct re
sult
ofm
ater
nal a
ntib
odie
s at
tack
ing
feta
l blo
od c
ells.
This
hap
pens
whe
n th
e m
othe
r is
rhes
usne
gativ
e bu
t the
fetu
s is
rhes
us p
ositi
ve.
The
mot
her m
ust h
ave
been
pre
viou
sly
sens
itize
d (b
y ex
posu
re to
rhes
us-p
ositi
ve b
lood
[e.g
. dur
ing
a pr
evio
us p
regn
ancy
]).
Inve
stig
atio
ns•
Rhes
us s
tatu
s is
diag
nose
d du
ring
the
rout
ine
U
K sc
reen
ing
prog
ram
me
(see
Tabl
e 2.
1, p
. 34)
.•
Coom
bs te
st –
blo
od s
ampl
ing
from
the
u
mbi
lical
cor
d as
sess
es b
aby’
s bl
ood
type
as
w
ell a
s w
heth
er a
nti-D
ant
ibod
ies
have
p
asse
d in
to th
e ba
by’s
bloo
d.
Sym
ptom
sSy
mpt
oms
depe
nd o
n th
e se
verit
y of
rhes
us
dise
ase.
Gen
eral
sym
ptom
s:•
Hypo
toni
a.•
Off
feed
s.•
Haem
olyt
ic a
naem
ia (o
f var
ying
sev
erity
).•
Jaun
dice
(of v
aryi
ng s
ever
ity).
Mild
ana
emia
Mod
erat
e ja
undi
ce
Mod
erat
e
Seve
re a
naem
iaHy
drop
s fo
etal
isHy
pogl
ycae
mia
Mod
erat
e an
aem
iaM
oder
ate–
seve
re ja
undi
ce
Mild
Seve
re
Bloo
d lo
stTi
me
elap
sed
afte
r bi
rth
Trea
tmen
t
Med
ical
:•
Prev
entin
g rh
esus
dis
ease
:
Ro
utin
e an
tena
tal a
nti-D
pro
phyl
axis
:
1.
Si
ngle
dos
e tr
eatm
ent –
at 2
8–30
wee
ks.
2.
Doub
le d
ose
trea
tmen
t – a
t 28
wee
ks a
nd 3
4 w
eeks
.
An
ti-D
imm
unog
lobu
lin g
iven
at a
ny
sen
sitiz
ing
even
t (e.
g. a
ny b
leed
ing)
.
Anti-
D im
mun
oglo
bulin
giv
en w
ithin
72 h
ours
afte
r birt
h if
mot
her h
as
not
bee
n se
nsiti
zed.
• Tr
eatin
g rh
esus
dis
ease
:
Ph
otot
hera
py.
In
trav
enou
s im
mun
oglo
bulin
.
Bloo
d tr
ansf
usio
ns.
Com
plic
atio
ns•
Haem
olyt
ic d
isea
se o
f the
new
born
.•
Still
birt
h.•
Lear
ning
diff
icul
ties.
• De
afne
ss.
• Bl
indn
ess.
MAP
2.1
6. R
hesu
s di
seas
e
K30033_C002.indd 66 28/02/17 11:16 am
67O
bste
tric
sM
ap 2
.16.
Rh
esu
s d
isea
se
Wha
t is
rhe
sus
dise
ase?
This
dis
ease
is o
ne c
ause
of h
aem
olyt
ic d
isea
seof
the
new
born
. Ant
ibod
ies
from
arh
esus
-neg
ativ
e m
othe
r des
troy
feta
l blo
odce
lls, r
esul
ting
in h
aem
olyt
ic d
isea
se.
Caus
esRh
esus
dis
ease
occ
urs
as a
dire
ct re
sult
ofm
ater
nal a
ntib
odie
s at
tack
ing
feta
l blo
od c
ells.
This
hap
pens
whe
n th
e m
othe
r is
rhes
usne
gativ
e bu
t the
fetu
s is
rhes
us p
ositi
ve.
The
mot
her m
ust h
ave
been
pre
viou
sly
sens
itize
d (b
y ex
posu
re to
rhes
us-p
ositi
ve b
lood
[e.g
. dur
ing
a pr
evio
us p
regn
ancy
]).
Inve
stig
atio
ns•
Rhes
us s
tatu
s is
diag
nose
d du
ring
the
rout
ine
U
K sc
reen
ing
prog
ram
me
(see
Tabl
e 2.
1, p
. 34)
.•
Coom
bs te
st –
blo
od s
ampl
ing
from
the
u
mbi
lical
cor
d as
sess
es b
aby’
s bl
ood
type
as
w
ell a
s w
heth
er a
nti-D
ant
ibod
ies
have
p
asse
d in
to th
e ba
by’s
bloo
d.
Sym
ptom
sSy
mpt
oms
depe
nd o
n th
e se
verit
y of
rhes
us
dise
ase.
Gen
eral
sym
ptom
s:•
Hypo
toni
a.•
Off
feed
s.•
Haem
olyt
ic a
naem
ia (o
f var
ying
sev
erity
).•
Jaun
dice
(of v
aryi
ng s
ever
ity).
Mild
ana
emia
Mod
erat
e ja
undi
ce
Mod
erat
e
Seve
re a
naem
iaHy
drop
s fo
etal
isHy
pogl
ycae
mia
Mod
erat
e an
aem
iaM
oder
ate–
seve
re ja
undi
ce
Mild
Seve
re
Bloo
d lo
stTi
me
elap
sed
afte
r bi
rth
Trea
tmen
t
Med
ical
:•
Prev
entin
g rh
esus
dis
ease
:
Ro
utin
e an
tena
tal a
nti-D
pro
phyl
axis
:
1.
Si
ngle
dos
e tr
eatm
ent –
at 2
8–30
wee
ks.
2.
Doub
le d
ose
trea
tmen
t – a
t 28
wee
ks a
nd 3
4 w
eeks
.
An
ti-D
imm
unog
lobu
lin g
iven
at a
ny
sen
sitiz
ing
even
t (e.
g. a
ny b
leed
ing)
.
Anti-
D im
mun
oglo
bulin
giv
en w
ithin
72 h
ours
afte
r birt
h if
mot
her h
as
not
bee
n se
nsiti
zed.
• Tr
eatin
g rh
esus
dis
ease
:
Ph
otot
hera
py.
In
trav
enou
s im
mun
oglo
bulin
.
Bloo
d tr
ansf
usio
ns.
Com
plic
atio
ns•
Haem
olyt
ic d
isea
se o
f the
new
born
.•
Still
birt
h.•
Lear
ning
diff
icul
ties.
• De
afne
ss.
• Bl
indn
ess.
MAP
2.1
6. R
hesu
s di
seas
e
K30033_C002.indd 67 28/02/17 11:16 am
68O
bste
tric
sM
ap 2
.17.
Sym
ph
ysis
pu
bis
dys
fun
ctio
n
Wha
t is
sym
phys
is p
ubis
dys
func
tion
?Th
is is
a c
ondi
tion
of p
ain
and
disc
omfo
rt th
atoc
curs
in s
ome
preg
nant
wom
en d
ue to
incr
ease
d m
ovem
ent a
nd m
isal
ignm
ent o
f the
pelv
ic b
ones
at t
he p
ubis
sym
phys
is. S
ympt
oms
tend
to w
orse
n as
the
preg
nanc
y pr
ogre
sses
and
ther
e is
an
incr
ease
d ris
k w
ith m
ultip
arity
.
Caus
esDu
e to
incr
ease
d la
xity
of t
he p
elvi
c lig
amen
ts.
This
occ
urs
due
to in
crea
sed
rela
xin
horm
one
leve
ls.
Inve
stig
atio
ns•
Usu
ally
a c
linic
al d
iagn
osis.
• Ra
diol
ogy
– U
SS m
ay b
e us
ed to
ass
ess
the
d
egre
e of
sep
arat
ion
at th
e pu
bic
sym
phys
is.
9 m
m is
con
side
red
phys
iolo
gica
l in
p
regn
ancy
; >10
mm
in p
regn
ancy
is
con
side
red
path
olog
ical
.
Sym
ptom
s•
Pain
and
pel
vic
disc
omfo
rt (t
ypic
ally
at t
he
p
ubic
sym
phys
is b
ut m
ay a
lso
occu
r at t
he
s
acro
iliac
join
ts).
• Pa
in w
orse
ns w
ith m
ovem
ent a
nd c
erta
in
a
ctiv
ities
suc
h as
clim
bing
sta
irs.
• W
addl
ing
gait.
• Pa
lpat
ion
– te
nder
ness
ove
r the
pub
ic
sym
phys
is; a
gap
may
be
felt.
Trea
tmen
t
Cons
erva
tive
:•
Phys
ioth
erap
y.•
Plac
e a
pillo
w b
etw
een
the
legs
whi
le in
bed
r
estin
g.•
Avoi
d ac
tiviti
es th
at w
orse
n th
e pa
in.
Med
ical
:•
Anal
gesi
a: p
arac
etam
ol.
Com
plic
atio
ns•
Dias
tasi
s of
the
sym
phys
is p
ubis.
MAP
2.1
7. S
ymph
ysis
pubi
s dy
sfun
ctio
n
K30033_C002.indd 68 28/02/17 11:16 am
69O
bste
tric
sTa
ble
2.4.
Bre
astf
eed
ing
TABL
E 2.
4. B
reas
tfee
ding
.
Adv
anta
ges
Dis
adva
ntag
esA
bsol
ute
cont
rain
dica
tion
s
Bene
fits
for
bab
y:•
Decr
ease
d ris
k of
infe
ctio
n (e
.g. c
hest
infe
ctio
n,
ear i
nfec
tion,
urin
ary
trac
t inf
ectio
n)•
Decr
ease
d ris
k of
ast
hma
• De
crea
sed
risk
of e
czem
a•
Decr
ease
d ris
k of
dia
bete
s m
ellit
us
• De
crea
sed
risk
of d
iarr
hoea
and
vom
iting
Bene
fits
for
mot
her:
• De
crea
sed
risk
of c
ance
r: br
east
and
ova
rian
• De
crea
sed
risk
of o
steo
poro
sis
• In
crea
sed
bond
ing
with
chi
ld
• Ve
rtic
al tr
ansm
issi
on•
Risk
of m
astit
is•
Mot
her r
equi
res
addi
tiona
l cal
orie
s
• Ve
rtic
al in
fect
ions
(e.g
. HIV
)•
Gal
acto
saem
ia•
Drug
s: re
mem
ber A
BCS:
A –
Ant
ibio
tics
(e.g
. tet
racy
clin
es)
A –
Asp
irin
A –
Am
ioda
rone
B –
Benz
odia
zepi
ne
C –
Cyto
toxi
c dr
ugs
C –
Carb
imaz
ole
S –
Sulp
hony
lure
as
K30033_C002.indd 69 28/02/17 11:16 am
Chap
ter T
hree
Gyn
aeco
logy
MAP
3.1
E
cto
pic
pre
gn
ancy
72
MAP
3.2
M
isca
rria
ge
74
MAP
3.3
M
ola
r p
reg
nan
cies
76
TABL
E 3.
1 S
exu
ally
tra
nsm
itte
d in
fect
ion
s 78
TABL
E 3.
2 N
on
-sex
ual
ly t
ran
smit
ted
infe
ctio
ns
80
TABL
E 3.
3 M
eno
rrh
agia
81
MAP
3.4
A
men
orr
ho
ea
82
MAP
3.5
P
oly
cyst
ic o
vary
sy
nd
rom
e (P
CO
S)
84
TABL
E 3.
4 Te
rmin
atio
n o
f p
reg
nan
cy (
TOP)
86
MAP
3.6
I
nfe
rtili
ty
88
MAP
3.7
C
ervi
cal c
ance
r 90
MAP
3.8
V
agin
al c
ance
r 92
MAP
3.9
E
nd
om
etri
al c
ance
r 94
MAP
3.1
0 O
vari
an c
ance
r 96
TABL
E 3.
5 O
vari
an c
ysts
98
TABL
E 3.
6 I
nco
nti
nen
ce
99
TABL
E 3.
7 C
on
trac
epti
on
10
0
Gyn
aeco
logy
71
K30033_C003.indd 71 28/02/17 11:17 am
Gyn
aeco
logy
72M
ap 3
.1.
Ecto
pic
pre
gn
ancy
Wha
t is
an
ecto
pic
preg
nanc
y?Th
is is
whe
n th
e em
bryo
impl
ants
out
side
the
uter
us. T
he e
mbr
yo m
ay im
plan
t in
the
abdo
men
but
mor
e of
ten
it is
a tu
bal p
regn
ancy
m
ost c
omm
only
loca
ted
in th
e am
pulla
regi
on
of th
e fa
llopi
an tu
be (8
0%).
Caus
esAn
ythi
ng th
at n
arro
ws
or d
amag
es th
e fa
llopi
an tu
be m
ay re
sult
in a
n ec
topi
c pr
egna
ncy.
Rem
embe
r as
TIPS
:T
– Th
e pr
oges
tero
ne o
nly
pill
– re
sults
in
thic
kene
d se
cret
ions
.I
– In
fect
ion
and
IVF
trea
tmen
t.P
– Pe
lvic
infla
mm
ator
y di
seas
e.S
– Su
rgic
al p
roce
dure
s –
resu
lt in
adh
esio
ns.
Inve
stig
atio
ns•
Preg
nanc
y te
st a
nd b
-hCG
leve
ls.•
Bloo
d te
sts:
FBC,
U&
E, g
roup
and
sav
e.•
Radi
olog
y: tr
ansv
agin
al U
SS.
Com
plic
atio
nsRe
mem
ber a
s TU
BE:
T –
Tuba
l rup
ture
.U
– s
Ubf
ertil
ity.
B –
Blue
s (i.
e. p
sych
olog
ical
impl
icat
ions
rela
ted
to c
hild
loss
and
pos
sibl
e su
bfer
tility
).E
– Ec
topi
c pr
egna
ncy
risk
incr
ease
s fo
r
su
bseq
uent
pre
gnan
cies
.
Trea
tmen
t
Emer
genc
y tr
eatm
ent
Depe
nds
on in
itial
pre
sent
atio
n:•
Gen
eral
resu
scita
tion
man
agem
ent
in
clud
ing
an A
BCDE
app
roac
h w
ith in
sert
ion
of
two
wid
e bo
re c
annu
las.
• Bl
oods
: cro
ss-m
atch
and
blo
od tr
ansf
usio
n.
• Co
nsid
er a
nti-D
pro
phyl
axis.
Med
ical
:•
Met
hotr
exat
e.
Surg
ical
:•
Lapa
rosc
opic
sal
ping
otom
y/sa
lpin
gect
omy.
• If
this
fails
, the
n co
nsid
er la
paro
tom
y.
MAP
3.1
. Ect
opic
pre
gnan
cy
Sym
ptom
sCo
nsid
er in
any
sex
ually
act
ive
fem
ale
who
has
abdo
min
al p
ain
and
who
has
mis
sed
a pe
riod:
• Ab
dom
inal
pai
n –
usua
lly in
the
low
er ri
ght
o
r low
er le
ft qu
adra
nts
and
colic
ky in
nat
ure.
• Va
gina
l ble
edin
g –
dark
col
oure
d an
d
lik
ened
to ‘p
rune
juic
e’.
• N
ause
a an
d vo
miti
ng.
• Si
gns
of s
hock
: cla
mm
y ap
pear
ance
, pal
e,
tac
hyca
rdic
, hyp
oten
sive
.•
Vag
inal
exa
min
atio
n: c
ervi
cal e
xcita
tion.
K30033_C003.indd 72 28/02/17 11:17 am
Wha
t is
an
ecto
pic
preg
nanc
y?Th
is is
whe
n th
e em
bryo
impl
ants
out
side
the
uter
us. T
he e
mbr
yo m
ay im
plan
t in
the
abdo
men
but
mor
e of
ten
it is
a tu
bal p
regn
ancy
m
ost c
omm
only
loca
ted
in th
e am
pulla
regi
on
of th
e fa
llopi
an tu
be (8
0%).
Caus
esAn
ythi
ng th
at n
arro
ws
or d
amag
es th
e fa
llopi
an tu
be m
ay re
sult
in a
n ec
topi
c pr
egna
ncy.
Rem
embe
r as
TIPS
:T
– Th
e pr
oges
tero
ne o
nly
pill
– re
sults
in
thic
kene
d se
cret
ions
.I
– In
fect
ion
and
IVF
trea
tmen
t.P
– Pe
lvic
infla
mm
ator
y di
seas
e.S
– Su
rgic
al p
roce
dure
s –
resu
lt in
adh
esio
ns.
Inve
stig
atio
ns•
Preg
nanc
y te
st a
nd b
-hCG
leve
ls.•
Bloo
d te
sts:
FBC,
U&
E, g
roup
and
sav
e.•
Radi
olog
y: tr
ansv
agin
al U
SS.
Com
plic
atio
nsRe
mem
ber a
s TU
BE:
T –
Tuba
l rup
ture
.U
– s
Ubf
ertil
ity.
B –
Blue
s (i.
e. p
sych
olog
ical
impl
icat
ions
rela
ted
to c
hild
loss
and
pos
sibl
e su
bfer
tility
).E
– Ec
topi
c pr
egna
ncy
risk
incr
ease
s fo
r
su
bseq
uent
pre
gnan
cies
.
Trea
tmen
t
Emer
genc
y tr
eatm
ent
Depe
nds
on in
itial
pre
sent
atio
n:•
Gen
eral
resu
scita
tion
man
agem
ent
in
clud
ing
an A
BCDE
app
roac
h w
ith in
sert
ion
of
two
wid
e bo
re c
annu
las.
• Bl
oods
: cro
ss-m
atch
and
blo
od tr
ansf
usio
n.
• Co
nsid
er a
nti-D
pro
phyl
axis.
Med
ical
:•
Met
hotr
exat
e.
Surg
ical
:•
Lapa
rosc
opic
sal
ping
otom
y/sa
lpin
gect
omy.
• If
this
fails
, the
n co
nsid
er la
paro
tom
y.
MAP
3.1
. Ect
opic
pre
gnan
cy
Sym
ptom
sCo
nsid
er in
any
sex
ually
act
ive
fem
ale
who
has
abdo
min
al p
ain
and
who
has
mis
sed
a pe
riod:
• Ab
dom
inal
pai
n –
usua
lly in
the
low
er ri
ght
o
r low
er le
ft qu
adra
nts
and
colic
ky in
nat
ure.
• Va
gina
l ble
edin
g –
dark
col
oure
d an
d
lik
ened
to ‘p
rune
juic
e’.
• N
ause
a an
d vo
miti
ng.
• Si
gns
of s
hock
: cla
mm
y ap
pear
ance
, pal
e,
tac
hyca
rdic
, hyp
oten
sive
.•
Vag
inal
exa
min
atio
n: c
ervi
cal e
xcita
tion.
73M
ap 3
.1.
Ecto
pic
pre
gn
ancy
Gyn
aeco
logy
K30033_C003.indd 73 28/02/17 11:17 am
Gyn
aeco
logy
74M
ap 3
.2.
Mis
carr
iag
e
Trea
tmen
t•
Depe
nds
on c
linic
al p
rese
ntat
ion
and
the
ty
pe o
f mis
carr
iage
.
Emer
genc
y tr
eatm
ent:
• M
ay b
e re
quire
d if
mot
her i
s ha
emor
rhag
ing.
Med
ical
:•
Pros
tagl
andi
ns +
/– m
ifepr
isto
ne
(a
nti-p
roge
ster
one)
.
Surg
ical
:•
Suct
ion
cure
ttag
e.
Com
plic
atio
ns•
Infe
ctio
n an
d py
rexi
a.•
Psyc
holo
gica
l im
plic
atio
ns in
clud
ing
de
pres
sion
.•
Com
plic
atio
n of
sur
gica
l cur
etta
ge (e
.g. t
he
risk
asso
ciat
ed w
ith g
ener
al a
naes
thet
ic,
ut
erin
e pe
rfora
tion,
Ash
erm
an’s
synd
rom
e
[intr
aute
rine
adhe
sion
s]).
Inve
stig
atio
ns•
b-hC
G le
vels.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave,
rh
esus
sta
tus.
• Ra
diol
ogy:
tran
svag
inal
USS
.
MAP
3.2
. Mis
carr
iage
Wha
t is
a m
isca
rria
ge?
This
is w
hen
the
fetu
s is
spon
tane
ously
abo
rted
<24
wee
ksge
stat
ion,
with
the
maj
ority
bei
ng<1
2 w
eeks
ges
tatio
n. Th
ere
are
man
y di
ffere
nt ty
pes
ofm
iscar
riage
. The
se m
ay b
e de
fined
as e
ither
com
plet
e or
inco
mpl
ete ,
or c
lass
ified
acc
ordi
ng to
thei
rpr
esen
tatio
n , s
uch
as in
evita
ble,
thre
aten
ed, m
issed
and
recu
rrent
.
Caus
esM
ostly
the
caus
e is
unkn
own
but
broa
d ca
uses
, par
ticul
arly
of r
ecur
rent
m
iscar
riage
, may
be
rem
embe
red
as A
BC:
A –
Antip
hosp
holip
id s
yndr
ome,
incr
easin
g Ag
eB
– Bl
eedi
ng d
isord
ers
(e.g
. von
Will
ebra
nd d
iseas
e)C
– Ch
rom
osom
al a
bnor
mal
ity,
Cerv
ical
inco
mpe
tenc
e
Type
of
mis
carr
iage
Sym
ptom
sCe
rvic
al o
sop
en o
r cl
osed
Inev
itabl
e
Thre
aten
ed
Mis
sed
Heav
y va
gina
l ble
edin
gAb
dom
inal
pai
n
Ligh
t vag
inal
ble
edin
gFe
tus
may
sur
vive
No
vagi
nal b
leed
ing
Fetu
s is
no
long
er v
iabl
e
Ope
n
Clos
ed
Clos
ed
Sym
ptom
sSy
mpt
oms
depe
nd o
n th
e ty
pe o
f mis
carr
iage
.
K30033_C003.indd 74 28/02/17 11:17 am
Gyn
aeco
logy
75M
ap 3
.2.
Mis
carr
iag
e
Trea
tmen
t•
Depe
nds
on c
linic
al p
rese
ntat
ion
and
the
ty
pe o
f mis
carr
iage
.
Emer
genc
y tr
eatm
ent:
• M
ay b
e re
quire
d if
mot
her i
s ha
emor
rhag
ing.
Med
ical
:•
Pros
tagl
andi
ns +
/– m
ifepr
isto
ne
(a
nti-p
roge
ster
one)
.
Surg
ical
:•
Suct
ion
cure
ttag
e.
Com
plic
atio
ns•
Infe
ctio
n an
d py
rexi
a.•
Psyc
holo
gica
l im
plic
atio
ns in
clud
ing
de
pres
sion
.•
Com
plic
atio
n of
sur
gica
l cur
etta
ge (e
.g. t
he
risk
asso
ciat
ed w
ith g
ener
al a
naes
thet
ic,
ut
erin
e pe
rfora
tion,
Ash
erm
an’s
synd
rom
e
[intr
aute
rine
adhe
sion
s]).
Inve
stig
atio
ns•
b-hC
G le
vels.
• Bl
ood
test
s: FB
C, U
&E,
gro
up a
nd s
ave,
rh
esus
sta
tus.
• Ra
diol
ogy:
tran
svag
inal
USS
.
MAP
3.2
. Mis
carr
iage
Wha
t is
a m
isca
rria
ge?
This
is w
hen
the
fetu
s is
spon
tane
ously
abo
rted
<24
wee
ksge
stat
ion,
with
the
maj
ority
bei
ng<1
2 w
eeks
ges
tatio
n. Th
ere
are
man
y di
ffere
nt ty
pes
ofm
iscar
riage
. The
se m
ay b
e de
fined
as e
ither
com
plet
e or
inco
mpl
ete,
or c
lass
ified
acc
ordi
ng to
thei
rpr
esen
tatio
n, s
uch
as in
evita
ble,
thre
aten
ed, m
issed
and
recu
rrent
.
Caus
esM
ostly
the
caus
e is
unkn
own
but
broa
d ca
uses
, par
ticul
arly
of r
ecur
rent
m
iscar
riage
, may
be
rem
embe
red
as A
BC:
A –
Antip
hosp
holip
id s
yndr
ome,
incr
easin
g Ag
eB
– Bl
eedi
ng d
isord
ers
(e.g
. von
Will
ebra
nd d
iseas
e)C
– Ch
rom
osom
al a
bnor
mal
ity,
Cerv
ical
inco
mpe
tenc
e
Type
of
mis
carr
iage
Sym
ptom
sCe
rvic
al o
sop
en o
r cl
osed
Inev
itabl
e
Thre
aten
ed
Mis
sed
Heav
y va
gina
l ble
edin
gAb
dom
inal
pai
n
Ligh
t vag
inal
ble
edin
gFe
tus
may
sur
vive
No
vagi
nal b
leed
ing
Fetu
s is
no
long
er v
iabl
e
Ope
n
Clos
ed
Clos
ed
Sym
ptom
sSy
mpt
oms
depe
nd o
n th
e ty
pe o
f mis
carr
iage
.
K30033_C003.indd 75 28/02/17 11:17 am
Gyn
aeco
logy
76M
ap 3
.3.
Mo
lar
pre
gn
anci
es
Wha
t is
a m
olar
pre
gnan
cy?
Mol
ar p
regn
anci
es, a
lso
know
n as
ges
tatio
nal t
roph
obla
stic
dise
ase,
are
due
to e
xces
sive
unc
ontr
olle
d pr
olife
ratio
n of
trop
hobl
astic
tiss
ue. T
hey
may
be
char
acte
rized
as
eith
erpa
rtia
l or c
ompl
ete
mol
ar p
regn
anci
es a
nd fu
rthe
rch
arac
teriz
ed a
s be
nign
or m
alig
nant
.
Type
of
mol
ar p
regn
ancy
Hyda
tidifo
rm m
ole
Inva
sive
mol
e
Beni
gn o
r m
alig
nant
?
Chor
ioca
rcin
oma
Beni
gn
Mal
igna
nt
Mal
igna
nt
Caus
es•
Part
ial m
oles
are
mad
e fro
m b
oth
mat
erna
l and
pat
erna
l
gene
tic m
ater
ial.
• Co
mpl
ete
mol
es a
re m
ade
from
onl
y pa
tern
al g
enet
ic
mat
eria
l.
Risk
fact
ors
• Ex
trem
es o
f mat
erna
l age
.•
Mor
e co
mm
on in
wom
en o
f Asi
an a
nces
try.
Inve
stig
atio
ns•
b-hC
G le
vels
: exc
essi
vely
hig
h.•
Bloo
d pr
essu
re.
• Bl
ood
test
s: FB
C, U
&E,
TFT
s (g
roup
and
sa
ve, r
hesu
s st
atus
if e
xces
sive
bl
eedi
ng).
• Ra
diol
ogy:
tran
svag
inal
USS
– a
‘sno
w
sto
rm’ a
ppea
ranc
e is
pat
hogn
omon
ic.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Co
ntac
t spe
cial
ist c
entr
es fo
r tro
phob
last
ic d
isea
se.
Med
ical
:•
Pros
tagl
andi
ns +
/– m
ifepr
isto
ne (a
nti-p
roge
ster
one)
so
met
imes
use
d to
aid
rem
oval
of t
roph
obla
stic
tiss
ue.
• Ch
emot
hera
py m
ay b
e re
quire
d.
Surg
ical
:•
Suct
ion
cure
ttag
e.
Com
plic
atio
ns•
Incr
ease
d ris
k of
trop
hobl
astic
dis
ease
in s
ubse
quen
t
preg
nanc
ies.
• Tr
opho
blas
tic d
isea
se m
ay b
ecom
e pe
rsis
tent
and
requ
ire
chem
othe
rapy
.•
Chor
ioca
rcin
oma
may
met
asta
size
.
MAP
3.3
. M
olar
pre
gnan
cies
Sym
ptom
s•
Ute
rus
larg
e fo
r dat
es.
• Va
gina
l ble
edin
g.•
Hype
rem
esis.
• Ra
re s
ympt
oms:
pre-
ecla
mps
ia,
hy
pert
hyro
idis
m.
K30033_C003.indd 76 28/02/17 11:17 am
Gyn
aeco
logy
77M
ap 3
.3.
Mo
lar
pre
gn
anci
es
Wha
t is
a m
olar
pre
gnan
cy?
Mol
ar p
regn
anci
es, a
lso
know
n as
ges
tatio
nal t
roph
obla
stic
dise
ase,
are
due
to e
xces
sive
unc
ontr
olle
d pr
olife
ratio
n of
trop
hobl
astic
tiss
ue. T
hey
may
be
char
acte
rized
as
eith
erpa
rtia
l or c
ompl
ete
mol
ar p
regn
anci
es a
nd fu
rthe
rch
arac
teriz
ed a
s be
nign
or m
alig
nant
.
Type
of
mol
ar p
regn
ancy
Hyda
tidifo
rm m
ole
Inva
sive
mol
e
Beni
gn o
r m
alig
nant
?
Chor
ioca
rcin
oma
Beni
gn
Mal
igna
nt
Mal
igna
nt
Caus
es•
Part
ial m
oles
are
mad
e fro
m b
oth
mat
erna
l and
pat
erna
l
gene
tic m
ater
ial.
• Co
mpl
ete
mol
es a
re m
ade
from
onl
y pa
tern
al g
enet
ic
mat
eria
l.
Risk
fact
ors
• Ex
trem
es o
f mat
erna
l age
.•
Mor
e co
mm
on in
wom
en o
f Asi
an a
nces
try.
Inve
stig
atio
ns•
b-hC
G le
vels
: exc
essi
vely
hig
h.•
Bloo
d pr
essu
re.
• Bl
ood
test
s: FB
C, U
&E,
TFT
s (g
roup
and
sa
ve, r
hesu
s st
atus
if e
xces
sive
bl
eedi
ng).
• Ra
diol
ogy:
tran
svag
inal
USS
– a
‘sno
w
sto
rm’ a
ppea
ranc
e is
pat
hogn
omon
ic.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Co
ntac
t spe
cial
ist c
entr
es fo
r tro
phob
last
ic d
isea
se.
Med
ical
:•
Pros
tagl
andi
ns +
/– m
ifepr
isto
ne (a
nti-p
roge
ster
one)
so
met
imes
use
d to
aid
rem
oval
of t
roph
obla
stic
tiss
ue.
• Ch
emot
hera
py m
ay b
e re
quire
d.
Surg
ical
:•
Suct
ion
cure
ttag
e.
Com
plic
atio
ns•
Incr
ease
d ris
k of
trop
hobl
astic
dis
ease
in s
ubse
quen
t
preg
nanc
ies.
• Tr
opho
blas
tic d
isea
se m
ay b
ecom
e pe
rsis
tent
and
requ
ire
chem
othe
rapy
.•
Chor
ioca
rcin
oma
may
met
asta
size
.
MAP
3.3
. M
olar
pre
gnan
cies
Sym
ptom
s•
Ute
rus
larg
e fo
r dat
es.
• Va
gina
l ble
edin
g.•
Hype
rem
esis.
• Ra
re s
ympt
oms:
pre-
ecla
mps
ia,
hy
pert
hyro
idis
m.
K30033_C003.indd 77 28/02/17 11:17 am
Gyn
aeco
logy
78Ta
ble
3.1.
Sex
ual
ly t
ran
smit
ted
infe
ctio
ns
TABL
E 3.
1. S
exua
lly t
rans
mit
ted
infe
ctio
ns.
Dis
ease
Caus
ativ
e or
gani
smSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Chla
myd
ia
Chla
myd
ia
trac
hom
atis
• As
ympt
omat
ic (t
here
is c
urre
ntly
an
oppo
rtun
istic
scr
eeni
ng p
rogr
amm
e in
the
UK
for u
nder
25’
s)•
Fem
ales
: vag
inal
dis
char
ge, i
nter
-men
stru
al
or p
ost-
coita
l ble
edin
g, c
ervi
citis
•
Mal
es: u
reth
ritis,
dys
uria
• It
is th
e m
ost c
omm
on c
ause
of p
elvi
c in
flam
mat
ory
dise
ase
Nuc
leic
aci
d am
plifi
catio
n te
st (N
AAT)
from
eith
er
endo
cerv
ical
sw
abs/
urin
e sa
mpl
e fo
r wom
en a
nd a
ur
ine
sam
ple
for m
en
• Do
xycy
clin
e (7
day
s)•
Azith
rom
ycin
(sin
gle
dose
)
Tric
hom
onia
sis
Tric
hom
onas
va
gina
lis•
Asym
ptom
atic
•
Fem
ales
: vag
inal
dis
char
ge (g
reen
and
of
fens
ive)
, vul
vova
gini
tis, ‘
stra
wbe
rry
cerv
ix’,
supe
rfici
al d
yspa
reun
ia, p
H >
4.5
• M
ales
: ure
thrit
is
Wet
mou
nt m
icro
scop
y to
vi
sual
ize
mot
ile tr
opho
zoite
s •
Met
roni
dazo
le
Gon
orrh
oea
Nei
sser
ia
gono
rrho
eae
• Fe
mal
es: g
ener
ally
asy
mpt
omat
ic, v
agin
al
disc
harg
e, c
ervi
citis
•
Mal
es: u
reth
ritis
Endo
cerv
ical
sw
abs
• az
ithro
myc
in a
nd IM
ce
ftria
xone
Gen
ital w
arts
(con
dylo
mat
a ac
cum
inat
a)
Hum
an
papi
llom
aviru
s (H
PV)
• Pa
pilli
form
or fl
at w
arts
•
May
be
pigm
ente
d•
May
ble
ed•
May
itch
Clin
ical
pre
sent
atio
n•
Firs
t lin
e –
topi
cal
podo
phyl
lum
or c
ryot
hera
py•
Seco
nd li
ne –
imiq
uim
od
crea
m
K30033_C003.indd 78 28/02/17 11:17 am
Gyn
aeco
logy
79Ta
ble
3.1.
Sex
ual
ly t
ran
smit
ted
infe
ctio
ns
Gen
ital h
erpe
sHe
rpes
sim
plex
vi
rus
(HSV
) 1 a
nd 2
• Pa
infu
l, ul
cera
ted
lesi
ons
• Dy
suria
• Ly
mph
aden
opat
hy
Vira
l sw
ab•
Acic
lovi
r
Syph
ilis
Trep
onem
a pa
llidu
m
See
Map
2.1
2 (p
. 58)
Split
into
:
• Pr
imar
y sy
phili
s –
chan
cre
• Se
cond
ary
syph
ilis
– ra
sh
• Te
rtia
ry s
yphi
lis –
car
diac
and
neu
rolo
gica
l in
volv
emen
t. G
umm
ata
form
atio
n
See
Map
2.1
2 (p
. 58)
VDRL
test
ing
• Pe
nici
llin
K30033_C003.indd 79 28/02/17 11:17 am
Gyn
aeco
logy
80Ta
ble
3.2.
No
n-s
exu
ally
tra
nsm
itte
d in
fect
ion
s
TABL
E 3.
2. N
on-s
exua
lly t
rans
mit
ted
infe
ctio
ns.
Dis
ease
Caus
ativ
e or
gani
smSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Cand
idia
sis
Cand
ida
albi
cans
•
Typi
cal d
isch
arge
(‘co
ttag
e ch
eese
’)•
Itchi
ng
• Vu
lviti
s
• M
icro
scop
y an
d cu
lture
• To
pica
l pre
para
tions
(e
.g. i
mid
azol
es)
• O
ral p
repa
ratio
ns
(e.g
. fluc
onaz
ole)
Bact
eria
l vag
inos
isG
ardn
erel
la
vagi
nalis
• M
ay b
e as
ympt
omat
ic•
Amse
l’s c
riter
ia –
thre
e of
the
four
crit
eria
list
ed b
elow
mus
t be
met
:1.
Whi
te h
omog
eneo
us d
isch
arge
2. C
lue
cells
vis
ible
on
mic
rosc
opy
3. V
agin
al p
H >
4.5
4. P
ositi
ve w
hiff
test
– a
fish
y od
our i
s cr
eate
d on
add
ition
of
pota
ssiu
m h
ydro
xide
• Re
fer t
o Am
sel’s
crit
eria
: m
icro
scop
y, in
crea
sed
vagi
nal p
H, a
dditi
on o
f po
tass
ium
hyd
roxi
de
• O
ral m
etro
nida
zole
(5
–7 d
ays)
• Se
cond
line
– to
pica
l met
roni
dazo
le o
r cl
inda
myc
in
K30033_C003.indd 80 28/02/17 11:17 am
Gyn
aeco
logy
81
TABL
E 3.
3. M
enor
rhag
ia. I
n la
yman
’s t
erm
s, m
enor
rhag
ia is
hea
vy m
enst
rual
ble
edin
g. P
revi
ousl
y it
was
defi
ned
obje
ctiv
ely
as >
80 m
L bl
ood
loss
; how
ever
, the
re h
as b
een
a sh
ift
to t
he s
ubje
ctiv
e w
here
hea
vy m
enst
rual
bl
eedi
ng is
defi
ned
by w
hat
the
wom
an f
eels
is e
xces
sive
.
Caus
esIn
vest
igat
ions
Trea
tmen
t
Rem
embe
r as
U B
LEED
:
U –
Ute
rine
poly
ps/U
terin
e fib
roid
sB
– B
leed
ing
diso
rder
s (e
.g. v
on W
illeb
rand
di
seas
e)L
– L
ikel
y no
und
erly
ing
path
olog
y (5
0%)
E –
End
omet
riosi
sE
– E
ndom
etria
l car
cino
ma/
hype
rpla
sia
D –
pel
vic
infla
mm
ator
y D
isea
se/
intr
aute
rine
Dev
ices
Depe
nds
on th
e ca
use
of m
enor
rhag
ia. I
t is
esse
ntia
l to
per
form
an
FBC
in e
ach
case
to e
xclu
de a
naem
ia.
Som
e in
vest
igat
ions
are
list
ed b
elow
:
• G
ener
al b
lood
test
s: FB
C, U
&E,
TFT
s•
Radi
olog
y: U
SS, h
yste
rosc
opy,
endo
met
rial b
iops
y if
indi
cate
d
Refe
r to
appr
opria
te lo
cal a
lgor
ithm
s.
Trea
tmen
t is
a st
epw
ise
appr
oach
.
Med
ical
:
• Fi
rst-
line:
Mire
na in
trau
terin
e sy
stem
• Se
cond
-line
: mef
enam
ic a
cid
(par
ticul
arly
if c
o-m
orbi
d dy
smen
orrh
oea)
, tra
nexa
mic
aci
d, c
ombi
ned
oral
co
ntra
cept
ive
pill
• Th
ird-li
ne: l
ong
actin
g pr
oges
toge
ns (o
ral o
r inj
ecte
d).
Cons
ider
GnR
H an
alog
ues
if th
is fa
ils
Surg
ical
:
• En
dom
etria
l abl
atio
n•
Hyst
erec
tom
y •
Not
e: S
urgi
cal i
nter
vent
ion
can
caus
e in
fert
ility
Tabl
e 3.
3. M
eno
rrh
agia
K30033_C003.indd 81 28/02/17 11:17 am
Gyn
aeco
logy
82M
ap 3
.4.
Am
eno
rrh
oea
Wha
t is
am
enor
rhoe
a?Th
is m
ay b
e de
fined
as
eith
er p
rimar
y or
seco
ndar
y am
enor
rhoe
a:•
Prim
ary:
men
stru
atio
n ha
s no
t com
men
ced
by
the
age
of 1
6.•
Seco
ndar
y: th
e ab
senc
e of
men
stru
atio
n fo
r
6 m
onth
s in
a w
oman
who
pre
viou
sly
had
no
rmal
men
stru
atio
n.
Caus
esTh
ese
are
split
into
prim
ary
and
seco
ndar
yca
uses
.
Prim
ary
caus
es (2
T 2C
):•
Turn
er s
yndr
ome
(45,
X).
• Te
stic
ular
fem
iniz
atio
n.•
Cong
enita
l mal
form
atio
ns (e
.g. M
ayer
–
Roki
tans
ky–K
üste
r–Ha
user
syn
drom
e
[Mül
leria
n ag
enes
is],
impe
rfora
te h
ymen
).•
Cong
enita
l adr
enal
hyp
erpl
asia
.
Seco
ndar
y ca
uses
(4P
3H):
• Pr
egna
ncy
– th
e m
ost c
omm
on c
ause
.•
Poly
cyst
ic o
vary
syn
drom
e (s
ee M
ap
3.5,
p. 8
4).
• Pr
emat
ure
ovar
ian
failu
re.
• Pi
tuita
ry n
ecro
sis
– Sh
eeha
n’s
synd
rom
e
afte
r PPH
.•
Hyp
erpr
olac
tinae
mia
.•
Hyp
otha
lam
ic d
isor
der (
e.g.
ano
rexi
a
nerv
osa,
exc
essi
ve e
xerc
ise,
str
ess)
.•
Hyp
er/H
ypot
hyro
idis
m.
Sym
ptom
sDe
pend
s on
the
caus
e of
am
enor
rhoe
a.So
me
exam
ples
are
list
ed b
elow
:•
Poly
cyst
ic o
vary
syn
drom
e (s
ee M
ap
3.5,
p. 8
4).
• Tu
rner
syn
drom
e –
web
bed
neck
, sho
rt
stat
ure.
• Pr
emat
ure
ovar
ian
failu
re –
ass
ocia
ted
with
ot
her a
utoi
mm
une
cond
ition
s su
ch a
s
Addi
son’
s di
seas
e an
d hy
poth
yroi
dism
.•
May
er–R
okita
nsky
–Küs
ter–
Haus
er
synd
rom
e –
vary
ing
degr
ees
of u
tero
vagi
nal
ap
lasi
a or
hyp
opla
sia.
Inve
stig
atio
ns•
b-hC
G le
vels
(urin
e or
ser
um) t
o ex
clud
e
preg
nanc
y.•
Bloo
d te
sts:
FBC,
U&
E, T
FTs,
gona
dotr
opin
le
vels,
pro
lact
in le
vels,
and
roge
n le
vels,
oe
stra
diol
.•
Radi
olog
y: m
ay b
e re
quire
d to
vis
ualiz
e
susp
ecte
d tu
mou
rs if
clin
ical
ly in
dica
ted.
Trea
tmen
tDe
pend
s on
the
caus
e of
am
enor
rhoe
a. S
ome
exam
ples
are
list
ed b
elow
.
Cons
erva
tive
:•
Pat
ient
edu
catio
n.
Med
ical
:•
Pol
ycys
tic o
vary
syn
drom
e (s
ee M
ap
3.5,
p. 8
4).
• P
rem
atur
e ov
aria
n fa
ilure
– h
orm
one
re
plac
emen
t the
rapy
.
Surg
ical
:•
Dep
ends
on
unde
rlyin
g pa
thol
ogy
(e
.g. M
ayer
–Rok
itans
ky–K
üste
r–Ha
user
sy
ndro
me
– th
e us
e of
vag
inal
dila
tors
and
su
rgic
al p
roce
dure
s su
ch a
s th
e Ve
cchi
etti
pr
oced
ure.
Com
plic
atio
ns•
Infe
rtili
ty.
• O
steo
poro
sis.
MAP
3.4
. Am
enor
rhoe
a
K30033_C003.indd 82 28/02/17 11:17 am
Gyn
aeco
logy
83M
ap 3
.4.
Am
eno
rrh
oea
Wha
t is
am
enor
rhoe
a?Th
is m
ay b
e de
fined
as
eith
er p
rimar
y or
seco
ndar
y am
enor
rhoe
a:•
Prim
ary:
men
stru
atio
n ha
s no
t com
men
ced
by
the
age
of 1
6.•
Seco
ndar
y: th
e ab
senc
e of
men
stru
atio
n fo
r
6 m
onth
s in
a w
oman
who
pre
viou
sly
had
no
rmal
men
stru
atio
n.
Caus
esTh
ese
are
split
into
prim
ary
and
seco
ndar
yca
uses
.
Prim
ary
caus
es (2
T 2C
):•
Turn
er s
yndr
ome
(45,
X).
• Te
stic
ular
fem
iniz
atio
n.•
Cong
enita
l mal
form
atio
ns (e
.g. M
ayer
–
Roki
tans
ky–K
üste
r–Ha
user
syn
drom
e
[Mül
leria
n ag
enes
is],
impe
rfora
te h
ymen
).•
Cong
enita
l adr
enal
hyp
erpl
asia
.
Seco
ndar
y ca
uses
(4P
3H):
• Pr
egna
ncy
– th
e m
ost c
omm
on c
ause
.•
Poly
cyst
ic o
vary
syn
drom
e (s
ee M
ap
3.5,
p. 8
4).
• Pr
emat
ure
ovar
ian
failu
re.
• Pi
tuita
ry n
ecro
sis
– Sh
eeha
n’s
synd
rom
e
afte
r PPH
.•
Hyp
erpr
olac
tinae
mia
.•
Hyp
otha
lam
ic d
isor
der (
e.g.
ano
rexi
a
nerv
osa,
exc
essi
ve e
xerc
ise,
str
ess)
.•
Hyp
er/H
ypot
hyro
idis
m.
Sym
ptom
sDe
pend
s on
the
caus
e of
am
enor
rhoe
a.So
me
exam
ples
are
list
ed b
elow
:•
Poly
cyst
ic o
vary
syn
drom
e (s
ee M
ap
3.5,
p. 8
4).
• Tu
rner
syn
drom
e –
web
bed
neck
, sho
rt
stat
ure.
• Pr
emat
ure
ovar
ian
failu
re –
ass
ocia
ted
with
ot
her a
utoi
mm
une
cond
ition
s su
ch a
s
Addi
son’
s di
seas
e an
d hy
poth
yroi
dism
.•
May
er–R
okita
nsky
–Küs
ter–
Haus
er
synd
rom
e –
vary
ing
degr
ees
of u
tero
vagi
nal
ap
lasi
a or
hyp
opla
sia.
Inve
stig
atio
ns•
b-hC
G le
vels
(urin
e or
ser
um) t
o ex
clud
e
preg
nanc
y.•
Bloo
d te
sts:
FBC,
U&
E, T
FTs,
gona
dotr
opin
le
vels,
pro
lact
in le
vels,
and
roge
n le
vels,
oe
stra
diol
.•
Radi
olog
y: m
ay b
e re
quire
d to
vis
ualiz
e
susp
ecte
d tu
mou
rs if
clin
ical
ly in
dica
ted.
Trea
tmen
tDe
pend
s on
the
caus
e of
am
enor
rhoe
a. S
ome
exam
ples
are
list
ed b
elow
.
Cons
erva
tive
:•
Pat
ient
edu
catio
n.
Med
ical
:•
Pol
ycys
tic o
vary
syn
drom
e (s
ee M
ap
3.5,
p. 8
4).
• P
rem
atur
e ov
aria
n fa
ilure
– h
orm
one
re
plac
emen
t the
rapy
.
Surg
ical
:•
Dep
ends
on
unde
rlyin
g pa
thol
ogy
(e
.g. M
ayer
–Rok
itans
ky–K
üste
r–Ha
user
sy
ndro
me
– th
e us
e of
vag
inal
dila
tors
and
su
rgic
al p
roce
dure
s su
ch a
s th
e Ve
cchi
etti
pr
oced
ure.
Com
plic
atio
ns•
Infe
rtili
ty.
• O
steo
poro
sis.
MAP
3.4
. Am
enor
rhoe
a
K30033_C003.indd 83 28/02/17 11:17 am
Gyn
aeco
logy
84M
ap 3
.5.
Poly
cyst
ic o
vary
syn
dro
me
(PC
OS)
Wha
t is
pol
ycys
tic
ovar
y sy
ndro
me?
This
is w
hen
a w
oman
has
pol
ycys
tic o
varie
s. It
is
diag
nose
d us
ing
the
Roth
erha
m c
riter
ia w
here
two
out o
f the
thre
e cr
iteria
list
ed b
elow
mus
t be
met
:1.
Rad
iolo
gica
l fea
ture
s: a
USS
vi
sual
izin
g m
ultip
le (>
12) s
mal
l fol
licle
s
mea
surin
g ~
2–9
mm
+/–
an
ovar
ian
volu
me
>
10 m
L.2.
Men
stru
al ir
regu
larit
y: p
erio
ds th
at a
re >
5
wee
ks a
part
.3.
End
ocrin
e ph
enom
ena:
•
Hype
rand
roge
nism
– h
irsut
ism
, acn
e.
Caus
esTh
e ex
act c
ause
of P
COS
is u
nkno
wn.
Fac
tors
incl
ude
insu
lin re
sist
ance
and
hor
mon
al im
bala
nce
caus
ing
incr
ease
d an
drog
en le
vels,
dec
reas
ed
leve
ls o
f sex
hor
mon
e bi
ndin
g gl
obul
in (S
HBG
), ra
ised
LH
leve
ls a
nd s
omet
imes
rais
ed p
rola
ctin
le
vels.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Li
fest
yle
advi
ce –
par
ticul
arly
wei
ght l
oss.
Med
ical
: thi
s ai
ms
to t
reat
sym
ptom
s•
Hirs
utis
m: o
ral c
ontr
acep
tive
pills
with
an
an
tiand
roge
n ef
fect
(e.g
. Yas
min
or D
iane
tte)
.•
Subf
ertil
ity: m
etfo
rmin
may
hel
p.•
Indu
cing
ovu
latio
n: c
lom
ifene
.
Surg
ical
:•
Not
indi
cate
d. IV
F m
ay b
e re
quire
d la
ter.
Sym
ptom
sM
ay b
e as
ympt
omat
ic b
ut o
ther
feat
ures
may
be
rem
embe
red
as H
AIR
:H
– H
irsut
ism
A –
Am
enor
rhoe
aI
– Irr
egul
ar p
erio
ds/In
crea
sed
wei
ght
R –
Redu
ced
fert
ility
and
mis
carr
iage
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, T
FTs.
• Sp
ecifi
c bl
ood
test
s: an
drog
en le
vels,
SHB
G, L
H,
FSH,
pro
lact
in.
• Ra
diol
ogy:
tran
svag
inal
USS
for s
peci
fic
feat
ures
(see
Rot
herh
am c
riter
ia).
Com
plic
atio
ns•
Infe
rtili
ty.
• Ty
pe 2
dia
bete
s m
ellit
us.
• G
esta
tiona
l dia
bete
s.•
Depr
essi
on.
• In
crea
sed
wei
ght,
whi
ch le
ads
to
co
mpl
icat
ions
suc
h as
:
Sl
eep
apno
ea.
Met
abol
ic s
yndr
ome.
Incr
ease
d ris
k of
dia
bete
s.
Hi
gh b
lood
pre
ssur
e.
MAP
3.5
. Pol
ycys
tic
ovar
y sy
ndro
me
(PCO
S)
K30033_C003.indd 84 28/02/17 11:17 am
Gyn
aeco
logy
85M
ap 3
.5.
Poly
cyst
ic o
vary
syn
dro
me
(PC
OS)
Wha
t is
pol
ycys
tic
ovar
y sy
ndro
me?
This
is w
hen
a w
oman
has
pol
ycys
tic o
varie
s. It
is
diag
nose
d us
ing
the
Roth
erha
m c
riter
ia w
here
two
out o
f the
thre
e cr
iteria
list
ed b
elow
mus
t be
met
:1.
Rad
iolo
gica
l fea
ture
s: a
USS
vi
sual
izin
g m
ultip
le (>
12) s
mal
l fol
licle
s
mea
surin
g ~
2–9
mm
+/–
an
ovar
ian
volu
me
>
10 m
L.2.
Men
stru
al ir
regu
larit
y: p
erio
ds th
at a
re >
5
wee
ks a
part
.3.
End
ocrin
e ph
enom
ena:
•
Hype
rand
roge
nism
– h
irsut
ism
, acn
e.
Caus
esTh
e ex
act c
ause
of P
COS
is u
nkno
wn.
Fac
tors
incl
ude
insu
lin re
sist
ance
and
hor
mon
al im
bala
nce
caus
ing
incr
ease
d an
drog
en le
vels,
dec
reas
ed
leve
ls o
f sex
hor
mon
e bi
ndin
g gl
obul
in (S
HBG
), ra
ised
LH
leve
ls a
nd s
omet
imes
rais
ed p
rola
ctin
le
vels.
Sym
ptom
sM
ay b
e as
ympt
omat
ic b
ut o
ther
feat
ures
may
be
rem
embe
red
as H
AIR
:H
– H
irsut
ism
A –
Am
enor
rhoe
aI
– Irr
egul
ar p
erio
ds/In
crea
sed
wei
ght
R –
Redu
ced
fert
ility
and
mis
carr
iage
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, T
FTs.
• Sp
ecifi
c bl
ood
test
s: an
drog
en le
vels,
SHB
G, L
H,
FSH,
pro
lact
in.
• Ra
diol
ogy:
tran
svag
inal
USS
for s
peci
fic
feat
ures
(see
Rot
herh
am c
riter
ia).
MAP
3.5
. Pol
ycys
tic
ovar
y sy
ndro
me
(PCO
S)
K30033_C003.indd 85 28/02/17 11:17 am
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Li
fest
yle
advi
ce –
par
ticul
arly
wei
ght l
oss.
Med
ical
: thi
s ai
ms
to t
reat
sym
ptom
s•
Hirs
utis
m: o
ral c
ontr
acep
tive
pills
with
an
an
tiand
roge
n ef
fect
(e.g
. Yas
min
or D
iane
tte)
.•
Subf
ertil
ity: m
etfo
rmin
may
hel
p.•
Indu
cing
ovu
latio
n: c
lom
ifene
.
Surg
ical
:•
Not
indi
cate
d. IV
F m
ay b
e re
quire
d la
ter.
Com
plic
atio
ns•
Infe
rtili
ty.
• Ty
pe 2
dia
bete
s m
ellit
us.
• G
esta
tiona
l dia
bete
s.•
Depr
essi
on.
• In
crea
sed
wei
ght,
whi
ch le
ads
to
co
mpl
icat
ions
suc
h as
:
Sl
eep
apno
ea.
Met
abol
ic s
yndr
ome.
Incr
ease
d ris
k of
dia
bete
s.
Hi
gh b
lood
pre
ssur
e.
Gyn
aeco
logy
86
TABL
E 3.
4. T
erm
inat
ion
of p
regn
ancy
(TO
P).
Curr
ent
lega
l sta
ndin
gM
etho
ds u
sed
Com
plic
atio
ns
Base
d on
the
Abor
tion
Act 1
967;
am
ende
d 19
90 b
y th
e Hu
man
Fer
tiliz
atio
n an
d Em
bryo
logy
Ac
t. Re
quire
s th
e si
gnat
ures
of t
wo
regi
ster
ed
prac
titio
ners
. Ful
l det
ails
of t
he H
uman
Fer
tiliz
a-tio
n an
d Em
bryo
logy
Act
may
be
foun
d at
: htt
p://
ww
w.le
gisl
atio
n.go
v.uk
/ukp
ga/1
990/
37/c
onte
nts
Key
feat
ures
of t
he A
ct:
• M
ust b
e no
gre
ater
than
24
wee
ks g
esta
tion
• M
ay b
e co
nsid
ered
>24
wee
ks g
esta
tion
if th
e lif
e of
the
mot
her i
s at
gre
at ri
sk•
Cons
ider
in c
ases
whe
re th
ere
may
be
grea
t ris
k to
the
mot
her’s
exi
stin
g ch
ildre
n •
Cons
ider
whe
n th
e ph
ysic
al o
r men
tal h
ealth
of
the
mot
her i
s in
gre
at je
opar
dy
• Co
nsid
er if
the
child
is h
ighl
y lik
ely
to b
e bo
rn
with
a s
ever
e m
enta
l or p
hysi
cal h
andi
cap
The
met
hod
used
for T
OP
depe
nds
on th
e ge
stat
ion
of th
e pr
egna
ncy.
Gen
eral
ly, th
e m
etho
ds u
sed
are
as fo
llow
s.
1. <
9 w
eeks
ges
tatio
n:
Mife
pris
tone
48
hou
rs a
fter d
ose
of m
ifepr
isto
ne
give
pro
stag
land
in (e
.g. m
isop
rost
ol).
Pros
tagl
andi
ns s
timul
ate
uter
ine
cont
ract
ion
2. <
13 w
eeks
ges
tatio
n:
Surg
ical
dila
tatio
n an
d va
cuum
asp
iratio
n 3.
15
wee
ks g
esta
tion:
Su
rgic
al d
ilata
tion
and
evac
uatio
n
Gen
eral
com
plic
atio
ns:
• Th
ose
of g
ener
al a
naes
thet
ic•
Haem
orrh
age
• In
fect
ion
• Re
tain
ed p
rodu
cts
of c
once
ptio
n•
Psyc
hiat
ric c
ompl
icat
ions
(e.g
. dep
ress
ion)
Spec
ific
com
plic
atio
ns:
• Tr
aum
a to
the
geni
tal t
ract
• As
herm
an’s
synd
rom
e•
Perfo
ratio
n of
pel
vic
orga
ns (i
.e. u
teru
s, bo
wel
an
d bl
adde
r)
Tabl
e 3.
4. T
erm
inat
ion
of
pre
gn
ancy
(TO
P)
K30033_C003.indd 86 28/02/17 11:17 am
Tabl
e 3.
4. T
erm
inat
ion
of
pre
gn
ancy
(TO
P)
K30033_C003.indd 87 28/02/17 11:17 am
Gyn
aeco
logy
88M
ap 3
.6.
Infe
rtili
ty
Wha
t is
infe
rtili
ty?
Infe
rtili
ty is
the
failu
re to
con
ceiv
e af
ter r
egul
ar
unpr
otec
ted
inte
rcou
rse
for 2
yea
rs in
the
abse
nce
of k
now
n re
prod
uctiv
e pa
thol
ogy.
This
m
ay b
e ca
tego
rized
as
bein
g ei
ther
prim
ary
or
seco
ndar
y. In
the
form
er th
e co
uple
hav
e ne
ver
conc
eive
d, w
here
as in
sec
onda
ry in
fert
ility
the
coup
le h
as p
revi
ousl
y co
ncei
ved.
Fe
rtili
ty re
quire
s a
norm
al s
perm
to re
ach
a no
rmal
egg
and
then
fert
ilize
it. T
his
fert
ilize
d eg
g th
en n
eeds
to im
plan
t suc
cess
fully
into
the
endo
met
rium
. Any
hin
dran
ce in
this
pro
cess
m
ay c
ause
infe
rtili
ty.
Caus
esTh
ese
are
clas
sifie
d in
to m
ale
and
fem
ale
caus
es. S
ome
exam
ples
are
list
ed b
elow
:•
Mal
e: o
ccur
s w
hen
ther
e is
a p
robl
em w
ith
sper
m v
olum
e, p
H, c
once
ntra
tion,
mor
phol
ogy,
mot
ility
or v
italit
y. Th
is m
ay b
e du
e to
sm
okin
g,
alco
hol u
se, s
tero
ids
or S
TIs.
• Fe
mal
e: th
ink
of th
e hy
poth
alam
ic o
varia
n ax
is to
rem
embe
r the
cau
ses:
Hypo
thal
amic
dys
func
tion:
– Hy
perp
rola
ctin
aem
ia.
– Hy
poth
alam
ic h
ypog
onad
ism
.
–
Hypo
thyr
oidi
sm.
– Hy
pert
hyro
idis
m.
Ova
rian
dysf
unct
ion:
– PC
OS.
– Pr
emat
ure
ovar
ian
failu
re.
Tuba
l dys
func
tion:
– PI
D.
–
Adhe
sion
s fro
m p
revi
ous
pelv
ic
sur
gery
.
–
Cyst
ic fi
bros
is.
Im
plan
tatio
n fa
ilure
:
–
Fibr
oids
.
An
atom
ical
abn
orm
ality
:
–
Bico
rnat
e ut
erus
.
–
May
er–R
okita
nsky
–Küs
ter–
Haus
er
sy
ndro
me.
Trea
tmen
tDe
pend
s on
the
caus
e of
infe
rtili
ty.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Re
gula
r int
erco
urse
3–4
tim
es a
wee
k.•
Life
styl
e ad
vice
– p
artic
ular
ly w
eigh
t los
s.
Med
ical
:•
Clom
ifene
.•
Gon
adot
ropi
n th
erap
y.
Surg
ical
:•
Ova
rian
diat
herm
y.•
IVF.
• In
tra-
uter
ine
inse
min
atio
n.•
Tuba
l sur
gery
.
Inve
stig
atio
ns•
Sem
en a
naly
sis.
Nor
mal
resu
lts a
re:
Volu
me
>1.
5 m
L.
pH
>7.
2.
Sper
m c
once
ntra
tion
>15
mill
ion/
mL.
Mor
phol
ogy
>4%
nor
mal
form
s.
M
otili
ty >
32%
pro
gres
sive
mot
ility
.
Vi
talit
y >
58%
live
spe
rmat
ozoa
.•
Bloo
d te
sts:
FBC,
U&
E, T
FTs,
andr
ogen
leve
ls,
SHBG
, LH,
FSH
, pro
lact
in, 2
1-da
y
prog
este
rone
(>30
nm
ol/L
= o
vula
tion)
.•
Radi
olog
y: tr
ansv
agin
al U
SS,
hy
ster
osal
ping
ogra
m.
• L
apar
osco
py a
nd d
ye te
sts.
Sym
ptom
s•
Prim
ary
or s
econ
dary
infe
rtili
ty.
• Th
ose
of u
nder
lyin
g ca
use.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
an
xiet
y.•
Side
effe
cts
of tr
eatm
ents
incl
udin
g:
O
varia
n hy
pers
timul
atio
n sy
ndro
me.
Ecto
pic
preg
nanc
y.
M
ultip
le p
regn
ancy
.
Map
3.6
. Inf
erti
lity
K30033_C003.indd 88 28/02/17 11:17 am
Wha
t is
infe
rtili
ty?
Infe
rtili
ty is
the
failu
re to
con
ceiv
e af
ter r
egul
ar
unpr
otec
ted
inte
rcou
rse
for 2
yea
rs in
the
abse
nce
of k
now
n re
prod
uctiv
e pa
thol
ogy.
This
m
ay b
e ca
tego
rized
as
bein
g ei
ther
prim
ary
or
seco
ndar
y. In
the
form
er th
e co
uple
hav
e ne
ver
conc
eive
d, w
here
as in
sec
onda
ry in
fert
ility
the
coup
le h
as p
revi
ousl
y co
ncei
ved.
Fe
rtili
ty re
quire
s a
norm
al s
perm
to re
ach
a no
rmal
egg
and
then
fert
ilize
it. T
his
fert
ilize
d eg
g th
en n
eeds
to im
plan
t suc
cess
fully
into
the
endo
met
rium
. Any
hin
dran
ce in
this
pro
cess
m
ay c
ause
infe
rtili
ty.
Caus
esTh
ese
are
clas
sifie
d in
to m
ale
and
fem
ale
caus
es. S
ome
exam
ples
are
list
ed b
elow
:•
Mal
e: o
ccur
s w
hen
ther
e is
a p
robl
em w
ith
sper
m v
olum
e, p
H, c
once
ntra
tion,
mor
phol
ogy,
mot
ility
or v
italit
y. Th
is m
ay b
e du
e to
sm
okin
g,
alco
hol u
se, s
tero
ids
or S
TIs.
• Fe
mal
e: th
ink
of th
e hy
poth
alam
ic o
varia
n ax
is to
rem
embe
r the
cau
ses:
Hypo
thal
amic
dys
func
tion:
– Hy
perp
rola
ctin
aem
ia.
– Hy
poth
alam
ic h
ypog
onad
ism
.
–
Hypo
thyr
oidi
sm.
– Hy
pert
hyro
idis
m.
Ova
rian
dysf
unct
ion:
– PC
OS.
– Pr
emat
ure
ovar
ian
failu
re.
Tuba
l dys
func
tion:
– PI
D.
–
Adhe
sion
s fro
m p
revi
ous
pelv
ic
sur
gery
.
–
Cyst
ic fi
bros
is.
Im
plan
tatio
n fa
ilure
:
–
Fibr
oids
.
An
atom
ical
abn
orm
ality
:
–
Bico
rnat
e ut
erus
.
–
May
er–R
okita
nsky
–Küs
ter–
Haus
er
sy
ndro
me.
Trea
tmen
tDe
pend
s on
the
caus
e of
infe
rtili
ty.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Re
gula
r int
erco
urse
3–4
tim
es a
wee
k.•
Life
styl
e ad
vice
– p
artic
ular
ly w
eigh
t los
s.
Med
ical
:•
Clom
ifene
.•
Gon
adot
ropi
n th
erap
y.
Surg
ical
:•
Ova
rian
diat
herm
y.•
IVF.
• In
tra-
uter
ine
inse
min
atio
n.•
Tuba
l sur
gery
.
Inve
stig
atio
ns•
Sem
en a
naly
sis.
Nor
mal
resu
lts a
re:
Volu
me
>1.
5 m
L.
pH
>7.
2.
Sper
m c
once
ntra
tion
>15
mill
ion/
mL.
Mor
phol
ogy
>4%
nor
mal
form
s.
M
otili
ty >
32%
pro
gres
sive
mot
ility
.
Vi
talit
y >
58%
live
spe
rmat
ozoa
.•
Bloo
d te
sts:
FBC,
U&
E, T
FTs,
andr
ogen
leve
ls,
SHBG
, LH,
FSH
, pro
lact
in, 2
1-da
y
prog
este
rone
(>30
nm
ol/L
= o
vula
tion)
.•
Radi
olog
y: tr
ansv
agin
al U
SS,
hy
ster
osal
ping
ogra
m.
• L
apar
osco
py a
nd d
ye te
sts.
Sym
ptom
s•
Prim
ary
or s
econ
dary
infe
rtili
ty.
• Th
ose
of u
nder
lyin
g ca
use.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
an
xiet
y.•
Side
effe
cts
of tr
eatm
ents
incl
udin
g:
O
varia
n hy
pers
timul
atio
n sy
ndro
me.
Ecto
pic
preg
nanc
y.
M
ultip
le p
regn
ancy
.
Map
3.6
. Inf
erti
lity
Gyn
aeco
logy
Map
3.6
. In
fert
ility
89
K30033_C003.indd 89 28/02/17 11:17 am
Gyn
aeco
logy
90
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Spec
ific
bloo
d te
sts:
colp
osco
py w
ith
biop
sy o
f cer
vix.
• Ra
diol
ogy:
MRI
of p
elvi
s.•
Stag
e us
ing
the
Fédé
ratio
n In
tern
atio
nale
de
G
ynéc
olog
ie e
t d’O
bsté
triq
ue (F
IGO
) sys
tem
.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
anxi
ety.
• G
ener
al a
nd s
peci
fic c
ompl
icat
ions
of
ch
emot
hera
py a
nd ra
diot
hera
py.
• Ly
mph
oede
ma
if ly
mph
nod
es a
re re
mov
ed.
• Fi
stul
a fo
rmat
ion.
• M
etas
tase
s.•
Deat
h.
Sym
ptom
s•
Inte
rmen
stru
al b
leed
ing.
• Po
st-c
oita
l ble
edin
g.•
Post
-men
opau
sal b
leed
ing.
• Ab
norm
al v
agin
al d
isch
arge
.•
Gen
eral
sym
ptom
s of
mal
igna
ncy
(e.g
.
fatig
ue, c
ache
xia,
wei
ght l
oss)
.•
Asym
ptom
atic
– a
bnor
mal
ities
pic
ked
up b
y
the
Nat
iona
l Scr
eeni
ng P
rogr
amm
e (N
SP) U
K.
The
NSP
for c
ervi
cal c
ance
r use
s liq
uid-
base
d
cyto
logy
to c
lass
ify c
ervi
cal i
ntra
epith
elia
l
neop
lasi
a as
wel
l as
iden
tify
HPV
infe
ctio
n.
This
occ
urs
3 ye
arly
age
d 25
–49
and
5 ye
arly
ag
ed 5
0–64
, pro
vidi
ng th
at re
sults
are
no
rmal
.
Wha
t is
cer
vica
l can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
d pr
olife
ratio
n of
cel
ls li
ning
the
cerv
ix. I
t may
be
cate
goriz
ed in
to tw
o di
ffere
nt c
ell t
ypes
:1.
Squ
amou
s ce
ll ca
rcin
oma
(80%
).2.
Ade
noca
rcin
oma
(20%
).
Caus
esTh
e ex
act c
ause
of c
ervi
cal c
ance
r rem
ains
un
know
n bu
t it i
s as
soci
ated
with
sev
eral
risk
fa
ctor
s, th
e m
ost p
rom
inen
t bei
ng th
e hu
man
pa
pillo
mav
irus
(HPV
) (se
e be
low
).
Risk
fact
ors
• HP
V –
type
s 16
, 18
and
33.
• HI
V.•
Mul
tiple
pre
gnan
cies
.•
Mul
tiple
sex
ual p
artn
ers.
• Ea
rly a
ge o
f firs
t sex
ual i
nter
cour
se.
• Co
mbi
ned
oral
con
trac
eptiv
e pi
ll (C
OCP
).•
Incr
easi
ng a
ge.
• Lo
w s
ocio
econ
omic
sta
tus.
• Sm
okin
g.
Cerv
ical
ect
ropi
onDo
es n
ot c
ause
cer
vica
l can
cer b
ut is
incl
uded
in
the
diffe
rent
ial d
iagn
osis
of v
agin
al b
leed
ing.
Wha
t is
cer
vica
l ect
ropi
on?
This
is w
hen
a gr
eate
r pro
port
ion
of c
olum
nar
epith
eliu
m c
ross
es th
e tr
ansi
tion
zone
and
is
pres
ent o
n th
e ec
toce
rvix
rath
er th
an s
trat
ified
sq
uam
ous
cell
epith
eliu
m. C
olum
nar e
pith
eliu
m
is th
inne
r and
far m
ore
fragi
le th
an s
trat
ified
squa
mou
s ce
ll ep
ithel
ium
, the
refo
re it
is m
ore
pron
e to
ble
edin
g.
Caus
es: a
nyth
ing
that
incr
ease
s oe
stro
gen
leve
ls (e
.g. C
OCP
, pre
gnan
cy).
Sym
ptom
s: p
ost-
coita
l ble
edin
g, a
bnor
mal
va
gina
l ble
edin
g, b
leed
ing
on c
onta
ct (e
.g. a
t co
lpos
copy
).
Trea
tmen
t: ab
lativ
e co
ld c
oagu
latio
n.
Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot
met
asta
ses
are
pres
ent.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Li
fest
yle
advi
ce –
sm
okin
g ce
ssat
ion.
• Pr
even
tion
(UK)
: HPV
vac
cina
tion
offe
red
to
scho
olgi
rls a
ged
12.
Med
ical
:•
Chem
othe
rapy
and
radi
othe
rapy
may
be
re
quire
d.
Surg
ical
:•
Cone
bio
psy.
• Hy
ster
ecto
my.
MAP
3.7
. Cer
vica
l can
cer
Map
3.7
. C
ervi
cal c
ance
r
K30033_C003.indd 90 28/02/17 11:17 am
Gyn
aeco
logy
91
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Spec
ific
bloo
d te
sts:
colp
osco
py w
ith
biop
sy o
f cer
vix.
• Ra
diol
ogy:
MRI
of p
elvi
s.•
Stag
e us
ing
the
Fédé
ratio
n In
tern
atio
nale
de
G
ynéc
olog
ie e
t d’O
bsté
triq
ue (F
IGO
) sys
tem
.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
anxi
ety.
• G
ener
al a
nd s
peci
fic c
ompl
icat
ions
of
ch
emot
hera
py a
nd ra
diot
hera
py.
• Ly
mph
oede
ma
if ly
mph
nod
es a
re re
mov
ed.
• Fi
stul
a fo
rmat
ion.
• M
etas
tase
s.•
Deat
h.
Sym
ptom
s•
Inte
rmen
stru
al b
leed
ing.
• Po
st-c
oita
l ble
edin
g.•
Post
-men
opau
sal b
leed
ing.
• Ab
norm
al v
agin
al d
isch
arge
.•
Gen
eral
sym
ptom
s of
mal
igna
ncy
(e.g
.
fatig
ue, c
ache
xia,
wei
ght l
oss)
.•
Asym
ptom
atic
– a
bnor
mal
ities
pic
ked
up b
y
the
Nat
iona
l Scr
eeni
ng P
rogr
amm
e (N
SP) U
K.
The
NSP
for c
ervi
cal c
ance
r use
s liq
uid-
base
d
cyto
logy
to c
lass
ify c
ervi
cal i
ntra
epith
elia
l
neop
lasi
a as
wel
l as
iden
tify
HPV
infe
ctio
n.
This
occ
urs
3 ye
arly
age
d 25
–49
and
5 ye
arly
ag
ed 5
0–64
, pro
vidi
ng th
at re
sults
are
no
rmal
.
Wha
t is
cer
vica
l can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
d pr
olife
ratio
n of
cel
ls li
ning
the
cerv
ix. I
t may
be
cate
goriz
ed in
to tw
o di
ffere
nt c
ell t
ypes
:1.
Squ
amou
s ce
ll ca
rcin
oma
(80%
).2.
Ade
noca
rcin
oma
(20%
).
Caus
esTh
e ex
act c
ause
of c
ervi
cal c
ance
r rem
ains
un
know
n bu
t it i
s as
soci
ated
with
sev
eral
risk
fa
ctor
s, th
e m
ost p
rom
inen
t bei
ng th
e hu
man
pa
pillo
mav
irus
(HPV
) (se
e be
low
).
Risk
fact
ors
• HP
V –
type
s 16
, 18
and
33.
• HI
V.•
Mul
tiple
pre
gnan
cies
.•
Mul
tiple
sex
ual p
artn
ers.
• Ea
rly a
ge o
f firs
t sex
ual i
nter
cour
se.
• Co
mbi
ned
oral
con
trac
eptiv
e pi
ll (C
OCP
).•
Incr
easi
ng a
ge.
• Lo
w s
ocio
econ
omic
sta
tus.
• Sm
okin
g.
Cerv
ical
ect
ropi
onDo
es n
ot c
ause
cer
vica
l can
cer b
ut is
incl
uded
in
the
diffe
rent
ial d
iagn
osis
of v
agin
al b
leed
ing.
Wha
t is
cer
vica
l ect
ropi
on?
This
is w
hen
a gr
eate
r pro
port
ion
of c
olum
nar
epith
eliu
m c
ross
es th
e tr
ansi
tion
zone
and
is
pres
ent o
n th
e ec
toce
rvix
rath
er th
an s
trat
ified
sq
uam
ous
cell
epith
eliu
m. C
olum
nar e
pith
eliu
m
is th
inne
r and
far m
ore
fragi
le th
an s
trat
ified
squa
mou
s ce
ll ep
ithel
ium
, the
refo
re it
is m
ore
pron
e to
ble
edin
g.
Caus
es: a
nyth
ing
that
incr
ease
s oe
stro
gen
leve
ls (e
.g. C
OCP
, pre
gnan
cy).
Sym
ptom
s: p
ost-
coita
l ble
edin
g, a
bnor
mal
va
gina
l ble
edin
g, b
leed
ing
on c
onta
ct (e
.g. a
t co
lpos
copy
).
Trea
tmen
t: ab
lativ
e co
ld c
oagu
latio
n.
Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot
met
asta
ses
are
pres
ent.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Li
fest
yle
advi
ce –
sm
okin
g ce
ssat
ion.
• Pr
even
tion
(UK)
: HPV
vac
cina
tion
offe
red
to
scho
olgi
rls a
ged
12.
Med
ical
:•
Chem
othe
rapy
and
radi
othe
rapy
may
be
re
quire
d.
Surg
ical
:•
Cone
bio
psy.
• Hy
ster
ecto
my.
MAP
3.7
. Cer
vica
l can
cer
Map
3.7
. C
ervi
cal c
ance
r
K30033_C003.indd 91 28/02/17 11:17 am
Gyn
aeco
logy
92 Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot m
etas
tase
s ar
e pr
esen
t.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Li
fest
yle
advi
ce –
sm
okin
g ce
ssat
ion.
• Pr
even
tion
(UK)
: HPV
vac
cina
tion
offe
red
to s
choo
lgirl
s ag
ed 1
2.
Med
ical
:•
Chem
othe
rapy
and
radi
othe
rapy
may
be
requ
ired.
Surg
ical
:•
Part
ial o
r rad
ical
vag
inec
tom
y.•
Radi
cal v
agin
ecto
my
plus
radi
cal h
yste
rect
omy.
• Pe
lvic
exe
nter
atio
n.
Sym
ptom
s•
Asym
ptom
atic
.•
Inte
rmen
stru
al b
leed
ing.
• Po
st-c
oita
l ble
edin
g.•
Post
-men
opau
sal b
leed
ing.
• Ab
norm
al v
agin
al d
isch
arge
.•
Dysp
areu
nia.
• G
ener
al s
ympt
oms
of m
alig
nanc
y
(e.g
. fat
igue
, cac
hexi
a, w
eigh
t los
s)
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
an
xiet
y.•
Gen
eral
and
spe
cific
com
plic
atio
ns o
f
chem
othe
rapy
and
radi
othe
rapy
.•
Lym
phoe
dem
a if
lym
ph n
odes
are
rem
oved
.•
Fist
ula
form
atio
n.•
Met
asta
ses.
• De
ath.
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Spec
ific
bloo
d te
sts:
colp
osco
py w
ith b
iops
y.•
Radi
olog
y: M
RI p
elvi
s.•
Stag
e us
ing
the
FIG
O s
yste
m o
r the
TN
M
stag
ing
syst
em.
MAP
3.8
. Vag
inal
can
cer
Wha
t is
vag
inal
can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
d pr
olife
ratio
n of
cel
ls li
ning
the
vagi
na. I
t may
be
cate
goriz
ed in
to d
iffer
ent c
ell t
ypes
:•
Squa
mou
s ce
ll ca
rcin
oma
(mos
t com
mon
).•
Aden
ocar
cino
ma.
• Cl
ear c
ell a
deno
carc
inom
a.•
Ger
m c
ell t
umou
rs (e
.g. t
erat
omas
).•
Mel
anom
a.
Caus
esTh
e ex
act c
ause
of v
agin
al c
ance
r rem
ains
un
know
n bu
t it i
s as
soci
ated
with
sev
eral
risk
fa
ctor
s (s
ee b
elow
).
Risk
fact
ors
Rem
embe
r the
se a
s VA
GIN
A:
V –
Viru
ses
(e.g
. HPV
, HIV
)A
– in
crea
sing
Age
G –
Gen
eral
fact
ors
such
as
smok
ing
and
alco
hol
I –
chro
nic
Irrita
tion
(e.g
. fro
m p
rolo
nged
pes
sary
use)
N –
Neo
plas
ms
(e.g
. hav
ing
cerv
ical
can
cer
in
crea
ses
the
risk
of v
agin
al s
quam
ous
cell
c
arci
nom
a)A
– v
agin
al A
deno
sis
Map
3.8
. V
agin
al c
ance
r
K30033_C003.indd 92 28/02/17 11:17 am
Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot m
etas
tase
s ar
e pr
esen
t.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Li
fest
yle
advi
ce –
sm
okin
g ce
ssat
ion.
• Pr
even
tion
(UK)
: HPV
vac
cina
tion
offe
red
to s
choo
lgirl
s ag
ed 1
2.
Med
ical
:•
Chem
othe
rapy
and
radi
othe
rapy
may
be
requ
ired.
Surg
ical
:•
Part
ial o
r rad
ical
vag
inec
tom
y.•
Radi
cal v
agin
ecto
my
plus
radi
cal h
yste
rect
omy.
• Pe
lvic
exe
nter
atio
n.
Sym
ptom
s•
Asym
ptom
atic
.•
Inte
rmen
stru
al b
leed
ing.
• Po
st-c
oita
l ble
edin
g.•
Post
-men
opau
sal b
leed
ing.
• Ab
norm
al v
agin
al d
isch
arge
.•
Dysp
areu
nia.
• G
ener
al s
ympt
oms
of m
alig
nanc
y
(e.g
. fat
igue
, cac
hexi
a, w
eigh
t los
s)
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
an
xiet
y.•
Gen
eral
and
spe
cific
com
plic
atio
ns o
f
chem
othe
rapy
and
radi
othe
rapy
.•
Lym
phoe
dem
a if
lym
ph n
odes
are
rem
oved
.•
Fist
ula
form
atio
n.•
Met
asta
ses.
• De
ath.
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Spec
ific
bloo
d te
sts:
colp
osco
py w
ith b
iops
y.•
Radi
olog
y: M
RI p
elvi
s.•
Stag
e us
ing
the
FIG
O s
yste
m o
r the
TN
M
stag
ing
syst
em.
MAP
3.8
. Vag
inal
can
cer
Wha
t is
vag
inal
can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
d pr
olife
ratio
n of
cel
ls li
ning
the
vagi
na. I
t may
be
cate
goriz
ed in
to d
iffer
ent c
ell t
ypes
:•
Squa
mou
s ce
ll ca
rcin
oma
(mos
t com
mon
).•
Aden
ocar
cino
ma.
• Cl
ear c
ell a
deno
carc
inom
a.•
Ger
m c
ell t
umou
rs (e
.g. t
erat
omas
).•
Mel
anom
a.
Caus
esTh
e ex
act c
ause
of v
agin
al c
ance
r rem
ains
un
know
n bu
t it i
s as
soci
ated
with
sev
eral
risk
fa
ctor
s (s
ee b
elow
).
Risk
fact
ors
Rem
embe
r the
se a
s VA
GIN
A:
V –
Viru
ses
(e.g
. HPV
, HIV
)A
– in
crea
sing
Age
G –
Gen
eral
fact
ors
such
as
smok
ing
and
alco
hol
I –
chro
nic
Irrita
tion
(e.g
. fro
m p
rolo
nged
pes
sary
use)
N –
Neo
plas
ms
(e.g
. hav
ing
cerv
ical
can
cer
in
crea
ses
the
risk
of v
agin
al s
quam
ous
cell
c
arci
nom
a)A
– v
agin
al A
deno
sis
93G
ynae
colo
gyM
ap 3
.8.
Vag
inal
can
cer
K30033_C003.indd 93 28/02/17 11:17 am
Gyn
aeco
logy
94 Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot m
etas
tase
s ar
e pr
esen
t.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Chem
othe
rapy
and
radi
othe
rapy
may
be
requ
ired.
Surg
ical
:•
Tota
l abd
omin
al h
yste
rect
omy
with
bila
tera
l sal
ping
o-oo
phor
ecto
my
+
/– ly
mph
aden
ecto
my.
Sym
ptom
s•
A w
oman
with
pos
t-m
enop
ausa
l ble
edin
g is
co
nsid
ered
to h
ave
endo
met
rial c
ance
r unt
il
prov
en o
ther
wis
e.•
Prem
enop
ausa
l wom
en: i
nter
men
stru
al
blee
ding
, pos
t-co
ital b
leed
ing.
• G
ener
al s
ympt
oms
of m
alig
nanc
y (e
.g. f
atig
ue,
ca
chex
ia, w
eigh
t los
s)
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
an
xiet
y.•
Gen
eral
and
spe
cific
com
plic
atio
ns o
f
chem
othe
rapy
and
radi
othe
rapy
.•
Lym
phoe
dem
a if
lym
ph n
odes
are
rem
oved
.•
Fist
ula
form
atio
n.•
Met
asta
ses.
• De
ath.
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Radi
olog
y: fi
rst l
ine
– tr
ansv
agin
al U
SS
(<4
mm
= n
orm
al).
• Th
is m
ay b
e fo
llow
ed b
y hy
ster
osco
py w
ith
endo
met
rial b
iops
y.•
MRI
of p
elvi
s –
for s
tagi
ng a
nd m
etas
tase
s.•
Stag
e us
ing
the
FIG
O s
yste
m o
r the
TN
M
stag
ing
syst
em.
MAP
3.9
. End
omet
rial
can
cer
Wha
t is
end
omet
rial
can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
dpr
olife
ratio
n of
the
endo
met
rium
.It
may
be
cate
goriz
ed in
to d
iffer
ent c
ell t
ypes
, m
ost o
f whi
ch a
re a
deno
carc
inom
as.
Caus
esIt
is d
ue to
the
unop
pose
d ac
tion
of o
estr
ogen
on
the
endo
met
rium
. Ris
k fa
ctor
s ar
e lis
ted
belo
w.
Risk
fact
ors
Rem
embe
r the
se a
s EN
DO
MET
RIU
M:
E –
Early
men
arch
eN
– N
ullip
arity
D –
Dia
bete
s m
ellit
usO
– p
olyc
ystic
Ova
ry s
yndr
ome
M –
Men
opau
se (l
ate)
E T –
Tam
oxife
nR
– H
RTI
– In
crea
sed
risk
with
oth
er c
ance
rs (e
.g. b
reas
t
an
d ov
aria
n)U
– U
nopp
osed
oes
trog
en (e
.g. a
novu
latio
n, H
RT)
M –
Men
stru
al ir
regu
larit
y
Map
3.9
. En
do
met
rial
can
cer
K30033_C003.indd 94 28/02/17 11:17 am
Gyn
aeco
logy
95Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot m
etas
tase
s ar
e pr
esen
t.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Chem
othe
rapy
and
radi
othe
rapy
may
be
requ
ired.
Surg
ical
:•
Tota
l abd
omin
al h
yste
rect
omy
with
bila
tera
l sal
ping
o-oo
phor
ecto
my
+
/– ly
mph
aden
ecto
my.
Sym
ptom
s•
A w
oman
with
pos
t-m
enop
ausa
l ble
edin
g is
co
nsid
ered
to h
ave
endo
met
rial c
ance
r unt
il
prov
en o
ther
wis
e.•
Prem
enop
ausa
l wom
en: i
nter
men
stru
al
blee
ding
, pos
t-co
ital b
leed
ing.
• G
ener
al s
ympt
oms
of m
alig
nanc
y (e
.g. f
atig
ue,
ca
chex
ia, w
eigh
t los
s)
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
and
an
xiet
y.•
Gen
eral
and
spe
cific
com
plic
atio
ns o
f
chem
othe
rapy
and
radi
othe
rapy
.•
Lym
phoe
dem
a if
lym
ph n
odes
are
rem
oved
.•
Fist
ula
form
atio
n.•
Met
asta
ses.
• De
ath.
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Radi
olog
y: fi
rst l
ine
– tr
ansv
agin
al U
SS
(<4
mm
= n
orm
al).
• Th
is m
ay b
e fo
llow
ed b
y hy
ster
osco
py w
ith
endo
met
rial b
iops
y.•
MRI
of p
elvi
s –
for s
tagi
ng a
nd m
etas
tase
s.•
Stag
e us
ing
the
FIG
O s
yste
m o
r the
TN
M
stag
ing
syst
em.
MAP
3.9
. End
omet
rial
can
cer
Wha
t is
end
omet
rial
can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
dpr
olife
ratio
n of
the
endo
met
rium
.It
may
be
cate
goriz
ed in
to d
iffer
ent c
ell t
ypes
, m
ost o
f whi
ch a
re a
deno
carc
inom
as.
Caus
esIt
is d
ue to
the
unop
pose
d ac
tion
of o
estr
ogen
on
the
endo
met
rium
. Ris
k fa
ctor
s ar
e lis
ted
belo
w.
Risk
fact
ors
Rem
embe
r the
se a
s EN
DO
MET
RIU
M:
E –
Early
men
arch
eN
– N
ullip
arity
D –
Dia
bete
s m
ellit
usO
– p
olyc
ystic
Ova
ry s
yndr
ome
M –
Men
opau
se (l
ate)
E T –
Tam
oxife
nR
– H
RTI
– In
crea
sed
risk
with
oth
er c
ance
rs (e
.g. b
reas
t
an
d ov
aria
n)U
– U
nopp
osed
oes
trog
en (e
.g. a
novu
latio
n, H
RT)
M –
Men
stru
al ir
regu
larit
y
Map
3.9
. En
do
met
rial
can
cer
K30033_C003.indd 95 28/02/17 11:17 am
Gyn
aeco
logy
96 Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot
met
asta
ses
are
pres
ent.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Chem
othe
rapy
usu
ally
requ
ired
and
ra
diot
hera
py m
ay b
e re
quire
d.
Surg
ical
:•
Depe
nds
on th
e in
divi
dual
cas
e an
d m
ay
incl
ude
ooph
orec
tom
y, sa
lpin
gect
omy,
hy
ster
ecto
my,
omen
tect
omy.
Sym
ptom
sSy
mpt
oms
are
gene
rally
real
ly v
ague
, whi
ch is
why
ov
aria
n ca
ncer
can
be
so d
iffic
ult t
o di
agno
se.
Sym
ptom
s in
clud
e:•
Abdo
min
al p
ain.
• Ab
dom
inal
blo
atin
g.•
Inte
rmen
stru
al b
leed
ing.
• Po
st-c
oita
l ble
edin
g.•
Early
sat
iety
.•
Sym
ptom
s of
bla
dder
dys
func
tion
or
irrita
tion
such
as
frequ
ency
and
urg
ency
.•
Gen
eral
sym
ptom
s of
mal
igna
ncy
(e.g
. fat
igue
,
cach
exia
, wei
ght l
oss)
.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
an
d an
xiet
y.•
Gen
eral
and
spe
cific
com
plic
atio
ns o
f
chem
othe
rapy
and
radi
othe
rapy
.•
Lym
phoe
dem
a if
lym
ph n
odes
are
rem
oved
.•
Fist
ula
form
atio
n.•
Met
asta
ses.
• De
ath.
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Tum
our m
arke
r: CA
125
(dia
gnos
is a
nd
follo
w-u
p).
• Ra
diol
ogy:
tran
svag
inal
USS
.•
CT o
r MRI
of p
elvi
s –
for s
tagi
ng a
nd
met
asta
ses.
• Su
rger
y: d
iagn
ostic
lapa
roto
my
with
bio
psy.
• St
age
usin
g th
e FI
GO
sys
tem
or t
he T
NM
sy
stem
.•
Risk
of M
alig
nanc
y In
dex
(RM
I) m
ay b
e us
ed to
ca
lcul
ate
the
risk
of h
avin
g a
mal
igna
nt
ovar
ian
tum
our =
ultr
asou
nd s
core
×
men
opau
sal s
core
× C
A 12
5 m
easu
rem
ent.
MAP
3.1
0. O
vari
an c
ance
r
Wha
t is
ova
rian
can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
dpr
olife
ratio
n of
ova
rian
tissu
e. A
ppro
xim
atel
y90
% a
rise
from
epi
thel
ial t
issu
e. M
ay o
ccur
se
cond
arily
(e.g
. met
asta
sis
from
ano
ther
site
, us
ually
the
GI t
ract
, whe
re it
is k
now
n as
a
Kruk
enbe
rg tu
mou
r).
Caus
esTh
e ex
act c
ause
of o
varia
n ca
ncer
is u
nkno
wn;
ho
wev
er, i
t is
stro
ngly
ass
ocia
ted
with
mul
tiple
ov
ulat
ions
and
oth
er ri
sk fa
ctor
s (s
ee b
elow
).
Risk
fact
ors
Rem
embe
r the
se a
s A
BCD
E:A
– in
crea
sing
Age
B –
BRC
A1 a
nd B
RCA2
gen
esC
– CO
CP is
pro
tect
ive!
!D
– D
urat
ion
of o
vula
tion
(i.e.
nul
lipar
ity, e
arly
men
arch
e an
d la
te m
enop
ause
)E
– En
dom
etrio
sis
Map
3.1
0. O
vari
an c
ance
r
K30033_C003.indd 96 28/02/17 11:17 am
Trea
tmen
tDe
pend
s on
FIG
O s
tage
and
whe
ther
or n
ot
met
asta
ses
are
pres
ent.
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Chem
othe
rapy
usu
ally
requ
ired
and
ra
diot
hera
py m
ay b
e re
quire
d.
Surg
ical
:•
Depe
nds
on th
e in
divi
dual
cas
e an
d m
ay
incl
ude
ooph
orec
tom
y, sa
lpin
gect
omy,
hy
ster
ecto
my,
omen
tect
omy.
Sym
ptom
sSy
mpt
oms
are
gene
rally
real
ly v
ague
, whi
ch is
why
ov
aria
n ca
ncer
can
be
so d
iffic
ult t
o di
agno
se.
Sym
ptom
s in
clud
e:•
Abdo
min
al p
ain.
• Ab
dom
inal
blo
atin
g.•
Inte
rmen
stru
al b
leed
ing.
• Po
st-c
oita
l ble
edin
g.•
Early
sat
iety
.•
Sym
ptom
s of
bla
dder
dys
func
tion
or
irrita
tion
such
as
frequ
ency
and
urg
ency
.•
Gen
eral
sym
ptom
s of
mal
igna
ncy
(e.g
. fat
igue
,
cach
exia
, wei
ght l
oss)
.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns –
dep
ress
ion
an
d an
xiet
y.•
Gen
eral
and
spe
cific
com
plic
atio
ns o
f
chem
othe
rapy
and
radi
othe
rapy
.•
Lym
phoe
dem
a if
lym
ph n
odes
are
rem
oved
.•
Fist
ula
form
atio
n.•
Met
asta
ses.
• De
ath.
Inve
stig
atio
ns•
Gen
eral
blo
od te
sts:
FBC,
U&
E, L
FTs,
TFTs
.•
Tum
our m
arke
r: CA
125
(dia
gnos
is a
nd
follo
w-u
p).
• Ra
diol
ogy:
tran
svag
inal
USS
.•
CT o
r MRI
of p
elvi
s –
for s
tagi
ng a
nd
met
asta
ses.
• Su
rger
y: d
iagn
ostic
lapa
roto
my
with
bio
psy.
• St
age
usin
g th
e FI
GO
sys
tem
or t
he T
NM
sy
stem
.•
Risk
of M
alig
nanc
y In
dex
(RM
I) m
ay b
e us
ed to
ca
lcul
ate
the
risk
of h
avin
g a
mal
igna
nt
ovar
ian
tum
our =
ultr
asou
nd s
core
×
men
opau
sal s
core
× C
A 12
5 m
easu
rem
ent.
MAP
3.1
0. O
vari
an c
ance
r
Wha
t is
ova
rian
can
cer?
This
is u
ncon
trol
led
diffe
rent
iatio
n an
dpr
olife
ratio
n of
ova
rian
tissu
e. A
ppro
xim
atel
y90
% a
rise
from
epi
thel
ial t
issu
e. M
ay o
ccur
se
cond
arily
(e.g
. met
asta
sis
from
ano
ther
site
, us
ually
the
GI t
ract
, whe
re it
is k
now
n as
a
Kruk
enbe
rg tu
mou
r).
Caus
esTh
e ex
act c
ause
of o
varia
n ca
ncer
is u
nkno
wn;
ho
wev
er, i
t is
stro
ngly
ass
ocia
ted
with
mul
tiple
ov
ulat
ions
and
oth
er ri
sk fa
ctor
s (s
ee b
elow
).
Risk
fact
ors
Rem
embe
r the
se a
s A
BCD
E:A
– in
crea
sing
Age
B –
BRC
A1 a
nd B
RCA2
gen
esC
– CO
CP is
pro
tect
ive!
!D
– D
urat
ion
of o
vula
tion
(i.e.
nul
lipar
ity, e
arly
men
arch
e an
d la
te m
enop
ause
)E
– En
dom
etrio
sis
97G
ynae
colo
gyM
ap 3
.10.
Ova
rian
can
cer
K30033_C003.indd 97 28/02/17 11:17 am
Gyn
aeco
logy
98Ta
ble
3.5.
Ova
rian
cys
ts
TABL
E 3.
5. O
vari
an c
ysts
. Ova
rian
cys
ts m
ay b
e be
nign
or
mal
igna
nt. U
ltra
soun
d is
use
d to
ass
ess
whi
ch is
mor
e lik
ely.
U
nilo
cula
r cy
sts
are
likel
y ph
ysio
logi
cal/b
enig
n, w
here
as m
ulti
locu
lar
com
plex
cys
ts r
aise
sus
pici
on o
f a
mal
igna
nt le
sion
.
Type
of
cyst
Key
feat
ures
Folli
cula
r cys
tTh
e m
ost c
omm
on ty
pe o
f phy
siol
ogic
al c
yst
Corp
us lu
teum
cys
tHi
gher
tend
ency
to c
ause
intr
aper
itone
al b
leed
ing
Derm
oid
cyst
Beni
gn g
erm
cel
l tum
our
Tors
ion
mor
e lik
ely
Epith
elia
l tum
ours
1. S
erou
s cy
stad
enom
a:
Com
mon
est
M
ay m
imic
feat
ures
of s
erou
s ca
rcin
oma
2. M
ucin
ous
cyst
aden
oma:
M
ay b
e m
assi
ve in
siz
e
Endo
met
riom
aAl
so k
now
n as
‘cho
cola
te c
ysts
’Co
mpl
icat
ion
of e
ndom
etrio
sis
Wha
t is
end
omet
rios
is?
A co
nditi
on w
here
end
omet
rial t
issu
e oc
curs
out
side
the
uter
ine
cavi
ty.
Caus
es: T
he e
xact
cau
se is
unk
now
n bu
t the
pre
sent
theo
ry re
gard
s re
trog
rade
men
stru
atio
n as
the
mos
t lik
ely
fact
or.
Sym
ptom
s: C
hron
ic p
elvi
c pa
in, r
etro
vert
ed u
teru
s, dy
smen
orrh
oea,
dee
p dy
spar
euni
a.In
vest
igat
ions
: Bim
anua
l and
spe
culu
m e
xam
inat
ion
follo
wed
by
lapa
rosc
opy.
Trea
tmen
t:
• Co
nser
vativ
e: p
atie
nt e
duca
tion.
• M
edic
al: a
ste
pwis
e ap
proa
ch is
em
ploy
ed. F
irst l
ine:
NSA
IDs.
Seco
nd li
ne: p
arac
etam
ol. T
hird
line
: cod
eine
. Hor
mon
al
ther
apy
such
as
the
COCP
may
be
used
if th
ese
pain
med
icat
ions
fail.
• Su
rgic
al: l
aser
abl
atio
n, a
dhes
ioly
sis,
tota
l abd
omin
al h
yste
rect
omy.
K30033_C003.indd 98 28/02/17 11:17 am
Gyn
aeco
logy
99Ta
ble
3.6.
In
con
tin
ence
TABL
E 3.
6. In
cont
inen
ce.
Type
Wha
t is
it?
Inve
stig
atio
nsTr
eatm
ent
Stre
ss in
cont
inen
ce•
Urin
e is
lost
by
any
mov
emen
t tha
t in
crea
ses
intr
a-ab
dom
inal
pre
ssur
e (e
.g. s
neez
ing
and
coug
hing
) •
Aggr
avat
ing
fact
ors
incl
ude
preg
nanc
y, ob
esity
, CO
PD
• U
rinal
ysis
•
Post
-voi
d re
sidu
al v
olum
e•
Uro
dyna
mic
test
ing
• En
dosc
ope
test
s•
Radi
olog
y: x
-ray
, USS
• Co
nser
vativ
e: p
atie
nt e
duca
tion,
lif
esty
le a
dvic
e su
ch a
s sm
okin
g ce
ssat
ion,
wei
ght l
oss
• Fi
rst l
ine:
Keg
el p
elvi
c flo
or e
xerc
ises
•
Med
ical
: oes
trog
en m
ay b
e gi
ven
to
post
-men
opau
sal w
omen
•
Surg
ery:
ure
thro
pexy
, bla
dder
nec
k su
spen
sion
sur
gery
(Bur
ch a
nd s
ling
proc
edur
es)
Urg
e in
cont
inen
ce•
Too
muc
h co
ntra
ctio
n •
Urin
e is
lost
by
inap
prop
riate
det
ruso
r m
uscl
e co
ntra
ctio
n •
Caus
e: m
ay b
e du
e to
neo
plas
ms
or
nerv
e da
mag
e (e
.g. m
ultip
le s
cler
osis,
Pa
rkin
son’
s di
seas
e, s
trok
e)
• U
rinal
ysis
•
Post
-voi
d re
sidu
al v
olum
e•
Uro
dyna
mic
test
ing
• En
dosc
ope
test
s•
Radi
olog
y: x
-ray
, USS
• An
ticho
liner
gic
med
icat
ions
(e
.g. o
xybu
tyni
n th
erap
y)•
Trea
tmen
t of u
nder
lyin
g co
nditi
on
Ove
rflow
inco
ntin
ence
• To
o lit
tle c
ontr
actio
n •
This
hap
pens
due
to a
mar
ked
incr
ease
d in
bla
dder
resi
dual
vol
ume;
th
eref
ore,
the
blad
der i
s us
ually
full
and
thus
freq
uent
ly le
aks
urin
e
• U
rinal
ysis
•
Post
-voi
d re
sidu
al v
olum
e•
Uro
dyna
mic
test
ing
• En
dosc
ope
test
s•
Radi
olog
y: x
-ray
, USS
• Co
nser
vativ
e: p
atie
nt e
duca
tion,
sto
p m
edic
atio
ns if
they
are
the
caus
e•
Inte
rmitt
ent c
athe
teriz
atio
n•
Beth
anec
hol (
chol
iner
gic)
may
impr
ove
detr
usor
mus
cle
activ
ity
K30033_C003.indd 99 28/02/17 11:17 am
Gyn
aeco
logy
100
Tabl
e 3.
7. C
on
trac
epti
on
TABL
E 3.
7. C
ontr
acep
tion
. Con
sult
the
UK
MEC
gui
delin
es r
egar
ding
con
trac
epti
ve c
hoic
es
(htt
p://w
ww
.fsr
h.or
g/pd
fs/U
KM
EC20
09.p
df).
Effic
acy
of c
ontr
acep
tion
depe
nds
on th
e Pe
arl I
ndex
(the
num
ber o
f uni
nten
ded
preg
nanc
ies
per 1
00 w
oman
yea
rs).
A
high
Pea
rl In
dex
equa
tes
to a
hig
her c
hanc
e of
an
unin
tend
ed p
regn
ancy
.
Type
Exam
ples
Barr
ier m
etho
dsCo
ndom
– m
ale
and
fem
ale
Diap
hrag
mCa
p
Horm
onal
con
trac
eptio
nCO
CP:
• M
echa
nism
of a
ctio
n: p
reve
nts
ovul
atio
n an
d pr
even
ts im
plan
tatio
n by
thin
ning
the
endo
met
rial l
inin
g•
Man
y co
ntra
indi
catio
ns. R
efer
to U
KMEC
gui
delin
es. T
here
are
four
cat
egor
ies
in th
e U
KMEC
gui
delin
es; 1
– g
ener
ally
saf
e;
2 –
bene
fits
outw
eigh
the
risks
; 3 –
risk
s ou
twei
gh th
e be
nefit
s; 4
– un
safe
•
Effe
ctiv
e co
ntra
cept
ion:
afte
r 7 d
ays
POP:
• M
echa
nism
of a
ctio
n: th
icke
ns th
e ce
rvic
al m
ucus
and
sec
retio
ns m
akin
g it
inho
spita
ble
to s
perm
• Ef
fect
ive
cont
race
ptio
n: a
fter 2
day
s
Cont
race
ptiv
e in
ject
ion:
• De
po-P
rove
ra is
mai
nly
used
in th
e U
K•
Giv
en 1
2 w
eekl
y•
Dela
y in
retu
rn o
f fer
tility
onc
e st
oppi
ng th
e in
ject
ion.
Mak
e ta
ke u
p to
12
mon
ths
to re
turn
• Ef
fect
ive
cont
race
ptio
n: a
fter 7
day
s
K30033_C003.indd 100 28/02/17 11:17 am
Gyn
aeco
logy
101
Tabl
e 3.
7. C
on
trac
epti
on
Cont
race
ptiv
e im
plan
t:•
The
radi
opaq
ue im
plan
t (N
expl
anon
) is
inse
rted
sub
derm
ally
in th
e no
n-do
min
ant a
rm•
Is th
e lo
ng-a
ctin
g co
ntra
cept
ion
of c
hoic
e in
you
ng p
eopl
e w
ho m
ay n
ot re
liabl
y ta
ke th
e pi
ll •
Effe
ctiv
e co
ntra
cept
ion:
afte
r 7 d
ays
Emer
genc
y co
ntra
cept
ive
pill:
• 1.
5 m
g le
vono
rges
trel
take
n w
ithin
72
hour
s of
unp
rote
cted
inte
rcou
rse
Intr
aute
rine
cont
race
ptio
nIn
trau
terin
e de
vice
(IU
D):
• IU
D al
so k
now
n as
the
copp
er c
oil
• M
echa
nism
of a
ctio
n: th
e co
pper
ions
are
thou
ght t
o cr
eate
a h
ostil
e en
viro
nmen
t for
spe
rm
• Ef
fect
ive
cont
race
ptio
n: im
med
iate
ly
Inte
rute
rine
syst
em (I
US)
:•
IUS,
als
o kn
own
as th
e M
irena
sys
tem
, rel
ease
s le
vono
rges
trel
•
Mec
hani
sm o
f act
ion:
thic
kens
cer
vica
l muc
us a
nd s
ecre
tions
. Pre
vent
s en
dom
etria
l pro
lifer
atio
n•
Effe
ctiv
e co
ntra
cept
ion:
afte
r 7 d
ays
Irrev
ersi
ble
cont
race
ptio
nM
ale
ster
iliza
tion:
•
An e
asie
r pro
cedu
re to
per
form
than
fem
ale
ster
iliza
tion
• M
ay b
e do
ne a
s an
out
patie
nt p
roce
dure
und
er lo
cal a
naes
thes
ia•
Two
sem
en s
ampl
es m
ust b
e su
pplie
d af
ter t
he p
roce
dure
at 1
6 an
d 20
wee
ks to
ens
ure
that
it h
as w
orke
d
Fem
ale
ster
iliza
tion:
•
Perfo
rmed
und
er g
ener
al a
naes
thes
ia•
Man
y di
ffere
nt m
etho
ds m
ay b
e us
ed (e
.g. F
ilshi
e cl
ips
or F
alop
e rin
gs)
K30033_C003.indd 101 28/02/17 11:17 am
Chap
ter F
our P
aedi
atri
cs
MAP
4.1
N
eon
atal
jau
nd
ice
104
MAP
4.2
N
ecro
tizi
ng
en
tero
colit
is (
NEC
) 10
6
MAP
4.3
H
yper
tro
ph
ic p
ylo
ric
sten
osi
s 10
8
MAP
4.4
H
irsc
hsp
run
g’s
dis
ease
10
9
MAP
4.5
In
tuss
usc
epti
on
11
0
TABL
E 4.
1 A
nte
rio
r ab
do
min
al w
all d
efec
ts
111
MAP
4.6
C
on
gen
ital
car
dia
c d
efec
ts
112
MAP
4.7
G
enit
ou
rin
ary
abn
orm
alit
ies
114
TABL
E 4.
2 N
euro
cuta
neo
us
syn
dro
mes
11
6
MAP
4.8
N
eura
l tu
be
def
ects
(N
TDs)
11
8
MAP
4.9
C
ereb
ral p
alsy
12
0
MAP
4.1
0 M
enin
git
is
122
MAP
4.1
1 Fa
ilure
to
th
rive
12
4
MAP
4.1
2 B
ron
chio
litis
12
6
MAP
4.1
3 C
rou
p
128
Paed
iatr
ics
MAP
4.1
4 C
ysti
c fi
bro
sis
(CF)
13
0
MAP
4.1
5 A
sth
ma
132
TABL
E 4.
3 Fl
ow
ch
art
sum
mar
izin
g t
he
B
riti
sh T
ho
raci
c So
ciet
y g
uid
elin
es
134
MAP
4.1
6 R
heu
mat
ic f
ever
13
6
MAP
4.1
7 U
rin
ary
trac
t in
fect
ion
(U
TI)
138
MAP
4.1
8 H
aem
oly
tic
ura
emic
syn
dro
me
(HU
S)
140
MAP
4.1
9 H
eno
ch–S
chö
nle
in p
urp
ura
(H
SP)
142
TABL
E 4.
4 C
hild
ho
od
ep
ilep
sy s
ynd
rom
es
144
MAP
4.2
0 D
iab
etic
ket
oac
ido
sis
(DK
A)
146
FIG
URE
4.1
Path
op
hys
iolo
gy
of
dia
bet
ic
keto
acid
osi
s 14
8
TABL
E 4.
5 Tr
iso
mie
s 14
9
MAP
4.2
1 K
awas
aki’s
dis
ease
15
0
TABL
E 4.
6 C
hild
ho
od
can
cers
15
2
103
K30033_C004.indd 103 28/02/17 11:43 am
Paed
iatr
ics
104 Wha
t is
neo
nata
l jau
ndic
e?Ja
undi
ce, a
lso
know
n as
icte
rus,
is th
e ye
llow
dis
colo
urat
ion
of m
ucou
s m
embr
anes
, scl
era
and
skin
. Thi
s oc
curs
due
to th
e ac
cum
ulat
ion
of
bilir
ubin
. Jau
ndic
e m
ay b
e se
en a
t a b
iliru
bin
conc
entra
tion
>42.
8 µm
ol/L
(2
.5 m
g/dL
).
Caus
esTh
e ca
uses
of j
aund
ice
may
be
split
into
thre
e ca
tego
ries:
1. P
re-h
epat
ic ja
undi
ce.
2. In
tra-
hepa
tic ja
undi
ce.
3. P
ost-
hepa
tic ja
undi
ce.
For n
eona
tes
it m
ay b
e fu
rthe
r sub
divi
ded
into
a ti
me
scal
e: <
24 h
ours
, 24
hou
rs to
3 w
eeks
, and
>3
wee
ks. S
ee Ta
ble
oppo
site
for m
ore
deta
ils.
Sym
ptom
sPo
or fe
edin
g, fa
ilure
to th
rive
and
yello
w d
isco
lour
atio
n as
wel
l as
SICK
:S
– Se
izur
esI
– Irr
itabi
lity,
Incr
ease
d m
uscl
e to
neC
– Co
ma
K –
Kern
icte
rus
MA
P 4.
1. N
eona
tal j
aund
ice
Inve
stig
atio
nsM
ust d
eter
min
e un
derly
ing
caus
e.
Use
thes
e te
sts
to d
eter
min
e th
e ty
pe o
f jau
ndic
e:•
Appe
aran
ce o
f urin
e an
d st
ool.
• LF
Ts.
• Bi
lirub
in le
vels.
• Al
kalin
e ph
osph
atas
e le
vels.
Tabl
e to
sho
w t
he d
iffer
ent
bloo
d re
sult
s fo
r di
ffer
ent
type
s of
ja
undi
ce:
Pre-
hepa
tic
jaun
dice
Inve
stig
atio
nIn
tra-
hepa
tic
jaun
dice
Post
-hep
atic
jaun
dice
Appe
aran
ce o
fur
ine
Nor
mal
Dark
Dark
Dark
Dark
Appe
aran
ce o
fst
ool
Nor
mal
Nor
mal
or p
ale
Pale
Conj
ugat
edbi
lirub
inN
orm
al
Unc
onju
gate
dbi
lirub
inN
orm
al o
r N
orm
al
Tota
l bili
rubi
nN
orm
al o
r
Alka
line
phos
phat
ase
Nor
mal
<24
hou
rs
>3
wee
ksU
ncon
juga
ted
caus
es: i
nfec
tion,
a p
hysi
olog
ical
cau
se, h
aem
olyt
ic c
ause
s. Co
njug
ated
cau
ses:
hepa
titis,
obs
truc
ted
bile
duc
t.
Infe
ctio
n (e
.g. T
ORC
HES
[see
Map
2.6
, p. 5
0])
Haem
olyt
ic d
isor
ders
:•
ABO
inco
mpa
tibili
ty.
• Rh
esus
inco
mpa
tibili
ty.
• G
6PD
defic
ienc
y:
X-
linke
d co
nditi
on.
Defic
ienc
y in
glu
cose
-6-p
hosp
hate
deh
ydro
gena
se. R
esul
tant
effe
ct is
a d
ecre
ase
in a
ntio
xida
nt N
ADPH
mea
ning
that
RBC
s ar
e
mor
e su
scep
tible
to o
xida
tive
stre
ss (e
.g. i
nfec
tion/
cert
ain
food
s su
ch a
s fa
va b
eans
). Bl
ood
smea
r: He
inz
bodi
es, b
ite c
ells.
• Sp
hero
cyto
sis:
Auto
som
al d
omin
ant c
ondi
tion.
Caus
ed b
y fu
nctio
nal a
bnor
mal
ity o
f str
uctu
ral R
BC m
embr
ane
prot
eins
(e.g
. spe
ctrin
, ank
yrin
)
Bl
ood
smea
r: sp
hero
cyte
s.
24 h
ours
to
3 w
eeks
Rem
embe
r as
ABC
:A
– A
phy
siol
ogic
al c
ause
B –
Brea
st m
ilk ja
undi
ceC
– Cr
igle
r–N
ajja
r syn
drom
e: a
utos
omal
rece
ssiv
e co
nditi
on. T
wo
type
s: ty
pe 1
: abs
ence
of U
DP g
lucu
rono
syl t
rans
fera
se 1
-A1;
t
ype
2: re
duce
d le
vels
of U
DP g
lucu
rono
syl t
rans
fera
se 1
-A1.
Haem
olys
isIn
fect
ion
Caus
eTi
me
elap
sed
post
nata
lly
Trea
tmen
tTr
eat u
nder
lyin
g ca
use
Com
plic
atio
ns•
Live
r fai
lure
.
• Pa
ncre
atiti
s.
• Re
nal f
ailu
re.
• Se
psis.
• Ch
olan
gitis
.•
Bilia
ry c
irrho
sis.
Map
4.1
. N
eon
atal
jau
nd
ice
K30033_C004.indd 104 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
. N
eon
atal
jau
nd
ice
Wha
t is
neo
nata
l jau
ndic
e?Ja
undi
ce, a
lso
know
n as
icte
rus,
is th
e ye
llow
dis
colo
urat
ion
of m
ucou
s m
embr
anes
, scl
era
and
skin
. Thi
s oc
curs
due
to th
e ac
cum
ulat
ion
of
bilir
ubin
. Jau
ndic
e m
ay b
e se
en a
t a b
iliru
bin
conc
entra
tion
>42.
8 µm
ol/L
(2
.5 m
g/dL
).
Caus
esTh
e ca
uses
of j
aund
ice
may
be
split
into
thre
e ca
tego
ries:
1. P
re-h
epat
ic ja
undi
ce.
2. In
tra-
hepa
tic ja
undi
ce.
3. P
ost-
hepa
tic ja
undi
ce.
For n
eona
tes
it m
ay b
e fu
rthe
r sub
divi
ded
into
a ti
me
scal
e: <
24 h
ours
, 24
hou
rs to
3 w
eeks
, and
>3
wee
ks. S
ee Ta
ble
oppo
site
for m
ore
deta
ils.
Sym
ptom
sPo
or fe
edin
g, fa
ilure
to th
rive
and
yello
w d
isco
lour
atio
n as
wel
l as
SICK
:S
– Se
izur
esI
– Irr
itabi
lity,
Incr
ease
d m
uscl
e to
neC
– Co
ma
K –
Kern
icte
rus
MA
P 4.
1. N
eona
tal j
aund
ice
Inve
stig
atio
nsM
ust d
eter
min
e un
derly
ing
caus
e.
Use
thes
e te
sts
to d
eter
min
e th
e ty
pe o
f jau
ndic
e:•
Appe
aran
ce o
f urin
e an
d st
ool.
• LF
Ts.
• Bi
lirub
in le
vels.
• Al
kalin
e ph
osph
atas
e le
vels.
Tabl
e to
sho
w t
he d
iffer
ent
bloo
d re
sult
s fo
r di
ffer
ent
type
s of
ja
undi
ce:
Pre-
hepa
tic
jaun
dice
Inve
stig
atio
nIn
tra-
hepa
tic
jaun
dice
Post
-hep
atic
jaun
dice
Appe
aran
ce o
fur
ine
Nor
mal
Dark
Dark
Dark
Dark
Appe
aran
ce o
fst
ool
Nor
mal
Nor
mal
or p
ale
Pale
Conj
ugat
edbi
lirub
inN
orm
al
Unc
onju
gate
dbi
lirub
inN
orm
al o
r N
orm
al
Tota
l bili
rubi
nN
orm
al o
r
Alka
line
phos
phat
ase
Nor
mal
<24
hou
rs
>3
wee
ksU
ncon
juga
ted
caus
es: i
nfec
tion,
a p
hysi
olog
ical
cau
se, h
aem
olyt
ic c
ause
s. Co
njug
ated
cau
ses:
hepa
titis,
obs
truc
ted
bile
duc
t.
Infe
ctio
n (e
.g. T
ORC
HES
[see
Map
2.6
, p. 5
0])
Haem
olyt
ic d
isor
ders
:•
ABO
inco
mpa
tibili
ty.
• Rh
esus
inco
mpa
tibili
ty.
• G
6PD
defic
ienc
y:
X-
linke
d co
nditi
on.
Defic
ienc
y in
glu
cose
-6-p
hosp
hate
deh
ydro
gena
se. R
esul
tant
effe
ct is
a d
ecre
ase
in a
ntio
xida
nt N
ADPH
mea
ning
that
RBC
s ar
e
mor
e su
scep
tible
to o
xida
tive
stre
ss (e
.g. i
nfec
tion/
cert
ain
food
s su
ch a
s fa
va b
eans
). Bl
ood
smea
r: He
inz
bodi
es, b
ite c
ells.
• Sp
hero
cyto
sis:
Auto
som
al d
omin
ant c
ondi
tion.
Caus
ed b
y fu
nctio
nal a
bnor
mal
ity o
f str
uctu
ral R
BC m
embr
ane
prot
eins
(e.g
. spe
ctrin
, ank
yrin
)
Bl
ood
smea
r: sp
hero
cyte
s.
24 h
ours
to
3 w
eeks
Rem
embe
r as
ABC
:A
– A
phy
siol
ogic
al c
ause
B –
Brea
st m
ilk ja
undi
ceC
– Cr
igle
r–N
ajja
r syn
drom
e: a
utos
omal
rece
ssiv
e co
nditi
on. T
wo
type
s: ty
pe 1
: abs
ence
of U
DP g
lucu
rono
syl t
rans
fera
se 1
-A1;
t
ype
2: re
duce
d le
vels
of U
DP g
lucu
rono
syl t
rans
fera
se 1
-A1.
Haem
olys
isIn
fect
ion
Caus
eTi
me
elap
sed
post
nata
lly
Trea
tmen
tTr
eat u
nder
lyin
g ca
use
Com
plic
atio
ns•
Live
r fai
lure
.
• Pa
ncre
atiti
s.
• Re
nal f
ailu
re.
• Se
psis.
• Ch
olan
gitis
.•
Bilia
ry c
irrho
sis.
105
K30033_C004.indd 105 28/02/17 11:43 am
Paed
iatr
ics
Map
4.2
. N
ecro
tizi
ng
en
tero
colit
is (
NEC
)
Wha
t is
nec
roti
zing
ent
eroc
olit
is?
This
is a
n in
flam
mat
ory
bow
el n
ecro
sis.
Caus
esTh
e ex
act c
ause
of N
EC is
unk
now
n, b
ut th
e pr
esen
t the
ory
conc
erni
ng th
e pa
thop
hysi
olog
y of
NEC
invo
lves
a h
ypox
ic
insu
lt th
at o
ccur
s in
a p
rem
atur
e in
fant
bec
ause
thei
r im
mun
e sy
stem
is n
ot fu
lly d
evel
oped
. Hyp
oxia
occ
urs
and
this
cau
ses
inte
stin
al s
loug
hing
. Thi
s al
low
s ba
cter
ia to
inva
de th
e in
test
inal
w
all a
nd c
ause
infla
mm
atio
n. T
his
even
tual
ly le
ads
to g
angr
ene,
ris
k of
per
fora
tion
and
NEC
.
Trea
tmen
t
Cons
erva
tive
:•
Info
rmat
ion
prov
ided
to p
aren
ts.
• St
op b
ottle
feed
ing.
• Ad
mit
to N
ICU
and
take
ser
ial x
-ray
s
look
ing
for p
erfo
ratio
n.•
Cont
inua
lly m
onito
r girt
h m
easu
rem
ent.
Med
ical
: onl
y co
nsid
er if
no
perfo
ratio
n ev
iden
t:•
Deco
mpr
ess
the
larg
e bo
wel
.•
Prov
ide
broa
d-sp
ectr
um a
ntib
iotic
s
(che
ck h
ospi
tal g
uide
lines
).•
Intr
aven
ous
fluid
s an
d nu
triti
on.
Surg
ical
:•
Man
age
surg
ical
ly if
per
fora
ted.
Sym
ptom
s•
Into
lera
nt o
f fee
ds.
• Ab
dom
inal
dis
tens
ion.
• De
crea
sed
bow
el s
ound
s.•
Bloo
dy s
tool
s.•
Vom
iting
(may
be
bile
sta
ined
).•
Shoc
k.
Com
plic
atio
ns•
Deat
h.•
Shor
t bow
el s
yndr
ome.
• Bo
wel
obs
truc
tion.
• An
aem
ia.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
WCC
, U&
E (th
ere
may
be
a m
etab
olic
aci
dosi
s).
• Ra
diol
ogy:
abd
omin
al x
-ray
(pne
umat
osis
in
test
inal
is/p
erfo
ratio
n). M
ay s
how
oth
er
sign
s (e
.g. f
ootb
all s
ign
[mas
sive
pn
eum
oper
itone
um],
th
umbp
rintin
g [la
rge
bow
el o
edem
a]).
MAP
4.2
. Nec
roti
zing
ent
eroc
olit
is (N
EC)
106
K30033_C004.indd 106 28/02/17 11:43 am
Paed
iatr
ics
Map
4.2
. N
ecro
tizi
ng
en
tero
colit
is (
NEC
)
Wha
t is
nec
roti
zing
ent
eroc
olit
is?
This
is a
n in
flam
mat
ory
bow
el n
ecro
sis.
Caus
esTh
e ex
act c
ause
of N
EC is
unk
now
n, b
ut th
e pr
esen
t the
ory
conc
erni
ng th
e pa
thop
hysi
olog
y of
NEC
invo
lves
a h
ypox
ic
insu
lt th
at o
ccur
s in
a p
rem
atur
e in
fant
bec
ause
thei
r im
mun
e sy
stem
is n
ot fu
lly d
evel
oped
. Hyp
oxia
occ
urs
and
this
cau
ses
inte
stin
al s
loug
hing
. Thi
s al
low
s ba
cter
ia to
inva
de th
e in
test
inal
w
all a
nd c
ause
infla
mm
atio
n. T
his
even
tual
ly le
ads
to g
angr
ene,
ris
k of
per
fora
tion
and
NEC
.
Trea
tmen
t
Cons
erva
tive
:•
Info
rmat
ion
prov
ided
to p
aren
ts.
• St
op b
ottle
feed
ing.
• Ad
mit
to N
ICU
and
take
ser
ial x
-ray
s
look
ing
for p
erfo
ratio
n.•
Cont
inua
lly m
onito
r girt
h m
easu
rem
ent.
Med
ical
: onl
y co
nsid
er if
no
perfo
ratio
n ev
iden
t:•
Deco
mpr
ess
the
larg
e bo
wel
.•
Prov
ide
broa
d-sp
ectr
um a
ntib
iotic
s
(che
ck h
ospi
tal g
uide
lines
).•
Intr
aven
ous
fluid
s an
d nu
triti
on.
Surg
ical
:•
Man
age
surg
ical
ly if
per
fora
ted.
Sym
ptom
s•
Into
lera
nt o
f fee
ds.
• Ab
dom
inal
dis
tens
ion.
• De
crea
sed
bow
el s
ound
s.•
Bloo
dy s
tool
s.•
Vom
iting
(may
be
bile
sta
ined
).•
Shoc
k.
Com
plic
atio
ns•
Deat
h.•
Shor
t bow
el s
yndr
ome.
• Bo
wel
obs
truc
tion.
• An
aem
ia.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
WCC
, U&
E (th
ere
may
be
a m
etab
olic
aci
dosi
s).
• Ra
diol
ogy:
abd
omin
al x
-ray
(pne
umat
osis
in
test
inal
is/p
erfo
ratio
n). M
ay s
how
oth
er
sign
s (e
.g. f
ootb
all s
ign
[mas
sive
pn
eum
oper
itone
um],
th
umbp
rintin
g [la
rge
bow
el o
edem
a]).
MAP
4.2
. Nec
roti
zing
ent
eroc
olit
is (N
EC)
107
K30033_C004.indd 107 28/02/17 11:43 am
Paed
iatr
ics
Map
4.3
. H
yper
tro
ph
ic p
ylo
ric
sten
osi
s
Wha
t is
hyp
ertr
ophi
c py
lori
c st
enos
is?
This
is w
hen
the
mus
cula
r lay
er o
f the
pyl
oris
hype
rtro
phie
s, re
sulti
ng in
a g
astr
ic o
utle
tob
stru
ctio
n by
nar
row
ing
the
outle
t fro
m th
est
omac
h to
the
duod
enum
. It p
rese
nts
arou
nd2–
8 w
eeks
of a
ge.
Caus
esHy
pert
roph
y of
the
mus
cula
r lay
er o
f the
pyl
oris.
The
exac
t rea
son
why
this
hap
pens
rem
ains
uncl
ear b
ut th
ere
are
som
e as
soci
ated
risk
fact
ors
(see
bel
ow).
Risk
fact
ors
(rem
embe
r as
the
3Fs
):Fi
rst-
born
mal
esFa
mily
his
tory
of t
he d
isor
der
Fair
skin
Inve
stig
atio
ns•
Feed
ing
test
may
sho
w p
eris
talti
c w
ave.
• Bl
ood
test
s: FB
C, W
CC, U
&E,
LFT
s (th
ere
may
be
a
hypo
chlo
raem
ic a
lkal
osis
).•
Mon
itor u
rine
outp
ut.
• Ra
diol
ogy:
USS
con
firm
s di
agno
sis
Com
plic
atio
ns•
Elec
trol
yte
imba
lanc
es.
• Du
oden
al p
erfo
ratio
n.•
Apno
ea.
• As
pira
tion
pneu
mon
ia.
Sym
ptom
sRe
mem
ber a
s PY
LORI
C:P
– Pr
ojec
tive
vom
iting
(non
-bili
ous)
wor
seni
ng w
ith ti
me
Y –
Yelli
ng, u
nhap
py c
hild
L –
Leth
argi
c ch
ild, L
oss
of w
eigh
tO
– ‘O
live’
(pyl
oric
mas
s) p
rese
nt in
the
RUQ
R –
Rum
blin
g tu
mm
y (i.
e. g
astr
ic p
eris
tals
is fr
om le
ft to
righ
t
see
n on
feed
ing
test
)I
– Irr
itabl
eC
– Co
nstip
ated
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Co
ntin
ual m
onito
ring.
Med
ical
:•
Corr
ect e
lect
roly
te im
bala
nce.
Surg
ical
:•
Ram
sted
t’s p
ylor
omyo
tom
y.
MAP
4.3
. Hyp
ertr
ophi
cpy
lori
c st
enos
is
108
K30033_C004.indd 108 28/02/17 11:43 am
Paed
iatr
ics
Map
4.4
. H
irsc
hsp
run
g’s
dis
ease
Wha
t is
Hir
schs
prun
g’s
dise
ase?
This
is a
con
geni
tal a
bsen
ce o
f gan
glio
n ce
lls fr
om th
em
uscu
lar a
nd m
ucos
al la
yers
of t
he c
olon
. The
regi
onus
ually
affe
cted
is th
e re
ctum
sin
ce, d
urin
g de
velo
pmen
t,th
e ce
lls m
igra
te c
rani
ocau
dally
. The
loss
of t
hese
gang
lion
cells
resu
lts in
con
stip
atio
n, o
bstr
uctio
n an
d,po
tent
ially
, meg
acol
on. T
his
cond
ition
affe
cts
mal
es m
ore
than
fem
ales
.
Caus
esAs
abo
ve –
def
ectiv
e cr
anio
caud
al m
igra
tion
of th
ene
urob
last
cel
ls o
ccur
ring
at 1
2 w
eeks
ges
tatio
n.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Co
ntin
ual m
onito
ring.
Surg
ical
:•
Surg
ery
is th
e de
finiti
ve tr
eatm
ent.
Rem
ove
the
af
fect
ed s
ectio
n of
bow
el +
/– c
olos
tom
y. Ex
ampl
es o
f
proc
edur
es u
sed
are
liste
d be
low
:
So
ave–
Bole
y pr
oced
ure.
Duha
mel
pro
cedu
re.
Com
plic
atio
ns•
Ente
roco
litis.
• Ac
ute
obst
ruct
ion.
• Co
mpl
icat
ions
of s
urge
ry a
nd
gene
ral c
ompl
icat
ions
.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
WCC
, U&
E, L
FTs.
• Re
ctal
suc
tion
biop
sy s
how
ing
agan
glio
nic
se
ctio
n of
bow
el is
gol
d st
anda
rd
inve
stig
atio
n.
Sym
ptom
s•
Failu
re to
pas
s m
econ
ium
.•
Abdo
min
al d
iste
nsio
n.•
Vom
iting
.•
Decr
ease
d fe
edin
g.•
Irrita
bilit
y.•
Empt
y re
ctal
vau
lt.•
Poss
ible
sig
ns o
f ent
eroc
oliti
s.
MAP
4.4
. Hir
schs
prun
g’s
dise
ase
109
K30033_C004.indd 109 28/02/17 11:43 am
Paed
iatr
ics
Map
4.5
. In
tuss
usc
epti
on
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
WCC
, U&
E, L
FTs
(usu
ally
un
rem
arka
ble
bloo
d re
sults
).•
Radi
olog
y: a
bdom
inal
x-r
ay –
may
vi
sual
ize
dila
ted
loop
s of
bow
el o
r
perfo
ratio
n.•
USS
– ‘t
arge
t sig
n’
Not
e: A
ir/co
ntra
st e
nem
a m
ay b
e us
ed a
s it
isbo
th d
iagn
ostic
and
ther
apeu
tic.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Co
ntin
ual m
onito
ring.
Radi
olog
ical
(see
inve
stig
atio
ns s
ecti
on):
• Hy
dros
tatic
redu
ctio
n us
ing
enem
a.
Surg
ical
:•
May
be
requ
ired
if ot
her m
easu
res
fail.
Wha
t is
intu
ssus
cept
ion?
This
is w
hen
a po
rtio
n of
the
inte
stin
e be
com
es in
vagi
nate
d in
to it
sow
n lu
men
to a
var
iabl
e de
gree
by
peris
tals
is.
Caus
esTh
ese
may
be
split
into
pae
diat
ric a
nd a
dult
caus
es.
Paed
iatr
ic:
• M
ecke
l’s d
iver
ticul
um. T
his
is th
e re
mna
nt o
f the
vite
lline
duc
t
(join
s yo
lk s
ac to
the
mid
gut l
umen
) tha
t usu
ally
obl
itera
tes
du
ring
9th w
eek
of g
esta
tion.
It is
ass
ocia
ted
with
the
rule
of 2
s:
It
affe
cts
2% o
f the
pop
ulat
ion.
2 ti
mes
mor
e co
mm
on in
mal
es.
It is
2 in
ches
long
.
It
is lo
cate
d 2
feet
from
the
ilioc
aeca
l val
ve (a
lthou
gh, i
n
re
ality
, thi
s m
ay b
e an
y di
stan
ce).
It co
ntai
ns 2
typ
es o
f tis
sues
, gas
tric
and
pan
crea
tic, w
hich
is w
hy a
tech
netiu
m-9
9m s
can
is th
e in
vest
igat
ion
of c
hoic
e.•
Hype
rtro
phie
d Pe
yer’s
pat
ches
Adu
lts
• Tu
mou
r. Sy
mpt
oms
Sym
ptom
s pr
esen
t in
a cl
assi
c tr
iad:
1. P
ain
– se
vere
, col
icky
abd
omin
al p
ain.
2. B
lood
in s
tool
– o
ften
desc
ribed
as ‘
redc
urra
nt je
lly’.
3. V
omiti
ng –
non
-bili
ous
initi
ally
but
may
bec
ome
bilio
us.
Com
plic
atio
ns•
Perfo
ratio
n.•
Shoc
k.•
Perit
oniti
s.
MAP
4.5
. In
tuss
usce
ptio
n
110
K30033_C004.indd 110 28/02/17 11:43 am
Paed
iatr
ics
Tabl
e 4.
1. A
nte
rio
r ab
do
min
al w
all d
efec
ts
TABL
E 4.
1. A
nter
ior
abdo
min
al w
all d
efec
ts. T
he d
iffe
renc
es b
etw
een
an o
mph
aloc
oele
and
a g
astr
osch
isis
ar
e ou
tlin
ed b
elow
.
Om
phal
ocoe
leG
astr
osch
isis
Loca
tion
Mid
line
defe
ct. I
t is
a ve
ntra
l def
ect o
f the
um
bilic
al ri
ngPa
raum
bilic
al d
efec
t due
to in
com
plet
e fu
sion
of t
he
abdo
min
al w
all
Cove
red
by v
isce
raYe
sN
o
Ass
ocia
ted
wit
h ot
her
defe
cts
Yes.
Gen
eral
ly, m
idlin
e de
fect
s ar
e as
soci
ated
with
oth
er a
bnor
mal
ities
su
ch a
s ca
rdia
c, g
enito
urin
ary
or c
hrom
osom
al a
bnor
mal
ities
No.
How
ever
, thi
s co
nditi
on h
as a
n as
soci
atio
n w
ith c
ocai
ne u
se a
nd b
abie
s w
ho a
re s
mal
l for
ge
stat
iona
l age
Inve
stig
atio
nsDe
tect
ed a
nten
atal
ly v
ia s
onog
raph
yDe
tect
ed a
nten
atal
ly v
ia s
onog
raph
y
Trea
tmen
tSe
vera
l ste
ps n
eed
to b
e fo
llow
ed:
1. T
he a
bdom
inal
con
tent
s m
ust b
e pr
otec
ted.
Thi
s m
ay b
e ac
hiev
ed
usin
g m
oist
ened
, ste
rile
gauz
e 2.
Flu
ids
and
elec
trol
ytes
mus
t be
mon
itore
d an
d co
rrec
ted
if ne
cess
ary
3. T
he le
sion
mus
t be
clos
ed (e
.g. u
sing
a s
ilo).
This
mus
t be
done
slo
wly
be
caus
e if
clos
ed to
o qu
ickl
y, th
e su
dden
add
ition
of t
he a
bdom
inal
co
nten
ts m
ay c
ause
hae
mod
ynam
ic c
ompr
omis
e an
d de
crea
se v
enou
s re
turn
to th
e he
art
Seve
ral s
teps
nee
d to
be
follo
wed
:1.
The
abd
omin
al c
onte
nts
mus
t be
prot
ecte
d. T
his
may
be
achi
eved
usi
ng m
oist
ened
, ste
rile
gauz
e2.
Flu
ids
and
elec
trol
ytes
mus
t be
mon
itore
d an
d co
rrec
ted
if ne
cess
ary
3. P
rovi
de b
road
-spe
ctru
m a
ntib
iotic
s.4.
Sur
gery
is n
eces
sary
usu
ally
with
in 2
4–48
hou
rs
111
K30033_C004.indd 111 28/02/17 11:43 am
Paed
iatr
ics
Map
4.6
. C
on
gen
ital
car
dia
c d
efec
ts
Atr
ial s
epta
l def
ects
(ASD
s):
Ost
ium
pri
mum
:•
Caus
ed b
y a
failu
re o
f the
sep
tum
prim
um to
join
the
endo
card
ial c
ushi
on.
• As
soci
ated
with
oth
er n
eura
l cre
st m
igra
tion
defe
cts
sinc
e th
e en
doca
rdia
l cus
hion
is p
rimar
ily fo
rmed
fro
m n
eura
l cre
st c
ells
that
hav
e m
igra
ted
to th
e
en
doca
rdia
l tub
e du
ring
embr
yolo
gica
l dev
elop
men
t.
Ost
ium
sec
undu
m:
• Ei
ght t
imes
mor
e co
mm
on th
an th
e pr
imum
type
.•
Caus
ed b
y ex
cess
ive
abso
rptio
n of
the
sept
um p
rimum
o
r inc
ompl
ete
grow
th o
f the
sep
tum
sec
undu
m.
Cond
itio
n
Mur
mur
s
Mur
mur
MAP
4.6
. Con
geni
tal c
ardi
ac d
efec
ts
Acy
anot
ic d
efec
ts
Dext
rapo
sitio
n of
the
aort
icop
ulm
onar
yse
ptum
(aka
the
spira
lse
ptum
)
Pers
iste
nt tr
uncu
sar
terio
sis
Tran
spos
ition
of t
hegr
eat v
esse
ls
The
spira
l sep
tum
fails
to fo
rmA
VSD
form
s si
nce
the
spira
l sep
tum
is th
eso
urce
of t
hem
embr
anou
sin
trav
entr
icul
ar s
eptu
m
Asso
ciat
ed w
ith o
ther
defe
cts
that
allo
w th
esh
untin
g of
blo
od,
othe
rwis
e th
e ne
onat
ew
ould
die
Durin
g de
velo
pmen
tth
e ao
rtico
pulm
onar
yse
ptum
spira
ls th
roug
h a
180
degr
ee a
nticl
ockw
ise ro
tatio
n,
henc
e its
nam
e th
e sp
iral
sept
um. T
his p
lace
s the
gre
at
vess
els i
nto
thei
r app
ropr
iate
an
atom
ical p
ositi
on (i
.e. t
he
aorta
pos
terio
r and
to th
e rig
ht, t
he p
ulm
onar
y tru
nk
ante
rior a
nd to
the
left)
. In
this
cond
ition
the
aorti
copu
lmo-
nary
sept
um fa
ils to
spira
l
Rem
embe
r as
PRO
V:P
– Pu
lmon
ary
sten
osis
R –
Righ
t ven
tric
ular
h
yper
trop
hyO
– O
verr
idin
g ao
rta
V –
VSD
Type
Caus
eFe
atur
es
Tetr
alog
y of
Fal
lot
Loca
tion
bes
t he
ard
VSD
ASD
PDA
Tetr
alog
y of
Fal
lot
Tran
spos
ition
of t
hegr
eat v
esse
ls
Pans
ysto
lic. S
mal
ler
lesi
ons
are
loud
est
Low
er le
ft st
erna
l edg
e
Syst
olic
eje
ctio
n
Mac
hine
ry m
urm
ur
Syst
olic
eje
ctio
n
No
mur
mur
Upp
er le
ft st
erna
l edg
e
Upp
er le
ft st
erna
l edg
e
Upp
er le
ft st
erna
l edg
e
N/A
Wha
t ar
e co
ngen
ital
car
diac
def
ects
?Th
is is
whe
n th
e he
art f
ails
to d
evel
op n
orm
ally.
The
y m
ay b
e br
oadl
y ca
tego
rized
as
cyan
otic
and
acy
anot
ic.
Cyan
otic
def
ects
: •
Trun
cus
arte
riosu
s.•
Tran
spos
ition
of t
he g
reat
ves
sels.
• Tr
icus
pid
insu
ffici
ency
.•
Tetr
alog
y of
Fal
lot.
Acy
anot
ic d
efec
ts: l
eft ®
righ
t shu
nt•
Rem
embe
r as
the
3Ds:
VS
D –
mos
t com
mon
def
ect
AS
D
PDA
Caus
esDe
pend
s on
the
spec
ific
defe
ct, b
ut th
ere
are
man
y ris
k fa
ctor
s as
soci
ated
with
them
:•
Unk
now
n.•
Mat
erna
l fac
tors
: e.g
. TO
RCHE
S in
fect
ion
(see
Map
2.6
, p. 5
0), d
iabe
tes
mel
litus
and
sys
tem
ic lu
pus
eryt
hem
atos
us.
• Te
rato
gens
:
Al
coho
l.
Li
thiu
m.
War
farin
.
Ph
enyt
oin.
• Ch
rom
osom
al a
bnor
mal
ities
.
right
® le
ft sh
unt
112
K30033_C004.indd 112 28/02/17 11:43 am
Atr
ial s
epta
l def
ects
(ASD
s):
Ost
ium
pri
mum
:•
Caus
ed b
y a
failu
re o
f the
sep
tum
prim
um to
join
the
endo
card
ial c
ushi
on.
• As
soci
ated
with
oth
er n
eura
l cre
st m
igra
tion
defe
cts
sinc
e th
e en
doca
rdia
l cus
hion
is p
rimar
ily fo
rmed
fro
m n
eura
l cre
st c
ells
that
hav
e m
igra
ted
to th
e
en
doca
rdia
l tub
e du
ring
embr
yolo
gica
l dev
elop
men
t.
Ost
ium
sec
undu
m:
• Ei
ght t
imes
mor
e co
mm
on th
an th
e pr
imum
type
.•
Caus
ed b
y ex
cess
ive
abso
rptio
n of
the
sept
um p
rimum
o
r inc
ompl
ete
grow
th o
f the
sep
tum
sec
undu
m.
Acy
anot
ic d
efec
ts
Dext
rapo
sitio
n of
the
aort
icop
ulm
onar
yse
ptum
(aka
the
spira
lse
ptum
)
Pers
iste
nt tr
uncu
sar
terio
sis
Tran
spos
ition
of t
hegr
eat v
esse
ls
The
spira
l sep
tum
fails
to fo
rmA
VSD
form
s si
nce
the
spira
l sep
tum
is th
eso
urce
of t
hem
embr
anou
sin
trav
entr
icul
ar s
eptu
m
Asso
ciat
ed w
ith o
ther
defe
cts
that
allo
w th
esh
untin
g of
blo
od,
othe
rwis
e th
e ne
onat
ew
ould
die
Durin
g de
velo
pmen
tth
e ao
rtico
pulm
onar
yse
ptum
spira
ls th
roug
h a
180
degr
ee a
nticl
ockw
ise ro
tatio
n,
henc
e its
nam
e th
e sp
iral
sept
um. T
his p
lace
s the
gre
at
vess
els i
nto
thei
r app
ropr
iate
an
atom
ical p
ositi
on (i
.e. t
he
aorta
pos
terio
r and
to th
e rig
ht, t
he p
ulm
onar
y tru
nk
ante
rior a
nd to
the
left)
. In
this
cond
ition
the
aorti
copu
lmo-
nary
sept
um fa
ils to
spira
l
Rem
embe
r as
PRO
V:P
– Pu
lmon
ary
sten
osis
R –
Righ
t ven
tric
ular
h
yper
trop
hyO
– O
verr
idin
g ao
rta
V –
VSD
Type
Caus
eFe
atur
es
Tetr
alog
y of
Fal
lot
K30033_C004.indd 113 28/02/17 11:43 am
Paed
iatr
ics
Map
4.6
. C
on
gen
ital
car
dia
c d
efec
ts
Cond
itio
n
Mur
mur
s
Mur
mur
MAP
4.6
. Con
geni
tal c
ardi
ac d
efec
ts
Loca
tion
bes
t he
ard
VSD
ASD
PDA
Tetr
alog
y of
Fal
lot
Tran
spos
ition
of t
hegr
eat v
esse
ls
Pans
ysto
lic. S
mal
ler
lesi
ons
are
loud
est
Low
er le
ft st
erna
l edg
e
Syst
olic
eje
ctio
n
Mac
hine
ry m
urm
ur
Syst
olic
eje
ctio
n
No
mur
mur
Upp
er le
ft st
erna
l edg
e
Upp
er le
ft st
erna
l edg
e
Upp
er le
ft st
erna
l edg
e
N/A
Wha
t ar
e co
ngen
ital
car
diac
def
ects
?Th
is is
whe
n th
e he
art f
ails
to d
evel
op n
orm
ally.
The
y m
ay b
e br
oadl
y ca
tego
rized
as
cyan
otic
and
acy
anot
ic.
Cyan
otic
def
ects
: •
Trun
cus
arte
riosu
s.•
Tran
spos
ition
of t
he g
reat
ves
sels.
• Tr
icus
pid
insu
ffici
ency
.•
Tetr
alog
y of
Fal
lot.
Acy
anot
ic d
efec
ts: l
eft ®
righ
t shu
nt•
Rem
embe
r as
the
3Ds:
VS
D –
mos
t com
mon
def
ect
AS
D
PDA
Caus
esDe
pend
s on
the
spec
ific
defe
ct, b
ut th
ere
are
man
y ris
k fa
ctor
s as
soci
ated
with
them
:•
Unk
now
n.•
Mat
erna
l fac
tors
: e.g
. TO
RCHE
S in
fect
ion
(see
Map
2.6
, p. 5
0), d
iabe
tes
mel
litus
and
sys
tem
ic lu
pus
eryt
hem
atos
us.
• Te
rato
gens
:
Al
coho
l.
Li
thiu
m.
War
farin
.
Ph
enyt
oin.
• Ch
rom
osom
al a
bnor
mal
ities
.
right
® le
ft sh
unt
113
Paed
iatr
ics
Map
4.7
. G
enit
ou
rin
ary
abn
orm
alit
ies
Hor
sesh
oe k
idne
y
Wha
t is
a h
orse
shoe
kid
ney?
This
occ
urs
durin
g de
velo
pmen
t whe
n th
e up
per a
nd lo
wer
pol
es o
f the
kid
neys
fuse
and
cann
ot a
scen
d to
thei
r nor
mal
an
atom
ical
pos
ition
due
to th
e in
ferio
r m
esen
teric
art
ery.
This
resu
lts in
aho
rses
hoe
shap
e.
Caus
es: c
onge
nita
l abn
orm
ality
.
Sign
s an
d sy
mpt
oms:
• As
ympt
omat
ic.
• Re
curr
ent u
rinar
y tr
act i
nfec
tions
.•
Rena
l cal
culi.
• O
bstr
uctiv
e ur
opat
hy.
Inve
stig
atio
ns: U
SS is
dia
gnos
tic.
Trea
tmen
t: tr
eatm
ent o
f com
plic
atio
ns.
Com
plic
atio
ns:
• Su
scep
tible
to tr
aum
a.•
Rena
l cal
culi
form
atio
n.•
Incr
ease
d ris
k of
tran
sitio
nal c
ell
c
arci
nom
a of
the
rena
l pel
vis.
Gen
itour
inar
y ab
norm
aliti
es a
re
asso
ciat
ed w
ith C
HA
RGE:
C –
Colo
bom
aH
– H
eart
def
ects
A –
Atr
esia
of t
he n
asal
cho
anae
R –
Reta
rded
gro
wth
/dev
elop
men
tG
– G
enito
urin
ary
abno
rmal
ities
E –
Ear a
bnor
mal
ities
/dea
fnes
s
Aut
osom
al r
eces
sive
pol
ycys
tic
kidn
ey d
isea
se
Wha
t is
aut
osom
al r
eces
sive
pol
ycys
tic
kidn
ey d
isea
se(A
RPKD
)?Th
is is
a re
cess
ivel
y in
herit
ed p
olyc
ystic
dis
ease
foun
d in
chi
ldre
n.
Caus
es:
• PK
HD1
on c
hrom
osom
e 6.
Sign
s an
d sy
mpt
oms:
• Hy
pert
ensi
on.
• Th
ose
of c
hron
ic k
idne
y in
jury
.•
Chro
nic
resp
irato
ry in
fect
ions
.•
Thos
e of
por
tal h
yper
tens
ion:
asc
ites,
capu
t med
usae
and
oes
opha
geal
varic
es (v
omiti
ng b
lood
).•
Failu
re to
thriv
e.•
Recu
rren
t urin
ary
trac
t inf
ectio
ns.
• Po
lyur
ia.
Inve
stig
atio
ns: a
nten
atal
scr
eeni
ng is
dia
gnos
tic. S
how
sen
larg
ed k
idne
y w
ith o
r with
out o
ligoh
ydra
mni
os.
Trea
tmen
t: no
spe
cific
trea
tmen
t. M
anag
e hy
pert
ensi
on.
Dial
ysis
and
kid
ney
tran
spla
ntat
ion
shou
ld b
e co
nsid
ered
. Lon
g-te
rmox
ygen
ther
apy
is o
ften
requ
ired
due
to c
hron
ic re
spira
tory
infe
ctio
ns.
Com
plic
atio
ns:
• He
patic
cys
ts.
•
Con
geni
tal h
epat
ic fi
bros
is.
• P
rolif
erat
ive
bile
duc
ts.
Blad
der
exst
roph
y
Wha
t is
bla
dder
exs
trop
hy?
This
is a
con
geni
tal m
alfo
rmat
ion
whe
re th
e bl
adde
r pro
trud
es th
roug
h an
abd
omin
al w
all d
efec
t.
Caus
es: c
onge
nita
l abn
orm
ality
.
Sign
s an
d sy
mpt
oms:
rem
embe
r as
ABC
DES
:A
– A
bdom
inal
wal
l def
ect
B –
Boys
als
o ha
ve e
pisp
adia
sC
– Cl
itoris
is b
ifid
in g
irls
affe
cted
D –
Div
erge
nt la
bia
may
als
o be
pre
sent
E –
Exte
rnal
ly ro
tate
d pe
lvis
S –
Shor
tene
d pu
bic
ram
i
Inve
stig
atio
ns: c
linic
al d
iagn
osis
aid
ed w
ith U
SS.
Trea
tmen
t: su
rger
y.
Com
plic
atio
ns:
• Ve
sico
uret
eral
reflu
x (d
iagn
osed
afte
r a m
ictu
ratin
g cy
stou
reth
rogr
am).
• U
rinar
y tr
act i
nfec
tions
.•
Blad
der s
pasm
.
Hyp
ospa
dias
Wha
t is
hyp
ospa
dias
?Th
is is
a c
onge
nita
l mal
form
atio
n of
the
uret
hral
gro
ove,
mea
ning
that
the
uret
hral
op
enin
g oc
curs
on
the
vent
ral a
spec
t of t
he p
enis.
The
hyp
ospa
dias
is c
lass
ified
by
the
loca
tion
of th
e ur
ethr
al o
peni
ng. E
pisp
adia
s is
whe
n th
e ur
ethr
al o
peni
ng o
ccur
s on
the
dors
al a
spec
t of t
he p
enis.
Caus
es: c
onge
nita
l abn
orm
ality
.
Sign
s an
d sy
mpt
oms:
Clas
sic
tria
d of
:1.
Abn
orm
al u
reth
ral o
peni
ng.
2. C
hord
ee (b
end
of p
enis
).3.
Hoo
ded
fore
skin
.
Inve
stig
atio
ns: c
linic
al d
iagn
osis.
Trea
tmen
t: su
rger
y.
Com
plic
atio
ns:
• In
fect
ion.
• H
aem
atom
a.•
Fist
ula.
• St
enos
is.
MAP
4.7
. Gen
itou
rina
ry a
bnor
mal
itie
s
114
K30033_C004.indd 114 28/02/17 11:43 am
Paed
iatr
ics
Map
4.7
. G
enit
ou
rin
ary
abn
orm
alit
ies
Hor
sesh
oe k
idne
y
Wha
t is
a h
orse
shoe
kid
ney?
This
occ
urs
durin
g de
velo
pmen
t whe
n th
e up
per a
nd lo
wer
pol
es o
f the
kid
neys
fuse
and
cann
ot a
scen
d to
thei
r nor
mal
an
atom
ical
pos
ition
due
to th
e in
ferio
r m
esen
teric
art
ery.
This
resu
lts in
aho
rses
hoe
shap
e.
Caus
es: c
onge
nita
l abn
orm
ality
.
Sign
s an
d sy
mpt
oms:
• As
ympt
omat
ic.
• Re
curr
ent u
rinar
y tr
act i
nfec
tions
.•
Rena
l cal
culi.
• O
bstr
uctiv
e ur
opat
hy.
Inve
stig
atio
ns: U
SS is
dia
gnos
tic.
Trea
tmen
t: tr
eatm
ent o
f com
plic
atio
ns.
Com
plic
atio
ns:
• Su
scep
tible
to tr
aum
a.•
Rena
l cal
culi
form
atio
n.•
Incr
ease
d ris
k of
tran
sitio
nal c
ell
c
arci
nom
a of
the
rena
l pel
vis.
Gen
itour
inar
y ab
norm
aliti
es a
re
asso
ciat
ed w
ith C
HA
RGE:
C –
Colo
bom
aH
– H
eart
def
ects
A –
Atr
esia
of t
he n
asal
cho
anae
R –
Reta
rded
gro
wth
/dev
elop
men
tG
– G
enito
urin
ary
abno
rmal
ities
E –
Ear a
bnor
mal
ities
/dea
fnes
s
Aut
osom
al r
eces
sive
pol
ycys
tic
kidn
ey d
isea
se
Wha
t is
aut
osom
al r
eces
sive
pol
ycys
tic
kidn
ey d
isea
se(A
RPKD
)?Th
is is
a re
cess
ivel
y in
herit
ed p
olyc
ystic
dis
ease
foun
d in
chi
ldre
n.
Caus
es:
• PK
HD1
on c
hrom
osom
e 6.
Sign
s an
d sy
mpt
oms:
• Hy
pert
ensi
on.
• Th
ose
of c
hron
ic k
idne
y in
jury
.•
Chro
nic
resp
irato
ry in
fect
ions
.•
Thos
e of
por
tal h
yper
tens
ion:
asc
ites,
capu
t med
usae
and
oes
opha
geal
varic
es (v
omiti
ng b
lood
).•
Failu
re to
thriv
e.•
Recu
rren
t urin
ary
trac
t inf
ectio
ns.
• Po
lyur
ia.
Inve
stig
atio
ns: a
nten
atal
scr
eeni
ng is
dia
gnos
tic. S
how
sen
larg
ed k
idne
y w
ith o
r with
out o
ligoh
ydra
mni
os.
Trea
tmen
t: no
spe
cific
trea
tmen
t. M
anag
e hy
pert
ensi
on.
Dial
ysis
and
kid
ney
tran
spla
ntat
ion
shou
ld b
e co
nsid
ered
. Lon
g-te
rmox
ygen
ther
apy
is o
ften
requ
ired
due
to c
hron
ic re
spira
tory
infe
ctio
ns.
Com
plic
atio
ns:
• He
patic
cys
ts.
•
Con
geni
tal h
epat
ic fi
bros
is.
• P
rolif
erat
ive
bile
duc
ts.
Blad
der
exst
roph
y
Wha
t is
bla
dder
exs
trop
hy?
This
is a
con
geni
tal m
alfo
rmat
ion
whe
re th
e bl
adde
r pro
trud
es th
roug
h an
abd
omin
al w
all d
efec
t.
Caus
es: c
onge
nita
l abn
orm
ality
.
Sign
s an
d sy
mpt
oms:
rem
embe
r as
ABC
DES
:A
– A
bdom
inal
wal
l def
ect
B –
Boys
als
o ha
ve e
pisp
adia
sC
– Cl
itoris
is b
ifid
in g
irls
affe
cted
D –
Div
erge
nt la
bia
may
als
o be
pre
sent
E –
Exte
rnal
ly ro
tate
d pe
lvis
S –
Shor
tene
d pu
bic
ram
i
Inve
stig
atio
ns: c
linic
al d
iagn
osis
aid
ed w
ith U
SS.
Trea
tmen
t: su
rger
y.
Com
plic
atio
ns:
• Ve
sico
uret
eral
reflu
x (d
iagn
osed
afte
r a m
ictu
ratin
g cy
stou
reth
rogr
am).
• U
rinar
y tr
act i
nfec
tions
.•
Blad
der s
pasm
.
Hyp
ospa
dias
Wha
t is
hyp
ospa
dias
?Th
is is
a c
onge
nita
l mal
form
atio
n of
the
uret
hral
gro
ove,
mea
ning
that
the
uret
hral
op
enin
g oc
curs
on
the
vent
ral a
spec
t of t
he p
enis.
The
hyp
ospa
dias
is c
lass
ified
by
the
loca
tion
of th
e ur
ethr
al o
peni
ng. E
pisp
adia
s is
whe
n th
e ur
ethr
al o
peni
ng o
ccur
s on
the
dors
al a
spec
t of t
he p
enis.
Caus
es: c
onge
nita
l abn
orm
ality
.
Sign
s an
d sy
mpt
oms:
Clas
sic
tria
d of
:1.
Abn
orm
al u
reth
ral o
peni
ng.
2. C
hord
ee (b
end
of p
enis
).3.
Hoo
ded
fore
skin
.
Inve
stig
atio
ns: c
linic
al d
iagn
osis.
Trea
tmen
t: su
rger
y.
Com
plic
atio
ns:
• In
fect
ion.
• H
aem
atom
a.•
Fist
ula.
• St
enos
is.
MAP
4.7
. Gen
itou
rina
ry a
bnor
mal
itie
s
115
K30033_C004.indd 115 28/02/17 11:43 am
Paed
iatr
ics
Tabl
e 4.
2. N
euro
cuta
neo
us
syn
dro
mes
TABL
E 4.
2. N
euro
cuta
neou
s sy
ndro
mes
.
Cond
itio
nG
enet
ics
Not
es
Neu
rofib
rom
atos
isAu
toso
mal
dom
inan
t Ty
pe 1
: neu
rofib
rom
in d
efec
t chr
omos
ome
17q1
1Ty
pe 2
: mer
lin d
efec
t chr
omos
ome
22q1
2
Type
1:
• Ak
a vo
n Re
cklin
ghau
sen
dise
ase
• Sk
in m
anife
stat
ions
:
Café
au
lait
spot
s
Axill
ary
freck
ling
N
euro
fibro
mas
Li
sch
nodu
les
(ham
arto
mas
on
the
iris)
• In
crea
sed
risk
of o
ptic
glio
ma
Type
2:
• Sk
in m
anife
stat
ions
are
mor
e m
ild th
an ty
pe 1
• As
soci
ated
with
aco
ustic
neu
rom
as a
nd d
eafn
ess
Tube
rous
scl
eros
isAu
toso
mal
dom
inan
t Ty
pe 1
: ham
artin
def
ect c
hrom
osom
e 9
Type
2: t
uber
in d
efec
t chr
omos
ome
16
• Sk
in m
anife
stat
ions
:
Ash
leaf
spo
ts
Shag
reen
pat
ches
Ad
enom
a se
bace
um•
Asso
ciat
ed w
ith e
pile
psy
and
beni
gn tu
mou
rs
Here
dita
ry h
aem
orrh
agic
tela
ngie
ctas
ia
Auto
som
al d
omin
ant c
ondi
tion
Mos
t due
to m
utat
ions
of:
•EN
G c
hrom
osom
e 9
•AC
VRL1
chr
omos
ome
12
• Ak
a O
sler
–Web
er–R
endu
syn
drom
e•
Asso
ciat
ed w
ith te
lang
iect
asia
, epi
stax
is a
nd v
ascu
lar
diso
rder
s of
the
cent
ral n
ervo
us s
yndr
ome
116
K30033_C004.indd 116 28/02/17 11:43 am
Paed
iatr
ics
Tabl
e 4.
2. N
euro
cuta
neo
us
syn
dro
mes
Stur
ge–W
eber
syn
drom
eM
utat
ion
of th
e G
NAQ
gen
e ca
uses
abn
orm
ality
of
mes
oder
m a
nd e
ctod
erm
dev
elop
men
t•
Skin
man
ifest
atio
n: fa
cial
por
t win
e st
ain
• Ra
diol
ogic
al a
ppea
ranc
e: in
trac
rani
al le
sion
s an
d ty
pica
l tr
am tr
ack
calc
ifica
tions
• As
soci
ated
with
epi
leps
y, he
mip
legi
a, g
lauc
oma
and
men
tal r
etar
datio
n
117
K30033_C004.indd 117 28/02/17 11:43 am
Paed
iatr
ics
Map
4.8
. N
eura
l tu
be
def
ects
(N
TDs)
Wha
t ar
e ne
ural
tub
e de
fect
s?Th
ese
are
cong
enita
l abn
orm
aliti
es in
the
deve
lopm
ent o
f th
e sp
ine,
spi
nal c
ord
and
brai
n. T
hey
occu
r to
vary
ing
degr
ees
but t
he m
ost c
omm
on is
spi
na b
ifida
, a d
isor
der
in w
hich
the
spin
al c
olum
n do
es n
ot c
ompl
etel
y cl
ose.
Caus
esTh
e ex
act c
ause
of N
TDs
is n
ot k
now
n. H
owev
er,
they
are
ass
ocia
ted
with
tera
toge
ns s
uch
asan
tiepi
lept
ic m
edic
atio
n, m
ater
nal d
iabe
tes
mel
litus
and
hig
h m
ater
nal B
MI.
Com
plic
atio
ns•
Decr
ease
d bl
adde
r con
trol
.•
Incr
ease
d ris
k of
UTI
.•
Decr
ease
d m
obili
ty.
• Le
arni
ng d
iffic
ultie
s.•
Hydr
ocep
halu
s.•
Com
plic
atio
ns o
f sur
gery
and
gen
eral
ana
esth
etic
.
Sym
ptom
sVa
ry d
epen
ding
on
type
of N
TD. A
brie
fou
tline
is p
rovi
ded
belo
w:
• An
ence
phal
y: th
e br
ain
and
cran
ium
fail
to
deve
lop
resu
lting
in fe
tal d
eath
.•
Ence
phal
ocoe
le: a
ka c
rani
um b
ifidu
m. T
his
is a
co
nditi
on w
here
the
brai
n, c
over
ed b
y its
m
enin
ges,
prot
rude
s th
roug
h a
mid
line
cran
ial d
efec
t.•
Spin
a bi
fida:
this
occ
urs
whe
n th
e sp
inal
col
umn
or
vert
ebra
l arc
h fa
ils to
clo
se. T
he s
pina
l col
umn
may
be
teth
ered
, whi
ch le
ads
to p
robl
ems
with
bla
dder
co
ntro
l. O
n ex
amin
atio
n, th
ere
is o
ften
hair
ov
erly
ing
the
defe
ct.
• M
enin
goco
ele:
is a
ssoc
iate
d w
ith s
pina
bifi
da.
Th
e m
enin
ges
prot
rude
thro
ugh
the
defe
ct b
ut it
doe
s
not c
onta
in th
e sp
inal
cor
d.•
Men
ingo
mye
loco
ele:
is a
ssoc
iate
d w
ith s
pina
bifi
da.
Th
e m
enin
ges
and
spin
al c
ord
prot
rude
thro
ugh
the
defe
ct.
Trea
tmen
tDe
pend
s on
the
type
of N
TD.
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Fo
lic a
cid
supp
lem
enta
tion
– hi
gher
dos
e to
mot
hers
at r
isk
(
e.g.
thos
e ta
king
ant
iepi
lept
ic m
edic
atio
n).
• Br
aces
, cru
tche
s an
d ot
her w
alki
ng a
ids
to h
elp
child
’s m
obili
ty.
Med
ical
:•
Trea
tmen
t of s
ympt
oms
(e.g
. UTI
s an
d di
fficu
lty
with
bla
dder
con
trol
).
Surg
ical
:•
Rele
ase
teth
ered
cor
d.•
Shun
ts fo
r hyd
roce
phal
us.
• Cl
osur
e if
spin
al c
ord
expo
sed.
MAP
4.8
. Neu
ral t
ube
defe
cts
(NTD
s)
Inve
stig
atio
ns•
Ante
nata
lly o
n ul
tras
ound
.•
Trip
le m
arke
r tes
t at 1
6–18
wee
ks:
1.
Alp
ha fe
topr
otei
n le
vels
(α-F
P).
2.
Oes
trio
l lev
els
(uE3
).
3. H
uman
cho
rioni
c go
nado
trop
in (h
CG).
Cond
itio
n
Spin
a bi
fida
Anen
ceph
aly
α-FP
uE3
hCG
Nor
mal
Nor
mal
¯¯
118
K30033_C004.indd 118 28/02/17 11:43 am
Paed
iatr
ics
Map
4.8
. N
eura
l tu
be
def
ects
(N
TDs)
Wha
t ar
e ne
ural
tub
e de
fect
s?Th
ese
are
cong
enita
l abn
orm
aliti
es in
the
deve
lopm
ent o
f th
e sp
ine,
spi
nal c
ord
and
brai
n. T
hey
occu
r to
vary
ing
degr
ees
but t
he m
ost c
omm
on is
spi
na b
ifida
, a d
isor
der
in w
hich
the
spin
al c
olum
n do
es n
ot c
ompl
etel
y cl
ose.
Caus
esTh
e ex
act c
ause
of N
TDs
is n
ot k
now
n. H
owev
er,
they
are
ass
ocia
ted
with
tera
toge
ns s
uch
asan
tiepi
lept
ic m
edic
atio
n, m
ater
nal d
iabe
tes
mel
litus
and
hig
h m
ater
nal B
MI.
Com
plic
atio
ns•
Decr
ease
d bl
adde
r con
trol
.•
Incr
ease
d ris
k of
UTI
.•
Decr
ease
d m
obili
ty.
• Le
arni
ng d
iffic
ultie
s.•
Hydr
ocep
halu
s.•
Com
plic
atio
ns o
f sur
gery
and
gen
eral
ana
esth
etic
.
Sym
ptom
sVa
ry d
epen
ding
on
type
of N
TD. A
brie
fou
tline
is p
rovi
ded
belo
w:
• An
ence
phal
y: th
e br
ain
and
cran
ium
fail
to
deve
lop
resu
lting
in fe
tal d
eath
.•
Ence
phal
ocoe
le: a
ka c
rani
um b
ifidu
m. T
his
is a
co
nditi
on w
here
the
brai
n, c
over
ed b
y its
m
enin
ges,
prot
rude
s th
roug
h a
mid
line
cran
ial d
efec
t.•
Spin
a bi
fida:
this
occ
urs
whe
n th
e sp
inal
col
umn
or
vert
ebra
l arc
h fa
ils to
clo
se. T
he s
pina
l col
umn
may
be
teth
ered
, whi
ch le
ads
to p
robl
ems
with
bla
dder
co
ntro
l. O
n ex
amin
atio
n, th
ere
is o
ften
hair
ov
erly
ing
the
defe
ct.
• M
enin
goco
ele:
is a
ssoc
iate
d w
ith s
pina
bifi
da.
Th
e m
enin
ges
prot
rude
thro
ugh
the
defe
ct b
ut it
doe
s
not c
onta
in th
e sp
inal
cor
d.•
Men
ingo
mye
loco
ele:
is a
ssoc
iate
d w
ith s
pina
bifi
da.
Th
e m
enin
ges
and
spin
al c
ord
prot
rude
thro
ugh
the
defe
ct.
Trea
tmen
tDe
pend
s on
the
type
of N
TD.
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Fo
lic a
cid
supp
lem
enta
tion
– hi
gher
dos
e to
mot
hers
at r
isk
(
e.g.
thos
e ta
king
ant
iepi
lept
ic m
edic
atio
n).
• Br
aces
, cru
tche
s an
d ot
her w
alki
ng a
ids
to h
elp
child
’s m
obili
ty.
Med
ical
:•
Trea
tmen
t of s
ympt
oms
(e.g
. UTI
s an
d di
fficu
lty
with
bla
dder
con
trol
).
Surg
ical
:•
Rele
ase
teth
ered
cor
d.•
Shun
ts fo
r hyd
roce
phal
us.
• Cl
osur
e if
spin
al c
ord
expo
sed.
MAP
4.8
. Neu
ral t
ube
defe
cts
(NTD
s)
Inve
stig
atio
ns•
Ante
nata
lly o
n ul
tras
ound
.•
Trip
le m
arke
r tes
t at 1
6–18
wee
ks:
1.
Alp
ha fe
topr
otei
n le
vels
(α-F
P).
2.
Oes
trio
l lev
els
(uE3
).
3. H
uman
cho
rioni
c go
nado
trop
in (h
CG).
Cond
itio
n
Spin
a bi
fida
Anen
ceph
aly
α-FP
uE3
hCG
Nor
mal
Nor
mal
¯¯
119
K30033_C004.indd 119 28/02/17 11:43 am
Paed
iatr
ics
Map
4.9
. C
ereb
ral p
alsy
Wha
t is
cer
ebra
l pal
sy?
This
is a
non
-pro
gres
sive
insu
lt th
at o
ccur
s on
the
deve
lopi
ng b
rain
. It r
esul
ts in
a d
isor
der o
f mov
emen
tan
d po
stur
e as
wel
l as
othe
r neu
rolo
gica
l com
plai
nts
such
as e
pile
psy,
depe
ndin
g on
the
loca
tion
of th
e le
sion
.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s of
cer
ebra
l pal
syin
clud
ing:
• In
fect
ion
– m
enin
gitis
and
TORC
HES.
• Tr
aum
a –
in e
arly
chi
ldho
od y
ears
or a
t birt
h.•
Hypo
xia.
• Pr
emat
urity
– in
crea
ses
risk.
• Va
scul
ar m
alfo
rmat
ion
(e.g
. art
erio
veno
us
mal
form
atio
ns, s
trok
e).
• Tu
mou
rs.
Inve
stig
atio
nsG
ener
ally
this
is a
clin
ical
dia
gnos
is, b
ut id
entif
ying
the
caus
e m
ay b
e ai
ded
byra
diol
ogic
al in
vest
igat
ion
such
as
CT a
nd M
RI. I
t is
also
impo
rtan
t to
perfo
rm a
n au
diol
ogic
al a
sses
smen
t as
wel
l as
an o
phth
alm
olog
ical
eva
luat
ion.
Com
plic
atio
ns•
Ort
hopa
edic
com
plic
atio
ns: m
uscl
e sh
orte
ning
, abn
orm
al p
ostu
ring.
• N
euro
logi
cal c
ompl
icat
ions
: epi
leps
y.•
Resp
irato
ry c
ompl
icat
ions
: asp
iratio
n pn
eum
onia
, res
tric
tive
lung
dis
ease
.•
Gas
troi
ntes
tinal
com
plic
atio
ns: g
astr
o-oe
soph
agea
l ref
lux
dise
ase,
con
stip
atio
n.•
Urin
ary
com
plic
atio
ns: U
TI, b
ladd
er c
ontr
ol is
sues
.•
Derm
atol
ogic
al c
ompl
icat
ions
: dec
ubitu
s ul
cers
.•
Psyc
holo
gica
l com
plic
atio
ns: d
epre
ssio
n.•
Slee
p di
sord
ers.
• Le
arni
ng d
iffic
ultie
s.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt a
nd p
atie
nt e
duca
tion.
• Ac
cess
to s
uppo
rt s
ervi
ces.
Med
ical
:•
Man
age
com
plic
atio
ns.
• An
tiepi
lept
ic m
edic
atio
n.•
Oth
ers
such
as
benz
odia
zepi
nes
and
bacl
ofen
may
be
r
equi
red.
Surg
ical
:•
Mus
cle
leng
then
ing.
• O
rtho
paed
ic s
urge
ry (e
.g. s
pina
l fus
ion)
.•
Sele
ctiv
e do
rsal
rhiz
otom
y.
MAP
4.9
. Cer
ebra
l pal
sy
Sym
ptom
sTh
e sy
mpt
oms
depe
nd o
n th
e su
btyp
e of
cer
ebra
l pal
sy (r
emem
ber a
s SA
D).
Split
sym
ptom
s in
to:
1. M
otor
abn
orm
ality
.
Subt
ype
Not
es
Ata
xic
Dys
kine
tic
Spas
tic
Abno
rmal
sen
se o
f bod
y in
spa
ce
Mos
t com
mon
~80
%Sc
isso
ring
post
ure
sinc
e fle
xors
, add
ucto
rs a
nd in
tern
alro
tato
rs a
re la
rgel
y af
fect
edPa
tient
may
pre
sent
with
dip
legi
a, h
emip
legi
a or
quad
riple
gia
Abno
rmal
, inv
olun
tary
pos
turin
g
2. L
earn
ing
diffi
culti
es.
3. N
euro
logi
cal a
bnor
mal
ities
: pat
ient
s m
ay s
uffe
r with
epi
leps
y.4.
Beh
avio
ural
abn
orm
aliti
es: d
isor
dere
d sl
eep
and
self-
inju
rious
beh
avio
ur.
5. S
enso
ry im
pairm
ent:
visu
al im
pairm
ent i
nclu
ding
refra
ctor
y er
rors
as
wel
l as
stra
bism
us.
I
ncre
ased
risk
of d
eafn
ess.
Esse
ntia
l to
scre
en fo
r bot
h.6.
Pse
udob
ulba
r pal
sy: p
rese
nt in
som
e pa
tient
s. Af
fect
s sp
eech
and
sw
allo
win
g.
120
K30033_C004.indd 120 28/02/17 11:43 am
Paed
iatr
ics
Map
4.9
. C
ereb
ral p
alsy
Wha
t is
cer
ebra
l pal
sy?
This
is a
non
-pro
gres
sive
insu
lt th
at o
ccur
s on
the
deve
lopi
ng b
rain
. It r
esul
ts in
a d
isor
der o
f mov
emen
tan
d po
stur
e as
wel
l as
othe
r neu
rolo
gica
l com
plai
nts
such
as e
pile
psy,
depe
ndin
g on
the
loca
tion
of th
e le
sion
.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s of
cer
ebra
l pal
syin
clud
ing:
• In
fect
ion
– m
enin
gitis
and
TORC
HES.
• Tr
aum
a –
in e
arly
chi
ldho
od y
ears
or a
t birt
h.•
Hypo
xia.
• Pr
emat
urity
– in
crea
ses
risk.
• Va
scul
ar m
alfo
rmat
ion
(e.g
. art
erio
veno
us
mal
form
atio
ns, s
trok
e).
• Tu
mou
rs.
Inve
stig
atio
nsG
ener
ally
this
is a
clin
ical
dia
gnos
is, b
ut id
entif
ying
the
caus
e m
ay b
e ai
ded
byra
diol
ogic
al in
vest
igat
ion
such
as
CT a
nd M
RI. I
t is
also
impo
rtan
t to
perfo
rm a
n au
diol
ogic
al a
sses
smen
t as
wel
l as
an o
phth
alm
olog
ical
eva
luat
ion.
Com
plic
atio
ns•
Ort
hopa
edic
com
plic
atio
ns: m
uscl
e sh
orte
ning
, abn
orm
al p
ostu
ring.
• N
euro
logi
cal c
ompl
icat
ions
: epi
leps
y.•
Resp
irato
ry c
ompl
icat
ions
: asp
iratio
n pn
eum
onia
, res
tric
tive
lung
dis
ease
.•
Gas
troi
ntes
tinal
com
plic
atio
ns: g
astr
o-oe
soph
agea
l ref
lux
dise
ase,
con
stip
atio
n.•
Urin
ary
com
plic
atio
ns: U
TI, b
ladd
er c
ontr
ol is
sues
.•
Derm
atol
ogic
al c
ompl
icat
ions
: dec
ubitu
s ul
cers
.•
Psyc
holo
gica
l com
plic
atio
ns: d
epre
ssio
n.•
Slee
p di
sord
ers.
• Le
arni
ng d
iffic
ultie
s.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt a
nd p
atie
nt e
duca
tion.
• Ac
cess
to s
uppo
rt s
ervi
ces.
Med
ical
:•
Man
age
com
plic
atio
ns.
• An
tiepi
lept
ic m
edic
atio
n.•
Oth
ers
such
as
benz
odia
zepi
nes
and
bacl
ofen
may
be
r
equi
red.
Surg
ical
:•
Mus
cle
leng
then
ing.
• O
rtho
paed
ic s
urge
ry (e
.g. s
pina
l fus
ion)
.•
Sele
ctiv
e do
rsal
rhiz
otom
y.
MAP
4.9
. Cer
ebra
l pal
sy
Sym
ptom
sTh
e sy
mpt
oms
depe
nd o
n th
e su
btyp
e of
cer
ebra
l pal
sy (r
emem
ber a
s SA
D).
Split
sym
ptom
s in
to:
1. M
otor
abn
orm
ality
.
Subt
ype
Not
es
Ata
xic
Dys
kine
tic
Spas
tic
Abno
rmal
sen
se o
f bod
y in
spa
ce
Mos
t com
mon
~80
%Sc
isso
ring
post
ure
sinc
e fle
xors
, add
ucto
rs a
nd in
tern
alro
tato
rs a
re la
rgel
y af
fect
edPa
tient
may
pre
sent
with
dip
legi
a, h
emip
legi
a or
quad
riple
gia
Abno
rmal
, inv
olun
tary
pos
turin
g
2. L
earn
ing
diffi
culti
es.
3. N
euro
logi
cal a
bnor
mal
ities
: pat
ient
s m
ay s
uffe
r with
epi
leps
y.4.
Beh
avio
ural
abn
orm
aliti
es: d
isor
dere
d sl
eep
and
self-
inju
rious
beh
avio
ur.
5. S
enso
ry im
pairm
ent:
visu
al im
pairm
ent i
nclu
ding
refra
ctor
y er
rors
as
wel
l as
stra
bism
us.
I
ncre
ased
risk
of d
eafn
ess.
Esse
ntia
l to
scre
en fo
r bot
h.6.
Pse
udob
ulba
r pal
sy: p
rese
nt in
som
e pa
tient
s. Af
fect
s sp
eech
and
sw
allo
win
g.
121
K30033_C004.indd 121 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
0. M
enin
git
is
Sym
ptom
s•
Gen
eral
sym
ptom
s:
Let
harg
y.
Cry
ing.
O
ff fe
eds.
• S
igns
of i
ncre
ased
intr
acra
nial
pre
ssur
e:
Dec
reas
ed le
vel o
f con
scio
usne
ss.
P
apill
oede
ma.
H
eada
che.
• S
peci
fic s
igns
:
Pur
puric
non
-bla
nchi
ng ra
sh (N
eiss
eria
m
enin
gitid
is).
N
eck
stiff
ness
.
Ker
nig’
s si
gn.
F
ocal
neu
rolo
gica
l sig
ns (e
.g. c
rani
al
n
erve
invo
lvem
ent).
Inve
stig
atio
ns•
Blo
od te
sts:
FBC
, WCC
, U&
E, L
FTs,
glu
cose
,
gro
up a
nd s
ave,
clo
ttin
g st
udie
s, b
lood
cul
ture
s an
d PC
R fo
r N. m
enin
gitid
is.
• G
ener
al in
vest
igat
ions
: thr
oat s
wab
,
urin
alys
is m
icro
scop
y an
d cu
lture
,
sto
ol s
ampl
e.•
Lum
bar p
unct
ure:
con
trai
ndic
ated
if ra
ised
i
ntra
cran
ial p
ress
ure
or m
enin
goco
ccal
s
eptic
aem
ia. V
alue
s sh
own
belo
w. P
CR
req
uire
d fo
r vira
l dia
gnos
is.
Org
anis
mW
CCPr
otei
nG
luco
se
Bact
eria
lN
eutr
ophi
ls
Vira
lLy
mph
ocyt
esN
orm
alN
orm
al
¯
• R
adio
logy
: CT
if in
dica
ted.
Com
plic
atio
nsM
enin
gitis
cau
ses
seve
ral c
ompl
icat
ions
.So
me
are
liste
d be
low
.Re
mem
ber a
s th
e 5C
s:C
– Ce
rebr
al p
alsy
C –
Conv
ulsi
ons
C –
Circ
ulat
ory
shoc
kC
– Ce
rebr
al a
bsce
ssC
– Cr
ania
l ner
ve p
alsi
es
Trea
tmen
t
Cons
erva
tive
:•
Par
ent e
duca
tion.
• C
onta
ct p
ublic
hea
lth c
onsu
ltant
sin
ce it
is a
n
otifi
able
dis
ease
.
Med
ical
:•
GP
may
giv
e IM
ben
zylp
enic
illin
in th
eir
pr
actic
e to
pre
vent
del
ay.
• I
V an
tibio
tics
depe
nd o
n ag
e:
<3
mon
ths:
am
oxic
illin
and
cef
otax
ime.
>
3 m
onth
s: c
efot
axim
e.•
Dex
amet
haso
ne if
>1
mon
th a
nd c
ausa
tive
or
gani
sm is
Hae
mop
hilu
s in
fluen
zae.
• A
ntib
iotic
pro
phyl
axis
for c
lose
men
ingo
cocc
al c
onta
cts
with
rifa
mpi
cin.MAP
4.10
. Men
ingi
tis
Wha
t is
men
ingi
tis?
This
is a
n in
fect
ion
of th
e su
bara
chno
id s
pace
by
an o
rgan
ism
that
sub
sequ
ently
cau
ses
infla
mm
atio
n of
the
men
inge
s.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s of
men
ingi
tis(s
ee b
elow
).
Cate
gory
Age
aff
ecte
dO
rgan
ism
s
Gro
up B
st
rept
ococ
cus
Esch
eric
hia
coli
List
eria
m
onoc
ytog
enes
Nei
sser
ia
men
ingi
tidis
Stre
ptoc
occu
spn
eum
onia
eHa
emop
hilu
s in
fluen
zae
type
B
Nei
sser
ia
men
ingi
tidis
Stre
ptoc
occu
s pn
eum
onia
eM
umps
Myc
obac
teriu
mtu
berc
ulos
is
Ente
rovi
rus
Cyto
meg
alov
irus
Arbo
viru
s
Any
age
Any
age
Ove
r6
year
s
1 m
onth
to6
year
s
Neo
nate
to2
mon
ths
Bact
eria
l
Vira
l
Risk
fact
ors:
rem
embe
r as
ABC
S:
A –
Age
(you
ng)
B
– Be
ing
of lo
w s
ocio
econ
omic
sta
tus
C
– Co
mpl
emen
t def
ects
S
– Si
ckle
cel
l dis
ease
122
K30033_C004.indd 122 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
0. M
enin
git
is
Sym
ptom
s•
Gen
eral
sym
ptom
s:
Let
harg
y.
Cry
ing.
O
ff fe
eds.
• S
igns
of i
ncre
ased
intr
acra
nial
pre
ssur
e:
Dec
reas
ed le
vel o
f con
scio
usne
ss.
P
apill
oede
ma.
H
eada
che.
• S
peci
fic s
igns
:
Pur
puric
non
-bla
nchi
ng ra
sh (N
eiss
eria
m
enin
gitid
is).
N
eck
stiff
ness
.
Ker
nig’
s si
gn.
F
ocal
neu
rolo
gica
l sig
ns (e
.g. c
rani
al
n
erve
invo
lvem
ent).
Inve
stig
atio
ns•
Blo
od te
sts:
FBC
, WCC
, U&
E, L
FTs,
glu
cose
,
gro
up a
nd s
ave,
clo
ttin
g st
udie
s, b
lood
cul
ture
s an
d PC
R fo
r N. m
enin
gitid
is.
• G
ener
al in
vest
igat
ions
: thr
oat s
wab
,
urin
alys
is m
icro
scop
y an
d cu
lture
,
sto
ol s
ampl
e.•
Lum
bar p
unct
ure:
con
trai
ndic
ated
if ra
ised
i
ntra
cran
ial p
ress
ure
or m
enin
goco
ccal
s
eptic
aem
ia. V
alue
s sh
own
belo
w. P
CR
req
uire
d fo
r vira
l dia
gnos
is.
Org
anis
mW
CCPr
otei
nG
luco
se
Bact
eria
lN
eutr
ophi
ls
Vira
lLy
mph
ocyt
esN
orm
alN
orm
al
¯
• R
adio
logy
: CT
if in
dica
ted.
Com
plic
atio
nsM
enin
gitis
cau
ses
seve
ral c
ompl
icat
ions
.So
me
are
liste
d be
low
.Re
mem
ber a
s th
e 5C
s:C
– Ce
rebr
al p
alsy
C –
Conv
ulsi
ons
C –
Circ
ulat
ory
shoc
kC
– Ce
rebr
al a
bsce
ssC
– Cr
ania
l ner
ve p
alsi
es
Trea
tmen
t
Cons
erva
tive
:•
Par
ent e
duca
tion.
• C
onta
ct p
ublic
hea
lth c
onsu
ltant
sin
ce it
is a
n
otifi
able
dis
ease
.
Med
ical
:•
GP
may
giv
e IM
ben
zylp
enic
illin
in th
eir
pr
actic
e to
pre
vent
del
ay.
• I
V an
tibio
tics
depe
nd o
n ag
e:
<3
mon
ths:
am
oxic
illin
and
cef
otax
ime.
>
3 m
onth
s: c
efot
axim
e.•
Dex
amet
haso
ne if
>1
mon
th a
nd c
ausa
tive
or
gani
sm is
Hae
mop
hilu
s in
fluen
zae.
• A
ntib
iotic
pro
phyl
axis
for c
lose
men
ingo
cocc
al c
onta
cts
with
rifa
mpi
cin.MAP
4.10
. Men
ingi
tis
Wha
t is
men
ingi
tis?
This
is a
n in
fect
ion
of th
e su
bara
chno
id s
pace
by
an o
rgan
ism
that
sub
sequ
ently
cau
ses
infla
mm
atio
n of
the
men
inge
s.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s of
men
ingi
tis(s
ee b
elow
).
Cate
gory
Age
aff
ecte
dO
rgan
ism
s
Gro
up B
st
rept
ococ
cus
Esch
eric
hia
coli
List
eria
m
onoc
ytog
enes
Nei
sser
ia
men
ingi
tidis
Stre
ptoc
occu
spn
eum
onia
eHa
emop
hilu
s in
fluen
zae
type
B
Nei
sser
ia
men
ingi
tidis
Stre
ptoc
occu
s pn
eum
onia
eM
umps
Myc
obac
teriu
mtu
berc
ulos
is
Ente
rovi
rus
Cyto
meg
alov
irus
Arbo
viru
s
Any
age
Any
age
Ove
r6
year
s
1 m
onth
to6
year
s
Neo
nate
to2
mon
ths
Bact
eria
l
Vira
l
Risk
fact
ors:
rem
embe
r as
ABC
S:
A –
Age
(you
ng)
B
– Be
ing
of lo
w s
ocio
econ
omic
sta
tus
C
– Co
mpl
emen
t def
ects
S
– Si
ckle
cel
l dis
ease
123
K30033_C004.indd 123 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
1. F
ailu
re t
o t
hri
ve
Wha
t is
failu
re t
o th
rive
?Th
is is
whe
n th
e ch
ild’s
wei
ght o
r rat
e of
wei
ght g
ain
is s
igni
fican
tly le
ss
than
thei
r ide
ntic
ally
mat
ched
pee
rs.
Caus
esTh
ere
are
man
y ca
uses
of f
ailu
re to
thriv
e, w
hich
may
be
cong
enita
l or
acqu
ired.
Som
e ar
e ca
tego
rized
bel
ow:
• N
ot e
noug
h di
etar
y in
take
:
Ab
use
and
negl
ect.
Anor
exia
ner
vosa
.
Po
or p
aren
tal d
ieta
ry u
nder
stan
ding
.•
Diffi
culty
feed
ing:
Clef
t pal
ate.
Oes
opha
geal
atr
esia
/trac
heo-
oeso
phag
eal a
tres
ia.
Neu
rolo
gica
l dis
orde
rs (e
.g. c
ereb
ral p
alsy
).•
Mal
abso
rptio
n:
Co
elia
c di
seas
e.
In
flam
mat
ory
bow
el d
isea
se (I
BD).
Lact
ose
into
lera
nce.
• Ch
roni
c di
seas
e:
Cy
stic
fibr
osis.
Asth
ma.
Gro
wth
hor
mon
e de
ficie
ncy.
Hypo
thyr
oidi
sm.
• Ch
rom
osom
al a
bnor
mal
ities
:
Tu
rner
syn
drom
e.•
Gen
etic
abn
orm
aliti
es:
Acho
ndro
plas
ia.
Inbo
rn e
rror
s of
met
abol
ism
.
Sym
ptom
s•
Gen
eral
sym
ptom
s:
Le
thar
gy.
Decr
ease
d w
eigh
t.
O
ff fe
eds.
• Si
gns
and
sym
ptom
s of
und
erly
ing
dise
ase
(see
bel
ow):
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
TFTs
, glu
cose
.•
Urin
alys
is.•
Stoo
l mic
rosc
opy
and
cultu
re.
• Sp
ecifi
c te
st (e
.g. s
wea
t tes
t for
cys
tic fi
bros
is,
endo
mes
ial a
nd g
liadi
n an
tibod
ies
for c
oelia
c
dise
ase)
.•
Chro
mos
omal
ana
lysi
s if
indi
cate
d.•
Radi
olog
y: m
ay b
e re
quire
d in
cer
tain
ci
rcum
stan
ces
(e.g
. cer
ebra
l pal
sy m
ay re
quire
CT
or M
RI).
Com
plic
atio
ns•
Psyc
holo
gica
l iss
ues
(e.g
. dep
ress
ion)
.•
Decr
ease
d gr
owth
.•
Deve
lopm
enta
l del
ay.
• Sp
ecifi
c pr
oble
ms
rela
ted
to c
ause
.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• In
volv
e so
cial
wor
kers
if n
eces
sary
.•
Ensu
re c
hild
has
an
appr
opria
te d
iet a
nd is
re
ceiv
ing
the
nece
ssar
y ca
lorie
s.
Med
ical
:•
Trea
t the
und
erly
ing
caus
e.
Surg
ical
:•
If in
dica
ted.
MAP
4.1
1. F
ailu
re t
o th
rive
Cond
itio
nN
otes
Anor
exia
ner
vosa
Cere
bral
pal
sy
Abus
e
Cyst
ic fi
bros
is
Asth
ma
See
Map
1.6
(p. 2
2)
See
Map
4.9
(p. 1
20)
See
Map
4.1
4 (p
. 130
)
See
Map
4.1
5 (p
. 132
)
Brui
sing
of v
aryi
ng a
ge. C
hang
ing
hist
ory
not i
n ke
epin
g w
ith in
jurie
s
Hypo
thyr
oidi
smCo
ld in
tole
ranc
e, c
onst
ipat
ion,
dry
ski
n/ha
ir,hy
pore
flexi
a, b
rady
card
ia
Acho
ndro
plas
iaAu
toso
mal
dom
inan
t inh
erita
nce.
A c
ause
of
dwar
fism
. Due
to m
utat
ion
of fi
brob
last
grow
th fa
ctor
rece
ptor
3 (F
GFR
3)
Coel
iac
dise
ase
Prox
imal
sm
all i
ntes
tine
mai
nly
affe
cted
.As
soci
ated
with
oth
er a
utoi
mm
une
cond
ition
san
d de
rmat
itis
herp
etifo
rmis
124
K30033_C004.indd 124 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
1. F
ailu
re t
o t
hri
ve
Wha
t is
failu
re t
o th
rive
?Th
is is
whe
n th
e ch
ild’s
wei
ght o
r rat
e of
wei
ght g
ain
is s
igni
fican
tly le
ss
than
thei
r ide
ntic
ally
mat
ched
pee
rs.
Caus
esTh
ere
are
man
y ca
uses
of f
ailu
re to
thriv
e, w
hich
may
be
cong
enita
l or
acqu
ired.
Som
e ar
e ca
tego
rized
bel
ow:
• N
ot e
noug
h di
etar
y in
take
:
Ab
use
and
negl
ect.
Anor
exia
ner
vosa
.
Po
or p
aren
tal d
ieta
ry u
nder
stan
ding
.•
Diffi
culty
feed
ing:
Clef
t pal
ate.
Oes
opha
geal
atr
esia
/trac
heo-
oeso
phag
eal a
tres
ia.
Neu
rolo
gica
l dis
orde
rs (e
.g. c
ereb
ral p
alsy
).•
Mal
abso
rptio
n:
Co
elia
c di
seas
e.
In
flam
mat
ory
bow
el d
isea
se (I
BD).
Lact
ose
into
lera
nce.
• Ch
roni
c di
seas
e:
Cy
stic
fibr
osis.
Asth
ma.
Gro
wth
hor
mon
e de
ficie
ncy.
Hypo
thyr
oidi
sm.
• Ch
rom
osom
al a
bnor
mal
ities
:
Tu
rner
syn
drom
e.•
Gen
etic
abn
orm
aliti
es:
Acho
ndro
plas
ia.
Inbo
rn e
rror
s of
met
abol
ism
.
Sym
ptom
s•
Gen
eral
sym
ptom
s:
Le
thar
gy.
Decr
ease
d w
eigh
t.
O
ff fe
eds.
• Si
gns
and
sym
ptom
s of
und
erly
ing
dise
ase
(see
bel
ow):
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
TFTs
, glu
cose
.•
Urin
alys
is.•
Stoo
l mic
rosc
opy
and
cultu
re.
• Sp
ecifi
c te
st (e
.g. s
wea
t tes
t for
cys
tic fi
bros
is,
endo
mes
ial a
nd g
liadi
n an
tibod
ies
for c
oelia
c
dise
ase)
.•
Chro
mos
omal
ana
lysi
s if
indi
cate
d.•
Radi
olog
y: m
ay b
e re
quire
d in
cer
tain
ci
rcum
stan
ces
(e.g
. cer
ebra
l pal
sy m
ay re
quire
CT
or M
RI).
Com
plic
atio
ns•
Psyc
holo
gica
l iss
ues
(e.g
. dep
ress
ion)
.•
Decr
ease
d gr
owth
.•
Deve
lopm
enta
l del
ay.
• Sp
ecifi
c pr
oble
ms
rela
ted
to c
ause
.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• In
volv
e so
cial
wor
kers
if n
eces
sary
.•
Ensu
re c
hild
has
an
appr
opria
te d
iet a
nd is
re
ceiv
ing
the
nece
ssar
y ca
lorie
s.
Med
ical
:•
Trea
t the
und
erly
ing
caus
e.
Surg
ical
:•
If in
dica
ted.
MAP
4.1
1. F
ailu
re t
o th
rive
Cond
itio
nN
otes
Anor
exia
ner
vosa
Cere
bral
pal
sy
Abus
e
Cyst
ic fi
bros
is
Asth
ma
See
Map
1.6
(p. 2
2)
See
Map
4.9
(p. 1
20)
See
Map
4.1
4 (p
. 130
)
See
Map
4.1
5 (p
. 132
)
Brui
sing
of v
aryi
ng a
ge. C
hang
ing
hist
ory
not i
n ke
epin
g w
ith in
jurie
s
Hypo
thyr
oidi
smCo
ld in
tole
ranc
e, c
onst
ipat
ion,
dry
ski
n/ha
ir,hy
pore
flexi
a, b
rady
card
ia
Acho
ndro
plas
iaAu
toso
mal
dom
inan
t inh
erita
nce.
A c
ause
of
dwar
fism
. Due
to m
utat
ion
of fi
brob
last
grow
th fa
ctor
rece
ptor
3 (F
GFR
3)
Coel
iac
dise
ase
Prox
imal
sm
all i
ntes
tine
mai
nly
affe
cted
.As
soci
ated
with
oth
er a
utoi
mm
une
cond
ition
san
d de
rmat
itis
herp
etifo
rmis
125
K30033_C004.indd 125 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
2. B
ron
chio
litis
MAP
4.1
2.Br
onch
iolit
is
Wha
t is
bro
nchi
olit
is?
This
is a
low
er re
spira
tory
trac
t inf
ectio
n th
at is
ch
arac
teriz
ed b
y pr
ogre
ssiv
e sy
mpt
oms
from
co
ryza
to a
per
sist
ent c
ough
, bre
athl
essn
ess
and
poss
ible
resp
irato
ry d
istr
ess.
This
con
ditio
n of
ten
affe
cts
child
ren
<1
year
of a
ge s
ince
thei
r airw
ays
are
so n
arro
w.
Caus
esRe
mem
ber a
s RI
P:R
– Re
spira
tory
syn
cytia
l viru
s (m
ost c
omm
on
cau
se)
I –
Influ
enza
P –
Para
influ
enza
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Co
ntin
ual m
onito
ring.
• Hi
gh-r
isk
infa
nts
may
requ
ire p
roph
ylac
tic
paliv
izum
ab (e
.g. i
nfan
ts w
ho a
re p
rem
atur
e or
ha
ve c
onge
nita
l hea
rt d
efec
ts).
Med
ical
:•
Hum
idifi
ed o
xyge
n de
liver
ed v
ia a
nas
al
cann
ula.
• Ve
ntila
tion
requ
ired
if sy
mpt
oms
are
seve
re.
• Br
onch
odila
tors
may
be
used
but
thei
r ben
efit
is
unp
rove
n.
Sym
ptom
s•
Gen
eral
sym
ptom
s:
Br
eath
less
ness
.
Pe
rsis
tent
cou
gh.
Leth
argy
.
O
ff fe
eds.
• Si
gns
of re
spira
tory
dep
ress
ion:
Nas
al fl
arin
g.
Su
bcos
tal a
nd in
terc
osta
l rec
essi
on.
Low
Gla
scow
Com
a Sc
ale
scor
e.
Cy
anos
is.•
Sign
s of
hyp
erin
flatio
n:
Do
wnw
ard
disp
lace
men
t of l
iver
.•
On
ausc
ulta
tion:
Expi
rato
ry w
heez
e.
Fi
ne e
nd in
spira
tory
cra
ckle
s.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
U&
E, L
FTs.
• Ca
pilla
ry b
lood
gas
.•
Spec
ific
test
s: na
sal a
spira
tes
with
imm
uno-
flu
ores
cent
sta
inin
g fo
r res
pira
tory
syn
cytia
l viru
s.•
Radi
olog
y: c
hest
x-r
ay
Com
plic
atio
ns•
Vent
ilatio
n m
ay b
e re
quire
d (th
is m
ay
inc
reas
e th
e ris
k of
pne
umon
ia).
• Re
spira
tory
failu
re.
• Ca
rdia
c fa
ilure
.•
Pneu
mot
hora
x.
126
K30033_C004.indd 126 28/02/17 11:43 am
Paed
iatr
ics
MAP
4.1
2.Br
onch
iolit
is
Wha
t is
bro
nchi
olit
is?
This
is a
low
er re
spira
tory
trac
t inf
ectio
n th
at is
ch
arac
teriz
ed b
y pr
ogre
ssiv
e sy
mpt
oms
from
co
ryza
to a
per
sist
ent c
ough
, bre
athl
essn
ess
and
poss
ible
resp
irato
ry d
istr
ess.
This
con
ditio
n of
ten
affe
cts
child
ren
<1
year
of a
ge s
ince
thei
r airw
ays
are
so n
arro
w.
Caus
esRe
mem
ber a
s RI
P:R
– Re
spira
tory
syn
cytia
l viru
s (m
ost c
omm
on
cau
se)
I –
Influ
enza
P –
Para
influ
enza
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Co
ntin
ual m
onito
ring.
• Hi
gh-r
isk
infa
nts
may
requ
ire p
roph
ylac
tic
paliv
izum
ab (e
.g. i
nfan
ts w
ho a
re p
rem
atur
e or
ha
ve c
onge
nita
l hea
rt d
efec
ts).
Med
ical
:•
Hum
idifi
ed o
xyge
n de
liver
ed v
ia a
nas
al
cann
ula.
• Ve
ntila
tion
requ
ired
if sy
mpt
oms
are
seve
re.
• Br
onch
odila
tors
may
be
used
but
thei
r ben
efit
is
unp
rove
n.
Sym
ptom
s•
Gen
eral
sym
ptom
s:
Br
eath
less
ness
.
Pe
rsis
tent
cou
gh.
Leth
argy
.
O
ff fe
eds.
• Si
gns
of re
spira
tory
dep
ress
ion:
Nas
al fl
arin
g.
Su
bcos
tal a
nd in
terc
osta
l rec
essi
on.
Low
Gla
scow
Com
a Sc
ale
scor
e.
Cy
anos
is.•
Sign
s of
hyp
erin
flatio
n:
Do
wnw
ard
disp
lace
men
t of l
iver
.•
On
ausc
ulta
tion:
Expi
rato
ry w
heez
e.
Fi
ne e
nd in
spira
tory
cra
ckle
s.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
U&
E, L
FTs.
• Ca
pilla
ry b
lood
gas
.•
Spec
ific
test
s: na
sal a
spira
tes
with
imm
uno-
flu
ores
cent
sta
inin
g fo
r res
pira
tory
syn
cytia
l viru
s.•
Radi
olog
y: c
hest
x-r
ay
Com
plic
atio
ns•
Vent
ilatio
n m
ay b
e re
quire
d (th
is m
ay
inc
reas
e th
e ris
k of
pne
umon
ia).
• Re
spira
tory
failu
re.
• Ca
rdia
c fa
ilure
.•
Pneu
mot
hora
x. Map
4.1
2. B
ron
chio
litis
127
K30033_C004.indd 127 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
3. C
rou
p
Wha
t is
cro
up?
This
is a
vira
l inf
ectio
n th
at c
ause
spr
ogre
ssiv
e in
flam
mat
ion
of th
ere
spira
tory
trac
t com
men
cing
with
the
lary
nx a
nd s
prea
ding
dist
ally
to th
e br
onch
i. Th
is is
why
it is
als
o kn
own
as a
cute
lary
ngot
rach
eobr
onch
itis.
Tend
sto
affe
ct c
hild
ren
aged
6 m
onth
sto
6 y
ears
.
Caus
esRe
mem
ber a
s RI
P:R
– Re
spira
tory
syn
cytia
l viru
sI
– In
fluen
zaP
– Pa
rain
fluen
za (m
ost
c
omm
on c
ause
)
Com
plic
atio
ns•
Deat
h.•
Trac
heiti
s.•
Pneu
mon
ia.
Sym
ptom
sTe
nd to
be
wor
se a
t nig
ht
• G
ener
al s
ympt
oms:
Br
eath
less
ness
.
Pers
iste
nt c
ough
.
Leth
argy
.
Off
feed
s.•
Typi
cal f
eatu
res:
wor
sen
with
pr
ogre
ssio
n of
infla
mm
atio
n:
Cory
za +
/– fe
ver (
prod
rom
e).
‘B
arki
ng’ c
ough
.
Hoar
sene
ss.
St
ridor
.•
Sign
s of
res
pira
tory
dep
ress
ion:
N
asal
flar
ing.
Su
bcos
tal a
nd in
terc
osta
l rec
essi
on.
Lo
w G
lasc
ow C
oma
Scal
e sc
ore.
Cy
anos
is.•
On
ausc
ulta
tion
:
St
ridor
– h
eard
in m
oder
ated
crou
p w
ith a
ste
thos
cope
. It i
s po
ssib
le
to
hea
r str
idor
with
out a
ste
thos
cope
in s
ever
e ca
ses. M
AP 4
.13.
Cro
up
Inve
stig
atio
ns•
Bloo
d te
sts
and
an e
xam
inat
ion
of th
e ch
ild’s
th
roat
is u
sual
ly n
ot u
nder
take
n si
nce
this
may
di
stre
ss th
e ch
ild a
nd in
adve
rten
tly c
lose
thei
r
airw
ay, l
eadi
ng to
an
emer
genc
y si
tuat
ion
in
whi
ch in
vasi
ve a
cces
s to
the
airw
ay m
ust b
e
esta
blis
hed.
• He
art r
ate,
resp
irato
ry ra
te a
nd o
xyge
n sa
tura
tion.
• As
sess
sev
erity
usi
ng th
e W
estle
y Cr
oup
Scor
e:
Cate
gory
Wes
tley
scor
eFe
atur
es
Mild
Mod
erat
e
Seve
re
0–2
3–5
6–11
Freq
uent
cou
gh.
Mar
ked
strid
or. M
arke
dst
erna
l wal
l ret
ract
ion.
Resp
irato
ry d
istr
ess
Freq
uent
cou
gh. S
trid
or.
Ster
nal w
all r
etra
ctio
n at
rest
Occ
asio
nal c
ough
. No
strid
or.
No
sign
s of
resp
irato
ryde
pres
sion
Trea
tmen
tDe
pend
s on
the
seve
rity
of c
roup
.
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Co
ntin
ual m
onito
ring.
Med
ical
:
Mild
Mos
t may
be
man
aged
at h
ome
with
par
acet
amol
,ne
w g
uida
nce
reco
mm
ends
giv
ing
a si
ngle
dos
e of
ora
lde
xam
etha
sone
to a
ll ch
ildre
n re
gard
less
of s
ever
ity.
Seve
re
Mod
erat
e
1. S
tero
ids,
e.g.
:- O
ral d
exam
etha
sone
or p
redn
isol
one
- Neb
uliz
ed b
udes
onid
e2.
Neb
uliz
ed a
dren
alin
e (5
mL
of 1
:1,0
00 w
ith o
xyge
n)
Ster
oids
, e.g
.:- O
ral d
exam
etha
sone
or p
redn
isol
one
- Neb
uliz
ed b
udes
onid
e
128
K30033_C004.indd 128 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
3. C
rou
p
Wha
t is
cro
up?
This
is a
vira
l inf
ectio
n th
at c
ause
spr
ogre
ssiv
e in
flam
mat
ion
of th
ere
spira
tory
trac
t com
men
cing
with
the
lary
nx a
nd s
prea
ding
dist
ally
to th
e br
onch
i. Th
is is
why
it is
als
o kn
own
as a
cute
lary
ngot
rach
eobr
onch
itis.
Tend
sto
affe
ct c
hild
ren
aged
6 m
onth
sto
6 y
ears
.
Caus
esRe
mem
ber a
s RI
P:R
– Re
spira
tory
syn
cytia
l viru
sI
– In
fluen
zaP
– Pa
rain
fluen
za (m
ost
c
omm
on c
ause
)
Com
plic
atio
ns•
Deat
h.•
Trac
heiti
s.•
Pneu
mon
ia.
Sym
ptom
sTe
nd to
be
wor
se a
t nig
ht
• G
ener
al s
ympt
oms:
Br
eath
less
ness
.
Pers
iste
nt c
ough
.
Leth
argy
.
Off
feed
s.•
Typi
cal f
eatu
res:
wor
sen
with
pr
ogre
ssio
n of
infla
mm
atio
n:
Cory
za +
/– fe
ver (
prod
rom
e).
‘B
arki
ng’ c
ough
.
Hoar
sene
ss.
St
ridor
.•
Sign
s of
res
pira
tory
dep
ress
ion:
N
asal
flar
ing.
Su
bcos
tal a
nd in
terc
osta
l rec
essi
on.
Lo
w G
lasc
ow C
oma
Scal
e sc
ore.
Cy
anos
is.•
On
ausc
ulta
tion
:
St
ridor
– h
eard
in m
oder
ated
crou
p w
ith a
ste
thos
cope
. It i
s po
ssib
le
to
hea
r str
idor
with
out a
ste
thos
cope
in s
ever
e ca
ses. M
AP 4
.13.
Cro
up
Inve
stig
atio
ns•
Bloo
d te
sts
and
an e
xam
inat
ion
of th
e ch
ild’s
th
roat
is u
sual
ly n
ot u
nder
take
n si
nce
this
may
di
stre
ss th
e ch
ild a
nd in
adve
rten
tly c
lose
thei
r
airw
ay, l
eadi
ng to
an
emer
genc
y si
tuat
ion
in
whi
ch in
vasi
ve a
cces
s to
the
airw
ay m
ust b
e
esta
blis
hed.
• He
art r
ate,
resp
irato
ry ra
te a
nd o
xyge
n sa
tura
tion.
• As
sess
sev
erity
usi
ng th
e W
estle
y Cr
oup
Scor
e:
Cate
gory
Wes
tley
scor
eFe
atur
es
Mild
Mod
erat
e
Seve
re
0–2
3–5
6–11
Freq
uent
cou
gh.
Mar
ked
strid
or. M
arke
dst
erna
l wal
l ret
ract
ion.
Resp
irato
ry d
istr
ess
Freq
uent
cou
gh. S
trid
or.
Ster
nal w
all r
etra
ctio
n at
rest
Occ
asio
nal c
ough
. No
strid
or.
No
sign
s of
resp
irato
ryde
pres
sion
Trea
tmen
tDe
pend
s on
the
seve
rity
of c
roup
.
Cons
erva
tive
:•
Pare
nt e
duca
tion.
• Co
ntin
ual m
onito
ring.
Med
ical
:
Mild
Mos
t may
be
man
aged
at h
ome
with
par
acet
amol
,ne
w g
uida
nce
reco
mm
ends
giv
ing
a si
ngle
dos
e of
ora
lde
xam
etha
sone
to a
ll ch
ildre
n re
gard
less
of s
ever
ity.
Seve
re
Mod
erat
e
1. S
tero
ids,
e.g.
:- O
ral d
exam
etha
sone
or p
redn
isol
one
- Neb
uliz
ed b
udes
onid
e2.
Neb
uliz
ed a
dren
alin
e (5
mL
of 1
:1,0
00 w
ith o
xyge
n)
Ster
oids
, e.g
.:- O
ral d
exam
etha
sone
or p
redn
isol
one
- Neb
uliz
ed b
udes
onid
e
129
K30033_C004.indd 129 28/02/17 11:43 am
Paed
iatr
ics
Map
4.1
4. C
ysti
c fi
bro
sis
(CF)
Inve
stig
atio
nsDe
pend
on
age
of p
atie
nt a
nd w
hen
the
dise
ase
pres
ents
.•
Spec
ific
test
s:
N
ewbo
rn b
lood
spo
t:
im
mun
orea
ctiv
e tr
ypsi
noge
n (IR
T)
Sw
eat t
est:
– Cl
– >50
mm
ol/L
– N
a+ >
60 m
mol
/L•
Bloo
d te
sts
with
eve
ry a
cute
ex
acer
batio
n: F
BC, U
&E,
LFT
s.•
Iden
tify
caus
e of
infe
ctio
n us
ing
sput
um
anal
ysis,
che
st x
-ray
and
blo
od
cultu
re. C
omm
on o
rgan
ism
s in
clud
e
Stap
hylo
cocc
us a
ureu
s, Ha
emop
hilu
s
influ
enza
e, P
seud
omon
as a
erug
inos
a.•
Radi
olog
y:
Ch
est x
-ray
:
–
Bron
chie
ctas
is: ‘
tram
trac
ks’.
– Co
nsol
idat
ion.
– Fi
bros
is.
Sym
ptom
sSy
mpt
oms
and
how
the
dise
ase
man
ifest
s its
elf m
ay v
ary
depe
ndin
g on
the
age
of th
e ch
ild.
Neo
nate
:•
Mec
oniu
m il
eus.
Youn
g ch
ild:
• Fa
ilure
to th
rive.
• Fr
eque
nt c
hest
infe
ctio
ns.
• St
eato
rrho
ea.
• Si
gns
of c
lubb
ing
com
men
ce.
Old
er c
hild
:•
Freq
uent
che
st in
fect
ions
.•
Asth
ma.
• Al
lerg
ic b
ronc
hopu
lmon
ary
aspe
rgill
osis.
• St
eato
rrho
ea.
Adu
ltho
od:
• As
abo
ve.
• Br
onch
iect
asis.
• In
fert
ility
.•
Diab
etes
.•
Cor p
ulm
onal
e.•
Depr
essi
on.
• Ci
rrho
sis.
Com
plic
atio
ns•
Incr
ease
d fre
quen
cy o
f
resp
irato
ry tr
act i
nfec
tions
.•
Bron
chie
ctas
is.•
Resp
irato
ry fa
ilure
.•
Infe
rtili
ty.
• Di
abet
es.
• G
alls
tone
s.•
Cor p
ulm
onal
e.•
Mal
nutr
ition
.•
Nas
al p
olyp
s.•
Depr
essi
on.
Wha
t is
cys
tic
fibro
sis?
This
is a
n au
toso
mal
rece
ssiv
e co
nditi
on th
at o
ccur
s in
1 in
2,50
0 liv
e bi
rths
and
has
a c
arrie
r rat
e of
1 in
25.
It o
ccur
s du
e to
a d
elet
ion
in p
heny
lala
nine
, mea
ning
that
an
abno
rmal
cys
tic fi
bros
is tr
ansm
embr
ane
cond
ucta
nce
regu
lato
r (CF
TR) p
rote
in is
then
cre
ated
. Thi
s in
turn
dec
reas
es
Cl– io
n tr
ansp
ort r
esul
ting
in th
icke
ned
dehy
drat
ed s
ecre
tions
.
Caus
esIt
is c
ause
d by
a d
elet
ion
in p
heny
lala
nine
, mos
t com
mon
ly a
t pos
ition
508
on
chr
omos
ome
7.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion
(e.g
. kee
p ch
ildre
n w
ith C
F se
para
te to
av
oid
cros
s-in
fect
ion)
.•
Cont
inua
l mon
itorin
g w
ith m
ultid
isci
plin
ary
team
in
volv
emen
t.•
Up
to d
ate
imm
uniz
atio
ns.
• Ph
ysio
ther
apy
(e.g
. Flu
tter
®, a
muc
us c
lear
ance
dev
ice
use
d by
resp
irato
ry p
hysi
othe
rapi
sts)
.
Med
ical
:•
Trea
t inf
ectio
ns a
ccor
ding
to c
ultu
ral s
ensi
tiviti
es.
Co
nsul
t mic
robi
olog
y an
d ho
spita
l gui
delin
es. S
ome
ex
ampl
es a
re g
iven
bel
ow:
Pipe
raci
llin
in c
ombi
natio
n w
ith ta
zoba
ctam
.
To
bram
ycin
.
M
erop
enem
.
Im
ipen
em.
• Pa
ncre
atic
enz
yme
supp
lem
ents
(e.g
. Cre
on).
• Fa
t sol
uble
vita
min
s.
MAP
4.1
4.Cy
stic
fib
rosi
s (C
F)
130
K30033_C004.indd 130 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
4. C
ysti
c fi
bro
sis
(CF)
Inve
stig
atio
nsDe
pend
on
age
of p
atie
nt a
nd w
hen
the
dise
ase
pres
ents
.•
Spec
ific
test
s:
N
ewbo
rn b
lood
spo
t:
im
mun
orea
ctiv
e tr
ypsi
noge
n (IR
T)
Sw
eat t
est:
– Cl
– >50
mm
ol/L
– N
a+ >
60 m
mol
/L•
Bloo
d te
sts
with
eve
ry a
cute
ex
acer
batio
n: F
BC, U
&E,
LFT
s.•
Iden
tify
caus
e of
infe
ctio
n us
ing
sput
um
anal
ysis,
che
st x
-ray
and
blo
od
cultu
re. C
omm
on o
rgan
ism
s in
clud
e
Stap
hylo
cocc
us a
ureu
s, Ha
emop
hilu
s
influ
enza
e, P
seud
omon
as a
erug
inos
a.•
Radi
olog
y:
Ch
est x
-ray
:
–
Bron
chie
ctas
is: ‘
tram
trac
ks’.
– Co
nsol
idat
ion.
– Fi
bros
is.
Sym
ptom
sSy
mpt
oms
and
how
the
dise
ase
man
ifest
s its
elf m
ay v
ary
depe
ndin
g on
the
age
of th
e ch
ild.
Neo
nate
:•
Mec
oniu
m il
eus.
Youn
g ch
ild:
• Fa
ilure
to th
rive.
• Fr
eque
nt c
hest
infe
ctio
ns.
• St
eato
rrho
ea.
• Si
gns
of c
lubb
ing
com
men
ce.
Old
er c
hild
:•
Freq
uent
che
st in
fect
ions
.•
Asth
ma.
• Al
lerg
ic b
ronc
hopu
lmon
ary
aspe
rgill
osis.
• St
eato
rrho
ea.
Adu
ltho
od:
• As
abo
ve.
• Br
onch
iect
asis.
• In
fert
ility
.•
Diab
etes
.•
Cor p
ulm
onal
e.•
Depr
essi
on.
• Ci
rrho
sis.
Com
plic
atio
ns•
Incr
ease
d fre
quen
cy o
f
resp
irato
ry tr
act i
nfec
tions
.•
Bron
chie
ctas
is.•
Resp
irato
ry fa
ilure
.•
Infe
rtili
ty.
• Di
abet
es.
• G
alls
tone
s.•
Cor p
ulm
onal
e.•
Mal
nutr
ition
.•
Nas
al p
olyp
s.•
Depr
essi
on.
Wha
t is
cys
tic
fibro
sis?
This
is a
n au
toso
mal
rece
ssiv
e co
nditi
on th
at o
ccur
s in
1 in
2,50
0 liv
e bi
rths
and
has
a c
arrie
r rat
e of
1 in
25.
It o
ccur
s du
e to
a d
elet
ion
in p
heny
lala
nine
, mea
ning
that
an
abno
rmal
cys
tic fi
bros
is tr
ansm
embr
ane
cond
ucta
nce
regu
lato
r (CF
TR) p
rote
in is
then
cre
ated
. Thi
s in
turn
dec
reas
es
Cl– io
n tr
ansp
ort r
esul
ting
in th
icke
ned
dehy
drat
ed s
ecre
tions
.
Caus
esIt
is c
ause
d by
a d
elet
ion
in p
heny
lala
nine
, mos
t com
mon
ly a
t pos
ition
508
on
chr
omos
ome
7.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt e
duca
tion
(e.g
. kee
p ch
ildre
n w
ith C
F se
para
te to
av
oid
cros
s-in
fect
ion)
.•
Cont
inua
l mon
itorin
g w
ith m
ultid
isci
plin
ary
team
in
volv
emen
t.•
Up
to d
ate
imm
uniz
atio
ns.
• Ph
ysio
ther
apy
(e.g
. Flu
tter
®, a
muc
us c
lear
ance
dev
ice
use
d by
resp
irato
ry p
hysi
othe
rapi
sts)
.
Med
ical
:•
Trea
t inf
ectio
ns a
ccor
ding
to c
ultu
ral s
ensi
tiviti
es.
Co
nsul
t mic
robi
olog
y an
d ho
spita
l gui
delin
es. S
ome
ex
ampl
es a
re g
iven
bel
ow:
Pipe
raci
llin
in c
ombi
natio
n w
ith ta
zoba
ctam
.
To
bram
ycin
.
M
erop
enem
.
Im
ipen
em.
• Pa
ncre
atic
enz
yme
supp
lem
ents
(e.g
. Cre
on).
• Fa
t sol
uble
vita
min
s.
MAP
4.1
4.Cy
stic
fib
rosi
s (C
F)
131
K30033_C004.indd 131 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
5. A
sth
ma
Wha
t is
ast
hma?
Asth
ma
is a
chr
onic
, inf
lam
mat
ory
dise
ase
that
is c
hara
cter
ized
by
reve
rsib
le a
irway
obs
truc
tion.
In
chi
ldre
n it
affe
cts
boys
mor
e th
angi
rls, b
ut in
adu
lts, f
emal
es a
re m
ore
grea
tly a
ffect
ed.
Caus
esTh
e ca
use
of a
sthm
a is
mul
tifac
toria
l en
com
pass
ing
both
gen
etic
and
envi
ronm
enta
l ele
men
ts:
• G
enet
ic:
Pers
onal
/fam
ily h
isto
ry o
f
at
opy
– in
volv
emen
t of
chro
mos
ome
11.
Fam
ily h
isto
ry o
f ast
hma.
• En
viro
nmen
tal:
Indo
or a
llerg
ens:
–
Hou
se d
ust m
ite.
–
Pet
s.
– F
unga
l spo
res.
Out
door
alle
rgen
s:
– P
olle
n.
– C
old
air.
Sym
ptom
s•
Resp
irato
ry fe
atur
es: w
heez
e, c
ough
, sho
rtne
ss
of
bre
ath.
• Sy
mpt
oms
wor
se a
t nig
ht o
r ear
ly m
orni
ng.
• Sy
mpt
oms
may
occ
ur a
fter e
xerc
ise
or a
trig
gerin
g
fac
tor s
uch
as c
old
wea
ther
.•
Sym
ptom
s m
ay o
ccur
afte
r bet
a bl
ocke
rs.
• De
crea
sed
peak
exp
irato
ry fl
ow ra
te (P
EFR)
and
forc
ed e
xpira
tory
vol
ume
in 1
sec
ond.
• Pe
rson
al/fa
mily
his
tory
of a
sthm
a/at
opy.
• U
nexp
lain
ed b
lood
eos
inop
hilia
.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
eosi
noph
ils.
• Sp
utum
sam
ple
if in
dica
ted.
• Pu
lmon
ary
func
tion
test
s:
PEFR
: din
ural
var
iatio
n.
Spiro
met
ry: F
EV1/
FVC
<0.
7
(o
bstr
uctiv
e de
fect
).•
Radi
olog
y:
Ches
t x-r
ay: o
nly
if re
quire
d/in
ac
ute
sett
ing.
May
sho
w
pn
eum
otho
rax
or c
onso
lidat
ion.
Com
plic
atio
ns•
Deat
h.•
Dist
urbe
d sl
eep.
• Pe
rsis
tent
cou
gh.
• Si
de e
ffect
s of
ste
roid
s, e.
g.:
W
eigh
t gai
n.
Thin
ning
of t
he s
kin.
St
riae
form
atio
n.
Cata
ract
s.
Cush
ing’
s sy
ndro
me.
G
row
th d
istu
rban
ce.
Occ
upat
iona
l alle
rgen
s:
– I
socy
anat
es.
–
Epo
xyre
sins
.
Oth
er fa
ctor
s:
– S
mok
ing.
–
Infe
ctio
n.
– E
mot
ion.
–
Dru
gs (e
.g. b
eta
bloc
kers
).
The
abov
e tr
igge
ring
fact
ors
caus
e th
e cl
assi
c tr
iad
that
cha
ract
eriz
es a
sthm
a:1.
Cop
ious
muc
us s
ecre
tion.
2. In
flam
mat
ion
of th
e ai
rway
s.3.
Con
trac
tion
of b
ronc
hial
sm
ooth
mus
cle.
This
tria
d oc
curs
due
to th
e ac
tivat
ion
of T
h2 c
ells,
w
hich
upr
egul
ate
the
imm
une
resp
onse
. Th2
cel
ls
stim
ulat
e th
e re
leas
e of
the
follo
win
g:•
Inte
rleuk
in (I
L)-4
: stim
ulat
es e
osin
ophi
ls a
nd B
lym
phoc
ytes
.•
IL-5
: stim
ulat
es e
osin
ophi
ls.•
IL-1
3: s
timul
ates
muc
us p
rodu
ctio
n.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vice
on
inha
ler t
echn
ique
, use
of s
pace
r
dev
ices
and
avo
idan
ce o
f trig
gerin
g fa
ctor
s.•
Annu
al a
sthm
a re
view
and
influ
enza
vac
cine
r
equi
red.
Med
ical
:•
Refe
r to
Briti
sh T
hora
cic
Soci
ety
Gui
delin
es (s
ee
Tab
le 4
.3, p
. 134
).
MAP
4.1
5. A
sthm
a
132
K30033_C004.indd 132 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
5. A
sth
ma
Wha
t is
ast
hma?
Asth
ma
is a
chr
onic
, inf
lam
mat
ory
dise
ase
that
is c
hara
cter
ized
by
reve
rsib
le a
irway
obs
truc
tion.
In
chi
ldre
n it
affe
cts
boys
mor
e th
angi
rls, b
ut in
adu
lts, f
emal
es a
re m
ore
grea
tly a
ffect
ed.
Caus
esTh
e ca
use
of a
sthm
a is
mul
tifac
toria
l en
com
pass
ing
both
gen
etic
and
envi
ronm
enta
l ele
men
ts:
• G
enet
ic:
Pers
onal
/fam
ily h
isto
ry o
f
at
opy
– in
volv
emen
t of
chro
mos
ome
11.
Fam
ily h
isto
ry o
f ast
hma.
• En
viro
nmen
tal:
Indo
or a
llerg
ens:
–
Hou
se d
ust m
ite.
–
Pet
s.
– F
unga
l spo
res.
Out
door
alle
rgen
s:
– P
olle
n.
– C
old
air.
Sym
ptom
s•
Resp
irato
ry fe
atur
es: w
heez
e, c
ough
, sho
rtne
ss
of
bre
ath.
• Sy
mpt
oms
wor
se a
t nig
ht o
r ear
ly m
orni
ng.
• Sy
mpt
oms
may
occ
ur a
fter e
xerc
ise
or a
trig
gerin
g
fac
tor s
uch
as c
old
wea
ther
.•
Sym
ptom
s m
ay o
ccur
afte
r bet
a bl
ocke
rs.
• De
crea
sed
peak
exp
irato
ry fl
ow ra
te (P
EFR)
and
forc
ed e
xpira
tory
vol
ume
in 1
sec
ond.
• Pe
rson
al/fa
mily
his
tory
of a
sthm
a/at
opy.
• U
nexp
lain
ed b
lood
eos
inop
hilia
.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
eosi
noph
ils.
• Sp
utum
sam
ple
if in
dica
ted.
• Pu
lmon
ary
func
tion
test
s:
PEFR
: din
ural
var
iatio
n.
Spiro
met
ry: F
EV1/
FVC
<0.
7
(o
bstr
uctiv
e de
fect
).•
Radi
olog
y:
Ches
t x-r
ay: o
nly
if re
quire
d/in
ac
ute
sett
ing.
May
sho
w
pn
eum
otho
rax
or c
onso
lidat
ion.
Com
plic
atio
ns•
Deat
h.•
Dist
urbe
d sl
eep.
• Pe
rsis
tent
cou
gh.
• Si
de e
ffect
s of
ste
roid
s, e.
g.:
W
eigh
t gai
n.
Thin
ning
of t
he s
kin.
St
riae
form
atio
n.
Cata
ract
s.
Cush
ing’
s sy
ndro
me.
G
row
th d
istu
rban
ce.
Occ
upat
iona
l alle
rgen
s:
– I
socy
anat
es.
–
Epo
xyre
sins
.
Oth
er fa
ctor
s:
– S
mok
ing.
–
Infe
ctio
n.
– E
mot
ion.
–
Dru
gs (e
.g. b
eta
bloc
kers
).
The
abov
e tr
igge
ring
fact
ors
caus
e th
e cl
assi
c tr
iad
that
cha
ract
eriz
es a
sthm
a:1.
Cop
ious
muc
us s
ecre
tion.
2. In
flam
mat
ion
of th
e ai
rway
s.3.
Con
trac
tion
of b
ronc
hial
sm
ooth
mus
cle.
This
tria
d oc
curs
due
to th
e ac
tivat
ion
of T
h2 c
ells,
w
hich
upr
egul
ate
the
imm
une
resp
onse
. Th2
cel
ls
stim
ulat
e th
e re
leas
e of
the
follo
win
g:•
Inte
rleuk
in (I
L)-4
: stim
ulat
es e
osin
ophi
ls a
nd B
lym
phoc
ytes
.•
IL-5
: stim
ulat
es e
osin
ophi
ls.•
IL-1
3: s
timul
ates
muc
us p
rodu
ctio
n.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vice
on
inha
ler t
echn
ique
, use
of s
pace
r
dev
ices
and
avo
idan
ce o
f trig
gerin
g fa
ctor
s.•
Annu
al a
sthm
a re
view
and
influ
enza
vac
cine
r
equi
red.
Med
ical
:•
Refe
r to
Briti
sh T
hora
cic
Soci
ety
Gui
delin
es (s
ee
Tab
le 4
.3, p
. 134
).
MAP
4.1
5. A
sthm
a
133
K30033_C004.indd 133 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
3. F
low
ch
art
sum
mar
izin
g t
he
Bri
tish
Th
ora
cic
Soci
ety
gu
idel
ines
Age
<5
year
s5–
12 y
ears
>12
yea
rsLi
fe-t
hrea
teni
ng a
sthm
a
Step
1: S
ABA
(sho
rt-a
ctin
g be
ta a
goni
st) (
e.g.
sal
buta
mol
)
Step
2: I
nhal
ed co
rtico
ster
oid
or
leuk
otrie
ne re
cept
or a
ntag
onist
Step
3: C
onsi
der l
euko
trie
ne
rece
ptor
ant
agon
ist i
n ch
ildre
n ta
king
inha
led
ster
oid.
Con
side
r inh
aled
st
eroi
d in
chi
ldre
n al
read
y ta
king
leuk
otrie
ne re
cept
or
anta
goni
st
Step
1: S
ABA
Step
2: I
nhal
ed c
ortic
oste
roid
Step
3: A
dd L
ABA
(long
-act
ing
beta
ago
nist
) (e
.g. s
alm
eter
ol)
Asse
ss c
ontr
ol:
• If
wel
l con
trol
led:
con
tinue
regi
me
• If
part
ial i
mpr
ovem
ent:
cont
inue
regi
me
but i
ncre
ase
inha
led
cort
icos
tero
id d
ose
Step
1: S
ABA
Step
2: I
nhal
ed c
ortic
oste
roid
Step
3: A
dd L
ABA
(long
-act
ing
beta
ago
nist
) (e
.g. s
alm
eter
ol)
Asse
ss c
ontr
ol:
• If
wel
l con
trol
led:
con
tinue
regi
me
• If
part
ial i
mpr
ovem
ent:
cont
inue
regi
me
but i
ncre
ase
inha
led
cort
icos
tero
id d
ose
Be a
war
e of
nat
iona
l and
lo
cal g
uide
lines
rega
rdin
g lif
e-th
reat
enin
g as
thm
a. G
ener
al
prot
ocol
may
incl
ude:
1. A
BCDE
app
roac
h. C
all f
or
assi
stan
ce2.
Hig
h flo
w o
xyge
n vi
a m
ask
3. N
ebul
ized
bro
ncho
dila
tors
su
ch a
s sa
lbut
amol
and
an
timus
carin
ics
such
as
ipra
trop
tium
bro
mid
e.
Mon
itor r
espo
nse.
4. S
ecur
e IV
acc
ess
and
cons
ider
hyd
roco
rtis
one
5. F
urth
er m
etho
ds s
houl
d be
in
itiat
ed u
nder
spe
cial
ist
supe
rvis
ion
and
incl
ude
amin
ophy
lline
bol
us o
r m
agne
sium
sul
phat
e IV
TABL
E 4.
3. F
low
cha
rt s
umm
ariz
ing
the
Brit
ish
Thor
acic
Soc
iety
gui
delin
es.
http
s://w
ww
.brit
-tho
raci
c.or
g.uk
/doc
umen
t-lib
rary
/clin
ical
-info
rmat
ion/
asth
ma/
btss
ign-
asth
ma-
guid
elin
e-qu
ick-
refe
renc
e-gu
ide-
2014
/
134
K30033_C004.indd 134 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
3. F
low
ch
art
sum
mar
izin
g t
he
Bri
tish
Th
ora
cic
Soci
ety
gu
idel
ines
Step
1: S
ABA
(sho
rt-a
ctin
g be
ta a
goni
st) (
e.g.
sal
buta
mol
)
Step
2: I
nhal
ed co
rtico
ster
oid
or
leuk
otrie
ne re
cept
or a
ntag
onist
Step
3: C
onsi
der l
euko
trie
ne
rece
ptor
ant
agon
ist i
n ch
ildre
n ta
king
inha
led
ster
oid.
Con
side
r inh
aled
st
eroi
d in
chi
ldre
n al
read
y ta
king
leuk
otrie
ne re
cept
or
anta
goni
st
Step
4: R
efer
to s
peci
alis
t
• N
o im
prov
emen
t: st
op L
ABA
and
incr
ease
in
hale
d co
rtic
oste
roid
dos
e•
Cons
ider
theo
phyl
line
(pho
spho
dies
tera
se
inhi
bito
r) or
mon
telu
kast
(leu
kotr
iene
re
cept
or a
ntag
onis
t)
Step
4: I
ncre
ase
inha
led
cort
icos
tero
id d
ose
Step
5:
• St
eroi
d ta
blet
(pre
dnis
olon
e)•
High
est d
ose
inha
led
cort
icos
tero
id•
Refe
r to
spec
ialis
t
• N
o im
prov
emen
t: st
op L
ABA
and
incr
ease
in
hale
d co
rtic
oste
roid
dos
e•
Cons
ider
theo
phyl
line
(pho
spho
dies
tera
se
inhi
bito
r) or
mon
telu
kast
(leu
kotr
iene
re
cept
or a
ntag
onis
t)
Step
4:
• In
crea
se in
hale
d co
rtic
oste
roid
dos
e•
Cons
ider
theo
phyl
line
(pho
spho
dies
tera
se
inhi
bito
r), m
onte
luka
st (l
euko
trie
ne
rece
ptor
ant
agon
ist)
or b
eta
2 ag
onis
t ta
blet
Step
5:
• St
eroi
d ta
blet
(pre
dnis
olon
e)•
High
est d
ose
inha
led
cort
icos
tero
id•
Refe
r to
spec
ialis
t
135
K30033_C004.indd 135 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
6. R
heu
mat
ic f
ever
Wha
t is
rhe
umat
ic fe
ver?
Rheu
mat
ic fe
ver i
s a
rare
infla
mm
ator
y di
sord
er th
at is
now
mor
e co
mm
on
in th
ose
from
the
Asia
n su
bcon
tinen
t. Te
nds
to a
ffect
chi
ldre
n ag
ed 5
–15
year
s ol
d.
Caus
es•
Gro
up A
bet
a ha
emol
ytic
str
epto
cocc
us (e
.g. S
trep
toco
ccus
pyo
gene
s).
• Rh
eum
atic
feve
r is
prec
eded
by
a st
rept
ococ
cal p
hary
ngiti
s an
d th
en
affe
cts
all l
ayer
s of
the
hear
t, cr
eatin
g a
path
olog
ical
lesi
on c
alle
d an
As
chof
f bod
y.•
Oth
er re
gion
s of
the
body
as
wel
l as
the
hear
t are
affe
cted
, suc
h as
the
sk
in, c
entr
al n
ervo
us s
yste
m a
nd th
e m
uscu
losk
elet
al s
yste
m.
Sym
ptom
sDi
agno
sed
usin
g th
e Jo
nes
crite
ria: 2
maj
or o
r 1 m
ajor
and
1 m
inor
crite
ria P
LUS
a pr
eced
ing
stre
ptoc
occa
l thr
oat i
nfec
tion.
Rem
embe
r maj
or c
riter
ia a
s A
BCD
:A
– A
rthr
itis
(pol
yart
hriti
s)B
– Be
atin
g he
art (
card
itis)
C –
Synd
enha
m’s
Chor
eaD
– D
erm
atol
ogic
al m
anife
stat
ions
(e.g
. sub
cuta
neou
s no
dule
s an
d
ery
them
a m
argi
natu
m)
Rem
embe
r min
or c
riter
ia a
s FA
T PA
D:
F –
Feve
rA
– A
rthr
algi
aT
– Th
roat
sw
ab p
ositi
ve fo
r Gro
up A
bet
a ha
emol
ytic
Str
epto
cocc
usP
– Pr
evio
us rh
eum
atic
feve
r/pro
long
ed P
R in
terv
alA
– A
cute
pha
se re
acta
nts
(e.g
. CRP
/ESR
/leuc
ocyt
osis
)D
– N
/A
Inve
stig
atio
ns•
Thro
at s
wab
s.•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
ASO
titr
es o
r
DNAa
se.
• EC
G: p
rolo
nged
PR
inte
rval
.•
ECHO
: vis
ualiz
e he
art v
alve
affe
cted
.
Com
plic
atio
ns•
Chro
nic
rheu
mat
ic h
eart
dis
ease
: mitr
al
valv
e af
fect
ed in
50%
.•
Atria
l fib
rilla
tion.
• He
art f
ailu
re.
• Pr
edis
posi
tion
for i
nfec
tive
endo
card
itis.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
nd p
aren
t edu
catio
n.
Med
ical
:•
Aspi
rin is
the
initi
al tr
eatm
ent o
f cho
ice
for
in
flam
mat
ion
but i
s co
ntra
indi
cate
d in
chi
ldre
n
due
to R
eye
synd
rom
e, w
hich
is a
rapi
dly
pr
ogre
ssiv
e en
ceph
alop
athy
.•
Cort
icos
tero
ids
may
be
used
for i
nfla
mm
atio
n.•
Antib
iotic
s (e
.g. p
enic
illin
). Ch
eck
sens
itivi
ties
w
ith m
icro
biol
ogy
and
hosp
ital g
uide
lines
.
MAP
4.1
6. R
heum
atic
fev
er
136
K30033_C004.indd 136 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
6. R
heu
mat
ic f
ever
Wha
t is
rhe
umat
ic fe
ver?
Rheu
mat
ic fe
ver i
s a
rare
infla
mm
ator
y di
sord
er th
at is
now
mor
e co
mm
on
in th
ose
from
the
Asia
n su
bcon
tinen
t. Te
nds
to a
ffect
chi
ldre
n ag
ed 5
–15
year
s ol
d.
Caus
es•
Gro
up A
bet
a ha
emol
ytic
str
epto
cocc
us (e
.g. S
trep
toco
ccus
pyo
gene
s).
• Rh
eum
atic
feve
r is
prec
eded
by
a st
rept
ococ
cal p
hary
ngiti
s an
d th
en
affe
cts
all l
ayer
s of
the
hear
t, cr
eatin
g a
path
olog
ical
lesi
on c
alle
d an
As
chof
f bod
y.•
Oth
er re
gion
s of
the
body
as
wel
l as
the
hear
t are
affe
cted
, suc
h as
the
sk
in, c
entr
al n
ervo
us s
yste
m a
nd th
e m
uscu
losk
elet
al s
yste
m.
Sym
ptom
sDi
agno
sed
usin
g th
e Jo
nes
crite
ria: 2
maj
or o
r 1 m
ajor
and
1 m
inor
crite
ria P
LUS
a pr
eced
ing
stre
ptoc
occa
l thr
oat i
nfec
tion.
Rem
embe
r maj
or c
riter
ia a
s A
BCD
:A
– A
rthr
itis
(pol
yart
hriti
s)B
– Be
atin
g he
art (
card
itis)
C –
Synd
enha
m’s
Chor
eaD
– D
erm
atol
ogic
al m
anife
stat
ions
(e.g
. sub
cuta
neou
s no
dule
s an
d
ery
them
a m
argi
natu
m)
Rem
embe
r min
or c
riter
ia a
s FA
T PA
D:
F –
Feve
rA
– A
rthr
algi
aT
– Th
roat
sw
ab p
ositi
ve fo
r Gro
up A
bet
a ha
emol
ytic
Str
epto
cocc
usP
– Pr
evio
us rh
eum
atic
feve
r/pro
long
ed P
R in
terv
alA
– A
cute
pha
se re
acta
nts
(e.g
. CRP
/ESR
/leuc
ocyt
osis
)D
– N
/A
Inve
stig
atio
ns•
Thro
at s
wab
s.•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
ASO
titr
es o
r
DNAa
se.
• EC
G: p
rolo
nged
PR
inte
rval
.•
ECHO
: vis
ualiz
e he
art v
alve
affe
cted
.
Com
plic
atio
ns•
Chro
nic
rheu
mat
ic h
eart
dis
ease
: mitr
al
valv
e af
fect
ed in
50%
.•
Atria
l fib
rilla
tion.
• He
art f
ailu
re.
• Pr
edis
posi
tion
for i
nfec
tive
endo
card
itis.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
nd p
aren
t edu
catio
n.
Med
ical
:•
Aspi
rin is
the
initi
al tr
eatm
ent o
f cho
ice
for
in
flam
mat
ion
but i
s co
ntra
indi
cate
d in
chi
ldre
n
due
to R
eye
synd
rom
e, w
hich
is a
rapi
dly
pr
ogre
ssiv
e en
ceph
alop
athy
.•
Cort
icos
tero
ids
may
be
used
for i
nfla
mm
atio
n.•
Antib
iotic
s (e
.g. p
enic
illin
). Ch
eck
sens
itivi
ties
w
ith m
icro
biol
ogy
and
hosp
ital g
uide
lines
.
MAP
4.1
6. R
heum
atic
fev
er
137
K30033_C004.indd 137 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
7. U
rin
ary
trac
t in
fect
ion
(U
TI)
Wha
t is
a u
rina
ry t
ract
infe
ctio
n?Th
is is
an
infe
ctio
n of
the
urin
ary
trac
t with
ty
pica
l sig
ns a
nd s
ympt
oms.
It m
ay b
e cl
assi
fied
as e
ither
low
er o
r upp
er (a
cute
py
elon
ephr
itis)
.
In c
hild
ren,
UTI
s ar
e m
ore
com
mon
in
boys
unt
il th
e ag
e of
3 m
onth
s. Af
ter t
his
time
the
inci
denc
e is
hig
her i
n gi
rls.
Caus
es
UTI
s ar
e ge
nera
lly c
ause
d by
infe
ctio
n of
the
urin
ary
trac
t with
Esc
heric
hia
coli.
How
ever
, th
ere
are
seve
ral r
isk
fact
ors
that
may
pr
edis
pose
to in
fect
ion
(see
bel
ow).
Risk
fact
ors
• Fe
mal
e ge
nder
.•
Gen
itour
inar
y m
alfo
rmat
ions
.•
Vesi
cour
eter
ic re
flux
(VU
R).
• Di
abet
es.
• Im
mun
osup
pres
sion
.•
Cond
ition
s th
at p
redi
spos
e to
sto
ne
fo
rmat
ion
and
ther
efor
e ur
inar
y tr
act
ob
stru
ctio
n.•
Cath
eter
izat
ion.
Inve
stig
atio
ns•
Urin
e di
pstic
k: p
ositi
ve fo
r leu
cocy
tes
and
nitr
ites.
The
prob
lem
in p
aedi
atric
s is
colle
ctin
g th
e ur
ine
sam
ple
and
the
met
hod
varie
s de
pend
ing
on th
e ag
e of
the
child
. Som
e ex
ampl
es in
clud
e: c
lean
catc
h m
etho
d, c
olle
ctio
n pa
ds a
nd
supr
apub
ic a
spira
tion.
U
rine
cultu
re: >
105 o
rgan
ism
s pe
r mL
of
m
idst
ream
urin
e.•
Radi
olog
y:
Ki
dney
s, ur
eter
and
bla
dder
USS
for
anat
omic
al a
bnor
mal
ities
.
Ve
sico
uret
eric
reflu
x: m
ictu
ratin
g
cyst
oure
thro
gram
.
Re
nal s
carr
ing:
dim
erca
ptos
ucci
nic
ac
id s
can.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt a
nd p
atie
nt e
duca
tion.
Med
ical
:•
Depe
nds
on th
e ag
e of
the
child
and
type
of i
nfec
tion.
• Tr
eat a
ccor
ding
to c
ultu
ral s
ensi
tiviti
es a
fter c
onta
ctin
g
mic
robi
olog
y an
d co
nsul
ting
loca
l gui
delin
es.
Age
Act
ion
<3
mon
ths
>3
mon
ths
with
low
er U
TIRe
fer
Antib
iotic
s (e
.g. t
rimet
hopr
im o
r nitr
ofur
anto
in)
>3
mon
ths
with
upp
er U
TIAd
mit
and
antib
iotic
s (e
.g. c
o-am
oxic
lav)
Com
plic
atio
ns•
Pyel
onep
hriti
s.•
Hydr
onep
hros
is.•
Rena
l fai
lure
.•
Rena
l abs
cess
.•
Seps
is.
MAP
4.1
7. U
rina
ry t
ract
infe
ctio
n (U
TI)
Sym
ptom
sG
ener
ally
dep
end
on th
e ag
e of
the
child
.
Neo
nate
s:•
Off
feed
s.•
Irrita
ble
• Fo
ul s
mel
ling
urin
e
Youn
g ch
ildre
n:•
Feve
r.•
Dysu
ria.
• Su
prap
ubic
pai
n.
Old
er c
hild
ren
(mor
e lik
e ad
ult
sym
ptom
s):
• Fe
ver.
• Dy
suria
.•
Freq
uenc
y.•
Urg
ency
.•
Supr
apub
ic p
ain.
Upp
er U
TI:
• Fe
ver/c
hills
.•
Flan
k pa
in.
• Ha
emat
uria
.
138
K30033_C004.indd 138 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
7. U
rin
ary
trac
t in
fect
ion
(U
TI)
Wha
t is
a u
rina
ry t
ract
infe
ctio
n?Th
is is
an
infe
ctio
n of
the
urin
ary
trac
t with
ty
pica
l sig
ns a
nd s
ympt
oms.
It m
ay b
e cl
assi
fied
as e
ither
low
er o
r upp
er (a
cute
py
elon
ephr
itis)
.
In c
hild
ren,
UTI
s ar
e m
ore
com
mon
in
boys
unt
il th
e ag
e of
3 m
onth
s. Af
ter t
his
time
the
inci
denc
e is
hig
her i
n gi
rls.
Caus
es
UTI
s ar
e ge
nera
lly c
ause
d by
infe
ctio
n of
the
urin
ary
trac
t with
Esc
heric
hia
coli.
How
ever
, th
ere
are
seve
ral r
isk
fact
ors
that
may
pr
edis
pose
to in
fect
ion
(see
bel
ow).
Risk
fact
ors
• Fe
mal
e ge
nder
.•
Gen
itour
inar
y m
alfo
rmat
ions
.•
Vesi
cour
eter
ic re
flux
(VU
R).
• Di
abet
es.
• Im
mun
osup
pres
sion
.•
Cond
ition
s th
at p
redi
spos
e to
sto
ne
fo
rmat
ion
and
ther
efor
e ur
inar
y tr
act
ob
stru
ctio
n.•
Cath
eter
izat
ion.
Inve
stig
atio
ns•
Urin
e di
pstic
k: p
ositi
ve fo
r leu
cocy
tes
and
nitr
ites.
The
prob
lem
in p
aedi
atric
s is
colle
ctin
g th
e ur
ine
sam
ple
and
the
met
hod
varie
s de
pend
ing
on th
e ag
e of
the
child
. Som
e ex
ampl
es in
clud
e: c
lean
catc
h m
etho
d, c
olle
ctio
n pa
ds a
nd
supr
apub
ic a
spira
tion.
U
rine
cultu
re: >
105 o
rgan
ism
s pe
r mL
of
m
idst
ream
urin
e.•
Radi
olog
y:
Ki
dney
s, ur
eter
and
bla
dder
USS
for
anat
omic
al a
bnor
mal
ities
.
Ve
sico
uret
eric
reflu
x: m
ictu
ratin
g
cyst
oure
thro
gram
.
Re
nal s
carr
ing:
dim
erca
ptos
ucci
nic
ac
id s
can.
Trea
tmen
t
Cons
erva
tive
:•
Pare
nt a
nd p
atie
nt e
duca
tion.
Med
ical
:•
Depe
nds
on th
e ag
e of
the
child
and
type
of i
nfec
tion.
• Tr
eat a
ccor
ding
to c
ultu
ral s
ensi
tiviti
es a
fter c
onta
ctin
g
mic
robi
olog
y an
d co
nsul
ting
loca
l gui
delin
es.
Age
Act
ion
<3
mon
ths
>3
mon
ths
with
low
er U
TIRe
fer
Antib
iotic
s (e
.g. t
rimet
hopr
im o
r nitr
ofur
anto
in)
>3
mon
ths
with
upp
er U
TIAd
mit
and
antib
iotic
s (e
.g. c
o-am
oxic
lav)
Com
plic
atio
ns•
Pyel
onep
hriti
s.•
Hydr
onep
hros
is.•
Rena
l fai
lure
.•
Rena
l abs
cess
.•
Seps
is.
MAP
4.1
7. U
rina
ry t
ract
infe
ctio
n (U
TI)
Sym
ptom
sG
ener
ally
dep
end
on th
e ag
e of
the
child
.
Neo
nate
s:•
Off
feed
s.•
Irrita
ble
• Fo
ul s
mel
ling
urin
e
Youn
g ch
ildre
n:•
Feve
r.•
Dysu
ria.
• Su
prap
ubic
pai
n.
Old
er c
hild
ren
(mor
e lik
e ad
ult
sym
ptom
s):
• Fe
ver.
• Dy
suria
.•
Freq
uenc
y.•
Urg
ency
.•
Supr
apub
ic p
ain.
Upp
er U
TI:
• Fe
ver/c
hills
.•
Flan
k pa
in.
• Ha
emat
uria
.
139
K30033_C004.indd 139 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
8. H
aem
oly
tic
ura
emic
syn
dro
me
(HU
S)
Wha
t is
hae
mol
ytic
ura
emic
syn
drom
e?Th
is is
a s
yndr
ome
that
pre
dom
inan
tly a
ffect
sch
ildre
n.
Caus
esU
sual
ly E
sche
richi
a co
li O
157:
H7 o
r Shi
gella
ent
eriti
s. Th
ese
orga
nism
s en
ter t
he b
ody
via
cont
amin
ated
food
or
wat
er. T
hen
they
exp
ress
vira
toxi
ns, w
hich
cau
seda
mag
e by
bin
ding
to g
lom
erul
ar e
ndot
helia
l cel
ls,re
sulti
ng in
rena
l ins
uffic
ienc
y, de
stro
ying
red
bloo
dce
lls a
nd c
ausi
ng a
naem
ia a
nd p
late
let d
amag
e.
Sym
ptom
sHU
S is
com
pris
ed o
f a tr
iad.
Rem
embe
r as
MAT
:1.
M –
Mic
roan
giop
athi
c ha
emol
ytic
ana
emia
2. A
– A
cute
kid
ney
inju
ry3.
T –
Thr
ombo
cyto
peni
a
Oth
er s
ympt
oms
incl
ude:
• N
ause
a•
Vom
iting
• Bl
oody
dia
rrho
ea•
Abdo
min
al p
ain
• N
O F
EVER
Inve
stig
atio
ns•
Stoo
l cul
ture
.•
Urin
alys
is a
nd e
stim
ated
GFR
.•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
Cr:B
UN,
LDH
.•
Perip
hera
l blo
od s
mea
r: sc
hist
ocyt
es.
Com
plic
atio
nsRe
mem
ber a
s A
BCS:
A –
Acu
te k
idne
y in
jury
B –
incr
ease
d Bl
ood
pres
sure
C –
Chro
nic
kidn
ey in
jury
C –
Card
iac
com
plic
atio
ns (e
.g. h
eart
failu
re)
C –
Com
aS
– St
roke
Trea
tmen
t
Cons
erva
tive
:•
Invo
lve
the
neph
rolo
gist
s an
d ha
emot
olog
ists
• HU
S is
a n
otifi
able
dis
ease
in th
e U
K.•
Patie
nt a
nd p
aren
t edu
catio
n.•
Mon
itor B
P.
Med
ical
:•
Trea
tmen
t is
gene
rally
sup
port
ive.
• Hy
drat
e pa
tient
with
IV fl
uids
.•
If hy
pert
ensi
on p
rese
nt, t
hen
cons
ider
cal
cium
c
hann
el b
lock
ers.
• Co
nsid
er d
ialy
sis
and
RBC
tran
sfus
ion
i
f nee
ded.
MAP
4.1
8. H
aem
olyt
ic u
raem
icsy
ndro
me
(HU
S)
140
K30033_C004.indd 140 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
8. H
aem
oly
tic
ura
emic
syn
dro
me
(HU
S)
Wha
t is
hae
mol
ytic
ura
emic
syn
drom
e?Th
is is
a s
yndr
ome
that
pre
dom
inan
tly a
ffect
sch
ildre
n.
Caus
esU
sual
ly E
sche
richi
a co
li O
157:
H7 o
r Shi
gella
ent
eriti
s. Th
ese
orga
nism
s en
ter t
he b
ody
via
cont
amin
ated
food
or
wat
er. T
hen
they
exp
ress
vira
toxi
ns, w
hich
cau
seda
mag
e by
bin
ding
to g
lom
erul
ar e
ndot
helia
l cel
ls,re
sulti
ng in
rena
l ins
uffic
ienc
y, de
stro
ying
red
bloo
dce
lls a
nd c
ausi
ng a
naem
ia a
nd p
late
let d
amag
e.
Sym
ptom
sHU
S is
com
pris
ed o
f a tr
iad.
Rem
embe
r as
MAT
:1.
M –
Mic
roan
giop
athi
c ha
emol
ytic
ana
emia
2. A
– A
cute
kid
ney
inju
ry3.
T –
Thr
ombo
cyto
peni
a
Oth
er s
ympt
oms
incl
ude:
• N
ause
a•
Vom
iting
• Bl
oody
dia
rrho
ea•
Abdo
min
al p
ain
• N
O F
EVER
Inve
stig
atio
ns•
Stoo
l cul
ture
.•
Urin
alys
is a
nd e
stim
ated
GFR
.•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
Cr:B
UN,
LDH
.•
Perip
hera
l blo
od s
mea
r: sc
hist
ocyt
es.
Com
plic
atio
nsRe
mem
ber a
s A
BCS:
A –
Acu
te k
idne
y in
jury
B –
incr
ease
d Bl
ood
pres
sure
C –
Chro
nic
kidn
ey in
jury
C –
Card
iac
com
plic
atio
ns (e
.g. h
eart
failu
re)
C –
Com
aS
– St
roke
Trea
tmen
t
Cons
erva
tive
:•
Invo
lve
the
neph
rolo
gist
s an
d ha
emot
olog
ists
• HU
S is
a n
otifi
able
dis
ease
in th
e U
K.•
Patie
nt a
nd p
aren
t edu
catio
n.•
Mon
itor B
P.
Med
ical
:•
Trea
tmen
t is
gene
rally
sup
port
ive.
• Hy
drat
e pa
tient
with
IV fl
uids
.•
If hy
pert
ensi
on p
rese
nt, t
hen
cons
ider
cal
cium
c
hann
el b
lock
ers.
• Co
nsid
er d
ialy
sis
and
RBC
tran
sfus
ion
i
f nee
ded.
MAP
4.1
8. H
aem
olyt
ic u
raem
icsy
ndro
me
(HU
S)
141
K30033_C004.indd 141 28/02/17 11:44 am
Paed
iatr
ics
Map
4.1
9. H
eno
ch–S
chö
nle
in p
urp
ura
(H
SP)
Wha
t is
Hen
och–
Schö
nlei
n pu
rpur
a?Th
is is
a s
yste
mic
vas
culit
is th
at p
rese
nts
with
typi
cal s
igns
and
sym
ptom
s.
Caus
esHS
P is
cau
sed
by Ig
A co
mpl
ex d
epos
ition
in th
eca
pilla
ries,
arte
riole
s an
d ve
nule
s in
org
ans
such
as th
e sk
in a
nd th
e ki
dney
s, w
hich
cau
ses
sym
ptom
s vi
a th
e ac
tivat
ion
of c
ompl
emen
t.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
nd p
aren
t edu
catio
n.
Med
ical
:•
Trea
tmen
t is
gene
rally
sup
port
ive
due
to h
igh
rate
s of
spo
ntan
eous
rem
issi
on.
• An
alge
sia.
• St
eroi
ds m
ay s
omet
imes
be
used
in s
ever
e
cas
es.
Sym
ptom
sHS
P is
com
pris
ed o
f a tr
iad.
Rem
embe
r as
RAP:
1. R
– R
enal
man
ifest
atio
ns:
•
Haem
atur
ia –
mic
rosc
opic
/mac
rosc
opic
.
• AN
CA n
egat
ive
glom
erul
onep
hriti
s.
• N
ephr
otic
syn
drom
e (ra
re).
2. A
– A
rthr
algi
a an
d ab
dom
inal
pai
n.3.
P –
Pur
pura
:
• Th
is ty
pica
lly a
ffect
s th
e bu
ttoc
ks a
nd th
e
lo
wer
lim
bs. H
owev
er, i
t may
affe
ct th
e
ar
ms.
Inve
stig
atio
ns•
Urin
alys
is a
nd e
stim
ated
GFR
.•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
Cr:B
UN,
LDH
, CRP
,
ESR
.•
IgA
leve
ls.•
Skin
bio
psy
if in
dica
ted
or if
ther
e is
dia
gnos
tic
unc
erta
inty
: im
mun
oflu
ores
cenc
e sh
ows
IgA
d
epos
its a
nd C
3.
Com
plic
atio
nsRe
mem
ber a
s A
BC:
A –
Acu
te k
idne
y in
jury
B –
Bow
el o
bstr
uctio
n: in
tuss
usce
ptio
nC
– Ch
roni
c ki
dney
inju
ry
MAP
4.1
9.H
enoc
h–Sc
hönl
ein
purp
ura
(HSP
)
142
K30033_C004.indd 142 28/02/17 11:44 am
143
Paed
iatr
ics
Wha
t is
Hen
och–
Schö
nlei
n pu
rpur
a?Th
is is
a s
yste
mic
vas
culit
is th
at p
rese
nts
with
typi
cal s
igns
and
sym
ptom
s.
Caus
esHS
P is
cau
sed
by Ig
A co
mpl
ex d
epos
ition
in th
eca
pilla
ries,
arte
riole
s an
d ve
nule
s in
org
ans
such
as th
e sk
in a
nd th
e ki
dney
s, w
hich
cau
ses
sym
ptom
s vi
a th
e ac
tivat
ion
of c
ompl
emen
t.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
nd p
aren
t edu
catio
n.
Med
ical
:•
Trea
tmen
t is
gene
rally
sup
port
ive
due
to h
igh
rate
s of
spo
ntan
eous
rem
issi
on.
• An
alge
sia.
• St
eroi
ds m
ay s
omet
imes
be
used
in s
ever
e
cas
es.
Sym
ptom
sHS
P is
com
pris
ed o
f a tr
iad.
Rem
embe
r as
RAP:
1. R
– R
enal
man
ifest
atio
ns:
•
Haem
atur
ia –
mic
rosc
opic
/mac
rosc
opic
.
• AN
CA n
egat
ive
glom
erul
onep
hriti
s.
• N
ephr
otic
syn
drom
e (ra
re).
2. A
– A
rthr
algi
a an
d ab
dom
inal
pai
n.3.
P –
Pur
pura
:
• Th
is ty
pica
lly a
ffect
s th
e bu
ttoc
ks a
nd th
e
lo
wer
lim
bs. H
owev
er, i
t may
affe
ct th
e
ar
ms.
Inve
stig
atio
ns•
Urin
alys
is a
nd e
stim
ated
GFR
.•
Bloo
d te
sts:
FBC,
U&
E, L
FTs,
Cr:B
UN,
LDH
, CRP
,
ESR
.•
IgA
leve
ls.•
Skin
bio
psy
if in
dica
ted
or if
ther
e is
dia
gnos
tic
unc
erta
inty
: im
mun
oflu
ores
cenc
e sh
ows
IgA
d
epos
its a
nd C
3.
Com
plic
atio
nsRe
mem
ber a
s A
BC:
A –
Acu
te k
idne
y in
jury
B –
Bow
el o
bstr
uctio
n: in
tuss
usce
ptio
nC
– Ch
roni
c ki
dney
inju
ry
MAP
4.1
9.H
enoc
h–Sc
hönl
ein
purp
ura
(HSP
)
Map
4.1
9. H
eno
ch–S
chö
nle
in p
urp
ura
(H
SP)
K30033_C004.indd 143 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
4. C
hild
ho
od
ep
ilep
sy s
ynd
rom
es
TABL
E 4.
4. C
hild
hood
epi
leps
y sy
ndro
mes
.
Type
of
epile
psy
Feat
ures
Inve
stig
atio
nsTr
eatm
ent
Abse
nce
Caus
e: e
xact
cau
se is
unk
now
n bu
t is
thou
ght t
o in
volv
e T-
type
Ca2+
cha
nnel
s. Se
izur
es m
ay b
e tr
igge
red
by h
yper
vent
ilatio
nFe
atur
es:
• Ak
a pe
tit m
al s
eizu
res
• Co
nsci
ousn
ess
is im
paire
d•
Ofte
n pi
cked
up
as d
ay d
ream
ing
in s
choo
l•
Mor
e co
mm
on fe
mal
es•
May
be
asso
ciat
ed w
ith a
utom
atis
ms
(e.g
. lip
sm
acki
ng)
EEG
: 3Hz
spi
ke a
nd
wav
e Et
hosu
xim
ide
Beni
gn ro
land
ic e
pile
psy
Caus
e: u
nkno
wn
Feat
ures
:•
Occ
urs
at n
ight
tim
e•
Abno
rmal
sen
satio
n (e
.g. p
arae
sthe
sia
of th
e co
rner
of
the
patie
nt’s
mou
th a
nd to
ngue
)•
Droo
ling
and
bed
wet
ting
may
occ
ur•
Tend
s to
rem
it by
pub
erty
EEG
: cen
trot
empo
ral
spik
esO
ften
not u
sed
sinc
e th
e co
nditi
on is
be
nign
Antie
pile
ptic
s: ca
rbam
azep
ine
is u
sed
first
line
144
K30033_C004.indd 144 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
4. C
hild
ho
od
ep
ilep
sy s
ynd
rom
es
Lenn
ox–G
asta
ut s
yndr
ome
Caus
e: o
vera
ll th
e ca
use
is u
nkno
wn
but i
t may
occ
ur
seco
ndar
y to
con
geni
tal o
r acq
uire
d ca
uses
. Con
geni
tal
caus
es in
clud
e tu
bero
us s
cler
osis
and
inhe
rited
m
etab
olic
dis
orde
rs. A
cqui
red
caus
es in
clud
e in
fect
ion,
tr
aum
a an
d tu
mou
rs
Feat
ures
: •
Vary
ing
type
s of
sei
zure
s•
Stat
us e
pile
ptic
us m
ay o
ccur
• As
soci
ated
with
dro
p at
tack
s•
Asso
ciat
ed w
ith le
arni
ng d
ifficu
lties
and
de
velo
pmen
tal d
elay
• Pe
rsis
ts in
to a
dult
life
EEG
: Slo
w s
pike
and
w
ave
Diffi
cult
to tr
eat
Antie
pile
ptic
: sod
ium
val
proa
te is
ofte
n us
ed fi
rst l
ine
Pred
niso
lone
is s
omet
imes
use
d
Wes
t’s s
yndr
ome
Caus
e: e
xact
cau
se is
unk
now
n. H
owev
er, t
here
are
th
eorie
s th
at s
ugge
st th
e in
volv
emen
t of a
bnor
mal
G
ABA
neur
otra
nsm
itter
or t
he e
xces
sive
pro
duct
ion
of
cort
icot
ropi
n-re
leas
ing
horm
one
Feat
ures
:•
Ther
e ar
e th
ree
diffe
rent
type
s of
att
ack:
1. L
ight
ning
att
acks
2. N
oddi
ng a
ttac
ks3.
Jac
kkni
fe a
ttac
ks
• As
soci
ated
with
: ABC
D:A
– A
icar
di s
yndr
ome
B –
Brai
n da
mag
eC
– C
ereb
ral a
trop
hyD
– D
yspl
asia
of t
he c
orex
EEG
: hyp
sarr
hyth
mia
Di
fficu
lt to
trea
tAn
tiepi
lept
ic: v
igab
atrin
is o
ften
used
fir
st li
nePr
edni
solo
ne is
som
etim
es u
sed
145
K30033_C004.indd 145 28/02/17 11:44 am
Paed
iatr
ics
Map
4.2
0. D
iab
etic
ket
oac
ido
sis
(DK
A)
Wha
t is
dia
beti
c ke
toac
idos
is?
This
is a
n em
erge
ncy
that
is a
ssoc
iate
d w
ithty
pe 1
dia
bete
s (s
ee M
ap 2
.2, p
. 40)
. It i
s a
stat
e of
unc
ontr
olle
d ca
tabo
lism
in w
hich
ket
one
bodi
es a
re fo
rmed
. The
ket
one
bodi
es a
re
acet
one,
ace
toac
etat
e an
d be
ta-h
ydro
xybu
tyra
te.
This
may
be
the
patie
nt’s
first
pre
sent
atio
n to
em
erge
ncy
serv
ices
prio
r to
a di
abet
ic d
iagn
osis
or
it m
ay b
e br
ough
t on
by th
e pa
tient
mis
sing
th
eir i
nsul
in d
ose
or b
ecau
se o
f str
ess
(e.g
. ill
ness
)
Caus
es•
Non
-del
iber
ate
omis
sion
of i
nsul
in
(e.g
. illn
ess)
.•
Delib
erat
e om
issi
on o
f ins
ulin
(e.g
. chi
ldre
n
w
ith u
nsta
ble
fam
ily c
ircum
stan
ces,
co
-mor
bid
psyc
hiat
ric d
isor
der s
uch
as
eatin
g di
sord
ers
or d
epre
ssio
n, p
sych
osoc
ial
im
pact
of h
avin
g a
chro
nic
illne
ss re
sulti
ng in
mis
sed
dose
s at
sch
ool o
r uni
vers
ity).
The
path
ophy
siol
ogy
of D
KA is
sum
mar
ized
in
Figu
re 4
.1 (p
. 148
).
Trea
tmen
t
Resu
scit
atio
n:•
Airw
ay –
+/–
nas
ogas
tric
tube
.•
Brea
thin
g –
100%
oxy
gen.
• Ci
rcul
atio
n –
IV s
alin
e so
lutio
n.
Clin
ical
ly a
cido
tic
but
not
in s
hock
:•
IV th
erap
y –
salin
e so
lutio
n an
d ad
ditio
nal
K
Cl th
erap
y (m
onito
r ECG
).•
Fixe
d ra
te in
sulin
infu
sion
of 0
.1un
it/kg
/h IV
(
typi
cally
50
units
Act
rapi
d® in
50m
l 0.9
%
sal
ine)
.•
Cons
tant
pat
ient
obs
erva
tions
(e.g
. glu
cose
leve
ls, u
rine
outp
ut, f
luid
inpu
t, ne
urol
ogic
al
st
atus
, ele
ctro
lyte
s an
d EC
G).
• St
art b
road
-spe
ctru
m a
ntib
iotic
s if
infe
ctio
n
s
uspe
cted
.
Clin
ical
ly w
ell a
nd t
oler
atin
g or
al fl
uids
:•
Star
t sub
cuta
neou
s in
sulin
.•
Cont
inue
ora
l hyd
ratio
n th
erap
y.
Inve
stig
atio
ns•
Bloo
ds: g
luco
se le
vels,
U&
E, b
lood
gas
es.
• U
rinal
ysis
: for
ket
ones
.•
If in
fect
ion
susp
ecte
d, th
en o
btai
n cu
lture
s
(blo
od, u
rine,
thro
at) a
nd p
erfo
rm th
e
'sep
tic s
ix'.
• EC
G –
tent
ed T-
wav
es a
nd b
road
enin
g of
the
Q
RS c
ompl
ex m
ay b
e se
en in
hyp
erka
laem
ia
a
ssoc
iate
d w
ith p
otas
sium
ther
apy
• AB
G: a
sses
s th
e de
gree
of a
cido
sis.
• Am
ylas
e: a
bdom
inal
pai
n an
d vo
miti
ng is
als
o as
soci
ated
with
pan
crea
titis.
• Ra
diol
ogy:
che
st x
-ray
may
be
requ
ired
to
l
ocat
e so
urce
of i
nfec
tion.
Sym
ptom
s
Gen
eral
sym
ptom
s:•
Poly
uria
/enu
resi
s.•
Poly
dips
ia.
• W
eigh
t los
s.•
Abdo
min
al p
ain.
• Le
thar
gy.
• Vo
miti
ng.
• Co
nfus
ion.
Clin
ical
sig
ns o
f DKA
:•
Dehy
drat
ion.
• Po
lyur
ia.
• Po
lydi
psia
.•
Tach
ycar
dia.
• Hy
pote
nsio
n.•
Kaus
smau
l bre
athi
ng (t
o ex
hale
exc
essi
ve
CO2)
.•
Acet
one
swee
t sm
ellin
g br
eath
.•
Conf
usio
n.•
Com
a.
Bioc
hem
ical
sig
ns:
• Ke
tonu
ria.
• In
crea
sed
bloo
d gl
ucos
e le
vel.
• Ac
idae
mia
.
Com
plic
atio
ns•
Com
a.•
Com
plic
atio
ns o
f tre
atm
ent,
e.g.
:
Ce
rebr
al o
edem
a.
Hy
poka
laem
ia.
Hypo
glyc
aem
ia.
MAP
4.2
0. D
iabe
tic
keto
acid
osis
(DK
A)
146
K30033_C004.indd 146 28/02/17 11:44 am
Paed
iatr
ics
Map
4.2
0. D
iab
etic
ket
oac
ido
sis
(DK
A)
Wha
t is
dia
beti
c ke
toac
idos
is?
This
is a
n em
erge
ncy
that
is a
ssoc
iate
d w
ithty
pe 1
dia
bete
s (s
ee M
ap 2
.2, p
. 40)
. It i
s a
stat
e of
unc
ontr
olle
d ca
tabo
lism
in w
hich
ket
one
bodi
es a
re fo
rmed
. The
ket
one
bodi
es a
re
acet
one,
ace
toac
etat
e an
d be
ta-h
ydro
xybu
tyra
te.
This
may
be
the
patie
nt’s
first
pre
sent
atio
n to
em
erge
ncy
serv
ices
prio
r to
a di
abet
ic d
iagn
osis
or
it m
ay b
e br
ough
t on
by th
e pa
tient
mis
sing
th
eir i
nsul
in d
ose
or b
ecau
se o
f str
ess
(e.g
. ill
ness
)
Caus
es•
Non
-del
iber
ate
omis
sion
of i
nsul
in
(e.g
. illn
ess)
.•
Delib
erat
e om
issi
on o
f ins
ulin
(e.g
. chi
ldre
n
w
ith u
nsta
ble
fam
ily c
ircum
stan
ces,
co
-mor
bid
psyc
hiat
ric d
isor
der s
uch
as
eatin
g di
sord
ers
or d
epre
ssio
n, p
sych
osoc
ial
im
pact
of h
avin
g a
chro
nic
illne
ss re
sulti
ng in
mis
sed
dose
s at
sch
ool o
r uni
vers
ity).
The
path
ophy
siol
ogy
of D
KA is
sum
mar
ized
in
Figu
re 4
.1 (p
. 148
).
Trea
tmen
t
Resu
scit
atio
n:•
Airw
ay –
+/–
nas
ogas
tric
tube
.•
Brea
thin
g –
100%
oxy
gen.
• Ci
rcul
atio
n –
IV s
alin
e so
lutio
n.
Clin
ical
ly a
cido
tic
but
not
in s
hock
:•
IV th
erap
y –
salin
e so
lutio
n an
d ad
ditio
nal
K
Cl th
erap
y (m
onito
r ECG
).•
Fixe
d ra
te in
sulin
infu
sion
of 0
.1un
it/kg
/h IV
(
typi
cally
50
units
Act
rapi
d® in
50m
l 0.9
%
sal
ine)
.•
Cons
tant
pat
ient
obs
erva
tions
(e.g
. glu
cose
leve
ls, u
rine
outp
ut, f
luid
inpu
t, ne
urol
ogic
al
st
atus
, ele
ctro
lyte
s an
d EC
G).
• St
art b
road
-spe
ctru
m a
ntib
iotic
s if
infe
ctio
n
s
uspe
cted
.
Clin
ical
ly w
ell a
nd t
oler
atin
g or
al fl
uids
:•
Star
t sub
cuta
neou
s in
sulin
.•
Cont
inue
ora
l hyd
ratio
n th
erap
y.
Inve
stig
atio
ns•
Bloo
ds: g
luco
se le
vels,
U&
E, b
lood
gas
es.
• U
rinal
ysis
: for
ket
ones
.•
If in
fect
ion
susp
ecte
d, th
en o
btai
n cu
lture
s
(blo
od, u
rine,
thro
at) a
nd p
erfo
rm th
e
'sep
tic s
ix'.
• EC
G –
tent
ed T-
wav
es a
nd b
road
enin
g of
the
Q
RS c
ompl
ex m
ay b
e se
en in
hyp
erka
laem
ia
a
ssoc
iate
d w
ith p
otas
sium
ther
apy
• AB
G: a
sses
s th
e de
gree
of a
cido
sis.
• Am
ylas
e: a
bdom
inal
pai
n an
d vo
miti
ng is
als
o as
soci
ated
with
pan
crea
titis.
• Ra
diol
ogy:
che
st x
-ray
may
be
requ
ired
to
l
ocat
e so
urce
of i
nfec
tion.
Sym
ptom
s
Gen
eral
sym
ptom
s:•
Poly
uria
/enu
resi
s.•
Poly
dips
ia.
• W
eigh
t los
s.•
Abdo
min
al p
ain.
• Le
thar
gy.
• Vo
miti
ng.
• Co
nfus
ion.
Clin
ical
sig
ns o
f DKA
:•
Dehy
drat
ion.
• Po
lyur
ia.
• Po
lydi
psia
.•
Tach
ycar
dia.
• Hy
pote
nsio
n.•
Kaus
smau
l bre
athi
ng (t
o ex
hale
exc
essi
ve
CO2)
.•
Acet
one
swee
t sm
ellin
g br
eath
.•
Conf
usio
n.•
Com
a.
Bioc
hem
ical
sig
ns:
• Ke
tonu
ria.
• In
crea
sed
bloo
d gl
ucos
e le
vel.
• Ac
idae
mia
.
Com
plic
atio
ns•
Com
a.•
Com
plic
atio
ns o
f tre
atm
ent,
e.g.
:
Ce
rebr
al o
edem
a.
Hy
poka
laem
ia.
Hypo
glyc
aem
ia.
MAP
4.2
0. D
iabe
tic
keto
acid
osis
(DK
A)
147
K30033_C004.indd 147 28/02/17 11:44 am
Paed
iatr
ics
FIG
URE
4.1.
Pat
ho
ph
ysio
log
y o
f d
iab
etic
ket
oac
ido
sis
Stat
e of
unc
ontr
olle
d ca
tabo
lism
Diab
etic
ket
oaci
dosi
s
Lipo
lysi
s In
crea
sed
bloo
d gl
ucos
e le
vels
Osm
otic
diu
resi
s
Rena
l hyp
oper
fusi
on
Stat
e of
unc
ontr
olle
d ca
tabo
lism
Keto
nes
man
ufac
ture
d
The
kidn
ey, b
ecau
se o
f ren
al h
ypop
erfu
sion
and
the
anti-
insu
lin a
ctio
n of
gluc
agon
, cor
tisol
and
cat
echo
lam
ines
,ca
nnot
exc
rete
ket
ones
pro
ficie
ntly
FIG
URE
4.1
. Pat
hoph
ysio
logy
of d
iabe
tic k
etoa
cido
sis
148
4.5.
Tri
som
ies
K30033_C004.indd 148 28/02/17 11:44 am
149
Paed
iatr
ics
TABL
E 4.
5. T
riso
mie
s.
Tris
omy
Synd
rom
e na
me
Sym
ptom
sIn
vest
igat
ions
Com
plic
atio
ns
21Do
wn’
s sy
ndro
me
• Le
arni
ng d
ifficu
lties
• Sh
ort s
tatu
re•
Flat
tene
d no
se•
Slan
ted
eyes
• Si
mia
n cr
ease
• G
ap b
etw
een
1st a
nd 2
nd to
e
Ante
nata
l tes
ting
– U
SS fo
r nuc
hal
tran
sluc
ency
(see
Tabl
e 2.
1, p
. 34)
Radi
olog
y –
pelv
ic x
-ray
sho
ws
dysp
last
ic p
elvi
s
• At
rial s
epta
l def
ects
• Ve
ntric
ular
sep
tal d
efec
ts•
Duod
enal
atr
esia
• Ac
ute
lym
phob
last
ic le
ukae
mia
• Al
zhei
mer
’s di
seas
e•
Hypo
thyr
oidi
sm
18Ed
war
d’s
synd
rom
e•
Rock
er b
otto
m fe
et•
Lear
ning
diffi
culti
es•
Clen
ched
han
ds•
Low
set
ear
s•
Mic
rogn
athi
a•
Clef
t lip
or c
left
pala
te•
Und
esce
nded
test
icle
s
Chro
mos
omal
ana
lysi
s co
nfirm
s di
agno
sis
ECG
and
ECH
O –
for c
ardi
ac
com
plic
atio
ns
• Co
arct
atio
n of
the
aort
a •
Atria
l sep
tal d
efec
ts•
Ingu
inal
her
nia
• O
mph
aloc
oele
• Re
nal a
gene
sis
13Pa
tau’
s sy
ndro
me
• Le
arni
ng d
ifficu
lties
• Co
ngen
ital h
eart
dis
ease
• Cl
eft l
ip/p
alat
e•
Mic
roce
phal
y •
Poly
dact
yly
• Ro
cker
bot
tom
feet
Chro
mos
omal
ana
lysi
s co
nfirm
s di
agno
sis
ECG
and
ECH
O –
for c
ardi
ac
com
plic
atio
ns
• O
mph
aloc
oele
• Po
lycy
stic
kid
neys
• Ve
ntric
ular
sep
tal d
efec
ts•
Ingu
inal
her
nia
Tabl
e 4.
5. T
riso
mie
s
4.5.
Tri
som
ies
K30033_C004.indd 149 28/02/17 11:44 am
Paed
iatr
ics
Map
4.2
1. K
awas
aki’s
dis
ease
Wha
t is
Kaw
asak
i’s d
isea
se?
This
is a
rare
form
of a
utoi
mm
une
vasc
uliti
s;al
so k
now
n as
lym
ph n
ode
synd
rom
e.It
is v
ital t
o di
agno
se d
ue to
its
seve
reco
mpl
icat
ions
.
Caus
esEx
act c
ause
is n
ot k
now
n. It
is th
ough
t to
bean
aut
oim
mun
e va
scul
itis.
Sym
ptom
sRe
mem
ber a
s A
BCD
ES:
A –
A h
igh
feve
r >5
days
B –
Brig
ht re
d lip
sC
– Ce
rvic
al ly
mph
aden
opat
hyD
– D
esqu
amat
ion
of h
ands
and
feet
E –
Eyes
: non
-pur
ulen
t bila
tera
l
con
junc
tiviti
sS
– St
raw
berr
y to
ngue
Inve
stig
atio
nsKa
was
aki’s
dis
ease
is a
clin
ical
dia
gnos
is a
ndth
ere
is n
o sp
ecifi
c te
st; h
owev
er, i
t is
vita
l to
perfo
rm a
n EC
HO lo
okin
g fo
r cor
onar
yan
eury
sms,
whi
ch a
re a
ser
ious
com
plic
atio
n.
• Bl
ood
test
s: FB
C, W
CC, U
&E,
LFT
s, ES
R, C
RP.
• U
rinal
ysis.
• EC
G.•
Radi
olog
y:
EC
HO.
USS
/CT
if in
dica
ted:
may
sho
w
ga
llbla
dder
enl
arge
men
t.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
nd p
aren
t edu
catio
n.
Med
ical
:•
IV im
mun
oglo
bulin
ther
apy.
• As
pirin
(Kaw
asak
i’s d
isea
se is
the
only
ex
cept
ion
for t
he u
se o
f asp
irin
in c
hild
ren
d
ue to
the
risk
of R
eye
synd
rom
e).
Com
plic
atio
ns•
Coro
nary
ane
urys
ms.
• Dy
srhy
thm
ias.
• M
yoca
rditi
s.•
Valv
ular
abn
orm
aliti
es.
MAP
4.2
1. K
awas
aki’s
dis
ease
150
K30033_C004.indd 150 28/02/17 11:44 am
Paed
iatr
ics
Map
4.2
1. K
awas
aki’s
dis
ease
Wha
t is
Kaw
asak
i’s d
isea
se?
This
is a
rare
form
of a
utoi
mm
une
vasc
uliti
s;al
so k
now
n as
lym
ph n
ode
synd
rom
e.It
is v
ital t
o di
agno
se d
ue to
its
seve
reco
mpl
icat
ions
.
Caus
esEx
act c
ause
is n
ot k
now
n. It
is th
ough
t to
bean
aut
oim
mun
e va
scul
itis.
Sym
ptom
sRe
mem
ber a
s A
BCD
ES:
A –
A h
igh
feve
r >5
days
B –
Brig
ht re
d lip
sC
– Ce
rvic
al ly
mph
aden
opat
hyD
– D
esqu
amat
ion
of h
ands
and
feet
E –
Eyes
: non
-pur
ulen
t bila
tera
l
con
junc
tiviti
sS
– St
raw
berr
y to
ngue
Inve
stig
atio
nsKa
was
aki’s
dis
ease
is a
clin
ical
dia
gnos
is a
ndth
ere
is n
o sp
ecifi
c te
st; h
owev
er, i
t is
vita
l to
perfo
rm a
n EC
HO lo
okin
g fo
r cor
onar
yan
eury
sms,
whi
ch a
re a
ser
ious
com
plic
atio
n.
• Bl
ood
test
s: FB
C, W
CC, U
&E,
LFT
s, ES
R, C
RP.
• U
rinal
ysis.
• EC
G.•
Radi
olog
y:
EC
HO.
USS
/CT
if in
dica
ted:
may
sho
w
ga
llbla
dder
enl
arge
men
t.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt a
nd p
aren
t edu
catio
n.
Med
ical
:•
IV im
mun
oglo
bulin
ther
apy.
• As
pirin
(Kaw
asak
i’s d
isea
se is
the
only
ex
cept
ion
for t
he u
se o
f asp
irin
in c
hild
ren
d
ue to
the
risk
of R
eye
synd
rom
e).
Com
plic
atio
ns•
Coro
nary
ane
urys
ms.
• Dy
srhy
thm
ias.
• M
yoca
rditi
s.•
Valv
ular
abn
orm
aliti
es.
MAP
4.2
1. K
awas
aki’s
dis
ease
151
K30033_C004.indd 151 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
6. C
hild
ho
od
can
cers
TABL
E 4.
6. C
hild
hood
can
cers
.
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Acut
e ly
mph
obla
stic
le
ukae
mia
(ALL
)
A ra
re n
eopl
asm
of t
he
bloo
d/bo
ne m
arro
w. T
he
exac
t cau
se is
unk
now
n bu
t it
is li
kely
due
to a
gen
etic
su
scep
tibili
ty c
oupl
ed w
ith
an e
nviro
nmen
tal t
rigge
r. It
is th
e co
mm
ones
t can
cer
in c
hild
ren.
Ass
ocia
ted
with
Do
wn’
s sy
ndro
me
• Bo
ne m
arro
w fa
ilure
•
Brui
sing
•
Shor
tnes
s of
bre
ath
• Pu
rpur
a •
Mal
aise
•
Wei
ght l
oss
• N
ight
sw
eats
Bloo
ds: F
BC, W
CC,
plat
elet
s, U
&E,
LF
Ts, E
SR, C
RPBo
ne m
arro
w
biop
sy, l
ymph
nod
e bi
opsy
Radi
olog
y: x
-ray
, USS
, CT
, MRI
ALL
is c
lass
ified
us
ing
the
Fren
ch–
Amer
ican
–Brit
ish
(FAB
) cla
ssifi
catio
n
To in
duce
rem
issi
on:
• De
xam
etha
sone
• Vi
ncris
tine
• An
thra
cycl
ine
antib
iotic
s•
Cycl
opho
spha
mid
e
Mai
nten
ance
:•
Met
hotr
exat
e•
Mer
capt
opur
ine
• Cy
tara
bine
• Hy
droc
ortis
one
• De
ath
• O
ften
spre
ads
to th
e ce
ntra
l ne
rvou
s sy
stem
• In
crea
sed
risk
of
infe
ctio
n•
Haem
orrh
age
• De
pres
sion
• Co
mpl
icat
ions
of
chem
othe
rapy
Neu
robl
asto
ma
This
is a
neu
roen
docr
ine
tum
our a
risin
g fro
m
neur
obla
st c
ells
with
in
the
sym
path
etic
ner
vous
sy
stem
. Neu
robl
asto
mas
m
ostly
orig
inat
e in
the
adre
nal g
land
s bu
t may
de
velo
p an
ywhe
re a
long
the
sym
path
etic
ner
vous
sys
tem
.
Sym
ptom
s di
ffer d
epen
ding
on
the
loca
tion
of th
e le
sion
. G
ener
al s
ympt
oms:
• W
eigh
t los
s•
Anor
exia
• Em
esis
Bloo
ds: F
BC, W
CC,
plat
elet
s, U
&E,
LFT
s, TF
Ts, E
SR, C
RP,
calc
ium
, mag
nesi
um,
phos
phor
us, u
ric a
cid,
LD
H, Ig
G le
vels
Trea
tmen
t dep
ends
on
the
stag
e of
the
tum
our a
nd is
de
liver
ed b
y a
mul
tidis
cipl
inar
y te
am.
• Re
laps
e an
d re
curr
ent d
isea
se•
Met
asta
sis
152
K30033_C004.indd 152 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
6. C
hild
ho
od
can
cers
It is
the
mos
t com
mon
ex
trac
rani
al s
olid
tum
our o
f in
fanc
y. Th
e ex
act c
ause
of
neur
obla
stom
a is
unk
now
n bu
t ALK
mut
atio
ns h
ave
been
iden
tified
in fa
mili
al
case
s. Fi
fty to
60%
pre
sent
w
ith m
etas
tase
s
Abdo
men
:•
Abdo
min
al p
ain
• Sw
ellin
gCh
est:
• Re
spira
tory
diffi
culty
Bone
/bon
e m
arro
w:
• Bo
ne p
ain
• Li
mp
Para
spin
al c
ord
gang
lia
resu
lts in
neu
rolo
gica
l sy
mpt
oms
such
as:
• W
eakn
ess
• Pa
raly
sis
• Bl
adde
r dys
func
tion
• Bo
wel
dys
func
tion
Rare
sym
ptom
s:•
Hype
rten
sion
(ren
al a
rter
y co
mpr
essi
on)
• Ch
roni
c di
arrh
oea
(vas
oact
ive
inte
stin
al
pept
ide
secr
etio
n)
Incr
ease
d le
vels
of
urin
e ca
tech
olam
ines
(o
r the
ir m
etab
olite
s [e
.g. h
omov
anill
ic
acid
/van
illyl
man
delic
ac
id])
Radi
olog
y: C
T, m
eta-
iodo
benz
ylgu
anid
ine
scan
Hist
olog
y: H
omer
W
right
rose
ttes
.N
euro
blas
tom
as
are
clas
sifie
d us
ing
the
Inte
rnat
iona
l N
euro
blas
tom
a St
agin
g Sy
stem
(IN
SS)
Med
ical
: com
mon
ch
emot
hera
py c
ombi
natio
ns
incl
ude:
• Vi
ncris
tine,
cy
clop
hosp
ham
ide
and
doxo
rubi
cin
• Ci
spla
tin a
nd e
topo
side
• Ca
rbop
latin
and
eto
posi
de•
Ifosf
amid
e an
d et
opos
ide
• Cy
clop
hosp
ham
ide
and
topo
teca
n
Surg
ical
: •
Surg
ical
rese
ctio
n in
lo
caliz
ed d
isea
se is
cur
ativ
e•
Surg
ery
post
che
mot
hera
py
may
be
seen
as
a de
bulk
ing
proc
edur
e
• Pa
rane
opla
stic
sy
ndro
mes
(e.g
. op
socl
onus
m
yocl
onus
sy
ndro
me)
• Co
mpl
icat
ions
of
chem
othe
rapy
Cont
inue
d ov
erle
af
153
K30033_C004.indd 153 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
6. C
hild
ho
od
can
cers
Wilm
s’ tu
mou
r(a
ka
neph
robl
asto
ma)
Is a
form
of r
enal
can
cer
that
occ
urs
in c
hild
ren.
It
is a
ssoc
iate
d w
ith a
nirid
ia.
Nep
hrob
last
omas
are
mos
tly
unila
tera
l. It
is a
ssoc
iate
d w
ith W
T1 g
ene
mut
atio
ns
(chr
omos
ome
11p1
3) in
20
% o
f cas
es.
Synd
rom
es a
ssoc
iate
d w
ith
Wilm
s’ tu
mou
rs:
• De
nys–
Dras
h sy
ndro
me
• Fr
asie
r syn
drom
e•
Spor
adic
ani
ridia
• Li
–Fra
umen
i syn
drom
e
• Ab
dom
inal
sw
ellin
g•
Abdo
min
al p
ain
• Ha
emat
uria
• N
ause
a •
Vom
iting
Bloo
ds: F
BC, W
CC,
plat
elet
s, U
&E,
LFT
s, ES
R, C
RP, B
UN
U
rinal
ysis
Radi
olog
y: a
bdom
inal
U
SS, a
bdom
inal
x-
ray,
ches
t x-r
ay, C
T ab
dom
en, M
RI, I
V py
elog
ram
Trea
tmen
t dep
ends
on
the
stag
e an
d si
ze o
f the
tum
our a
s w
ell a
s hi
stop
atho
logi
cal a
nd
mol
ecul
ar tu
mou
r fea
ture
s.
Chem
othe
rapy
: som
e st
anda
rd c
hem
othe
rapy
re
gim
ens
are
liste
d be
low
:•
Vinc
ristin
e an
d da
ctin
omyc
in•
Vinc
ristin
e, d
actin
omyc
in
and
doxo
rubi
cin
• Vi
ncris
tine,
dox
orub
icin
, cy
clop
hosp
ham
ide
and
etop
osid
e
Radi
othe
rapy
Surg
ical
: nep
hrec
tom
y
• M
etas
tasi
s•
Hype
rten
sion
, pa
rtic
ular
ly if
bi
late
ral r
enal
in
volv
emen
t
TABL
E 4.
6. C
hild
hood
can
cers
(con
tinue
d).
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
154
K30033_C004.indd 154 28/02/17 11:44 am
Paed
iatr
ics
Tabl
e 4.
6. C
hild
ho
od
can
cers
Ewin
g’s
sarc
oma
This
is a
rare
, mal
igna
nt
smal
l, ro
und,
blu
e ce
ll tu
mou
r affe
ctin
g th
e bo
ne/
soft
tissu
e. It
typi
cally
affe
cts
teen
ager
s an
d yo
ung
adul
ts.
Usu
ally
a re
sult
of t(
11;2
2)
tran
sloc
atio
ns re
sulti
ng in
a
EWSR
1/FL
I1 fu
sion
gen
e.
The
mos
t com
mon
regi
ons
affe
cted
are
:
• Pe
lvis
• Fe
mur
• Hu
mer
us•
Ribs
• Cl
avic
le
• Pa
in in
the
loca
tion
of th
e tu
mou
r, w
hich
wor
sens
ov
er ti
me
• A
swel
ling
in th
e lo
catio
n of
the
tum
our
• Sw
ellin
g an
d de
crea
sed
rang
e of
mov
emen
t of t
he
affe
cted
join
t•
Feve
r of u
nkno
wn
orig
in•
Unp
rovo
ked
bone
frac
ture
• G
ener
al s
ympt
oms
such
as
leth
argy
and
wei
ght l
oss
Bloo
ds: F
BC, W
CC,
plat
elet
s, U
&E,
LFT
s, TF
Ts, E
SR, C
RPRa
diol
ogy:
x-r
ays
(sho
w ‘m
oth-
eate
n’
radi
oluc
enci
es),
CT, M
RI, P
ET, b
one
scin
tigra
phy
Hist
olog
y: s
mal
l, ro
und,
blu
e ce
ll tu
mou
r. Cl
ear
cyto
plas
m w
ith H
&E
stai
ning
Trea
tmen
t dep
ends
on
the
stag
e an
d si
ze o
f the
tum
our
as w
ell a
s hi
stop
atho
logi
cal
feat
ures
.
Chem
othe
rapy
: som
e ch
emot
hera
py re
gim
ens
are
liste
d be
low
:•
Ifosf
amid
e an
d et
opos
ide
• Vi
ncris
tine,
dox
orub
icin
and
cy
clop
hosp
ham
ide
Radi
othe
rapy
Surg
ical
: lim
b am
puta
tion
• M
etas
tasi
s•
Lim
b am
puta
tion
155
K30033_C004.indd 155 28/02/17 11:44 am
Chap
ter F
ive
Oph
thal
mol
ogy
Oph
thal
mol
ogy
TABL
E 5.
1 S
ud
den
pai
nle
ss v
isu
al lo
ss
158
MAP
5.1
M
acu
lar
deg
ener
atio
n
162
MAP
5.2
G
lau
com
a 16
4
MAP
5.3
Cat
arac
ts
166
TABL
E 5.
2 R
ed e
ye
168
TABL
E 5.
3 D
iab
etic
eye
dis
ease
17
0
157
K30033_C005.indd 157 28/02/17 11:10 am
Oph
thal
mol
ogy
158
Tabl
e 5.
1. S
ud
den
pai
nle
ss v
isu
al lo
ss
TABL
E 5.
1. S
udde
n pa
inle
ss v
isua
l los
s.
Ther
e ar
e m
any
caus
es o
f pai
nles
s lo
ss o
f vis
ion.
The
y m
ay b
e re
mem
bere
d by
the
mne
mon
ic O
IRO
V:
Opt
ical
– o
cclu
sion
of t
he re
tinal
vei
n; Is
sues
– is
chae
mic
opt
ic n
euro
path
y; R
eally
– re
tinal
det
achm
ent;
Obs
cure
– o
cclu
sion
of t
he
retin
al a
rter
y; V
isio
n –
vitr
eous
hae
mor
rhag
e.
Dis
ease
Caus
eFe
atur
esIn
vest
igat
ions
Trea
tmen
t
Occ
lusi
on o
f the
re
tinal
vei
n•
Hype
rten
sion
• G
lauc
oma
• Po
lycy
thae
mia
• Su
dden
pai
nles
s m
onoc
ular
vis
ion
loss
or d
ense
cen
tral
sco
tom
a•
Isch
aem
ic s
ubty
pe is
ass
ocia
ted
with
acu
te p
rese
ntat
ion,
whe
reas
no
n-is
chae
mic
sub
type
may
pr
esen
t mor
e su
btly
• Vi
sual
acu
ity•
Pupi
l ana
lysi
s: m
ay s
how
an
ipsi
late
ral a
ffere
nt p
upill
ary
defe
ct•
Intr
aocu
lar p
ress
ure
(IOP)
: us
ually
nor
mal
• An
terio
r slit
lam
p ex
amin
atio
n: n
orm
al•
Fund
osco
py: d
iagn
ostic
. Vi
sual
izes
retin
al
haem
orrh
age
and
oede
ma
(aka
‘blo
od a
nd th
unde
r fu
ndus
’)•
Fluo
resc
ein
angi
ogra
phy:
re
tinal
cap
illar
y is
chae
mia
, m
acul
ar o
edem
a,
neov
ascu
lariz
atio
n
Emer
genc
y ca
re
Med
ical
:•
No
exac
t tre
atm
ent.
Man
age
risk
fact
ors
and
com
plic
atio
ns
as th
ey o
ccur
• M
acul
ar o
edem
a: in
trav
itrea
l an
ti-VE
GF
or s
tero
ids
• N
eova
scul
ariz
atio
n: la
ser
phot
ocoa
gula
tion
Surg
ical
:
• Vi
trec
tom
y
K30033_C005.indd 158 28/02/17 11:10 am
159
Oph
thal
mol
ogy
Tabl
e 5.
1. S
ud
den
pai
nle
ss v
isu
al lo
ss
Isch
aem
ic o
ptic
ne
urop
athy
• Te
mpo
ral a
rter
itis
• At
hero
scle
rosi
s•
Non
-mod
ifiab
le ri
sk fa
ctor
s: ag
e, m
ale
gend
er, p
ositi
ve
fam
ily h
isto
ry•
Mod
ifiab
le ri
sk fa
ctor
s: di
abet
es m
ellit
us,
hype
rten
sion
, sm
okin
g,
obes
ity, l
ipid
and
cho
lest
erol
le
vels
• Vi
sual
loss
: usu
ally
on
w
akin
g•
Tem
pora
l art
eriti
s:
Gen
eral
sym
ptom
s: w
eigh
t los
s, m
uscl
e ac
hes
(ass
ocia
ted
with
pol
ymya
lgia
rh
eum
atic
a), s
calp
tend
erne
ss,
tem
pora
l art
ery
is th
icke
ned,
te
nder
but
non
pul
satil
e, ja
w
clau
dica
tion
Vi
sual
sym
ptom
s: op
tic
neur
opat
hy, b
lindn
ess,
di
plop
ia
Neu
rolo
gy s
ympt
oms:
stro
ke, m
yelo
path
y, ne
urop
athy
• Sp
ecifi
c bl
ood
test
s: ES
R in
crea
sed
mar
kedl
y in
te
mpo
ral a
rter
itis
and
is th
e fir
st-li
ne in
vest
igat
ion
• O
ther
blo
od te
sts:
FBC,
CRP
• Bi
opsy
: of t
empo
ral a
rter
y if
indi
cate
d. S
how
s gi
ant c
ell
infil
trat
ion
Pred
niso
lone
for t
empo
ral
arte
ritis
Cont
inue
d ov
erle
af
K30033_C005.indd 159 28/02/17 11:10 am
Oph
thal
mol
ogy
160
Tabl
e 5.
1. S
ud
den
pai
nle
ss v
isu
al lo
ss
TABL
E 5.
1. S
udde
n pa
inle
ss v
isua
l los
s (c
ontin
ued
).
Dis
ease
Caus
eFe
atur
esIn
vest
igat
ions
Trea
tmen
t
Retin
al
deta
chm
ent
• Tr
aum
a –
part
icul
arly
ac
cele
ratio
n–de
cele
ratio
n in
jurie
s •
Retin
al te
ars
• Po
sitiv
e fa
mily
his
tory
• Co
mpl
icat
ion
of c
atar
act
surg
ery
• M
yopi
a (h
igh
leve
l)
• Th
ere
are
thre
e di
ffere
nt w
ays
in
whi
ch re
tinal
det
achm
ent m
ay
man
ifest
. Rem
embe
r as
RETi
nal:
R –
Rheg
mat
ogen
ous
E –
Exud
ativ
eT
– Tr
actio
nal
• Sy
mpt
oms
may
be
rem
embe
red
as th
e 4F
s:F
– Fl
oate
rsF
– Fl
ashe
s (p
hoto
psia
) F
– Fi
eld
loss
F –
Fall
in a
cuity
occ
urs
whe
n m
acul
a de
tach
es•
Supe
rior t
empo
ral q
uadr
ant m
ost
com
mon
ly a
ffect
ed
• Vi
sual
acu
ity
• Pu
pil a
naly
sis:
may
de
mon
stra
te a
rela
tive
affe
rent
pup
illar
y de
fect
or
a M
arcu
s G
unn
pupi
l if n
ot
cons
ensu
al
• Vi
sual
fiel
d an
alys
is•
Ante
rior s
lit la
mp
exam
inat
ion
• Fu
ndos
copy
: vis
ualiz
es
deta
ched
por
tion
of th
e re
tina
(gre
y op
ales
cent
)
Emer
genc
y ca
re
Surg
ical
:
• Re
atta
ch th
e re
tina
(e.g
. vitr
ecto
my
with
gas
ta
mpo
nade
)
K30033_C005.indd 160 28/02/17 11:10 am
Oph
thal
mol
ogy
161
Tabl
e 5.
1. S
ud
den
pai
nle
ss v
isu
al lo
ss
Occ
lusi
on o
f the
re
tinal
art
ery
• Te
mpo
ral a
rter
itis
• At
hero
scle
rosi
s•
Risk
fact
ors
incr
ease
w
ith a
tria
l fibr
illat
ion,
co
agul
opat
hies
and
sic
kle
cell
dise
ase
• Su
dden
pai
nles
s ce
ntra
l vis
ual
loss
• Pe
rform
blo
od te
sts
to
dete
ct th
e un
derly
ing
caus
e (e
.g. F
BC, s
ickl
e ce
ll st
udie
s, ES
R, C
RP, p
roth
rom
bin
time,
act
ivat
ed p
artia
l th
rom
bopl
astin
tim
e,
chol
este
rol a
nd tr
igly
cerid
e le
vels
)•
ECG
: for
atr
ial fi
brill
atio
n•
Full
opht
halm
olog
y as
sess
men
t as
abov
e
Trea
tmen
t dep
ends
on
the
time
elap
sed
sinc
e vi
sual
loss
det
ecte
d.
Retin
al a
rter
y oc
clus
ion
requ
ires
prom
pt e
mer
genc
y tr
eatm
ent:
• Lo
wer
IOP:
ocu
lar m
assa
ge,
ante
rior c
ham
ber p
arac
ente
sis
• O
ther
med
icat
ions
: tim
olol
, ac
etaz
olam
ide,
man
nito
l, th
rom
boly
tics
may
be
usef
ul,
hype
rbar
ic o
xyge
n th
erap
y (w
ithin
2–1
2 ho
urs
of o
nset
)
Vitr
eous
ha
emor
rhag
e•
Diab
etes
mel
litus
• Co
agul
atio
n di
sord
ers
• Su
dden
pai
nles
s vi
sual
loss
: ‘c
obw
ebs
and
float
ers’
• Ph
otop
hobi
a •
Phot
opsi
a
Trea
t und
erly
ing
caus
e
Cons
erva
tive
:•
Bed
rest
with
the
head
of t
he
bed
elev
ated
30–
45°
Med
ical
:•
Depe
nds
on u
nder
lyin
g ca
use
Surg
ical
:•
Lase
r the
rapy
•
Cryo
ther
apy
• Vi
trec
tom
y
K30033_C005.indd 161 28/02/17 11:10 am
Oph
thal
mol
ogy
162
MAP
5.1
. M
acu
lar
deg
ener
atio
n
Com
plic
atio
ns•
Blin
dnes
s.•
Depr
essi
on.
Wha
t is
mac
ular
deg
ener
atio
n?Th
is is
a c
hron
ic o
cula
r con
ditio
n, w
hich
is
mor
e co
mm
on in
old
er p
atie
nts.
Ther
e ar
e th
ree
diffe
rent
type
s:
1. D
ry (g
eogr
aphi
c) m
acul
ar d
egen
erat
ion:
•
Char
acte
ristic
yel
low
dru
sen.
•
Mos
t com
mon
type
.
2. W
et (e
xuda
tive)
mac
ular
deg
ener
atio
n:
• Se
vere
and
acc
eler
ativ
e.
• As
soci
ated
with
neo
vasc
ular
izat
ion
of
the
cho
roid
and
, the
refo
re,
haem
orrh
age.
3. S
targ
ardt
mac
ular
deg
ener
atio
n:
• O
ccur
s in
teen
ager
s.
• Ra
re.
Caus
esU
nkno
wn.
The
re a
re th
eorie
s w
hich
sug
gest
th
at V
EGF
play
s a
role
in th
e pa
thop
hysi
olog
y of
the
dise
ase
and
ther
e is
a li
nk w
ith
smok
ing
(incr
ease
s th
e ris
k by
3.6
).
Risk
fact
ors:
rem
embe
r as
ABC
S:A
– A
ge: g
ener
ally
ove
r 60
B –
high
Blo
od p
ress
ure
C –
incr
ease
d Ch
oles
tero
l lev
els/
Cauc
asia
n et
hnic
ityS
– Sm
okin
g/Su
nlig
ht (U
V) e
xpos
ure
Sym
ptom
s•
Prog
ress
ive
cent
ral v
isua
l los
s.•
Scot
omas
.•
Visu
al a
cuity
: dec
reas
ed.
• M
etam
orph
opsi
a.
Trea
tmen
t
Trea
tmen
tD
ryW
et
Cons
erva
tive
Med
ical
Patie
nt e
duca
tion
Refe
rral
to o
ccup
atio
nal
ther
apy
to im
prov
e qu
ality
of li
fe (e
.g. a
dapt
ed h
ouse
aids
suc
h as
mag
nifie
dho
me
appl
ianc
es)
No
effe
ctiv
e tr
eatm
ent
As w
ith d
ry m
acul
arde
gene
ratio
n
Ora
l vita
min
s an
d an
tioxi
dant
s An
ti-VE
GF
ther
apy
(e.g
. ran
ibiz
umab
)Su
rgic
alN
o ef
fect
ive
trea
tmen
tPh
otod
ynam
ic th
erap
y
MAP
5.1
. Mac
ular
deg
ener
atio
n
Inve
stig
atio
ns•
Oph
thal
mol
ogy
exam
inat
ion:
Visu
al a
cuity
.
Vi
sual
fiel
ds.
Amsl
er g
rid: m
etam
orph
opsi
a.
Fl
uore
scei
n an
giog
raph
y: w
et m
acul
ar
de
gene
ratio
n (n
eova
scul
ariz
atio
n).
• Bl
ood
test
s: FB
C, U
&E,
glu
cose
, cho
lest
erol
an
d lip
id le
vels.
K30033_C005.indd 162 28/02/17 11:10 am
Oph
thal
mol
ogy
163
Com
plic
atio
ns•
Blin
dnes
s.•
Depr
essi
on.
Wha
t is
mac
ular
deg
ener
atio
n?Th
is is
a c
hron
ic o
cula
r con
ditio
n, w
hich
is
mor
e co
mm
on in
old
er p
atie
nts.
Ther
e ar
e th
ree
diffe
rent
type
s:
1. D
ry (g
eogr
aphi
c) m
acul
ar d
egen
erat
ion:
•
Char
acte
ristic
yel
low
dru
sen.
•
Mos
t com
mon
type
.
2. W
et (e
xuda
tive)
mac
ular
deg
ener
atio
n:
• Se
vere
and
acc
eler
ativ
e.
• As
soci
ated
with
neo
vasc
ular
izat
ion
of
the
cho
roid
and
, the
refo
re,
haem
orrh
age.
3. S
targ
ardt
mac
ular
deg
ener
atio
n:
• O
ccur
s in
teen
ager
s.
• Ra
re.
Caus
esU
nkno
wn.
The
re a
re th
eorie
s w
hich
sug
gest
th
at V
EGF
play
s a
role
in th
e pa
thop
hysi
olog
y of
the
dise
ase
and
ther
e is
a li
nk w
ith
smok
ing
(incr
ease
s th
e ris
k by
3.6
).
Risk
fact
ors:
rem
embe
r as
ABC
S:A
– A
ge: g
ener
ally
ove
r 60
B –
high
Blo
od p
ress
ure
C –
incr
ease
d Ch
oles
tero
l lev
els/
Cauc
asia
n et
hnic
ityS
– Sm
okin
g/Su
nlig
ht (U
V) e
xpos
ure
Sym
ptom
s•
Prog
ress
ive
cent
ral v
isua
l los
s.•
Scot
omas
.•
Visu
al a
cuity
: dec
reas
ed.
• M
etam
orph
opsi
a.
Trea
tmen
t
Trea
tmen
tD
ryW
et
Cons
erva
tive
Med
ical
Patie
nt e
duca
tion
Refe
rral
to o
ccup
atio
nal
ther
apy
to im
prov
e qu
ality
of li
fe (e
.g. a
dapt
ed h
ouse
aids
suc
h as
mag
nifie
dho
me
appl
ianc
es)
No
effe
ctiv
e tr
eatm
ent
As w
ith d
ry m
acul
arde
gene
ratio
n
Ora
l vita
min
s an
d an
tioxi
dant
s An
ti-VE
GF
ther
apy
(e.g
. ran
ibiz
umab
)Su
rgic
alN
o ef
fect
ive
trea
tmen
tPh
otod
ynam
ic th
erap
y
MAP
5.1
. Mac
ular
deg
ener
atio
n
Inve
stig
atio
ns•
Oph
thal
mol
ogy
exam
inat
ion:
Visu
al a
cuity
.
Vi
sual
fiel
ds.
Amsl
er g
rid: m
etam
orph
opsi
a.
Fl
uore
scei
n an
giog
raph
y: w
et m
acul
ar
de
gene
ratio
n (n
eova
scul
ariz
atio
n).
• Bl
ood
test
s: FB
C, U
&E,
glu
cose
, cho
lest
erol
an
d lip
id le
vels.
MAP
5.1
. M
acu
lar
deg
ener
atio
n
K30033_C005.indd 163 28/02/17 11:10 am
Oph
thal
mol
ogy
164
MAP
5.2
. G
lau
com
a
Sym
ptom
s•
Gla
ucom
a m
ay b
e pi
cked
up
on ro
utin
e op
htha
lmol
ogy
exam
inat
ion.
• Di
min
ishe
d vi
sion
.•
Clos
ed a
ngle
gla
ucom
a: h
azy
corn
ea, s
emid
ilate
d pu
pil.
• Pa
in.
• Ke
y tr
iad:
1, v
isua
l fie
ld lo
ss;
2,
alte
ratio
n to
the
optic
nerv
e cu
p; a
nd 3
, alte
ratio
n
to
the
optic
dis
c.
Com
plic
atio
n•
Blin
dnes
s.
Inve
stig
atio
ns•
Tono
met
ry: m
easu
res
IOP.
• Fu
ndos
copy
.•
Visu
al fi
eld
asse
ssm
ent.
• Cu
p-to
-dis
c ra
tio.
• G
onio
scop
y: a
sses
ses
the
i
ridoc
orne
al a
ngle
.•
Scan
ning
lase
r oph
thal
mos
copy
.•
Scan
ning
lase
r pol
arim
etry
.
Wha
t is
gla
ucom
a?G
lauc
oma
com
pris
es a
gro
up o
f ocu
lar d
isor
ders
cha
ract
eriz
ed b
y th
e fo
llow
ing
tria
d:•
Visu
al fi
eld
loss
(nas
al a
nd s
uper
ior f
ield
s af
fect
ed fi
rst).
• O
ptic
dis
c cu
ppin
g.•
Opt
ic n
erve
dam
age.
IOP
is o
ften
rais
ed b
ut it
may
be
norm
al.
Caus
esTh
ere
are
two
type
s of
gla
ucom
a: o
pen
angl
e (m
ost c
omm
on) a
nd c
lose
d an
gle.
The
follo
win
g ta
ble
expl
ores
the
diffe
renc
es b
etw
een
the
two.
Drai
nage
of a
queo
us h
umou
rth
roug
h th
e tr
abec
ular
mes
hwor
kis
rest
ricte
d
Feat
ure
Ope
n an
gle
Clos
ed a
ngle
Caus
e
Path
olog
y
Prim
ary:
• M
YOC
mut
atio
nSe
cond
ary:
• Tr
aum
a –
obst
ruct
ion
to th
e
trab
ecul
ar m
eshw
ork
Prim
ary:
• Sh
allo
w a
nter
ior c
ham
bers
Seco
ndar
y:•
Trau
ma
• Tu
mou
r of t
he c
iliar
y bo
dy
Out
flow
of a
queo
us h
umou
r is
obst
ruct
ed s
ince
iris
bow
s ag
ains
tth
e tr
abec
ular
mes
hwor
k
Pain
ful
No
Yes
Asso
ciat
ions
Myo
pia
Hype
rmet
ropi
a
Trea
tmen
t
Cons
erva
tive
: pat
ient
edu
catio
n an
d an
nual
ass
essm
ent
Med
ical
:
Brim
onid
ine
Clas
sEx
ampl
e
Beta
blo
cker
s
Sym
path
omim
etic
s
Beta
xolo
l
Carb
onic
anh
ydra
se in
hibi
tors
Acet
azol
amid
e
Mio
tics
Pilo
carp
ine
MO
ASi
de e
ffec
ts
¯ IO
P by
slo
win
g th
e ra
te o
f aqu
eous
hum
our
prod
uctio
n
Sele
ctiv
e a
2-ad
reno
rece
ptor
ago
nist
; ¯ IO
P by
slow
ing
the
rate
of a
queo
us h
umou
r pro
duct
ion
and
by in
crea
sing
uve
oscl
eral
out
flow
Lata
nopr
ost
Pros
tagl
andi
n an
alog
ues
¯ IO
P by
incr
easi
ng u
veos
cler
al o
utflo
w
Inhi
bits
car
boni
c an
hydr
ase,
ther
efor
e ¯
IOP
bysl
owin
g th
e ra
te o
f aqu
eous
hum
our p
rodu
ctio
n
¯ IO
P by
ope
ning
dra
inag
e ch
anne
ls in
trab
ecul
arm
eshw
ork
Cont
rain
dica
ted
in a
sthm
a, h
eart
blo
ckan
d br
adyc
ardi
a
¯ vi
sual
acu
ity, i
tchi
ng, d
iplo
pia,
redn
ess
of th
eey
elid
, exc
essi
ve te
arin
g, tu
nnel
vis
ion
Brow
n pi
gmen
tatio
n of
iris,
¯ v
isua
l acu
ity
Wea
k sy
stem
ic d
iure
tic. I
s a
sulp
hona
mid
ede
rivat
ive,
ther
efor
e su
lpho
nam
ide
side
effe
cts
(e.g
. ras
hes)
Blur
red
visi
on, c
iliar
y sp
asm
, itc
hing
and
lens
chan
ges
(with
chr
onic
use
)
MAP
5.2
. Gla
ucom
a
K30033_C005.indd 164 28/02/17 11:10 am
Oph
thal
mol
ogy
165
Sym
ptom
s•
Gla
ucom
a m
ay b
e pi
cked
up
on ro
utin
e op
htha
lmol
ogy
exam
inat
ion.
• Di
min
ishe
d vi
sion
.•
Clos
ed a
ngle
gla
ucom
a: h
azy
corn
ea, s
emid
ilate
d pu
pil.
• Pa
in.
• Ke
y tr
iad:
1, v
isua
l fie
ld lo
ss;
2,
alte
ratio
n to
the
optic
nerv
e cu
p; a
nd 3
, alte
ratio
n
to
the
optic
dis
c.
Com
plic
atio
n•
Blin
dnes
s.
Inve
stig
atio
ns•
Tono
met
ry: m
easu
res
IOP.
• Fu
ndos
copy
.•
Visu
al fi
eld
asse
ssm
ent.
• Cu
p-to
-dis
c ra
tio.
• G
onio
scop
y: a
sses
ses
the
i
ridoc
orne
al a
ngle
.•
Scan
ning
lase
r oph
thal
mos
copy
.•
Scan
ning
lase
r pol
arim
etry
.
Wha
t is
gla
ucom
a?G
lauc
oma
com
pris
es a
gro
up o
f ocu
lar d
isor
ders
cha
ract
eriz
ed b
y th
e fo
llow
ing
tria
d:•
Visu
al fi
eld
loss
(nas
al a
nd s
uper
ior f
ield
s af
fect
ed fi
rst).
• O
ptic
dis
c cu
ppin
g.•
Opt
ic n
erve
dam
age.
IOP
is o
ften
rais
ed b
ut it
may
be
norm
al.
Caus
esTh
ere
are
two
type
s of
gla
ucom
a: o
pen
angl
e (m
ost c
omm
on) a
nd c
lose
d an
gle.
The
follo
win
g ta
ble
expl
ores
the
diffe
renc
es b
etw
een
the
two.
Drai
nage
of a
queo
us h
umou
rth
roug
h th
e tr
abec
ular
mes
hwor
kis
rest
ricte
d
Feat
ure
Ope
n an
gle
Clos
ed a
ngle
Caus
e
Path
olog
y
Prim
ary:
• M
YOC
mut
atio
nSe
cond
ary:
• Tr
aum
a –
obst
ruct
ion
to th
e
trab
ecul
ar m
eshw
ork
Prim
ary:
• Sh
allo
w a
nter
ior c
ham
bers
Seco
ndar
y:•
Trau
ma
• Tu
mou
r of t
he c
iliar
y bo
dy
Out
flow
of a
queo
us h
umou
r is
obst
ruct
ed s
ince
iris
bow
s ag
ains
tth
e tr
abec
ular
mes
hwor
k
Pain
ful
No
Yes
Asso
ciat
ions
Myo
pia
Hype
rmet
ropi
a
Trea
tmen
t
Cons
erva
tive
: pat
ient
edu
catio
n an
d an
nual
ass
essm
ent
Med
ical
:
Brim
onid
ine
Clas
sEx
ampl
e
Beta
blo
cker
s
Sym
path
omim
etic
s
Beta
xolo
l
Carb
onic
anh
ydra
se in
hibi
tors
Acet
azol
amid
e
Mio
tics
Pilo
carp
ine
MO
ASi
de e
ffec
ts
¯ IO
P by
slo
win
g th
e ra
te o
f aqu
eous
hum
our
prod
uctio
n
Sele
ctiv
e a
2-ad
reno
rece
ptor
ago
nist
; ¯ IO
P by
slow
ing
the
rate
of a
queo
us h
umou
r pro
duct
ion
and
by in
crea
sing
uve
oscl
eral
out
flow
Lata
nopr
ost
Pros
tagl
andi
n an
alog
ues
¯ IO
P by
incr
easi
ng u
veos
cler
al o
utflo
w
Inhi
bits
car
boni
c an
hydr
ase,
ther
efor
e ¯
IOP
bysl
owin
g th
e ra
te o
f aqu
eous
hum
our p
rodu
ctio
n
¯ IO
P by
ope
ning
dra
inag
e ch
anne
ls in
trab
ecul
arm
eshw
ork
Cont
rain
dica
ted
in a
sthm
a, h
eart
blo
ckan
d br
adyc
ardi
a
¯ vi
sual
acu
ity, i
tchi
ng, d
iplo
pia,
redn
ess
of th
eey
elid
, exc
essi
ve te
arin
g, tu
nnel
vis
ion
Brow
n pi
gmen
tatio
n of
iris,
¯ v
isua
l acu
ity
Wea
k sy
stem
ic d
iure
tic. I
s a
sulp
hona
mid
ede
rivat
ive,
ther
efor
e su
lpho
nam
ide
side
effe
cts
(e.g
. ras
hes)
Blur
red
visi
on, c
iliar
y sp
asm
, itc
hing
and
lens
chan
ges
(with
chr
onic
use
)
MAP
5.2
. Gla
ucom
a
MAP
5.2
. G
lau
com
a
K30033_C005.indd 165 28/02/17 11:10 am
Oph
thal
mol
ogy
166
MAP
5.3
. C
atar
acts
Wha
t ar
e ca
tara
cts?
A ca
tara
ct is
opa
city
of t
he c
ryst
allin
e le
ns
and
is a
lead
ing
wor
ldw
ide
caus
e of
bl
indn
ess.
Ther
e ar
e m
any
diffe
rent
type
s of
cata
ract
s an
d th
ese
may
be
defin
ed b
ased
on
loca
tion
or c
ausa
tive
dise
ase.
Som
e ex
ampl
es a
re p
rovi
ded
belo
w.
Loca
tion
:•
Nuc
lear
cat
arac
t.•
Subc
apsu
lar c
atar
act.
• Co
rtic
al c
atar
act.
Ass
ocia
ted
wit
h di
seas
e:•
Diab
etes
: sno
wfla
ke c
atar
act.
• W
ilson
’s di
seas
e: s
unflo
wer
cat
arac
t.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s an
d ris
k fa
ctor
s fo
r the
dev
elop
men
t of c
atar
acts
. Th
ese
may
be
cong
enita
l or a
cqui
red.
Cong
enit
al:
• TO
RCHE
S in
fect
ions
(see
Map
2.6
, p. 5
0).
• G
enet
ic c
ause
s:
Tr
isom
ies.
Gal
acto
saem
ia.
Low
e’s
synd
rom
e.
Acq
uire
d: re
mem
ber
VITA
MIN
D:
V –
Vas
cula
r com
plic
atio
ns
(e.
g. h
yper
tens
ion)
.I
– In
fect
ion
(e.g
. onc
hoce
rcia
sis
[rive
r
blin
dnes
s]).
T –
Tra
uma
(e.g
. UV
expo
sure
, blu
nt fo
rce)
.A
– A
utoi
mm
une
(e.g
. hyp
opar
athy
roid
ism
),
Age
M –
Met
abol
ic (e
.g. d
iabe
tes
mel
litus
,
W
ilson
’s di
seas
e).
I –
Irra
diat
ion
N –
Nev
er fo
rget
dru
gs (e
.g. s
ide
effe
ct o
f
cor
ticos
tero
ids)
D –
Der
mat
olog
y (e
.g. e
czem
a).
Sym
ptom
s•
Leuk
ocor
ia.
• De
crea
sed
visu
al a
cuity
.•
Dipl
opia
.•
Gla
re.
• M
yopi
c sh
ift.
• N
ysta
gmus
(con
geni
tal c
atar
acts
).
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion
and
annu
al o
phth
alm
ic
rev
iew
.
Med
ical
:•
Trea
tmen
t of u
nder
lyin
g ca
use
(
e.g.
pen
icill
amin
e fo
r Wils
on’s
dis
ease
).
Surg
ical
:•
Phac
oem
ulsi
ficat
ion
may
onl
y be
per
form
ed
on
ripe
cat
arac
ts a
nd th
en a
n in
trao
cula
r
l
ens
is im
plan
ted.
Com
plic
atio
ns•
Blin
dnes
s.•
Com
plic
atio
ns o
f cat
arac
t sur
gery
(e
.g. r
etin
al d
etac
hmen
t).
MAP
5.3
. Cat
arac
ts
Inve
stig
atio
ns•
Oph
thal
mic
exa
min
atio
n.•
Bloo
d te
sts:
to u
ncov
er th
e un
derly
ing
caus
e;
FBC
, U&
E, L
FTs,
gluc
ose,
cho
lest
erol
leve
ls
+/–
spe
cific
test
s (e
.g. c
oppe
r stu
dies
for
W
ilson
’s di
seas
e or
urin
e am
ino
acid
s,
pho
spha
te a
nd c
alci
um fo
r Low
e’s
synd
rom
e).
K30033_C005.indd 166 28/02/17 11:10 am
Oph
thal
mol
ogy
167Wha
t ar
e ca
tara
cts?
A ca
tara
ct is
opa
city
of t
he c
ryst
allin
e le
ns
and
is a
lead
ing
wor
ldw
ide
caus
e of
bl
indn
ess.
Ther
e ar
e m
any
diffe
rent
type
s of
cata
ract
s an
d th
ese
may
be
defin
ed b
ased
on
loca
tion
or c
ausa
tive
dise
ase.
Som
e ex
ampl
es a
re p
rovi
ded
belo
w.
Loca
tion
:•
Nuc
lear
cat
arac
t.•
Subc
apsu
lar c
atar
act.
• Co
rtic
al c
atar
act.
Ass
ocia
ted
wit
h di
seas
e:•
Diab
etes
: sno
wfla
ke c
atar
act.
• W
ilson
’s di
seas
e: s
unflo
wer
cat
arac
t.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s an
d ris
k fa
ctor
s fo
r the
dev
elop
men
t of c
atar
acts
. Th
ese
may
be
cong
enita
l or a
cqui
red.
Cong
enit
al:
• TO
RCHE
S in
fect
ions
(see
Map
2.6
, p. 5
0).
• G
enet
ic c
ause
s:
Tr
isom
ies.
Gal
acto
saem
ia.
Low
e’s
synd
rom
e.
Acq
uire
d: re
mem
ber
VITA
MIN
D:
V –
Vas
cula
r com
plic
atio
ns
(e.
g. h
yper
tens
ion)
.I
– In
fect
ion
(e.g
. onc
hoce
rcia
sis
[rive
r
blin
dnes
s]).
T –
Tra
uma
(e.g
. UV
expo
sure
, blu
nt fo
rce)
.A
– A
utoi
mm
une
(e.g
. hyp
opar
athy
roid
ism
),
Age
M –
Met
abol
ic (e
.g. d
iabe
tes
mel
litus
,
W
ilson
’s di
seas
e).
I –
Irra
diat
ion
N –
Nev
er fo
rget
dru
gs (e
.g. s
ide
effe
ct o
f
cor
ticos
tero
ids)
D –
Der
mat
olog
y (e
.g. e
czem
a).
Sym
ptom
s•
Leuk
ocor
ia.
• De
crea
sed
visu
al a
cuity
.•
Dipl
opia
.•
Gla
re.
• M
yopi
c sh
ift.
• N
ysta
gmus
(con
geni
tal c
atar
acts
).
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion
and
annu
al o
phth
alm
ic
rev
iew
.
Med
ical
:•
Trea
tmen
t of u
nder
lyin
g ca
use
(
e.g.
pen
icill
amin
e fo
r Wils
on’s
dis
ease
).
Surg
ical
:•
Phac
oem
ulsi
ficat
ion
may
onl
y be
per
form
ed
on
ripe
cat
arac
ts a
nd th
en a
n in
trao
cula
r
l
ens
is im
plan
ted.
Com
plic
atio
ns•
Blin
dnes
s.•
Com
plic
atio
ns o
f cat
arac
t sur
gery
(e
.g. r
etin
al d
etac
hmen
t).
MAP
5.3
. Cat
arac
ts
Inve
stig
atio
ns•
Oph
thal
mic
exa
min
atio
n.•
Bloo
d te
sts:
to u
ncov
er th
e un
derly
ing
caus
e;
FBC
, U&
E, L
FTs,
gluc
ose,
cho
lest
erol
leve
ls
+/–
spe
cific
test
s (e
.g. c
oppe
r stu
dies
for
W
ilson
’s di
seas
e or
urin
e am
ino
acid
s,
pho
spha
te a
nd c
alci
um fo
r Low
e’s
synd
rom
e).
MAP
5.3
. C
atar
acts
K30033_C005.indd 167 28/02/17 11:10 am
Oph
thal
mol
ogy
168
Tabl
e 5.
2. R
ed e
ye
TABL
E 5.
2. R
ed e
ye. T
here
are
man
y ca
uses
of
red
eye.
The
se a
re o
utlin
ed b
elow
.
Dis
ease
Caus
eFe
atur
esIn
vest
igat
ions
Trea
tmen
t
Acut
e an
gle
clos
ure
glau
com
aSe
e M
ap 5
.2 (p
. 164
)Se
e M
ap 5
.2 (p
. 164
)Se
e M
ap 5
.2 (p
. 164
)Se
e M
ap 5
.2 (p
. 164
)
Ante
rior u
veiti
s As
soci
ated
with
HLA
-B27
Som
e ex
ampl
es in
clud
e: A
BCS:
A –
Ank
ylos
ing
spon
dylit
is, ju
veni
le
idio
path
ic A
rthr
itis,
psor
iatic
Art
hriti
s, re
activ
e A
rthr
itis
B –
Behç
et’s
dise
ase
C –
Croh
n’s
dise
ase
S –
Sarc
oido
sis, S
yste
mic
lupu
s ery
them
atos
us
• Pa
infu
l red
eye
• Ac
ute
onse
t•
Phot
opho
bia
• Bl
urre
d vi
sion
• Fi
xed
oval
pup
il
Inve
stig
atio
ns to
est
ablis
h un
derly
ing
caus
e
Fund
osco
py
Radi
olog
y: x
-ray
may
be
usef
ul in
cas
es o
f art
hriti
s
Cons
erva
tive
:•
Patie
nt e
duca
tion
Med
ical
:•
Trea
tmen
t of u
nder
lyin
g ca
use
• Sp
ecifi
c tr
eatm
ent o
f ant
erio
r uv
eitis
: cor
ticos
tero
ids
and
cycl
ople
gics
may
be
used
Scle
ritis
Asso
ciat
ed w
ith a
utoi
mm
une
dise
ases
su
ch a
s rh
eum
atoi
d ar
thrit
is a
nd S
jögr
en’s
synd
rom
e
• Pa
infu
l red
eye
• Pa
in w
orse
on
mov
emen
t•
Dim
inis
hed
visu
al
acui
ty
Inve
stig
atio
ns to
est
ablis
h un
derly
ing
caus
e
Full
opht
halm
ic
exam
inat
ion
Diffe
rent
iate
scle
ritis
from
ep
iscle
ritis
by a
dmin
ister
ing
phen
ylep
hrin
e ey
e dr
ops.
In e
pisc
lerit
is bl
ood
vess
els
turn
pal
e
Cons
erva
tive
:•
Patie
nt e
duca
tion
Med
ical
:•
Trea
tmen
t of u
nder
lyin
g ca
use
• Sp
ecifi
c tr
eatm
ent o
f scl
eriti
s: N
SAID
s, co
rtic
oste
roid
s
K30033_C005.indd 168 28/02/17 11:10 am
Oph
thal
mol
ogy
169Conj
unct
iviti
s Ba
cter
ial:
•St
aphy
loco
ccus
spp
.•
Stre
ptoc
occu
s sp
p.•
Chla
myd
iatr
acho
mat
is
Vira
l:•
Influ
enza
• HS
V•
VZV
Alle
rgic
Aut
oim
mun
e:
• As
soci
ated
with
con
ditio
ns s
uch
as
reac
tive
arth
ritis
Occ
upat
iona
l exp
osur
e:•
Expo
sure
to c
hem
ical
s
• Itc
hy, r
ed e
ye•
Bact
eria
l: pu
rule
nt, s
ticky
di
scha
rge
• Vi
ral:
clea
r di
scha
rge
Clin
ical
dia
gnos
is
Cons
erva
tive
:•
Patie
nt e
duca
tion
Med
ical
:•
Bact
eria
l: an
tibio
tic e
ye d
rops
• Vi
ral:
self-
limiti
ng
• Al
lerg
ic: a
ntih
ista
min
es•
Auto
imm
une:
art
ifici
al te
ars
and
trea
tmen
t of u
nder
lyin
g ca
use
• O
ccup
atio
nal e
xpos
ure:
irr
igat
ion
of c
hem
ical
with
sa
line
solu
tion
Subc
onju
nctiv
al
haem
orrh
age
Rem
embe
r as
ABC
DE:
A –
Acu
te h
aem
orrh
agic
con
junc
tiviti
sB
– in
crea
sed
Bloo
d pr
essu
reC
– Co
ughi
ng
D –
Dis
orde
rs o
f coa
gula
tion
E –
Eye
trau
ma
• Re
d ey
eCl
inic
al d
iagn
osis
Cons
erva
tive
:•
Patie
nt e
duca
tion
• Ad
vise
that
it lo
oks
mor
e al
arm
ing
than
it is
Med
ical
:•
Self-
limiti
ng c
ondi
tion
• Ar
tifici
al te
ars
may
som
etim
es
be g
iven
Tabl
e 5.
2. R
ed e
ye
K30033_C005.indd 169 28/02/17 11:10 am
Oph
thal
mol
ogy
170
Tabl
e 5.
3. D
iab
etic
eye
dis
ease
TABL
E 5.
3. D
iabe
tic
eye
dise
ase.
Thi
s is
a m
icro
vasc
ular
com
plic
atio
n of
dia
bete
s m
ellit
us.
Path
ophy
siol
ogy:
hyp
ergl
ycae
mia
⇒ v
ascu
lar p
eric
yte
loss
and
end
othe
lial d
amag
e ⇒
mic
roan
eury
sm fo
rmat
ion
⇒ re
tinal
isch
aem
ia ⇒
st
imul
atio
n of
gro
wth
fact
ors
⇒ n
eova
scul
ariz
atio
n.Th
e fe
atur
es th
at a
re c
hara
cter
istic
of e
ach
phas
e of
dia
betic
retin
opat
hy a
re e
xplo
red
belo
w.
Phas
eFe
atur
e
Back
grou
ndRe
mem
ber a
s A
BCD
E:A
– m
icro
Ane
urym
s (d
ots)
B –
Blot
hae
mor
rhag
es <
3C
– Co
tton
woo
l spo
ts (o
edem
a fro
m re
tinal
infa
rcts
)D
– v
enou
s D
ilata
tion
E –
har
d Ex
udat
es
Pre-
prol
ifera
tive
Rem
embe
r as
ABC
D:
A –
mic
roA
neur
yms
(dot
s). M
ore
than
bac
kgro
und
retin
opat
hy
B –
veno
us B
eadi
ng a
nd lo
opin
gC
– Co
tton
woo
l spo
ts >
5D
– D
ark
clus
ter h
aem
orrh
ages
Prol
ifera
tive
Neo
vasc
ular
izat
ion
Fibr
ous
prol
ifera
tion
Haem
orrh
ages
Adva
nced
Retin
al d
etac
hmen
tRu
beos
is ir
idis
Neo
vasc
ular
gla
ucom
a
Mac
ulop
athy
As a
bove
but
invo
lves
the
mac
ular
K30033_C005.indd 170 28/02/17 11:10 am
Chap
ter S
ix E
ar, n
ose
and
thro
at
MAP
6.1
a H
eari
ng
loss
(fl
ow
ch
art)
17
2
MAP
6.1
b H
eari
ng
loss
(sp
ecifi
c co
nd
itio
ns)
17
4
MAP
6.2
B
enig
n p
aro
xysm
al p
osi
tio
nal
ve
rtig
o (
BPP
V)
176
MAP
6.3
Ep
ista
xis
178
MAP
6.4
N
aso
ph
aryn
gea
l can
cer
180
MAP
6.5
O
rop
har
yng
eal c
ance
r 18
1
MAP
6.6
La
ryn
gea
l can
cer
182
Ear,
nose
and
thr
oat
171
K30033_C006.indd 171 28/02/17 11:13 am
172
Ear,
nose
and
thr
oat
MAP
6.1
a. H
eari
ng
loss
(fl
ow
ch
art)
Caus
esM
ay b
e su
bdiv
ided
into
con
geni
tal a
nd a
cqui
red.
Cong
enit
al:
• In
fect
ion
(e.g
. rub
ella
).•
Gen
etic
s (e
.g. A
lpor
t’s s
yndr
ome)
.
Acq
uire
d•
Pres
bycu
sis.
• In
fect
ion
(e.g
. men
ingi
tis, m
easl
es).
• Tr
aum
a (e
.g. n
oise
inju
ry, h
ead
trau
ma)
.•
Tum
our (
e.g.
aco
ustic
neu
rom
a).
• O
toto
xic
drug
s (e
.g. g
enta
mic
in, f
uros
emid
e,
cisp
latin
).•
Mén
ière
’s di
seas
e (s
ee M
ap 6
.1b,
p. 1
74).
MAP
6.1
a. H
eari
ng lo
ss (f
low
cha
rt)
Cond
uctiv
e he
arin
g lo
ss
Inne
r ear
Caus
esM
ay b
e su
bdiv
ided
into
con
geni
tal a
nd a
cqui
red.
Cong
enit
al:
• At
resi
a.•
Abno
rmal
ities
of t
he o
ssic
les.
• O
tosc
lero
sis.
Acq
uire
d•
Wax
.•
Otit
is e
xter
na.
• G
lue
ear (
see
Map
6.2
, p. 1
76).
• Pe
rfora
ted
drum
.
Sens
orin
eura
l hea
ring
loss
Out
er e
arM
iddl
e ea
r
K30033_C006.indd 172 28/02/17 11:13 am
Ear,
nose
and
thr
oat
173
MAP
6.1
a. H
eari
ng
loss
(fl
ow
ch
art)
Caus
esM
ay b
e su
bdiv
ided
into
con
geni
tal a
nd a
cqui
red.
Cong
enit
al:
• In
fect
ion
(e.g
. rub
ella
).•
Gen
etic
s (e
.g. A
lpor
t’s s
yndr
ome)
.
Acq
uire
d•
Pres
bycu
sis.
• In
fect
ion
(e.g
. men
ingi
tis, m
easl
es).
• Tr
aum
a (e
.g. n
oise
inju
ry, h
ead
trau
ma)
.•
Tum
our (
e.g.
aco
ustic
neu
rom
a).
• O
toto
xic
drug
s (e
.g. g
enta
mic
in, f
uros
emid
e,
cisp
latin
).•
Mén
ière
’s di
seas
e (s
ee M
ap 6
.1b,
p. 1
74).
MAP
6.1
a. H
eari
ng lo
ss (f
low
cha
rt)
Cond
uctiv
e he
arin
g lo
ss
Inne
r ear
Caus
esM
ay b
e su
bdiv
ided
into
con
geni
tal a
nd a
cqui
red.
Cong
enit
al:
• At
resi
a.•
Abno
rmal
ities
of t
he o
ssic
les.
• O
tosc
lero
sis.
Acq
uire
d•
Wax
.•
Otit
is e
xter
na.
• G
lue
ear (
see
Map
6.2
, p. 1
76).
• Pe
rfora
ted
drum
.
Sens
orin
eura
l hea
ring
loss
Out
er e
arM
iddl
e ea
r
K30033_C006.indd 173 28/02/17 11:13 am
Ear,
nose
and
thr
oat
174
MAP
6.1
b. H
eari
ng
loss
(sp
ecifi
c co
nd
itio
ns)
Glu
e ea
r
Wha
t is
glu
e ea
r?G
lue
ear,
also
kno
wn
as o
titis
med
ia w
ith
effu
sion
, is
a co
llect
ion
of fl
uid
with
in th
e m
iddl
e ea
r. Th
is fl
uid
is th
ough
t to
occu
r due
to
dysf
unct
iona
l Eus
tach
ian
tube
s, w
hich
cre
ate
nega
tive
pres
sure
. It o
ccur
s in
mal
es m
ore
than
fe
mal
es.
Caus
eTh
e ex
act c
ause
is u
nkno
wn.
It o
ften
occu
rs
seco
ndar
y to
a v
iral u
pper
resp
irato
ry tr
act
infe
ctio
n or
acu
te b
acte
rial o
titis
med
ia.
Risk
fact
ors:
rem
embe
r as
EARS
:E
– Eu
stac
hian
tube
abn
orm
aliti
es
(e.g
. in
Dow
n’s
synd
rom
e)A
– A
deno
ids
(enl
arge
d)R
– Re
spira
tory
infe
ctio
nsS
– Sm
okin
g (u
sual
ly p
aren
ts),
Seas
on (w
inte
r)
Sym
ptom
sM
ay v
ary
depe
ndin
g on
age
of c
hild
/adu
lt.
Bulg
ing
drum
of v
aryi
ng c
olou
r. A
fluid
leve
l m
ay b
e pr
esen
t.
Inve
stig
atio
nsAu
diog
ram
s (c
ondu
ctiv
e de
fect
s), i
mpe
danc
e au
diom
etry
.
Trea
tmen
tCo
nser
vati
ve:
• O
ften
self-
limiti
ng.
• He
arin
g ai
ds o
nly
if bi
late
ral s
ympt
oms.
Med
ical
:•
NIC
E do
es n
ot re
com
men
d an
tibio
tics.
Surg
ical
:•
Myr
ingo
tom
y.•
Gro
mm
ets
+/–
ade
noid
ecto
my.
Mén
ière
’s d
isea
se
Wha
t is
Mén
ière
’s d
isea
se?
Mén
ière
’s di
seas
e, a
lso
know
n as
end
olym
phat
ic h
ydro
ps, i
s a
caus
e of
sen
sorin
eura
l hea
ring
loss
. It i
s th
ough
t to
be c
ause
d by
the
dila
tatio
n an
d ex
cess
ive
fluid
colle
ctio
n w
ithin
the
endo
lym
phat
ic s
pace
s. It
is m
ore
com
mon
in fe
mal
es th
an m
ales
and
pre
sent
s m
ore
com
mon
ly in
mid
dle
aged
adu
lts.
Caus
e. T
he e
xact
cau
se is
unk
now
n.
Sym
ptom
s. P
rese
nts
with
a c
hara
cter
istic
tria
d:1.
Ver
tigo.
2. L
ow p
itch
tinni
tus.
3. S
enso
rineu
ral h
earin
g lo
ss.
Oth
er fe
atur
es in
clud
e au
ral f
ulln
ess,
a po
sitiv
e Ro
mbe
rg te
st a
nd n
ysta
gmus
.
Inve
stig
atio
ns. C
linic
al d
iagn
osis
but
als
o pe
rform
MRI
of h
ead
to ru
le o
ut s
pace
-occ
upyi
ng le
sion
.
Trea
tmen
tCo
nser
vati
ve: p
atie
nt e
duca
tion.
Med
ical
: acu
te a
ttac
ks –
cyc
lizin
e or
pro
chlo
rper
azin
e; lo
ng-t
erm
trea
tmen
t – b
etah
istin
e or
thia
zide
dr
ugs;
trea
t sym
ptom
s (e
.g. v
omiti
ng w
ith p
roch
lorp
eraz
ine)
.
Surg
ical
: end
olym
phat
ic s
hunt
s; ot
otox
ic d
rugs
.
Oto
scle
rosi
s
Wha
t is
oto
scle
rosi
s? T
his
is a
n au
toso
mal
dom
inan
t con
ditio
n th
at ty
pica
lly a
ffect
s fe
mal
es a
ged
20–4
0 ye
ars.
Caus
es. H
ered
itary
. Nor
mal
oss
icle
bon
e is
repl
aced
by
vasc
ular
bon
e, w
hich
is s
pong
y.
Sym
ptom
s. Co
nduc
tive
hear
ing
loss
, tin
nitu
s, fla
min
go ti
nge
appe
aran
ce to
the
tym
pani
c m
embr
ane
(Sch
war
t’s s
ign)
.
Inve
stig
atio
n. A
udio
met
ry.
Trea
tmen
t:•
Cons
erva
tive:
pat
ient
edu
catio
n.•
Med
ical
: sod
ium
fluo
ride.
• Su
rgic
al: s
tape
dect
omy.MAP
6.1
b. H
eari
ng lo
ss (s
peci
fic
cond
itio
ns)
K30033_C006.indd 174 28/02/17 11:13 am
Ear,
nose
and
thr
oat
175
MAP
6.1
b. H
eari
ng
loss
(sp
ecifi
c co
nd
itio
ns)
Glu
e ea
r
Wha
t is
glu
e ea
r?G
lue
ear,
also
kno
wn
as o
titis
med
ia w
ith
effu
sion
, is
a co
llect
ion
of fl
uid
with
in th
e m
iddl
e ea
r. Th
is fl
uid
is th
ough
t to
occu
r due
to
dysf
unct
iona
l Eus
tach
ian
tube
s, w
hich
cre
ate
nega
tive
pres
sure
. It o
ccur
s in
mal
es m
ore
than
fe
mal
es.
Caus
eTh
e ex
act c
ause
is u
nkno
wn.
It o
ften
occu
rs
seco
ndar
y to
a v
iral u
pper
resp
irato
ry tr
act
infe
ctio
n or
acu
te b
acte
rial o
titis
med
ia.
Risk
fact
ors:
rem
embe
r as
EARS
:E
– Eu
stac
hian
tube
abn
orm
aliti
es
(e.g
. in
Dow
n’s
synd
rom
e)A
– A
deno
ids
(enl
arge
d)R
– Re
spira
tory
infe
ctio
nsS
– Sm
okin
g (u
sual
ly p
aren
ts),
Seas
on (w
inte
r)
Sym
ptom
sM
ay v
ary
depe
ndin
g on
age
of c
hild
/adu
lt.
Bulg
ing
drum
of v
aryi
ng c
olou
r. A
fluid
leve
l m
ay b
e pr
esen
t.
Inve
stig
atio
nsAu
diog
ram
s (c
ondu
ctiv
e de
fect
s), i
mpe
danc
e au
diom
etry
.
Trea
tmen
tCo
nser
vati
ve:
• O
ften
self-
limiti
ng.
• He
arin
g ai
ds o
nly
if bi
late
ral s
ympt
oms.
Med
ical
:•
NIC
E do
es n
ot re
com
men
d an
tibio
tics.
Surg
ical
:•
Myr
ingo
tom
y.•
Gro
mm
ets
+/–
ade
noid
ecto
my.
Mén
ière
’s d
isea
se
Wha
t is
Mén
ière
’s d
isea
se?
Mén
ière
’s di
seas
e, a
lso
know
n as
end
olym
phat
ic h
ydro
ps, i
s a
caus
e of
sen
sorin
eura
l hea
ring
loss
. It i
s th
ough
t to
be c
ause
d by
the
dila
tatio
n an
d ex
cess
ive
fluid
colle
ctio
n w
ithin
the
endo
lym
phat
ic s
pace
s. It
is m
ore
com
mon
in fe
mal
es th
an m
ales
and
pre
sent
s m
ore
com
mon
ly in
mid
dle
aged
adu
lts.
Caus
e. T
he e
xact
cau
se is
unk
now
n.
Sym
ptom
s. P
rese
nts
with
a c
hara
cter
istic
tria
d:1.
Ver
tigo.
2. L
ow p
itch
tinni
tus.
3. S
enso
rineu
ral h
earin
g lo
ss.
Oth
er fe
atur
es in
clud
e au
ral f
ulln
ess,
a po
sitiv
e Ro
mbe
rg te
st a
nd n
ysta
gmus
.
Inve
stig
atio
ns. C
linic
al d
iagn
osis
but
als
o pe
rform
MRI
of h
ead
to ru
le o
ut s
pace
-occ
upyi
ng le
sion
.
Trea
tmen
tCo
nser
vati
ve: p
atie
nt e
duca
tion.
Med
ical
: acu
te a
ttac
ks –
cyc
lizin
e or
pro
chlo
rper
azin
e; lo
ng-t
erm
trea
tmen
t – b
etah
istin
e or
thia
zide
dr
ugs;
trea
t sym
ptom
s (e
.g. v
omiti
ng w
ith p
roch
lorp
eraz
ine)
.
Surg
ical
: end
olym
phat
ic s
hunt
s; ot
otox
ic d
rugs
.
Oto
scle
rosi
s
Wha
t is
oto
scle
rosi
s? T
his
is a
n au
toso
mal
dom
inan
t con
ditio
n th
at ty
pica
lly a
ffect
s fe
mal
es a
ged
20–4
0 ye
ars.
Caus
es. H
ered
itary
. Nor
mal
oss
icle
bon
e is
repl
aced
by
vasc
ular
bon
e, w
hich
is s
pong
y.
Sym
ptom
s. Co
nduc
tive
hear
ing
loss
, tin
nitu
s, fla
min
go ti
nge
appe
aran
ce to
the
tym
pani
c m
embr
ane
(Sch
war
t’s s
ign)
.
Inve
stig
atio
n. A
udio
met
ry.
Trea
tmen
t:•
Cons
erva
tive:
pat
ient
edu
catio
n.•
Med
ical
: sod
ium
fluo
ride.
• Su
rgic
al: s
tape
dect
omy.MAP
6.1
b. H
eari
ng lo
ss (s
peci
fic
cond
itio
ns)
K30033_C006.indd 175 28/02/17 11:13 am
Ear,
nose
and
thr
oat
176
MAP
6.2
. B
enig
n p
aro
xysm
al p
osi
tio
nal
ver
tig
o (
BPP
V)
Com
plic
atio
n•
Dizz
ines
s, th
eref
ore
incr
ease
d ris
k of
fa
lls.
Sym
ptom
s•
Vert
igo.
• N
ause
a.•
Ligh
thea
dedn
ess.
• Im
bala
nce.
• N
ysta
gmus
.
The
abov
e sy
mpt
oms
are
near
ly a
lway
s pr
ecip
itate
d by
a s
udde
n ch
ange
in h
ead
posi
tion,
suc
h as
lyin
g do
wn.
Inve
stig
atio
nsA
diag
nosi
s is
mad
e de
pend
ing
on
sym
ptom
s, pa
tient
his
tory
and
exa
min
atio
n.
• Di
x–Ha
llpik
e te
st –
a p
ositi
ve te
st
stim
ulat
es b
urst
s of
nys
tagm
us.
• U
nder
take
ves
tibul
ar a
nd a
udito
ry te
sts.
Trea
tmen
tCo
nser
vati
ve:
• Pa
tient
edu
catio
n –
said
to b
e a
self-
limiti
ng c
ondi
tion
that
may
reso
lve
in ~
2 m
onth
s af
ter o
nset
.•
Eple
y m
anoe
uvre
– a
ttem
pts
to re
posi
tion
the
disp
lace
d ot
ocon
ia.
Med
ical
:•
Anti-
emet
ics
for n
ause
a if
seve
re.
Surg
ical
:•
Very
rare
ly p
erfo
rmed
and
sho
uld
not b
e co
nsid
ered
un
less
the
abov
e m
etho
ds h
ave
faile
d. E
xam
ples
incl
ude
po
ster
ior c
anal
plu
ggin
g.
Wha
t is
ben
ign
paro
xysm
al p
osit
iona
l ver
tigo
?Th
is p
atho
logy
of t
he in
ner e
ar re
sults
in th
e su
dden
ons
et o
f na
usea
, ver
tigo
and
nyst
agm
us fo
llow
ing
cert
ain
mov
emen
ts
of th
e he
ad.
Caus
esBP
PV is
thou
ght t
o be
cau
sed
by th
e di
spla
cem
ent o
f ot
ocon
ia (s
mal
l cal
cium
car
bona
te c
ryst
als)
from
the
utric
le
into
the
sem
icirc
ular
can
als.
Mov
emen
t of t
hese
cry
stal
s al
ong
the
cana
l in
ques
tion
stim
ulat
es th
e se
nsat
ion
of
rota
tion.
Risk
fact
ors
Ther
e ar
e m
any
fact
ors
that
con
trib
ute
to th
e di
spla
cem
ent o
f ot
ocon
ia. T
he c
omm
ones
t is
head
inju
ry, b
ut o
ther
s in
clud
e in
fect
ion
and
dege
nera
tion
attr
ibut
ed to
old
age
.
MAP
6.2
. Ben
ign
paro
xysm
al p
osit
iona
l ver
tigo
(BPP
V)
K30033_C006.indd 176 28/02/17 11:13 am
Ear,
nose
and
thr
oat
177
MAP
6.2
. B
enig
n p
aro
xysm
al p
osi
tio
nal
ver
tig
o (
BPP
V)
Com
plic
atio
n•
Dizz
ines
s, th
eref
ore
incr
ease
d ris
k of
fa
lls.
Sym
ptom
s•
Vert
igo.
• N
ause
a.•
Ligh
thea
dedn
ess.
• Im
bala
nce.
• N
ysta
gmus
.
The
abov
e sy
mpt
oms
are
near
ly a
lway
s pr
ecip
itate
d by
a s
udde
n ch
ange
in h
ead
posi
tion,
suc
h as
lyin
g do
wn.
Inve
stig
atio
nsA
diag
nosi
s is
mad
e de
pend
ing
on
sym
ptom
s, pa
tient
his
tory
and
exa
min
atio
n.
• Di
x–Ha
llpik
e te
st –
a p
ositi
ve te
st
stim
ulat
es b
urst
s of
nys
tagm
us.
• U
nder
take
ves
tibul
ar a
nd a
udito
ry te
sts.
Trea
tmen
tCo
nser
vati
ve:
• Pa
tient
edu
catio
n –
said
to b
e a
self-
limiti
ng c
ondi
tion
that
may
reso
lve
in ~
2 m
onth
s af
ter o
nset
.•
Eple
y m
anoe
uvre
– a
ttem
pts
to re
posi
tion
the
disp
lace
d ot
ocon
ia.
Med
ical
:•
Anti-
emet
ics
for n
ause
a if
seve
re.
Surg
ical
:•
Very
rare
ly p
erfo
rmed
and
sho
uld
not b
e co
nsid
ered
un
less
the
abov
e m
etho
ds h
ave
faile
d. E
xam
ples
incl
ude
po
ster
ior c
anal
plu
ggin
g.
Wha
t is
ben
ign
paro
xysm
al p
osit
iona
l ver
tigo
?Th
is p
atho
logy
of t
he in
ner e
ar re
sults
in th
e su
dden
ons
et o
f na
usea
, ver
tigo
and
nyst
agm
us fo
llow
ing
cert
ain
mov
emen
ts
of th
e he
ad.
Caus
esBP
PV is
thou
ght t
o be
cau
sed
by th
e di
spla
cem
ent o
f ot
ocon
ia (s
mal
l cal
cium
car
bona
te c
ryst
als)
from
the
utric
le
into
the
sem
icirc
ular
can
als.
Mov
emen
t of t
hese
cry
stal
s al
ong
the
cana
l in
ques
tion
stim
ulat
es th
e se
nsat
ion
of
rota
tion.
Risk
fact
ors
Ther
e ar
e m
any
fact
ors
that
con
trib
ute
to th
e di
spla
cem
ent o
f ot
ocon
ia. T
he c
omm
ones
t is
head
inju
ry, b
ut o
ther
s in
clud
e in
fect
ion
and
dege
nera
tion
attr
ibut
ed to
old
age
.
MAP
6.2
. Ben
ign
paro
xysm
al p
osit
iona
l ver
tigo
(BPP
V)
K30033_C006.indd 177 28/02/17 11:13 am
Ear,
nose
and
thr
oat
178
MAP
6.3
. Ep
ista
xis
Trea
tmen
t
Cons
erva
tive
:•
ABCD
E –
emer
genc
y ca
re.
• Pi
nch
flesh
y pa
rts
of th
e no
se to
geth
er a
nd
tilt h
ead
forw
ard.
Pla
ce a
n ic
e pa
ck o
n th
e
brid
ge o
f the
nos
e or
the
back
of t
he n
eck.
Do
this
for 2
0–30
min
utes
.
Med
ical
:•
Ante
rior e
pist
axis
:
Ad
rena
line
solu
tion
to c
lean
the
nose
and
caus
e va
soco
nstr
ictio
n. R
eass
ess
to
id
entif
y bl
eed.
Silv
er n
itrat
e st
icks
– u
sed
for n
asal
caut
ery
if bl
eedi
ng p
oint
cle
arly
iden
tifie
d. A
pply
to th
is p
oint
and
a
sm
all a
rea
arou
nd it
. Cau
tion
: do
not
use
bila
tera
lly s
ince
ther
e is
a ri
sk o
f
na
sal p
erfo
ratio
n. A
lway
s pr
escr
ibe
Nas
eptin
cre
am a
fter c
aute
ry. T
his
cons
ists
of n
eom
ycin
and
chlo
ram
phen
icol
. Con
trai
ndic
atio
ns:
pean
ut a
llerg
y.
If
blee
ding
stil
l per
fuse
afte
r cau
tery
,
th
en c
onsi
der n
asal
pac
king
with
eith
er
(1
) Rap
id R
hino
®, (
2) M
eroc
el®
or
(3) B
IPP
gauz
e.
• Po
ster
ior e
pist
axis
ENT
team
requ
ired
to p
oste
riorly
pack
age
the
nasa
l cav
ity w
ith a
Fol
ey
ca
thet
er. A
nter
ior p
acki
ng is
app
lied
as
w
ell.
Surg
ical
:•
Refe
r to
ENT
team
for s
phen
opal
atin
e ar
tery
a
blat
ion.
Sym
ptom
s•
Haem
orrh
age
of v
aryi
ng s
ever
ity fr
om o
ne o
r
both
nos
trils
.•
Pres
ence
of b
lood
in th
e or
opha
rynx
.
Com
plic
atio
ns•
Com
prom
ise
to a
irway
.•
Anae
mia
.
Inve
stig
atio
nsIt
is e
ssen
tial i
n al
l cas
es to
exa
min
e bo
th n
ostr
ils w
ith a
nas
al s
pecu
lum
and
a p
en to
rch
to id
entif
y w
heth
er b
leed
ing
is u
nila
tera
l or b
ilate
ral,
as w
ell a
s id
entif
ying
the
sour
ce o
f the
ble
ed. I
t is
also
vita
l to
asse
ss w
heth
er p
ost-
nasa
l ble
edin
g ha
s co
mpr
omis
ed b
reat
hing
.
In m
ost a
cute
cas
es s
peci
fic te
sts
are
unne
cess
ary.
How
ever
, rec
urre
nt c
ases
requ
ire:
• Bl
ood
test
s: FB
C, c
oagu
latio
n st
udie
s.•
Radi
olog
y: C
T (if
mal
igna
ncy
susp
ecte
d).
• O
ther
: nas
opha
ryng
osco
py (i
f mal
igna
ncy
susp
ecte
d).
Wha
t is
epi
stax
is?
Epis
taxi
s is
the
term
use
d fo
r nos
eble
ed. I
t is
very
co
mm
on a
nd th
ere
are
two
maj
or ty
pes:
1. A
nter
ior e
pist
axis
: mos
t com
mon
. Ofte
n
pres
ents
as
unila
tera
l nas
al b
leed
ing
and
oc
curs
from
Kie
ssel
bach
’s pl
exus
(a
lso
know
n as
Litt
le’s
area
).2.
Pos
terio
r epi
stax
is: l
ess
com
mon
but
mor
e
diffi
cult
to m
anag
e. P
rese
nts
with
bila
tera
l
nasa
l ble
edin
g an
d al
so p
ost-
nasa
l ble
edin
g
into
the
orop
hary
nx.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s of
nos
eble
eds
rang
ing
from
the
idio
path
ic to
fore
ign
bodi
es a
nd
tum
ours
. Som
e ca
uses
are
list
ed b
elow
. Re
mem
ber a
s EP
ISTA
XIS:
E –
Epis
taxi
s pa
st h
isto
ry (e
.g. a
nato
mic
al
defo
rmiti
es o
r her
edita
ry h
aem
orrh
agic
tela
ngie
ctas
ia)
P –
Punc
h to
the
face
/trau
ma
I –
Infla
mm
ator
y re
actio
ns (e
.g. r
ecen
t upp
er
resp
irato
ry tr
act i
nfec
tion)
S –
Syst
emic
fact
ors
(e.g
. hyp
erte
nsio
n)T
– Th
rom
bocy
tope
nia
A –
Alc
ohol
– c
ause
s va
sodi
latio
nX
– fa
ctor
X d
efic
ienc
yI
– In
tran
asal
tum
ours
S –
Spra
ys (e
.g. p
rolo
nged
use
of n
asal
ste
roid
s)
Risk
fact
ors
• Tr
aum
a.•
Antic
oagu
latio
n m
edic
atio
n.•
Hype
rten
sion
.•
Rece
nt u
pper
resp
irato
ry tr
act i
nfec
tion.
• Hi
stor
y of
epi
stax
is.•
Drug
s –
coca
ine
use.
MAP
6.3
. Epi
stax
is
ppyy
ggpp
gg
K30033_C006.indd 178 28/02/17 11:13 am
Ear,
nose
and
thr
oat
179
MAP
6.3
. Ep
ista
xis
Trea
tmen
t
Cons
erva
tive
:•
ABCD
E –
emer
genc
y ca
re.
• Pi
nch
flesh
y pa
rts
of th
e no
se to
geth
er a
nd
tilt h
ead
forw
ard.
Pla
ce a
n ic
e pa
ck o
n th
e
brid
ge o
f the
nos
e or
the
back
of t
he n
eck.
Do
this
for 2
0–30
min
utes
.
Med
ical
:•
Ante
rior e
pist
axis
:
Ad
rena
line
solu
tion
to c
lean
the
nose
and
caus
e va
soco
nstr
ictio
n. R
eass
ess
to
id
entif
y bl
eed.
Silv
er n
itrat
e st
icks
– u
sed
for n
asal
caut
ery
if bl
eedi
ng p
oint
cle
arly
iden
tifie
d. A
pply
to th
is p
oint
and
a
sm
all a
rea
arou
nd it
. Cau
tion
: do
not
use
bila
tera
lly s
ince
ther
e is
a ri
sk o
f
na
sal p
erfo
ratio
n. A
lway
s pr
escr
ibe
Nas
eptin
cre
am a
fter c
aute
ry. T
his
cons
ists
of n
eom
ycin
and
chlo
ram
phen
icol
. Con
trai
ndic
atio
ns:
pean
ut a
llerg
y.
If
blee
ding
stil
l per
fuse
afte
r cau
tery
,
th
en c
onsi
der n
asal
pac
king
with
eith
er
(1
) Rap
id R
hino
®, (
2) M
eroc
el®
or
(3) B
IPP
gauz
e.
• Po
ster
ior e
pist
axis
ENT
team
requ
ired
to p
oste
riorly
pack
age
the
nasa
l cav
ity w
ith a
Fol
ey
ca
thet
er. A
nter
ior p
acki
ng is
app
lied
as
w
ell.
Surg
ical
:•
Refe
r to
ENT
team
for s
phen
opal
atin
e ar
tery
a
blat
ion.
Sym
ptom
s•
Haem
orrh
age
of v
aryi
ng s
ever
ity fr
om o
ne o
r
both
nos
trils
.•
Pres
ence
of b
lood
in th
e or
opha
rynx
.
Com
plic
atio
ns•
Com
prom
ise
to a
irway
.•
Anae
mia
.
Inve
stig
atio
nsIt
is e
ssen
tial i
n al
l cas
es to
exa
min
e bo
th n
ostr
ils w
ith a
nas
al s
pecu
lum
and
a p
en to
rch
to id
entif
y w
heth
er b
leed
ing
is u
nila
tera
l or b
ilate
ral,
as w
ell a
s id
entif
ying
the
sour
ce o
f the
ble
ed. I
t is
also
vita
l to
asse
ss w
heth
er p
ost-
nasa
l ble
edin
g ha
s co
mpr
omis
ed b
reat
hing
.
In m
ost a
cute
cas
es s
peci
fic te
sts
are
unne
cess
ary.
How
ever
, rec
urre
nt c
ases
requ
ire:
• Bl
ood
test
s: FB
C, c
oagu
latio
n st
udie
s.•
Radi
olog
y: C
T (if
mal
igna
ncy
susp
ecte
d).
• O
ther
: nas
opha
ryng
osco
py (i
f mal
igna
ncy
susp
ecte
d).
Wha
t is
epi
stax
is?
Epis
taxi
s is
the
term
use
d fo
r nos
eble
ed. I
t is
very
co
mm
on a
nd th
ere
are
two
maj
or ty
pes:
1. A
nter
ior e
pist
axis
: mos
t com
mon
. Ofte
n
pres
ents
as
unila
tera
l nas
al b
leed
ing
and
oc
curs
from
Kie
ssel
bach
’s pl
exus
(a
lso
know
n as
Litt
le’s
area
).2.
Pos
terio
r epi
stax
is: l
ess
com
mon
but
mor
e
diffi
cult
to m
anag
e. P
rese
nts
with
bila
tera
l
nasa
l ble
edin
g an
d al
so p
ost-
nasa
l ble
edin
g
into
the
orop
hary
nx.
Caus
esTh
ere
are
man
y di
ffere
nt c
ause
s of
nos
eble
eds
rang
ing
from
the
idio
path
ic to
fore
ign
bodi
es a
nd
tum
ours
. Som
e ca
uses
are
list
ed b
elow
. Re
mem
ber a
s EP
ISTA
XIS:
E –
Epis
taxi
s pa
st h
isto
ry (e
.g. a
nato
mic
al
defo
rmiti
es o
r her
edita
ry h
aem
orrh
agic
tela
ngie
ctas
ia)
P –
Punc
h to
the
face
/trau
ma
I –
Infla
mm
ator
y re
actio
ns (e
.g. r
ecen
t upp
er
resp
irato
ry tr
act i
nfec
tion)
S –
Syst
emic
fact
ors
(e.g
. hyp
erte
nsio
n)T
– Th
rom
bocy
tope
nia
A –
Alc
ohol
– c
ause
s va
sodi
latio
nX
– fa
ctor
X d
efic
ienc
yI
– In
tran
asal
tum
ours
S –
Spra
ys (e
.g. p
rolo
nged
use
of n
asal
ste
roid
s)
Risk
fact
ors
• Tr
aum
a.•
Antic
oagu
latio
n m
edic
atio
n.•
Hype
rten
sion
.•
Rece
nt u
pper
resp
irato
ry tr
act i
nfec
tion.
• Hi
stor
y of
epi
stax
is.•
Drug
s –
coca
ine
use.
MAP
6.3
. Epi
stax
is
ppyy
ggpp
gg
K30033_C006.indd 179 28/02/17 11:13 am
Ear,
nose
and
thr
oat
180
MAP
6.4
. N
aso
ph
aryn
gea
l can
cer
Wha
t is
nas
opha
ryng
eal c
ance
r?N
asop
hary
neal
can
cer i
s ty
pica
lly a
squ
amou
s ce
ll ca
rcin
oma
(85%
). O
ther
cel
l typ
es in
clud
e ad
enoc
arci
nom
a, ly
mph
oma
and
mel
anom
a.It
is m
ore
com
mon
in A
sian
pop
ulat
ions
and
in
mal
es.
Caus
esTh
e ex
act c
ause
of n
asop
hary
ngea
l tum
ours
is
unkn
own
but r
isk
fact
ors
incl
ude:
• G
enet
ics:
HLA-
A2.
• In
fect
ion:
Eps
tein
–Bar
r viru
s.•
Diet
: nitr
osam
ines
and
vita
min
C d
efic
ienc
y.
Sym
ptom
sRe
mem
ber a
s N
OSE
:N
– N
eck
lum
pO
– O
talg
ia, n
asal
Obs
truc
tion
S –
Sym
ptom
s of
spr
ead
(e.g
. ner
ve p
alsi
es –
m
andi
bula
r ner
ve; c
rani
al n
erve
s –
mos
t
com
mon
ly C
Ns V
, VI a
nd X
II; H
orne
r’s
syn
drom
e).
E –
Epis
taxi
s.
Com
plic
atio
ns•
Met
asta
sis.
• In
vasi
on o
f loc
al s
truc
ture
s.•
Deat
h.
Trea
tmen
tCo
nser
vati
ve:
• Pa
tient
edu
catio
n, M
acm
illan
nur
ses
refe
rral
.
Med
ical
:•
Chem
othe
rapy
and
radi
othe
rapy
.
Surg
ical
:•
For a
ngio
fibro
ma.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
WCC
, U&
E, L
FTs,
ESR,
Ep
stei
n–Ba
rr v
irus
and
vira
l cap
sid
antig
en.
• Sp
ecifi
c te
sts:
audi
ogra
m, t
ympa
nogr
am a
nd
visu
al fi
elds
.•
Radi
olog
y: C
T, M
RI w
ith T
NM
cla
ssifi
catio
n.
Angi
ogra
phy
for a
ngio
fibro
ma.
MAP
6.4
. Nas
opha
ryng
eal c
ance
r
K30033_C006.indd 180 28/02/17 11:13 am
Ear,
nose
and
thr
oat
181
MAP
6.5
. O
rop
har
yng
eal c
ance
r
Wha
t is
oro
phar
ynge
al c
ance
r?M
ost o
roph
aryn
geal
can
cers
are
squ
amou
s ce
ll ca
rcin
omas
(85%
). Ap
prox
imat
ely
8% o
f the
se
pres
ent w
ith d
ista
nt m
etas
tasi
s. O
ther
cel
l ty
pes
incl
ude
non-
Hodg
kin’
s ly
mph
oma
and
rhab
dom
yosa
rcom
a. It
is m
ore
com
mon
in
mal
es.
Caus
esTh
e ex
act c
ause
of o
roph
aryn
geal
tum
ours
is
unkn
own
but r
isk
fact
ors
incl
ude:
• Sm
okin
g/to
bacc
o ch
ewin
g.•
Alco
hol.
• HP
V in
fect
ion
(type
s 8
and
16).
• Io
nizi
ng ra
diat
ion.
Sym
ptom
s•
Ody
noph
agia
.•
Ota
lgia
.•
Nec
k lu
mp.
• Tr
ism
us.
• So
re th
roat
.•
Leuk
opla
kia.
Com
plic
atio
ns•
Met
asta
sis.
• In
vasi
on o
f loc
al s
truc
ture
s.•
Deat
h.
Trea
tmen
tTr
eatm
ent d
epen
ds o
n th
e ce
ll ty
pe a
nd th
e TN
M g
radi
ng.
• Sq
uam
ous
cell
carc
inom
a: ra
diot
hera
py a
nd s
urge
ry.
• Ca
rcin
oma
of th
e so
ft pa
late
: T1/
T2 –
radi
othe
rapy
; T3/
4 –
rese
ctio
n.•
Post
erio
r pha
ryng
eal w
all c
arci
nom
a: T
1/2
– ra
dica
l rad
ioth
erap
y, re
sect
ion.
• To
nsil
carc
inom
a: T
1/2
– ra
dica
l rad
ioth
erap
y, tr
anso
ral s
urge
ry;
T3
/4 –
rese
ctio
n +
/– d
isse
ctio
n an
d re
cons
truc
tion.
• Po
stop
erat
ive
radi
othe
rapy
requ
ired
for n
odal
invo
lvem
ent.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
WCC
, U&
E, L
FTs,
ESR,
Ep
stei
n–Ba
rr v
irus
and
vira
l cap
sid
antig
en.
• Sp
ecifi
c te
sts:
audi
ogra
m, t
ympa
nogr
am a
nd
visu
al fi
elds
.•
Radi
olog
y: C
T, M
RI w
ith T
NM
cla
ssifi
catio
n.
Angi
ogra
phy
for a
ngio
fibro
ma.
MAP
6.5
. Oro
phar
ynge
al c
ance
r
K30033_C006.indd 181 28/02/17 11:13 am
Ear,
nose
and
thr
oat
182
MAP
6.6
. La
ryn
gea
l can
cer
Wha
t is
lary
ngea
l can
cer?
Lary
ngea
l tum
ours
may
be
beni
gn o
r mal
igna
nt:
• M
alig
nant
: squ
amou
s ce
ll ca
rcin
omas
, ade
noca
rcin
omas
, sar
com
a, v
erru
cous
car
cino
ma,
un
diffe
rent
iate
d.•
Beni
gn: p
apill
omas
, cho
ndro
mas
, lip
omas
.
Caus
esTh
e ex
act c
ause
of l
aryn
geal
tum
ours
is u
nkno
wn
but r
isk
fact
ors
incl
ude:
• Ag
e.•
Mal
e.•
Smok
ing.
• Al
coho
l.
Sym
ptom
s•
Coug
h.•
Hoar
se v
oice
– re
curr
ent l
aryn
geal
ner
ve
invo
lvem
ent.
• Ly
mph
aden
opat
hy.
• St
ridor
.
Com
plic
atio
ns•
Met
asta
sis.
• In
vasi
on o
f loc
al s
truc
ture
s.•
Deat
h.•
Voca
l cor
d pa
raly
sis.
Trea
tmen
tCo
nser
vati
ve:
• Pa
tient
edu
catio
n, M
acm
illan
nur
ses
refe
rral
.•
Spee
ch th
erap
y af
ter c
hem
othe
rapy
, rad
ioth
erap
y an
d su
rger
y.
Med
ical
:•
Trea
tmen
t of l
aryn
geal
can
cer i
s di
ctat
ed b
y th
e TM
N s
tage
.•
Radi
othe
rapy
and
che
mot
hera
py.
Surg
ical
:•
Lary
nx s
parin
g su
rger
y (e
.g. e
ndos
copi
c la
ser r
esec
tion,
lary
ngof
issu
re,
co
rdec
tom
y, ve
rtic
al p
artia
l lar
ynge
ctom
y).
• To
tal o
r par
tial l
aryn
gect
omy.
• N
eck
diss
ectio
n.
Inve
stig
atio
ns•
Bloo
d te
sts:
FBC,
WCC
, U&
E,
LFTs
, ESR
.•
Spec
ific
test
s: ex
amin
atio
n
unde
r ana
esth
esia
and
bi
opsy
.•
Radi
olog
y: c
hest
x-r
ay, C
T,
MRI
.
MAP
6.6
. Lar
ynge
al c
ance
r
K30033_C006.indd 182 28/02/17 11:13 am
Chap
ter S
even
Der
mat
olog
y
MAP
7.1
A
top
ic e
czem
a 18
4
MAP
7.2
Se
bo
rrh
oei
c d
erm
atit
is
186
MAP
7.3
Ps
ori
asis
18
8
MAP
7.4
Pi
tyri
asis
19
0
MAP
7.5
Er
yth
emat
ou
s le
sio
ns
192
MAP
7.6
Li
chen
oid
lesi
on
s 19
4
MAP
7.7
B
ullo
us
dis
ord
ers
196
MAP
7.8
A
cne
vulg
aris
19
8
MAP
7.9
R
osa
cea
200
MAP
7.1
0 A
lop
ecia
are
ata
202
TABL
E 7.
1 V
iral
ski
n in
fect
ion
s 20
4
TABL
E 7.
2 Pa
rasi
tic
skin
infe
ctio
ns
207
TABL
E 7.
3 B
acte
rial
ski
n in
fect
ion
s 20
8
TABL
E 7.
4 Fu
ng
al s
kin
infe
ctio
ns
210
TABL
E 7.
5 Sk
in lu
mp
s 21
2
TABL
E 7.
6 Sk
in t
um
ou
rs
216
Der
mat
olog
y18
3
K30033_C007.indd 183 28/02/17 11:21 am
184
Der
mat
olog
yM
ap 7
.1.
Ato
pic
ecz
ema
MAP
7.1
. Ato
pic
ecze
ma
Wha
t is
ato
pic
ecze
ma?
Ecze
ma
is a
com
mon
chr
onic
infla
mm
ator
y sk
in
cond
ition
that
pre
sent
s w
ith it
chy,
dry
, sca
lyle
sion
s. A
topi
c ec
zem
a is
the
mos
t com
mon
type
of
ecz
ema,
but
ther
e ar
e ot
her v
aria
tions
, suc
h as
con
tact
der
mat
itis,
as
wel
l as
thos
e th
at a
re
defin
ed b
y ap
pear
ance
suc
h as
dis
coid
ecze
ma
and
veno
us e
czem
a.
Caus
esTh
e ex
act c
ause
of a
topi
c ec
zem
a is
not
kno
wn.
It
is th
ough
t to
be m
ultif
acto
rial a
nd is
gen
eral
lyco
nsid
ered
to b
e an
inte
ract
ion
betw
een
gene
ticco
mpo
nent
s an
d th
e im
mun
e sy
stem
.
• G
enet
ic: i
ncre
ased
risk
with
a p
ositi
ve
fam
ily h
isto
ry. F
ilagg
rin g
ene
mut
atio
ns
pred
ispo
se to
ecz
ema.
• A
llerg
en e
xpos
ure:
e.g
. cer
tain
was
hing
de
terg
ents
, per
fum
es, f
ood
alle
rgie
s.•
Exac
erba
ting
fact
ors:
em
otio
nal s
tres
s,
tem
pera
ture
fluc
tuat
ion.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion
and
avoi
danc
e of
tr
igge
ring
fact
ors.
Med
ical
:•
Emol
lient
s –
wet
wra
ps m
ay b
e us
ed to
aid
ab
sorp
tion.
• To
pica
l ste
roid
s –
use
low
est p
oten
cy fi
rst.
• An
tibio
tics
– fo
r sec
onda
ry b
acte
rial
in
fect
ion.
• An
ti-vi
rals
– a
cicl
ovir
is u
sed
in e
czem
a
herp
etic
um.
• PU
VA tr
eatm
ent m
ay b
e us
ed in
resi
stan
t
case
s.
Com
plic
atio
ns•
Chro
nic
dry
skin
.•
Supe
radd
ed in
fect
ion:
Usu
ally
Sta
phyl
ococ
cus
aure
us re
sulti
ng
in
impe
tigin
ized
ecz
ema.
Herp
es s
impl
ex v
irus
may
cau
se e
czem
a
herp
etic
um.
• Ey
e pr
oble
ms
such
as
conj
unct
iviti
s an
d
blep
harit
is.
• De
crea
sed
qual
ity o
f sle
ep.
Inve
stig
atio
ns•
Alw
ays
ask
abou
t oth
er a
topi
c co
nditi
ons
su
ch a
s as
thm
a an
d ha
y fe
ver a
s w
ell a
s fo
od
alle
rgy.
• Bl
ood
test
s: s
erum
IgE
(hig
h).
• O
ther
: ski
n pr
ick
or R
AST.
• Sw
ab –
to id
entif
y ca
usat
ive
orga
nism
if
infe
ctio
n pr
esen
t.
Sym
ptom
s•
Xero
sis
(gen
eral
ized
dry
ski
n).
• Er
ythe
mat
ous
lesi
ons.
• Ex
coria
tion.
• Li
chen
ifica
tions
.•
Sign
s of
sup
erad
ded
infe
ctio
n (e
.g. v
esic
les)
.•
Itchi
ng.
• N
ote
dist
ribut
ion:
Face
– o
ften
in b
abie
s.
An
tecu
bita
l fos
sa.
Popl
iteal
foss
a.
W
rists
.
An
kles
.•
Nai
ls –
pol
ishe
d fro
m s
crat
chin
g.
K30033_C007.indd 184 28/02/17 11:21 am
185
Der
mat
olog
yM
ap 7
.1.
Ato
pic
ecz
ema
MAP
7.1
. Ato
pic
ecze
ma
Wha
t is
ato
pic
ecze
ma?
Ecze
ma
is a
com
mon
chr
onic
infla
mm
ator
y sk
in
cond
ition
that
pre
sent
s w
ith it
chy,
dry
, sca
lyle
sion
s. A
topi
c ec
zem
a is
the
mos
t com
mon
type
of
ecz
ema,
but
ther
e ar
e ot
her v
aria
tions
, suc
h as
con
tact
der
mat
itis,
as
wel
l as
thos
e th
at a
re
defin
ed b
y ap
pear
ance
suc
h as
dis
coid
ecze
ma
and
veno
us e
czem
a.
Caus
esTh
e ex
act c
ause
of a
topi
c ec
zem
a is
not
kno
wn.
It
is th
ough
t to
be m
ultif
acto
rial a
nd is
gen
eral
lyco
nsid
ered
to b
e an
inte
ract
ion
betw
een
gene
ticco
mpo
nent
s an
d th
e im
mun
e sy
stem
.
• G
enet
ic: i
ncre
ased
risk
with
a p
ositi
ve
fam
ily h
isto
ry. F
ilagg
rin g
ene
mut
atio
ns
pred
ispo
se to
ecz
ema.
• A
llerg
en e
xpos
ure:
e.g
. cer
tain
was
hing
de
terg
ents
, per
fum
es, f
ood
alle
rgie
s.•
Exac
erba
ting
fact
ors:
em
otio
nal s
tres
s,
tem
pera
ture
fluc
tuat
ion.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion
and
avoi
danc
e of
tr
igge
ring
fact
ors.
Med
ical
:•
Emol
lient
s –
wet
wra
ps m
ay b
e us
ed to
aid
ab
sorp
tion.
• To
pica
l ste
roid
s –
use
low
est p
oten
cy fi
rst.
• An
tibio
tics
– fo
r sec
onda
ry b
acte
rial
in
fect
ion.
• An
ti-vi
rals
– a
cicl
ovir
is u
sed
in e
czem
a
herp
etic
um.
• PU
VA tr
eatm
ent m
ay b
e us
ed in
resi
stan
t
case
s.
Com
plic
atio
ns•
Chro
nic
dry
skin
.•
Supe
radd
ed in
fect
ion:
Usu
ally
Sta
phyl
ococ
cus
aure
us re
sulti
ng
in
impe
tigin
ized
ecz
ema.
Herp
es s
impl
ex v
irus
may
cau
se e
czem
a
herp
etic
um.
• Ey
e pr
oble
ms
such
as
conj
unct
iviti
s an
d
blep
harit
is.
• De
crea
sed
qual
ity o
f sle
ep.
Inve
stig
atio
ns•
Alw
ays
ask
abou
t oth
er a
topi
c co
nditi
ons
su
ch a
s as
thm
a an
d ha
y fe
ver a
s w
ell a
s fo
od
alle
rgy.
• Bl
ood
test
s: s
erum
IgE
(hig
h).
• O
ther
: ski
n pr
ick
or R
AST.
• Sw
ab –
to id
entif
y ca
usat
ive
orga
nism
if
infe
ctio
n pr
esen
t.
Sym
ptom
s•
Xero
sis
(gen
eral
ized
dry
ski
n).
• Er
ythe
mat
ous
lesi
ons.
• Ex
coria
tion.
• Li
chen
ifica
tions
.•
Sign
s of
sup
erad
ded
infe
ctio
n (e
.g. v
esic
les)
.•
Itchi
ng.
• N
ote
dist
ribut
ion:
Face
– o
ften
in b
abie
s.
An
tecu
bita
l fos
sa.
Popl
iteal
foss
a.
W
rists
.
An
kles
.•
Nai
ls –
pol
ishe
d fro
m s
crat
chin
g.
K30033_C007.indd 185 28/02/17 11:21 am
186
Der
mat
olog
yM
ap 7
.2.
Seb
orr
ho
eic
der
mat
itis
Wha
t is
seb
orrh
oeic
der
mat
itis
?Th
is is
a c
hron
ic in
flam
mat
ory
skin
con
ditio
n re
sulti
ng in
der
mat
itis
in a
reas
rich
in s
ebac
eous
gl
ands
, suc
h as
the
naso
labi
al fo
lds.
Caus
esTh
e ex
act c
ause
of s
ebor
rhoe
ic d
erm
atiti
s is
not
kn
own
but c
urre
nt th
eorie
s su
gges
t tha
t the
yeas
t Mal
asse
zia
furfu
r pla
ys a
role
. Add
ition
ally,
se
borr
hoei
c de
rmat
itis
is m
ore
com
mon
in
patie
nts
suffe
ring
with
HIV
and
, the
refo
re, a
w
eake
ned
imm
une
syst
em m
ay p
lay
a ro
le.
Sym
ptom
s•
Red/
whi
te/y
ello
w, s
caly
lesi
ons
pres
ent
us
ually
aro
und
the
naso
labi
al fo
lds,
eyeb
row
s,
ches
t and
sca
lp. M
ay a
lso
occu
r in
othe
r hai
r
bear
ing
area
s an
d in
flex
ural
fold
s.•
Itchi
ng.
• Cr
adle
cap
– s
een
in b
abie
s.
Inve
stig
atio
nsSe
borr
hoei
c de
rmat
itis
tend
s to
be
a cl
inic
aldi
agno
sis.
• Sk
in s
crap
ing
mic
rosc
opy
– m
ay s
how
M
alas
sezi
a fu
rfur.
• Sk
in s
wab
s fo
r sup
erad
ded
infe
ctio
n, u
sual
ly
Stap
hylo
cocc
us a
ureu
s.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Was
h w
ith a
nti-d
andr
uff s
ham
poo
cont
aini
ng
antif
unga
l age
nts,
such
as
keto
cona
zole
,
or a
ker
atol
ytic
suc
h as
sal
icyl
ic a
cid
• In
term
itten
t use
of a
mild
topi
cal s
tero
id.
Com
plic
atio
ns•
Supe
radd
ed in
fect
ion.
• Ps
ycho
logi
cal e
ffect
s re
latin
g to
app
eara
nce.
MAP
7.2
. Seb
orrh
oeic
der
mat
itis
K30033_C007.indd 186 28/02/17 11:21 am
187
Map
7.2
. Se
bo
rrh
oei
c d
erm
atit
isD
erm
atol
ogy
Wha
t is
seb
orrh
oeic
der
mat
itis
?Th
is is
a c
hron
ic in
flam
mat
ory
skin
con
ditio
n re
sulti
ng in
der
mat
itis
in a
reas
rich
in s
ebac
eous
gl
ands
, suc
h as
the
naso
labi
al fo
lds.
Caus
esTh
e ex
act c
ause
of s
ebor
rhoe
ic d
erm
atiti
s is
not
kn
own
but c
urre
nt th
eorie
s su
gges
t tha
t the
yeas
t Mal
asse
zia
furfu
r pla
ys a
role
. Add
ition
ally,
se
borr
hoei
c de
rmat
itis
is m
ore
com
mon
in
patie
nts
suffe
ring
with
HIV
and
, the
refo
re, a
w
eake
ned
imm
une
syst
em m
ay p
lay
a ro
le.
Sym
ptom
s•
Red/
whi
te/y
ello
w, s
caly
lesi
ons
pres
ent
us
ually
aro
und
the
naso
labi
al fo
lds,
eyeb
row
s,
ches
t and
sca
lp. M
ay a
lso
occu
r in
othe
r hai
r
bear
ing
area
s an
d in
flex
ural
fold
s.•
Itchi
ng.
• Cr
adle
cap
– s
een
in b
abie
s.
Inve
stig
atio
nsSe
borr
hoei
c de
rmat
itis
tend
s to
be
a cl
inic
aldi
agno
sis.
• Sk
in s
crap
ing
mic
rosc
opy
– m
ay s
how
M
alas
sezi
a fu
rfur.
• Sk
in s
wab
s fo
r sup
erad
ded
infe
ctio
n, u
sual
ly
Stap
hylo
cocc
us a
ureu
s.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Was
h w
ith a
nti-d
andr
uff s
ham
poo
cont
aini
ng
antif
unga
l age
nts,
such
as
keto
cona
zole
,
or a
ker
atol
ytic
suc
h as
sal
icyl
ic a
cid
• In
term
itten
t use
of a
mild
topi
cal s
tero
id.
Com
plic
atio
ns•
Supe
radd
ed in
fect
ion.
• Ps
ycho
logi
cal e
ffect
s re
latin
g to
app
eara
nce.
MAP
7.2
. Seb
orrh
oeic
der
mat
itis
K30033_C007.indd 187 28/02/17 11:21 am
188
Der
mat
olog
yM
ap 7
.3.
Pso
rias
is
Wha
t is
pso
rias
is?
Psor
iasi
s is
a c
hron
ic, n
on-in
fect
ious
in
flam
mat
ory
skin
con
ditio
n ch
arac
teriz
ed b
y w
ell-d
emar
cate
d sa
lmon
pin
k pl
aque
s w
ith
silv
ery
scal
es. I
t is
very
com
mon
and
may
oc
cur a
t any
age
. Tw
o pe
aks
have
bee
n id
entif
ied
– in
the
20s
and
50s.
Mal
es a
nd
fem
ales
are
equ
ally
affe
cted
. Thi
s co
nditi
on
caus
es h
yper
prol
ifera
tion
of th
e ep
ider
mis,
in
flam
mat
ion
of th
e ep
ider
mis
and
der
mis
as
wel
l as
rete
ntio
n of
nuc
lei i
n ke
ratin
ocyt
es in
th
e ho
rny
laye
r (pa
rake
rato
sis)
.
Caus
esTh
e ex
act c
ause
of p
soria
sis
is u
nkno
wn
but
broa
dly
it is
thou
ght t
o be
due
to a
com
plex
in
tera
ctio
n be
twee
n ge
netic
s an
d en
viro
nmen
-ta
l trig
gers
.•
Gen
etic
fact
ors:
Mut
atio
ns o
f PSO
RS1
on c
hrom
osom
e
6
– as
soci
ated
mor
e w
ith g
utta
te
ps
oria
sis.
Poly
mor
phis
ms
in g
enes
for I
L-12
and
IL
-23.
• En
viro
nmen
tal t
rigge
rs:
Infe
ctio
n, p
artic
ular
ly
st
rept
ococ
cal i
nfec
tion
(gut
tate
pso
riasi
s).
Stre
ss.
Drug
s (e
.g. b
eta
bloc
kers
,
AC
E in
hibi
tors
,
an
timal
aria
ls a
nd li
thiu
m).
Trau
ma
– Ko
ebne
r
ph
enom
enon
.
Sm
okin
g.
Al
coho
l.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Avo
id tr
igge
ring
fact
ors
(e
.g. s
mok
ing
is s
tron
gly
linke
d w
ith
palm
opla
ntar
pso
riasi
s)•
Prov
ide
info
rmat
ion
on tr
eatm
ent o
ptio
ns
and
mon
itor b
lood
s re
gula
rly, e
spec
ially
w
hen
patie
nts
are
taki
ng s
yste
mic
ther
apy
or
bio
logi
cal a
gent
s. Al
so, b
e aw
are
of
tera
toge
nici
ty in
wom
en o
f chi
ld-b
earin
g
age.
• As
sess
sev
erity
:
Pa
tient
’s pe
rspe
ctiv
e: a
sses
sed
usin
g
th
e De
rmat
olog
y Li
fe Q
ualit
y
In
dex
(DLQ
I).
Ph
ysic
ian’
s pe
rspe
ctiv
e: a
sses
sed
usin
g
th
e Ps
oria
sis A
rea
and
Seve
rity
Inde
x
(P
ASI).
Med
ical
:•
Topi
cal t
hera
py: e
mol
lient
s, ke
rato
lytic
ag
ents
, Goe
cker
man
trea
tmen
t (co
al ta
r and
U
VB),
dith
rano
l tre
atm
ent (
shor
t con
tact
th
erap
y), t
opic
al s
tero
ids
(e.g
. bet
amet
ha-
so
ne o
intm
ent,
calc
ipot
riol w
ith a
nd
with
out b
etam
etha
sone
).
• Ph
otot
hera
py: U
VB o
r PU
VA. W
ith P
UVA
pa
tient
mus
t tak
e ps
oral
en e
ither
ora
lly o
r
in a
bat
h so
lutio
n.•
Syst
emic
ther
apy
(e.g
. met
hotr
exat
e,
cicl
ospo
rin)
• Bi
olog
ical
age
nts
(e.g
. eta
nerc
ept,
ad
alim
umab
, inf
lixim
ab a
nd u
stek
inum
ab).
Inve
stig
atio
nsDi
agno
sis
is u
sual
ly b
ased
on
clin
ical
exa
min
atio
n.•
Wel
l-dem
arca
ted
salm
on p
ink
plaq
ues
with
silv
ery
whi
te s
cale
s.•
Usu
ally
ove
r ext
enso
r sur
face
s bu
t als
o m
ay b
e pr
esen
t on
the
scal
p an
d na
vel.
• W
hite
bla
nchi
ng ri
ng p
rese
nt o
n sk
in s
urro
undi
ng p
laqu
e. T
his
is c
alle
d W
oron
off’s
ring
.•
Nai
l cha
nges
: (se
e sy
mpt
oms)
.•
Spec
ial s
igns
:
Au
spitz
’s si
gn: c
apill
ary
blee
ding
whe
n in
divi
dual
sca
les
rem
oved
from
pla
que.
Koeb
ner’s
phe
nom
enon
: new
lesi
ons
at s
ite o
f tra
uma.
Bulk
eley
’s m
embr
ane:
moi
st re
d su
rface
on
rem
oval
of s
cale
s.
Sym
ptom
s•
Gen
eral
sym
ptom
s: itc
hing
, pai
n, d
ecre
ased
de
xter
ity.
• Le
sion
type
:
1.
Chro
nic
plaq
ue p
soria
sis
– ex
tens
or
su
rface
s.
•
Psor
iasi
s gy
rate
– c
urve
d lin
ear
pa
tter
ns.
• An
nula
r pso
riasi
s –
ring-
like
lesi
ons,
ce
ntra
l cle
arin
g.
•
Psor
iasi
s fo
llicu
laris
– s
caly
pap
ules
at
pilo
seba
ceou
s fo
llicl
es.
2.
Ru
pioi
d pl
aque
s –
limpe
t she
ll
ap
pear
ance
, 2–5
cm
.
3.
Ost
race
ous
psor
iasi
s –
oyst
er s
hell
appe
aran
ce.
4.
In
vers
e ps
oria
sis
– in
tert
rigin
ous
area
s.
5.
Gut
tate
pso
riasi
s –
rain
drop
app
eara
nce
over
bod
y. As
soci
ated
with
prio
r
st
rept
ococ
cal p
hary
ngiti
s. U
sual
ly
yo
unge
r pat
ient
s.
6.
Pust
ular
pso
riasi
s –
palm
s an
d so
les
usua
lly.
7.
Er
ythr
oder
mic
pso
riasi
s –
derm
atol
ogic
al
em
erge
ncy.
• N
ail c
hang
es:
Pitt
ing.
Yello
win
g.
Su
bung
ual k
erat
osis.
Ony
chol
ysis.
• Jo
int p
ain
– ps
oria
tic a
rthr
itis
is p
rese
nt in
10
–15%
of p
atie
nts.
Com
plic
atio
ns•
Psor
iatic
art
hriti
s.•
Eye
dise
ase
(e.g
. ble
phar
itis
and
co
njun
ctiv
itis)
.•
Incr
ease
d ris
k of
:
Ca
rdio
vasc
ular
dis
ease
.
M
etab
olic
syn
drom
e.
De
pres
sion
.
MAP
7.3
. Pso
rias
is
K30033_C007.indd 188 28/02/17 11:21 am
189
Der
mat
olog
yM
ap 7
.3.
Pso
rias
is
Wha
t is
pso
rias
is?
Psor
iasi
s is
a c
hron
ic, n
on-in
fect
ious
in
flam
mat
ory
skin
con
ditio
n ch
arac
teriz
ed b
y w
ell-d
emar
cate
d sa
lmon
pin
k pl
aque
s w
ith
silv
ery
scal
es. I
t is
very
com
mon
and
may
oc
cur a
t any
age
. Tw
o pe
aks
have
bee
n id
entif
ied
– in
the
20s
and
50s.
Mal
es a
nd
fem
ales
are
equ
ally
affe
cted
. Thi
s co
nditi
on
caus
es h
yper
prol
ifera
tion
of th
e ep
ider
mis,
in
flam
mat
ion
of th
e ep
ider
mis
and
der
mis
as
wel
l as
rete
ntio
n of
nuc
lei i
n ke
ratin
ocyt
es in
th
e ho
rny
laye
r (pa
rake
rato
sis)
.
Caus
esTh
e ex
act c
ause
of p
soria
sis
is u
nkno
wn
but
broa
dly
it is
thou
ght t
o be
due
to a
com
plex
in
tera
ctio
n be
twee
n ge
netic
s an
d en
viro
nmen
-ta
l trig
gers
.•
Gen
etic
fact
ors:
Mut
atio
ns o
f PSO
RS1
on c
hrom
osom
e
6
– as
soci
ated
mor
e w
ith g
utta
te
ps
oria
sis.
Poly
mor
phis
ms
in g
enes
for I
L-12
and
IL
-23.
• En
viro
nmen
tal t
rigge
rs:
Infe
ctio
n, p
artic
ular
ly
st
rept
ococ
cal i
nfec
tion
(gut
tate
pso
riasi
s).
Stre
ss.
Drug
s (e
.g. b
eta
bloc
kers
,
AC
E in
hibi
tors
,
an
timal
aria
ls a
nd li
thiu
m).
Trau
ma
– Ko
ebne
r
ph
enom
enon
.
Sm
okin
g.
Al
coho
l.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Avo
id tr
igge
ring
fact
ors
(e
.g. s
mok
ing
is s
tron
gly
linke
d w
ith
palm
opla
ntar
pso
riasi
s)•
Prov
ide
info
rmat
ion
on tr
eatm
ent o
ptio
ns
and
mon
itor b
lood
s re
gula
rly, e
spec
ially
w
hen
patie
nts
are
taki
ng s
yste
mic
ther
apy
or
bio
logi
cal a
gent
s. Al
so, b
e aw
are
of
tera
toge
nici
ty in
wom
en o
f chi
ld-b
earin
g
age.
• As
sess
sev
erity
:
Pa
tient
’s pe
rspe
ctiv
e: a
sses
sed
usin
g
th
e De
rmat
olog
y Li
fe Q
ualit
y
In
dex
(DLQ
I).
Ph
ysic
ian’
s pe
rspe
ctiv
e: a
sses
sed
usin
g
th
e Ps
oria
sis A
rea
and
Seve
rity
Inde
x
(P
ASI).
Med
ical
:•
Topi
cal t
hera
py: e
mol
lient
s, ke
rato
lytic
ag
ents
, Goe
cker
man
trea
tmen
t (co
al ta
r and
U
VB),
dith
rano
l tre
atm
ent (
shor
t con
tact
th
erap
y), t
opic
al s
tero
ids
(e.g
. bet
amet
ha-
so
ne o
intm
ent,
calc
ipot
riol w
ith a
nd
with
out b
etam
etha
sone
).
• Ph
otot
hera
py: U
VB o
r PU
VA. W
ith P
UVA
pa
tient
mus
t tak
e ps
oral
en e
ither
ora
lly o
r
in a
bat
h so
lutio
n.•
Syst
emic
ther
apy
(e.g
. met
hotr
exat
e,
cicl
ospo
rin)
• Bi
olog
ical
age
nts
(e.g
. eta
nerc
ept,
ad
alim
umab
, inf
lixim
ab a
nd u
stek
inum
ab).
Inve
stig
atio
nsDi
agno
sis
is u
sual
ly b
ased
on
clin
ical
exa
min
atio
n.•
Wel
l-dem
arca
ted
salm
on p
ink
plaq
ues
with
silv
ery
whi
te s
cale
s.•
Usu
ally
ove
r ext
enso
r sur
face
s bu
t als
o m
ay b
e pr
esen
t on
the
scal
p an
d na
vel.
• W
hite
bla
nchi
ng ri
ng p
rese
nt o
n sk
in s
urro
undi
ng p
laqu
e. T
his
is c
alle
d W
oron
off’s
ring
.•
Nai
l cha
nges
: (se
e sy
mpt
oms)
.•
Spec
ial s
igns
:
Au
spitz
’s si
gn: c
apill
ary
blee
ding
whe
n in
divi
dual
sca
les
rem
oved
from
pla
que.
Koeb
ner’s
phe
nom
enon
: new
lesi
ons
at s
ite o
f tra
uma.
Bulk
eley
’s m
embr
ane:
moi
st re
d su
rface
on
rem
oval
of s
cale
s.
Sym
ptom
s•
Gen
eral
sym
ptom
s: itc
hing
, pai
n, d
ecre
ased
de
xter
ity.
• Le
sion
type
:
1.
Chro
nic
plaq
ue p
soria
sis
– ex
tens
or
su
rface
s.
•
Psor
iasi
s gy
rate
– c
urve
d lin
ear
pa
tter
ns.
• An
nula
r pso
riasi
s –
ring-
like
lesi
ons,
ce
ntra
l cle
arin
g.
•
Psor
iasi
s fo
llicu
laris
– s
caly
pap
ules
at
pilo
seba
ceou
s fo
llicl
es.
2.
Ru
pioi
d pl
aque
s –
limpe
t she
ll
ap
pear
ance
, 2–5
cm
.
3.
Ost
race
ous
psor
iasi
s –
oyst
er s
hell
appe
aran
ce.
4.
In
vers
e ps
oria
sis
– in
tert
rigin
ous
area
s.
5.
Gut
tate
pso
riasi
s –
rain
drop
app
eara
nce
over
bod
y. As
soci
ated
with
prio
r
st
rept
ococ
cal p
hary
ngiti
s. U
sual
ly
yo
unge
r pat
ient
s.
6.
Pust
ular
pso
riasi
s –
palm
s an
d so
les
usua
lly.
7.
Er
ythr
oder
mic
pso
riasi
s –
derm
atol
ogic
al
em
erge
ncy.
• N
ail c
hang
es:
Pitt
ing.
Yello
win
g.
Su
bung
ual k
erat
osis.
Ony
chol
ysis.
• Jo
int p
ain
– ps
oria
tic a
rthr
itis
is p
rese
nt in
10
–15%
of p
atie
nts.
Com
plic
atio
ns•
Psor
iatic
art
hriti
s.•
Eye
dise
ase
(e.g
. ble
phar
itis
and
co
njun
ctiv
itis)
.•
Incr
ease
d ris
k of
:
Ca
rdio
vasc
ular
dis
ease
.
M
etab
olic
syn
drom
e.
De
pres
sion
.
MAP
7.3
. Pso
rias
is
K30033_C007.indd 189 28/02/17 11:21 am
190
Der
mat
olog
yM
ap 7
.4.
Pity
rias
is
Pity
rias
is r
osea
Wha
t is
pit
yria
sis
rose
a?Th
is is
a b
enig
n, s
elf-l
imiti
ng b
ran-
like
scal
y ra
sh th
at o
ccur
s on
the
trun
k.
Caus
esTh
e ex
act c
ause
of t
his
cond
ition
is u
nkno
wn,
but
HHV
-7 h
as b
een
impl
icat
ed.
Sym
ptom
s•
Itchi
ng.
• 70
% o
f pat
ient
s ha
ve a
n up
per r
espi
rato
ry tr
act i
nfec
tion
befo
re
derm
atol
ogic
al s
ympt
oms
pres
ent.
• He
rald
pat
ch –
a s
ingl
e, la
rger
lesi
on p
rece
des
smal
ler o
val p
laqu
es. I
t is
pi
nk in
app
eara
nce
and
has
a ce
ntra
l cle
arin
g.•
Smal
ler o
val l
esio
ns fo
llow
a ‘C
hris
tmas
tree
’ dis
trib
utio
n.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is.
Trea
tmen
tO
ften
no tr
eatm
ent i
s re
quire
d si
nce
it is
a s
elf-l
imiti
ng c
ondi
tion.
Cons
erva
tive
:•
Patie
nt e
duca
tion
that
con
ditio
n is
ben
ign.
M
edic
al:
• An
ti-hi
stam
ines
or s
tero
id to
aid
itch
ing.
Pity
rias
is v
ersi
colo
r
Wha
t is
pit
yria
sis
vers
icol
or?
This
is a
com
men
sal y
east
infe
ctio
n of
the
skin
that
cau
ses
num
erou
sle
sion
s of
var
ying
col
ours
on
the
trun
k an
d ba
ck.
Caus
esTh
e ye
asts
Mal
asse
zia
glob
osa
and
Mal
asse
zia
furfu
r. Tr
igge
ring
fact
ors
incl
ude
exce
ssiv
e sw
eatin
g an
d liv
ing
in h
ot c
limat
es a
s w
ell a
s im
mun
osup
pres
sion
.
Sym
ptom
s•
Mild
itch
ing.
• Br
an-li
ke s
cale
s of
var
ying
col
our.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is.•
Fung
al c
ultu
res
for M
alas
sezi
a.•
Woo
d la
mp
exam
inat
ion
– ye
llow
-gre
en fl
uore
scen
ce in
affe
cted
regi
ons.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Topi
cal a
nti-f
unga
l age
nts/
sham
poos
.•
Prop
ylen
e gl
ycol
sol
utio
n.•
Sodi
um th
iosu
lpha
te s
olut
ion.
• O
ral a
nti-f
unga
l age
nts
in e
xten
sive
dis
ease
.
MAP
7.4
. Pit
yria
sis
K30033_C007.indd 190 28/02/17 11:21 am
191
Der
mat
olog
yM
ap 7
.4.
Pity
rias
is
Pity
rias
is r
osea
Wha
t is
pit
yria
sis
rose
a?Th
is is
a b
enig
n, s
elf-l
imiti
ng b
ran-
like
scal
y ra
sh th
at o
ccur
s on
the
trun
k.
Caus
esTh
e ex
act c
ause
of t
his
cond
ition
is u
nkno
wn,
but
HHV
-7 h
as b
een
impl
icat
ed.
Sym
ptom
s•
Itchi
ng.
• 70
% o
f pat
ient
s ha
ve a
n up
per r
espi
rato
ry tr
act i
nfec
tion
befo
re
derm
atol
ogic
al s
ympt
oms
pres
ent.
• He
rald
pat
ch –
a s
ingl
e, la
rger
lesi
on p
rece
des
smal
ler o
val p
laqu
es. I
t is
pi
nk in
app
eara
nce
and
has
a ce
ntra
l cle
arin
g.•
Smal
ler o
val l
esio
ns fo
llow
a ‘C
hris
tmas
tree
’ dis
trib
utio
n.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is.
Trea
tmen
tO
ften
no tr
eatm
ent i
s re
quire
d si
nce
it is
a s
elf-l
imiti
ng c
ondi
tion.
Cons
erva
tive
:•
Patie
nt e
duca
tion
that
con
ditio
n is
ben
ign.
M
edic
al:
• An
ti-hi
stam
ines
or s
tero
id to
aid
itch
ing.
Pity
rias
is v
ersi
colo
r
Wha
t is
pit
yria
sis
vers
icol
or?
This
is a
com
men
sal y
east
infe
ctio
n of
the
skin
that
cau
ses
num
erou
sle
sion
s of
var
ying
col
ours
on
the
trun
k an
d ba
ck.
Caus
esTh
e ye
asts
Mal
asse
zia
glob
osa
and
Mal
asse
zia
furfu
r. Tr
igge
ring
fact
ors
incl
ude
exce
ssiv
e sw
eatin
g an
d liv
ing
in h
ot c
limat
es a
s w
ell a
s im
mun
osup
pres
sion
.
Sym
ptom
s•
Mild
itch
ing.
• Br
an-li
ke s
cale
s of
var
ying
col
our.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is.•
Fung
al c
ultu
res
for M
alas
sezi
a.•
Woo
d la
mp
exam
inat
ion
– ye
llow
-gre
en fl
uore
scen
ce in
affe
cted
regi
ons.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
Med
ical
:•
Topi
cal a
nti-f
unga
l age
nts/
sham
poos
.•
Prop
ylen
e gl
ycol
sol
utio
n.•
Sodi
um th
iosu
lpha
te s
olut
ion.
• O
ral a
nti-f
unga
l age
nts
in e
xten
sive
dis
ease
.
MAP
7.4
. Pit
yria
sis
K30033_C007.indd 191 28/02/17 11:21 am
192
Der
mat
olog
yM
ap 7
.5.
Eryt
hem
ato
us
lesi
on
s
Eryt
hem
a no
dosu
m
Wha
t is
ery
them
a no
dosu
m?
This
is a
n im
mun
e-m
edia
ted
diso
rder
resu
lting
in a
pan
nicu
litis.
Caus
esTh
ere
are
man
y va
ryin
g ca
uses
of e
ryth
ema
nodo
sum
. Rem
embe
r as
NO
DO
SUM
:N
– N
o ca
use
foun
dO
– O
ccul
t mal
igna
ncy
D –
Dru
gs (e
.g. s
ulph
onam
ides
, ora
l con
trac
eptiv
e pi
ll)O
– O
ther
infe
ctio
ns (e
.g. s
trep
toco
ccal
pha
ryng
itis)
S –
Sarc
oido
sis
U –
Ulc
erat
ive
colit
is/C
rohn
’s di
seas
eM
– M
ycob
acte
rium
Sym
ptom
sPa
infu
l red
nod
ules
on
the
ante
rior s
urfa
ce o
f the
shi
n.
Inve
stig
atio
nsId
entif
y th
e un
derly
ing
caus
e.•
Thro
at s
wab
.•
Acid
fast
bac
illus
sta
inin
g (Z
iehl
–Nie
lsen
) if T
B su
spec
ted.
• Bl
ood
test
s –
FBC,
WCC
, U&
E, L
FTs,
CRP,
ASO
titr
es, v
iral s
tudi
es.
• Ra
diol
ogy
– ch
est x
-ray
.
Trea
tmen
t
Cons
erva
tive
:•
Com
pres
sion
sto
ckin
gs.
Med
ical
:•
Trea
tmen
t of u
nder
lyin
g ca
use.
• An
alge
sia.
Com
plic
atio
nsSe
rious
com
plic
atio
ns a
re ra
re.
Eryt
hem
a m
ulti
form
e
Wha
t is
ery
them
a m
ulti
form
e?Th
is is
a s
kin
cond
ition
that
is c
ause
d by
a h
yper
sens
itivi
ty re
actio
n. T
here
are
va
ryin
g de
gree
s of
sev
erity
:1.
Ery
them
a m
ultif
orm
e m
inor
– le
ast s
ever
e.2.
Ery
them
a m
ultif
orm
e m
ajor
.3.
Ste
vens
–Joh
nson
syn
drom
e (S
JS) <
10%
bod
y su
rface
are
a; to
xic
ep
ider
mal
nec
roly
sis
(TEN
) >30
% b
ody
surfa
ce a
rea
– po
tent
ially
lif
e-th
reat
enin
g.
Caus
esTh
e ex
act c
ause
rem
ains
unk
now
n in
50%
of c
ases
. Som
e sp
ecifi
c ca
uses
in
clud
e:•
Bact
eria
l inf
ectio
ns (e
.g. S
trep
toco
ccus
, Nei
sser
ia m
enin
gitid
is).
• Vi
ral i
nfec
tions
(e.g
. her
pes
sim
plex
viru
s).
• Fu
ngal
(e.g
. Coc
cidi
odes
imm
itis)
.•
Para
sitic
infe
ctio
n (e
.g. T
oxop
lasm
a go
ndii)
.•
Adve
rse
drug
reac
tions
(e.g
. pen
icill
in, s
ulph
onam
ides
, asp
irin,
al
lopu
rinol
).•
Mal
igna
ncie
s –
non-
Hodg
kin’
s ly
mph
oma,
mul
tiple
mye
lom
a, le
ukae
mia
.
Sym
ptom
s•
Mul
tiple
ery
them
atou
s pl
aque
s ap
pear
ing
as c
once
ntric
ring
s in
a
sym
met
rical
dis
trib
utio
n.•
SJS:
feve
r >39
°C; f
atig
ue; l
esio
ns in
the
muc
ous
mem
bran
es; c
onju
nctiv
itis.
Inve
stig
atio
nsN
ot e
ssen
tial t
o m
ake
the
diag
nosi
s, bu
t vita
l for
mon
itorin
g, e
spec
ially
in S
JS.
• Bl
ood
test
s –
FBC
(¯),
WCC
(¯),
eosi
noph
ils (
), LF
Ts (
), vi
ral t
itres
.•
Urin
alys
is –
mild
pro
tein
uria
.
Trea
tmen
t
Cons
erva
tive
:•
Rem
ove
caus
ativ
e ag
ent.
• U
se th
e SC
ORT
EN s
core
to p
redi
ct m
orta
lity
in S
JS a
nd T
EN.
• In
cise
and
dra
in la
rge
bulla
e.
Med
ical
:•
Eryt
hem
a m
ultif
orm
e m
inor
– to
pica
l ste
roid
s an
d or
al a
ntih
ista
min
es•
Eryt
hem
a m
ultif
orm
e m
ajor
– in
trav
enou
s flu
ids,
mou
thw
ash
(a
ntis
eptic
and
ana
lges
ic).
• SJ
S –
intr
aven
ous
fluid
s, m
outh
was
h (a
ntis
eptic
and
ana
lges
ic),
op
htha
lmol
ogy
revi
ew, g
enita
l car
e w
ith c
athe
teriz
atio
n, a
sses
smen
t and
tr
eatm
ent o
f sup
erad
ded
infe
ctio
n.
Com
plic
atio
ns•
Dehy
drat
ion
and
elec
trol
yte
imba
lanc
e.•
Acut
e re
spira
tory
dis
tres
s sy
ndro
me.
• Ey
e pr
oble
ms
(e.g
. con
junc
tiviti
s, co
rnea
l ulc
ers,
sym
blep
haro
n).
• Re
nal f
ailu
re.
MAP
7.5
. Ery
them
atou
s le
sion
s
K30033_C007.indd 192 28/02/17 11:21 am
193
Der
mat
olog
yM
ap 7
.5.
Eryt
hem
ato
us
lesi
on
s
Eryt
hem
a no
dosu
m
Wha
t is
ery
them
a no
dosu
m?
This
is a
n im
mun
e-m
edia
ted
diso
rder
resu
lting
in a
pan
nicu
litis.
Caus
esTh
ere
are
man
y va
ryin
g ca
uses
of e
ryth
ema
nodo
sum
. Rem
embe
r as
NO
DO
SUM
:N
– N
o ca
use
foun
dO
– O
ccul
t mal
igna
ncy
D –
Dru
gs (e
.g. s
ulph
onam
ides
, ora
l con
trac
eptiv
e pi
ll)O
– O
ther
infe
ctio
ns (e
.g. s
trep
toco
ccal
pha
ryng
itis)
S –
Sarc
oido
sis
U –
Ulc
erat
ive
colit
is/C
rohn
’s di
seas
eM
– M
ycob
acte
rium
Sym
ptom
sPa
infu
l red
nod
ules
on
the
ante
rior s
urfa
ce o
f the
shi
n.
Inve
stig
atio
nsId
entif
y th
e un
derly
ing
caus
e.•
Thro
at s
wab
.•
Acid
fast
bac
illus
sta
inin
g (Z
iehl
–Nie
lsen
) if T
B su
spec
ted.
• Bl
ood
test
s –
FBC,
WCC
, U&
E, L
FTs,
CRP,
ASO
titr
es, v
iral s
tudi
es.
• Ra
diol
ogy
– ch
est x
-ray
.
Trea
tmen
t
Cons
erva
tive
:•
Com
pres
sion
sto
ckin
gs.
Med
ical
:•
Trea
tmen
t of u
nder
lyin
g ca
use.
• An
alge
sia.
Com
plic
atio
nsSe
rious
com
plic
atio
ns a
re ra
re.
Eryt
hem
a m
ulti
form
e
Wha
t is
ery
them
a m
ulti
form
e?Th
is is
a s
kin
cond
ition
that
is c
ause
d by
a h
yper
sens
itivi
ty re
actio
n. T
here
are
va
ryin
g de
gree
s of
sev
erity
:1.
Ery
them
a m
ultif
orm
e m
inor
– le
ast s
ever
e.2.
Ery
them
a m
ultif
orm
e m
ajor
.3.
Ste
vens
–Joh
nson
syn
drom
e (S
JS) <
10%
bod
y su
rface
are
a; to
xic
ep
ider
mal
nec
roly
sis
(TEN
) >30
% b
ody
surfa
ce a
rea
– po
tent
ially
lif
e-th
reat
enin
g.
Caus
esTh
e ex
act c
ause
rem
ains
unk
now
n in
50%
of c
ases
. Som
e sp
ecifi
c ca
uses
in
clud
e:•
Bact
eria
l inf
ectio
ns (e
.g. S
trep
toco
ccus
, Nei
sser
ia m
enin
gitid
is).
• Vi
ral i
nfec
tions
(e.g
. her
pes
sim
plex
viru
s).
• Fu
ngal
(e.g
. Coc
cidi
odes
imm
itis)
.•
Para
sitic
infe
ctio
n (e
.g. T
oxop
lasm
a go
ndii)
.•
Adve
rse
drug
reac
tions
(e.g
. pen
icill
in, s
ulph
onam
ides
, asp
irin,
al
lopu
rinol
).•
Mal
igna
ncie
s –
non-
Hodg
kin’
s ly
mph
oma,
mul
tiple
mye
lom
a, le
ukae
mia
.
Sym
ptom
s•
Mul
tiple
ery
them
atou
s pl
aque
s ap
pear
ing
as c
once
ntric
ring
s in
a
sym
met
rical
dis
trib
utio
n.•
SJS:
feve
r >39
°C; f
atig
ue; l
esio
ns in
the
muc
ous
mem
bran
es; c
onju
nctiv
itis.
Inve
stig
atio
nsN
ot e
ssen
tial t
o m
ake
the
diag
nosi
s, bu
t vita
l for
mon
itorin
g, e
spec
ially
in S
JS.
• Bl
ood
test
s –
FBC
(¯),
WCC
(¯),
eosi
noph
ils (
), LF
Ts (
), vi
ral t
itres
.•
Urin
alys
is –
mild
pro
tein
uria
.
Trea
tmen
t
Cons
erva
tive
:•
Rem
ove
caus
ativ
e ag
ent.
• U
se th
e SC
ORT
EN s
core
to p
redi
ct m
orta
lity
in S
JS a
nd T
EN.
• In
cise
and
dra
in la
rge
bulla
e.
Med
ical
:•
Eryt
hem
a m
ultif
orm
e m
inor
– to
pica
l ste
roid
s an
d or
al a
ntih
ista
min
es•
Eryt
hem
a m
ultif
orm
e m
ajor
– in
trav
enou
s flu
ids,
mou
thw
ash
(a
ntis
eptic
and
ana
lges
ic).
• SJ
S –
intr
aven
ous
fluid
s, m
outh
was
h (a
ntis
eptic
and
ana
lges
ic),
op
htha
lmol
ogy
revi
ew, g
enita
l car
e w
ith c
athe
teriz
atio
n, a
sses
smen
t and
tr
eatm
ent o
f sup
erad
ded
infe
ctio
n.
Com
plic
atio
ns•
Dehy
drat
ion
and
elec
trol
yte
imba
lanc
e.•
Acut
e re
spira
tory
dis
tres
s sy
ndro
me.
• Ey
e pr
oble
ms
(e.g
. con
junc
tiviti
s, co
rnea
l ulc
ers,
sym
blep
haro
n).
• Re
nal f
ailu
re.
MAP
7.5
. Ery
them
atou
s le
sion
s
K30033_C007.indd 193 28/02/17 11:21 am
194
Der
mat
olog
yM
ap 7
.6.
Lich
eno
id le
sio
ns
Lich
en s
cler
osus
Wha
t is
lich
en s
cler
osus
?It
is a
chr
onic
ski
n co
nditi
on th
at re
sults
in th
inni
ng o
f the
epi
thel
ium
,pa
rtic
ular
ly in
the
geni
tal r
egio
n of
wom
en.
Caus
esTh
e ex
act c
ause
of l
iche
n sc
lero
sus
is u
nkno
wn
but s
ever
al ri
sk fa
ctor
s ha
vebe
en p
ropo
sed
such
as:
• G
enet
ic p
redi
spos
ition
.•
Prev
ious
his
tory
of a
utoi
mm
une
cond
ition
s (e
.g. t
hyro
id d
isea
se, t
ype
1
diab
etes
mel
litus
, viti
ligo)
.•
Low
oes
trog
en s
tatu
s –
due
to h
ighe
r pre
vale
nce
in p
ost-
men
opau
sal
w
omen
.
Sym
ptom
s•
Anog
enita
l les
ions
– a
trop
hic
whi
te m
acul
es.
• Fi
ssur
es.
• Ex
coria
tions
.
Inve
stig
atio
nsTy
pica
lly a
clin
ical
dia
gnos
is. A
bio
psy
may
be
need
ed to
con
firm
dia
gnos
isan
d as
sess
for c
ance
r.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion
– w
ash
regu
larly
, wea
r loo
se c
loth
ing.
• Ph
otog
raph
ic m
onito
ring
of le
sion
.
Med
ical
:•
Topi
c tr
eatm
ents
– e
mol
lient
s, st
eroi
ds, c
alci
neur
in in
hibi
tors
,
tacr
olim
us o
intm
ent,
retin
oids
.•
Syst
emic
– o
ral p
redn
isol
one,
retin
oids
, met
hotr
exat
e, c
iclo
spor
in.
Com
plic
atio
ns•
Incr
ease
d ris
k of
squ
amou
s ce
ll ca
rcin
oma.
• Ad
hesi
ons
and
scar
ring:
Phim
osis.
Intr
oita
l ste
nosi
s.
La
bia
min
ora
shrin
kage
.
Lich
en p
lanu
s
Wha
t is
lich
en p
lanu
s?Li
chen
pla
nus
is a
chr
onic
infla
mm
ator
y sk
in c
ondi
tion
char
acte
rized
by
wel
l-dem
arca
ted
purp
le p
apul
es p
rese
nt o
n m
ucou
s m
embr
anes
, fle
xor
surfa
ces
and
the
geni
tal a
rea.
It h
as a
sym
met
rical
dis
trib
utio
n.
Ther
e ar
e m
any
clin
ical
cla
ssifi
catio
ns o
f lic
hen
plan
us in
clud
ing,
bu
t not
lim
ited
to, c
utan
eous
lich
en p
lanu
s, m
ucos
al li
chen
pla
nus,
liche
n pl
anop
ilaris
and
lich
en p
lanu
s of
the
nails
.
Caus
esLi
chen
pla
nus
is th
ough
t to
be a
T-ce
ll m
edia
ted
auto
imm
une
dise
ase.
Re
sear
ch h
as s
ugge
sted
som
e co
ntrib
utin
g fa
ctor
s su
ch a
s:•
Gen
etic
pre
disp
ositi
on –
HLA
-DR1
.•
Trau
ma.
• Vi
ral i
nfec
tion
– HS
V, h
epat
itis
C.
Sym
ptom
s•
Poly
gona
l pur
ple
papu
les
in s
peci
fic re
gion
s su
ch a
s th
e w
rists
, shi
ns,
lo
wer
bac
k an
d ge
nita
l reg
ion.
• O
ral m
ucos
al in
volv
emen
t – W
ickh
am’s
stria
e.•
Scar
ring
alop
ecia
.•
Nai
l les
ions
– o
nych
olys
is, th
inni
ng, r
idgi
ng, p
tery
gium
, ano
nych
ia.
Inve
stig
atio
nsTy
pica
lly a
clin
ical
dia
gnos
is. A
bio
psy
may
be
need
ed to
con
firm
dia
gnos
is
and
asse
ss fo
r can
cer.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Dr
ug c
essa
tion
if re
spon
sibl
e fo
r lic
hen
plan
us-li
ke re
actio
n
(e.g
. ant
ibio
tics
[tetr
acyc
line]
, ant
i-rhe
umat
ic d
rugs
[pen
icill
amin
e]).
Med
ical
:•
Topi
c tr
eatm
ents
– s
tero
ids,
calc
ineu
rin in
hibi
tors
, tac
rolim
us o
intm
ent,
re
tinoi
ds.
• Sy
stem
ic –
ora
l pre
dnis
olon
e, m
etho
trex
ate,
aza
thio
prin
e.
Com
plic
atio
ns•
Incr
ease
d ris
k of
squ
amou
s ce
ll ca
rcin
oma.
MAP
7.6
. Lic
heno
id le
sion
s
K30033_C007.indd 194 28/02/17 11:21 am
195
Der
mat
olog
yM
ap 7
.6.
Lich
eno
id le
sio
ns
Lich
en s
cler
osus
Wha
t is
lich
en s
cler
osus
?It
is a
chr
onic
ski
n co
nditi
on th
at re
sults
in th
inni
ng o
f the
epi
thel
ium
,pa
rtic
ular
ly in
the
geni
tal r
egio
n of
wom
en.
Caus
esTh
e ex
act c
ause
of l
iche
n sc
lero
sus
is u
nkno
wn
but s
ever
al ri
sk fa
ctor
s ha
vebe
en p
ropo
sed
such
as:
• G
enet
ic p
redi
spos
ition
.•
Prev
ious
his
tory
of a
utoi
mm
une
cond
ition
s (e
.g. t
hyro
id d
isea
se, t
ype
1
diab
etes
mel
litus
, viti
ligo)
.•
Low
oes
trog
en s
tatu
s –
due
to h
ighe
r pre
vale
nce
in p
ost-
men
opau
sal
w
omen
.
Sym
ptom
s•
Anog
enita
l les
ions
– a
trop
hic
whi
te m
acul
es.
• Fi
ssur
es.
• Ex
coria
tions
.
Inve
stig
atio
nsTy
pica
lly a
clin
ical
dia
gnos
is. A
bio
psy
may
be
need
ed to
con
firm
dia
gnos
isan
d as
sess
for c
ance
r.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion
– w
ash
regu
larly
, wea
r loo
se c
loth
ing.
• Ph
otog
raph
ic m
onito
ring
of le
sion
.
Med
ical
:•
Topi
c tr
eatm
ents
– e
mol
lient
s, st
eroi
ds, c
alci
neur
in in
hibi
tors
,
tacr
olim
us o
intm
ent,
retin
oids
.•
Syst
emic
– o
ral p
redn
isol
one,
retin
oids
, met
hotr
exat
e, c
iclo
spor
in.
Com
plic
atio
ns•
Incr
ease
d ris
k of
squ
amou
s ce
ll ca
rcin
oma.
• Ad
hesi
ons
and
scar
ring:
Phim
osis.
Intr
oita
l ste
nosi
s.
La
bia
min
ora
shrin
kage
.
Lich
en p
lanu
s
Wha
t is
lich
en p
lanu
s?Li
chen
pla
nus
is a
chr
onic
infla
mm
ator
y sk
in c
ondi
tion
char
acte
rized
by
wel
l-dem
arca
ted
purp
le p
apul
es p
rese
nt o
n m
ucou
s m
embr
anes
, fle
xor
surfa
ces
and
the
geni
tal a
rea.
It h
as a
sym
met
rical
dis
trib
utio
n.
Ther
e ar
e m
any
clin
ical
cla
ssifi
catio
ns o
f lic
hen
plan
us in
clud
ing,
bu
t not
lim
ited
to, c
utan
eous
lich
en p
lanu
s, m
ucos
al li
chen
pla
nus,
liche
n pl
anop
ilaris
and
lich
en p
lanu
s of
the
nails
.
Caus
esLi
chen
pla
nus
is th
ough
t to
be a
T-ce
ll m
edia
ted
auto
imm
une
dise
ase.
Re
sear
ch h
as s
ugge
sted
som
e co
ntrib
utin
g fa
ctor
s su
ch a
s:•
Gen
etic
pre
disp
ositi
on –
HLA
-DR1
.•
Trau
ma.
• Vi
ral i
nfec
tion
– HS
V, h
epat
itis
C.
Sym
ptom
s•
Poly
gona
l pur
ple
papu
les
in s
peci
fic re
gion
s su
ch a
s th
e w
rists
, shi
ns,
lo
wer
bac
k an
d ge
nita
l reg
ion.
• O
ral m
ucos
al in
volv
emen
t – W
ickh
am’s
stria
e.•
Scar
ring
alop
ecia
.•
Nai
l les
ions
– o
nych
olys
is, th
inni
ng, r
idgi
ng, p
tery
gium
, ano
nych
ia.
Inve
stig
atio
nsTy
pica
lly a
clin
ical
dia
gnos
is. A
bio
psy
may
be
need
ed to
con
firm
dia
gnos
is
and
asse
ss fo
r can
cer.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Dr
ug c
essa
tion
if re
spon
sibl
e fo
r lic
hen
plan
us-li
ke re
actio
n
(e.g
. ant
ibio
tics
[tetr
acyc
line]
, ant
i-rhe
umat
ic d
rugs
[pen
icill
amin
e]).
Med
ical
:•
Topi
c tr
eatm
ents
– s
tero
ids,
calc
ineu
rin in
hibi
tors
, tac
rolim
us o
intm
ent,
re
tinoi
ds.
• Sy
stem
ic –
ora
l pre
dnis
olon
e, m
etho
trex
ate,
aza
thio
prin
e.
Com
plic
atio
ns•
Incr
ease
d ris
k of
squ
amou
s ce
ll ca
rcin
oma.
MAP
7.6
. Lic
heno
id le
sion
s
K30033_C007.indd 195 28/02/17 11:21 am
196
Der
mat
olog
yM
ap 7
.7.
Bu
llou
s d
iso
rder
s
Bullo
us p
emph
igoi
d
Wha
t is
bul
lous
pem
phig
oid?
Bullo
us p
emph
igoi
d is
a c
hron
ic a
utoi
mm
une,
blis
terin
g co
nditi
on. I
t is
twic
eas
com
mon
as
bullo
us p
emph
igus
and
tend
s to
pre
sent
in e
lder
ly p
atie
nts.
Caus
esIt
is th
ough
t to
be a
n au
toim
mun
e co
nditi
on in
whi
ch p
atie
nts
prod
uce
IgG
antib
odie
s an
d so
met
imes
als
o Ig
E an
tibod
ies
agai
nst s
peci
fic b
asem
ent
mem
bran
e gl
ycop
rote
ins.
Thes
e ar
e:•
BP18
0 (m
ost c
omm
on),
aka
type
XVI
I col
lage
n.•
BP23
0, a
ka p
laki
n.
Sym
ptom
s•
Wid
espr
ead
itchy
blis
ters
, typ
ical
ly in
flex
ural
are
as, w
hich
hea
l with
out
sc
arrin
g (th
e ex
cept
ion
to th
is is
cic
atric
ial p
emph
igoi
d, w
hich
doe
s sc
ar
and
also
affe
cts
the
orop
hary
nx).
Inve
stig
atio
nsTy
pica
lly a
clin
ical
dia
gnos
is c
onfir
med
with
pun
ch b
iops
y fo
llow
ed b
yim
mun
oflu
ores
cenc
e –
visu
aliz
es Ig
G a
nd C
3 at
der
moe
pide
rmal
junc
tion.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Dr
ug c
essa
tion
if re
spon
sibl
e fo
r pem
phig
oid-
like
reac
tion
(e
.g. f
uros
emid
e an
d pe
nici
llam
ine)
.
Med
ical
:•
Topi
cal t
reat
men
ts –
ste
roid
s in
mod
erat
e ca
ses.
• O
ral c
ortic
oste
roid
s.•
Imm
unos
uppr
essa
nts
(e.g
. aza
thio
prin
e an
d m
etho
trex
ate)
.•
Antib
iotic
s if
supe
radd
ed in
fect
ion
pres
ent.
Com
plic
atio
ns•
Usu
ally
a s
elf-l
imiti
ng c
ondi
tion
that
rem
its a
fter 1
–2 y
ears
.•
Supe
radd
ed in
fect
ion.
• Si
de e
ffect
s as
soci
ated
with
long
-ter
m s
tero
id o
r im
mun
osup
pres
sant
use
.
Bullo
us p
emph
igus
Wha
t is
bul
lous
pem
phig
us?
Bullo
us p
emph
igus
is a
gro
up o
f aut
oim
mun
e su
perfi
cial
ski
n di
sord
ers.
They
m
ay b
e cl
assi
fied
into
pem
phig
us v
ulga
ris, p
emph
igus
folia
ceus
and
pa
rane
opla
stic
pem
phig
us, w
ith p
emph
igus
vul
garis
bei
ng th
e m
ost
com
mon
.
Caus
esIt
is th
ough
t to
be a
n au
toim
mun
e co
nditi
on w
here
pat
ient
s pr
oduc
e Ig
G
antib
odie
s ag
ains
t des
mog
lein
(typ
ical
ly ty
pes
1 an
d 3)
. Des
mog
lein
is a
n ad
hesi
on m
olec
ule
that
is re
spon
sibl
e fo
r glu
ing
epid
erm
al c
ells
toge
ther
.
Sym
ptom
s•
Pain
ful s
uper
ficia
l blis
ters
– m
ay b
e er
ythe
mat
ous.
• In
itial
ly in
volv
es th
e or
opha
rynx
but
then
spr
eads
to o
ther
regi
ons
such
as
the
face
, che
st a
nd g
enita
l are
a.•
Nik
olsk
y’s
sign
may
be
appa
rent
.
Inve
stig
atio
nsPu
nch
biop
sy w
ith im
mun
oflu
ores
cenc
e –
visu
aliz
es a
cant
holy
sis.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Dr
ug c
essa
tion
if re
spon
sibl
e fo
r pem
phig
us-li
ke re
actio
n (e
.g. a
ntib
iotic
s
[pen
icill
in] a
nd o
ther
med
icat
ions
suc
h as
cap
topr
il an
d pe
nici
llam
ine)
.
Med
ical
:•
Ora
l cor
ticos
tero
ids.
• Im
mun
osup
pres
sant
s (e
.g. a
zath
iopr
ine
and
met
hotr
exat
e)•
Plas
map
here
sis
cons
ider
ed in
refra
ctor
y ca
ses.
Com
plic
atio
ns•
Seps
is.•
Side
effe
cts
asso
ciat
ed w
ith lo
ng-t
erm
ste
roid
use
.
MAP
7.7
. Bul
lous
dis
orde
rs
K30033_C007.indd 196 28/02/17 11:21 am
197
Der
mat
olog
yM
ap 7
.7.
Bu
llou
s d
iso
rder
s
Bullo
us p
emph
igoi
d
Wha
t is
bul
lous
pem
phig
oid?
Bullo
us p
emph
igoi
d is
a c
hron
ic a
utoi
mm
une,
blis
terin
g co
nditi
on. I
t is
twic
eas
com
mon
as
bullo
us p
emph
igus
and
tend
s to
pre
sent
in e
lder
ly p
atie
nts.
Caus
esIt
is th
ough
t to
be a
n au
toim
mun
e co
nditi
on in
whi
ch p
atie
nts
prod
uce
IgG
antib
odie
s an
d so
met
imes
als
o Ig
E an
tibod
ies
agai
nst s
peci
fic b
asem
ent
mem
bran
e gl
ycop
rote
ins.
Thes
e ar
e:•
BP18
0 (m
ost c
omm
on),
aka
type
XVI
I col
lage
n.•
BP23
0, a
ka p
laki
n.
Sym
ptom
s•
Wid
espr
ead
itchy
blis
ters
, typ
ical
ly in
flex
ural
are
as, w
hich
hea
l with
out
sc
arrin
g (th
e ex
cept
ion
to th
is is
cic
atric
ial p
emph
igoi
d, w
hich
doe
s sc
ar
and
also
affe
cts
the
orop
hary
nx).
Inve
stig
atio
nsTy
pica
lly a
clin
ical
dia
gnos
is c
onfir
med
with
pun
ch b
iops
y fo
llow
ed b
yim
mun
oflu
ores
cenc
e –
visu
aliz
es Ig
G a
nd C
3 at
der
moe
pide
rmal
junc
tion.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Dr
ug c
essa
tion
if re
spon
sibl
e fo
r pem
phig
oid-
like
reac
tion
(e
.g. f
uros
emid
e an
d pe
nici
llam
ine)
.
Med
ical
:•
Topi
cal t
reat
men
ts –
ste
roid
s in
mod
erat
e ca
ses.
• O
ral c
ortic
oste
roid
s.•
Imm
unos
uppr
essa
nts
(e.g
. aza
thio
prin
e an
d m
etho
trex
ate)
.•
Antib
iotic
s if
supe
radd
ed in
fect
ion
pres
ent.
Com
plic
atio
ns•
Usu
ally
a s
elf-l
imiti
ng c
ondi
tion
that
rem
its a
fter 1
–2 y
ears
.•
Supe
radd
ed in
fect
ion.
• Si
de e
ffect
s as
soci
ated
with
long
-ter
m s
tero
id o
r im
mun
osup
pres
sant
use
.
Bullo
us p
emph
igus
Wha
t is
bul
lous
pem
phig
us?
Bullo
us p
emph
igus
is a
gro
up o
f aut
oim
mun
e su
perfi
cial
ski
n di
sord
ers.
They
m
ay b
e cl
assi
fied
into
pem
phig
us v
ulga
ris, p
emph
igus
folia
ceus
and
pa
rane
opla
stic
pem
phig
us, w
ith p
emph
igus
vul
garis
bei
ng th
e m
ost
com
mon
.
Caus
esIt
is th
ough
t to
be a
n au
toim
mun
e co
nditi
on w
here
pat
ient
s pr
oduc
e Ig
G
antib
odie
s ag
ains
t des
mog
lein
(typ
ical
ly ty
pes
1 an
d 3)
. Des
mog
lein
is a
n ad
hesi
on m
olec
ule
that
is re
spon
sibl
e fo
r glu
ing
epid
erm
al c
ells
toge
ther
.
Sym
ptom
s•
Pain
ful s
uper
ficia
l blis
ters
– m
ay b
e er
ythe
mat
ous.
• In
itial
ly in
volv
es th
e or
opha
rynx
but
then
spr
eads
to o
ther
regi
ons
such
as
the
face
, che
st a
nd g
enita
l are
a.•
Nik
olsk
y’s
sign
may
be
appa
rent
.
Inve
stig
atio
nsPu
nch
biop
sy w
ith im
mun
oflu
ores
cenc
e –
visu
aliz
es a
cant
holy
sis.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Dr
ug c
essa
tion
if re
spon
sibl
e fo
r pem
phig
us-li
ke re
actio
n (e
.g. a
ntib
iotic
s
[pen
icill
in] a
nd o
ther
med
icat
ions
suc
h as
cap
topr
il an
d pe
nici
llam
ine)
.
Med
ical
:•
Ora
l cor
ticos
tero
ids.
• Im
mun
osup
pres
sant
s (e
.g. a
zath
iopr
ine
and
met
hotr
exat
e)•
Plas
map
here
sis
cons
ider
ed in
refra
ctor
y ca
ses.
Com
plic
atio
ns•
Seps
is.•
Side
effe
cts
asso
ciat
ed w
ith lo
ng-t
erm
ste
roid
use
.
MAP
7.7
. Bul
lous
dis
orde
rs
K30033_C007.indd 197 28/02/17 11:21 am
198
Der
mat
olog
yM
ap 7
.8.
Acn
e vu
lgar
is
Wha
t is
acn
e vu
lgar
is?
Acne
vul
garis
is a
com
mon
con
ditio
n th
at re
sults
in a
ser
ies
of s
kin
lesi
ons
rang
ing
from
co
meo
dom
es to
pus
tule
s, pa
pule
s an
d sc
arrin
g. It
may
be
clas
sifie
d as
mild
, mod
erat
e or
se
vere
.•
Mild
– c
omeo
dom
es (o
pen
and
clos
ed),
som
e pa
pule
s, so
me
pust
ules
.•
Mod
erat
e –
incr
easi
ng n
umbe
r of p
apul
es a
nd p
ustu
les,
mild
sca
rrin
g.•
Seve
re –
com
eodo
mes
, pap
ules
, pus
tule
s pl
us m
ore
exte
nsiv
e sc
arrin
g an
d no
dula
r
absc
esse
s.Ac
ne fu
lmin
ans
is a
rare
but
ver
y se
vere
form
of a
cne
seen
exc
lusi
vely
in a
dole
scen
t mal
es.
It is
cau
sed
by a
n im
mun
e re
actio
n to
Pro
pion
obac
teriu
m a
cnes
.
Caus
esFo
llicu
lar k
erat
iniz
atio
n, s
ebor
rhoe
a an
d co
loni
zatio
n of
the
pilo
seba
ceou
s un
it w
ithP.
acne
s ar
e ce
ntra
l to
the
deve
lopm
ent o
f acn
e sk
in le
sion
s.
Rese
arch
has
sho
wn
that
hor
mon
al fa
ctor
s an
d ge
netic
com
pone
nts
may
als
o pl
ay a
ro
le s
ince
they
may
faci
litat
e an
env
ironm
ent p
rovi
ding
opt
imal
con
ditio
ns fo
r the
gro
wth
of P
. acn
es a
s w
ell a
s im
pact
ing
on th
e su
bseq
uent
infla
mm
ator
y re
actio
n.Ex
acer
batin
g fa
ctor
s in
clud
e:•
Cosm
etic
s –
part
icul
arly
oily
cre
ams.
• Ce
rtai
n cl
othi
ng (e
.g. h
igh
colla
red
shirt
s)•
Exce
ssiv
e sw
eatin
g.•
Exce
ssiv
e an
drog
en p
rodu
ctio
n (e
.g. p
olyc
ystic
ova
ry s
yndr
ome
[PCO
S]).
Sym
ptom
sAl
l or s
ome
of th
e fo
llow
ing
lesi
ons
may
be
pres
ent:
• Co
meo
dom
es.
• Pa
pule
s.•
Pust
ules
.•
Cyst
s.•
Pseu
docy
sts.
• Sc
arrin
g (ic
e pi
ck s
carr
ing)
.•
Exco
riatio
ns.
• Er
ythe
mat
ous
or p
igm
ente
d m
acul
es.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vice
rega
rdin
g sk
in h
ygie
ne.
Med
ical
:•
Mild
: bla
ckhe
ads
and
whi
tehe
ads:
Topi
cal r
etin
oid
(e.g
. iso
tret
inoi
n).
Benz
oyl p
erox
ide.
Cons
ider
com
bine
d or
al c
ontr
acep
tive
pill
(CO
CP).
• M
oder
ate:
pap
ules
and
pus
tule
s:
To
pica
l ant
ibio
tic w
ith to
pica
l ret
inoi
d or
ben
zoyl
per
oxid
e.
O
ral a
ntib
iotic
(e.g
. lym
ecyc
line
com
bine
d w
ith to
pica
l age
nt).
Cons
ider
CO
CP.
• Se
vere
: pap
ulop
ustu
lar w
ith n
odul
es +
/– s
carr
ing:
Refe
r to
derm
atol
ogy
for t
reat
men
t with
isot
retin
oin.
Prov
ide
mod
erat
e le
vel a
cne
man
agem
ent w
hile
wai
ting
for
refe
rral
.
Co
nsid
er C
OCP
, spe
cific
ally
Dia
nett
e.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is; h
owev
er, i
n so
me
case
s if
hype
rand
roge
nism
is s
uspe
cted
in
fem
ales
, fur
ther
test
s sh
ould
be
unde
rtak
en.
(See
Map
3.5
[PCO
S], p
. 84.
)
Com
plic
atio
ns•
Scar
ring.
• Ps
ycho
logi
cal (
e.g.
dep
ress
ion)
.•
Side
effe
cts
of tr
eatm
ent (
e.g.
isot
retin
oin
–
chei
litis,
incr
ease
d ris
k of
sun
burn
,
tera
toge
nic,
mya
lgia
).
MAP
7.8
. Acn
e vu
lgar
is
K30033_C007.indd 198 28/02/17 11:21 am
199
Der
mat
olog
yM
ap 7
.8.
Acn
e vu
lgar
is
Wha
t is
acn
e vu
lgar
is?
Acne
vul
garis
is a
com
mon
con
ditio
n th
at re
sults
in a
ser
ies
of s
kin
lesi
ons
rang
ing
from
co
meo
dom
es to
pus
tule
s, pa
pule
s an
d sc
arrin
g. It
may
be
clas
sifie
d as
mild
, mod
erat
e or
se
vere
.•
Mild
– c
omeo
dom
es (o
pen
and
clos
ed),
som
e pa
pule
s, so
me
pust
ules
.•
Mod
erat
e –
incr
easi
ng n
umbe
r of p
apul
es a
nd p
ustu
les,
mild
sca
rrin
g.•
Seve
re –
com
eodo
mes
, pap
ules
, pus
tule
s pl
us m
ore
exte
nsiv
e sc
arrin
g an
d no
dula
r
absc
esse
s.Ac
ne fu
lmin
ans
is a
rare
but
ver
y se
vere
form
of a
cne
seen
exc
lusi
vely
in a
dole
scen
t mal
es.
It is
cau
sed
by a
n im
mun
e re
actio
n to
Pro
pion
obac
teriu
m a
cnes
.
Caus
esFo
llicu
lar k
erat
iniz
atio
n, s
ebor
rhoe
a an
d co
loni
zatio
n of
the
pilo
seba
ceou
s un
it w
ithP.
acne
s ar
e ce
ntra
l to
the
deve
lopm
ent o
f acn
e sk
in le
sion
s.
Rese
arch
has
sho
wn
that
hor
mon
al fa
ctor
s an
d ge
netic
com
pone
nts
may
als
o pl
ay a
ro
le s
ince
they
may
faci
litat
e an
env
ironm
ent p
rovi
ding
opt
imal
con
ditio
ns fo
r the
gro
wth
of P
. acn
es a
s w
ell a
s im
pact
ing
on th
e su
bseq
uent
infla
mm
ator
y re
actio
n.Ex
acer
batin
g fa
ctor
s in
clud
e:•
Cosm
etic
s –
part
icul
arly
oily
cre
ams.
• Ce
rtai
n cl
othi
ng (e
.g. h
igh
colla
red
shirt
s)•
Exce
ssiv
e sw
eatin
g.•
Exce
ssiv
e an
drog
en p
rodu
ctio
n (e
.g. p
olyc
ystic
ova
ry s
yndr
ome
[PCO
S]).
Sym
ptom
sAl
l or s
ome
of th
e fo
llow
ing
lesi
ons
may
be
pres
ent:
• Co
meo
dom
es.
• Pa
pule
s.•
Pust
ules
.•
Cyst
s.•
Pseu
docy
sts.
• Sc
arrin
g (ic
e pi
ck s
carr
ing)
.•
Exco
riatio
ns.
• Er
ythe
mat
ous
or p
igm
ente
d m
acul
es.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vice
rega
rdin
g sk
in h
ygie
ne.
Med
ical
:•
Mild
: bla
ckhe
ads
and
whi
tehe
ads:
Topi
cal r
etin
oid
(e.g
. iso
tret
inoi
n).
Benz
oyl p
erox
ide.
Cons
ider
com
bine
d or
al c
ontr
acep
tive
pill
(CO
CP).
• M
oder
ate:
pap
ules
and
pus
tule
s:
To
pica
l ant
ibio
tic w
ith to
pica
l ret
inoi
d or
ben
zoyl
per
oxid
e.
O
ral a
ntib
iotic
(e.g
. lym
ecyc
line
com
bine
d w
ith to
pica
l age
nt).
Cons
ider
CO
CP.
• Se
vere
: pap
ulop
ustu
lar w
ith n
odul
es +
/– s
carr
ing:
Refe
r to
derm
atol
ogy
for t
reat
men
t with
isot
retin
oin.
Prov
ide
mod
erat
e le
vel a
cne
man
agem
ent w
hile
wai
ting
for
refe
rral
.
Co
nsid
er C
OCP
, spe
cific
ally
Dia
nett
e.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is; h
owev
er, i
n so
me
case
s if
hype
rand
roge
nism
is s
uspe
cted
in
fem
ales
, fur
ther
test
s sh
ould
be
unde
rtak
en.
(See
Map
3.5
[PCO
S], p
. 84.
)
Com
plic
atio
ns•
Scar
ring.
• Ps
ycho
logi
cal (
e.g.
dep
ress
ion)
.•
Side
effe
cts
of tr
eatm
ent (
e.g.
isot
retin
oin
–
chei
litis,
incr
ease
d ris
k of
sun
burn
,
tera
toge
nic,
mya
lgia
).
MAP
7.8
. Acn
e vu
lgar
is
K30033_C007.indd 199 28/02/17 11:21 am
200
Der
mat
olog
yM
ap 7
.9.
Ro
sace
a
Wha
t is
ros
acea
?Ro
sace
a is
a c
hron
ic in
flam
mat
ory
eryt
hem
atou
s de
rmat
osis
typi
cally
invo
lvin
g th
e ce
ntra
l fa
ce. I
t is
mor
e co
mm
on in
wom
en a
nd g
ener
ally
affe
cts
thos
e ag
ed 3
0–60
yea
rs.
Caus
esTh
e ex
act c
ause
of r
osac
ea is
unk
now
n bu
t it i
s th
ough
t to
invo
lve
both
gen
etic
and
en
viro
nmen
tal f
acto
rs. P
oten
tial i
nflu
enci
ng fa
ctor
s in
clud
e:•
Skin
type
– m
ore
com
mon
in fa
ir sk
inne
d in
divi
dual
s w
ith C
eltic
orig
in.
• Hi
gh le
vels
of c
athe
licid
ins
(ant
imic
robi
al p
eptid
es).
• Va
sodi
latio
n of
blo
od v
esse
ls c
oupl
ed w
ith fa
ctor
s in
fluen
cing
hyp
erpl
asia
of t
he
se
bace
ous
glan
ds.
• In
volv
emen
t of m
atrix
met
allo
prot
eina
ses
(e.g
. ela
stas
e an
d co
llage
nase
).Ex
acer
batin
g fa
ctor
s in
clud
e:•
Cosm
etic
s –
part
icul
arly
oily
cre
ams.
• Sp
icy
food
s.•
Alco
hol.
• He
at (e
.g. h
ot s
how
ers
or h
ot ro
oms)
.•
UV
expo
sure
.•
Topi
cal s
tero
ids.
Sym
ptom
sAl
l or s
ome
of th
e fo
llow
ing
lesi
ons
may
be
pres
ent:
• Do
me
shap
ed p
apul
es +
/– p
ustu
les.
• Fa
cial
flus
hing
.•
Tela
ngie
ctas
ia.
• Dr
y an
d se
nsiti
ve s
kin.
• Se
bace
ous
hype
rpla
sia.
• Rh
inop
hym
a (w
hisk
ey n
ose)
.•
Blep
haro
phym
a.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vice
to a
void
exa
cerb
atin
g fa
ctor
s.
Med
ical
:•
Mild
:
To
pica
l met
roni
dazo
le (1
st li
ne).
Azel
aic
acid
(alte
rnat
ive)
.•
Mod
erat
e –
seve
re:
Ora
l tet
racy
clin
es o
r ery
thro
myc
in.
• O
cula
r ros
acea
:
O
cula
r lub
rican
ts.
Ora
l tet
racy
clin
es.
Inve
stig
atio
nsTh
is is
a c
linic
al d
iagn
osis.
If a
ski
n bi
opsy
is
perfo
rmed
, it w
ill d
emon
stra
te v
ascu
lar a
nd
chro
nic
infla
mm
ator
y ch
ange
s.
Com
plic
atio
ns•
Psyc
holo
gica
l (e.
g. d
epre
ssio
n).
• O
cula
r ros
acea
.
MAP
7.9
. Ros
acea
K30033_C007.indd 200 28/02/17 11:21 am
201
Der
mat
olog
yM
ap 7
.9.
Ro
sace
a
Wha
t is
ros
acea
?Ro
sace
a is
a c
hron
ic in
flam
mat
ory
eryt
hem
atou
s de
rmat
osis
typi
cally
invo
lvin
g th
e ce
ntra
l fa
ce. I
t is
mor
e co
mm
on in
wom
en a
nd g
ener
ally
affe
cts
thos
e ag
ed 3
0–60
yea
rs.
Caus
esTh
e ex
act c
ause
of r
osac
ea is
unk
now
n bu
t it i
s th
ough
t to
invo
lve
both
gen
etic
and
en
viro
nmen
tal f
acto
rs. P
oten
tial i
nflu
enci
ng fa
ctor
s in
clud
e:•
Skin
type
– m
ore
com
mon
in fa
ir sk
inne
d in
divi
dual
s w
ith C
eltic
orig
in.
• Hi
gh le
vels
of c
athe
licid
ins
(ant
imic
robi
al p
eptid
es).
• Va
sodi
latio
n of
blo
od v
esse
ls c
oupl
ed w
ith fa
ctor
s in
fluen
cing
hyp
erpl
asia
of t
he
se
bace
ous
glan
ds.
• In
volv
emen
t of m
atrix
met
allo
prot
eina
ses
(e.g
. ela
stas
e an
d co
llage
nase
).Ex
acer
batin
g fa
ctor
s in
clud
e:•
Cosm
etic
s –
part
icul
arly
oily
cre
ams.
• Sp
icy
food
s.•
Alco
hol.
• He
at (e
.g. h
ot s
how
ers
or h
ot ro
oms)
.•
UV
expo
sure
.•
Topi
cal s
tero
ids.
Sym
ptom
sAl
l or s
ome
of th
e fo
llow
ing
lesi
ons
may
be
pres
ent:
• Do
me
shap
ed p
apul
es +
/– p
ustu
les.
• Fa
cial
flus
hing
.•
Tela
ngie
ctas
ia.
• Dr
y an
d se
nsiti
ve s
kin.
• Se
bace
ous
hype
rpla
sia.
• Rh
inop
hym
a (w
hisk
ey n
ose)
.•
Blep
haro
phym
a.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• Ad
vice
to a
void
exa
cerb
atin
g fa
ctor
s.
Med
ical
:•
Mild
:
To
pica
l met
roni
dazo
le (1
st li
ne).
Azel
aic
acid
(alte
rnat
ive)
.•
Mod
erat
e –
seve
re:
Ora
l tet
racy
clin
es o
r ery
thro
myc
in.
• O
cula
r ros
acea
:
O
cula
r lub
rican
ts.
Ora
l tet
racy
clin
es.
Inve
stig
atio
nsTh
is is
a c
linic
al d
iagn
osis.
If a
ski
n bi
opsy
is
perfo
rmed
, it w
ill d
emon
stra
te v
ascu
lar a
nd
chro
nic
infla
mm
ator
y ch
ange
s.
Com
plic
atio
ns•
Psyc
holo
gica
l (e.
g. d
epre
ssio
n).
• O
cula
r ros
acea
.
MAP
7.9
. Ros
acea
K30033_C007.indd 201 28/02/17 11:21 am
202
Der
mat
olog
yM
ap 7
.10.
Alo
pec
ia a
reat
a
Wha
t is
alo
peci
a ar
eata
?Ha
ir gr
owth
con
sist
s of
four
sta
ges:
1. A
nage
n –
the
grow
th p
hase
.2.
Cat
agen
– th
e in
volu
tion
phas
e.3.
Tel
ogen
– th
e re
stin
g ph
ase.
4. R
elea
se –
the
rele
ase
of th
e ha
ir sh
aft.
Alop
ecia
are
ata
is a
chr
onic
rela
psin
g au
toim
mun
e co
nditi
on w
here
the
anag
en p
hase
is
prem
atur
ely
arre
sted
. It i
s a
loca
lized
non
-sca
rrin
g al
opec
ia. B
road
ly s
peak
ing,
alo
peci
a m
ay b
e de
fined
as
diffu
se n
on-s
carr
ing,
loca
lized
sca
rrin
g, a
nd s
carr
ing.
Eac
h ca
tego
ry h
as
a di
ffere
nt c
ause
:•
Diffu
se n
on-s
carr
ing:
dru
g in
duce
d, m
etab
olic
.•
Loca
lized
sca
rrin
g: a
lope
cia
area
ta, t
raum
a, ri
ngw
orm
.•
Scar
ring:
trau
ma
(bur
ns),
liche
n pl
anus
, dis
coid
lupu
s.
Caus
esTh
e ex
act c
ause
and
mec
hani
sm o
f alo
peci
a ar
eata
is u
nkno
wn.
In s
ome
case
s th
e au
toim
mun
e co
nditi
on m
ay b
e tr
igge
red
by tr
aum
a, s
tres
s or
vira
l inf
ectio
n. T
hose
with
a
first
-deg
ree
rela
tive
suffe
ring
with
alo
peci
a ar
eata
are
mor
e lik
ely
to b
e af
fect
ed.
Sym
ptom
sHa
ir lo
ss m
ay in
volv
e th
e sc
alp,
eye
brow
s,ey
elas
hes
or b
eard
.•
Circ
ular
regi
ons
of h
air l
oss.
• N
on-s
carr
ing.
• Ex
clam
atio
n m
ark
hairs
.•
Nai
l cha
nges
are
app
aren
t in
10–1
5%
o
f pat
ient
s an
d in
clud
e Be
au's
line
s,
onyc
holy
sis
and
koilo
nych
ia.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• As
sess
the
exte
nt o
f hai
r los
s us
ing
scal
es
such
as
the
Lugw
ig S
cale
and
the
Nor
woo
d
Scal
e.•
Cons
ider
the
use
of w
igs
or p
artia
l wig
s.
Med
ical
:•
Evid
ence
of h
air r
egro
wth
:
N
o tr
eatm
ent.
• N
o ha
ir re
grow
th a
nd <
50%
hai
r los
s:
Di
scus
s w
atch
ful w
aitin
g an
d pa
tient
pref
eren
ce.
If tr
eatm
ent p
refe
rred
, ref
er to
derm
atol
ogy
whe
re tr
eatm
ent w
ith
in
tral
esio
nal c
ortic
oste
roid
s m
ay b
e
co
mm
ence
d.•
No
hair
regr
owth
and
>50
% h
air l
oss:
Derm
atol
ogy
refe
rral
whe
re to
pica
l
im
mun
othe
rapy
may
be
com
men
ced.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is. Tr
icho
scop
y is
use
dto
exa
min
e th
e ha
ir an
d sc
alp.
Com
plic
atio
ns•
Psyc
holo
gica
l (e.
g. d
epre
ssio
n).
• In
crea
sed
risk
of o
ther
aut
oim
mun
e
cond
ition
s (e
.g. d
iabe
tes
and
thyr
oid
dise
ase)
.
MAP
7.1
0. A
lope
cia
area
ta
K30033_C007.indd 202 28/02/17 11:21 am
203
Der
mat
olog
yM
ap 7
.10.
Alo
pec
ia a
reat
a
Wha
t is
alo
peci
a ar
eata
?Ha
ir gr
owth
con
sist
s of
four
sta
ges:
1. A
nage
n –
the
grow
th p
hase
.2.
Cat
agen
– th
e in
volu
tion
phas
e.3.
Tel
ogen
– th
e re
stin
g ph
ase.
4. R
elea
se –
the
rele
ase
of th
e ha
ir sh
aft.
Alop
ecia
are
ata
is a
chr
onic
rela
psin
g au
toim
mun
e co
nditi
on w
here
the
anag
en p
hase
is
prem
atur
ely
arre
sted
. It i
s a
loca
lized
non
-sca
rrin
g al
opec
ia. B
road
ly s
peak
ing,
alo
peci
a m
ay b
e de
fined
as
diffu
se n
on-s
carr
ing,
loca
lized
sca
rrin
g, a
nd s
carr
ing.
Eac
h ca
tego
ry h
as
a di
ffere
nt c
ause
:•
Diffu
se n
on-s
carr
ing:
dru
g in
duce
d, m
etab
olic
.•
Loca
lized
sca
rrin
g: a
lope
cia
area
ta, t
raum
a, ri
ngw
orm
.•
Scar
ring:
trau
ma
(bur
ns),
liche
n pl
anus
, dis
coid
lupu
s.
Caus
esTh
e ex
act c
ause
and
mec
hani
sm o
f alo
peci
a ar
eata
is u
nkno
wn.
In s
ome
case
s th
e au
toim
mun
e co
nditi
on m
ay b
e tr
igge
red
by tr
aum
a, s
tres
s or
vira
l inf
ectio
n. T
hose
with
a
first
-deg
ree
rela
tive
suffe
ring
with
alo
peci
a ar
eata
are
mor
e lik
ely
to b
e af
fect
ed.
Sym
ptom
sHa
ir lo
ss m
ay in
volv
e th
e sc
alp,
eye
brow
s,ey
elas
hes
or b
eard
.•
Circ
ular
regi
ons
of h
air l
oss.
• N
on-s
carr
ing.
• Ex
clam
atio
n m
ark
hairs
.•
Nai
l cha
nges
are
app
aren
t in
10–1
5%
o
f pat
ient
s an
d in
clud
e Be
au's
line
s,
onyc
holy
sis
and
koilo
nych
ia.
Trea
tmen
t
Cons
erva
tive
:•
Patie
nt e
duca
tion.
• As
sess
the
exte
nt o
f hai
r los
s us
ing
scal
es
such
as
the
Lugw
ig S
cale
and
the
Nor
woo
d
Scal
e.•
Cons
ider
the
use
of w
igs
or p
artia
l wig
s.
Med
ical
:•
Evid
ence
of h
air r
egro
wth
:
N
o tr
eatm
ent.
• N
o ha
ir re
grow
th a
nd <
50%
hai
r los
s:
Di
scus
s w
atch
ful w
aitin
g an
d pa
tient
pref
eren
ce.
If tr
eatm
ent p
refe
rred
, ref
er to
derm
atol
ogy
whe
re tr
eatm
ent w
ith
in
tral
esio
nal c
ortic
oste
roid
s m
ay b
e
co
mm
ence
d.•
No
hair
regr
owth
and
>50
% h
air l
oss:
Derm
atol
ogy
refe
rral
whe
re to
pica
l
im
mun
othe
rapy
may
be
com
men
ced.
Inve
stig
atio
nsU
sual
ly a
clin
ical
dia
gnos
is. Tr
icho
scop
y is
use
dto
exa
min
e th
e ha
ir an
d sc
alp.
Com
plic
atio
ns•
Psyc
holo
gica
l (e.
g. d
epre
ssio
n).
• In
crea
sed
risk
of o
ther
aut
oim
mun
e
cond
ition
s (e
.g. d
iabe
tes
and
thyr
oid
dise
ase)
.
MAP
7.1
0. A
lope
cia
area
ta
K30033_C007.indd 203 28/02/17 11:21 am
204
Der
mat
olog
yTa
ble
7.1.
Vir
al s
kin
infe
ctio
ns
TABL
E 7.
1. V
iral
ski
n in
fect
ions
.
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Herp
es
sim
plex
vi
rus
(HSV
)
Type
1: H
SV ty
pe 1
Type
2: H
SV ty
pe 2
Spre
ad v
ia d
irect
con
tact
as
wel
l as
drop
let s
prea
d. M
ay
reac
tivat
e w
ith tr
igge
ring
fact
ors
such
as
stre
ss a
nd
trau
ma
Both
form
s of
HSV
may
pr
esen
t with
a b
urni
ng
or ti
nglin
g se
nsat
ion
befo
re th
e ou
tbre
ak o
f vi
sual
lesi
ons
Type
1: p
erio
ral l
esio
ns –
pa
infu
l ves
icle
s an
d ul
cers
. May
man
ifest
as
her
petic
whi
tlow
on
infe
cted
fing
er
Type
2: p
enile
lesi
ons,
vulv
ovag
initi
s, an
al
lesi
ons
Cultu
re/P
CR o
f vira
l sw
ab•
Acic
lovi
r•
Vala
cicl
ovir
• Fa
mci
clov
ir
• En
ceph
aliti
s•
Ocu
lar i
nfec
tion
• Ec
zem
a he
rpet
icum
•
Recu
rren
t ery
them
a m
ultif
orm
e
K30033_C007.indd 204 28/02/17 11:21 am
205
Der
mat
olog
yTa
ble
7.1.
Vir
al s
kin
infe
ctio
ns
Herp
es
zost
er
(shi
ngle
s)
Varic
ella
zos
ter v
irus
(VZV
)
Initi
al in
fect
ion
caus
es c
hick
-en
pox.
Thi
s re
mai
ns d
orm
ant
in a
sen
sory
root
gan
glio
n.
Whe
n re
activ
ated
, shi
ngle
s oc
curs
Pain
and
par
aest
hesi
a de
velo
p al
ong
a de
rmal
di
strib
utio
n up
to 5
da
ys b
efor
e th
e on
set
of v
esic
le d
evel
opm
ent.
Thes
e ve
sicl
es e
vent
ually
cr
ust o
ver
• U
sual
ly a
clin
ical
di
agno
sis
• VZ
V sp
ecifi
c Ig
M
antib
ody
• El
ectr
on m
icro
scop
y
• An
tivira
l age
nt:
acic
lovi
r sho
uld
be
give
n w
ithin
72
hour
s of
rash
ons
et•
Anal
gesi
a:M
ild to
mod
erat
e –
para
ceta
mol
alo
ne o
r in
com
bina
tion
with
an
NSA
ID o
r cod
eine
.Se
vere
– if
the
abov
e m
etho
ds h
ave
faile
d an
d pa
in is
sev
ere,
co
nsid
er a
mitr
ipty
line
or p
rega
balin
• Sc
arrin
g•
Post
-her
petic
ne
ural
gia
• Ra
msa
y Hu
nt
synd
rom
e (c
rani
al n
erve
VII
invo
lvem
ent)
• Zo
ster
oph
thal
mic
us
(oph
thal
mic
div
isio
n of
the
trig
emin
al
nerv
e af
fect
ed)
Cont
inue
d ov
erle
af
K30033_C007.indd 205 28/02/17 11:21 am
206
Der
mat
olog
yTa
ble
7.1.
Vir
al s
kin
infe
ctio
ns
TABL
E 7.
1. V
iral
ski
n in
fect
ions
(con
tinue
d ).
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Vira
l war
tsHu
man
pap
illom
aviru
s (H
PV) –
a d
oubl
e-st
rand
ed
DNA
viru
s. Th
ere
are
man
y di
ffere
nt ty
pes
invo
lved
with
w
art f
orm
atio
n in
diff
eren
t re
gion
s of
the
body
:
• Ty
pe 1
: pla
ntar
war
ts•
Type
2: p
lant
ar w
arts
and
co
mm
on w
arts
• Ty
pe 4
: com
mon
war
ts•
Type
s 6
& 1
1: a
noge
nita
l w
arts
•
Type
16:
oro
phar
ynge
al
canc
er•
Type
16
& 1
8: c
ervi
cal
canc
er
Dom
e-sh
aped
pap
ules
/no
dule
s w
ith a
n irr
egul
ar
papi
llife
rous
sur
face
• Cl
inic
al d
iagn
osis
•
Mic
rosc
opy
– hy
perk
erat
otic
ep
ider
mis
• Ce
rvic
al s
mea
r w
ith li
quid
-bas
ed
cyto
logy
– fo
r cer
vica
l HP
V
• HP
V va
ccin
atio
n pr
ogra
mm
e ai
min
g to
re
duce
the
prev
alen
ce
of c
ervi
cal c
ance
r•
For w
arts
:
Salic
ylic
aci
d
Imiq
uim
od c
ream
Cryo
ther
apy
with
liq
uid
nitr
ogen
• Pa
in (e
.g. p
lant
ar w
art
affe
ctin
g ga
it cy
cle)
• Sp
read
• Lo
cal i
nfec
tion
• M
alig
nant
cha
nge
K30033_C007.indd 206 28/02/17 11:21 am
207
TABL
E 7.
2. P
aras
itic
ski
n in
fect
ions
.
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Head
lice
Pe
dicu
losi
s hu
man
us c
apiti
s•
May
be
asym
ptom
atic
• Itc
hing
Vi
sual
izat
ion
of
infe
stat
ion.
A fi
ne
toot
hcom
b is
ofte
n us
ed
Inse
ctic
idal
sha
mpo
o co
ntai
ning
per
met
hrin
or
mal
athi
on. T
reat
ho
useh
old
mem
bers
and
cl
ose
cont
acts
if in
fest
ed
Infe
ctio
n se
cond
ary
to
scra
tchi
ng
Scab
ies
Sarc
opte
s sc
abie
i•
Itchi
ng
• Sm
all p
apul
es w
here
the
mite
ha
s bu
rrow
ed b
enea
th th
e sk
in –
ofte
n at
the
web
s of
fin
gers
, the
wris
t and
in th
e ge
nita
l reg
ion
• Li
near
trac
ks o
f the
bu
rrow
ing
mite
Clin
ical
dia
gnos
isM
ite m
ay b
e vi
sual
ized
on
der
mat
osco
py
• Pe
rmet
hrin
or
mal
athi
on s
houl
d be
ap
plie
d to
the
entir
e bo
dy e
xcep
t the
face
• Al
l hou
seho
ld
mem
bers
and
clo
se
cont
acts
requ
ire
trea
tmen
t•
Bed
linen
etc
. req
uire
s th
orou
gh w
ashi
ng o
n hi
gh h
eat
Nor
weg
ian
crus
ted
scab
ies
in
imm
unos
uppr
esse
d pa
tient
s
Tabl
e 7.
2. P
aras
itic
skin
infe
ctio
nsD
erm
atol
ogy
K30033_C007.indd 207 28/02/17 11:21 am
208
Der
mat
olog
yTa
ble
7.3.
Bac
teri
al s
kin
infe
ctio
ns
TABL
E 7.
3. B
acte
rial
ski
n in
fect
ions
.
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Impe
tigo
Stap
hylo
cocc
us
aure
us (c
omm
on-
est)
Stre
ptoc
occi
• Er
ythe
mat
ous
eros
ions
with
ye
llow
cru
stin
gBa
cter
ial s
wab
s•
Topi
cal f
ucid
in
crea
m•
Fluc
loxa
cilli
n
(S. a
ureu
s)•
Peni
cilli
n (s
trep
toco
cci)
• Er
ythr
omyc
in if
al
lerg
ic to
pen
icill
in
• Sc
arrin
g•
Post
-str
epto
cocc
al
glom
erul
onep
hriti
s•
Scar
let f
ever
• Se
ptic
aem
ia
• St
aphy
loco
ccal
sca
lded
sk
in s
yndr
ome
Cellu
litis
Beta
-hae
mol
ytic
st
rept
ococ
ci
Stap
hylo
cocc
us
aure
us
• Te
nder
ness
on
palp
atio
n•
Eryt
hem
atou
s le
sion
• Ca
rdin
al s
igns
of i
nflam
mat
ion
• Ly
mph
aden
opat
hy•
Feve
r •
Mal
aise
Ofte
n a
clin
ical
di
agno
sis.
Follo
w lo
cal
hosp
ital g
uide
lines
an
d ta
ke b
lood
cu
lture
s
• Fl
uclo
xaci
llin
(S
. aur
eus)
• Pe
nici
llin
(str
epto
cocc
i )•
Eryt
hrom
ycin
if
alle
rgic
to p
enic
illin
• Se
ptic
aem
ia•
Absc
ess
form
atio
n –
requ
ires
surg
ical
dr
aina
ge•
Toxi
c sh
ock-
like
synd
rom
e
K30033_C007.indd 208 28/02/17 11:21 am
209
Der
mat
olog
yTa
ble
7.3.
Bac
teri
al s
kin
infe
ctio
ns
Gas
ga
ngre
neCl
ostr
idiu
m
perfr
inge
ns•
Sym
ptom
s oc
cur a
t the
site
of
trau
ma
• In
flam
mat
ion
• Pa
in•
Indu
ratio
n•
In a
dvan
ced
dise
ase
– cr
epitu
s fe
lt in
mus
cle
and
dist
al p
ulse
s ar
e lo
st
• Sw
abs
– G
ram
st
ain
• Bl
ood
test
s –
FBC,
WCC
, LDH
, bl
ood
cultu
res,
bioc
hem
istr
y pr
ofile
• Im
agin
g –
radi
ogra
phy
and
CT s
cann
ing
• W
ound
de
brid
emen
t •
Skin
gra
fting
may
be
requ
ired
in
seve
re c
ases
• Pe
nici
llin
• Sc
arrin
g –
may
requ
ire
reco
nstr
uctiv
e su
rger
y•
Mul
ti-or
gan
failu
re
Lepr
osy
(Han
sen’
s di
seas
e)
Myc
obac
teriu
m
lepr
ae, a
n in
trac
ellu
lar
acid
–fas
t bac
illus
(g
ranu
lom
atou
s di
seas
e)
• Sk
in le
sion
s –
eryt
hem
atou
s or
hy
popi
gmen
ted
• Pe
riphe
ral n
erve
invo
lvem
ent
– m
otor
wea
knes
s an
d se
nsor
y im
pairm
ent
• Sa
ddle
nos
e•
Loss
of d
igits
/lim
bs d
ue to
se
cond
ary
infe
ctio
ns
Ther
e ar
e th
ree
diffe
rent
form
s of
le
pros
y:
• Tu
berc
uloi
d: m
ildes
t for
m
• Le
prom
atou
s: m
ost s
ever
e fo
rm
and
very
con
tagi
ous
• Bo
rder
line:
mix
ed p
ictu
re o
f tu
berc
uloi
d an
d le
prom
atou
s fo
rms
Skin
bio
psy
– ac
id–f
ast
baci
llus
• Da
pson
e•
Rifa
mpi
cin
• Sc
arrin
g an
d di
sfigu
ratio
n•
Mal
e in
fert
ility
and
er
ectil
e dy
sfun
ctio
n•
Gla
ucom
a•
Kidn
ey fa
ilure
• Pe
rman
ent p
erip
hera
l ne
rve
inju
ry
K30033_C007.indd 209 28/02/17 11:21 am
210
Der
mat
olog
yTa
ble
7.4.
Fu
ng
al s
kin
infe
ctio
ns
TABL
E 7.
4. F
unga
l ski
n in
fect
ions
.
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Cand
idia
sis
Cand
ida
albi
cans
, a
com
men
sal
yeas
t
Risk
fact
ors
incl
ude
anyt
hing
th
at c
ause
s im
mun
o-su
ppre
ssio
n,
for e
xam
ple:
• HI
V
• Di
abet
es
• Ca
ncer
• An
aem
ia
Depe
nds
on lo
catio
n:
1. S
kin
– so
re, i
tchy
ski
n.
Com
mon
ly a
ffect
s fle
xure
s, w
here
lesi
ons
appe
ar
eryt
hem
atou
s2.
Ora
l can
didi
asis
– p
ain,
di
fficu
lty e
atin
g/sw
allo
win
g,
alte
red
tast
e, w
hite
ps
eudo
mem
bran
e m
ay b
e pr
esen
t3.
Can
dida
l oes
opha
gitis
–
odyn
opha
gia,
wei
ght l
oss
4. B
alan
itis
– pe
nile
itch
ing
and
sore
ness
, dys
uria
5. V
ulvo
vagi
nal c
andi
dias
is –
vu
lval
itch
ing
and
sore
ness
, va
gina
l dis
char
ge, d
ysur
ia,
supe
rfici
al d
yspa
reun
ia
Tend
s to
be
a cl
inic
al d
iagn
osis
bu
t it i
s im
port
ant
to s
wab
the
lesi
on
if th
ere
is a
ny
unce
rtai
nty,
if th
ere
is a
sup
erad
ded
bact
eria
l inf
ectio
n or
if th
e pa
tient
is
imm
unoc
ompr
o-m
ised
.
1. S
kin: Ad
ult,
not i
mm
unoc
ompr
omis
ed –
topi
cal
imid
azol
e
Child
, not
imm
unoc
ompr
omis
ed –
topi
cal
clot
rimaz
ole,
mic
onaz
ole,
eco
nazo
le
Adul
t, im
mun
ocom
prom
ised
– o
ral fl
ucon
azol
e
Child
, im
mun
ocom
prom
ised
– s
eek
spec
ialis
t ad
vice
, con
side
r ora
l fluc
onaz
ole
2. O
ral:
Ad
ults
and
chi
ldre
n, n
ot im
mun
ocom
prom
ised
–
mic
onaz
ole
gel o
r nys
tatin
sus
pens
ion
Ad
ults
, im
mun
ocom
prom
ised
– o
ral fl
ucon
azol
e
3. C
andi
dal o
esop
hagi
tis:
O
ral fl
ucon
azol
e
4. B
alan
itis:
Ad
ults
– im
idaz
ole
crea
m (o
r ora
l fluc
onaz
ole,
si
ngle
dos
e fo
r tho
se o
ver 1
6 ye
ars)
Ch
ildre
n –
a to
pica
l im
idaz
ole
crea
m
5. V
ulvo
vagi
nal c
andi
dias
is
Adul
ts, n
ot im
mun
ocom
prom
ised
– in
trav
agin
al
fluco
nazo
le o
r itr
acon
azol
e. V
ulva
l sym
ptom
s m
ay b
e tr
eate
d w
ith a
topi
cal i
mid
azol
e cr
eam
. If
seve
re, c
lotr
imaz
ole
crea
m m
ay b
e us
ed
Adul
ts, i
mm
unoc
ompr
omis
ed –
ora
l fluc
onaz
ole
or it
raco
nazo
le
• Su
pera
dded
infe
ctio
n
• Sp
ecifi
c com
plica
tions
de
pend
ing
on
loca
tion;
for e
xam
ple,
od
ynop
hagi
a or
supe
rficia
l dy
spar
euni
a
K30033_C007.indd 210 28/02/17 11:21 am
211
Der
mat
olog
yTa
ble
7.4.
Fu
ng
al s
kin
infe
ctio
ns
Ring
wor
mDe
rmat
o-ph
yte
fung
i1.
Bod
y an
d gr
oin
– tin
ea
crur
is
Eryt
hem
atou
s, fla
t or
pote
ntia
lly m
ildly
rais
ed
ring
shap
ed le
sion
s w
ith
a ce
ntra
l cle
arin
g
2. S
calp
– ti
nea
capi
tis
Itchi
ng
Scal
p sc
arrin
g
Patc
hy h
air l
oss
3. F
oot –
tine
a pe
dis
Ty
pica
l whi
te, c
rack
ed
inte
rdig
ital l
esio
ns
1. B
ody
and
groi
n –
tinea
cru
ris
Usua
lly
a cli
nica
l di
agno
sis b
ut
if th
ere
is an
y do
ubt,
send
a
sam
ple
for
micr
osco
py
and
cultu
re
2. S
calp
– ti
nea
capi
tis
Scal
p sc
rapi
ng fo
r m
icro
scop
y an
d cu
lture
3. F
oot –
tine
a pe
dis
Us
ually
a
clini
cal
diag
nosis
but
if
ther
e is
any
doub
t, se
nd
a sa
mpl
e fo
r m
icros
copy
an
d cu
lture
1. B
ody
and
groi
n –
tinea
cru
ris
Mild
– to
pica
l ant
ifung
al c
ream
s
Seve
re –
ora
l ant
ifung
al a
gent
s
2. S
calp
– ti
nea
capi
tis
Adul
ts –
ora
l ant
ifung
als
Ch
ildre
n –
cons
ider
ora
l ant
ifung
als
or re
fer t
o sp
ecia
list
If
kerio
n pr
esen
t – re
fer t
o de
rmat
olog
y
3. F
oot –
tine
a pe
dis
M
ild –
topi
cal c
lotr
imaz
ole,
mic
onaz
ole
or
econ
azol
e
Seve
re –
ora
l ant
ifung
al a
gent
s
• Po
tent
ially
ser
ious
an
d re
fract
ory
case
s in
thos
e w
ho a
re im
mun
o-co
mpr
omis
ed
K30033_C007.indd 211 28/02/17 11:21 am
212
Der
mat
olog
yTa
ble
7.5.
Ski
n lu
mp
s
TABL
E 7.
5. S
kin
lum
ps.
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Sebo
rrho
eic
kera
tosi
sPr
olife
ratio
n of
the
basa
l lay
er o
f epi
derm
is.
Incr
ease
d ris
k w
ith s
un
expo
sure
and
age
• Fl
at/ra
ised
pap
ules
/pla
ques
•
War
t-lik
e, p
edun
cula
ted
yello
w-b
row
n ap
pear
ance
• Le
sion
may
itch
and
ble
ed•
Typi
cally
aris
es o
n th
e tr
unk
• Cl
inic
al d
iagn
osis
• De
rmat
osco
py m
ay b
e us
eful
• Cr
yoth
erap
y •
Cure
ttag
eSk
in c
ance
r may
ar
ise
from
or
be d
ifficu
lt to
di
stin
guis
h fro
m
thes
e le
sion
s
Sola
r ker
atos
isSc
aly
plaq
ues
that
occ
ur a
s a
resu
lt of
UVB
dam
age
• W
ell-d
emar
cate
d ye
llow
–br
own,
ery
them
atou
s hy
perk
erat
otic
sca
ly le
sion
• Le
sion
may
itch
and
ble
ed
• Cl
inic
al d
iagn
osis
• De
rmat
osco
py m
ay b
e us
eful
• Bi
opsy
may
be
used
to
rule
out
squ
amou
s ce
ll ca
rcin
oma
• Cr
yoth
erap
y•
Cure
ttag
e•
Crea
ms
– 5-
fluor
oura
cil
(cyt
otox
ic),
imiq
uim
od
Squa
mou
s ce
ll ca
rcin
oma
Derm
atofi
brom
aA
beni
gn n
odul
e th
at ty
pi-
cally
aris
es o
n th
e lo
wer
leg
but m
ay a
rise
else
whe
re.
Mor
e co
mm
on in
wom
en
than
in m
en
• Fi
rm, p
igm
ente
d no
dule
s us
ually
pre
sent
on
the
low
er le
g •
Betw
een
1 an
d 15
in
num
ber
• M
obile
ove
r sub
cuta
neou
s tis
sue
• N
odul
e(s)
may
be
itchy
or
asym
ptom
atic
• Cl
inic
al d
iagn
osis
• De
rmat
osco
py m
ay b
e us
eful
• Bi
opsy
take
n if
ther
e is
any
unc
erta
inty
co
ncer
ning
dia
gnos
is
Onl
y re
mov
e if
caus
ing
trou
ble
to
patie
nts
Blee
ding
if
trau
mat
ized
K30033_C007.indd 212 28/02/17 11:21 am
213
Der
mat
olog
yTa
ble
7.5.
Ski
n lu
mp
s
Haem
angi
oma
This
is a
ben
ign
cond
ition
of
cut
aneo
us b
lood
ves
sels
ca
used
by
arte
riove
nous
m
alfo
rmat
ion
or a
bnor
mal
ve
ssel
pro
lifer
atio
n.Th
ere
are
man
y di
ffere
nt
type
s. So
me
exam
ples
are
lis
ted
belo
w:
1. S
traw
berr
y na
evus
–
this
reso
lves
with
tim
e.
Trea
tmen
t is
gene
rally
no
t req
uire
d un
less
su
pera
dded
infe
ctio
n oc
curs
or i
t dev
elop
s in
a
prob
lem
atic
regi
on
(e.g
. the
eye
lid)
2. P
ort-
win
e st
ain
– as
soci
ated
with
Stu
rge–
Web
er s
yndr
ome
3. C
aver
nous
ha
eman
giom
a –
asso
ciat
ed w
ith
Kasa
bach
–Mer
ritt
synd
rom
e4.
Pyo
geni
c gr
anul
oma
– fo
llow
s tr
aum
a
• De
pend
s on
the
type
of
haem
angi
oma
• Le
sion
s m
ay b
e si
ngul
ar b
ut
in s
ome
case
s m
ultip
le•
The
lesi
ons
are
eryt
hem
atou
s an
d m
ay b
e fla
t or r
aise
d•
Ther
e m
ay b
e th
icke
ning
of
the
over
lyin
g ep
ider
mis
• U
sual
ly a
clin
ical
dia
gnos
is•
USS
is u
sed
to
inve
stig
ate
deep
infa
ntile
ha
eman
giom
as
• M
RI a
nd a
ngio
grap
hy
may
be
requ
ired
in m
ore
com
plex
cas
es
• So
met
imes
no
trea
tmen
t is
requ
ired
• Pr
opan
olol
• Co
mpr
essi
ve
ther
apy
• La
ser t
hera
py•
Intr
ales
iona
l st
eroi
d in
ject
ions
• Ps
ycho
logi
cal
impl
icat
ions
(e
.g.
depr
essi
on)
• U
lcer
atio
n•
Blee
ding
Cont
inue
d ov
erle
af
K30033_C007.indd 213 28/02/17 11:21 am
214
Der
mat
olog
yTa
ble
7.5.
Ski
n lu
mp
s
TABL
E 7.
5. S
kin
lum
ps (c
ontin
ued ).
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Lipo
ma
Beni
gn s
low
gro
win
g tu
mou
r com
pris
ed o
f lo
bula
ted
fat c
ells.
A th
in
fibro
us c
apsu
le e
ncas
es th
e tu
mou
r. It
affe
cts
mal
es a
nd
fem
ales
equ
ally
; how
ever
, m
ultip
le le
sion
s ar
e m
ore
com
mon
in m
en
Smoo
th, s
oft,
rubb
ery
swel
ling
~2–
10 c
m in
dia
met
er•
Usu
ally
a c
linic
al d
iagn
osis
• Sk
in b
iops
y m
ay b
e pe
rform
ed if
ther
e is
any
do
ubt o
f the
dia
gnos
is.
This
will
vis
ualiz
e a
thin
fib
rous
cap
sule
and
ca
pilla
ries
with
fibr
ous
stra
nds
Ofte
n tr
eatm
ent
is n
ot re
quire
d.
If pr
oble
mat
ic,
surg
ical
exc
isio
n m
ay b
e re
quire
d
Inte
rfere
nce
with
ad
jace
nt m
uscl
e m
ovem
ent
Epid
erm
oid
cyst
Epith
eliu
m li
ned
cavi
ty
fille
d w
ith s
emi-s
olid
m
ater
ial.
Mos
tly o
ccur
in
hair
bear
ing
area
s
Derm
al lu
mp
with
cha
ract
eris
tic
cent
ral p
unct
um
Usu
ally
a c
linic
al d
iagn
osis
Surg
ical
exc
isio
n•
Rupt
ure
• In
fect
ion
• Sk
in c
ance
r
Derm
oid
cyst
Cyst
aris
ing
from
epi
derm
al
cells
, lin
ed b
y sq
uam
ous
epith
eliu
m
Smoo
th, s
oft,
rubb
ery
swel
ling.
Two
diffe
rent
type
s:
1. I
mpl
anta
tion
cyst
s –
aris
e fo
llow
ing
trau
ma
2. C
onge
nita
l cys
ts –
aris
e fro
m e
mbr
yoni
c fu
sion
site
s
Usu
ally
a c
linic
al d
iagn
osis
Surg
ical
exc
isio
nRu
ptur
e In
fect
ion
Tors
ion
K30033_C007.indd 214 28/02/17 11:21 am
216
Der
mat
olog
yTa
ble
7.6.
Ski
n t
um
ou
rs
TABL
E 7.
6. S
kin
tum
ours
. Ris
k fa
ctor
s in
clud
e: s
kin
type
1, h
isto
ry o
f su
n bu
rn/s
un e
xpos
ure
(par
ticu
larl
y in
chi
ldho
od),
prec
ance
rous
ski
n le
sion
s, p
erso
nal o
r fa
mily
his
tory
of
skin
can
cer,
radi
atio
n ex
posu
re, m
ulti
ple
mol
es,
gene
tics
– f
amili
al d
yspl
asti
c na
evus
syn
drom
e (c
hrom
osom
e 1)
.
Dis
ease
Caus
eSy
mpt
oms
Inve
stig
atio
nsTr
eatm
ent
Com
plic
atio
ns
Basa
l cel
l car
cino
ma
Sun
expo
sure
, par
ticul
arly
pr
eval
ent i
n sk
in ty
pe 1
an
d ex
cess
ive
child
hood
su
n ex
posu
re
Asso
ciat
ed w
ith
mut
atio
ns o
f the
tu
mou
r sup
pres
sor g
ene
(chr
omos
ome
9)
Depe
nds
on th
e ty
pe o
f bas
al
cell
carc
inom
a:
1. N
odul
ar ty
pe: c
omm
ones
t, pi
gmen
ted
nodu
le w
ith
tela
ngie
ctas
ia
2. S
uper
ficia
l typ
e: ir
regu
lar
pigm
ente
d pl
aque
s3.
Mor
phoe
ic ty
pe: fl
esh
colo
ured
pla
ques
• De
rmat
osco
py•
Exci
sion
bio
psy
Surg
ical
exc
isio
nLo
cal i
nvas
ion
– ro
dent
ulc
er
Squa
mou
s ce
ll ca
rcin
oma
Refe
r to
abov
e ris
k fa
ctor
sA
loca
lly in
vasi
ve tu
mou
r th
at ty
pica
lly u
lcer
ates
with
ro
lled
edge
s.
Two
type
s:
1. B
owen
’s di
seas
e –
squa
mou
s ce
ll ca
rcin
oma
in s
itu2.
Ker
atoa
cant
hom
a –
cent
ral k
erat
in p
lug
• De
rmat
osco
py•
Exci
sion
bio
psy
• Bo
wen
’s di
seas
e –
cryo
ther
apy,
cure
ttag
e or
topi
cal
5-flu
orou
raci
l
• Su
rgic
al
exci
sion
Spre
ad to
lym
ph
node
s
K30033_C007.indd 216 28/02/17 11:21 am
217
Der
mat
olog
yTa
ble
7.6.
Ski
n t
um
ou
rs
Mal
igna
nt m
elan
oma
Refe
r to
abov
e ris
k fa
ctor
sRe
mem
ber t
o as
sess
the
lesi
on A
BCD
E, w
hich
dire
ctly
re
late
s to
the
sym
ptom
s of
th
is m
alig
nanc
y:
A –
Asy
mm
etric
al le
sion
B –
Bord
ers
are
irreg
ular
C –
Colo
ur h
as c
hang
edD
– D
iam
eter
incr
ease
dE
– Ev
olvi
ng le
sion
The
lesi
on m
ay a
lso
itch
and
blee
d
• De
rmat
osco
py•
Asse
ssm
ent u
sing
Cl
ark
leve
ls a
nd
Bres
low
’s th
ickn
ess
Clar
k le
vels
:
1. M
elan
oma
in s
itu2.
Inv
asio
n of
the
papi
llary
der
mis
3. I
nvas
ion
into
the
junc
tion
of th
e pa
pilla
ry a
nd re
ticul
ar
derm
is4.
Inv
asio
n of
the
retic
ular
der
mis
5. I
nvas
ion
of th
e su
bcut
aneo
us fa
t
Bres
low
’s th
ickn
ess:
Thin
: <1
mm
Inte
rmed
iate
: 1–4
mm
Thic
k: >
4 m
m
• W
ide
surg
ical
ex
cisi
on•
If m
etas
tasi
s, th
en
chem
othe
rapy
an
d ra
diot
hera
py is
re
quire
d
• M
etas
tasi
s•
Deat
h
K30033_C007.indd 217 28/02/17 11:21 am
Chap
ter E
ight
Ort
hopa
edic
s
TABL
E 8.
1a
Gen
eral
co
mp
licat
ion
s o
f fr
actu
res
220
TABL
E 8.
1b
Spec
ific
com
plic
atio
ns
of
frac
ture
s 22
1
MAP
8.1
N
eck
pat
ho
log
y 22
2
MAP
8.2
Sh
ou
lder
pat
ho
log
y 22
4
FIG
URE
8.1
The
bra
chia
l ple
xus
227
MAP
8.3
A
rth
riti
s 22
8
MAP
8.4
El
bo
w p
ath
olo
gy
230
MAP
8.5
H
and
pat
ho
log
y 23
2
MAP
8.6
Sp
inal
pat
ho
log
y 23
6
MAP
8.7
H
ip p
ath
olo
gy
240
TABL
E 8.
2 K
nee
pat
ho
log
y 24
4
TABL
E 8.
3 Fo
ot
pat
ho
log
y 24
8
MAP
8.8
O
rth
op
aed
ic in
fect
ion
s 25
0
FIG
URE
8.2
The
lum
bar
ple
xus
252
Ort
hopa
edic
s21
9
K30033_C008.indd 219 28/02/17 11:26 am
Ort
hopa
edic
s22
0Ta
ble
8.1a
. G
ener
al c
om
plic
atio
ns
of
frac
ture
s
TABL
E 8.
1a. G
ener
al c
ompl
icat
ions
of
frac
ture
s.
Com
plic
atio
nCo
mm
ents
Gen
eral
• Ha
emor
rhag
e•
Shoc
k•
Infe
ctio
n•
Fat e
mbo
lus
resu
lting
in p
ulm
onar
y em
bolis
m a
nd re
spira
tory
dis
tres
s sy
ndro
me
• Rh
abdo
myo
lysi
s
Asso
ciat
ed w
ith p
rolo
nged
be
d re
st•
Deep
vei
n th
rom
bosi
s an
d pu
lmon
ary
embo
lism
• Pr
essu
re s
ores
• M
uscl
e w
astin
g•
Infe
ctio
n
Asso
ciat
ed w
ith p
last
er c
asts
• Re
mem
ber a
s SP
AN
:S
– S
tiffn
ess
P –
Pre
ssur
eA
– A
llerg
yN
– N
erve
and
circ
ulat
ory
dist
urba
nce
Asso
ciat
ed w
ith a
naes
thes
ia•
Anap
hyla
xis
• As
pira
tion
Frac
ture
s Th
ere
are
man
y di
ffere
nt ty
pes o
f fra
ctur
e an
d th
ey m
ay b
e de
fined
(1) b
y lo
catio
n, (2
) as o
pen
(com
poun
d) o
r clo
sed,
(3) a
s int
ra- o
r ext
ra-a
rtic
ular
, (4)
as d
ispl
aced
or n
ot
disp
lace
d, (5
) by
type
: (a)
com
plex
– c
omm
inut
ed, s
egm
enta
l, (b
) non
-com
plex
– tr
ansv
erse
, obl
ique
, spi
ral,
avul
sion
etc
., (c
) spe
cific
(e.g
. gre
enst
ick)
, and
(6) b
y di
seas
e in
volv
emen
t (e.
g. o
steo
poro
sis)
. Fr
actu
res m
ust b
e fu
rthe
r ass
esse
d us
ing
radi
ogra
phy,
and
a de
scrip
tion
of im
pact
ion,
ang
ulat
ion
and
tran
sloc
atio
n m
ust b
e re
port
ed. T
he m
any
com
plic
atio
ns a
ssoc
i-at
ed w
ith fr
actu
res
are
outli
ned
belo
w.
K30033_C008.indd 220 28/02/17 11:26 am
221
Ort
hopa
edic
sTa
ble
8.1b
. Sp
ecifi
c co
mp
licat
ion
s o
f fr
actu
res
TABL
E 8.
1b. S
peci
fic
com
plic
atio
ns o
f fr
actu
res.
Com
plic
atio
nCo
mm
ents
Imm
edia
te•
Haem
orrh
age
• N
euro
vasc
ular
com
plic
atio
ns
Early
• In
fect
ion
• Co
mpa
rtm
ent s
yndr
ome:
Fr
actu
res
caus
e sw
ellin
g, w
hich
incr
ease
s th
e pr
essu
re w
ithin
the
com
part
men
t. Th
is re
sults
in d
ecre
ased
cap
illar
y bl
ood
flow
. Isc
haem
ia
deve
lops
whe
n ca
pilla
ry p
ress
ure
is le
ss th
an th
at o
f the
com
part
men
t pre
ssur
e. Ir
reve
rsib
le c
hang
e re
sults
afte
r 6 h
ours
Sym
ptom
s in
clud
e pa
in, w
hich
is o
ut o
f pro
port
ion
with
pre
sent
ing
sym
ptom
s. Th
is p
ain
is p
rese
nt/w
orse
ned
on p
assi
ve s
tret
chin
g.
Para
esth
esia
and
tigh
tnes
s m
ay a
lso
be p
rese
nt
Late
• M
alun
ion
Tw
o di
ffere
nt fo
rms:
1. H
yper
trop
hic
– pl
enty
of n
ew b
one
grow
th b
ut th
ese
fail
to u
nite
2. A
trop
hic
– la
ck o
f new
bon
e gr
owth
. Ost
eope
nic
in a
ppea
ranc
e•
Avas
cula
r nec
rosi
s•
Com
plex
regi
onal
pai
n sy
ndro
me
Tw
o di
ffere
nt fo
rms:
1. N
o un
derly
ing
nerv
e pr
oble
m2.
Und
erly
ing,
dem
onst
rabl
e ne
rve
prob
lem
• M
yosi
tis o
ssifi
cans
– c
alci
ficat
ion
of th
e so
ft tis
sues
, whi
ch o
ccur
s af
ter s
urge
ry o
r inj
ury
• G
row
th d
istur
banc
e –
occu
rs a
fter d
amag
e to
the
grow
th p
late
. Thi
s is
desc
ribed
usin
g th
e Sa
lter-H
arris
cla
ssifi
catio
n. R
emem
ber a
s SA
LT C
:S
– Se
para
te (f
ract
ure
occu
rs th
roug
h th
e gr
owth
pla
te)
A –
Abo
ve (a
bove
the
grow
th p
late
. Mos
t com
mon
type
)L
– L
ower
(bel
ow th
e gr
owth
pla
te)
T –
Thr
ough
(bot
h up
per a
nd lo
wer
. Com
mon
est c
ause
of p
rem
atur
e gr
owth
arr
est)
C –
Crus
hed
phys
is (w
orst
inju
ry)
K30033_C008.indd 221 28/02/17 11:26 am
Ort
hopa
edic
s22
2 Cerv
ical
spo
ndyl
osis
Wha
t is
cer
vica
l spo
ndyl
osis
?De
gene
rativ
e ar
thrit
is o
f the
cer
vica
l ver
tebr
ae. T
here
is in
crea
sed
risk
with
age
.
Caus
es•
Ost
eoar
thrit
is re
sulti
ng in
bon
y sp
urs.
This
may
resu
lt in
a c
ervi
cal
ra
dicu
lopa
thy
or m
yelo
path
y.•
Trau
ma.
Sym
ptom
s•
May
be
asym
ptom
atic
.•
Redu
ced
rang
e of
mov
emen
t.•
Pain
.•
Para
esth
esia
follo
win
g a
derm
atom
al d
istr
ibut
ion.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Lher
mitt
e’s
sign
.•
Radi
olog
y –
CT/M
RI.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py.
• M
edic
al: N
SAID
s, co
dein
e et
c.; f
ollo
w W
HO a
nalg
esic
ladd
er.
• Su
rgic
al: a
nter
ior c
ervi
cal d
isce
ctom
y, ce
rvic
al la
min
ecto
my.
Com
plic
atio
ns•
Vert
ebro
basi
lar i
nsuf
ficie
ncy.
Cerv
ical
spo
ndyl
olis
thes
is
Wha
t is
cer
vica
l spo
ndyl
olis
thes
is?
This
is w
hen
a su
perio
rly lo
cate
d ce
rvic
al v
erte
bra
is d
ispl
aced
ant
erio
rly
rela
tive
to th
e ve
rteb
ra b
elow
. Thi
s m
ay n
arro
w th
e ve
rteb
ral c
anal
and
resu
lts
in d
efor
mity
.
Caus
es•
Cong
enita
l: fa
ilure
of o
ndon
toid
pro
cess
fusi
on.
• Tr
aum
a: re
sults
in in
stab
ility
.•
Softe
ning
of t
he tr
ansv
erse
liga
men
t due
to in
flam
mat
ion.
Sym
ptom
s•
Pain
– m
ay b
e ra
dicu
lar o
r may
radi
ate
betw
een
the
shou
lder
bla
des
and
t
o th
e ba
ck o
f the
hea
d.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Radi
olog
y: C
T/M
RI.
• M
eyer
ding
gra
ding
sys
tem
– d
escr
ibes
per
cent
age
slip
page
.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py.
• M
edic
al: N
SAID
s, co
dein
e et
c.; f
ollo
w W
HO a
nalg
esic
ladd
er. C
onsi
der
co
rtic
oste
roid
inje
ctio
ns.
• Su
rgic
al: m
icro
disc
ecto
my,
hem
ilam
inec
tom
y, an
terio
r cer
vica
l dis
cect
omy
+/–
fusi
on.
Cerv
ical
dis
c pr
olap
se
Wha
t is
a c
ervi
cal d
isc
prol
apse
?Th
is o
ccur
s w
hen
the
nucl
eus
pulp
osus
her
niat
es th
roug
h a
tear
in th
e an
nulu
s fib
rosu
s. Ty
pica
lly a
ffect
sC5
/6 a
nd C
6/7
sinc
e th
ese
are
the
mos
t mob
ile s
egm
ents
. Pro
laps
es m
ay b
e ce
ntra
l or l
ater
al.
Sym
ptom
s•
Brac
halg
ia w
ith a
ssoc
iate
d ra
dicu
lopa
thy.
• Pa
in, p
arae
sths
ia, w
eakn
ess.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Radi
olog
y –
MRI
.
Trea
tmen
tDe
pend
s on
the
exte
nt o
f the
pro
laps
e an
d th
e pr
esen
ce o
r abs
ence
of n
euro
logi
cal s
ympt
oms.
• M
ild –
no
neur
olog
ical
sym
ptom
s. Ph
ysio
ther
apy
and
anal
gesi
a m
ay s
uffic
e.•
Mod
erat
e –
only
radi
cula
r sym
ptom
s. Su
rger
y m
ay b
e re
quire
d (e
.g. d
isce
ctom
y or
lam
inec
tom
y).
• Se
vere
– u
rgen
t sur
gica
l dec
ompr
essi
on.MAP
8.1
. Nec
k pa
thol
ogy
Map
8.1
. N
eck
pat
ho
log
y
K30033_C008.indd 222 28/02/17 11:26 am
Ort
hopa
edic
s22
3Cerv
ical
spo
ndyl
osis
Wha
t is
cer
vica
l spo
ndyl
osis
?De
gene
rativ
e ar
thrit
is o
f the
cer
vica
l ver
tebr
ae. T
here
is in
crea
sed
risk
with
age
.
Caus
es•
Ost
eoar
thrit
is re
sulti
ng in
bon
y sp
urs.
This
may
resu
lt in
a c
ervi
cal
ra
dicu
lopa
thy
or m
yelo
path
y.•
Trau
ma.
Sym
ptom
s•
May
be
asym
ptom
atic
.•
Redu
ced
rang
e of
mov
emen
t.•
Pain
.•
Para
esth
esia
follo
win
g a
derm
atom
al d
istr
ibut
ion.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Lher
mitt
e’s
sign
.•
Radi
olog
y –
CT/M
RI.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py.
• M
edic
al: N
SAID
s, co
dein
e et
c.; f
ollo
w W
HO a
nalg
esic
ladd
er.
• Su
rgic
al: a
nter
ior c
ervi
cal d
isce
ctom
y, ce
rvic
al la
min
ecto
my.
Com
plic
atio
ns•
Vert
ebro
basi
lar i
nsuf
ficie
ncy.
Cerv
ical
spo
ndyl
olis
thes
is
Wha
t is
cer
vica
l spo
ndyl
olis
thes
is?
This
is w
hen
a su
perio
rly lo
cate
d ce
rvic
al v
erte
bra
is d
ispl
aced
ant
erio
rly
rela
tive
to th
e ve
rteb
ra b
elow
. Thi
s m
ay n
arro
w th
e ve
rteb
ral c
anal
and
resu
lts
in d
efor
mity
.
Caus
es•
Cong
enita
l: fa
ilure
of o
ndon
toid
pro
cess
fusi
on.
• Tr
aum
a: re
sults
in in
stab
ility
.•
Softe
ning
of t
he tr
ansv
erse
liga
men
t due
to in
flam
mat
ion.
Sym
ptom
s•
Pain
– m
ay b
e ra
dicu
lar o
r may
radi
ate
betw
een
the
shou
lder
bla
des
and
t
o th
e ba
ck o
f the
hea
d.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Radi
olog
y: C
T/M
RI.
• M
eyer
ding
gra
ding
sys
tem
– d
escr
ibes
per
cent
age
slip
page
.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py.
• M
edic
al: N
SAID
s, co
dein
e et
c.; f
ollo
w W
HO a
nalg
esic
ladd
er. C
onsi
der
co
rtic
oste
roid
inje
ctio
ns.
• Su
rgic
al: m
icro
disc
ecto
my,
hem
ilam
inec
tom
y, an
terio
r cer
vica
l dis
cect
omy
+/–
fusi
on.
Cerv
ical
dis
c pr
olap
se
Wha
t is
a c
ervi
cal d
isc
prol
apse
?Th
is o
ccur
s w
hen
the
nucl
eus
pulp
osus
her
niat
es th
roug
h a
tear
in th
e an
nulu
s fib
rosu
s. Ty
pica
lly a
ffect
sC5
/6 a
nd C
6/7
sinc
e th
ese
are
the
mos
t mob
ile s
egm
ents
. Pro
laps
es m
ay b
e ce
ntra
l or l
ater
al.
Sym
ptom
s•
Brac
halg
ia w
ith a
ssoc
iate
d ra
dicu
lopa
thy.
• Pa
in, p
arae
sths
ia, w
eakn
ess.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Radi
olog
y –
MRI
.
Trea
tmen
tDe
pend
s on
the
exte
nt o
f the
pro
laps
e an
d th
e pr
esen
ce o
r abs
ence
of n
euro
logi
cal s
ympt
oms.
• M
ild –
no
neur
olog
ical
sym
ptom
s. Ph
ysio
ther
apy
and
anal
gesi
a m
ay s
uffic
e.•
Mod
erat
e –
only
radi
cula
r sym
ptom
s. Su
rger
y m
ay b
e re
quire
d (e
.g. d
isce
ctom
y or
lam
inec
tom
y).
• Se
vere
– u
rgen
t sur
gica
l dec
ompr
essi
on.MAP
8.1
. Nec
k pa
thol
ogy
Map
8.1
. N
eck
pat
ho
log
y
K30033_C008.indd 223 28/02/17 11:26 am
Ort
hopa
edic
s22
4 Shou
lder
dis
loca
tion
Wha
t is
a s
houl
der
disl
ocat
ion?
This
is w
hen
ther
e is
a lo
ss o
f con
grui
ty b
etw
een
the
head
of t
he h
umer
us
and
the
glen
oid
foss
a. T
here
are
two
type
s –
ante
rior a
nd p
oste
rior.
Caus
es•
Ante
rior –
com
mon
est.
Trau
ma.
Incr
ease
d ris
k in
thos
e w
ith c
onne
ctiv
e
tis
sue
diso
rder
s or
thos
e w
ith p
rior s
houl
der d
islo
catio
ns.
• Po
ster
ior –
rare
. Sei
zure
s an
d el
ectr
ocut
ion.
Sym
ptom
s•
Pain
.•
Decr
ease
d ra
nge
of m
ovem
ent.
• A
nter
ior –
hum
eral
hea
d is
pro
min
ent a
nd h
eld
in a
n ab
duct
ed,
e
xter
nally
rota
ted
posi
tion.
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y (la
tera
l and
AP
view
s).
Trea
tmen
t•
Clos
ed re
duct
ion
and
slin
g im
mob
iliza
tion.
• Ad
equa
te a
nalg
esia
.
Com
plic
atio
ns•
Axill
ary
nerv
e or
art
ery
dam
age.
• Da
mag
e to
the
brac
hial
ple
xus.
• In
crea
sed
risk
of re
curr
ence
.•
Spec
ific
lesi
ons:
Bank
art l
esio
n: a
vuls
ion
of a
nter
o-in
ferio
r gle
noid
labr
um.
Hill–
Sach
s le
sion
: ind
enta
tion
fract
ure
of th
e po
ster
olat
eral
hum
eral
he
ad.
Rota
tor
cuff
tea
rs
Wha
t ar
e ro
tato
r cu
ff t
ears
?Th
e ro
tato
r cuf
f com
pris
es fo
ur te
ndon
s an
d m
uscl
es th
at a
im to
pro
vide
stab
ility
to th
e hi
ghly
mob
ile s
houl
der j
oint
. The
four
mus
cles
(rem
embe
red
as S
ITS)
are
the
Supr
aspi
natu
s (m
ost c
omm
only
torn
), In
frasp
inat
us, T
eres
min
or a
nd S
ubsc
apul
aris.
Fur
ther
impo
rtan
t ana
tom
ical
det
ails
abo
ut th
ese
mus
cles
are
pro
vide
d be
low
:
Caus
es•
Dege
nera
tion.
• Tr
aum
a.•
Wei
ght l
iftin
g.
Sym
ptom
s•
Part
ial t
ears
resu
lt in
a p
ainf
ul a
rc s
yndr
ome.
• Co
mpl
ete
tear
s lim
it sh
ould
er a
bduc
tion.
• Pa
in to
a v
aria
ble
degr
ee d
epen
ding
on
the
sign
ifica
nce
of th
e te
ar.
• Sh
ould
er te
nder
ness
on
palp
atio
n.•
Wea
knes
s.
Inve
stig
atio
ns•
Thor
ough
exa
min
atio
n w
ith s
peci
fic te
sts
as o
utlin
ed in
Tabl
e ab
ove.
• Ra
diol
ogy
– x-
ray,
MRI
.
Trea
tmen
t•
Cons
erva
tive:
rest
and
phy
siot
hera
py.
• M
edic
al: a
dequ
ate
pain
relie
f.•
Surg
ical
: art
hros
copy
+/−
repa
ir if
indi
cate
d.
Com
plic
atio
ns•
Decr
ease
d ra
nge
of m
ovem
ent,
whi
ch m
ay in
hibi
t dai
ly a
ctiv
ities
suc
h as
ge
ttin
g dr
esse
d.•
Com
plic
atio
ns a
ssoc
iate
d w
ith s
urge
ry in
clud
e ge
nera
l ris
ks fr
om
anae
sthe
sia
and
infe
ctio
n as
wel
l as
spec
ific
com
plic
atio
ns s
uch
as
dam
age
to th
e ax
illar
y ne
rve.
Exte
rnal
ly ro
tate
shu
mer
us
Mus
cle
Act
ion
Supr
aspi
natu
s
Tere
s m
inor
Abdu
cts
hum
erus
Subs
capu
laris
Inte
rnal
ly ro
tate
shu
mer
us
Inne
rvat
ion
Supr
asca
pula
rne
rve
(C5)
Axill
ary
nerv
e(C
5)
Exte
rnal
ly ro
tate
shu
mer
usIn
frasp
inat
usSu
pras
capu
lar
nerv
e (C
5–6)
Upp
er a
nd lo
wer
subs
capu
lar n
erve
(C5–
6)
Empt
y be
er c
ante
st (e
limin
ates
delto
id)
-Resi
sted
ext
erna
lro
tatio
n
Lift-
off t
est
Spec
ific
test
MAP
8.2
. Sho
ulde
r pa
thol
ogy
Map
8.2
. Sh
ou
lder
pat
ho
log
y
K30033_C008.indd 224 28/02/17 11:26 am
Ort
hopa
edic
s22
5Shou
lder
dis
loca
tion
Wha
t is
a s
houl
der
disl
ocat
ion?
This
is w
hen
ther
e is
a lo
ss o
f con
grui
ty b
etw
een
the
head
of t
he h
umer
us
and
the
glen
oid
foss
a. T
here
are
two
type
s –
ante
rior a
nd p
oste
rior.
Caus
es•
Ante
rior –
com
mon
est.
Trau
ma.
Incr
ease
d ris
k in
thos
e w
ith c
onne
ctiv
e
tis
sue
diso
rder
s or
thos
e w
ith p
rior s
houl
der d
islo
catio
ns.
• Po
ster
ior –
rare
. Sei
zure
s an
d el
ectr
ocut
ion.
Sym
ptom
s•
Pain
.•
Decr
ease
d ra
nge
of m
ovem
ent.
• A
nter
ior –
hum
eral
hea
d is
pro
min
ent a
nd h
eld
in a
n ab
duct
ed,
e
xter
nally
rota
ted
posi
tion.
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y (la
tera
l and
AP
view
s).
Trea
tmen
t•
Clos
ed re
duct
ion
and
slin
g im
mob
iliza
tion.
• Ad
equa
te a
nalg
esia
.
Com
plic
atio
ns•
Axill
ary
nerv
e or
art
ery
dam
age.
• Da
mag
e to
the
brac
hial
ple
xus.
• In
crea
sed
risk
of re
curr
ence
.•
Spec
ific
lesi
ons:
Bank
art l
esio
n: a
vuls
ion
of a
nter
o-in
ferio
r gle
noid
labr
um.
Hill–
Sach
s le
sion
: ind
enta
tion
fract
ure
of th
e po
ster
olat
eral
hum
eral
he
ad.
Rota
tor
cuff
tea
rs
Wha
t ar
e ro
tato
r cu
ff t
ears
?Th
e ro
tato
r cuf
f com
pris
es fo
ur te
ndon
s an
d m
uscl
es th
at a
im to
pro
vide
stab
ility
to th
e hi
ghly
mob
ile s
houl
der j
oint
. The
four
mus
cles
(rem
embe
red
as S
ITS)
are
the
Supr
aspi
natu
s (m
ost c
omm
only
torn
), In
frasp
inat
us, T
eres
min
or a
nd S
ubsc
apul
aris.
Fur
ther
impo
rtan
t ana
tom
ical
det
ails
abo
ut th
ese
mus
cles
are
pro
vide
d be
low
:
Caus
es•
Dege
nera
tion.
• Tr
aum
a.•
Wei
ght l
iftin
g.
Sym
ptom
s•
Part
ial t
ears
resu
lt in
a p
ainf
ul a
rc s
yndr
ome.
• Co
mpl
ete
tear
s lim
it sh
ould
er a
bduc
tion.
• Pa
in to
a v
aria
ble
degr
ee d
epen
ding
on
the
sign
ifica
nce
of th
e te
ar.
• Sh
ould
er te
nder
ness
on
palp
atio
n.•
Wea
knes
s.
Inve
stig
atio
ns•
Thor
ough
exa
min
atio
n w
ith s
peci
fic te
sts
as o
utlin
ed in
Tabl
e ab
ove.
• Ra
diol
ogy
– x-
ray,
MRI
.
Trea
tmen
t•
Cons
erva
tive:
rest
and
phy
siot
hera
py.
• M
edic
al: a
dequ
ate
pain
relie
f.•
Surg
ical
: art
hros
copy
+/−
repa
ir if
indi
cate
d.
Com
plic
atio
ns•
Decr
ease
d ra
nge
of m
ovem
ent,
whi
ch m
ay in
hibi
t dai
ly a
ctiv
ities
suc
h as
ge
ttin
g dr
esse
d.•
Com
plic
atio
ns a
ssoc
iate
d w
ith s
urge
ry in
clud
e ge
nera
l ris
ks fr
om
anae
sthe
sia
and
infe
ctio
n as
wel
l as
spec
ific
com
plic
atio
ns s
uch
as
dam
age
to th
e ax
illar
y ne
rve.
Exte
rnal
ly ro
tate
shu
mer
us
Mus
cle
Act
ion
Supr
aspi
natu
s
Tere
s m
inor
Abdu
cts
hum
erus
Subs
capu
laris
Inte
rnal
ly ro
tate
shu
mer
us
Inne
rvat
ion
Supr
asca
pula
rne
rve
(C5)
Axill
ary
nerv
e(C
5)
Exte
rnal
ly ro
tate
shu
mer
usIn
frasp
inat
usSu
pras
capu
lar
nerv
e (C
5–6)
Upp
er a
nd lo
wer
subs
capu
lar n
erve
(C5–
6)
Empt
y be
er c
ante
st (e
limin
ates
delto
id)
-Resi
sted
ext
erna
lro
tatio
n
Lift-
off t
est
Spec
ific
test
MAP
8.2
. Sho
ulde
r pa
thol
ogy
Cont
inue
d ov
erle
af
Map
8.2
. Sh
ou
lder
pat
ho
log
y
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edic
s22
6 Adh
esiv
e ca
psul
itis
Wha
t is
adh
esiv
e ca
psul
itis
?Ad
hesi
ve c
apsu
litis
is a
lso
know
n as
froz
en s
houl
der.
Typi
cally
the
path
olog
y en
com
pass
es th
ree
phas
es:
1. P
ain
with
free
zing
.2.
Tha
win
g.3.
Res
olut
ion
– m
ay ta
ke u
p to
and
pos
sibl
y m
ore
than
2 y
ears
.
Caus
es•
The
exac
t aet
iolo
gy o
f thi
s co
nditi
on is
unk
now
n bu
t it i
s lin
ked
to
trau
ma
and
past
sho
ulde
r sur
gery
.
Risk
fact
ors
• In
crea
sed
age.
• Fe
mal
e.•
Diab
etes
mel
litus
.•
Rheu
mat
oid
arth
ritis.
Sym
ptom
s•
Pain
– o
n ac
tive
and
pass
ive
mov
emen
t.•
Rest
ricte
d ra
nge
on m
ovem
ent –
act
ivel
y an
d pa
ssiv
ely.
Exte
rnal
ro
tatio
n is
ofte
n af
fect
ed fi
rst.
• O
ften
no m
ovem
ent a
t the
gle
nohu
mer
al jo
int.
• Di
fficu
lty s
leep
ing
on th
e af
fect
ed s
ide.
MAP
8.2
. Sho
ulde
r pa
thol
ogy
(con
tinue
d )
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Radi
olog
y: U
SS a
nd M
RI.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py.
• M
edic
al: a
dequ
ate
anal
gesi
a, s
tero
id in
ject
ions
.•
Surg
ery:
onl
y pe
rform
ed in
sev
ere
case
s (e
.g. c
apsu
lar r
elea
se v
ia
arth
rosc
opy)
.
Com
plic
atio
ns•
Stiff
ness
.•
Loss
of f
unct
ion.
Map
8.2
. Sh
ou
lder
pat
ho
log
y
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Ort
hopa
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s22
7Fi
gure
8.1
. The
bra
chia
l ple
xus
FIG
URE
8.1
. The
bra
chia
l ple
xus
Dor
sal s
capu
lar
nerv
e:Rh
ombo
id m
ajor
and
min
or,
Leva
tor s
capu
lae
Supr
asca
pula
r ne
rve:
Supr
aspi
natu
s, In
frasp
inat
usLa
tera
l pec
tora
l ner
ve:
Pect
oral
is m
ajor
Low
er s
ubsc
apul
ar n
erve
:Su
bsca
pula
ris, T
eres
maj
or
Upp
er s
ubsc
apul
ar n
erve
:Su
bsca
pula
ris
Long
tho
raci
c ne
rve:
Serr
atus
ant
erio
rTh
orac
odor
sal n
erve
:La
tissi
mus
dor
si
Med
ial p
ecto
ral n
erve
:Pe
ctor
alis
maj
or a
nd m
inor
Axi
llary
ner
ve:
Delto
id, T
eres
min
or
Uln
ar n
erve
:Fl
exo
r ca
rpi u
lnar
isU
lnar
hal
f o
f th
e fl
exo
rd
igit
oru
m p
rofu
nd
us
Med
ian
nerv
e:Fl
exor
s of
the
fore
arm
EXCE
PT fl
exor
car
piul
naris
. The
med
ian
nerv
e in
nerv
ates
th
e LO
AF m
uscl
es:
L –
Late
ral l
umbr
ical
sO
– O
ppon
ens
polli
cis
A –
Abd
ucto
r pol
licis
brev
isF
– Fl
exor
pol
licis
bre
vis
Radi
al n
erve
:Tr
icep
s br
achi
iAn
cone
usEx
tens
or m
uscl
es
Mus
culo
cuta
neou
sne
rve:
Cora
cobr
achi
alis
Bice
ps b
rach
iiBr
achi
alis
C5 C6 C7 C8 T1
K30033_C008.indd 227 28/02/17 11:26 am
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s22
8 Rheu
mat
oid
arth
riti
s
Wha
t is
rhe
umat
oid
arth
riti
s (R
A)?
This
is a
chr
onic
, aut
oim
mun
e ty
pe II
I hyp
erse
nsiti
vity
reac
tion
that
prin
cipa
lly
affe
cts
the
syno
vium
but
may
als
o af
fect
oth
er o
rgan
s. Jo
int i
nvol
vem
ent i
s ch
arac
teriz
ed b
y sy
mm
etric
al d
efor
mat
ion
with
pai
n th
at is
wor
se in
the
mor
ning
. Thi
s co
nditi
on is
ass
ocia
ted
with
HLA
-DR4
and
HLA
-DR1
.
Caus
eTh
e ex
act c
ause
of R
A is
unk
now
n, b
ut it
is th
ough
t to
invo
lve
a ty
pe II
Ihy
pers
ensi
tivity
reac
tion.
Sign
s an
d sy
mpt
oms
• Ha
nds
– Z
defo
rmity
, bou
tonn
ière
def
orm
ity, s
wan
nec
k de
form
ity, u
lnar
de
viat
ion,
sub
luxa
tion
of th
e fin
gers
, Ray
naud
’s as
soci
atio
n.•
Wris
t – c
arpa
l tun
nel s
yndr
ome.
• Fe
et –
sub
luxa
tion
of th
e to
es, h
amm
er to
e de
form
ity.
• Sk
in –
rheu
mat
oid
nodu
le, v
ascu
litis.
• Ca
rdio
vasc
ular
– a
ther
oscl
eros
is is
incr
ease
d in
RA.
• Re
spira
tory
– p
ulm
onar
y fib
rosi
s.•
Bone
s –
oste
opor
osis.
• Pa
in a
nd s
tiffn
ess.
Inve
stig
atio
ns•
Bloo
ds:
80%
test
pos
itive
for r
heum
atoi
d fa
ctor
.
ES
R an
d CR
P ra
ised
.
Cy
clic
citr
ullin
ated
pep
tide.
If p
ositi
ve, s
ugge
stiv
e of
ero
sive
dis
ease
.•
Radi
olog
y: ra
diol
ogic
al s
igns
of R
A ar
e vi
sual
ized
on
plai
n fil
m:
Bony
ero
sion
, sub
luxa
tion,
car
pal i
nsta
bilit
y.
In
volv
emen
t of m
etac
arpo
- and
met
atar
soph
alan
geal
join
ts.
Peria
rtic
ular
ost
eopo
rosi
s.
Trea
tmen
t•
Cons
erva
tive:
pat
ient
edu
catio
n. E
ncou
rage
exe
rcis
e. R
efer
to p
hysi
othe
rapy
an
d as
sess
act
iviti
es o
f dai
ly li
ving
(ADL
s).
• M
edic
al: g
luco
cort
icoi
ds, d
isea
se m
odify
ing
antir
heum
atic
dru
gs (D
MAR
Ds)
(e
.g. g
old
salts
, met
hotr
exat
e, s
ulph
asal
azin
e). A
ntic
ytok
ine
ther
apie
s m
ay b
e
cons
ider
ed in
pat
ient
s in
tole
rant
to m
etho
trex
ate.
• Su
rger
y: e
xcis
ion
arth
ropl
asty
or r
epla
cem
ent m
ay b
e co
nsid
ered
in
seve
rely
affe
cted
join
ts.
Com
plic
atio
ns•
Carp
al tu
nnel
syn
drom
e.•
Peric
ardi
tis.
• Sj
ögre
n’s
synd
rom
e.•
Cerv
ical
myo
path
y.•
Tend
on ru
ptur
e.
Ost
eoar
thri
tis
Wha
t is
ost
eoar
thri
tis
(OA
)?Th
is is
a d
egen
erat
ive
arth
ritis
affe
ctin
g sy
novi
al jo
ints
and
isch
arac
teriz
ed b
y ca
rtila
ge d
egen
erat
ion,
ass
ocia
ted
resp
onse
of t
hepe
riart
icul
ar ti
ssue
and
pai
n th
at is
typi
cally
wor
se a
t the
end
of t
he d
ay.
Caus
eDa
mag
e to
the
join
ts a
nd g
ener
al w
ear a
nd te
ar o
f the
join
t ove
r tim
e is
thou
ght t
o be
the
prim
ary
caus
e of
OA.
The
re a
re c
erta
in fa
ctor
s th
atin
crea
se th
e ris
k of
OA
such
as:
• In
crea
sed
age.
• O
besi
ty.
• Tr
aum
a to
the
join
t.•
Cond
ition
s su
ch a
s ha
emoc
hrom
atos
is a
nd E
hler
s–Da
nlos
syn
drom
e.
Sign
s an
d sy
mpt
oms
• Pa
in a
nd s
tiffn
ess.
• Sw
ellin
g ar
ound
join
t inv
olve
d.•
Crep
itus.
• He
berd
en’s
node
s (d
ista
l int
erph
alan
geal
join
ts).
• Bo
ucha
rd’s
node
s (p
roxi
mal
inte
rpha
lang
eal j
oint
s).
Inve
stig
atio
ns•
Bloo
ds: u
sual
ly n
ot d
iagn
ostic
but
may
be
rele
vant
whe
n O
A is
rela
ted
to
ano
ther
con
ditio
n su
ch a
s ha
emoc
hrom
atos
is.•
Radi
olog
y: ra
diol
ogic
al s
igns
(LO
SS):
L
– Lo
ss o
f joi
nt s
pace
O
– O
steo
phyt
es
S –
Subc
hond
ral c
ysts
S
– Sc
lero
sis
Trea
tmen
t•
Cons
erva
tive:
pat
ient
edu
catio
n. E
ncou
rage
exe
rcis
e an
d w
eigh
t los
s.•
Med
ical
: ana
lges
ia (e
.g. p
arac
etam
ol o
r NSA
IDs)
. Gel
s su
ch a
s
caps
aici
n m
ay b
e us
eful
. Ste
roid
inje
ctio
ns.
• Su
rgic
al: a
rthr
opla
sty.
Com
plic
atio
ns•
Incr
ease
d ris
k of
gou
t.•
Chon
droc
alci
nosi
s.
MAP
8.3
. Art
hrit
is
Map
8.3
. A
rth
riti
s
K30033_C008.indd 228 28/02/17 11:26 am
Ort
hopa
edic
s22
9Rheu
mat
oid
arth
riti
s
Wha
t is
rhe
umat
oid
arth
riti
s (R
A)?
This
is a
chr
onic
, aut
oim
mun
e ty
pe II
I hyp
erse
nsiti
vity
reac
tion
that
prin
cipa
lly
affe
cts
the
syno
vium
but
may
als
o af
fect
oth
er o
rgan
s. Jo
int i
nvol
vem
ent i
s ch
arac
teriz
ed b
y sy
mm
etric
al d
efor
mat
ion
with
pai
n th
at is
wor
se in
the
mor
ning
. Thi
s co
nditi
on is
ass
ocia
ted
with
HLA
-DR4
and
HLA
-DR1
.
Caus
eTh
e ex
act c
ause
of R
A is
unk
now
n, b
ut it
is th
ough
t to
invo
lve
a ty
pe II
Ihy
pers
ensi
tivity
reac
tion.
Sign
s an
d sy
mpt
oms
• Ha
nds
– Z
defo
rmity
, bou
tonn
ière
def
orm
ity, s
wan
nec
k de
form
ity, u
lnar
de
viat
ion,
sub
luxa
tion
of th
e fin
gers
, Ray
naud
’s as
soci
atio
n.•
Wris
t – c
arpa
l tun
nel s
yndr
ome.
• Fe
et –
sub
luxa
tion
of th
e to
es, h
amm
er to
e de
form
ity.
• Sk
in –
rheu
mat
oid
nodu
le, v
ascu
litis.
• Ca
rdio
vasc
ular
– a
ther
oscl
eros
is is
incr
ease
d in
RA.
• Re
spira
tory
– p
ulm
onar
y fib
rosi
s.•
Bone
s –
oste
opor
osis.
• Pa
in a
nd s
tiffn
ess.
Inve
stig
atio
ns•
Bloo
ds:
80%
test
pos
itive
for r
heum
atoi
d fa
ctor
.
ES
R an
d CR
P ra
ised
.
Cy
clic
citr
ullin
ated
pep
tide.
If p
ositi
ve, s
ugge
stiv
e of
ero
sive
dis
ease
.•
Radi
olog
y: ra
diol
ogic
al s
igns
of R
A ar
e vi
sual
ized
on
plai
n fil
m:
Bony
ero
sion
, sub
luxa
tion,
car
pal i
nsta
bilit
y.
In
volv
emen
t of m
etac
arpo
- and
met
atar
soph
alan
geal
join
ts.
Peria
rtic
ular
ost
eopo
rosi
s.
Trea
tmen
t•
Cons
erva
tive:
pat
ient
edu
catio
n. E
ncou
rage
exe
rcis
e. R
efer
to p
hysi
othe
rapy
an
d as
sess
act
iviti
es o
f dai
ly li
ving
(ADL
s).
• M
edic
al: g
luco
cort
icoi
ds, d
isea
se m
odify
ing
antir
heum
atic
dru
gs (D
MAR
Ds)
(e
.g. g
old
salts
, met
hotr
exat
e, s
ulph
asal
azin
e). A
ntic
ytok
ine
ther
apie
s m
ay b
e
cons
ider
ed in
pat
ient
s in
tole
rant
to m
etho
trex
ate.
• Su
rger
y: e
xcis
ion
arth
ropl
asty
or r
epla
cem
ent m
ay b
e co
nsid
ered
in
seve
rely
affe
cted
join
ts.
Com
plic
atio
ns•
Carp
al tu
nnel
syn
drom
e.•
Peric
ardi
tis.
• Sj
ögre
n’s
synd
rom
e.•
Cerv
ical
myo
path
y.•
Tend
on ru
ptur
e.
Ost
eoar
thri
tis
Wha
t is
ost
eoar
thri
tis
(OA
)?Th
is is
a d
egen
erat
ive
arth
ritis
affe
ctin
g sy
novi
al jo
ints
and
isch
arac
teriz
ed b
y ca
rtila
ge d
egen
erat
ion,
ass
ocia
ted
resp
onse
of t
hepe
riart
icul
ar ti
ssue
and
pai
n th
at is
typi
cally
wor
se a
t the
end
of t
he d
ay.
Caus
eDa
mag
e to
the
join
ts a
nd g
ener
al w
ear a
nd te
ar o
f the
join
t ove
r tim
e is
thou
ght t
o be
the
prim
ary
caus
e of
OA.
The
re a
re c
erta
in fa
ctor
s th
atin
crea
se th
e ris
k of
OA
such
as:
• In
crea
sed
age.
• O
besi
ty.
• Tr
aum
a to
the
join
t.•
Cond
ition
s su
ch a
s ha
emoc
hrom
atos
is a
nd E
hler
s–Da
nlos
syn
drom
e.
Sign
s an
d sy
mpt
oms
• Pa
in a
nd s
tiffn
ess.
• Sw
ellin
g ar
ound
join
t inv
olve
d.•
Crep
itus.
• He
berd
en’s
node
s (d
ista
l int
erph
alan
geal
join
ts).
• Bo
ucha
rd’s
node
s (p
roxi
mal
inte
rpha
lang
eal j
oint
s).
Inve
stig
atio
ns•
Bloo
ds: u
sual
ly n
ot d
iagn
ostic
but
may
be
rele
vant
whe
n O
A is
rela
ted
to
ano
ther
con
ditio
n su
ch a
s ha
emoc
hrom
atos
is.•
Radi
olog
y: ra
diol
ogic
al s
igns
(LO
SS):
L
– Lo
ss o
f joi
nt s
pace
O
– O
steo
phyt
es
S –
Subc
hond
ral c
ysts
S
– Sc
lero
sis
Trea
tmen
t•
Cons
erva
tive:
pat
ient
edu
catio
n. E
ncou
rage
exe
rcis
e an
d w
eigh
t los
s.•
Med
ical
: ana
lges
ia (e
.g. p
arac
etam
ol o
r NSA
IDs)
. Gel
s su
ch a
s
caps
aici
n m
ay b
e us
eful
. Ste
roid
inje
ctio
ns.
• Su
rgic
al: a
rthr
opla
sty.
Com
plic
atio
ns•
Incr
ease
d ris
k of
gou
t.•
Chon
droc
alci
nosi
s.
MAP
8.3
. Art
hrit
is
Map
8.3
. A
rth
riti
s
K30033_C008.indd 229 28/02/17 11:26 am
Ort
hopa
edic
s23
0 Tenn
is e
lbow
Wha
t is
ten
nis
elbo
w?
Tenn
is e
lbow
is a
lso
know
n as
late
ral e
pico
ndyl
itis
and
is th
em
ost c
omm
on e
lbow
ove
ruse
inju
ry. T
he la
tera
l epi
cond
yle
isth
e or
igin
of t
he c
omm
on e
xten
sor t
endo
n an
d in
tenn
is e
lbow
it be
com
es in
flam
ed a
nd c
ause
s el
bow
pai
n.
Caus
esTe
nnis
elb
ow is
a fo
rm o
f rep
etiti
ve s
trai
n in
jury
(e.g
. pla
ying
spor
ts s
uch
as te
nnis,
squ
ash)
or u
nder
taki
ng o
ther
act
iviti
essu
ch a
s ga
rden
ing
and
pain
ting.
Thi
s re
sults
inm
icro
rupt
ure/
mic
rote
ars
and
dege
nera
tive
chan
ges
in th
ete
ndon
as
wel
l as
infla
mm
atio
n, p
artic
ular
ly a
t the
mus
cula
ror
igin
of e
xten
sor c
arpi
radi
alis
bre
vis.
Sym
ptom
s•
Achi
ng e
lbow
pai
n, ty
pica
lly o
ver t
he la
tera
l epi
cond
yle,
w
hich
wor
sens
with
act
ivity
.•
Typi
cally
affe
cts
the
dom
inan
t arm
.•
Wor
se d
urin
g si
mpl
e da
ily ta
sks
utili
zing
ext
enso
rs, s
uch
as
liftin
g a
cup
of c
offe
e.•
Decr
ease
d po
wer
grip
in a
ffect
ed a
rm.
Inve
stig
atio
ns•
No
spec
ific
test
s or
imag
ing
requ
ired.
• Cl
inic
al d
iagn
osis.
• M
ill's
test
and
Coz
en’s
test
.
Trea
tmen
t•
Cons
erva
tive:
usu
ally
a s
elf-l
imiti
ng c
ondi
tion,
sto
p/de
crea
se
activ
ity th
at tr
igge
red
tenn
is e
lbow
, ice
elb
ow, u
tiliz
e an
elb
ow
stra
p, p
hysi
othe
rapy
may
be
requ
ired.
• M
edic
al: p
aink
iller
s (e
.g. p
arac
etam
ol a
nd N
SAID
s), l
ocal
st
eroi
d in
ject
ions
if s
ever
e an
d ot
her m
etho
ds h
ave
faile
d.•
Surg
ery:
onl
y co
nsid
ered
if a
bove
met
hods
hav
e fa
iled
and
if
pain
last
s fo
r up
to 4
mon
ths.
Com
plic
atio
ns•
Loss
of f
unct
ion.
• Ch
roni
c pa
in.
Gol
fer’s
elb
ow
Wha
t is
gol
fer’s
elb
ow?
Gol
fer’s
elb
ow is
als
o kn
own
as m
edia
l epi
cond
yliti
s an
d is
a ty
pe o
f el
bow
ove
ruse
inju
ry. T
he m
edia
l epi
cond
yle
is th
e or
igin
of t
he c
omm
on
flexo
r ten
don
and
in g
olfe
r’s e
lbow
it b
ecom
es in
flam
ed a
nd c
ause
s el
bow
pai
n.
Caus
esG
olfe
r’s e
lbow
is a
form
of r
epet
itive
str
ain
inju
ry (e
.g. p
layi
ng s
port
s su
ch
as g
olf,
bow
ling,
bas
ebal
l, ro
ck c
limbi
ng) o
r und
erta
king
oth
er a
ctiv
ities
su
ch a
s ga
rden
ing,
pai
ntin
g an
d us
ing
tool
s lik
e sc
rew
driv
ers.
This
resu
lts
in m
icro
rupt
ure/
mic
rote
ars
and
dege
nera
tive
chan
ges
in th
e te
ndon
as
wel
l as
infla
mm
atio
n.
Sym
ptom
s•
Achi
ng e
lbow
pai
n, ty
pica
lly o
ver t
he m
edia
l epi
cond
yle,
whi
ch
wor
sens
with
act
ivity
.•
Typi
cally
affe
cts
the
dom
inan
t arm
.•
Wor
se d
urin
g si
mpl
e da
ily ta
sks
utili
zing
flex
ors.
• De
crea
sed
pow
er g
rip in
affe
cted
arm
.
Inve
stig
atio
ns•
No
spec
ific
test
s or
imag
ing
requ
ired.
• Cl
inic
al d
iagn
osis.
• G
olfe
r’s e
lbow
test
.
Trea
tmen
t•
Cons
erva
tive:
usu
ally
a s
elf-l
imiti
ng c
ondi
tion,
sto
p/de
crea
se
activ
ity th
at tr
igge
red
golfe
r’s e
lbow
, ice
elb
ow, u
tiliz
e an
elb
ow
stra
p, p
hysi
othe
rapy
may
be
requ
ired.
• M
edic
al: p
aink
iller
s (e
.g. p
arac
etam
ol a
nd N
SAID
s), l
ocal
ste
roid
in
ject
ions
if s
ever
e an
d ot
her m
etho
ds h
ave
faile
d.•
Surg
ery:
onl
y co
nsid
ered
if a
bove
met
hods
hav
e fa
iled
and
if
pain
last
s fo
r up
to 4
mon
ths.
Com
plic
atio
ns•
Loss
of f
unct
ion.
• Ch
roni
c pa
in.
• As
soci
ated
uln
ar n
euro
path
y.
Rem
embe
r th
e di
ffer
ence
bet
wee
n te
nnis
elbo
w a
nd g
olfe
r’s e
lbow
as:
Tenn
is is
pla
yed
on th
e La
wn
(i.e.
Ten
nis
elbo
w is
Lat
eral
epi
cond
yliti
s)
Gol
f is
play
ed o
n th
e M
eado
w (i
.e. G
olfe
r’sel
bow
is M
edia
l epi
cond
yliti
s)
MAP
8.4
. Elb
ow p
atho
logy
Map
8.4
. El
bo
w p
ath
olo
gy
K30033_C008.indd 230 28/02/17 11:26 am
Ort
hopa
edic
s23
1Tenn
is e
lbow
Wha
t is
ten
nis
elbo
w?
Tenn
is e
lbow
is a
lso
know
n as
late
ral e
pico
ndyl
itis
and
is th
em
ost c
omm
on e
lbow
ove
ruse
inju
ry. T
he la
tera
l epi
cond
yle
isth
e or
igin
of t
he c
omm
on e
xten
sor t
endo
n an
d in
tenn
is e
lbow
it be
com
es in
flam
ed a
nd c
ause
s el
bow
pai
n.
Caus
esTe
nnis
elb
ow is
a fo
rm o
f rep
etiti
ve s
trai
n in
jury
(e.g
. pla
ying
spor
ts s
uch
as te
nnis,
squ
ash)
or u
nder
taki
ng o
ther
act
iviti
essu
ch a
s ga
rden
ing
and
pain
ting.
Thi
s re
sults
inm
icro
rupt
ure/
mic
rote
ars
and
dege
nera
tive
chan
ges
in th
ete
ndon
as
wel
l as
infla
mm
atio
n, p
artic
ular
ly a
t the
mus
cula
ror
igin
of e
xten
sor c
arpi
radi
alis
bre
vis.
Sym
ptom
s•
Achi
ng e
lbow
pai
n, ty
pica
lly o
ver t
he la
tera
l epi
cond
yle,
w
hich
wor
sens
with
act
ivity
.•
Typi
cally
affe
cts
the
dom
inan
t arm
.•
Wor
se d
urin
g si
mpl
e da
ily ta
sks
utili
zing
ext
enso
rs, s
uch
as
liftin
g a
cup
of c
offe
e.•
Decr
ease
d po
wer
grip
in a
ffect
ed a
rm.
Inve
stig
atio
ns•
No
spec
ific
test
s or
imag
ing
requ
ired.
• Cl
inic
al d
iagn
osis.
• M
ill's
test
and
Coz
en’s
test
.
Trea
tmen
t•
Cons
erva
tive:
usu
ally
a s
elf-l
imiti
ng c
ondi
tion,
sto
p/de
crea
se
activ
ity th
at tr
igge
red
tenn
is e
lbow
, ice
elb
ow, u
tiliz
e an
elb
ow
stra
p, p
hysi
othe
rapy
may
be
requ
ired.
• M
edic
al: p
aink
iller
s (e
.g. p
arac
etam
ol a
nd N
SAID
s), l
ocal
st
eroi
d in
ject
ions
if s
ever
e an
d ot
her m
etho
ds h
ave
faile
d.•
Surg
ery:
onl
y co
nsid
ered
if a
bove
met
hods
hav
e fa
iled
and
if
pain
last
s fo
r up
to 4
mon
ths.
Com
plic
atio
ns•
Loss
of f
unct
ion.
• Ch
roni
c pa
in.
Gol
fer’s
elb
ow
Wha
t is
gol
fer’s
elb
ow?
Gol
fer’s
elb
ow is
als
o kn
own
as m
edia
l epi
cond
yliti
s an
d is
a ty
pe o
f el
bow
ove
ruse
inju
ry. T
he m
edia
l epi
cond
yle
is th
e or
igin
of t
he c
omm
on
flexo
r ten
don
and
in g
olfe
r’s e
lbow
it b
ecom
es in
flam
ed a
nd c
ause
s el
bow
pai
n.
Caus
esG
olfe
r’s e
lbow
is a
form
of r
epet
itive
str
ain
inju
ry (e
.g. p
layi
ng s
port
s su
ch
as g
olf,
bow
ling,
bas
ebal
l, ro
ck c
limbi
ng) o
r und
erta
king
oth
er a
ctiv
ities
su
ch a
s ga
rden
ing,
pai
ntin
g an
d us
ing
tool
s lik
e sc
rew
driv
ers.
This
resu
lts
in m
icro
rupt
ure/
mic
rote
ars
and
dege
nera
tive
chan
ges
in th
e te
ndon
as
wel
l as
infla
mm
atio
n.
Sym
ptom
s•
Achi
ng e
lbow
pai
n, ty
pica
lly o
ver t
he m
edia
l epi
cond
yle,
whi
ch
wor
sens
with
act
ivity
.•
Typi
cally
affe
cts
the
dom
inan
t arm
.•
Wor
se d
urin
g si
mpl
e da
ily ta
sks
utili
zing
flex
ors.
• De
crea
sed
pow
er g
rip in
affe
cted
arm
.
Inve
stig
atio
ns•
No
spec
ific
test
s or
imag
ing
requ
ired.
• Cl
inic
al d
iagn
osis.
• G
olfe
r’s e
lbow
test
.
Trea
tmen
t•
Cons
erva
tive:
usu
ally
a s
elf-l
imiti
ng c
ondi
tion,
sto
p/de
crea
se
activ
ity th
at tr
igge
red
golfe
r’s e
lbow
, ice
elb
ow, u
tiliz
e an
elb
ow
stra
p, p
hysi
othe
rapy
may
be
requ
ired.
• M
edic
al: p
aink
iller
s (e
.g. p
arac
etam
ol a
nd N
SAID
s), l
ocal
ste
roid
in
ject
ions
if s
ever
e an
d ot
her m
etho
ds h
ave
faile
d.•
Surg
ery:
onl
y co
nsid
ered
if a
bove
met
hods
hav
e fa
iled
and
if
pain
last
s fo
r up
to 4
mon
ths.
Com
plic
atio
ns•
Loss
of f
unct
ion.
• Ch
roni
c pa
in.
• As
soci
ated
uln
ar n
euro
path
y.
Rem
embe
r th
e di
ffer
ence
bet
wee
n te
nnis
elbo
w a
nd g
olfe
r’s e
lbow
as:
Tenn
is is
pla
yed
on th
e La
wn
(i.e.
Ten
nis
elbo
w is
Lat
eral
epi
cond
yliti
s)
Gol
f is
play
ed o
n th
e M
eado
w (i
.e. G
olfe
r’sel
bow
is M
edia
l epi
cond
yliti
s)
MAP
8.4
. Elb
ow p
atho
logy
Map
8.4
. Elb
ow p
atho
logy
K30033_C008.indd 231 28/02/17 11:26 am
Ort
hopa
edic
s23
2M
AP 8
.5. H
and
pat
ho
log
y
Dup
uytr
en’s
con
trac
ture
Wha
t is
Dup
uytr
en’s
con
trac
ture
?Du
puyt
ren’
s co
ntra
ctur
e is
a p
rolif
erat
ive
fibro
plas
ia o
f the
pal
mar
an
d di
gita
l fas
cia.
Ove
r tim
e th
is le
ads
to th
e fo
rmat
ion
of
nodu
les
and
cord
s, w
hich
in tu
rn re
sult
in fi
nger
flex
ion.
The
ring
fin
ger i
s m
ost c
omm
only
affe
cted
.
Caus
esTh
e ex
act c
ause
of t
his
path
olog
y is
unk
now
n. It
is k
now
n th
at it
is
mor
e co
mm
on in
mal
es th
an fe
mal
es a
s w
ell a
s in
thos
e w
ith a
po
sitiv
e fa
mily
his
tory
. It i
s as
soci
ated
with
the
follo
win
g:•
Diab
etes
mel
litus
.•
Hepa
tic c
irrho
sis.
• Ce
rtai
n dr
ugs
(e.g
. phe
nyto
in)
• Tr
aum
a.
The
aggr
essi
ve fo
rm o
f the
dis
ease
is c
alle
d Du
puyt
ren’
s di
athe
sis
and
is a
ssoc
iate
d w
ith P
eyro
nie’
s di
seas
e (p
enile
fibr
omat
osis
) an
d Le
dder
hose
’s di
seas
e (p
lant
ar fa
scia
fibr
omat
osis
).
Sym
ptom
s•
Flex
ion
cont
ract
ure
of th
e fin
gers
.•
Nod
ular
thic
keni
ng o
f pal
mar
fasc
ia a
nd c
ord
deve
lopm
ent.
Inve
stig
atio
ns•
No
spec
ific
test
but
can
test
for u
nder
lyin
g as
soci
atio
ns.
• Pe
rform
Hue
ston
’s ta
blet
op te
st.
Trea
tmen
t•
Surg
ical
– o
nly
perfo
rm fa
scio
tom
y, fa
scie
ctom
y or
de
rmof
asci
ecto
my
if co
ntra
ctur
e is
caus
ing
func
tiona
l pro
blem
s.
Phys
ioth
erap
y an
d sp
lintin
g re
quire
d af
ter t
reat
men
t.
Com
plic
atio
ns•
Loss
of f
unct
ion.
• Co
mpl
icat
ions
ass
ocia
ted
with
sur
gery
(e.g
. hae
mat
oma
fo
rmat
ion,
infe
ctio
n, n
erve
inju
ry a
nd re
curr
ence
).
de Q
uerv
ain’
s sy
ndro
me
Wha
t is
de
Que
rvai
n’s
synd
rom
e?de
Que
rvai
n’s
synd
rom
e, a
lso
know
n as
was
herw
oman
’s sp
rain
, is
a st
enos
ing
teno
syno
vitis
of t
he e
xten
sor p
ollic
is b
revi
s an
d th
e ab
duct
or p
ollic
is te
ndon
s.
Caus
esTh
e ex
act c
ause
of t
his
cond
ition
is u
nkno
wn
but i
t is
asso
ciat
ed w
ithov
erus
e/re
petit
ive
task
s.
Sym
ptom
s•
Wris
t pai
n (ra
dial
sid
e), w
hich
is w
orse
on
mov
emen
t.
Inve
stig
atio
ns•
Fink
elst
ein’
s te
st –
pai
n on
pas
sive
uln
ar d
evia
tion
(fist
form
ed o
ver t
hum
b).
• Ra
diol
ogy
– x-
ray
to ru
le o
ut o
ther
con
ditio
ns s
uch
as o
steo
arth
ritis.
Trea
tmen
t•
Cons
erva
tive:
rest
and
avo
idan
ce o
f pre
cipi
tatin
g fa
ctor
s.•
Med
ical
: ana
lges
ia, s
tero
id in
ject
ions
.•
Surg
ical
: las
t res
ort f
or s
ever
e ca
ses
– re
leas
e of
firs
t ext
enso
r com
part
men
t.
Com
plic
atio
ns•
Decr
ease
d ra
nge
of m
ovem
ent o
f the
wris
t.
Sten
osin
g te
nosy
novi
tis
Wha
t is
ste
nosi
ng t
enos
ynov
itis
?Th
is is
als
o kn
own
as tr
igge
r fin
ger.
The
flexo
r ten
don
shea
th n
arro
ws
due
toth
icke
ning
of t
he te
ndon
she
ath,
usu
ally
due
to tr
aum
a. T
he ri
ng a
nd m
iddl
e fin
ger a
re m
ost c
omm
only
affe
cted
.
Caus
es•
Typi
cally
trau
ma.
• As
soci
ated
with
dia
bete
s m
ellit
us, r
heum
atoi
d ar
thrit
is a
nd g
out.
Sym
ptom
s•
Trap
ped
flexo
r ten
don,
usu
ally
rela
ted
to th
e A1
pul
ley.
• Di
git l
ocke
d in
flex
ion
and
mus
t be
pass
ivel
y re
leas
ed.
Inve
stig
atio
ns: c
linic
al d
iagn
osis.
Trea
tmen
t•
Cons
erva
tive:
imm
obili
zatio
n.•
Med
ical
: ana
lges
ia, s
tero
id in
ject
ions
.•
Surg
ery:
intr
acta
ble
case
s m
ay re
quire
sur
gica
l rel
ease
.
Com
plic
atio
ns•
Rela
ted
to s
urge
ry (e
.g. i
nfec
tion,
ner
ve in
jury
, ten
don
bow
strin
ging
).
MAP
8.5
. Han
d pa
thol
ogy
StStiii
ttiii
ititi
K30033_C008.indd 232 28/02/17 11:26 am
Ort
hopa
edic
s23
3M
AP 8
.5. H
and
pat
ho
log
y
Dup
uytr
en’s
con
trac
ture
Wha
t is
Dup
uytr
en’s
con
trac
ture
?Du
puyt
ren’
s co
ntra
ctur
e is
a p
rolif
erat
ive
fibro
plas
ia o
f the
pal
mar
an
d di
gita
l fas
cia.
Ove
r tim
e th
is le
ads
to th
e fo
rmat
ion
of
nodu
les
and
cord
s, w
hich
in tu
rn re
sult
in fi
nger
flex
ion.
The
ring
fin
ger i
s m
ost c
omm
only
affe
cted
.
Caus
esTh
e ex
act c
ause
of t
his
path
olog
y is
unk
now
n. It
is k
now
n th
at it
is
mor
e co
mm
on in
mal
es th
an fe
mal
es a
s w
ell a
s in
thos
e w
ith a
po
sitiv
e fa
mily
his
tory
. It i
s as
soci
ated
with
the
follo
win
g:•
Diab
etes
mel
litus
.•
Hepa
tic c
irrho
sis.
• Ce
rtai
n dr
ugs
(e.g
. phe
nyto
in)
• Tr
aum
a.
The
aggr
essi
ve fo
rm o
f the
dis
ease
is c
alle
d Du
puyt
ren’
s di
athe
sis
and
is a
ssoc
iate
d w
ith P
eyro
nie’
s di
seas
e (p
enile
fibr
omat
osis
) an
d Le
dder
hose
’s di
seas
e (p
lant
ar fa
scia
fibr
omat
osis
).
Sym
ptom
s•
Flex
ion
cont
ract
ure
of th
e fin
gers
.•
Nod
ular
thic
keni
ng o
f pal
mar
fasc
ia a
nd c
ord
deve
lopm
ent.
Inve
stig
atio
ns•
No
spec
ific
test
but
can
test
for u
nder
lyin
g as
soci
atio
ns.
• Pe
rform
Hue
ston
’s ta
blet
op te
st.
Trea
tmen
t•
Surg
ical
– o
nly
perfo
rm fa
scio
tom
y, fa
scie
ctom
y or
de
rmof
asci
ecto
my
if co
ntra
ctur
e is
caus
ing
func
tiona
l pro
blem
s.
Phys
ioth
erap
y an
d sp
lintin
g re
quire
d af
ter t
reat
men
t.
Com
plic
atio
ns•
Loss
of f
unct
ion.
• Co
mpl
icat
ions
ass
ocia
ted
with
sur
gery
(e.g
. hae
mat
oma
fo
rmat
ion,
infe
ctio
n, n
erve
inju
ry a
nd re
curr
ence
).
de Q
uerv
ain’
s sy
ndro
me
Wha
t is
de
Que
rvai
n’s
synd
rom
e?de
Que
rvai
n’s
synd
rom
e, a
lso
know
n as
was
herw
oman
’s sp
rain
, is
a st
enos
ing
teno
syno
vitis
of t
he e
xten
sor p
ollic
is b
revi
s an
d th
e ab
duct
or p
ollic
is te
ndon
s.
Caus
esTh
e ex
act c
ause
of t
his
cond
ition
is u
nkno
wn
but i
t is
asso
ciat
ed w
ithov
erus
e/re
petit
ive
task
s.
Sym
ptom
s•
Wris
t pai
n (ra
dial
sid
e), w
hich
is w
orse
on
mov
emen
t.
Inve
stig
atio
ns•
Fink
elst
ein’
s te
st –
pai
n on
pas
sive
uln
ar d
evia
tion
(fist
form
ed o
ver t
hum
b).
• Ra
diol
ogy
– x-
ray
to ru
le o
ut o
ther
con
ditio
ns s
uch
as o
steo
arth
ritis.
Trea
tmen
t•
Cons
erva
tive:
rest
and
avo
idan
ce o
f pre
cipi
tatin
g fa
ctor
s.•
Med
ical
: ana
lges
ia, s
tero
id in
ject
ions
.•
Surg
ical
: las
t res
ort f
or s
ever
e ca
ses
– re
leas
e of
firs
t ext
enso
r com
part
men
t.
Com
plic
atio
ns•
Decr
ease
d ra
nge
of m
ovem
ent o
f the
wris
t.
Sten
osin
g te
nosy
novi
tis
Wha
t is
ste
nosi
ng t
enos
ynov
itis
?Th
is is
als
o kn
own
as tr
igge
r fin
ger.
The
flexo
r ten
don
shea
th n
arro
ws
due
toth
icke
ning
of t
he te
ndon
she
ath,
usu
ally
due
to tr
aum
a. T
he ri
ng a
nd m
iddl
e fin
ger a
re m
ost c
omm
only
affe
cted
.
Caus
es•
Typi
cally
trau
ma.
• As
soci
ated
with
dia
bete
s m
ellit
us, r
heum
atoi
d ar
thrit
is a
nd g
out.
Sym
ptom
s•
Trap
ped
flexo
r ten
don,
usu
ally
rela
ted
to th
e A1
pul
ley.
• Di
git l
ocke
d in
flex
ion
and
mus
t be
pass
ivel
y re
leas
ed.
Inve
stig
atio
ns: c
linic
al d
iagn
osis.
Trea
tmen
t•
Cons
erva
tive:
imm
obili
zatio
n.•
Med
ical
: ana
lges
ia, s
tero
id in
ject
ions
.•
Surg
ery:
intr
acta
ble
case
s m
ay re
quire
sur
gica
l rel
ease
.
Com
plic
atio
ns•
Rela
ted
to s
urge
ry (e
.g. i
nfec
tion,
ner
ve in
jury
, ten
don
bow
strin
ging
).
MAP
8.5
. Han
d pa
thol
ogy
StStiii
ttiii
ititi
Cont
inue
d ov
erle
af
K30033_C008.indd 233 28/02/17 11:26 am
Ort
hopa
edic
s23
4 Carp
al t
unne
l syn
drom
e
Wha
t is
car
pal t
unne
l syn
drom
e?Ca
rpal
tunn
el s
yndr
ome
may
be
defin
ed a
s th
e co
mpr
essi
on o
f th
e m
edia
n ne
rve
as it
pas
ses
thro
ugh
the
carp
al tu
nnel
, ben
eath
th
e fle
xor r
etin
acul
um. I
t is
mor
e co
mm
on in
fem
ales
than
mal
es.
Caus
esRe
mem
ber a
s M
EDIA
N T
RAP:
M –
Myx
oede
ma
E –
oEd
ema
D –
Dia
bete
s m
ellit
usI
– Id
iopa
thic
A –
Acr
omeg
aly
N –
Neo
plas
m
T –
Tra
uma
R –
Rhe
umat
oid
arth
ritis
A –
Am
yloi
dosi
sP
– P
regn
ancy
Sym
ptom
sRe
mem
ber a
s 3P
s•
Pain
– in
the
med
ian
nerv
e di
strib
utio
n, w
orse
at n
ight
.
• Pa
raes
thes
ia –
in th
e m
edia
n ne
rve
dist
ribut
ion,
relie
ve b
y
shak
ing
hand
s.•
Patc
h –
on th
enar
em
inen
ce is
pre
serv
ed s
ince
the
supe
rfici
al
bran
ch o
f the
med
ian
nerv
e su
pplie
s th
is a
rea.
The
nar m
uscl
e
may
hav
e w
aste
d in
adv
ance
d di
seas
e.
Inve
stig
atio
ns•
Usu
ally
a c
linic
al d
iagn
osis
cou
pled
with
a th
orou
gh p
hysi
cal
ex
amin
atio
n in
clud
ing
spec
ific T
inel
’s an
d Ph
alen
’s te
sts.
• N
erve
con
duct
ion
stud
ies
– di
ffere
ntia
tes
from
cer
vica
l
spon
dylo
sis
(C6/
7).
Trea
tmen
t•
Cons
erva
tive:
spl
intin
g.•
Med
ical
: ste
roid
inje
ctio
n.•
Surg
ical
: car
pal t
unne
l rel
ease
.
Scap
hoid
frac
ture
Wha
t is
a s
caph
oid
frac
ture
?Th
e sc
apho
id is
the
mos
t com
mon
ly fr
actu
red
wris
t bon
e. T
he re
ason
this
frac
ture
is s
o im
port
ant t
o as
sess
fund
amen
tally
rest
s in
the
bloo
d su
pply
to th
is b
one.
The
blo
od
supp
ly e
nter
s th
e di
stal
par
t of t
he s
caph
oid
bone
and
runs
pro
xim
ally.
Thi
s m
eans
that
th
ere
is a
risk
of p
roxi
mal
ava
scul
ar n
ecro
sis
if fra
ctur
ed.
Caus
es•
Trau
ma
– ty
pica
lly ‘f
all o
n ou
tstr
etch
ed h
and’
(FO
OSH
).
Sym
ptom
s•
Pain
ove
r the
sca
phoi
d bo
ne (i
.e. o
n pa
lpat
ion
of th
e an
atom
ical
snu
ff bo
x).
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y. Fr
actu
re m
ay n
ot b
e se
en in
itial
ly. If
not
see
n bu
t it i
s su
spec
ted
cl
inic
ally,
imm
obili
ze in
a s
caph
oid
splin
t and
repe
at th
e x-
ray
in 1
0 da
ys to
2 w
eeks
.
Trea
tmen
t•
Scap
hoid
pla
ster
.
Com
plic
atio
ns•
Avas
cula
r nec
rosi
s (p
roxi
mal
third
).•
Ost
eoar
thrit
is.•
Mal
unio
n.
MAP
8.5
. Han
d pa
thol
ogy
(con
tinue
d )
MAP
8.5
. Han
d p
ath
olo
gy
K30033_C008.indd 234 28/02/17 11:26 am
Ort
hopa
edic
s23
5Carp
al t
unne
l syn
drom
e
Wha
t is
car
pal t
unne
l syn
drom
e?Ca
rpal
tunn
el s
yndr
ome
may
be
defin
ed a
s th
e co
mpr
essi
on o
f th
e m
edia
n ne
rve
as it
pas
ses
thro
ugh
the
carp
al tu
nnel
, ben
eath
th
e fle
xor r
etin
acul
um. I
t is
mor
e co
mm
on in
fem
ales
than
mal
es.
Caus
esRe
mem
ber a
s M
EDIA
N T
RAP:
M –
Myx
oede
ma
E –
oEd
ema
D –
Dia
bete
s m
ellit
usI
– Id
iopa
thic
A –
Acr
omeg
aly
N –
Neo
plas
m
T –
Tra
uma
R –
Rhe
umat
oid
arth
ritis
A –
Am
yloi
dosi
sP
– P
regn
ancy
Sym
ptom
sRe
mem
ber a
s 3P
s•
Pain
– in
the
med
ian
nerv
e di
strib
utio
n, w
orse
at n
ight
.
• Pa
raes
thes
ia –
in th
e m
edia
n ne
rve
dist
ribut
ion,
relie
ve b
y
shak
ing
hand
s.•
Patc
h –
on th
enar
em
inen
ce is
pre
serv
ed s
ince
the
supe
rfici
al
bran
ch o
f the
med
ian
nerv
e su
pplie
s th
is a
rea.
The
nar m
uscl
e
may
hav
e w
aste
d in
adv
ance
d di
seas
e.
Inve
stig
atio
ns•
Usu
ally
a c
linic
al d
iagn
osis
cou
pled
with
a th
orou
gh p
hysi
cal
ex
amin
atio
n in
clud
ing
spec
ific T
inel
’s an
d Ph
alen
’s te
sts.
• N
erve
con
duct
ion
stud
ies
– di
ffere
ntia
tes
from
cer
vica
l
spon
dylo
sis
(C6/
7).
Trea
tmen
t•
Cons
erva
tive:
spl
intin
g.•
Med
ical
: ste
roid
inje
ctio
n.•
Surg
ical
: car
pal t
unne
l rel
ease
.
Scap
hoid
frac
ture
Wha
t is
a s
caph
oid
frac
ture
?Th
e sc
apho
id is
the
mos
t com
mon
ly fr
actu
red
wris
t bon
e. T
he re
ason
this
frac
ture
is s
o im
port
ant t
o as
sess
fund
amen
tally
rest
s in
the
bloo
d su
pply
to th
is b
one.
The
blo
od
supp
ly e
nter
s th
e di
stal
par
t of t
he s
caph
oid
bone
and
runs
pro
xim
ally.
Thi
s m
eans
that
th
ere
is a
risk
of p
roxi
mal
ava
scul
ar n
ecro
sis
if fra
ctur
ed.
Caus
es•
Trau
ma
– ty
pica
lly ‘f
all o
n ou
tstr
etch
ed h
and’
(FO
OSH
).
Sym
ptom
s•
Pain
ove
r the
sca
phoi
d bo
ne (i
.e. o
n pa
lpat
ion
of th
e an
atom
ical
snu
ff bo
x).
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y. Fr
actu
re m
ay n
ot b
e se
en in
itial
ly. If
not
see
n bu
t it i
s su
spec
ted
cl
inic
ally,
imm
obili
ze in
a s
caph
oid
splin
t and
repe
at th
e x-
ray
in 1
0 da
ys to
2 w
eeks
.
Trea
tmen
t•
Scap
hoid
pla
ster
.
Com
plic
atio
ns•
Avas
cula
r nec
rosi
s (p
roxi
mal
third
).•
Ost
eoar
thrit
is.•
Mal
unio
n.
MAP
8.5
. Han
d pa
thol
ogy
(con
tinue
d )
MAP
8.5
. Han
d p
ath
olo
gy
K30033_C008.indd 235 28/02/17 11:26 am
Ort
hopa
edic
s23
6
Kyph
osis
Wha
t is
kyp
hosi
s?Th
is is
an
exag
gera
ted
ante
rior c
urva
ture
of t
he th
orac
ic s
pine
. Kyp
hosi
s m
ay b
e cl
assi
fied
as fi
xed,
as
in a
nkyl
osin
g sp
ondy
litis,
or m
obile
as
in p
ostu
ral k
ypho
sis.
It m
ay a
lso
be d
efin
ed re
late
d to
sha
pe (i
.e. r
egul
ar o
r ang
ular
[gib
bus]
).
Ther
e ar
e m
any
diffe
rent
type
s of
kyp
hosi
s. Re
mem
ber a
s PO
ND
S:P
– Po
stur
al –
mor
e co
mm
on in
ado
lesc
ent g
irls
O –
Ost
eopo
rotic
N –
Neu
rom
uscu
lar
D –
Deg
ener
ativ
eS
– Sc
heue
rman
n’s
dise
ase
– al
so k
now
n as
spi
nal o
steo
chon
dros
is. D
efin
edas
kyp
hosi
s >
40°
and
wed
ging
of i
ndiv
idua
l ver
tebr
a of
5°
(sin
ce th
eve
rteb
ra g
row
s m
ore
thic
kly
post
erio
rly th
an a
nter
iorly
)
Caus
esCa
uses
incl
ude:
• In
fect
ion
– TB
, pol
io.
• M
alig
nanc
y.•
Bone
dis
ease
– o
steo
poro
sis,
Page
t’s d
isea
se.
• An
kylo
sing
spo
ndyl
itis.
• Ca
lvé’
s di
seas
e.
Sym
ptom
s•
Cosm
etic
def
orm
ity.
• Ac
hing
, but
not
sev
ere,
pai
n. If
pai
n is
ver
y se
vere
, the
n m
ust e
xclu
de s
pina
l
tum
ours
/ost
eoid
ost
eom
as.
• Sy
mpt
oms
of u
nder
lyin
g co
nditi
on.
Inve
stig
atio
ns•
Thor
ough
spi
nal e
xam
inat
ion.
• Ra
diol
ogy
– x-
ray
(AP
and
late
ral v
iew
s) a
nd C
obb
angl
e m
easu
rem
ent.
• In
vest
igat
ions
con
cern
ing
an u
nder
lyin
g ca
use
if su
spec
ted.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py, e
xerc
ise,
par
ticul
arly
sw
imm
ing.
• M
edic
al: a
dequ
ate
anal
gesi
a.•
Surg
ery:
onl
y in
sev
ere
case
s.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns (e
.g. d
epre
ssio
n)•
Rest
rictiv
e lu
ng d
isea
se.
• Ca
rdia
c co
mpl
icat
ions
.•
Cord
com
pres
sion
.•
Para
pleg
ia.
Scol
iosi
s
Wha
t is
sco
liosi
s?Th
is is
a la
tera
l cur
vatu
re o
f the
spi
ne th
at is
>10
° (C
obb
angl
e). I
t may
be
stru
ctur
al o
r non
-str
uctu
ral a
nd b
road
ly s
peak
ing
ther
e ar
e fiv
e di
ffere
ntty
pes.
Rem
embe
r as
PON
DS:
P –
Post
ural
: non
-str
uctu
ral c
ompe
nsat
ory
scol
iosi
sO
– O
steo
path
ic: s
truc
tura
l abn
orm
ality
. Mos
tly c
onge
nita
l but
som
e ca
ses
m
ay b
e as
soci
ated
with
bon
e di
seas
eN
– N
euro
mus
cula
r: as
soci
ated
with
cer
ebra
l pal
sy, F
riedr
eich
’s at
axia
etc
.D
– D
egen
erat
ive:
ass
ocia
ted
with
face
t joi
nt fa
ilure
S –
Stru
ctur
al id
iopa
thic
: may
be
subd
ivid
ed in
to fi
ve ty
pes:
1
. Tho
raco
lum
bar –
usu
ally
cur
ves
to th
e rig
ht
2. L
umba
r – u
sual
ly c
urve
s to
the
left
3
. Inf
antil
e th
orac
ic –
usu
ally
cur
ves
to th
e le
ft
4. A
dole
scen
t tho
raci
c –
usua
lly c
urve
s to
the
right
5
. Dou
ble
maj
or –
two
curv
es in
eac
h di
rect
ion
Caus
esSe
e ab
ove.
Rem
embe
r to
ask
abou
t fam
ily h
isto
ry a
nd p
regn
ancy
.
Sym
ptom
s•
Cosm
etic
def
orm
ity.
• Ac
hing
, but
not
sev
ere,
pai
n. If
pai
n is
ver
y se
vere
, the
n m
ust e
xclu
de
spin
al tu
mou
rs/o
steo
id o
steo
mas
.
Inve
stig
atio
ns•
Thor
ough
spi
nal e
xam
inat
ion.
• Ra
diol
ogy
– x-
ray
(AP
and
late
ral v
iew
s) a
nd C
obb
angl
e m
easu
rem
ent.
• In
vest
igat
ions
con
cern
ing
an u
nder
lyin
g ca
use
if su
spec
ted.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py, e
xerc
ise
(par
ticul
arly
sw
imm
ing)
, bra
ce –
Bo
ston
or M
ilwau
kee.
• M
edic
al: a
dequ
ate
anal
gesi
a.•
Surg
ical
: onl
y in
sev
ere
case
s.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns (e
.g. d
epre
ssio
n).
• Re
stric
tive
lung
dis
ease
.•
Card
iac
com
plic
atio
ns.
• N
erve
com
pres
sion
.
MAP
8.6
. Spi
nal p
atho
logy
MAP
8.6
. Sp
inal
pat
ho
log
y
K30033_C008.indd 236 28/02/17 11:26 am
Ort
hopa
edic
s23
7
Kyph
osis
Wha
t is
kyp
hosi
s?Th
is is
an
exag
gera
ted
ante
rior c
urva
ture
of t
he th
orac
ic s
pine
. Kyp
hosi
s m
ay b
e cl
assi
fied
as fi
xed,
as
in a
nkyl
osin
g sp
ondy
litis,
or m
obile
as
in p
ostu
ral k
ypho
sis.
It m
ay a
lso
be d
efin
ed re
late
d to
sha
pe (i
.e. r
egul
ar o
r ang
ular
[gib
bus]
).
Ther
e ar
e m
any
diffe
rent
type
s of
kyp
hosi
s. Re
mem
ber a
s PO
ND
S:P
– Po
stur
al –
mor
e co
mm
on in
ado
lesc
ent g
irls
O –
Ost
eopo
rotic
N –
Neu
rom
uscu
lar
D –
Deg
ener
ativ
eS
– Sc
heue
rman
n’s
dise
ase
– al
so k
now
n as
spi
nal o
steo
chon
dros
is. D
efin
edas
kyp
hosi
s >
40°
and
wed
ging
of i
ndiv
idua
l ver
tebr
a of
5°
(sin
ce th
eve
rteb
ra g
row
s m
ore
thic
kly
post
erio
rly th
an a
nter
iorly
)
Caus
esCa
uses
incl
ude:
• In
fect
ion
– TB
, pol
io.
• M
alig
nanc
y.•
Bone
dis
ease
– o
steo
poro
sis,
Page
t’s d
isea
se.
• An
kylo
sing
spo
ndyl
itis.
• Ca
lvé’
s di
seas
e.
Sym
ptom
s•
Cosm
etic
def
orm
ity.
• Ac
hing
, but
not
sev
ere,
pai
n. If
pai
n is
ver
y se
vere
, the
n m
ust e
xclu
de s
pina
l
tum
ours
/ost
eoid
ost
eom
as.
• Sy
mpt
oms
of u
nder
lyin
g co
nditi
on.
Inve
stig
atio
ns•
Thor
ough
spi
nal e
xam
inat
ion.
• Ra
diol
ogy
– x-
ray
(AP
and
late
ral v
iew
s) a
nd C
obb
angl
e m
easu
rem
ent.
• In
vest
igat
ions
con
cern
ing
an u
nder
lyin
g ca
use
if su
spec
ted.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py, e
xerc
ise,
par
ticul
arly
sw
imm
ing.
• M
edic
al: a
dequ
ate
anal
gesi
a.•
Surg
ery:
onl
y in
sev
ere
case
s.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns (e
.g. d
epre
ssio
n)•
Rest
rictiv
e lu
ng d
isea
se.
• Ca
rdia
c co
mpl
icat
ions
.•
Cord
com
pres
sion
.•
Para
pleg
ia.
Scol
iosi
s
Wha
t is
sco
liosi
s?Th
is is
a la
tera
l cur
vatu
re o
f the
spi
ne th
at is
>10
° (C
obb
angl
e). I
t may
be
stru
ctur
al o
r non
-str
uctu
ral a
nd b
road
ly s
peak
ing
ther
e ar
e fiv
e di
ffere
ntty
pes.
Rem
embe
r as
PON
DS:
P –
Post
ural
: non
-str
uctu
ral c
ompe
nsat
ory
scol
iosi
sO
– O
steo
path
ic: s
truc
tura
l abn
orm
ality
. Mos
tly c
onge
nita
l but
som
e ca
ses
m
ay b
e as
soci
ated
with
bon
e di
seas
eN
– N
euro
mus
cula
r: as
soci
ated
with
cer
ebra
l pal
sy, F
riedr
eich
’s at
axia
etc
.D
– D
egen
erat
ive:
ass
ocia
ted
with
face
t joi
nt fa
ilure
S –
Stru
ctur
al id
iopa
thic
: may
be
subd
ivid
ed in
to fi
ve ty
pes:
1
. Tho
raco
lum
bar –
usu
ally
cur
ves
to th
e rig
ht
2. L
umba
r – u
sual
ly c
urve
s to
the
left
3
. Inf
antil
e th
orac
ic –
usu
ally
cur
ves
to th
e le
ft
4. A
dole
scen
t tho
raci
c –
usua
lly c
urve
s to
the
right
5
. Dou
ble
maj
or –
two
curv
es in
eac
h di
rect
ion
Caus
esSe
e ab
ove.
Rem
embe
r to
ask
abou
t fam
ily h
isto
ry a
nd p
regn
ancy
.
Sym
ptom
s•
Cosm
etic
def
orm
ity.
• Ac
hing
, but
not
sev
ere,
pai
n. If
pai
n is
ver
y se
vere
, the
n m
ust e
xclu
de
spin
al tu
mou
rs/o
steo
id o
steo
mas
.
Inve
stig
atio
ns•
Thor
ough
spi
nal e
xam
inat
ion.
• Ra
diol
ogy
– x-
ray
(AP
and
late
ral v
iew
s) a
nd C
obb
angl
e m
easu
rem
ent.
• In
vest
igat
ions
con
cern
ing
an u
nder
lyin
g ca
use
if su
spec
ted.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py, e
xerc
ise
(par
ticul
arly
sw
imm
ing)
, bra
ce –
Bo
ston
or M
ilwau
kee.
• M
edic
al: a
dequ
ate
anal
gesi
a.•
Surg
ical
: onl
y in
sev
ere
case
s.
Com
plic
atio
ns•
Psyc
holo
gica
l im
plic
atio
ns (e
.g. d
epre
ssio
n).
• Re
stric
tive
lung
dis
ease
.•
Card
iac
com
plic
atio
ns.
• N
erve
com
pres
sion
.
MAP
8.6
. Spi
nal p
atho
logy
Cont
inue
d ov
erle
af
MAP
8.6
. Sp
inal
pat
ho
log
y
K30033_C008.indd 237 28/02/17 11:26 am
Ort
hopa
edic
s23
8 Ank
ylos
ing
spon
dylit
is
Wha
t is
ank
ylos
ing
spon
dylit
is?
This
is a
chr
onic
infla
mm
ator
y di
seas
e of
the
spin
e an
d sa
croi
liac
join
ts. T
here
is
pre
dom
inan
ce in
you
ng m
ales
and
the
cond
ition
is a
ssoc
iate
d w
ith H
LA-B
27
(pos
itive
in 9
5%).
Caus
esTh
e ex
act c
ause
and
pat
hoph
ysio
logy
of t
his
cond
ition
are
unk
now
n.Ho
wev
er, i
t is
thou
ght t
o be
ass
ocia
ted
with
HLA
-B27
.
Sign
s an
d sy
mpt
oms
Sym
ptom
s im
prov
e w
ith e
xerc
ise.
• Q
uest
ion
mar
k po
stur
e.•
Pain
and
stif
fnes
s.•
Extr
a-ar
ticul
ar fe
atur
es:
Iritis
.
Ao
rtiti
s.
Ap
ical
pul
mon
ary
fibro
sis.
Amyl
oido
sis
(sec
onda
ry).
Card
iac
cond
uctio
n de
fect
s.•
Spec
ific
spin
al s
ympt
oms:
Bam
boo
spin
e –
due
to c
alci
ficat
ion
of li
gam
ents
.
Lo
w b
ack
pain
and
stif
fnes
s.
Lo
ss o
f lum
bar l
ordo
sis.
Com
pens
ator
y fix
ed k
ypho
sis.
Spin
al s
teno
sis
Wha
t is
spi
nal s
teno
sis?
This
is a
nar
row
ing
of th
e sp
inal
can
al, w
hich
resu
lts in
com
pres
sion
of t
he
spin
al c
ord
and
corr
espo
ndin
g ne
rves
.
Caus
es•
Arth
ritis.
• Ag
e.•
Trau
ma.
• Sp
ace-
occu
pyin
g le
sion
.•
Spon
dylo
listh
esis.
Sym
ptom
s•
Uni
late
ral o
r bila
tera
l leg
pai
n +
/– b
ack
pain
that
is u
sual
ly
of g
radu
al o
nset
.•
Num
bnes
s an
d w
eakn
ess
that
wor
sens
with
wal
king
.•
Pain
relie
ved
by s
ittin
g an
d le
anin
g fo
rwar
ds.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Radi
olog
y –
MRI
.
Inve
stig
atio
ns•
Wal
l tes
t – d
imin
ishe
d sp
ine
exte
nsio
n m
eans
that
the
pa
tient
's o
ccip
ut, s
capu
la, b
utto
cks
and
heel
s ca
nnot
con
tact
th
e w
all s
imul
tane
ousl
y.•
Bloo
ds –
ser
oneg
ativ
e fo
r rhe
umat
oid
fact
or.
• Ra
diol
ogy
– ch
est x
-ray
and
MRI
to a
sses
s ch
ange
s in
the
spin
e.
Trea
tmen
t•
Cons
erva
tive:
pat
ient
edu
catio
n. R
efer
to p
hysi
othe
rapy
.•
Med
ical
: ana
lges
ia (N
SAID
s) a
nd D
MAR
Ds (e
.g. s
ulph
asal
azin
e [fi
rst l
ine]
).•
Surg
ical
: cor
rect
ive
spin
al s
urge
ry.
Com
plic
atio
ns•
Ost
eopo
rosi
s.•
Spin
al fr
actu
res.
• In
crea
sed
risk
of c
ardi
ovas
cula
r dis
ease
(e.g
. str
oke
and
m
yoca
rdia
l inf
arct
ion)
.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py.
• M
edic
al: e
ffect
ive
anal
gesi
a.•
Surg
ical
: lam
inec
tom
y.
Com
plic
atio
ns•
Para
lysi
s.•
Inco
ntin
ence
.•
Diffi
culty
bal
anci
ng.
MAP
8.6
. Spi
nal p
atho
logy
(con
tinue
d )
MAP
8.6
. Sp
inal
pat
ho
log
y
K30033_C008.indd 238 28/02/17 11:26 am
Ort
hopa
edic
s23
9Ank
ylos
ing
spon
dylit
is
Wha
t is
ank
ylos
ing
spon
dylit
is?
This
is a
chr
onic
infla
mm
ator
y di
seas
e of
the
spin
e an
d sa
croi
liac
join
ts. T
here
is
pre
dom
inan
ce in
you
ng m
ales
and
the
cond
ition
is a
ssoc
iate
d w
ith H
LA-B
27
(pos
itive
in 9
5%).
Caus
esTh
e ex
act c
ause
and
pat
hoph
ysio
logy
of t
his
cond
ition
are
unk
now
n.Ho
wev
er, i
t is
thou
ght t
o be
ass
ocia
ted
with
HLA
-B27
.
Sign
s an
d sy
mpt
oms
Sym
ptom
s im
prov
e w
ith e
xerc
ise.
• Q
uest
ion
mar
k po
stur
e.•
Pain
and
stif
fnes
s.•
Extr
a-ar
ticul
ar fe
atur
es:
Iritis
.
Ao
rtiti
s.
Ap
ical
pul
mon
ary
fibro
sis.
Amyl
oido
sis
(sec
onda
ry).
Card
iac
cond
uctio
n de
fect
s.•
Spec
ific
spin
al s
ympt
oms:
Bam
boo
spin
e –
due
to c
alci
ficat
ion
of li
gam
ents
.
Lo
w b
ack
pain
and
stif
fnes
s.
Lo
ss o
f lum
bar l
ordo
sis.
Com
pens
ator
y fix
ed k
ypho
sis.
Spin
al s
teno
sis
Wha
t is
spi
nal s
teno
sis?
This
is a
nar
row
ing
of th
e sp
inal
can
al, w
hich
resu
lts in
com
pres
sion
of t
he
spin
al c
ord
and
corr
espo
ndin
g ne
rves
.
Caus
es•
Arth
ritis.
• Ag
e.•
Trau
ma.
• Sp
ace-
occu
pyin
g le
sion
.•
Spon
dylo
listh
esis.
Sym
ptom
s•
Uni
late
ral o
r bila
tera
l leg
pai
n +
/– b
ack
pain
that
is u
sual
ly
of g
radu
al o
nset
.•
Num
bnes
s an
d w
eakn
ess
that
wor
sens
with
wal
king
.•
Pain
relie
ved
by s
ittin
g an
d le
anin
g fo
rwar
ds.
Inve
stig
atio
ns•
Thor
ough
phy
sica
l exa
min
atio
n.•
Radi
olog
y –
MRI
.
Inve
stig
atio
ns•
Wal
l tes
t – d
imin
ishe
d sp
ine
exte
nsio
n m
eans
that
the
pa
tient
's o
ccip
ut, s
capu
la, b
utto
cks
and
heel
s ca
nnot
con
tact
th
e w
all s
imul
tane
ousl
y.•
Bloo
ds –
ser
oneg
ativ
e fo
r rhe
umat
oid
fact
or.
• Ra
diol
ogy
– ch
est x
-ray
and
MRI
to a
sses
s ch
ange
s in
the
spin
e.
Trea
tmen
t•
Cons
erva
tive:
pat
ient
edu
catio
n. R
efer
to p
hysi
othe
rapy
.•
Med
ical
: ana
lges
ia (N
SAID
s) a
nd D
MAR
Ds (e
.g. s
ulph
asal
azin
e [fi
rst l
ine]
).•
Surg
ical
: cor
rect
ive
spin
al s
urge
ry.
Com
plic
atio
ns•
Ost
eopo
rosi
s.•
Spin
al fr
actu
res.
• In
crea
sed
risk
of c
ardi
ovas
cula
r dis
ease
(e.g
. str
oke
and
m
yoca
rdia
l inf
arct
ion)
.
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py.
• M
edic
al: e
ffect
ive
anal
gesi
a.•
Surg
ical
: lam
inec
tom
y.
Com
plic
atio
ns•
Para
lysi
s.•
Inco
ntin
ence
.•
Diffi
culty
bal
anci
ng.
MAP
8.6
. Spi
nal p
atho
logy
(con
tinue
d )
MAP
8.6
. Sp
inal
pat
ho
log
y
K30033_C008.indd 239 28/02/17 11:26 am
Ort
hopa
edic
s24
0 Prox
imal
fem
oral
frac
ture
Wha
t is
a p
roxi
mal
fem
oral
frac
ture
?Fr
actu
res
may
be
defin
ed a
s a
disc
ontin
uity
of b
one
and,
whe
re th
epr
oxim
al fe
mur
is c
once
rned
, it u
sual
ly o
ccur
s in
the
elde
rly a
nd is
mor
eco
mm
on in
wom
en.
Th
e fra
ctur
e m
ay b
e de
fined
as
extr
acap
sula
r or i
ntra
caps
ular
.In
trac
apsu
lar f
ract
ures
are
furt
her s
ubdi
vide
d in
to s
ub-c
apita
l and
tr
ans-
cerv
ical
type
s, w
here
as e
xtra
caps
ular
frac
ture
s m
ay b
e ca
tego
rized
as
basi
-cer
vica
l, in
ter-t
roch
ante
ric a
nd s
ub-t
roch
ante
ric. T
here
is a
hig
h ris
k of
av
ascu
lar n
ecro
sis
with
intr
acap
sula
r fra
ctur
es. T
he b
lood
sup
ply
of th
e pr
oxim
al fe
mur
is fr
om:
1. T
he m
edia
l fem
oral
circ
umfle
x ar
tery
.2.
The
late
ral f
emor
al c
ircum
flex
arte
ry.
3. T
he a
rter
y of
the
ligam
entu
m te
res.
Caus
es•
Path
olog
ical
frac
ture
– o
steo
poro
sis,
met
asta
ses
to b
one.
• Tr
aum
a.
Sym
ptom
s•
Pain
.•
Shor
teni
ng o
f the
affe
cted
leg.
• Ex
tern
al ro
tatio
n of
the
affe
cted
leg.
Inve
stig
atio
ns•
Rout
ine
pre-
oper
ativ
e bl
ood
test
s.•
Radi
olog
y –
x-ra
y. Th
e G
arde
n cl
assi
ficat
ion
is u
sed
to d
escr
ibe
pr
oxim
al in
trac
apsu
lar f
emor
al fr
actu
res:
Type
I: u
ndis
plac
ed.
Type
II: u
ndis
plac
ed b
ut c
ompl
ete
fract
ure.
Type
III:
disp
lace
d fra
ctur
e bu
t stil
l bon
y co
ntac
t.
Ty
pe IV
: com
plet
ely
disp
lace
d.
Trea
tmen
t•
Extr
acap
sula
r fra
ctur
es:
Dyna
mic
hip
scr
ew.
• In
trac
apsu
lar f
ract
ures
:
U
ndis
plac
ed: i
nter
nal f
ixat
ion
or h
emia
rthr
opla
sty.
Disp
lace
d: h
emia
rthr
opla
sty
or to
tal h
ip re
plac
emen
t.
Com
plic
atio
ns•
Avas
cula
r nec
rosi
s.•
Thro
mbo
embo
lism
.•
Com
plic
atio
ns a
ssoc
iate
d w
ith fr
actu
res
(see
Tabl
es 8
.1a,
b,
pp
. 220
, 221
).
Slip
ped
uppe
r fe
mor
al e
piph
ysis
Wha
t is
slip
ped
uppe
r fe
mor
al e
piph
ysis
(SU
FE)?
This
is a
rare
con
ditio
n in
whi
ch th
e up
per f
emor
al e
piph
ysis
slip
s po
ster
oinf
erio
rly fr
om th
e fe
mor
al n
eck.
It m
ay o
ccur
bila
tera
lly in
20%
of
case
s. It
is v
ery
diffi
cult
to d
iagn
ose.
Caus
es•
Cart
ilagi
nous
phy
sis
failu
re.
Risk
fact
ors
Incl
ude:
• O
besi
ty.
• M
ale
sex.
• En
docr
ine
imba
lanc
es (e
.g. h
ypot
hyro
idis
m, d
ecre
ased
sex
hor
mon
es).
Sym
ptom
s•
Pain
– te
nds
to b
e lo
caliz
ed to
the
knee
and
thig
h.•
Decr
ease
d le
g ab
duct
ion,
incr
ease
d ad
duct
ion,
slig
ht le
g sh
orte
ning
and
ex
tern
al ro
tatio
n. L
oss
of in
tern
al ro
tatio
n.
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y. Se
verit
y is
ass
esse
d us
ing
the
Sout
hwic
k an
gle.
Trea
tmen
t•
Exte
rnal
in-s
itu p
inni
ng o
r ope
n re
duct
ion
and
pinn
ing.
Com
plic
atio
ns•
Chon
drol
ysis.
• De
form
ity.
• O
steo
arth
ritis.
• Av
ascu
lar n
ecro
sis
– hi
gh ri
sk fr
om re
duct
ion
of S
UFE
.
MAP
8.7
. Hip
pat
holo
gy
Map
8.7
. H
ip p
ath
olo
gy
K30033_C008.indd 240 28/02/17 11:26 am
Ort
hopa
edic
s24
1Prox
imal
fem
oral
frac
ture
Wha
t is
a p
roxi
mal
fem
oral
frac
ture
?Fr
actu
res
may
be
defin
ed a
s a
disc
ontin
uity
of b
one
and,
whe
re th
epr
oxim
al fe
mur
is c
once
rned
, it u
sual
ly o
ccur
s in
the
elde
rly a
nd is
mor
eco
mm
on in
wom
en.
Th
e fra
ctur
e m
ay b
e de
fined
as
extr
acap
sula
r or i
ntra
caps
ular
.In
trac
apsu
lar f
ract
ures
are
furt
her s
ubdi
vide
d in
to s
ub-c
apita
l and
tr
ans-
cerv
ical
type
s, w
here
as e
xtra
caps
ular
frac
ture
s m
ay b
e ca
tego
rized
as
basi
-cer
vica
l, in
ter-t
roch
ante
ric a
nd s
ub-t
roch
ante
ric. T
here
is a
hig
h ris
k of
av
ascu
lar n
ecro
sis
with
intr
acap
sula
r fra
ctur
es. T
he b
lood
sup
ply
of th
e pr
oxim
al fe
mur
is fr
om:
1. T
he m
edia
l fem
oral
circ
umfle
x ar
tery
.2.
The
late
ral f
emor
al c
ircum
flex
arte
ry.
3. T
he a
rter
y of
the
ligam
entu
m te
res.
Caus
es•
Path
olog
ical
frac
ture
– o
steo
poro
sis,
met
asta
ses
to b
one.
• Tr
aum
a.
Sym
ptom
s•
Pain
.•
Shor
teni
ng o
f the
affe
cted
leg.
• Ex
tern
al ro
tatio
n of
the
affe
cted
leg.
Inve
stig
atio
ns•
Rout
ine
pre-
oper
ativ
e bl
ood
test
s.•
Radi
olog
y –
x-ra
y. Th
e G
arde
n cl
assi
ficat
ion
is u
sed
to d
escr
ibe
pr
oxim
al in
trac
apsu
lar f
emor
al fr
actu
res:
Type
I: u
ndis
plac
ed.
Type
II: u
ndis
plac
ed b
ut c
ompl
ete
fract
ure.
Type
III:
disp
lace
d fra
ctur
e bu
t stil
l bon
y co
ntac
t.
Ty
pe IV
: com
plet
ely
disp
lace
d.
Trea
tmen
t•
Extr
acap
sula
r fra
ctur
es:
Dyna
mic
hip
scr
ew.
• In
trac
apsu
lar f
ract
ures
:
U
ndis
plac
ed: i
nter
nal f
ixat
ion
or h
emia
rthr
opla
sty.
Disp
lace
d: h
emia
rthr
opla
sty
or to
tal h
ip re
plac
emen
t.
Com
plic
atio
ns•
Avas
cula
r nec
rosi
s.•
Thro
mbo
embo
lism
.•
Com
plic
atio
ns a
ssoc
iate
d w
ith fr
actu
res
(see
Tabl
es 8
.1a,
b,
pp
. 220
, 221
).
Slip
ped
uppe
r fe
mor
al e
piph
ysis
Wha
t is
slip
ped
uppe
r fe
mor
al e
piph
ysis
(SU
FE)?
This
is a
rare
con
ditio
n in
whi
ch th
e up
per f
emor
al e
piph
ysis
slip
s po
ster
oinf
erio
rly fr
om th
e fe
mor
al n
eck.
It m
ay o
ccur
bila
tera
lly in
20%
of
case
s. It
is v
ery
diffi
cult
to d
iagn
ose.
Caus
es•
Cart
ilagi
nous
phy
sis
failu
re.
Risk
fact
ors
Incl
ude:
• O
besi
ty.
• M
ale
sex.
• En
docr
ine
imba
lanc
es (e
.g. h
ypot
hyro
idis
m, d
ecre
ased
sex
hor
mon
es).
Sym
ptom
s•
Pain
– te
nds
to b
e lo
caliz
ed to
the
knee
and
thig
h.•
Decr
ease
d le
g ab
duct
ion,
incr
ease
d ad
duct
ion,
slig
ht le
g sh
orte
ning
and
ex
tern
al ro
tatio
n. L
oss
of in
tern
al ro
tatio
n.
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y. Se
verit
y is
ass
esse
d us
ing
the
Sout
hwic
k an
gle.
Trea
tmen
t•
Exte
rnal
in-s
itu p
inni
ng o
r ope
n re
duct
ion
and
pinn
ing.
Com
plic
atio
ns•
Chon
drol
ysis.
• De
form
ity.
• O
steo
arth
ritis.
• Av
ascu
lar n
ecro
sis
– hi
gh ri
sk fr
om re
duct
ion
of S
UFE
.
MAP
8.7
. Hip
pat
holo
gy
Map
8.7
. H
ip p
ath
olo
gy
Cont
inue
d ov
erle
af
K30033_C008.indd 241 28/02/17 11:26 am
Ort
hopa
edic
s24
2 Dev
elop
men
tal d
yspl
asia
of t
he h
ip
Wha
t is
dev
elop
men
tal d
yspl
asia
of t
he h
ip (D
DH
)?Th
is ra
nges
from
mild
dys
plas
ia to
irre
duci
ble
disl
ocat
ion
due
to a
de
velo
pmen
tal d
efor
mat
ion
of th
e hi
p jo
int.
Fem
ales
are
affe
cted
mor
e th
an m
ales
. The
con
ditio
n m
ay b
e bi
late
ral.
Caus
esTh
e ex
act c
ause
of t
his
cond
ition
is u
nkno
wn
but s
ever
al ri
sk fa
ctor
s ha
ve
been
iden
tifie
d su
ch a
s:•
Fem
ale
sex.
• Fi
rst b
orn
child
.•
Bree
ch d
eliv
ery.
• O
ligoh
ydra
mni
os.
• Po
sitiv
e fa
mily
his
tory
.•
Ethn
icity
: Cau
casi
an a
nd N
orth
Am
eric
an In
dian
s.
DDH
is a
ssoc
iate
d w
ith:
• Co
ngen
tial t
alip
es e
quin
ovar
us.
• To
rtic
ollis
.•
Met
atar
sus
addu
ctus
.
Sym
ptom
s•
Asym
ptom
atic
.•
Asym
met
ric g
lute
al s
kin
fold
s.•
Lim
p.
Inve
stig
atio
ns•
DDH
scre
enin
g.•
Ort
olan
i’s a
nd B
arlo
w’s
test
.•
Radi
olog
y –
USS
.
Trea
tmen
tDe
pend
s on
age
of d
iagn
osis
• Cl
osed
redu
ctio
n: P
avlik
har
ness
, hip
spi
ca.
• O
pen
redu
ctio
n: d
erot
atio
n va
rus
oste
otom
y, Sa
lter o
steo
tom
y.
Com
plic
atio
ns•
Gai
t abn
orm
aliti
es.
• Li
mb
shor
teni
ng.
• Ex
tern
al ro
tatio
n of
the
foot
.
Pert
hes
dise
ase
Wha
t is
Per
thes
dis
ease
?Th
is is
als
o kn
own
as L
egg-
Calv
é-Pe
rthe
s di
seas
e an
d is
ost
eone
cros
is o
fth
e fe
mor
al h
ead
resu
lting
in d
efor
mat
ion
of th
e ep
iphy
sis
(frag
men
tatio
n an
d fla
tten
ing)
. The
re a
re th
ree
phas
es in
the
dise
ase
proc
ess:
1. I
nitia
l – c
resc
ent s
hape
d fe
mor
al h
ead.
2. R
esor
ptio
n –
rare
fact
ion
(Gag
e’s
sign
on
x-ra
y –
a V
shap
ed lu
cenc
y).
3. R
epar
ativ
e.
Caus
esU
nkno
wn
Sym
ptom
s•
Child
with
a li
mp
(boy
s af
fect
ed m
ore
than
girl
s).
• Hi
p pa
in, w
hich
may
radi
ate
to th
e kn
ee a
nd g
roin
.•
Decr
ease
d ra
nge
of h
ip m
ovem
ent.
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y. M
ay s
how
sev
eral
feat
ures
(e.g
. ABC
):
A –
Abn
orm
al p
hyse
al g
row
th
B –
Bone
den
sity
incr
ease
d at
epi
phys
is
C –
Calc
ifica
tion
late
ral t
o ep
iphy
sis
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py, b
race
, tra
ctio
n.•
Med
ical
: ade
quat
e an
alge
sia.
• Su
rgic
al: f
emor
al +
/- pe
lvic
ost
eoto
my.
Com
plic
atio
ns•
Gai
t abn
orm
aliti
es.
• Ar
thrit
is.
MAP
8.7
. Hip
pat
holo
gy (c
ontin
ued
)
Map
8.7
. H
ip p
ath
olo
gy
K30033_C008.indd 242 28/02/17 11:26 am
Ort
hopa
edic
s24
3Dev
elop
men
tal d
yspl
asia
of t
he h
ip
Wha
t is
dev
elop
men
tal d
yspl
asia
of t
he h
ip (D
DH
)?Th
is ra
nges
from
mild
dys
plas
ia to
irre
duci
ble
disl
ocat
ion
due
to a
de
velo
pmen
tal d
efor
mat
ion
of th
e hi
p jo
int.
Fem
ales
are
affe
cted
mor
e th
an m
ales
. The
con
ditio
n m
ay b
e bi
late
ral.
Caus
esTh
e ex
act c
ause
of t
his
cond
ition
is u
nkno
wn
but s
ever
al ri
sk fa
ctor
s ha
ve
been
iden
tifie
d su
ch a
s:•
Fem
ale
sex.
• Fi
rst b
orn
child
.•
Bree
ch d
eliv
ery.
• O
ligoh
ydra
mni
os.
• Po
sitiv
e fa
mily
his
tory
.•
Ethn
icity
: Cau
casi
an a
nd N
orth
Am
eric
an In
dian
s.
DDH
is a
ssoc
iate
d w
ith:
• Co
ngen
tial t
alip
es e
quin
ovar
us.
• To
rtic
ollis
.•
Met
atar
sus
addu
ctus
.
Sym
ptom
s•
Asym
ptom
atic
.•
Asym
met
ric g
lute
al s
kin
fold
s.•
Lim
p.
Inve
stig
atio
ns•
DDH
scre
enin
g.•
Ort
olan
i’s a
nd B
arlo
w’s
test
.•
Radi
olog
y –
USS
.
Trea
tmen
tDe
pend
s on
age
of d
iagn
osis
• Cl
osed
redu
ctio
n: P
avlik
har
ness
, hip
spi
ca.
• O
pen
redu
ctio
n: d
erot
atio
n va
rus
oste
otom
y, Sa
lter o
steo
tom
y.
Com
plic
atio
ns•
Gai
t abn
orm
aliti
es.
• Li
mb
shor
teni
ng.
• Ex
tern
al ro
tatio
n of
the
foot
.
Pert
hes
dise
ase
Wha
t is
Per
thes
dis
ease
?Th
is is
als
o kn
own
as L
egg-
Calv
é-Pe
rthe
s di
seas
e an
d is
ost
eone
cros
is o
fth
e fe
mor
al h
ead
resu
lting
in d
efor
mat
ion
of th
e ep
iphy
sis
(frag
men
tatio
n an
d fla
tten
ing)
. The
re a
re th
ree
phas
es in
the
dise
ase
proc
ess:
1. I
nitia
l – c
resc
ent s
hape
d fe
mor
al h
ead.
2. R
esor
ptio
n –
rare
fact
ion
(Gag
e’s
sign
on
x-ra
y –
a V
shap
ed lu
cenc
y).
3. R
epar
ativ
e.
Caus
esU
nkno
wn
Sym
ptom
s•
Child
with
a li
mp
(boy
s af
fect
ed m
ore
than
girl
s).
• Hi
p pa
in, w
hich
may
radi
ate
to th
e kn
ee a
nd g
roin
.•
Decr
ease
d ra
nge
of h
ip m
ovem
ent.
Inve
stig
atio
ns•
Radi
olog
y –
x-ra
y. M
ay s
how
sev
eral
feat
ures
(e.g
. ABC
):
A –
Abn
orm
al p
hyse
al g
row
th
B –
Bone
den
sity
incr
ease
d at
epi
phys
is
C –
Calc
ifica
tion
late
ral t
o ep
iphy
sis
Trea
tmen
t•
Cons
erva
tive:
phy
siot
hera
py, b
race
, tra
ctio
n.•
Med
ical
: ade
quat
e an
alge
sia.
• Su
rgic
al: f
emor
al +
/- pe
lvic
ost
eoto
my.
Com
plic
atio
ns•
Gai
t abn
orm
aliti
es.
• Ar
thrit
is.
MAP
8.7
. Hip
pat
holo
gy (c
ontin
ued
)
Map
8.7
. H
ip p
ath
olo
gy
K30033_C008.indd 243 28/02/17 11:26 am
Ort
hopa
edic
s24
4Ta
ble
8.2.
Kn
ee p
ath
olo
gy
TABL
E 8.
2. K
nee
path
olog
y. T
he k
nee
is s
usce
ptib
le t
o bo
th p
rim
ary
and
seco
ndar
y os
teoa
rthr
itis
, but
the
sta
bilit
y of
the
kn
ee r
ests
upo
n in
tra-
and
ext
ra-a
rtic
ular
liga
men
ts a
nd m
enis
ci, w
hich
are
sus
cept
ible
to
inju
ry.
Path
olog
yCa
use
Sym
ptom
sIn
vest
igat
ions
Trea
tmen
tCo
mpl
icat
ions
Ante
rior
cruc
iate
lig
amen
t (A
CL) t
ear
The
func
tion
of th
e AC
L is
to:
1. P
reve
nt a
nter
ior d
ispl
acem
ent o
f th
e tib
ia o
ff th
e fe
mur
2. P
reve
nt ro
tatio
n 3.
Pre
vent
hyp
erex
tens
ion
Any
type
of t
raum
a th
at in
volv
es
twis
ting
of a
slig
htly
flex
ed k
nee
(e.g
. foo
tbal
l inj
urie
s, or
ove
r-ex
tens
ion
of th
e kn
ee) c
an d
amag
e th
e AC
L
Fem
ales
(pos
t pub
erty
) are
mor
e lik
ely
to d
amag
e th
eir A
CL th
an
mal
es. T
he re
ason
for t
his
is
deba
ted
but i
s po
tent
ially
due
to:
• Ho
rmon
es –
whi
ch c
ause
laxi
ty
of li
gam
ents
• A
narr
ower
inte
rcon
dyla
r not
ch•
A la
rger
Q a
ngle
in w
omen
• Pa
in
• Kn
ee s
wel
ling
• He
arin
g or
fe
elin
g a
‘pop
’
• An
terio
r dra
w te
st
posi
tive/
Lach
man
te
st p
ositi
ve•
Pivo
t shi
ft te
st•
Radi
olog
y:
x-ra
y –
rule
out
fra
ctur
e
MRI
– c
onfir
ms
diag
nosi
s
Cons
erva
tive
: Em
ploy
RIC
E te
chni
ques
(R
est,
Ice,
Com
pres
sion
and
El
evat
ion)
, phy
siot
hera
py, k
nee
brac
e
Med
ical
: ana
lges
ia
Surg
ical
: ACL
reco
nstr
uctio
n
• Kn
ee in
stab
ility
• O
steo
arth
ritis
• Co
mpl
icat
ions
re
latin
g to
su
rger
y su
ch
as th
e ge
nera
l co
mpl
icat
ions
of
ana
esth
esia
, in
fect
ion,
DVT
, da
mag
e to
su
rrou
ndin
g st
ruct
ures
K30033_C008.indd 244 28/02/17 11:26 am
Ort
hopa
edic
sTa
ble
8.2.
Kn
ee p
ath
olo
gy
Post
erio
r cr
ucia
te li
ga-
men
t (PC
L)
tear
The
func
tion
of th
e PC
L is
to p
reve
nt
post
erio
r dis
plac
emen
t of t
he ti
bia
off t
he fe
mur
Inju
ry to
the
PCL
is v
ery
rare
. It t
ends
to
occ
ur in
road
traf
fic a
ccid
ent
dash
boar
d in
jurie
s
• Pa
in•
Knee
sw
ellin
g•
Posi
tive
post
erio
r dr
aw te
st
• Ra
diol
ogy:
x-
ray
– ru
le o
ut
fract
ure
M
RI –
con
firm
s di
agno
sis
Cons
erva
tive
: Em
ploy
RIC
E te
chni
ques
(Res
t, Ic
e, C
ompr
essi
on a
nd E
leva
tion)
, ph
ysio
ther
apy,
knee
bra
ce
Med
ical
: ana
lges
ia
Surg
ical
: PCL
reco
nstr
uctio
n
• Kn
ee in
stab
ility
• O
steo
arth
ritis
• Co
mpl
icat
ions
re
latin
g to
sur
gery
su
ch a
s th
e
gene
ral
com
plic
atio
ns
of a
naes
thes
ia,
infe
ctio
n, D
VT,
dam
age
to
surr
ound
ing
stru
ctur
es
Cont
inue
d ov
erle
af
245
K30033_C008.indd 245 28/02/17 11:26 am
Ort
hopa
edic
s24
6Ta
ble
8.2.
Kn
ee p
ath
olo
gy
TABL
E 8.
2. K
nee
path
olog
y. T
he k
nee
is s
usce
ptib
le t
o bo
th p
rim
ary
and
seco
ndar
y os
teoa
rthr
itis
, but
the
sta
bilit
y of
the
kn
ee r
ests
upo
n in
tra-
and
ext
ra-a
rtic
ular
liga
men
ts a
nd m
enis
ci, w
hich
are
sus
cept
ible
to
inju
ry ( c
ontin
ued
).
Path
olog
yCa
use
Sym
ptom
sIn
vest
igat
ions
Trea
tmen
tCo
mpl
icat
ions
Men
isca
l te
ars
The
med
ial m
enis
cus
is to
rn m
ore
ofte
n th
en th
e la
tera
l men
iscu
s. Th
e re
ason
for t
his
rest
s in
ana
tom
ical
di
ffere
nces
. The
med
ial m
enis
cus
is
firm
ly a
ttac
hed
to b
oth
the
med
ial
colla
tera
l lig
amen
t and
join
t cap
sule
. It
is a
lso
mor
e C
shap
ed in
con
tras
t with
th
e la
tera
l men
iscu
s, w
hich
is ro
und
in
appe
aran
ce
Trau
ma
as a
resu
lt of
twis
ting
is th
e co
mm
on m
echa
nism
of i
njur
y. Te
ars
may
be
cate
goriz
ed a
s co
mpl
ete
or
inco
mpl
ete
The
com
bina
tion
of a
med
ial m
enis
cus
tear
, med
ial c
olla
tera
l lig
amen
t te
ar a
nd a
torn
ACL
is k
now
n as
O
’Don
oghu
e’s
unha
ppy
tria
d
• Kn
ee lo
ckin
g•
Giv
ing
way
of t
he k
nee
• Pa
in
• Sw
ellin
g•
Decr
ease
d ra
nge
of
mov
emen
t
• Po
sitiv
e M
cMur
ray
test
•
Radi
olog
y:
x-ra
y –
rule
ou
t fra
ctur
e
MRI
–
confi
rms
diag
nosi
s
Cons
erva
tive
: Em
ploy
RIC
E te
chni
ques
(Res
t, Ic
e, C
ompr
essi
on a
nd E
leva
tion)
, ph
ysio
ther
apy,
knee
bra
ce
Med
ical
: ana
lges
ia
Surg
ical
: dep
ends
on
the
loca
-tio
n an
d th
e ex
tent
of t
he te
ar.
If lo
cate
d in
the
oute
r thi
rd o
f th
e m
enis
cus,
also
kno
wn
as th
e ‘re
d zo
ne’,
the
tear
will
hea
l on
its o
wn
sinc
e th
is is
a re
gion
of
copi
ous
bloo
d su
pply.
How
ever
, if
loca
ted
in th
e in
ner t
wo
third
s, th
e ‘w
hite
zon
e’, p
atie
nts
may
re
quire
sur
gica
l int
erve
ntio
n
• Kn
ee in
stab
ility
• O
steo
arth
ritis
K30033_C008.indd 246 28/02/17 11:26 am
247
Ort
hopa
edic
sTa
ble
8.2.
Kn
ee p
ath
olo
gy
Osg
ood–
Schl
atte
r di
seas
e
This
is a
tibi
al tu
bero
sity
apo
phys
itis
that
typi
cally
affe
cts
athl
etic
mal
es
aged
10–
15 y
ears
The
exac
t cau
se is
not
kno
wn
but
over
use
is th
ough
t to
play
a ro
le
• Pa
in, s
wel
ling
and
tend
erne
ss o
f the
tibi
al
tube
rosi
ty
• U
sual
ly
a cl
inic
al
diag
nosi
s•
Radi
olog
y –
x-ra
y m
ay
show
sig
ns
of tu
bero
sity
en
larg
emen
t
Cons
erva
tive
: res
t, ph
ysio
ther
apy,
knee
bra
ce
Med
ical
: ana
lges
ia
• U
nlik
ely
to
caus
e se
rious
co
mpl
icat
ions
bu
t pai
n m
ay
pers
ist
Ost
eo-
chon
driti
s di
ssec
ans
This
is a
par
tial o
r com
plet
e de
tach
-m
ent o
f eith
er b
one
or a
rtic
ular
ca
rtila
ge th
at is
cau
sed
by a
vasc
ular
ne
cros
is o
f the
sub
chon
dral
bon
e.
This
resu
lts in
mic
rofra
ctur
e w
ithou
t re
mod
ellin
g
Oth
er c
ause
s in
clud
e:•
Gen
etic
s•
Repe
titiv
e m
inor
trau
ma
• Dr
ugs
(e.g
. ste
roid
s)
• Pa
in –
wor
sens
with
ex
erci
se•
Swel
ling
• Lo
ckin
g an
d gi
ving
way
• Ra
diol
ogy:
x-
ray
– ru
le o
ut
fract
ure
M
RI –
co
nfirm
s di
agno
sis
The
Ande
rson
st
agin
g cr
iteria
ar
e em
ploy
ed
Cons
erva
tive
: wat
chfu
l wai
t-in
g, re
st
Med
ical
: ana
lges
ia
Surg
ical
: art
hros
copy
, ost
eo-
chon
dral
aut
ogra
ft tr
ansp
lan-
tatio
n
• O
steo
arth
ritis
Pate
llar
sub-
luxa
tion
synd
rom
e
Exac
t cau
se is
unk
now
n bu
t som
e fa
ctor
s ha
ve b
een
sugg
este
d su
ch a
s:
• G
ait a
bnor
mal
ities
• Sh
allo
w p
atel
lar g
roov
e
• W
ide
pelv
is
This
con
ditio
n is
mor
e co
mm
on in
w
omen
• Kn
ee th
at g
ives
way
or
lock
s du
ring
mov
emen
t
• Sl
idin
g an
d hi
ghly
m
obile
pat
ella
• Pa
in –
whe
n si
ttin
g an
d w
orse
ns w
ith
mov
emen
t
• Sw
ellin
g
• Ra
diol
ogy:
x-
ray,
MRI
Cons
erva
tive
: phy
siot
hera
py,
brac
es, o
rtho
tics
Med
ical
: ana
lges
ia
Surg
ical
: med
ial p
atel
lofe
mor
al
ligam
ent r
econ
stru
ctio
n. Th
is lig
amen
t may
tear
whe
n th
e pa
tella
disl
ocat
es o
utw
ards
• Kn
ee in
stab
ility
• Re
curr
ent
subl
uxat
ion
or
disl
ocat
ion
K30033_C008.indd 247 28/02/17 11:26 am
Ort
hopa
edic
s24
8Ta
ble
8.3.
Fo
ot
pat
ho
log
y
TABL
E 8.
3. F
oot
path
olog
y.
Path
olog
yCa
use
Sym
ptom
sIn
vest
igat
ions
Trea
tmen
tCo
mpl
icat
ions
Hallu
x va
lgus
(b
unio
n)Th
e ex
act c
ause
is
unkn
own
but i
t is
asso
ci-
ated
with
:
• Fe
mal
e se
x•
Posi
tive
fam
ily h
isto
ry•
Incr
ease
d ag
e•
Wea
ring
heel
s
• Th
e ha
llux
devi
ates
la
tera
lly a
t the
m
etat
arso
phal
ange
al
join
t •
Pain
• Er
ythe
mat
ous,
irrita
ted
skin
ove
rlyin
g th
e bu
nion
• Th
orou
gh
phys
ical
ex
amin
atio
n in
clud
ing
an
asse
ssm
ent o
f ga
it•
Radi
olog
y: x
-ray
w
ill v
isua
lize
the
defo
rmity
Cons
erva
tive
: app
ropr
i-at
e fo
otw
ear
Med
ical
: ana
lges
ia
Surg
ical
: onl
y in
dica
ted
if th
ere
is s
ever
e pa
in
or if
the
defo
rmity
si
gnifi
cant
ly im
pact
s on
w
alki
ng/li
fest
yle
• O
steo
arth
ritis
•
Com
plic
atio
ns re
latin
g to
sur
gery
suc
h as
in
fect
ion,
DVT
, dam
age
to s
urro
undi
ng
stru
ctur
es
Pes
plan
usCo
llaps
e of
the
med
ial
long
itudi
nal a
rch
• As
ympt
omat
ic
• Pa
in –
ove
r the
tibi
alis
po
ster
ior t
endo
n •
Prog
ress
ed d
isea
se –
in
abili
ty to
rais
e he
el.
Fore
foot
– a
bduc
ted;
hi
ndfo
ot –
val
gus
• Pa
edia
tric
s –
foot
pr
ofor
ma
• Th
orou
gh
phys
ical
ex
amin
atio
n in
clud
ing
an
asse
ssm
ent o
f ga
it•
Radi
olog
y:
x-ra
y m
ay h
elp
eval
uate
the
exte
nt o
f the
de
form
ity
Mos
t are
asy
mpt
omat
ic
and
do n
ot re
quire
tr
eatm
ent
Cons
erva
tive
: ort
hotic
s, ph
ysio
ther
apy
(e.g
. Ach
il-le
s te
ndon
str
etch
ing)
Surg
ical
: in
seve
re c
ases
an
d ai
ms
to re
alig
n th
e fo
ot. E
xam
ple
oper
atio
ns
incl
ude
Achi
lles
tend
on
leng
then
ing,
tibi
alis
pos
-te
rior t
endo
n re
cons
truc
-tio
n an
d re
cons
truc
tive
oste
otom
ies
• Ti
bial
is p
oste
rior
tend
on d
ysfu
nctio
n•
May
con
trib
ute
to
othe
r foo
t con
ditio
ns
such
as
hallu
x va
lgus
an
d pl
anta
r fas
ciiti
s
K30033_C008.indd 248 28/02/17 11:26 am
249
Ort
hopa
edic
sTa
ble
8.3.
Fo
ot
pat
ho
log
y
Pes
cavu
sTh
e ex
act c
ause
of t
he
acce
ntua
ted
long
itudi
nal
arch
in th
is c
ondi
tion
is
unkn
own,
but
is a
ssoc
iate
d w
ith c
ondi
tions
suc
h as
:
• Ce
rebr
al p
alsy
• Sp
ina
bifid
a•
Mus
cula
r dys
trop
hy•
Char
cot–
Mar
ie–T
ooth
di
seas
e
• Pa
in o
n w
alki
ng
• Cl
aw to
es•
Ankl
e in
stab
ility
• Pa
edia
tric
s –
foot
pr
ofor
ma
• Th
orou
gh
phys
ical
ex
amin
atio
n in
clud
ing
an
asse
ssm
ent o
f ga
it•
Radi
olog
y:
x-ra
y m
ay h
elp
eval
uate
the
exte
nt o
f the
de
form
ity
Cons
erva
tive
: ort
hotic
s, ph
ysio
ther
apy
Surg
ical
: pla
ntar
fasc
ia
rele
ase,
Jone
s pr
oced
ure,
ex
tens
or s
hift
proc
edur
e,
Gird
lest
one-
Tayl
or
tran
sfer
, per
oneu
s lo
ngus
to
per
oneu
s br
evis
te
node
sis
• Co
mpl
icat
ions
rela
ting
to s
urge
ry s
uch
as
infe
ctio
n, D
VT, d
amag
e to
sur
roun
ding
st
ruct
ures
, mal
unio
n
Stre
ss fr
actu
reFr
actu
res
tend
to a
ffect
th
e sh
aft o
f the
2nd
or 3
rd
met
atar
sal s
ince
thes
e ar
e le
ss ro
bust
than
the
othe
r m
etat
arsa
l bon
es
• Pa
in o
n w
alki
ng a
nd
over
the
met
atar
sal
• Ra
diol
ogy:
x-r
ayCo
nser
vati
ve: r
est,
plas
ter c
ast m
ay b
e re
quire
d
Med
ical
: ana
lges
ia
• Co
mpl
icat
ions
of
fract
ure
(see
Tabl
es
8.1a
, b, p
p. 2
20, 2
21)
• O
steo
arth
ritis
Talip
es e
quin
o-va
rus
(clu
b fo
ot)
The
exac
t cau
se o
f thi
s co
nditi
on is
unk
now
n bu
t it
is a
ssoc
iate
d w
ith:
• A
posi
tive
fam
ily h
isto
ry•
DDH
• O
ligoh
ydra
mni
os•
Spin
a bi
fida
• In
vert
ed a
nd s
upin
ated
fo
ot•
Addu
cted
fore
foot
• In
war
dly
rota
ted
heel
he
ld in
pla
ntar
flexi
on
• U
SS s
cree
ning
du
ring
preg
nanc
y •
Diag
nosi
s ba
sed
on ty
pica
l ap
pear
ance
• In
vest
igat
e un
derly
ing
caus
e
Pons
eti m
etho
d•
Gai
t abn
orm
ailit
y •
Arth
ritis
•
Smal
ler s
hoe
size
of
affe
cted
foot
K30033_C008.indd 249 28/02/17 11:26 am
Ort
hopa
edic
s25
0 Sept
ic a
rthr
itis
Wha
t is
sep
tic
arth
riti
s?Th
is is
infe
ctio
n of
any
join
t by
a m
icro
orga
nism
. It i
s a
surg
ical
em
erge
ncy.
Caus
esTh
e ex
act m
echa
nism
by
whi
ch th
e or
gani
sm in
vade
s th
e jo
int i
s un
know
n.Sp
read
may
be
syst
emic
, fro
m a
pen
etra
ting
wou
nd o
r fro
m p
rior
oste
omye
litis.
Caus
ativ
e or
gani
sms
incl
ude:
• St
aphy
loco
ccus
aur
eus
(com
mon
est).
• N
eiss
eria
gon
orrh
oea.
• Ha
emop
hilu
s in
fluen
zae.
• Pn
eum
ococ
cus
sp.
• G
roup
B s
trep
toco
cci.
• Es
cher
ichi
a co
li.•
Pseu
dom
onas
sp.
• Pr
oteu
s sp
.•
Fung
i.
Sept
ic a
rthr
itis
is a
ssoc
iate
d w
ith:
• Di
abet
es m
ellit
us.
• IV
dru
g ab
use.
• Ex
trem
es o
f age
(i.e
. the
ver
y yo
ung/
old)
.
Sym
ptom
s•
Gen
eral
feat
ures
of i
nfec
tion:
spi
king
pyr
exia
, mal
aise
• De
crea
sed
rang
e of
mov
emen
t of a
ffect
ed jo
int
• In
flam
mat
ion
and
pain
of a
ffect
ed jo
int
Inve
stig
atio
ns•
Bloo
d te
sts
– FB
C, W
CC, U
&E,
CRP
, blo
od c
ultu
res,
uric
aci
d to
exc
lude
gou
t.•
Spec
ific
test
s –
join
t asp
iratio
n an
d cu
lture
, gon
orrh
oea
swab
s.•
Radi
olog
y:
x-
ray
of jo
int (
and
ches
t if T
B su
spec
ted)
.
U
SS –
allo
ws
diag
nost
ic jo
int a
spira
tion.
Trea
tmen
tTh
is m
ust b
e do
ne w
ithou
t del
ay s
ince
sep
tic a
rthr
itis
is a
n em
erge
ncy.
Surg
ical
: joi
nt a
spira
tion
and
surg
ical
was
hout
follo
wed
by
antib
iotic
sse
nsiti
ve to
cau
sativ
e or
gani
sm.
Com
plic
atio
ns•
Join
t des
truc
tion.
• Se
cond
ary
oste
oart
hriti
s.•
Fibr
ous
anky
losi
s.•
In c
hild
ren
– gr
owth
dis
rupt
ion
from
gro
wth
pla
te d
amag
e.
Ost
eom
yelit
is
Wha
t is
ost
eom
yelit
is?
This
is a
bac
teria
l inf
ectio
n of
the
bone
, whi
ch m
ay b
e sp
read
to th
e bo
neha
emat
ogen
ousl
y, tr
aum
atic
ally
or f
rom
infe
ctio
n of
sof
t tis
sue.
It m
ay
have
an
acut
e or
chr
onic
pre
sent
atio
n.
Caus
esCa
usat
ive
orga
nism
s in
clud
e:•
Stap
hylo
cocc
us a
ureu
s (c
omm
ones
t).•
Haem
ophi
lus
influ
enza
e (m
ore
com
mon
in c
hild
ren)
.•
Salm
onel
la s
p. (m
ore
com
mon
in p
atie
nts
with
sic
kle
cell
dise
ase)
.O
steo
mye
litis
is a
ssoc
iate
d w
ith:
• Di
abet
es m
ellit
us.
• IV
dru
g ab
use.
• Ex
trem
es o
f age
(i.e
. the
ver
y yo
ung/
old)
.•
Sick
le c
ell d
isea
se.
• Im
mun
ocom
prom
ise.
• Ch
roni
c os
teom
yelit
is –
sm
okin
g, s
tero
id u
se a
nd v
ascu
lar d
isea
se.
Sym
ptom
s•
Gen
eral
feat
ures
of i
nfec
tion:
pyr
exia
, mal
aise
.•
Decr
ease
d ra
nge
of m
ovem
ent o
f affe
cted
join
t.•
Infla
mm
atio
n an
d pa
in o
f affe
cted
join
t.
Inve
stig
atio
ns•
Bloo
d te
sts
– FB
C, W
CC, U
&E,
CRP
, ESR
, blo
od c
ultu
res,
uric
aci
d to
ex
clud
e go
ut.
• Sp
ecifi
c te
sts
– jo
int a
spira
tion
and
cultu
re.
• Ra
diol
ogy:
x-ra
y of
join
t (no
abn
orm
al fe
atur
es in
the
first
10–
14 d
ays)
.
U
SS –
allo
ws
diag
nost
ic jo
int a
spira
tion.
CT –
may
be
used
to g
uide
nee
dle
aspi
ratio
n.
M
RI.
Trea
tmen
t•
Cons
erva
tive:
spl
inta
ge, r
ehab
ilita
tion
and
phys
ioth
erap
y.•
Med
ical
: IV
antib
iotic
s.•
Surg
ical
: gui
ded
aspi
ratio
n an
d su
rgic
al e
vacu
atio
n.
Com
plic
atio
ns•
Join
t des
truc
tion.
• Ch
roni
c os
teoa
rthr
itis.
• Se
ptic
art
hriti
s.•
Path
olog
ical
frac
ture
.•
In c
hild
ren
– gr
owth
dis
rupt
ion
from
gro
wth
pla
te d
amag
e.
MAP
8.8
. Ort
hopa
edic
infe
ctio
ns
SSSySySySySym
pm
pm
pm
pm
pttototototo
ms
ms
ms
ms
ms
MAP
8.8
. O
rth
op
aed
ic in
fect
ion
s
K30033_C008.indd 250 28/02/17 11:26 am
251Se
ptic
art
hrit
is
Wha
t is
sep
tic
arth
riti
s?Th
is is
infe
ctio
n of
any
join
t by
a m
icro
orga
nism
. It i
s a
surg
ical
em
erge
ncy.
Caus
esTh
e ex
act m
echa
nism
by
whi
ch th
e or
gani
sm in
vade
s th
e jo
int i
s un
know
n.Sp
read
may
be
syst
emic
, fro
m a
pen
etra
ting
wou
nd o
r fro
m p
rior
oste
omye
litis.
Caus
ativ
e or
gani
sms
incl
ude:
• St
aphy
loco
ccus
aur
eus
(com
mon
est).
• N
eiss
eria
gon
orrh
oea.
• Ha
emop
hilu
s in
fluen
zae.
• Pn
eum
ococ
cus
sp.
• G
roup
B s
trep
toco
cci.
• Es
cher
ichi
a co
li.•
Pseu
dom
onas
sp.
• Pr
oteu
s sp
.•
Fung
i.
Sept
ic a
rthr
itis
is a
ssoc
iate
d w
ith:
• Di
abet
es m
ellit
us.
• IV
dru
g ab
use.
• Ex
trem
es o
f age
(i.e
. the
ver
y yo
ung/
old)
.
Sym
ptom
s•
Gen
eral
feat
ures
of i
nfec
tion:
spi
king
pyr
exia
, mal
aise
• De
crea
sed
rang
e of
mov
emen
t of a
ffect
ed jo
int
• In
flam
mat
ion
and
pain
of a
ffect
ed jo
int
Inve
stig
atio
ns•
Bloo
d te
sts
– FB
C, W
CC, U
&E,
CRP
, blo
od c
ultu
res,
uric
aci
d to
exc
lude
gou
t.•
Spec
ific
test
s –
join
t asp
iratio
n an
d cu
lture
, gon
orrh
oea
swab
s.•
Radi
olog
y:
x-
ray
of jo
int (
and
ches
t if T
B su
spec
ted)
.
U
SS –
allo
ws
diag
nost
ic jo
int a
spira
tion.
Trea
tmen
tTh
is m
ust b
e do
ne w
ithou
t del
ay s
ince
sep
tic a
rthr
itis
is a
n em
erge
ncy.
Surg
ical
: joi
nt a
spira
tion
and
surg
ical
was
hout
follo
wed
by
antib
iotic
sse
nsiti
ve to
cau
sativ
e or
gani
sm.
Com
plic
atio
ns•
Join
t des
truc
tion.
• Se
cond
ary
oste
oart
hriti
s.•
Fibr
ous
anky
losi
s.•
In c
hild
ren
– gr
owth
dis
rupt
ion
from
gro
wth
pla
te d
amag
e.
Ost
eom
yelit
is
Wha
t is
ost
eom
yelit
is?
This
is a
bac
teria
l inf
ectio
n of
the
bone
, whi
ch m
ay b
e sp
read
to th
e bo
neha
emat
ogen
ousl
y, tr
aum
atic
ally
or f
rom
infe
ctio
n of
sof
t tis
sue.
It m
ay
have
an
acut
e or
chr
onic
pre
sent
atio
n.
Caus
esCa
usat
ive
orga
nism
s in
clud
e:•
Stap
hylo
cocc
us a
ureu
s (c
omm
ones
t).•
Haem
ophi
lus
influ
enza
e (m
ore
com
mon
in c
hild
ren)
.•
Salm
onel
la s
p. (m
ore
com
mon
in p
atie
nts
with
sic
kle
cell
dise
ase)
.O
steo
mye
litis
is a
ssoc
iate
d w
ith:
• Di
abet
es m
ellit
us.
• IV
dru
g ab
use.
• Ex
trem
es o
f age
(i.e
. the
ver
y yo
ung/
old)
.•
Sick
le c
ell d
isea
se.
• Im
mun
ocom
prom
ise.
• Ch
roni
c os
teom
yelit
is –
sm
okin
g, s
tero
id u
se a
nd v
ascu
lar d
isea
se.
Sym
ptom
s•
Gen
eral
feat
ures
of i
nfec
tion:
pyr
exia
, mal
aise
.•
Decr
ease
d ra
nge
of m
ovem
ent o
f affe
cted
join
t.•
Infla
mm
atio
n an
d pa
in o
f affe
cted
join
t.
Inve
stig
atio
ns•
Bloo
d te
sts
– FB
C, W
CC, U
&E,
CRP
, ESR
, blo
od c
ultu
res,
uric
aci
d to
ex
clud
e go
ut.
• Sp
ecifi
c te
sts
– jo
int a
spira
tion
and
cultu
re.
• Ra
diol
ogy:
x-ra
y of
join
t (no
abn
orm
al fe
atur
es in
the
first
10–
14 d
ays)
.
U
SS –
allo
ws
diag
nost
ic jo
int a
spira
tion.
CT –
may
be
used
to g
uide
nee
dle
aspi
ratio
n.
M
RI.
Trea
tmen
t•
Cons
erva
tive:
spl
inta
ge, r
ehab
ilita
tion
and
phys
ioth
erap
y.•
Med
ical
: IV
antib
iotic
s.•
Surg
ical
: gui
ded
aspi
ratio
n an
d su
rgic
al e
vacu
atio
n.
Com
plic
atio
ns•
Join
t des
truc
tion.
• Ch
roni
c os
teoa
rthr
itis.
• Se
ptic
art
hriti
s.•
Path
olog
ical
frac
ture
.•
In c
hild
ren
– gr
owth
dis
rupt
ion
from
gro
wth
pla
te d
amag
e.
MAP
8.8
. Ort
hopa
edic
infe
ctio
ns
SSSySySySySym
pm
pm
pm
pm
pttototototo
ms
ms
ms
ms
ms
Ort
hopa
edic
sM
AP 8
.8.
Ort
ho
pae
dic
infe
ctio
ns
K30033_C008.indd 251 28/02/17 11:26 am
Ort
hopa
edic
s25
2Fi
gure
8.2
. The
lum
bar p
lexu
s
Med
ial p
lant
ar n
erve
:Ab
duct
or h
allic
usFl
exor
dig
itoru
m b
revi
sFl
exor
hal
licus
bre
vis
Fem
oral
ner
ve:
ante
rior c
ompa
rtm
ent o
f thi
gh
Obt
urat
or n
erve
:m
edia
l com
part
men
t of t
high
Supe
rfic
ial f
ibul
ar n
erve
:Fi
bula
ris lo
ngus
and
bre
vis
Late
ral p
lant
ar n
erve
:Th
ose
not s
uppl
ied
by m
edia
lpl
anta
r ner
ve
Dee
p fib
ular
ner
ve:
Tibi
alis
ant
erio
rEx
tens
or h
allic
us lo
ngus
Fibu
laris
tert
ius
Exte
nsor
dig
itoru
m lo
ngus
and
brev
is
L2 L3 L4 L5 S1 S2 S3 S4
FIG
URE
8.2
. The
lum
bar
plex
us
Peri
neal
ner
ve:
Perin
eum
K30033_C008.indd 252 28/02/17 11:26 am
253
Appendix One Useful diagnostic classifications
Classification Name of disease
DSM-5, ICD-10 Psychiatric disorders
HADS, PHQ-9, GAD-7 Depression
SCOFF questionnaire Anorexia nervosa/bulimia
ACE-III Dementia
Amsel’s criteria Bacterial vaginosis
Rotherham criteria Polycystic ovary syndrome
FIGO Obstetric malignancy staging system
Jones criteria Rheumatic fever
Duke criteria Infective endocarditis
Psoriasis Area and Severity Index Psoriasis
Ludwig scale/Norwood scale Alopecia
Clark levels and Breslow’s thickness Malignant melanoma
Salter–Harris classification Growth plate fracture
Garden classification Proximal femur fracture
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th Revision; HADS, Hospital Anxiety and Depression Scale; PHQ-9, Patient Health Questionnaire; GAD-7, Generalized Anxiety Disorder 7; SCOFF, Sick, Control, One stone, Fat, Food; ACE-III, Addenbrooke’s Cognitive Examination; FIGO, Fédération Internationale de Gynécologie et d’Obstétrique.
K30033_Appendices.indd 253 28/02/17 11:51 am
Appendix Two Useful websites
Disease Website
Acne vulgaris http://cks.nice.org.uk/acne-vulgaris
Age-related macular degeneration
https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-SCI-318-RCOphth-AMD-Guidelines-Sept-2013-FINAL-2.pdf
Alopecia areata http://cks.nice.org.uk/alopecia-areata
Amenorrhoea http://cks.nice.org.uk/amenorrhoea
Antepartum haemorrhage
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg63_05122011aph.pdf
Anxiety disorders https://www.nice.org.uk/guidance/qs53
Bacterial meningitis http://pathways.nice.org.uk/pathways/bacterial-meningitis-and-meningococcal-septicaemia
Benign paroxysmal positioning disorder
http://cks.nice.org.uk/benign-paroxysmal-positional-vertigo
http://www.aafp.org/dam/AAFP/documents/patient_care/ clinical_recommendations/RecToBOD-020810-Attachment1BPPV-Jan2010Cluster.pdf
Bipolar disorder https://www.nice.org.uk/guidance/cg38
Borderline personality disorder
https://www.nice.org.uk/guidance/cg78
Bronchiolitis https://www.nice.org.uk/guidance/ng9
Cataracts https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0741
https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2010-SCI-069-Cataract-Surgery-Guidelines-2010-SEPTEMBER-2010.pdf
Cervical cancer http://cks.nice.org.uk/cervical-cancer-and-hpv
Cervical screening http://cks.nice.org.uk/cervical-screening
Childhood cancers http://cks.nice.org.uk/childhood-cancers-recognition-and-referral
Cough in children http://cks.nice.org.uk/cough-acute-with-chest-signs-in-children
Croup http://cks.nice.org.uk/croup
Depression https://www.nice.org.uk/guidance/cg90
Eating disorders https://www.nice.org.uk/guidance/cg9
Ectopic pregnancy and miscarriage
https://www.nice.org.uk/guidance/cg154
Eczema http://cks.nice.org.uk/eczema-atopic
Endometrial cancer http://www.esmo.org/Guidelines/Gynaecological-Cancers/ Endometrial-Cancer
254
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Useful websites
Disease Website
Endometriosis http://cks.nice.org.uk/endometriosis
Epilepsy http://cks.nice.org.uk/epilepsy
Epistaxis http://cks.nice.org.uk/epistaxis-nosebleeds
Gestational trophoblastic disease
https://www.rcog.org.uk/globalassets/documents/guidelines/gt38managementgestational0210.pdf
Glaucoma https://www.nice.org.uk/guidance/cg85
Hearing loss https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0833
Hip fracture https://www.nice.org.uk/guidance/cg124
https://www.nice.org.uk/guidance/cg124/evidence/full- guideline-183081997
Hot swollen joints/septic arthritis
http://bestpractice.bmj.com/best-practice/monograph/486/ treatment/guidelines.html
Infertility http://cks.nice.org.uk/infertility
Ménière’s disease http://cks.nice.org.uk/menieres-disease
Menorrhagia http://cks.nice.org.uk/menorrhagia
Non-complex fractures https://www.nice.org.uk/guidance/NG38/documents/fractures-full-guideline2
Osteomyelitis http://bestpractice.bmj.com/best-practice/monograph/354/ diagnosis.html
Paediatric diabetes https://www.nice.org.uk/guidance/ng18
Paediatric urinary tract infection
https://www.nice.org.uk/guidance/cg54
Pityriasis rosea http://cks.nice.org.uk/pityriasis-rosea
Pityriasis versicolor http://cks.nice.org.uk/pityriasis-versicolor
Polycystic ovarian syndrome
http://cks.nice.org.uk/polycystic-ovary-syndrome
Postpartum haemorrhage
https://www.rcog.org.uk/globalassets/documents/guidelines/gt52postpartumhaemorrhage0411.pdf
Psoriasis http://cks.nice.org.uk/psoriasis
Rosacea http://cks.nice.org.uk/rosacea-acne
Schizophrenia https://www.nice.org.uk/guidance/cg82
Shoulder dystocia https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf
Vaginal discharge http://cks.nice.org.uk/vaginal-discharge
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257
abdominal wall defects 111abortion (miscarriage) 74–5abortion (termination) 86absence epilepsy 144achondroplasia 124acne vulgaris 198–9acute fatty liver of
pregnancy 48–9acute lymphoblastic leukaemia
(ALL) 152adhesive capsulitis 226allergy
asthma 132–5eczema 184–5
alopecia areata 202–3α-2 antagonists 7Alzheimer’s disease 28amenorrhoea 82–3amobarbital 12Amsel’s criteria 80anankastic personality
disorder 21anencephaly 118ankylosing spondylitis 238–9anorexia nervosa 22–3antenatal booking
appointments 34–6, 67antepartum haemorrhage
60–3, 74anterior cruciate ligament 244anterior uveitis 168antibiotics
cystic fibrosis 131meningitis 123sexually transmitted
infections 78skin infections 208, 209syphilis 59, 78urinary tract infections 139
anti-D prophylaxis 35, 67antidepressants 4, 6–7, 10antiepileptics 43, 144, 145antifungals 80, 210antihypertensives 45
antipsychotics 16–17, 30antisocial personality
disorder 20antivirals
human immunodeficiency virus (HAART) 57
herpes simplex virus 55, 79, 204
varicella zoster virus 205anxiety 8–9, 12, 21
obsessive compulsive disorder 10–11
anxiolytics 12arthritis
ankylosing spondylitis 238–9
osteoarthritis 222, 228–9rheumatoid 228–9septic 250–1
arthropod parasites 207aspirin 137, 151asthma 132–5atopic eczema 184–5atrial septal defects
(ASDs) 112–13attention deficit hyperactive
disorder (ADHD) 26–7autosomal recessive polycystic
kidney disease (ARPKD) 114avoidant personality
disorder 21
bacterial vaginosis 80balanitis 210barrier contraception 100basal cell carcinoma 216bed rest, prolonged 220benign paroxysmal positional
vertigo 176–7benign rolandic epilepsy 144benign tumours
ovarian cysts 98of the skin 212–14
benzodiazepines 12
beta blockers 45, 165bipolar disorder 18–19bladder exstrophy 115blindness see vision, loss ofblistering disorders 196–7bone
Ewing’s sarcoma 155infections 250–1see also fractures
borderline personality disorder 20
Bowen’s disease 216brachial plexus 227breastfeeding 69Breslow’s thickness 217bronchiolitis 126–7bulimia nervosa 24–5bullous pemphigoid 196–7bullous pemphigus 196–7bunion 248buspirone 12
cancercervical 90–1choriocarcinoma 76–7endometrial 94–5laryngeal 182nasopharyngeal 180oropharyngeal 181ovarian 96–7paediatric 152–5skin 216–17vaginal 92–3
candidiasis 80, 210carbonic anhydrase
inhibitors 165cardiovascular system
congenital defects 112–13
rheumatic fever 136–7carpal tunnel syndrome 234–5cataracts 166–7cavernous haemangioma 213cellulitis 208
Index
K30033_Index.indd 257 28/02/17 2:24 pm
258
cephalopelvic disproportion 38cerebral palsy 120–1cerebrovascular disease 29cervical cancer 90–1cervical disc prolapse 223cervical ectropion 91cervical spondylolisthesis 222cervical spondylosis 222chemotherapy, paediatric
cancers 152, 153, 154, 155child abuse 124childbirth
dystocia 38physiology of labour 37post-partum
haemorrhage 64–5chlamydia 78chocolate cyst
(endometrioma) 98cholestasis (of pregnancy) 46–7choriocarcinoma 76–7chromosomal abnormalities
34, 149Clark levels 217closed angle glaucoma
164, 168Clostridium perfringens 209clozapine 17club foot 249COCP (combined oral
contraceptive pill) 100coeliac disease 124cognitive dysfunction 28–32cold sores 204compartment syndrome 221complex regional pain
syndrome 221condylomata accuminata
(genital warts) 78congenital defects
cardiovascular 112–13cataracts 166genitourinary 114–15hearing loss 172
neural tube defects 43, 118–19
rubella syndrome 53conjunctivitis 169contraception 100–1Coombs test 66corticosteroids see steroidsCotard’s syndrome 3Creutzfeldt–Jakob disease
(CJD) 32Crigler–Najjar syndrome 105croup 128–9cruciate ligament
tears 244–5cyclothymia 18cystadenoma 98cystic fibrosis (CF) 130–1cysts
ovarian 98skin 214
cytomegalovirus (CMV) 54
D2 (dopamine) receptor 16de Quervain’s syndrome 232deafness 172–5dementia 28–32dependent personality
disorder 21depression 2–7dermatitis
atopic eczema 184–5seborrhoeic 186–7
dermatofibroma 212dermoid cyst 98, 214developmental dysplasia of
the hip 242–3diabetes mellitus
eye disease 170in pregnancy 40–1
diabetic ketoacidosis (DKA) 146–8
diagnostic classifications 253diazepam 12disc prolapse, cervical 223
Down’s syndrome (trisomy 21) 34, 149
dry macular degeneration 162, 163
Dupuytren’s contracture 232–3dystocia 38
earhearing loss 172–5vertigo 176–7
eating disordersanorexia 22–3bulimia 24–5
ectopic pregnancy 72–3eczema, atopic 184–5Edward’s syndrome (trisomy
18) 149elbow 230–1emergency contraception 101encephalocoele 118endolymphatic hydrops 174endometrial cancer 94–5endometrioma/endometriosis
98epidermoid cyst 214epilepsy
childhood 144–5in pregnancy 42–3
episcleritis 168epistaxis 178–9erythema multiforme 192–3erythema nodosum 192–3Ewing’s sarcoma 155eye
diabetic retinopathy 170glaucoma 164–5, 168red eye 168–9see also vision, loss of
failure to thrive 124–5Fallot’s tetralogy 112–13fatty liver, in pregnancy
48–9femur, proximal see hip
Index
K30033_Index.indd 258 28/02/17 2:24 pm
259
fetusanti-D status 66–7antiepileptic drugs 43complications of maternal
infections 51, 53, 54, 55, 59
flat foot 248flumazenil 12foot
orthopaedic conditions 248–9tinea pedis 211
fracturescomplications 220–1hip 240–1metatarsal 249scaphoid 234
frontal lobe epilepsy 42frontotemporal dementia 30–1frozen shoulder 226fungal infections 80, 210–11
G6PD (glucose-6-phosphate dehydrogenase) deficiency 105
gangrene 209Garden classification 241Gardnerella vaginalis 80gas gangrene 209gastrointestinal tract
candidiasis 210Hirschsprung’s disease 109intussusception 110necrotizing enterocolitis
106–7pyloric stenosis 108
gastroschisis 111generalized anxiety disorder
8–9, 12genital herpes 79genital warts 78genitourinary system
abnormalities 114–15infections 58–9, 78–80,
138–9
see also kidneyGerman measles 52–3gestational diabetes
mellitus 41gestational trophoblastic
disease 76–7glaucoma 164–5, 168glucose tolerance test 40glue ear 174–5golfer’s elbow 230–1gonorrhoea 78groin 211
haemangioma 213haemolytic disease of the
newborn 66–7haemolytic uraemic syndrome
(HUS) 140–1haemorrhage
antepartum 60–3, 74epistaxis 178–9menorrhagia 81post-partum 64–5
hair lossalopecia areata 202–3tinea capitis 211
hallucinations 3hallux valgus 248hand
carpal tunnel syndrome 234–5
de Quervain’s syndrome 232Dupuytren’s contracture
232–3scaphoid fracture 234stenosing tenosynovitis 233
Hansen’s disease (leprosy) 209head lice 207hearing loss 172–5heart
congenital defects 112–13rheumatic fever 136–7
Henoch–Schönlein purpura (HSP) 142–3
hepatic diseaseneonatal jaundice 104–5in pregnancy 46–9
hereditary haemorrhagic telangiectasia 116
herpes simplex virus (HSV) 55, 204genital 79
herpes zoster 205highly active antiretroviral
therapy (HAART) 57hip
developmental dysplasia 242–3
fracture 240–1Perthes disease 242–3Slipped upper femoral
epiphysis 240–1Hirschsprung’s disease 109histrionic personality
disorder 20hormonal contraception 100–1horseshoe kidney 114human immunodeficiency virus
(HIV) 56–7human papillomavirus (HPV)
78, 90, 206Huntington’s dementia 31hydatidiform mole 76–7hyperemesis gravidarum 46–7hypertension in pregnancy 44–5hypertrophic pyloric
stenosis 108hypospadias 115hypothyroidism 124
impetigo 208implants, contraceptive 101incontinence 99infertility 88–9
amenorrhoea 82–3infraspinatus 224injections, contraceptive 100insomnia 12
Index
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260
intra-hepatic cholestasis of pregnancy 46–7
intra-hepatic jaundice 104intraocular pressure (IOP),
raised 164–5intrauterine contraception
(IUD/IUS) 101intussusception 110
Jarisch–Herxheimer reaction 59jaundice, neonatal 104–5jock itch (tinea cruris) 211Jones criteria 136
Kawasaki’s disease 150–1keratoacanthoma 216ketoacidosis, diabetic 146–8kidney
autosomal recessive polycystic kidney disease 114
horseshoe 114Henoch– Schönlein
purpura 142haemolytic uraemic
syndrome 140–1Wilms’ tumour 154
kneecruciate ligament tears
244–5meniscal tears 246other pathology 247
kyphosis 236–7
labour 37dystocia 38
laryngeal cancer 182lateral epicondylitis 230–1Legg–Calvé–Perthes
disease 242–3Lennox–Gastaut syndrome 145leprosy 209leukaemia (ALL) 152
Lewy body dementia 30lichen planus 194–5lichen sclerosus 194–5lipoma 214lithium 17liver disease
neonatal jaundice 104–5in pregnancy 46–9
lumbar plexus 252lumbar puncture (in
meningitis) 122lymph node syndrome 150–1
macular degeneration 162–3Malassezia spp. 186, 190malignant disease see cancermania 19Meckel’s diverticulum 110medial epicondylitis 230–1melanoma 217Ménière’s disease 174meningitis 122–3meningocoele 118meningomyelocoele 118meniscal tears 246menorrhagia 81menstrual disorders 81–3metatarsal fracture 249miotic drugs 165miscarriage 74–5molar pregnancy 76–7monoamine oxidase inhibitors
(MAOIs) 7montelukast 135mood disorders
bipolar disorder 18–19depression 2–7
morning-after pill 101murmurs, cardiac 113Mycobacterium leprae 209
nails 189, 202narcissistic personality
disorder 21
nasopharyngeal cancer 180neck
disc prolapse 223spondylolisthesis 222spondylosis 222
necrotizing enterocolitis 106–7Neisseria gonorrhoeae 78neonates
jaundice 104–5rhesus disease 66–7
nephroblastoma 154nerves
brachial plexus 227lumbar plexus 252
neural tube defects (NTDs) 43, 118–19
neuroblastoma 152–3neurocutaneous syndromes
116–17neurofibromatosis 116neuroleptic drugs 16–17, 30neuroleptic malignant
syndrome 16noradrenaline reuptake
inhibitors (NRIs) 7nosebleeds 178–9
obsessive compulsive disorder (OCD) 10–11
oesophagitis, candidal 210olanzapine 17omphalocoele 111open angle glaucoma 164optic neuropathy 159oral candidiasis 210oral contraception 100oropharyngeal cancer 181Osgood–Schlatter disease 247Osler–Weber–Rendu
syndrome 116osteoarthritis 228–9
cervical spondylosis 222osteochondritis dissecans 247
Index
K30033_Index.indd 260 28/02/17 2:24 pm
261
osteomyelitis 250–1osteonecrosis of the femoral
head 242–3ostium primum 112ostium secundum 112otitis media 174–5otosclerosis 175ovary
cancer 96–7cysts 98polycystic ovary syndrome
84–5overflow incontinence 99
pancreatitis, chronic 40paranoid personality disorder 20parasites, skin 207Parkinson’s disease 30Patau’s syndrome (trisomy 13) 149patellar subluxation
syndrome 247Pearl Index 100pemphigus 196–7personality disorders 20–1Perthes disease 242–3pes cavus 249pes planus 248petit mal (absence)
epilepsy 144Pick’s disease 30–1pityriasis rosea 190–1pityriasis versicolor 190–1placenta praevia 62–3placental abruption 60–1plaster casts 220polycystic ovary syndrome
(PCOS) 84–5POP (progesterone only
pill) 100port-wine stain 213post-hepatic jaundice 104post-partum haemorrhage
(PPH) 64–5
posterior cruciate ligament 245pre-eclampsia 44–5pre-hepatic jaundice 104pregnancy 39
antenatal care 34–6, 67diabetes 40–1ectopic 72–3epilepsy 42–3liver disease 46–9miscarriage 74–5molar 76–7placenta praevia 62–3placental abruption 60–1pre-eclampsia 44–5symphysis pubis
dysfunction 68TORCHES infections 50–9see also childbirth
primary amenorrhoea 82prion disease 32prostaglandin analogues 165psoriasis 188–9psychosis 14–17punch drunk syndrome 32pyloric stenosis 108pyogenic granuloma 213
red eye 168–9refeeding syndrome 23renal disorders
autosomal recessive polycystic kidney disease 114
horseshoe kidney 114Henoch– Schönlein
purpura 142haemolytic uraemic
syndrome 140–1Wilms’ tumour 154
respiratory tractasthma 132–5bronchiolitis 126–7croup 128–9
retinal artery occlusion 161retinal detachment 160retinal vein occlusion 158retinopathy, diabetic 170Reye syndrome 137rhesus disease 66–7rheumatic fever 136–7rheumatoid arthritis 228–9ringworm 211Risk of Malignancy Index 96rosacea 200–1rotator cuff tears 224–5Rotherham criteria 84rubella 52–3
salbutamol 134salmeterol 134Salter-Harris classification 221scabies 207scalp
alopecia areata 202–3head lice 207tinea capitis 211
scaphoid fracture 234Scheuermann’s disease 236schizoid personality
disorder 20schizophrenia 14–17schizotypal personality
disorder 20Schneider’s first rank
symptoms 14scleritis 168SCOFF questionnaire 23scoliosis 236–7seborrhoeic dermatitis 186–7seborrhoeic keratosis 212secondary amenorrhoea 83seizures see epilepsyselective serotonin reuptake
inhibitors (SSRIs) 6, 10semen analysis 88septic arthritis 250–1
Index
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262
serotonin noradrenaline reuptake inhibitors (SNRIs) 6–7
sexually transmitted infections (STIs) 58–9, 78–9see also human
immunodeficiency virusshingles 205shoulder
adhesive capsulitis 226dislocation 224–5rotator cuff tears 224–5
shoulder dystocia 38sight, loss of see vision,
loss ofsilver nitrate cautery 178skin
benign lumps 212–14bullous disorders 196–7infections 204–11lichenoid lesions 194–5malignancies 216–17neurocutaneous syndromes
116–17rashes 184–93, 198–201
slipped upper femoral epiphysis (SUFE) 240–1
solar keratosis 212spherocytosis 105spina bifida 43, 118–19spine
ankylosing spondylitis 238–9
cervical 222–3curvature 236–7stenosis of the spinal
canal 238–9spondylolisthesis, cervical 222spondylosis, cervical 222squamous cell carcinoma 216Staphylococcus aureus 208stenosing tenosynovitis 233
sterilization 101steroids
asthma 134–5croup 129side effects 133
Stevens–Johnson syndrome 192, 193
strawberry naevus 213Streptococcus spp. 136, 208stress incontinence 99stridor 128Sturge–Weber syndrome 117subconjunctival
haemorrhage 169subscapularis 224supraspinatus 224sweat test 131sympathomimetics 165symphysis pubis dysfunction 68syphilis 58–9, 79
talipes equinovarus 249temporal arteritis 159temporal lobe epilepsy 42tennis elbow 230–1teres minor 224termination of pregnancy 86tetracyclic antidepressants 7tetralogy of Fallot 112–13theophylline 135thyroid disorders 124tinea cruris/tinea capitis/tinea
pedis 211TORCHES infections 50–9
HSV 55, 79, 204syphilis 58–9, 79
toxoplasmosis 51transposition of the great
vessels 112–13Treponema pallidum 58–9, 79trichomoniasis 78tricyclic antidepressants 6
trigger finger 233trisomy 149
Down’s syndrome 34, 149
truncus arteriosis 112–13tubal (ectopic) pregnancy 72–3tubal ligation 101tuberous sclerosis 116tumours see benign tumours;
cancer
urge incontinence 99urinary incontinence 99urinary tract
congenital defects 114–15infections (UTIs) 138–9
uterine (endometrial) cancer 94–5
vaginableeding per 60–5, 81, 90,
92, 94cancer 92–3infections 78–80lichen sclerosus 194–5
varicella zoster virus (VZV) 205
vascular dementia 29vasculitis
Henoch– Schönlein purpura 142–3
Kawasaki’s disease 150–1vasectomy 101ventricular septal defects
(VSDs) 112–13vertigo 176–7vision, loss of
cataracts 166–7glaucoma 164–5macular degeneration 162–3sudden 158–61
vitreous haemorrhage 161
Index
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263
vomiting, hyperemesis gravidarum 46–7
von Recklinghausen disease 116
vulvovaginal candidiasis 80, 210
wall test 239warts 206
genital 78
washerwoman’s sprain 232
websites 34, 100, 134, 254–5
Westley Croup Score 128West’s syndrome 145wet macular degeneration
162, 163
Wilms’ tumour 154Wilson’s disease 32wrist fracture 234
Yerkes–Dodson law 8
zidovudine 57zolpidem 12
Index
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