Navaidot Internal Medicine

• Anatomy and physiology
• Diseases
• Medication
• Laboratory
Ngam Punlork
HOME EDITION D-ork-L

EDITION
NAVAIDOT
Internal Medicine
Prepared by
Ngam Punlork, MD
NAVAIDOT of Internal Medicine edited by Ngam Punlork, MD.

First up to date 2007
Second up to date 2008
Third up to date 2009
Fourth up to date 2010
Copyright © 01-01-2011
Convert to adobe PDF 06-06-2012
NAVAIDOT of Internal Medicine

• Personal book
• Fourth edition
• Information update throughout the other books
• New up-to-date references
Contents
1. Anatomy and physiology………………………………..
2. Emergency problems…………………………………….
3. Fluid and electrolytes………………………………….. ..
4. Most common pediatric disorders …………………….
5. Hematology ………………………………………………..
6. Immunology …………………………………………........
7. Cardiology …………………………………………………
8. Pulmonary diseases ……………………………………..
9. Ear, Nose and Throat disorders ……………………….
10. Stomatology ……………………………………………….
11. Common eye disorders………………………………... ..
12. Dermatology………………………………………….........
13. Neurologic diseases………………………………………
14. Rheumatology………………………………………….......
15. Psychiatric disorders……………………………………..
16. Endocrine disorders………………………………………
17. Infectious Diseases………………………………………..
18. Genitourinary diseases………………………………......
19. Congenital malformations……………………………….
20. Gastrointestinal diseases………………………………..
21. Common Surgical Disorders…………………………….
22. Gynecology-Obstetric Disorders……………………….
23. Toxicology…………………………………………………..
24. Common Medications……………………………………..
25. Laboratory……………………………………………………
Preface
I am NGAM PUNLORK. I studied and finished successful at University of Health
Science, Diploma in Nurse 2003 and Diploma in Medical Doctor 2010, other Diploma
in Child Health 2011, Diploma in Economy 2012, Diploma in Development
Management and Diploma in English Language 2012. I have worked in health
system more than ten years as national hospital, international organizations, and
companies.
My sincere thanks also to my parent, wife, teachers, friends, participants that

supported my writing. In my memory Miss Phearkdy Chenda, Mr Ngam Saray, and
Dr Touch Sivutha.
NAVAIDOT INTERNAL MEDICINE-my personal book was not audited, it only edited
throughout my experiences and information update from the other books. First edition
in 2007 described pediatric, geriatric, surgery, and gynecology obstetric. As new
research and clinical experience broaden knowledge, changes in treatment and drug
therapy are required.
I hope that NAVAIDOT INTERNAL MEDICINE will be a useful resource for medical
students and junior residents in medicine.
NGAM PUNLORK, MD
The Intergumentary System/Skin
________________________________________
Hair
Sweat pore
Stratum corneum
Epidermis
Sebaceous gland
Dermis
Receptor for
touch(Corpuscule) Sweat gland
Hypodermis
(Subcutaneous)
Hair follicle
Adipose tissue
Nerve Arteriole Nenule
Structure of the skin
Structure of the skin

The integumentary system is composed of the skin, and associated structures (hair,
gland, and nails). This system accounts for approximately 7 percent of the body
weight and is covered the body.
• The skin is composed of two layers
- The epidermis
- The dermis and hypodermis
• Associated Structures of the skin : Hair, hair follicle, nail
• Exocrine glands : 3 types
- Sebaceous glands : Oil glands, acid sebum and waterproof the skin
- Sudoriferous glands : Sweat glands ( Eccrine glands and Apocrine glands )
- Mammary glands : Breast of female
Physiology of the skin
Function Site
Protects against Epidermis
• Dehydration ( Sweat )
• Injury and UV light
• Pathogens
Absorption and synthesis Epidermis and dermis
• Pigments and vitamin D
• Vitamins A , D , E and K
• Absorption of oil, ointments
Excretion Epidermis and dermis
• Sweat , drug
• Elimination of wastes : Salts,
water, urea
Temperature regulation Dermis and hypodermis
• Regulation of water balance
Sensory receptor Epidermis, dermis, and hypodermis
The Nervous System
________________________________________
Neurons and Neuroglia

Neuron is a nerve cell found in both the CNS and the PNS.
• Cell body (Grey matter)
• Dendrites ( Synapse )
• Axon (Axolemma, myelin, neurilemma)
Myelin is a sheath of fatty material which surrounds most axons (White matter)
Neuroglia is specialized connective tissue found in the brain and spinal cord, there
are three types (Oligodendrocytes, astrocytes, microglia)
• Synapse : Connective between dendrite with axon, chemical transmitter and
information passes from one to another.
• Grey Matter : In the four ventricles of brain, shape H-litter
• White Matter : In the fiber of spinal cord
Nucleus
Dendrites
Axon
Cell body
Schwann cell
nucleus
Myelin Functional dendrite
Axon
Receptor
The neuron
Type of nervous system

Peripheral Nervous System (PNS)
• 12 pairs of cranial nerves
• 31 pairs of spinal nerves
• The autonomic part of the nervous system
Central Nervous System (Brain and spinal cord)
• The cerebrum or fore brain
• The brain stem (Midbrain, pons varolii, medulla oblongata)
• The cerebellum or hind brain
NS
PNS CNS
Spinal Nerve Autonomic Nervous System Brain Spinal cord

(Cranial nerve)
Peripheral Nervous System
Cranial Nerve : 12 pairs

Sensory nerves
Cranial nerve Pathway Function
I Olfactory From olfactory epithelium Smell
II Optic From retina of eye Sight
VIII Vestibulocochlear From organs of hearing Hearing and balance
Motor
III Oculomotor Four eye muscles position Movement of eye, eyelid
From ciliary body Chang in pupil size, sense
IV Trochlear Superior oblique muscle Movement of eye, sense
VI Abducens of eye Lateral rectus muscle Movement of eye, sense
XI Accessory Neck muscle : Trapezius Head and shoulder
and sternocleidomastoid movement ,muscle sense
XII Hypoglossal Muscle of tongue Speech, swallowing ,
sense
Mix nerve
V Trigeminal
V1 Ophalmic Sensory from cornea, skin General sensation from
of upper 1/3 of face, skin of face
superior nasal mucosa.
V2 Maxillary Sensory from middle 1/3 of General sensation from
face, teeth and gums, skin of face
jaw, lateral-inferior nasal.
V3 Mandibular Sensory from lower 1/3 of General sensation from
face, teeth, mouth and skin of face
tongue.
Motor to mastication Chewing of food
VII Facial nerve Sensory from taste buds. Test
Motor to facial muscle, Movement of face,
lacrimal gland, salivary secretion of saliva and
gland tears
IX Glossopharyngeal Sensory from pharyngeal Taste, muscle sense
muscle and taste buds.
Motor to pharyngeal Swallowing
muscles and salivary Secretion of saliva
glands
X Vagus Sensory from viscera, Taste , vomiting ,
taste peristalsis
Motor to viscera Visceral muscles and
glands
Spinal Nerve : 31 pairs

There are 31 pairs of spinal nerve :
• 8 cervical nerves
• 12 thoracic nerves
• 5 lumbar nerves
• 5 sacral nerves
• 1 coccygeal nerve
Autonomic Nervous System

Feature Sympathetic Parasympathetic
Origin of preganglionic Thoracolumbar nerves Craniosacral nerves
fiber
Location of ganglia Far from visceral effector Near or within viscera
organs, in sympathetic effector organs.
chain or collateral ganglia
Neurotransmitter In ganglia acetylcholine, in In ganglia, acetylcholine,
effector organ, in effector organs.
norepinephrine.
Organ Sympathetic Response Parasympathetic Response

• Heart (Cardiac ) • Increase rate • Decrease rate (to normal)
• Bronchioles(Muscle) • Dilate • Constrict (to normal)
• Iris (smooth muscle) • Pupil dilates • Pupil constricts (to normal)
• Salivary glands • Decrease secretion • Increase secretion (to
• GI tract (Muscle) • Decrease peristalsis normal)
• GI tract (Glands) • Decrease secretion • Increase peristalsis for
• Internal anal • Contracts to prevent normal
sphincter defecation • Increase secretion for
• Urinary bladder • Relaxes to prevent normal
(smooth muscle) urination • Relaxes to permit
• Internal urethral • Contracts to prevent defecation
sphincter urination
• Liver • Glycogen to glucose • Contracts for normal
• Pancreas • Secretes glucagons urination
• Sweat glands • Increase secretion
• Blood vessels in • Constriction • Relaxes to permit urination
skin and viscera
(smooth muscle) • None
• Blood vessels in • Dilate • Secretes insulin & GI
skeletal muscle enzymes
(smooth muscle) • None
• Adrenal glands • Increase secretion of • None
epinephrine,
norepinephrine
• None
• None
Central Nervous System

Brain : 5 regions of brain
• Telencephalone : Cerebrum
• Diencephalon : Thalamus, hypothalamus, and pituitary gland
• Mesencephalon : Superior colliculus, inferior colliculus, and cerebral
peduncles
• Metencephalon : Cerebrum and pons
• Myelencephalon : Medulla oblongata
5 cerebral lobes and functions
• Frontal lobe : Voluntary control of skeletal muscles
• Parietal lobe : Cutaneous and muscular sensory, understand and speech
• Temporal lobe : Sensory, auditory, memory
• Occipital lobe : Movement, visual images
• Insular : Memory
Ventricles of the brain : 4 ventricles
• The right and left lateral ventricles
• The third ventricle
• The fourth ventricle
Cerebrospinal fluid
• CSF produced by fourth ventricle that flows through two foramina, the media
and lateral foramena, into the subarachnoid space and subsequently
completely surrounds the brain and spinal cord.
• Normal hydrostatic pressure of CSF about 100-200 mm water (10 mmHg), in
the patient cryptococcal meningitis intracranial pressure > 250 mm water.
• Functions of CSF
- Protect of the brain and spinal cord to trauma
- Maintain a uniform pressure and the brain
- Transport and support : Protein, glucose, mineral
Meninges
• The connective tissue membranes cover of the entire CNS
• There are 3 layers
- Dura mater : Epideral space and subarachnoid space
- Arachoid : Subarachnoid space and contain cerebrospinal fluid
- Pia mater : Connective tissue that adherent to brain surface
Midbrain is the area of the brain between the cerebrum about and pons varolii.
Pons varolii is situated in front of the cerebellum below the midbrain and above
medulla oblongata. It differs from that the cerebrum in that the nerve cell lie deeply
and nerve fiber are on the surface.
Medulla oblongata, It is about 2.5 cm, extends from th pons varolii above and is
continuous with the spinal cordbelow.
Cerebrum
• The cerebrum is largest part of the brain
• There are frontal, parietal, temporal, occipital
• Function
- Memory
- Sensory : Pain, temperature, sight, hearing, tastes and smell
- Control of the contraction of voluntary muscle
Cerebellum
• Position : Behind the pons varolii and immediately below the posterior portion
of the cerebrum
• There are three tracts
- Superior cerebellar peduncle
- Middle cerebrallar peduncle
- Inferior cerebellar peduncle
• Function : Control and co-ordinates the movements of muscle and balance
Basal ganglia : This area of grey matter, lying deep within the cerebral hemispheres,
control of skeletal muscle tone (Inadequate or absent movement, tremor, and unco-
ordinated).
Thalamus : It’s mass of nerve cell within the cerebral hemispheres just below the
corpus callosum. All sensory nerves from the peripheral of the body associated with
impulses of pain, temperature, pressure and touch are conveyed to the thalamus.
Hypothalamus is composed of a number of groups of nerve cells. It’s situated below
and in front of the thalamus. The hypothalamus is linked to the posterior lobe of
pituitary gland, control the output of hormones and autonomic nervous system
(Hunger, thirsty, fear, temperature, heart and blood vessels).
Corpus callosum
Cerebrum
Lateral ventricle
Third ventricle
Cerebellum
Pons varolii
Fourth ventricle
Medulla
oblongata
Thalamus Spinal cord
The cerebral and spinal cord Terminal of spinal cord

(1st lumbar vertebral )
8
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The Digestive System/GI Tract

________________________________________
Parotid gland
Teeth
Pharynx
Tongue
Esophagus
Sublingual gland
Submandibular gland
Liver Stomach
Spleen
Gallblade
r Pancreas
Duodenum
Transverse colon Small intestine
Ascending colon
Descending colon
Cecum and appendix Rectum
The organs of the digestive system
Structure of the GI tract

Layer Structure Function
Mucosa Simple columnar Secretion and absorption
epithelium
Submucosa Highly vascular Absortion
Muscularis Smooth muscle Peristalsis
Serosa Visceral peritoneum Binding and protection
Serosa
(Peritoneum)
Cardiac orifice
Muscularis
Longitudinal
Circular
Lesser curvature
Oblique
Submucosa
Pyloric sphincter (Submucous layer)
Greater curvature
Duodenum Pyloric
antrum
Longitudinal section of stomach

Component of Gastric Juice
Component Source Function
Hydrochloric acid (HCl) Parietal cells Converts pepsinogen to
pepsin, kills pathogens
Pepsin Chief cells Protein-splitting enzyme
Mucus Goblet cells Protects the mucosa
Intrinsic factor Parietal cells Absorption of vitamin B 12
Gastrin G cells Stimulates of HCl and
pepsin
Serotonin and histamine Argentaffin cells Autocrine regulators
Divisions of intestine
Small intestine Large intestine
Duodenum : C-shaped, 4-segments, Colon : 1-1.5m-long, 400-800mL-water
25cm-long, from pyloric to jejunum, absorption.
there are common bile duct and Cecum : First portion, a dilated pouch,
pancreatic duct. appendix 13-15cm-long and 5cm-
Jejunum : Middle section of small diameter.
intestine, 3-3.5m-long. Ascending colon : Right colon
Ileum : Joins the cecum of the large Transverse colon : Upper peritoneal
intestine at the ileocecal valve. 3m- cavity.
longe. Descending colon : Left colon
Sigmoid colon : S-shaped
Rectum : Terminal portion
Intestinal Enzymes
Enzyme Function
Peptidase Converts protein in amino acids
Sucrase ( Maltase and lactase) Converts disaccharides in to
monosaccharides
Lipase Converts fats into fatty acids and glycerol
Amylase Converts starch and glycogen into
disaccharides
Nuclease Converts nucleic acid into nucleotides
Enterokinase Activates trypsin secreted from the
pancreas
Oral Cavity
Teeth
• First teeth are primary teeth about 20 and it will fall out during 4-5 years of age
• Permanent teeth 32, four types : 8 incisors, 4 canines, 8 premolars, 12 molars.
Tongue : Moves food around mouth during mastication, assists in swallowing, speech
sound, location of taste buds.
Salivary glands : 3 glands
• Parotid gland : Over the master muscle
• Submandibular gland : Inferior to the base of the tongue
• Sublingual gland : Under the tongue
Palate : Hard palate anterior and soft palate posterior, the uvular is suspended from
the soft
Accessory Organs
Liver Gall bladder Pancreas
Anatomy : 8 segments Anatomy : Pouchlike Anatomy : Inferior to the
- Right and left, separated organ attached to inferior stomach, Pancreatic islets
by the falciform ligament surface of the liver. (islets of Langerhans)
- Caudate lobe is near - Gall bladder : 10cm-long Function
inferior vena cava and 5cm-wide. - Exocrine secretions
- Quadrate lobe : - Common bile duct : (Alkaline pH 8)
Gallbladder 7.5cm-long, 6mm-diameter . Peptidase : Convert
- Crosses by portal vein Function protein into amino acids
- Weigh : 1200g (2% of - Stores and concentrates . Lipase : Convert fats
body) - Store bile about 60 mL into fatty acid and
Function and excreted about 500- glycerol
- Synthesis, storage and 1000 mL per day. . Amylase : Convert
release of vitamin A, D, - Bile product by liver, glycogen into
E, and K, glycogen, when the small disaccharides
iron. intestine is empty, - Endocrine secretions
- Phagocyte, removal bile is forced up the . Glugagon : Secreted
toxic and production of cystic duct to the by alpha cells,
bile salt. gallbladder for storage increased blood
- Breaks down the by hepatic duct glucose.
nucleoprotein of worn- - When eating, bile to the . Insulin : Secreted by
out cells of the body duodenum by bile duct. beta cells, decreased
from uric acid which is blood glucose.
excreted in the urine. . Somatostatin :
Secreted by delta cells,
cartilage and collage
formation.
Hepatic duct
Body and tail
Cystic duct of pancreas
Duodenu Pancreatic duct

m
Ampulla of vater
Superior mesenteric
Theiliary and pancreatic tract artery and vein
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Hematology and Immunology

________________________________________
Hemostasis
Hemostasis : Vasoconstriction, tissue swelling, coagulation (Clotting of blood), and
thrombosis (Aggregated platelets)
• Coagulation :
- Platelet and fibrinogen adherent : Thromboxane A2 (Aggregated platelet)
- Joint of monocyte and macrophage
- Interactions of endothelial cells when vessel destroy
• Blood coagulation factor : Factor V, VII, IX, X, XII
• Thrombosis : Interaction Factor Xa, factor V, calcium, and platelet factor 3
→Fibrinogen → Fibrin→ Clot
Factor
I Fibrinogen
II Prothrombin
III Thromboplastin
IV Calcium
V Accelerator globin or labile factor (AcG)
VI ( There is no factor VI )
VII Stable factor
VIII Antihemophilic factor (AHF)
IX Plasma thromboplastic component. Christmas factor (PTC)
X Stuart-Prower factor
XI Plasma thromboplastin antecedent (PTA)
XII Hagemen factor
XIII Fibrin-stabilising factor
Vitamin K : Factors (II, VII, IX, X) affecting blood clotting
Prothrombin (Inactive) + Calcium + Thromboplastin (Platelet) = Thrombin (Active)
Thrombin + Fibrinogen (Inactive) = Fibrin
Fibrin + Blood cells = Clot
Blood component
Whole blood (Total blood)
• Plasma 50-60%
- Water 90%
- Solutes10% (Protein7% and electrolyte, urea, glucose 3%)
• Formed elements
- Erythrocyte : 3.8-5.5 million / mm3
- Platelets : 150-400 000 / mm3
- Leukocytes 4 000-10 000 / mm3 (Netrophils, Monocytes, Eosinophils,
Basophils, Lymphocyts )
Plasma Protein : 6-8 g / dL or 60-80 g / L

• Albumin 55% (3.2-4.5 g / dL)
• Globulins 41% (2.3-3.5 g / dL)
• Fibrins 4% (0.3-0.4 g / dL) : Fibrinogen (0.2-0.4 g / dL) + Prothrombin (0.015 g
/ dL)
Erythrocyte
• RBCs lifespan 120 days, produce by bone marrow, and the kidneys secrete
the hormone erythropoietin. Erythrocyte substances : Protein, lipids, amino
acid, iron, vita-B12, folic acid, copper, and cobalt. RBC has approximately 280
million hemoglobin molecules.
Hemoglobin (Hb) : 4-Iron (Heme) + 4-Polypeptide (Globin)
Platelets (Thrombocytes) : Small cellular fragment that origin in the bone marrow
from megakaryocytes. Platelets contain severe clotting factor. calcium irons, ADP,
serotonin and protein that join to arrest of bleeding.
Leukocytes : 5 types of white blood cells
• Netrophils : Phagocytosis (Substances-chemotaxis, through the wall capillary
as diapedesis and kill organisms by digesting), life-span about 30 hours.
• Monocytes : Phagocytosis (Large cells in the bone marrow, spleen, liver and
the wall of blood vessels. When its leave the blood stream to ingest call
macrophage).
• Eosinophils : Phagocytize antigen-antibody complexes (Histamine).
• Basophils : Release heparin, histamine, and serotonin.
• Lymphocytes (T cells and B cells) : Produce antibodies, destroy specific target
cells, and life-span about 200 days.
HEMOCYTOBLAST
(Stem cell)
Proerythrocyte Myeloblast
Erythroblast Promyelocyte Monoblastocyte Lymphoblast
Megakaryocyte
Normoblast
Basophilic Neutrophilic Eosinophilic

myelocyte myelocyte myelocyte
Reticulocyte
Erythrocyte Monocyte Lymphocyte

Thrombocyte
Basophil Neutrophil Eosinophil
Granulocytes
Erythrocytes
Neutrophil
Reticulocyte
s
Basophil
Normoblasts
Bands cell
Eosinophil
Thrombocytes Stem Cell
(Platelets)
Natural killer cell
Monocyte
B cell
T cell
Lymphoblast
Macrophage Plasma Cell
The stem cell (Hemocytoblast)
Blood ABO system

Blood Group Antigens Antibodies Donors
A 42% A Anti-B A or O
B 8% B Anti-A B or O
AB 4% A and B none A, B, O
O 46% none Anti-A and Anti-B O
Another group of antigens associated with blood Rhesus. Rh-positive about 85% and
Rh-negative about 15%
Lymphatic system
Lymphatic vessels : Lymph flows into right and left subclavian vein, the right
lymphatic duct which drains lymph from the upper right quadrant of the body, and the
large thorax duct .
Lymph nodes : Produce lymphocytes and macrophages, some principal groups are
popliteal, inguinal, lumbar, cubital, axillary, cervical, and mesenteric nodes
Lymphoid organs : Tonsils, palatine, lingual, spleen, thymus
Cell-Mediated Immunity
T lymphocytes : Produce cell-mediated immunity by thymus, there are 3 types
• T-cells Memory : Remain inactive until future exposure to same antigen.
• T-cells Killer : Release cytokines and lysis antigen, tumor or foreign cells.
• T-cells Helper : Help to activate other T or B cells.
B lymphocytes : Produce antibody-mediated immunity, and specific antibodies from
clones of daughter cells
• B-cells Memory : Turn in plasma cell upon a later exposure to same antigen.
• Plasma cells : Produce specific antibodies (Immunoglobulins)
Immunoglobulin (Ig)
Name Location Functions
IgG Blood • Crosses the placenta to provide passive
Extracellular fluid immunity for newborns
• Provides long-term immunity following
recovery or a vaccine
IgA External secretions • Present in breast milk to provide passive
(tears, saliva, etc.) immunity for breast-fed infants
• Found in secretions of all mucous
membranes
IgM Blood • Produced first by the maturing immune
system of infants
• Produced first during an infection (IgG
production follows)
• Part of the ABO blood group
IgD B lymphocytes • Receptors on B lymphocytes
IgE Mast cel ls or basophils • Important in allergic reactions (Mast cells
release histamine)
Antibody-Mediated Immunity
• Active-mediated immunity : Post-immunization
• Passive immunity : Result of the of antibodies from one person to another,
post infection or transfer across the placenta
Immunization
Passive ( Serum –antitoxic ) Active ( Immunoglobulin )

• SAT
• Anti-D
• Serum antirabique
• Serum antivermineux Passive immunity Active immunity
Maternal and post infection Vaccination

The Cardiovascular System
________________________________________
Left common carotid artery

Brachiocephalic artery
Left subclavian artery
Superior vena cava
Aortic arch
Left pulmonary artery

Right pulmonary artery Left atrium
Right pulmonary veins Left pulmonary veins
Pulmonary semilunar Mitral valve
valve
Left ventricle
Right atrium
Aortic semilunar valve
Tricuspid valve
Interventricular
Inferior vena cava septum
Right ventricle Apex

Chordae tendineae
Papillary
muscles
The heart
Structure
Heart structure : 3 layers
• Epicardium : Serous membrane of connective tissues covered and outer layer
• Myocardium : Cardiac muscle tissue and connective tissues, contraction layer
• Endocardium : Epithelial membrane and connective tissues, inner layer
Vascular structure : 3 layers
• Tunica interna : Inner layer of squamous epithelium, call endothelium
• Tunica media : Middle layer of smooth muscle fibrin mixed elastic fibers
• Turnica externa : Outer layer of connective tissue containing elastic and
collagenous.
Heart Valves
Atrioventricular valves (AV valves)
• Tricuspid valve : Between the right atrium and the right ventricle
• Bicuspid valve : Between the left atrium and left ventricle
Semilunar valves
• Pulmonary semilunar valve : Between the right ventricle and pulmonary truct
• Aortic semilunar valve : Between the left ventricle and ascending aorta
Function of vessels
Vessel Structure Function
Artery • Strong elastic • Distributive channel to
take blood from the heart vessel, contain all body tissues, blood
three tunics, lumen carried under high
diameter large pressure.
relative to wall
thickness.
Vein • Thin, distensible • Serves as fluid
take blood into the heart vessel consisting of reservoir, constricts in
three tunics, lumen response to
diameter very large. sympathetic
• Valves present stimulation.
• Valves ensure unidi-
rectional blood flow.
Capillary • Wall composed of • Allow exchange of
exchange area of the system single layer of endo- fluid, nutrients, and
• Arteriole : Small artery thelium (Tunica gases between the
• Venules : Small veins interna), smooth blood and the
mus-cle cuff at its interstitial fluid.
origin regulates flow.
Cardiac Cycle
• Cardiac Output (CO) : Stroke volume (SV) x Heart rate (HR)
• Increased cardiac output
- Sympathetic stimulation of heart (Increased heart rate)
- Increased end-diastolic volume (Increased blood volume)
- Various forms of anemia that result in decreased total peripheral resistant
• Diastolic : The atria and ventricle relaxation, AV valves are open and
semilunar valves are closed. Blood flows from atria into ventricle.
• Systolic : Ventricle contraction, AV valves are close and semilunar valves are
opened. Volume of blood ejected from either ventricle into aorta and
pulmonary artery.
- Stroke volume ejected from either ventricle about 70-90 mL
- Right ventricle exceeds the diastolic pressure in the pulmonary artery 10
mmHg
- Left ventricle exceeds the diastolic pressure in the aorta 80 mmHg
- Under normal resting conditions, the pressure reaches 25 mmHg on the right
side and 120 mmHg on the left side.
Regulation of Blood Flow

• Neural mechanism. Baroreceptors (Sensory receptors that monitor blood
pressure) in the walls of large vessels and the chambers of the heart detect a
decrease in blood pressure. This initiates the following responses :
- Increased secretion of ADH from the pituitary gland. Under the action of
ADH, the kidneys restore water to the blood, increasing blood volume.
- Sympathetic impulses sent to the heart, which increase heart rate.
- Sympathetic response of smooth muscle of vessels that changes vessel
diameter and thus peripheral resistance.
• Renal mechanism
Decrease in blood pressure in the kidneys activates the renin angiotensin
system. The aldosterone produced alters the electrolyte balance and
stimulates increased reabsorption of water by the kidneys, resulting in
increased blood volume.
Cardiac Circulation
The two pathway of circulation
• Systemic circulation (Major circulation)
• Pulmonary circulation (Minor circulation)
Pulmonary circulation
• The right ventricle pumps blood into the pulmonary artery (or trunk), which
divides into the right and left pulmonary arteries, one going to each lung.
Within the lungs each artery branches extensively into smaller arteries and
arterioles, then to capillaries. The pulmonary artery with blood carbon dioxide
carries.
• The pulmonary capillaries surround the alveoli of the lungs; it is here that
exchanges of oxygen and carbon dioxide take place. The capillaries unite to
form venules, which merge into veins, and finally into the two pulmonary veins
from each lung that return blood to the left atrium. The pulmonary vein return
with oxygen carries.
Systemic circulation
• The left ventricle pump blood in the aorta, the large artery of the body with
oxygen carries. We will return to the aorta and its branches in a moment, but
first we will summarize the rest of systemic circulation. The branches of the
aorta take blood into arterioles and capillary networks throughout the body.
Capillaries merge to form venules and veins.
• The veins from the lower body take blood to the inferior vena cava veins from
the upper body take blood to the superior vena cava. These two caval veins
return blood to the right atrium with carbon dioxide carries.
Aorta
The aorta is a continuous vessel, but for the sake of precise description it is divided
into sections that are named anatomically: ascending aorta, aortic arch, thoracic
aorta, and abdominal aorta.
• The ascending aorta is the first inch that emerges from the top of the left
ventricle. The two branches : the right and left coronary arteries, which supply
blood to the myocardium.
• The aortic arch curves posteriorly over the heart and turns down ward. The
three branches into carotid and subclavian arteries (Brachiocephalic).
• The thoracic aorta continues down through the chest cavity and through the
diaphragm.
• Below the level of the diaphragm, the abdominal aorta continues to the level of
the 4th lumbar vertebra, where it divides into the two common iliac arteries.
Along its course, the aorta has many branches through which blood travels to
specific organs and parts of the body.
The body circulation
The Muscular System
______________________________________
Structure of the muscle tissue

Type Location and Function
Skeletal muscle • Covers of skeleton
• Voluntry
Smooth muscle • Walls of hollow organs
• Involuntary
Cardiac muscle • Walls of the heart
• Involuntary
• Rhythmic contraction
Muscles of the head and neck

Muscle Location and Function
Frontalis • Raises eyebrows, wrinkles skin of forehead
Orbicularis oculi • Closes eye
Orbicularis oris • Puckers lips
Masseter • Closes jaw
Buccinator • Pulls corners of mouth laterally
Sternocleidomastoid • Turns head to opposite side (Both flex head and
neck)
Semispinalis capitis • Turns head to same side (Both extend head and
(Deep muscle) neck)
Splenius capitis • Turns head to same side
Muscles of the back

Muscles Location and Function
2 trapezius • Control movement of scapula and shoulder
2 teres major • Movement of shoulder
2 psoas • Movement at hip joint
2 sacrospinalis • Flexion or extension of vertebral colon
2 latissimus dorsi • Movement and extend
2 quadratus lumborum • Flexion or extension of vertebral colon
Trapezius
Splenius capitis
Deltoid
Rhomboideus major
Teres major
Latissimus dorsi
External oblique
Gluteus maximus
The muscle of the back
Muscles of the posterior abdominal wall

Quadratus lumborum • Posterior of iliac crest into vertebral, 12th rib
Psoas • Transverse process of lumbar vertebral into
lesser trochanter of femur.
Internal oblique • Iliac crest, inguinal ligament, lumba fascia into
linea alba, cotralcartilages of lower ribs.
Transversus abdominis • Iliac crest, inguinal ligament, lower ribs into
xiphoid process, linea alba, pubis.
Muscles of the anterior abdominal wall

2 rectus abdominis • Attached and separated by the linea alba
2 external oblique • Extends from the lower rib into iliac crest
2 internal oblique • Remove of external oblique
2 transversus abdominis • Deepest layer of muscle tissue , oblique
muscles folded back
Inguinal canal
This is a canal 2.5-4 cm long which passes
obliquely through the abdominal wall.
Muscles of the pelvic floor
Levator ani Supporting the organs of the pelvic cavity
Coccygeus Triangular shape , behind the levator ani , these
two muscles complete the formation of the pelvic
floor ( Anus , urethra , and vagina ).
Muscles of the upper limbs

The muscles of the pectoral girdle
Serratus minor Origin : Upper 8 or 9 ribs
Insertion : Anterior medial border of scapula
Pectoralis minor Origin : Sternal ends (ribs 3-5)
Insertion : Coracoid process of scapula
Trapezius Origin : Occipal bone , spines
Insertion : Clavicle , acromion , and spine
of scapula
Levator scapular Origin : Cervical 1-4th
Insertion : Sup-border of scapula
Rhomboideus Origin : Thoracic vertebrae 1st
Insertion : Med-border-scapula
The muscles and movement of the hand

Pectoralis major anterior Origin : Clavico-sternal ribs2-6
Insertion : Greater tubercle of humorus
Latissimus dorsi Origin : Lumbar-sacral and lower thoracic,
vertebral
Teres major posterior Origin : Inferior angle and lateral border of scapula
Insertion : Greater tubercle of femorus
Teres minor posterior Origin : Lateral border scapula
Insertion : Greater tubercle of femorus
Coraco-brachiali anterior Origin : Coracoid precess
Insertion : Shaft of humorus
Biceps brachii Origin : Coracoid and tuberosity above glenoid
fossa of scapula
Insertion : Radial tuberosity
Brachialis Origin : Anterior shaft-humorus
Insertion : Coronoid of ulna
Deltoid Origin : Clavicle, acromion &spine scapula
Insertion : Deltoid tuberosity
Triceps brachii Origin : Tuberosity below glenoid fossa and shaft
of humerus
Insertion : Olecranon of ulna
Wrist muscles • Abduction : Flexor and extensor carpi radialis
• Thenar • Adduction : Flexor and extensor carpi ulnaris
• Hypothenar
Deltoid Deltoid
Pectoralis
major Teres
Corachobrachialis Triceps
Biceps
Brachioradialis
Brachialis Pronator Extensor carpi

teres radialis
Brachioradialis
Extensor
Flexor carpi carpi ulnaris
radialis Flexor carpi Extensor
ulnaris carpi digitorum
Thenar
muscles Hypothenar
muscles
The muscles of upper limb
Muscles of the lower limbs

Muscles Location
Sartorius Origin : Antero-superior iliac spine
Insertion : Medial surface of tibia
Rectus femoris Origin : Antero-inferior iliac spine
Insertion : Patella by tendon
Vastus lateral Origin : Linea aspera
and median Insertion : Patella by tendon
Gastrocneumius Origin : Lateral and medial epicondyle of femur
Insertion : Posterior surface of calcaneus
Soleus Origin : Posterior aspect of fibula and tibia
Insertion : Calcaneus
Tibialis anterior Origin : Lateral condyle of tibia
Insertion : First metarsal and tarsal
Psoas
Gluteal
Sartorius muscles
Rectus femeris
Hamstring
muscles
Vastus
lateralis
medialis
Patella and Gastrocnemius

tendon
Soleus
Anterior
tibialis Calcanean
tendon
The muscles of lower limb
Pathology
Neuromuscular disorder
Some bacteria cause disease by producing toxins. A neurotoxin is a chemical
that in some way disrupts the normal functioning of the nervous system. Because
skeletal muscle contraction depends on nerve impulses, the serious
consequences for the individual may be seen in the muscular system.
Tetanus
• Tetanus is characterized by the inability of muscles to relax. The toxin
produced by the tetanus bacteria (Clostridium tetani) affects the nervous
system in such a way that muscle fibers receive too many impulses, and
muscles go into spasms.
• Symptom : Lockjaw (Trismus), dysphagia, neck stiffness, opisthotonos,
central contraction but peripheral flaccid, photophobia, phonophobia.
• Treatment requires the antitoxin (SAT or TIG) to neutralize the toxin. In
untreated tetanus the cause of death is spasm of the respiratory muscles.
Botulism
• Botulism is usually a type of food poisoning, but it is not characterized by
typical food poisoning symptoms such as diarrhea or vomiting. The
neurotoxin produced by the botulism bacteria (Clostridium botulinum)
prevents the release of acetylcholine at neuromuscular junctions. Without
acetylcholine, muscle fibers cannot contract, and muscles become
paralyzed.
• Symptoms of botulism include : Diplopia, dry mouth, dysphagia, dilated
pupils, digestive symptoms.
• Treatment with the antitoxin (The specific antibody to this toxin), botulism
is fatal because of paralysis of the respiratory muscles.
Myasthenia gravis
Myasthenia gravis
• Myasthenia gravis is an autoimmune disorder characterized by extreme
muscle fatigue even after minimal exertion. Women are affected more
often than are men. Cause by acetylcholine receptor antibody and block of
neuromuscular
• Symptom : Ptosis, diplosia, dysphagia, facial weakness and arthralgia
• Treatment of myasthenia gravis may involve anticholinesterase (Neo-
stigmin) and corticoid or azathioprim. If severe form should be
thymectomy.
The Skeletal System
________________________________________
Structure and function of bone
The skeletal system consist of bones, cartilage, and joints. The functions of the
skeletal system fall into five categories.
1. Support
2. Protection
3. Movement
4. Hemopoiesis
5. Mineral and energy storage
Bone formation
• Osteogenic cells are progenitor cells that give rise to all bones cells
• Osteoblasts are the principle bone building cells, they synthesize the
collagenous fibers and bone matrix and promote mineralization during
ossification.
• Osteoclasts are bone dystroying cells that contain lysosomes and phagocytic
vacuoles thal demineralize bone tissue.
Classification of bones
• Long bones : The bones of the arms, legs, hands, and feet (but not the wrists
and ankles). The shaft of a long bone is the diaphysis, and the ends are called
epiphyses. Although red bone marrow is present in the epiphyses of children’s
bones, it is largely replaced by yellow bone marrow in adult bones.
• Short bones : The bones of the wrists and ankles.
• Flat bones : The ribs, shoulder blades, hip bones, and cranial bones.
• Irregular bones : The vertebrae and facial bones.
The bones of skeleton are divided into two groups
• The axial skeleton : Skull, vertebral column, ribs and sternum.
• The appendicular skeleton : Shoulder girdle, upper and low limbs, pelvic girdle
Proximal epiphysis
Diaphysis
Bone marrow
Marrow (Medullary) cavity
Compact bone
Distal epiphysis Periosteum
Spongy bone
Axial skeleton The structure of bone

• The skull consists of 8 cranial bones and 14 facial bones. Also in the head
are three small bones in each middle ear cavity and the hyoid bone that
supports the base of the tongue.
• The cranial bones form the braincase (lined with the meninges) that encloses
and protects the brain, eyes, and ears. The names of some of these bones will
be familiar to you; they are the same as the terminology used to describe
areas of the head. These are the frontal bone, parietal bones (two), temporal
bones (two), and occipital bone.The sphenoid bone and ethmoid bone are
part of the floor of the braincase and the orbits (sockets) for the eyes.
• The frontal bone forms the forehead and the anterior part of the top of the
skull. Joint formed between the frontal bone and the parietal bones is called
coronal suture. The frontal bone froms other improvable joints with the
sphenoid, zygomatic, lacrimal, nasal and ethmoid bones.
• The parietal means “wall,” and the two large parietal bones form the posterior
top and much of the side walls of the skull. They articulate with each other at
the sagittal suture, with the frontal bone at the coronal suture, with the occipital
bone at the lambdoidal suture and with the temporal bones at the squamous
sutures. The inner surface is concave and is grooved by the brain and blood
vessels.
• The temporal bone on the side of the head and from immovable joints with
the parietal, occipital, sphenoid and zygomatic bones. Each temporal bone is
divided into four parts : Squamous part, mastoid process, petrous portion,
zygomatic process.
Parietal bone
Frontal bone
Temperal bone
Occipital bone Nasal bone

Ethmoid bone
Lacrimal bone
Sphenoid bone
Lambdoidal suture Zygomatic bone
Squamous suture
Maxilla bone
Mastoid process
Coronal suture Condyloid process
Styloid process
Mandibula nocth
Mandible
Coronoid process
The bones of skull and their suture
Sinuses
• Sinuses are lighten the bones of the face and cranium. They are all in
communication with upper air passages and are lined with ciliated mucous
membrane. There are maxillary, ethmoid, sphenoid and frontal sinuses.
• Function
- Air warmed
- Secretion drainage
- To give resonance to the voice
Face bone
The are 13 bones which from the skeleton of the face but for completeness, the
frontal bone which has already been described should be added
• 2 zygomatic or cheek bones
• 1 maxilla (Originated as 2)
• 2 nasal bones
• 2 lacrimal bones
• 1 vomer
• 2 palatine bones (L-shaped)
• 2 inferior conchae or turbinated bones
• 1 mandible
Hyoid bone
This is an isolated horse-shoe-shaped bone lying in the soft tissue of the neck just
about the larynx and below the mandible. it doesn’t articulate with any other bone but
is attached to the styloid process of the temporal bone by ligaments. It gives
attachment to the base of tongue.
Frontal bone
Coronal suture Frontal sinus
Parietal bone Lacrimal bone
Sphenoid
Temporal bone
Ethmoid
Nasal bone
Zygomatic bone Vomer
Maxillar Nasal concha
Mandible bone
The bones of face (Anterior view)
Vertebral column
The vertebral column supports and permits movement of the head and trunk and
provides a site for muscle attachment. The vertebrae also support and protect the
spinal cord and permit the passage of spinal nerves. There are
• 7 cervical vertebrae
• 12 thoracic
• 5 lumbar
• 4 to 5 sacral fused into 1 sacrum
• 4 to 5 small coccygeal vertebrae fused into 1 coccyx
• The seven cervical vertebrae are those within the neck. The first vertebra is
called the atlas, which articulates with the occipital bone to support the skull
and forms a pivot joint with the odontoid process of the axis, the second
cervical vertebra. This pivot joint allows us to turn our heads from side to side.
The remaining five cervical vertebrae do not have individual names.
• The thoracic vertebrae articulate (Form joints) with the ribs on the posterior
side of the trunk. The lumbar vertebrae, the largest and strongest bones of
the spine, are found in the small of the back. The sacrum permits the
articulation of the two hip bones : the sacroiliac joints. The coccyx is the
remnant of tail vertebrae, and some muscles of the perineum (Pelvic floor) are
anchored to it.
• The lumbar vertebrae are the largest and the vertebral foramina are the
smallest. The spinous processes are the short, flat-sided and project back.
• The sacrum, There are five vertebrae fused to form a wedge-shaped bone
with a concave anterior surface. The upper part attached with the fifth lumbar
vertebra. On each side it articulates with the ilium to form a sacroiliac joint,
The first sacrum into the pelvic cavity is called the promontory.
• The coccyx , The are 4 to 5 terminal vertebrae fused and very small
triangular bone the broad base of which articulates with the tip of the sacrum.
7 Cervical
vertebrae Odontoid process
of axia
Atlas
12 Thoracic
vertebrae Axis
Spine of axis
Body of
7th thoracic Pedicle
5 Lumbar
vertebrae Transver
process
Spinous
Sacrum Faces for ribs process
articulation
Coccyx
1st lumbar
The vertebral column (Lateral view)

Rib and sternum
The rib cage consists of the 12 pairs of ribs and the sternum, or breastbone. The
three parts of the sternum are the upper manubrium, the central body, and the lower
xiphoid process.
• All of the ribs articulate posteriorly with the thoracic vertebrae. The first seven
pairs of ribs are called true ribs; they articulate directly with the manubrium
and body of the sternum by means of costal cartilages.
• The next three pairs are called false ribs; their cartilages cartilages join the 7th
rib cartilage. The last two pairs are called floating ribs because they do not
articulate with the sternum at all.
• An obvious function of the rib cage is that it encloses and protects the heart
and lungs. Keep in mind, though, that the rib cage also protects organs in the
upper abdominal cavity, such as the liver and spleen.
• The other important function of the rib cage depends upon its flexibility: The
ribs are pulled upward and outward by the external intercostal muscles. This
enlarges the chest cavity, which expands the lungs and contributes to
inhalation.
7th cervical
vertebral
Ribs Manubrium
of sternum
Costal Body of
cartilages sternum
Xiphoid process
of sternum
Rib 11 12th Thoracic

vertebral
Rib 12 1st Lumbar
The thoracic cage (Anterior view)
Appendicular skeleton
Shoulder girdle, Each shoulder girdle consists of the following bones
• 1 clavicle or collar bone is a long bone which attached sternum to acromial
process
• 1 scapula or shoulder blade is a flat triangular-shaped bone which lies on the
posterior chest wall . It is described as having : 3 borders, 3 angles, 3 fossae
Upper limb, Each shoulder girdle consists of the following bones
• 1 humerus
• 1 radius
• 1 ulna
• 8 carpal bones
• 5 metacarpal bones
• 14 phalanges
Acromial end
Acromial process
Sternum end
Coracoid process
Clavicle
Humerus
Scapula
Radius Ulna
8 carpal bones
- Lunate
- Triquetrum
- Pisiform 5 metacarpal bones
- Hamate
- Scapoid 14 phalange bones
- Trapezum
- Trapezoid
- Capitate
The right shoulder girdle and upper limb
Pelvic girdle
The pelvic girdle is formed by two ossa coxae united anteriorly by the symphysis
pubic. It is attached posteriorly to the sacrum of the vertebral column at the
sacroiliac joint. Each os coxae (Hipbone) :
• Ilium
• Ischium
• Pubis
Sacroiliac joint
Pubic symphysis The bones of the pelvis
Iliac crest
Ilium
Pelvis
Sacrum
Coccy Acetabulum
x Pubis
Ischium Obturator
foramen
Lower limb
The lower extremity is divided into the thigh and the leg. The femur is the only bone
of the thigh. The kneecap (Patella) is the sesamoid bone (Tendon) of the anterior
knee region. The tibia and fibula are the bone of the leg. The distal end of the tibia
articulates with the talus in the ankle.
Tarsal or angle bones
There are seven tarsal bones which from the posterior part of the foot. They are :
• 1 talus
• 1 calcaneus
• 1 navicular
• 3 cuneiform
• 1 cuboid
Pelvis
Head of femur
Obturator Greater trochanter
foramen Lesser trochanter
Surgical
Neck
Femur
Patella
Tibia Fibula
Navicular
3 cuneiform
Talus
Calcaneus
Cuboid
14 phalanges
5 metatarsal
The bones of the foot
Articulation
Articulations or joints, may be classified according to structure or function. In the
structural classification, a joint is fibrous, cartilaginous, or synovial. The function
classification distinguishes synarthroses (Immovable joints), amphiarthroses (Slightly
movable joints), and diarthroses (Freely movable joints)
Hormone involved in bone growth

Growth hormone • Increases the rate of mitosis of chondrocytes and
(Anterior pituitary gland) osteoblasts
• Increases the rate of protein synthesis (collagen,
cartilage matrix, and enzymes for cartilage and bone
formation)
Thyroxin (Thyroid gland) • Increases the rate of protein synthesis
• Increases energy production from all food types
Insulin (Pancreas) • Increases energy production from glucose
Parathyroid hormone • Increases the reabsorption of calcium from bones to
(Parathyroid glands) the blood (Raises blood calcium level)
• Increases the absorption of calcium by the small
intestine and kidneys
Calcitonin (Thyroid gland) • Decreases the reabsorption of calcium from bones
(lowers blood calcium level)
Estrogen (Ovaries) • Promotes closure of the epiphyses of long bones
(growth stops)
Testosterone (Testes) • Helps retain calcium in bones to maintain a strong
bone matrix
Fracture of bone
A fracture means that a bone has been broken. Pathologic (Spontaneous) a bone
breaks without apparent trauma, may accompany bone disorders such as
osteoporosis. There are different types of fractures classified as to extent of damage.
• Simple (Closed fracture), the broken parts are still in normal anatomic
position; surrounding tissue damage is minimal (skin is not pierced).
• Compound (Open fracture), the broken end of a bone has been moved, and
it pierces the skin; there may be extensive damage to surrounding blood
vessels, nerves, and muscles.
• Greenstick, the bone splits longitudinally. The bones of children contain more
collagen than do adult bones and tend to splinter rather than break
completely.
• Comminuted, two or more intersecting breaks create several bone fragments.
• Impacted, the broken ends of a bone are forced into one another; many bone
fragments may be created.
The Repair Process
• Fragments of dead or damaged bone must first be removed.
• The repair process is usually relatively rapid, and a simple fracture often heals
within 6 weeks. Some parts of bones, however, have a poor blood supply, and
repair of fractures takes longer.
• Other factors that influence repair include the age of the person, general state
of health and nutrition.
Herniated Disc
• The terms herniated disc or ruptured disc more accurately describe what
happens. The nucleus pulposus is forced out, often posteriorly, where it puts
pressure on a spinal nerve. For this reason a herniated disc may be very
painful or impair function in the muscles supplied by the nerve.
• Healing of a herniated disc may occur naturally if the damage is not severe
and the person rests and avoids activities that would further compress the
disc.
• Surgery may be required, however, to remove the portion of the nucleus
pulposus that is out of place and disrupting nerve functioning.
34
D-ork-L
The Urinary Tract System

________________________________________
Aorta
Rib
Inferior vena cava
Right adrenal gland
Left kidney
Right kidney Left renal artery

and vein
Abdominal aorta Left ureter
Superior vena cava
Left common iliac
Psoas major muscle artery and vein
Iliacus muscle
Pelvic Bladder
Urinary tract system
Component of urinary tract system

• The urinary system is one of the excretory systems of the body. It regulates
the composition of body fluids (Water balance, electrolyte balance, and acid-
base balance). It also rids the body of metabolic wastes and foreign matter
(Chemical, drugs).
• Component : 2 kidneys, 2 ureters, 1 bladder, 1 urethra
Anatomy Function
Kidneys Function of the kidneys
• The two kidneys, bean-shaped, • Passes the urine from pelvic
11cm-long and 6cm-wide calyces through the ureters to the
• It lies on the posterior of bladder for excretion.
abdominal wall, between the 12th Nephron : 3 phases of formation urine
rib to the 3th lumbar vertebral • Simple filtration
(Retroperitoneal). • Selective reabsorption
• There are a few minor calyces in • Secretion
the major calyx, 3-5 major calyces
in pelvic.
• There are over 1 million nephrons
per kidney.
Ureters
• The two tubes which convey the • The intrinsic function is not under
urine from the kidneys to the nerve control.
bladder. • Peristalsis is stimulated by
• Long tube : 25-30 cm, diameter : presence of urine in the ureter and
6-5-4 mm the stretch effect stimulates the
• Structure : Outer coat-fibrous syncytium of muscle.
tissue, middle layer-muscular,
inner-mucous membrane
Urinary bladder Bladder
• It lies in the pelvic cavity at • Urinary bladder is reservoir of
symphysis pubic and anterior to urine.
the rectum. • When approximately 200-300 mL
• Structure : Pear-shaped, four layer of urine. It stimulates the
- Peritoneum covers (Serosa) autonomic nerve endings within
- Muscle layer ( Muscularis) the bladder wall to pass of urine.
- Submucous coat (Submucosa) • Empty of bladder, sphincter of
- Mucous membrane (Mucosa) bladder is closed.
• The floor of the bladder is a • If nerve deficiency or obstruction
triangular area called the trigone. or infant micturition occurs by
• The three orifices in the bladder. reflex action.
The upper two orifices on the Micturition
posterior wall are the openings of • Micturition occurs when the
the two ureters and inferior orifice muscle of bladder contracts, the
to urethra. internal sphincter dilates and the
• Volume 200-300 mL of urine external sphincter relaxes.
• The abdominal muscle
contruction, increased pelvic
cavity pressure.
• Over distension of the bladder
sends signals via sensory
neurons to the spinal cord and up
to the brain.
Urethra In male
• The urethra is a canal which • The spongy urethra also carries
extends from the neck of bladder. during ejaculation.
• Female is about 4 cm, and that of • The first part is surrounded by the
a male about 20 cm long. prostate gland and is called the
• The thee layer : Muscular coat, prostatic urethra.
spongy coat and mucous
membrane.
• The internal sphincter, composed
of smooth muscle, and external
sphincter, of skeletal muscle.
Nephron and Function

Nephron function, over 1 million nephrons per a kidney
• Simple filtration : Fluid and blood plasma, through the basement membrane
(Glomerular capsule) can pass to proximal tube (< 5600 moles) and afferent
arteriole hydrostatic pressure about 70 mmHg with glomerular capsule
pressure about 5 mmHg.
• Selective reabsorption : 100 percent of the filtrate is reabsorption 99%
(Glucose 100%, sodium 99.5%, urea 50%), about 1percent is excreted as
urine.
• Secretion : Filtration occurs as blood flows through the glomerulus about
180L. Secreted water, urea, potassium, sodium, chlorides, creatinin, ammonia,
drug, toxin. Normal urine output about 0.5-1mL/kg/h.
Component of the nephron
• Glomerulus : Site of glomerular filtration
• Proximal convoluted tubule : Reabsorption tube
• Loop of Henle : Urine concentration
• Distal convoluted tubule : Absorb sodium and excrete potassium
• Collecting tubule : Urine regulated by antidiuretic hormone (ADH)
Glomerular Bowman's capsule

Efferent artery
Proximal tubule
Afferent artery
Distal tubule
Collecting tubule
Artery
Loop of Henle Vein
Nephron
Adrenal glands
Adrenal cortex
• Glucocorticoids (Corticosterone and cortisol) :
- Regulation of carbohydrate and lipid metabolism, breakdown of proteins
- Inhibited inflammatory responses
- Help the body resistance with stress
- Vasoconstriction
• Mineralocorticoids (Deoxycorticosterone and aldosterone) : Regulate
concentration of extracellular electrolytes, especially sodium and potassium.
Aldosterone secretion controlled by the renin-angiotesin system, plasma
potassium concentration, and ACTH.
Adrenal medulla
• Amine hormones (Epinephrine and norepinephrine) : Release stimulated
by sympathetic stimulation. Increases release of ACTH and TSH from the
adenohypophysis.
Decreased blood pressure Stimulates juxtaglomerular Angiotensin
or dehydration of kidney to secrete renin (Plasma protein)
Adrenal gland Angiotensin II converting Angiotensin I

(Adrenal cortex) (Lung and vascular epithelium) (Liver)
Increased BP Aldosterone (Absorb Na+ and excrete K+)
Erythroporietin
Anemia is one of the most debilitating consequences of renal failure, one that
hemodialysis can not reverse. Diseased kidneys stop producing erythropoietin, a
natural stimulus for RBC production. Erythropoietin can be produced by genetic
engineering and is available for hemodialysis patients. In the past, their anemia could
only be treated with transfusions, which exposed these patients to possible
immunologic complications of repeated exposure to donated blood or to viral
diseases. The synthetic erythropoietin eliminates such risks. Others who benefit from
this medication are cancer patients and AIDS patients with severe anemia.
Contents of urine
Blood Daily filtration Actual excretion
Water 180 liter 1.5 liter
Salts 700 g 15 g
Glucose 170 g 0
Urea 50 g 30 g
Urine
• Daily output 1200 to 1500 mL
• 95 % water, 5 % salts & organic matter
• Urea, uric acid, salts of potassium, magnesium and calcium
Endocrinology
________________________________________
Pituitary gland
Anatomy and physiology
• On the inferior side of the brain
• 2 divided lobes
- Anterior lobe : Adenohypophysis
- Posterior lobe : Neurohypophysis
Anterior lobe (Antero-hypophysis) secreted by the adenohypophysis
• Human growth hormone (HGH) : Targets the bones and soft tissue.
Action : Stimulating amino acid, synthesis of tRNA, increased the number of
ribosomes.
• Thyroid stimulating hormone (TSH) : Targets the thyroid gland. Stimulates
synthesis and release of thyroid hormones.
• Adrenocorticotropic hormone (ACTH) : Targets the adrenal cortex.
Stimulates and secretion of glucocorticoids.
• Prolactin (PRL) : Targets the mammary glands. Promotes development of
mammary glands , production of milk.
• Follicle stimulating hormone (FSH) : Targets the ovaries and testes.
Stimulates growth of ovarian follicles and spermatogenesis.
• Luteinizing hormone (ADH) : Targets the ovaries and testes. Stimulates
maturation of follicles, estrogen and progesterone in females. Secreted
testosterone in males.
Posterior lobe (Post-hypophysis) secreted by the neurohypophysis
• Antidiuretic hormone (ADH) : Targets the kidney collecting duct. Release
stimulated when dehydration or increased plasma osmolarity.
• Oxytocin : Targets the uterus and mammary glands. Secretion of milk and
uterus contraction during delivery.
Adrenal glands
Adrenal cortex
• Glucocorticoids (Corticosterone and cortisol) :
- Regulation of carbohydrate and lipid metabolism, breakdown of proteins
- Inhibited inflammatory responses
- Help the body resistance with stress
- Vasoconstriction
• Mineralocorticoids (Deoxycorticosterone and aldosterone) : Regulate
concentration of extracellular electrolytes, especially sodium and potassium.
Aldosterone secretion controlled by the renin-angiotesin system, plasma
potassium concentration, and ACTH.
Adrenal medulla
• Amine hormones (Epinephrine and norepinephrine) : Release stimulated
by sympathetic stimulation. Increases release of ACTH and TSH from the
adenohypophysis.
Decreased blood pressure Stimulates juxtaglomerular Angiotensin
or dehydration of kidney to secrete renin (Plasma protein)
Adrenal gland Angiotensin II converting Angiotensin I

(Adrenal cortex) (Lung and vascular epithelium) (Liver)
Increased BP Aldosterone (Absorb Na+ and excrete K+)
Thyroid gland
Anatomy : Located in the neck on either side of the thyroid cartilage at the top of the
trachea
Physiology : Secreted of triodothyronine (T3) and tetraiodotyrosine (T4 or
Thyroxine) are secreted under the stimulation of TSH from the pituitary.
• The hormone accelerate metabolic rate
• Oxygen consumption
• Glucose absorption
• Increased body temperature
• Body growth and development
Parathyroid glands
Anatomy : Small glands and posterior surface of the thyroid gland, 4-glands.
Physiology : Secreted of Parathyroid hormone (PTH) : Increased plasma calcium l
• Osteoclasts : Break down bone tissue, release calcium from the bones into the
blood
• Increased calcium reabsorption by kidney
• Absorption calcium from GI tyract
• Increased synthesis of 1/25-dihydroxycholecalferol
Pancreatic hormone
• Glugagon : Secreted by alpha cells, increased blood glucose.
• Insulin : Secreted by beta cells, decreased blood glucose.
• Somatostatin : Secreted by delta cells, cartilage and collage formation.
Other glands secrete endocrine

Placenta
• Secreted human chorionic gonadotropin (hCG)
• Secreted human somatomammatropin (hCS) : Developing of mammary gland
• Estrogens and progesterone : Steroid hormone
Hormone effects on the mammary glands
• Estrogen : Secreted by follicle of ovary, promotes growth of duct system.
• Progesterone : Secreted by corpus luteum, promotes growth of secretory cells.
• Prolactin : Secreted by anterior pituitary gland, promotes production of milks.
• Oxytocin :Secreted by posterior pituitary gland, promotes release of milk.
Thymus
• Secreted thymosin
• Stimulated T-lymphocyte activity
Pineal gland : Secreted melatonin, affects secretion of gonadotropins and ACTH.
Gastric mucosa : G cell secrete gastric juice.
Duodenal mucosa : Secretes secretin, stimulates secretion of pancreatic juice.
The Respiratory System
________________________________________
Respiration
• Respiratory means ventilation or breast, all cells require a continuous supply
of oxygen and must continuously eliminate a metabolic waste product, carbon
dioxide.
• The organs of the respiratory systems are
- The nose
- The pharynx
- The larynx
- The trachea
- Two bronchi (Bronchus)
- The bronchioles
- Alveoli
Sinus frontal
Sphenoid bone
Nasal bone
Nasopharynx
Nasal cavity Soft palate and
Maxilla uvula
Palatine tonsil
Hard palate
Epiglottis
Tongue
Laryngopharynx
Mandible
bone Esophagus
Nasal cavity and upper airway
Upper Respiratory Tract

Nose
• Nasal cavity is olfactory epithelium and pseudostratified ciliated columnar
epithelium.
• The structure middle is nasal superior septum and inferior nasal is conchea.
• The function : Olfaction and warm the inspired air
Pharynx
• The pharynx is a muscular tube posterior to the nasal and oral cavities and
anterior to the cervical vertebrae, three are three parts : the nasopharynx,
oropharynx, and laryngopharyn.
• The uppermost portion is the nasopharynx, which is behind the nasal cavities.
The soft palate is elevated during swallowing to block the nasopharynx and
prevent food or saliva from going up rather than down.
• The uvula is the part of the soft palate you can see at the back of the throat.
On the posterior wall of the nasopharynx is the adenoid or pharyngeal tonsil, a
lymph nodule that contains macrophages. Opening into the nasopharynx are
the two eustachian tubes, which extend to the middle ear cavities.
• The laryngopharynx is the most inferior portion of the pharynx. It opens
anteriorly into the larynx and posteriorly into the esophagus. Contraction of the
muscular wall of the oropharynx and laryngopharynx is part of the swallowing
reflex.
Larynx
• The larynx is often called the voice box, a name that indicates one of its
functions, which is speaking. The other function of the larynx is to be an air
passageway between the pharynx and the trachea. Air passages must be kept
open at all times, and so the larynx is made of nine pieces of cartilage
connected by ligaments.
• The vocal cords (or vocal folds) are on either side of the glottis, the opening
between them.
- During breathing, the vocal cords are held at the sides of the glottis, so
that air passes freely into and out of the trachea.
- During speaking, the intrinsic muscles of the larynx pull the vocal cords
across the glottis, and exhaled air vibrates the vocal cords to produce
sounds that can be turned into speech. It is also physically possible to
speak while inhaling, but this is not what we are used to.
- The cranial nerves that are motor nerves to the larynx for speaking are
the vagus and accessory nerves. You may also recall that for most
people, the speech areas are in the left cerebral hemisphere.
Trachea and Bronchial Tree
• Structures : Trachea branches into right and left primary bronchi, further
branching into secondary bronchi, tertiary bronchi, and bronchioles.
• Tissues : Cartilaginous rings, lined with mucous secreting pseudostratified
ciliated columnar epithelium. Cartilaginous rings hold passages open.
• Trachea into the bronchus : 10cm long and C-shaped
Hyoid bone
Epiglottis
Thyroid
Epiglottis
gland
Thyroid
cartilage
Vocal cords
Trachea
Cricoid
cartilage
cartilage
Larynx and trachea

Lower Respiratory Tract
Bronchi
• The two bronchi commence when the trachea divides, that is at about the level
of the 5th thoracic vertebra
• The left bronchus is about 5cm long and the right bronchus is a wider, short
tube than the left bronchus.
Bronchioles and alveoli
• There is no clear anatomical divided between bronchi and bronchioles.
• The larger bronchioles are composed of muscle tissue, fibrous tissues and
elastic tissue with ciliated columnar epithelium.
• The alveolar ducts then lead into minute sac-like structure known as the
alveoli. It is here that interchange of gases takes place between the air in the
alveoli and the blood in the capillaries, which are also composed of a single
layer of flattened epithelial cells.
Lungs and pleura
• There are two lungs within thoracic cavity, separated from each other by the
mediastinum.
• The left lung has a cardiac notch on its medial surface. It is subdivided into
two lobes by a single fissure and contains eight bronchial segment.
• The right lung is subdivided into three lobes by two fissure, and contains ten
bronchial segment.
• The lungs are surrounded by a two-layer serous membrane. The inner layer,
visceral pleura, is attached to the surface of the lung and the outer layer,
parietal pleura, lines the thoracic cavity.
Mechanics of breathing
• Inspiration occurs when contraction of the inspiratory muscles causes an
increase in thoracic volume, with expiration of the lungs and a decrease in
intrathoracic and intrapulmonic (Alveolar) pressure. Air enters the lungs when
intrapulmonic pressure falls below atmospheric pressure (760 mmHg at sea
level). Expiration follows passively, causing thoracic volume and decrease
and intrapulmonic pressure to rise.
• Muscles of breathing
The cycle of respiratory, about 15 times per minute, consists of three phases :
- Inspiration : Diaphragm and external intercostal muscles
- Expiration : Passive recoil of inspiratory muscles
- Forced expiration (Pause) : Internal intercostals and abdominal muscles
• Alveolar ventilation
- Tidal volume : 400 mL
- Dead space volume : 150 mL
- Vital capacity : 4500 mL
- Total lung capacity : 6000 mL
- Residual volume : 1350 mL
- Expiratory reserve : 1500 mL
- Inspiratory capacity : 3000 mL
- Respiratory rate : 15 / mn
Alveolar ventilation : RR (tidal volume – dead space volume) mL
: 15 (400-150) : 3.75 litres per minute
Gases in respiratory O2 N2 CO2
Inspired air 21% 79% 0
Exhaled air 16% 79% 5%
Arteriole
Pulmonary
capillaries
Nose Alveolar duct
Pharynx
Alveolar
Epiglottis
Larynx
Venous
Trachea
Upper lobe Pleura
R-bronchus
L-bronchus
Middle lobe
Mediastinum
space
Lower lobe
Heart space
Diaphragm
The organs of respiration
Sternum
Lung
Diaphragm
Inhalation Exhalation
The Reproductive System
________________________________________
Sex determination
XX = Female, all ova produced contain a single X chromosome
XY = Male, equal number of X and Y spermatozoa are produced
Sex of offspring determined by whether the fertilizing spermatozoa is X-bearing or Y-
bearing.
Peritoneum
Urinary
bladder
Sacrum
Deferent
ducts Rectum
Corpus Seminal vesicle

cavernosa
Corpus Prostate gland
spongiosum
Anus
Glans
penis Testis
Prepuce
The male reproductive organs in the pelvis

Male Reproductive System
The male reproductive consists of following organs
• 2 testes
• 2 epididymides
• 2 deferent ducts and spermatic cords
• 2 seminal vesicles
• 2 ejaculatory ducts
• 1 prostate gland
• 1 penis
Scrotum is a pouch of deeply pigment skin divided into two compartments each of
which contains one testes, one epididymis and the testicular end of a spermatic cord.
It lies below the symphysis pubis, and in front of the upper parts of the thighs behind
the penis.
Testes are approximately 4.5 cm long, 2.5 cm wide and 3 cm thick. Surrounded by 3
layers
• Tunica vaginalis is outer covering of testes and downgrowth of the abdominal
and pelvic peritoneum.
• Tunica albuginea is a fibrous covering that under tunica vaginalis and is a
septa dividing of the testes into lobules.
• Tunica vasculosa consists of a network of capillaries
Epididymis (Plural: epididymides) is a tube about 20 feet (6 m) long that is coiled on
the posterior surface of each testis. Within the epididymis the sperm complete their
maturation, and their flagella become functional. Smooth muscle in the wall of the
epididymis propels the sperm into the ductus deferens.
Spermatic cord suspends the testes in the scrotum, that passes through the
inguinlal canal. Fine connective tissue surrounds : Testicular artery, testicular vein,
lymph drainage, deferent duct, nerve. One spermatozoa are mature, they pass
through a series of tubular during ejaculation.
Seminal vesicles are two pouches which lie on the posterior aspect of the bladder. 5
cm long and roughly pyramidal in shape. Their secretion contains fructose to provide
an energy source for sperm and is alkaline to enhance sperm motility. The duct of
each seminal vesicle joins the ductus deferens on that side to form the ejaculatory
duct.
Ejaculatory duct, Each of the two ejaculatory ducts receives sperm from the ductus
deferens and the secretion of the seminal vesicle on its own side. Both ejaculatory
ducts empty into the single urethra. The ejaculatory are approximately 2 cm long, and
3 layers : Fibrous, muscular and locumnar epithelial tissue.
Prostate gland, A muscular gland just below the urinary bladder, the prostate gland
is about 1.2 inches high by 1.6 inches wide by 0.8 inch deep (3 cm by 4 cm by 2 cm,
about the size of a walnut). It surrounds the first inch of the urethra as it emerges
from the bladder. The glandular tissue of the prostate secretes an alkaline which
passes into the urethra through numerous ducts.
Urethra and Penis
• The urethra is the last of the ducts through which semen travels, and its
longest portion is enclosed within the penis.
• The penis is an external genital organ, its distal end is called the glans penis
and is covered with a fold of skin called the prepuce or foreskin. Circumcision
is the surgical removal of the foreskin
Testicular artery
Spermatic cord
Vein
Nerve
Deferent duct
Head of epididymis
Rete testis
Septum of testis
Epididyme
Convoluted
seminiferous
tubular
Tunica vasculosa
Tunica albuginea
Tunica vaginalis
Muscle
Midsagittal section of portion of a testis
46
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Male Hormone Reproductive

Hormone Secreted by Functions
FSH Anterior pituitary • Initiates production of sperm in the testes
LH (ICSH) Anterior pituitary • Stimulates secretion of testosterone by
testes
Testosterone Testes (interstitial cells) • Promotes maturation of sperm
• Initiates development of the secondary
sex characteristics:
- Growth of the reproductive organs
- Growth of the larynx
- Growth of facial and body hair
- Increased protein synthesis, especially
in skeletal muscles
Inhibin Testes (sustentacular • Decreases secretion of FSH to maintain

cells) constant rate of spermatogenesis
Uterine
tube Ovary
Peritoneum
Uterus
Ureter
Symphysis pubic Cervix
Urinary
bladder Rectum
Clitoris
Vagina
Urethra
Labium Labium Bartholin

majora minora gland
The female reproductive organs in the pelvis
Female Reproductive System

The primary female sex organs are the ovaries. Secondary female sex organs
develop prenatally and during puberty they mature and become functional under the
influence of estrogens secreted by the ovaries.
The female reproductive organs are divided into two groups
• The external genitalia
• The internal genitalia
The external genitalia
• Labia majora (Labia majus)
• Labia minora (Labia minus)
• Clitoris
• Vestibular and greater vestibular glands
• Hymen
Internal genitalia
• Vagina
• Uterus
• 2 uterine tube
• 2 ovaries
Vagina
• The vagina extends from the cervix to the vaginal opening of the external
genitalia. It coveys uterine secretions to outside the body, and receives the
erect penis and semen during coitus.
• The vaginal wall has longitudinal fold, vaginal rugae, which allow for
distension of vagina.
Ovaries
• The ovaries are a pair of oval structures about 1.5 inches (4 cm) long on either
side of the uterus in the pelvic cavity. The ovarian ligament extends from the
medial side of an ovary to the uterine wall, and the broad ligament is a fold of
the peri-toneum that covers the ovaries. These ligaments help keep the
ovaries in place.
• In the outer region of each ovary are tiny masses of cells, called primary
follicles, each of which contains an immature egg. During a woman’s
childbearing years, only 300 to 400 of these follicles will produce mature ova.
The ovary releases the ovum is called ovulation
• After ovulation, if not fertilization, corpus luteum secreted progesterone and
estrogens which supported on the uterine endometrium for menstrual cycle.
Uterine
• The uterus is shaped like an upside-down pear, about 3 inches long by 2
inches wide by 1 inch deep (7.5 cm by 5 cm by 2.5 cm) and weigh about 50g,
superior to the urinary bladder and between the two ovaries in the pelvic
cavity. The broad ligament also covers the uterus.
• Three layers : Perimetrium, myometrium, endometrium
• During pregnancy the uterus increases greatly in size, contains the placenta to
nourish the embryo-fetus, and expels the baby at the end of gestation.
Fallopain tubes (Uterine tubes)
• There two uterine tubes extend from the ovaries to the uterus each is about 4
inches (10 cm) long. They function to convey the ova toward the uterus and as
the site of fertilization and early development.
• Fertilization usually takes place in the fallopian tube (About 1/3 external of
tube : Ampulla). If not fertilized, an ovum dies within 24 to 48 hours and
disintegrates, either in the tube or the uterus. If fertilized, the ovum becomes a
zygote and is swept into the uterus; this takes about 4 to 5 days.
Uterine tube Fundus of uterus Fibriae
(Fallopain)
Ampulla
Body of uterus
Ovary Endometrium
Myometrium
Broad
ligament Cervix of uterus
Round Vagina rugae

ligament
Section of the uterus
Hormone of mammary glands

Estrogen • Ovary (Follicle) and placenta • Promotes growth of duct system
Progesterone • Ovary (Corpus luteum) and • Promotes growth of secretory
placenta cells
Prolactin • Anterior pituitary • Promotes production of milk
Oxytocin • Posterior pituitary (hypotha lamus) • Promotes release of milk
Skin
Adipose tissue Rib
Areola
Pectoralis major
muscle
Nipple
Lactiferous
duct Intercostal muscles
Lactiferous
glands
Mammary gland shown in a midsagittal section.

Female Hormone Productyive
FSH • Anterior pituitary • Initiates development of ovarian follicles
• Stimulates secretion of estrogen by follicle
LH • Anterior pituitary • Causes ovulationand converts the ruptured

ovarian follicle into the corpus luteum
• Stimulates secretion of progesterone by the
corpus luteum
• Promotes maturation of ovarian follicles
Estrogen • Ovary (Follicle) • Promotes growth of vessels in endometrium
• Placenta during • Initiates development of the secondary sex
pregnancy characteristics:
- Growth of the uterus and other reproductive
organs
- Growth of the mammary ducts and fat
deposition in the breasts
- Broadening of the pelvic bone
- Subcutaneous fat deposition in hips and
thighs
Progesterone • Ovary (Corpus luteum) • Promotes further growth of blood vessels in
• Placenta during the endometrium and storage of nutrients
pregnancy • Inhibits contractions of the myometrium
Inhibin • Ovary (Corpus luteum) • Inhibits secretion of FSH
Relaxin
• Ovary (Corpus luteum) • Inhibits contractions of the myometrium to
• Placenta during facilitate implantation
pregnancy • Promotes stretching of ligaments of the pubic
Menstrual Cycle
The menstrual cycle includes the activity of the hormones of the ovaries and
anterior pituitary gland and the resultant changes in the ovaries (Ovarian cycle) and
uterus (Uterine cycle). These are all incorporated into, which may look complicated at
first, but refer to it as you read the following. Notice first the four hormones involved:
FSH and LH from the anterior pituitary gland, estrogen from the ovarian follicle, and
progesterone from the corpus luteum. The fluctuations of these hormones are shown
as they would occur in an average 28-day cycle. A cycle may be described in terms
of three phases: menstrual phase, follicular phase, and luteal phase
• Menstrual phase, may last 2 to 8 days (Menstrual flow 4 days), secretion of
FSH is increasing, and several begin to develop. The loss of the functional
layer of the endometrium is called menstruation or the menses.
• Follicular phase (Proliferative phase 10 days)
LRH stimulates secretion of follicle-stimulating hormone (FSH) and Luteinizing
hormone (LH), which stimulates follicle development in the ovaries. The
secretion of LH is also increasing, but more slowly. FSH and estrogen
promote the growth and maturation of the ovum, and estrogen stimulates the
growth of blood vessels in the endometrium to regenerate the functional layer.
• Luteal phase (Secretory phase 14 days)
- After ovulation, the corpus luteum secretes progesterone and estrogen,
which act to level off the endometrium and ready it for implantation.
- As progesterone secretion increases, LH secretion decreases, and if the
ovum is not fertilized, the secretion of progesterone also begins to
decrease. Without progesterone, the endometrium cannot be maintained
and begins to slough off in menstruation. FSH secretion begins to increase
(as estrogen and progesterone decrease), and the cycle begins again
(Ischemic phase of the menstrual cycle)
Fertilization and pregnancy

Fertilization
• Although millions of sperm are deposited in the vagina during sexual
intercourse, only one will fertilize an ovum. As the sperm swim through the
fluid of the uterus and fallopian tube, they undergo a final metabolic change,
called capacitation. This change involves the acrosome, which becomes
more fragile.
• The zygote (Fertilization egg) undergoes mitosis during its 3 days journey
down the uterine cavity. The zygote (The human diploid number of 46
chromosomes is actually 23 pairs of chromosomes; 23 from the sperm and 23
from the egg. These 23 pairs consist of 22 pairs of autosomes (designated by
the numerals 1 through 22) and one pair of sex chromosomes. Women have
the sex chromosomes XX, and men have the sex chromosomes XY)
• The developing blastocyte remains free for 3 days before it begins to implant
in the endometrium.
Implantation
• A fluid-filled blastocyst consists of an outer layer of cells called the trophoblast
and an inner cell mass that contains the potential embryo. It is the blastocyst
stage that becomes implanted in the uterine wall, about 5 to 8 days after
fertilization.
• Successful implantation, blastocyte is individed : Emplyo and placenta
• Under the influence of hCG, the corpus luteum is maintained and continues to
secrete progesterone and estrogen until be the placenta is ready to take over
this function. That supporting endometrium, stimulate development of the
mammary glands, inhibit release of FSH and LH , and inhibit progesterone,
estrogen and uterine contraction.
Embryo-Fetus Growth
Month of Organs development Size in inches
Gestation
(end)
1 • Heart begins to beat; limb buds, backbone 0.25
forms, facial features, not distinct
2 • Calcification of bones begins, fingers and 1.25–1.5
toes are apparent on limbs; facial features
more distinct; body systems are
established
3 • Facial features distinct but eyes are still 3
closed, nails develop on fingers and toes,
ossification of skeleton continues, fetus is
distinguishable as male or female
4 • Head still quite large in proportion to body, 5–7
but the arms and legs lengthen, hair
appears on head, body systems continue
to develop
5 • Skeletal muscles become active 10–12
(“Quickening” may be felt by the mother),
body grows more rapidly than head, body
is covered with fine hair (lanugo)
6 • Eyelashes and eyebrows form, eyelids 11–14
open, skin is quite wrinkled, pulmonary
surfactant is first produced
7 • Head and body approach normal infant 13–17
proportions, deposition of subcutaneous
fat makes skin less wrinkled
8 • Testes of male fetus descend into 16–18
scrotum; more subcutaneous fat is
deposited, production of pulmonary
surfactant is sufficient to permit breathing
if birth is premature
9 • Lanugo is shed, nails are fully developed, 19–21
cranial bones are ossified with fontanels
present; lungs are more mature
Apgas Score
The Apgar score is an overall assessment of an infant and is usually made 1 minute
after birth (may be repeated at 5 minutes if the first score is low). The highest
possible score is 10. Infants who score less than 5 require immediate medical
attention.
Score 0 1 2
Respiratory No respiratory Weak cry Strong cry
effort
Heart rate No < 100 > 100
Muscle tone No response Some motoin Spontaneous action
Stimulation of No response Grimace in Cry in response
sole the foot response
Color Central cyanosis Peripheral cyanosis Pink color
Grunting No Minimal Obvious
Air entry Good Decreased Very poor
Fetal alcohol syndrome

Fetal alcohol syndrome is the term for a group of characteristics present in infants
who were exposed to alcohol during their fetal life.
• Alcohol is a toxin for adults and even more so for fetal tissues that are
immature and growing rapidly. Either alcohol or its toxic intermediate product
(acetaldehyde) may pass from maternal to fetal circulation and impair fetal
development.
• Consequences for infants include low birth weight, small head with facial
abnormalities, heart defects, malformation of other organs, and irritability and
agitation. The infant often grows slowly, both physically and mentally, and
mental retardationis also a possible outcome.
• Because there is no way to reverse the damage done by intrauterine exposure
to alcohol, the best course is prevention. Education is very important, women
should be aware of the consequences their consumption of alcohol may have
for a fetus.
Congenital fetal infections

A teratogen is anything that may cause developmental abnormalities in an embryo-
fetus. Several infectious microorganisms are known to be teratogenic; they may
cross the placenta from maternal blood to fetal blood and damage the fetus.
Congenital rubella syndrome
• Congenital rubella syndrome, the virus of German measles (rubella) is
perhaps the best known of the infectious teratogens. If a woman acquires
rubella during pregnancy, there is a 20% chance that her fetus will be affected.
Consequences for the fetus may be death (stillbirth), heart defects, deafness,
or mental retardation. Women who have never had rubella should consider
receiving the vaccine before they begin to have children. In this way,
congenital rubella syndrome is completely prevented. Use of the rubella
vaccine has made this syndrome rare in the United States, but many
developing nations do not have extensive vaccination programs.
Congenital varicella syndrome (Chickenpox)
• Herpes zoster is a viral disease that most people have during childhood. If a
pregnant woman acquires chickenpox, however, the virus may cross the
placenta. Consequences for the fetus include malformed limbs, cutaneous
scars, blindness, and mental retardation. This is not a common congenital
syndrome, and the success of the chickenpox vaccine should make it truly
rare.
Congenital syphilis
• Syphilis is a sexually transmitted disease caused by a bacterium (Treponema
pallidum). These bacteria may cross the placenta after the fourth month of
gestation. Consequences of early infection of the fetus are death,
malformations of bones and teeth, or cataracts. If infection occurs toward the
end of gestation, the child may be born with syphilis. This is most often
apparent as a rash on the skin and mucous membranes. Syphilis in adults can
be cured by penicillin; prevention of congenital syphilis depends upon good
prenatal care for women who may be infected. The Centers for Disease
Control and Prevention has a goal of eradicating syphilis in the United States,
which would eliminate fetal infection.
Congenital toxoplasmosis
• Caused by the protozoan parasite Toxoplasma gondii. For most healthy
people, toxoplasmosis has no symptoms at all; it is a harmless infection.
Because cats and some other mammals are hosts for this parasite, pregnant
women may acquire infection from contact with cat feces or by eating rare
beef or lamb. Consequences for the fetus are death, mental retardation, or
blindness. Retinal infection may only become apparent during childhood or
adolescence. Prevention now depends upon education of pregnant women to
avoid potential sources of infection.
Adenohypophyse
LH
FSH FSH
Developing ovarian follicle Corpus luteum New ovarian

and ovum follicle and
degeneration of
Ovulation corpus luteum
Estrogen Progesterone
1 4 14 28
Proliferative phase Secretory phase Menstrual

10 days 14 days 4 days
Menstrual cycle : 3 phases
• Proliferative phase 10 days : Increase estrogen
• Secretory phase 14 days : Increase progesterone and decrease estrogen
• Menstrual phase 4 days : Increase FSH and decrease LH (Decrease estrogen and
progesterone), vascular degeneration
Ovulation occurs the lining cells of ovarian follicle are stimulated by the luteinising hormone (LH)
57
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Emergency Drugs
Medication Adult dose Pediatric dose

Adenosine 0.05-0.2mg / kg IV bolus Maximun single dose : 12mg
Bicarbonate Na 1mEq / kg IV bolus , repeat ½ 1mEq/kg
8.4% dose q 10mn PRN 1mL/kg/dose
Calcium chloride 8-16 mg / kg IV 20mg/kg IV, PIV
Ca-gluconate10% : 1mL/kg IV
Dopamine Renal : 1-5µg/kg/mn 5-10µg/kg/mn
Cardiac : 5-10µg/kg/mn
Vasopressor : 10-20µg/kg/mn
Epinephrine Shock :1mg + 10mL NSS Pulseness arrest : 0.1mg/kg IV
repeat 2mL every 5mn Bradycardia : 0.01mg/kg IV
Furosemide 0.5-1mg/kg IV 0.5mg/kg IV
Glucose Dextrose 50% : 1mL/kg or Dextrose10% : 5mL/kg IVL,PIV
Hydrocortisone 5mg/kg IVL , PIV 5mg/kg IVL , PIV
Isoproterenol 0.05-0.5µg/kg/mn
JE-VAX
K-vitamins 10mg IV 2-10mg IM, IV
Lopril 25mg PO bid-tid 0.05-0.25mg/kg/dose PO
Morphine 2-4mg IV ( Max 15mg /dose ) 0.05mg/kg IV, IM, PO
Naloxone 0.4-2mg IVor IM, repeat for 0.01mg/kg IV
3 dose
Oxytocine Infusion : 20UI + 1000mL, PIV 10UI/ Intramuscular
Promethazine 0.5-1mg/kg/day PO 1mg/kg/day PO
Quinidine 200-300mg PO tid-qid 30mg/kg/day PO
Rho(D)-Ig Mother-Rh (-) : 300μg after ITP non splenomegaly:
delivery 25-50μg/kg
Salbutamol 0.1mg/kg IV, PO, inhalation
Thiamine 100 mg IM , IVL 50mg IVL
Valium 0.2-0.5/kg/dose IVL , IM 0.5 mg/kg/dose intrarectal, IVL
Warfarin 10-15mg/day PO , IM , IV 0.1mg/kg/day PO
Xylocaine Tachycardias arrhythmias :
1mg/kg IV bolus, then 2-4mg infusion
/mn
YF-VAX
Zinc 0.5-1mg/kg/day PO
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Antidote
ANTIDOTE INDICATION DOSE
Acetylcysteine Acetaminophen poisoning 150mg/kg in dextrose 5%

Calcium chloride Carbamate poisoning 0.05mg/kg IV every 15mn
Calcium gluconate Organophosphate insecticide
Cyanide antidotes Cyanide poisoning
• Sodium nitrite ( Eg , Hydrogen cyanide ) • Use 6mg/kg or 0.15-
0.33mL/kg to max of
10mL ( 3% solution )
• If hypotension , dilute
in 50-100mL of saline
and run over 5mn .
• IV : 400mg/kg (1.5mL/
• Sodium The prefered dose kg of 25% solution )
thiosulphate - Rate at 2.5-5mL/mn
- Half the initial dose
can give after 30mn
Deferoxamine Iro poisoning 15mg/kg/h ( Max 6g/day )
mesylate
Digoxin immune Fab Digoxin or digitoxin Digidote 80mg in D5% bolus
Flumazenil Benzodiazepines 0.2mg every hour ( Max 2g )
Anexate®
Glucagon • β adrenergic Loading 0.15mg/kg IV bolus
antagonist then 0.05-0.1mg/kg/h
• Ca channel blocker
Methylene blue Methaemoglobinemia 1-2 mg/kg IV , 30-60mn
Naloxone Acute opiod poisoning 0.4-2mgIV every 2-3mn
( Max 10mg)
Physiostigmine Anticholinergic poisoning 0.02mg/kg IV
Neostigmin®
Pyrodoxin Isoniazide 10-15mg/kg/h
Protamin sulfatate Heparin
Vitamin K Antivitamin K(Warfarin®) 10mg IV
Folic acid Methotrexate
Sodium bicarbonate Acidosis 1mEq/kg IV or infusion
1mL/kg
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Internal Medicine 2010, 4th ed.

Ngam Punlork, MD.
______________________________________
ADVANTAGE
• Rehydration
• Resuscitation of shock
- Hypovolemic shock
- Septic shock
- Anaphylactic shock
• Drug-intravenously route
• Child sickness
DISADVANTAGE
• Fluid overload
• Acute pulmonary edema
• Cerebral edema
• Heart failure risk of edema
SURVEILLANCE
• Urine (Normal : 0.5-1mL /kg/h)
• Lung sound auscultation
• Cardiac function (JVD, increased central vein pressure)
• Apparent : Face or lower extremity edema
Clinical signs of fluid overload
• Lung : Dyspnea and crackle sound
• Edema : Face or lower extremity
• Cause : Heart failure or anuria
DOSAGE
• Oral route
• IV route (IV Fluid : Infusion : PIV)
Body weight Fluid per 24h Fluid per 1h

< 10 kg 100mL/kg/24h 2-4mL/kg/1h
10 - 20 kg 50mL/kg/24h 2mL/kg/1h
> 20 kg 20mL/kg/24h 1mL/kg/1h
• 1 mL = 1 cc = 20 drops = 60 droplets
V(mL) x M(drops/mL) V(mL)

• Drop ( drop/mn ) = --------------------------------- = ---------------
60 T(h) 3 T(h)
60
D-ork-L
• Fluid for neonatal
Day Fluid per 24h (Infusion and oral)
D1 60mL/kg/d
D2 70mL/kg/d
D3 80mL/kg/d
--- ---
--- ---
--- ---
D7 120mL/kg/d
VOLUME EXPANDERS
Cristalloids Duration Volume Indications Advantag Disadvantage
Lactate 1 to 2 hs 3 times the -Hypovolemia -Isotonic -Rapidly
NSS 0.9% estimated -Dehydration -Fluid overload
Colloids 2 to 3 hs 1-1.5 times -Hypovolemia -Good -Allergy
Polygeline Estimate expansion -Expensive
Gelufexil fluid loss
Dextran 40 3 to 4 hs Expansion -Hypovolemia -Good -Anaphylactic
of volume expansion -Renal failure
Emergency Problems 61
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Increase body temperature that upper normal limit (N : 36.5-37.5 ˚C)
• Febrile or pyrexia or hyperthermia
• Characteristic
- Moderate fever 38.3 ˚C
- Elevate fever > 39 ˚C
- Severe hyperthermia > 40.5 ˚C
ETIOLOGY
• Hyperthermia : Viral or bacterial infection, other infectious diseases
• Metabolic trouble : Hyperthyroidism
• Dehydration : Severe dehydration, hypovolemia
• Drugs allergy : Penicillin, sulfonamide, anticholinergic
• Systemic inflammation : Rheumatic fever, SLE, IBD
• Hematology : Hemolytic anemia, leukemia, sickle cell disease
• Neoplasm : Lymphomas, leukemia, hepatoma, metastatic carcinomas
PATHOPHYSIOLOGY
• Fever is caused by increased prostaglandin E2 (PGE2) synthesis in the
hypothalamus.
• Autonomic discharge from hypothalamus raises core temperature
through shivering and dermal vasoconstriction.
• Both exogenous and endogenous factors can raise the body's set
thermoregulatory point :
- Endogenous factors include IL-1 and IL-6, tumor necrosis factor,
and IFN.
- Exogenous factors include endotoxin (lipopolysaccharide) and
other toxins and metabolites produced by infectious organisms.
PARACLINIC
• Complex blood count, CRP, ESR
• Electrolyte, glycemia, calcemia ,TSH, T3, T4 test
• Hemoculture, urinalysis, uroculture, puncture lumbar
CLASSIFICATION OF FEVER
• Acute fever < 7 days
• Persistent fever 7-14 days
• Chronic fever > 14 days
DIFFERENTIAL DIAGNOSIS
• Fever of unknown origin ( FUO ): Defined as fever > 38.3 °C for at
least 3 weeks as an outpatient and 3 days of inpatient evaluation or
three outpatient visits without determining etiology.
62 Emergency Problems
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•Fever with infections
- Bacterial infections ( Media otitis, urinary tract infections, respiratory
infections, meningitis, septicemia )
- Infectious diseases (Malaria, typhoid fever, shigella, clostridium
difficile, dengue infection)
- Viral infections (Rotavirus, Herpes simplex, Dengue, HIV)
• Fever with localizing signs
- Fever with change position (Septic arthritis, osteomyelitis,
appendicitis)
- Fever with neurological (Meningitis, convulsion, brain abscess)
- Fever with digestives (Diarrhea, abdominal pain, constipation,
appendicitis, pancreatitis, gall stone, bowel obstruction)
• Fever with hematology
- Leukemia, aplastic anemia, thalassemia
- Immune response : Post transfusion hemolytic, anemia hemolytic
auto-immune,HUS, ITP.
• Fever with chronic diseases : TB, neoplasm, HIV, rheumatology
COMPLICATION
• Convulsion with fever ( Convulsion febrile or convulsion hyperthermic )
- Convulsion febrile physiologic : Durant < 15mn, in children 1-
years, most common ENT infection, but without sign of neurologic.
- Convulsion febrile pathologic : Durant > 20mn, in children < 9
months, with sing of neurologic.
• Dehydration
• Neurological disorder
MANAGEMENT
1. Admission Criteria Infants
• All toxic patients
• Infants 0-28days of age with temperature >38 °C
• Nontoxic infants 28-90days of age with temperature >38°C
• Poor compliance or follow-up
2. Treatment in children and adult
• High fever ( T > 39 ˚C or > 102.2 F )
- Paracetamol® 15mg/kg/dose PO, IM or Intra-rectal
or NSAIDs : Aspirin®, Ibuprofen®
• Fever with convulsion ( Convulsion febrile )
- Diazepam 0.5-1mg/kg/dose intra-rectal, may be repeted for 2 doses
- Paracetamol® 15mg/kg/dose IM, repeated 15mg/kg/dose every 6 h
• Supportive care
- For children put out of clothes
- Coolness compress
- Increased fluid by oral or intravenous if necessary
• Treat underlying disorders
References
Hospital care for children (WHO)
Rosen and Barkin’s 5 minute medicine
Emergency problem 63
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Seizure is collection of cerebral neurons excessive active abnormality
• Convulsion due febrile seizure or afebrile seizure
• Febrile seizures less 15mn in development mentally normal but more
than 15mn risk consequent of epilepsy or meningitis or other
neurological disease.
ETIOLOGY
• Hyperthermia : Acute pharyngitis, acute tonsillitis
• Infections : Meningitis, encephalitis, brain abscess, septicemia
• Intoxications
- Lead poisoning
- Drugs : Opiates, cocaine, aspirin, theophylline, metoclopramide
- Drug withdrawal : Diazepam®
• Metabolic disorder
- Hypoglycemia < 45mg/dL ( < 2.2mmoL/L )
- Hyponatremia < 135 mmoL/L, hypernatremia > 145mmoL/L
- Hypocalcemia < 2.2mmoL/L, hypomagnesemia < 0.8mmoL/L
• Neurological disorder
- Epilepsy ( Recurrent seizure )
- Cerebral tumor, hypertension intracranial, Stoke
• Head trauma ( Hematoma )
CLINICAL SIGNS
• History of seizure
- Benign or recurrent seizure
- Onset, frequency, time of seizure
• Any factors
- Family history of seizure
- Congenital malformation
- Head trauma or CNS infection
• Any evidence of progressive intracranial lesion
- Headache, vomiting, leathagy, somnolent, visual disorder, mental
status change
• Physical examination and vital signs : Neurologic signs finding
• Common childhood infections :
- Upper respiratory illnesses
- Otitis media
- Roseola
- Gastrointestinal infections
- Shigella gastroenteritis
64 Emergency problem
D-ork-L
CHARACTERISTIC
Generalized tonic-clonic seizure most common :
• Tonic phase:
- Muscular rigidity
- Apnea and incontinence
- Self-limited and last only a few minutes
• Other seizure types:
- Staring with stiffness
- Limpness
- Jerking movements without prior stiffening
PARACLINIC
• CBC, CRP, electrolyte , glycemia
• Lumbar puncture CSF gram stein or culture
• CT scan and EEG
MANGEMENT
1. Admission Criteria in children
• Intensive care unit : Active status epilepticus, intubated, or persistent
mental status changes.
• Inpatient unit:
- Status epilepticus resolved in the ED
- Underlying cause of seizure not resolved or controlled
- Intracranial hemorrhage
- Meningitis/Encephalitis
- Mass lesion, drug, toxin ingestions
2. Admission Criteria in adult
• Patients with status epilepticus should be admitted to the intensive
care unit.
• Patients with seizures secondary to underlying disease (e.g.,
meningitis, intracranial lesion) must be admitted for appropriate
treatment and monitoring.
• Patients with poorly controlled repetitive seizures should be admitted
for monitoring.
• Delirium tremens
3. Treatment
• Basic assessment of resuscitation : ABCDE
• Control of seizure : Diazepam 0.5mg/kg intrarectal , may be
repeated after10mn for 2doses
• Control hyperthermia : Paracetamole 10-15mg/kg IM, compress cold
• Monitoring to follow up vital signs and oxygen
• Treat underlying disorders
4. Drugs
• Lorazepam : 0.1mg/kg IV per dose (Max. 10 mg)
• Paraldehyde : 0.3-0.5mL/kg (Peds: 0.3mL/kg PR 1:2 in mineral oil)
• Phenobarbital : 15-20mg/kg IV at rate of 1mg/kg/min
• Phenytoin: 15-20mg/kg IV (Peds : use rate of 0.5-1.0 mg/kg/min)
References
Handbook of pediatric
Rosen and Barkin’s 5-minute medicine
D-ork-L
Ngam Punlork, MD.
_____________________________________
DEFINITION
• Shock is hypoperfusion and circulatory collapse
• Shock is delayed progression due compensate of multiple organs
reversible.
• Shock may be hemodynamic measurements depend upon causes
• Shock may be damage any all tissue and organ systems in body
ETIOLOGY
• Hypovolemic : Dehydration, hemorrhage, burn
• Ischemic heart disese, sepsis
• Distributive of brain, cardiac, CNS
• Miscellaneous : Denal failure , hepatic failure
CLASSIFICATION
• Hypovolemic shock
• Distributive shock ( Vascular shock )
- Anaphylactic shock
- Neurologic shock
- Painful shock
- Septic shock
• Cardiogenic shock : Obstructive shock
DIAGNOSTRIC
• Depend upon history
- Dehydration, hemorrhage, sepsis, trauma, drug-anaphylaxis,
heart disease, renal or hepatic failure
• Clinical signs
- Oliguria, sweaty skin with pallor, altered mental status, cyanosis,
somnolence, capillary time refill retarded
• Physical exam
- Hypothermia, tachycardia, hypotension, tachypnea
• Vital signs : Temperature, RR, Pulse, BP, Saturation evaluation
CLINICAL SIGNS
• Generalized shock : Hypotension, decreased peripheral pulses,
tachycardia, tachypnea, decreased urine output, diaphoresis,
obtundation, lethargy.
• Hypovolemic shock : Cold and clammy extremities, pallor, flattened
neck veins, decreased capillary refill, narrowed pulse pressure
• Cardiogenic shock : Chest pain/pressure, dyspnea, orthopnea, JVD,
cool, clammy, sweaty extremities, pales, wheezes, dullness at lung.
D-ork-L
• Septic shock : Warm flushed extremities, strong pulses, hyperthermia,
hypothermia, purpura or petechial rash
• Anaphylactic shock : Warm flushed extremities, urticaria, stridor,
throat tightness, hoarseness, wheezing
• Neurogenic shock : Flaccid paralysis, loss of rectal tone, hypotension
with bradycardia.
PARACLINIC
• CBC, CRP, electrolyte, glycemia, calcemia
• Creatinine, BUN, transaminase
• ABG : Acid-base status
• Urinalysis, urine culture, blood culture
• Imagery : Chest radiography, ECG
MANAGEMENT
1. Admission Criteria
• All patients in shock need to be admitte
• All patients with persisting shock need ICU monitoring.
• Patients with shock definitively reversed may be admitted to non-ICU
setting (e.g., tension pneumothorax that has been decompressed and
chest tube placed).
2. Treatment
• Resuscitation ABCDE
• Correct cause of shock
- Hypovolemic with NSS 20mL/kg body weight Bolus
- Sepsis with broad spectrum antibiotic
- Correct of hemorrhage
• Correct of cardiovascular
- Dopamine or epinephrine
- Corticotherapy
• Correct of electrolyte and metabolic acidosis : Sodium bicarbonate
• Dextrose 10 % : 5mL/kg for hypoglycemia, intravenous
• Treat underlying disorder
3. Drugs
• Albuterol : 2.5mg/2.5 cc nebulizer PRN
• Bicarbonate sodium 8.4% : 1mL/kg/dose infusion
• Calcium gluconate 10% : 1mL/kg/dose IVL
• Cimetidine : 300mg IV
• Dopaminergic : 1-3µg/kg/min IV
• Epinephrine :
- Infusion 1-4µg/min IV
- SQ/IM (1 :1000) : 0.1-0.3mg repeat q5min-20min to 3 PRN
- IV (1 :10,000) : 10mL (1mg) over 10min IV
• Glucagon : 1-5 mg IV bolus initial, then 1-20mg/h infusion
• Hydrocortisone : 5-10mg/kg IV
• Naloxone : 0.05-0.1mg/kg IV initial, titrate to effect
References
Pediatric emergency medicine (McGraw-Hill)
Urgences Reanimation Transfusion (Masson)
D-ork-L

Ngam Punlork, MD.
______________________________________
DEFINITION
• Dysfunction of the reticular activating system in the brainstem or
bilateral cerebral dysfunction.
•Coma is defined as a state of lost consciousness not respond to
- Ordinary verbal
- Sensory
- Physical stimuli
ETIOLOGY
• Traumatism
• Intoxication
- Salicylic : Hyperventilation, seizure, dehydration, ↑serum salicylate
- Hypoglycemia : Sweating, headache, seizure, BS < 45mg/dL
- Barbiturates : Hypoventilation, hypotension, myosis
- Hyperglycemia in diabetes mellitus ( Ketoacidosis )
- Opiots
• Electrolyte disorder : Hypernatremia, hyponatremia, hypocalcemia
•CNS infections : Meningitis, encephalitis, encephalopathy, epilepsy .
•Reye syndrome : Hypercapnia, pupils dilated, seizure, increased
serum ammoniac.
• Hypertension (Renal, coartation of aorta) : Increased brachial BP and
decreased femoral BP.
• Lead poisoning : Vomiting, abdominal pain, seizure
• Hemolytic uremic syndrome : Anemia, bruising, oliguria or anuria,
elevated BUN .
• Coma post seizure : Pupils dilated, Barbinski +, rapid return of
consciousness .
STAGES OF COMA
• Light coma : Responds to noxious stimuli
• Deep coma : Does not respond to pain
• Unresponsiveness
- Loss of either arousability or cognition
- Stupor : Deep sleep, although not unconsciousness
- Obtundation : Mental blunting with moderate reduction in alertness
- Delirium : Floridly abnormal mental status and motor restlessness
- Clouding of consciousness : Disturbance of consciousness
D-ork-L
EVALUATION
1. Primary assessment for coma
• Urgent medication
- A : alert
- V : verbal response
- P : pain response
- U : unresponsive to pain
• Access adequate breathing ( Retraction, nasal flaring, grunting ,
cyaosis, tachpnea )
• Access adequate cardiovascular (Pulse volume, hypotension, pale,
cyanosis, capillary time refill, tachycardia, or bradycardia)
2. Secondary assessment for coma
• Glasgow coma scale (No urgent)
- Eye opening 4
- Verbal response 5
- Motor response 6
• EVALUATION
- GCS : 13-15 normal
- GCS : 9-12 pre-coma
- GCS < 8 coma
- GCS : 6-4 profound coma
- GCS : 3 dead
3. General physical examination and Vital signs
• Cerebral hemorrhage
• Cerebrovascular accident (Stroke)
• Head trauma
• Hepatic encephalopathy
• Meningitis
• Metabolic disorders : DKA, HHNC, myxedema, hyperglycemia
MANAGEMENT
1. Basic assessment of resuscitation : ABCDE
2. Coma Cocktail : DON’T in adolescent
• Dextrose 10% : 5mL/kg IV
• Oxygen
• Naloxone 0.05-0.1mg/kg/dose IV
• Thiamine 100 mg IVL
3. Treat underlying disorder
References
Emergency Problem 69
D-ork-L

Ngam Punlork, MD.
______________________________________
DEFINITION
• Poisoning may be intentional or unintentional
• Intoxication
- Toxic ingestion : Clostridium botulism type A, B or E, food smoked
eating, fish poisoning (Ciguatera, Scombrotoxin, Paralytic
shellfish poisoning)
- Drug overdose or intravenous drug caused by black tar heroin
ETIOLOGY
1. Intentional :
• Depression
• Suicide
• Homicide
• Recreational drug abuse
2. Unintentional (accidental) :
• Common cause in children
• Therapeutic error (Double dose, overdose)
• Recreational drug experimentation
DIAGNOSIS
• Neurologic :
- Lethargy
- Agitation
- Coma
- Hallucinations
- Seizures
• Respiratory :
- Tachypnea/bradypnea/apnea
- Inability to protect airway
• Cardiovascular :
- Dysrhythmias
- Conduction blocks
• Vital signs :
- Varies depending on toxic substance
- Hyperthermia/hypothermia
- Tachycardia/bradycardia
- Hypertension/hypotension
70 Emergency Problem
D-ork-L
CLINICAL SIGNS
1. Food poisoning
• History food-smoked eating
• Onset 12-36 hours after ingestion of the toxins
• Sudden symptoms : Diplopia, Dry mouth, Dysphagia, Digestive trouble
(Vomiting, nausea, abdominal pain) and Dilated pupils fixed 50 %
• Sudden onset of cranial nerve paralysis and muscle weakness
• Muscle weakness progressing to respiratory paralysis
2. Selected Toxidromes
• Anticholinergic : Altered mental status, dry skin and mucous
membranes, fixed dilated pupils, tachycardia, hyperthermia, flushing,
urinary retention
• Cholinergic : Salivation, lacrimation, urination, diaphoresis, miosis,
bronchospasm and wheezing
• Opiate : CNS and respiratory depression, pinpoint pupils
• Sympathomimetic : CNS excitation, seizures, tachycardia,
hypertension, diaphoresis
PARACLINIC
• Complex blood count
• Stool test / culture
• Demonstration of toxin in blood or food
• Poliomyelitis
• Mayasthenia gravis
• Tick paralysis
• Guillain-Barré syndrome
MANAGEMENT
• Removal of unabsorbed toxin from gut (Gastric decontamination < 1h)
• Active charcoal per oral
- Adult : 30-100mg/day
- Enfant : 1-2g/day
• Specific antitoxin
• Rehydration and electrolyte
• Vigilant support, including attention to respiratory function
• Treatment by symptomatic (Atropine, cimetidine)
• Heroin poison or coma
- Dextrose 50% : 1mL/kg IVL
- Oxygen therapy
- Naloxone 0.05-0.1mg/kd/dose IV
- Thiamin 100 mg IV
References
Maladies infectieuses (E. PILLY)
Fluid and electrolyte 73
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Metabolic acidosis
- Decreased serum pH < 7.35
- Decreased serum HCO3
ETIOLOGY
• Most common in shock : Hypovolecmic shock, septic shock
• Diabetes ketoacidosis
• Other : Diarrhea with severe dehydration, diuretic, lactic acidosis, uremia,
renal tubular disease, pulmonary or liver diseases.
• Cause
- Gap acidosis (SLUMPED) : Salicylate, lactic, uremic, methanol,
paraldehyde, ethylene glycol, diabetes .
- Non-gap acidosis (2-RGD) :
2Renal : Renal tubular acidosis, renal failure
2GI : Enterocutaneous fistula, urine diversion to gastrointestinal tract
2Drugs : Ammonium chloride, acetazolamide
CLINICAL SIGNS
• History of severe disease
• Early hyperventilation , late hypoventilation
• Tachypnea or Kussmaul respirations with metabolic acidosis
• Tachycardia
• CO2 narcosis
• Conscious : Somnolence, confusion, lethargy, coma
PARACLINIC
• Hyperkalemia and hypercalcemia with severe metabolic acidosis
• Arterial blood gas (ABG) measurement
• pH < 7.35
• Calculate anion gap : Na – (Cl + HCO3)
- Anion gap < 15 : HCO3 loss : Diarrhea, renal tubular disease,
acetazolamide.
- Anion gap < 15 : H excess : Lactic acidosis , DKA , methanol ingestion
ethyleneglycol ingestion , salicylate intoxication.
- Anion gap >25 mEq/L is seen only with : Lactic acidosis, ketoacidosis
,toxin-associated acidosis.
MANAGEMENT
• Rehydrate with 0.9% normal saline if patient hypovolemic
• Sodium bicarbonate (NaHCO3 8.4%) : 1mL/kg intravenous
• Coma Cocktail : DON’T in adolescent :
Dextrose, oxygen, naloxone, and thiamine.
• Treat underlying disorder : Diabetic ketoacidosis, Lactic acidosis,
Alcohol ketoacidosis, Ingestion.
Reference
Current essentials of fluid and electrolyte (LANGE)
74 Fluid and electrolyte
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Defined as PaCO2 >45 mm Hg or higher than expected for calculated
respiratory compensation for metabolic acidosis
- Inadequate ventilation
- Carbon dioxide accumulation
ETIOLOGY
• Acute airway obstruct, aspiration, respiratory arrest, chronic respiratory
disease, pulmonary edema, respiratory failure
• Reduced pH owing to alveolar hypoventilation with elevated PaCO2
• Divided into three broad categories :
- Primary failure in central nervous system drive to ventilate : Sleep
apnea, anesthesia, sedative overdose
- Primary failure in transport of CO2 from alveolar space : Chronic
obstructive pulmonary disease, myasthenic crisis, severe hypokalemia,
Guillain-Barré syndrome
- Primary failure in transport of CO2 from tissue to alveoli : Severe heart
failure
CLINICAL SIGNS
• Respiratory distress
- Hypoventilation
- Cyanosis
• Neurologic signs : Headache, confusion, convulsion, somnolence, coma
PARACLINIC
• Respiratory acidosis :
- Acute: expected HCO3- increased by 1mEq/L for every 10mmHg
increase in PaCO2
- Chronic: expected HCO3- increased by 4mEq/L for every 10mmHg
increase in PaCO2
• Increased pCO2 > 45mmHg
• Decreased serum pH < 7.35
• HCO3 > 25 mmoL / L
MANAGEMENT
• Rehydrate with 0.9% normal saline if patient hypovolemic
• Intubation if necessary
• Chronic or rapid correction may lead to severe metabolic alkalosis
• Coma Cocktail : DON’T in adolescent :
Dextrose, oxygen, naloxone, and thiamine.
• Respiratory acidosis :
- Treat underlying disorder.
- Provide ventilatory support for worsening hypercapnia.
- Identify and correct aggravating factors (pneumonia) in chronic
hypercapnia.
References
Current essentials of fluid and electrolyte ( LANGE )
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Increased serum pH > 7.45
• Increased serum HCO3
ETIOLOGY
• Most common acid-base distrucbance in surgery patients
• Pathogenesis involves of loss of H via nasogastric suction, volume
depletion, and hypokalemia.
• Mixed metabolic alkalosis with respiratory acidosis
• Loss of H+ :
- Gastrointestinal, vomiting, nasogastric suctioning, bulimia
- Antacid therapy
• Renal loss :
- Diuretics (loop and thiazide)
- Post-chronic hypercapnia
- Mineralocorticoid excess
- Hyperaldosteronism
• Bicabonate sodium infusion
• Milk-alkali syndrome
• Blood transfusions
CLINICAL SIGNS
• Bradypnea
• Sign of hypokalemia
- Decreased muscle contractility
- Decreased peristalsis
- Muscle clamp
- Paralysis
• Signs of hypocalcemia
- Paresthesia, carpopedal spam, positive Chvostek sign
- Numbness, tingling
PARACLINIC
• Elevated HCO3- with metabolic alkalosis
• Evaluate for hypokalemia and hypocalcemia.
• Diagnostic depend on ABG pH measurement
- pH > 7.45
- HCO3 > 25mmoL/L
- Urine chloride > 40mEq/L
MANAGEMENT
• Antiemetics for vomiting
• Proton pump inhibitors for patients with nasogastric (NG) suction
• Rehydrate with 0.9% saline for chloride-responsive alkalosis .
• Potassium chloride for chloride-responsive alkalosis in edematous states.
KCL : 20-120mEq PO daily
Reference
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Acute hyperventilation lower Pco2
ETIOLOGY
• Septic shock
• Hyperchloremia acidosis
• Chronic respiratory disease, pulmonary embolus, liver disease
• Hyperthyroidism
• Drugs : Progesterone, Methylxanthines, Salicylates, Catecholamines
CLINICAL SIGNS
• Signs of hypocalcemia
- Paresthesia, carpopedal spam, positive Chvostek sign
- Numbness, tingling
- Tetany, seizure
- Arrhythmias
- Altered mental status
PARACLINIC
• Evaluate for hypocalcemia.
• Diagnostic depend on ABG pH measurement
- Decreased Pco2
- Increased plasma bicarbonate
- Increased serum pH > 7.35
1. Acute Respiratory Alkalosis
• HCO3- decreases secondary to intracellular shift and buffering within 20mn
• Expected HCO3- decreased by 2mEq/dL for each 10mmHg decrease
in PCO2
2. Chronic Respiratory Alkalosis
• HCO3- decreased secondary to renal secretion of HCO3- (48-72 hours)
• Expected HCO3- decreased by 5mEq/dL for each 10mmHg decrease
in PCO2
- If HCO3- greater than predicted, concomitant metabolic alkalosis
- If HCO3- less than predicted, concomitant metabolic acidosis
MANAGEMENT
• Respiratory alkalosis does not generally require treatment
• Treatment of chronic respiratory alkalosis may lead to metabolic acidosis
and hyperchloremia
• Dextrose 50% 1mL/kg/dose IVL
• Naloxone: 2mg (Peds : 0.1mg/kg) IV or IM initial dose
• Thiamine (vitamin B1) : 100mg (Peds: 50mg) IV or IM
• Calcium gluconate 10% : 1mL/kg/dose IVL
References
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Elevated serum calcium > 11mg/dL (N : 8.8-10.2 mg/dL)
• Hypercalcemic crisis, usually >14mg/dL, associated with serious signs
• Calcium in bloodstream in three forms :
- Ionized : 45%
- Bound to protein (Primarily albumin) : 40%
- Bound to other anions : 15%
ETIOLOGY
• Primary hyperparathyroidism
• Malignancy : Cancer bone with metastases
• Miscellaneous
- Most common in patients with hyperparathyroidism
- Excess parathyroid hormone (PTH)
- Other : Vitamin D or calcium intake, prolonged thiazide diuretics,
addison disease, Milk-alkali syndrome.
CLINICAL SIGNS
• Neurologic
- Headache, fatigue, muscle weakness
- Depression, altered mental status, coma
• Renal
- Polydipsia, polyuria but anorexia
- Chronically : Nephrocalcinosis, interstitial nephritis
• Cardiovascular : Tachycardia, hypertension or hyotension
• Digestive : Anorexia, nausea, constipation and peptic ulcer, pancreatitis
• Dermatologic : Pruritus, ectopic calcification
• Pediatric Considerations
- Characteristic facies : Pug nose, fat nasal bridge
- Failure to thrive, slow development, hypotonia
- Mental retardation may ensue
PARACLINIC
• Diagnostic hypercalcemia with PTH >15% above normal
• Electrolyte, BUN, creatinine, glycemia for oliguric renal failure
• ECG :
- Shortening of QT interval
- Prolongation of PR interval
- QRS widening
- Sinus bradycardia, bundle branch block, AV block, cardiac arrest with
severe hypercalcemia (rare)
MANAGEMENT
• If severe ( Ca > 14mg/dL ), intravenous isotonic saline with furosemide
• Corticotherapy for sarcoidosis, vitamin D intoxication and Addison’s
• Plicamycine with metastases cancer
• Calcitonin for patient with renal failure or cardiopathy
Reference
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• High serum potassium > 5.5mmoL/L (3.5 and 5.0 mmoL/L)
ETIOLOGY
1. Increased Potassium Distribution
• Extracellular space 2% (Speudohyperkalcemia)
- Severe hemolytic, thrombocytosis > 1 000 000/µL
- Severe trauma, burn
• Intracellular space : 98%
2. Decreased Potassium Excretion
• Renal 90% : Renal excretion of potassium affected by
- Distal renal tubular function, acute renal failure
- Acid-base balance
- Mineralocorticoids, addison’s disease, hypoaldosteronism
- Drugs : Drugs : Antialdosteron, NSAIDs, insulin
• GI 10% : Dietary intake, oral KCL
CLINICAL SIGNS
• History of acute renal failure
• Neuromuscular : Weakness which can progress to paralysis
• Respiration : Dyspnea owing to respiratory muscle weakness
• Cardiovascular : Palpitation, chest pain, dysrhythmia, syncope
PARACLINIC
• Electrolytes, BUN, creatinine, glucose :
- Elevated BUN, creatinine in renal failure
- Hyponatremia with mineralocorticoid deficiency
- Mild metabolic acidosis with type IV renal tubular acidosis
• Arterial blood gases : Assess acid-base status
• Hypocalcemia
• ECG : Heightened T waves or loss of P wave
MANAGEMENT
1. Mild hyperkalemia > 5.5mmoL/L
• Furosemide : 0.5mg/kg/day PO
• Calcium or sodium polystyrene sulfonate orally or by enema (PR)
• Avoid in patient bowel obstruction
2. Modered and severe hyperkalemia > 7mmoL/L
• Insulin 20 ui in dextrose 50% (100mL) IVL
• NaHCO3 : 1mEq/kg IVL or infusion
• Beta-Agonist : Inhaled albuterol
3. Hyperkalemia with ECG change
• Pulse weakness : Calcium gluconate 10% : 1mL/kg infusion
• Hydrocortisone : 2mg/kg IVL
• Dialysis for renal failure
Reference
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• High serum magnesium > 2.5mEq/L (N : 1.5-2.5mEq /L)
ETIOLOGY
• Most common in patients with renal failure
• Hypokalemia
• Post-operation is rare
CLINICAL SIGNS
• History of chronic renal failure
• Neuromusular
- Weakness
- Decreased deep tendon reflex
- Lethargy
- Somnolence
• Severe hypermagnesemia
- Confusion
- Coma
- Death
PARACLINIC
• When serum magnesium reaches 6 mEq/L, risk deep tendon reflex lost
• Magnesium > 10mEq/L, risk somnolence, coma and death
• ECG :
- Widened QRS complex
- Depressed ST segment
- Peaked T waves
MANAGEMENT
• Intravenous isotonic saline to increase renal excretion
• Infusion of calcium chloride
• Dialysis my be necessary
• Monitoring electrocardiogram and serum magnesium
References
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• High serum sodium > 145mEq/L
- Mild hypernatremia: serum sodium 146-155mEq/L
- Severe hypernatremia: serum sodium >155mEq/L
ETIOLOGY
• Pure water loss (Hypovolemic hypernatremia)
- Acute diarrhea (Loss of water > sodium)
- Dehydration of extravascular
- Diabetes insipidus
• Hypertonic sodium gain (Hypervolemic hypernatremia)
- Hypertonic sodium infusion or feeding solution
- Sodium bicarbonate therapy
- Sea water ingestion or drowning
- ACTH disorders : Primary hyperaldosteronism, Cushing syndrome
CLINICAL SIGNS
• History of
- Acute diarrhea
- Repeated vomiting
- Oliguria
• Severe hypernatremic dehydration
- Mental status : Seizure, lethargy to coma
- Cerebral edema, or hemorrhagic
• Hypervolemic hypernatremia
- Respiratory distress
- Peripheral edema
- Pulmonary edema
PARACLINIC
• Electrolytes, BUN/creatinine, glucose
• CBC
• Urinalysis :
- Urine/serum osmolality
- Urine Na
• Chest radiography :
- For infection/aspiration
- Pulmonary edema with hypervolemic hypernatremia
MANAGEMENT
• Water replacement with sodium restriction
• Hypervolemic hypernatrenia : Remove excess water with diuretics or
dialysis.
• Hypovolemic hypernatremia
- Replace volume contraction with 0.9% NS IV bolus
• For children with Diabetes Insipidus : Hormonal replacement therapy
- The drug of choice is desmopressin (DDAVP)
- Intranasal vaspressin
Reference
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Depressed serum calcium < 8mg/dL (2mmoL/L)
ETIOLOGY
• Post thyroidectomy / parathyroidectomy
• In newborn : Premature, neonatal infection
• Vitamin D deficiency, prolonged administration of total parenteral nutrition
• Malabsorption, poor dietary intake (Severe malnutrition : MPC/MPE)
PATHOPHYSIOLOGY
• Calcium in bloodstream in three forms
- Ionized : 45%
- Bound to protein (Primarily albumin) : 40%
- Bound to complexing ions (Citrate, phosphate, carbonate) : 15%
• Serum levels of calcium are primarily controlled by three hormones
- Parathyroid hormone (PTH) : Decrease in calcium levels leads to an
increase in PTH secretion (Increasing bone resorption, renal
absorption, intestinal absorption, and urinary phosphate excretion).
- Vitamin D (1,25-dihydroxyvitamin D) : Decrease in calcium level
activates vitamin D (Increasing bone resorption and GI absorption).
- Calcitonin : Direct inhibition of bone resorption with increased Ca.
• Hypoalbuminemia is most common cause of hypocalcemia
PARACLINIC
• Diagnostic hypercalcemia with PTH > 15% above normal
• ECG : Prolonged QT interval
CLINICAL SIGNS
• Neuromuscular : Increased muscle contractility
- Hyperactive deep tendon reflexes
- Muscle-abdominal cramps
- Peripheral spasm (Carpopedal spam) and positive Chvostek sign
- Mental status : Headache, convulsions
• Cardiovascular
- Hypothermia , bradycardia , bradypnea
- Hypotension, dysrhythmia
• Pediatric Considerations
- Children have higher values of normal calcium (9.2-11mg/dL).
- Neonatal hypocalcemia: total serum calcium concentrations < 7mg/dL
or serum-ionized calcium levels < 4.4mg/dL
- Symptoms of hypocalcemia in infancy: Hyperactivity, tachypnea, apneic
MANAGEMENT
• Correct alkalosis respiratory if present
• Acute hypocalcemia with convulsion, give calcium gluconate 10% :
1mL/kg slow intravenously or in 500mL of D5% infusion
• Long-term treatment : Oral vitamin D, calcium, or sterogyl®
Reference
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Depressed serum potassium < 3.5mEq /L (< 3.5mmoL/L)
- Mild to moderate 2.5-3.5mEq/L
- Moderate to severe < 2.5mEq/L
ETIOLOGY
• GI losses
- Severe dehydration (Acute diarrhea , repeated vomiting)
- Laxative abuse
- Alcoholism
- Prolonged NPO status
• Congenital disorders :
- Bartter and Gitelman syndromes with hypotension
- Liddle syndrome is the same but with hypertension
• Miscellaneous
- Post-operation potassium < 2.8mEq/L
- Drugs : Loop diuretic, insulin
CLINICAL SIGNS
• Neuromuscular : Decreased muscle contractility
- Decreased peristalsis (Potassium < 2.8mEq/L)
- Muscle clamp
- Decreased reflexes
- Paralysis
• Cardiovascular : Dysrhythmia, cardiac arrest
• Polyuria, fatigue, malaise
PARACLINIC
• Decreased magnesium, decreased urine potassium < 30mEq/L
• Electrolytes, BUN, creatinine, glucose :
- High HCO3 suggests diuretic abuse, vomiting, mineralocorticoid
- Low HCO3 suggests renal tubular disease.
• Urine K (Spot sample) :
- < 20mEq/L suggests GI loss, potassium shift into cells, poor intake.
- > 40mEq/L suggests renal loss.
• Urine Na < 20mEq/L with elevated urine K suggests secondary
hyperaldosteronism.
• Plasma renin if hypertensive :
- High renin : Secondary hyperaldosteronism, renal artery stenosis
- Low renin : Primary hyperaldosteronism
• ECG findings : Low-voltage T waves and Sagging of the ST segments
MANAGEMENT
• Replace magnesium if necessary (MgSO4) : 2g infusion
• Correct alkalosis if present
• Potassium chloride (KCL) oral or 0.1-0.2mEq/kg infusion
• Do not give IV potassium until urine production is assured
Reference
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Depressed serum magnesium < 1.5 mEq / L
ETIOLOGY
• GI losses
- Chronic diarrhea
- Malabsorption
- Poor dietary intake (Severe malnutrition : MPC/MPE)
- Prolonged NPO status (Prolonged administration of total parenteral
nutriction)
• Miscellaneous
- Hypercalcemia
- Acute pancreatitis
- DKA
- Burn
CLINICAL SIGNS
• Increased muscle contractility
- Tremors
- Hyperactive deep tendon reflexes
• Mental status
- Headache
- Delirium
- Convulsions
• Positive Chvostek sign
PARACLINIC
• Diagnostic depends on clinical suspicion and serum magnesium levels
MANAGEMENT
• Correct underlying problem
• Replace magnesium for mild to moderate hypomagnesium
- Oral magnesium sulfate
- Magné-B6 orally
• Severe hypomagnesemia
- Magnesium sulfate 2g IVL or infusion
References
D-ork-L
Ngam Punlork, MD.
______________________________________
DIFINITION
• Low serum sodium < 130mEq/L
ETIOLOGY
• Severe dehydration (Acute diarrhea , repeated vomiting, burn, diuretics)
• Syndrome of inappropriate antidiuretic hormone ( SIADH )
• Occurs in post-operation
• Hypothyroidism
• Drugs : Chlorpropamide, NSAIDs, barbiturates, amitriptyline, clofibrate
CLINICAL SIGNS
• Mild hyponatremia >120mEq/L
- Headache
- Nausea, vomiting, anorexia
- Weakness
- Muscle cramps
- Rhabdomyolysis
• Moderate hyponatremia 110-120mEq/L
- Impaired response to verbal stimuli and painful stimuli
- Visual/Auditory hallucinations
- Bizarre behavior
- Hyperventilation
• Severe hyponatremia <110mEq/L
- Bradycardia, hypertension
- Altered temperature regulation
- Dilated pupils, seizure activity
- Respiratory arrest
- Coma/Unresponsive
PARACLINIC
• Electrolytes, blood urea nitrogen, creatinine
• Glucose : Correct sodium value accordingly if severe hyperglycemia.
• Urine sodium
MANAGEMENT
• Replace sodium
• Mild to moderated hyponatremia
- Initiate IV fluid with 0.9% NS
• Give hypertonic sodium when condition is severe
- DON’T : Dextrose 50%, Oxygen, Naloxone, Thiamine
- Raise serum sodium no more than 1-2 mEq/L/h
• Calculate sodium deficit = 0.6 (Weight in kg) x (140 –Na deficit)
- Half-dose give slow intravenously
- Half-dose infusion over 4hours
• Hypervolemic hyponatremia
- Water restriction to less than 1 L per day with high dietary salt intake
- Furosemide 20-40mg intravenously
Reference
Rosen and barkin’s 5-minute medicine
Neonatal disorders 89
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Souffrance foetal aiguë
• Anoxia encephalopathy
• Post delivery asphyxia depend upon
- Apgar Score < 7 at 5mn
- Respiratory failure
• Effect asphyxia : ischemia and hypoxia affective to brain, liver, kidney
, heart.
ETIOLOGY
• Ante-partum 90 %
- Meconium staining of liquor, abnormal lung
- Hypertonia or hypotonia of uterus
- Prolonged menbraneous rupture
- Metabolic acidosis
• Post partum 10 %
- Hypoxic ischemic encephalopathy
- Multiorgans systemic dysfunction (Lung, liver, kidney, heart, brain)
CLINICAL SIGNS
• Early
- Apgar Scare < 7 at 5mn
- Respiratory failure
- Cyanosis
• Late
- No feeding
- Seizure, loss muscle tone and Reflex (Moro’s)
CLASSIFICATION
• Stage I (Mild) : Hyper excitability, extremities contraction
• Stage II (Moderate) : Loss reflex, lethargy
• Stage III (Severe) : Repeated convulsion, coma
PARACLINIC
• CBC, CRP
• Peripheral Blood Gaz (pH)
• Electrolyte, glycemia, calcemia, blood culture
• Radiography, ultrasound, transfontanel ultrasound, MRI
• Presence : Hypoglycemia, hypocalcemia and prolong PT
90 Neonatal disorder
D-ork-L
MANAGEMENT
• Prophylaxis
- Regular antenatal check (In pregnancy > 2 times) and fetal’s
arrhythmia, scal pH < 7. 2
- Abnormal ultrasound : Cesarean
• Assessment of resuscitation ABCDE
• Monitoring
- Maintain of saturationSaO2 90-95%, pulse, urine
- If apgar score < 3 at 5mn transfer to neonate ICU
- Avoid ventilation : Diaphramatic hernia, meconium aspiration
- Nasogastric milk : 5-10mL/kg/day
• Medication
- Vitamin K : 2mg IM or IV
- Dextrose10% : 5mL/kg IVL or infusion
- Calcium gluconate10% : 1mL/kg infusion
- For seizure give Phenobarbital 20mg/kg and 5mg/kg/day after 24h
- Antibiotherapy if necessary
References
Pulmonary disorder 91
Pediatric-Medicine disorder D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Episodic and chronic symptom of airway obstruction
- Chronic inflammation disease
- Recurrent dyspnea type bradyspnea expiration
- Periodic wheezing > 3 times
ETIOLOGY
• Most common trigger inhaled allergen
• Multifactor : SRV infection in nourrisson, psychologic, medication
- Viral infections, particularly respiratory syncytial virus (RSV),
during infancy may play a role in the development of asthma or
may modify the severity of asthma.
- Exposure to cigarette smoke and other airway irritants influences
the development and severity of asthma.
- Atopy and asthma are related : Eosinophilia and the ability to
make excess IgE in response to antigen is associated with
increased airway reactivity. Asthma is more common in children
who have allergic rhinitis and eczema.
PATHOPHYSIOLOGY Immune and inflammatory responses in the airways are
triggered by an array of environmental antigens, irritants, or infectious organisms.
• Increase immune response : Inflammatory cells respond to and
produce various mediators (Cytokines, leukotrienes, lymphokines),
augmenting the inflammatory response.
• Bronchial edema : Airway epithelium is inflamed and becomes
disrupted, and basal membrane is thickened. Bronchospasm : Airway
smooth muscle is hyperresponsive, and bronchoconstriction ensues.
• Hypersecretion : Airway epithelium is inflamed and Goblet cell
secrete mucous.
CLINICAL SIGNS
• A family history of asthma
• History of periodic wheezing > 3 times
• Recurrent dyspnea
- Nocturnal dyspnea
- Bradypnea expiration
• Cough or running nose
• Not able to drink
• Physical exam
- Chest in drawing
- Central cyanosis
- Wheezing expiration
128 Pulmonary disorder
D-ork-L Pediatric-Medicine disorder
PARACLINIC
• CBC (Increase eosinophil)
• ABG (pH)
• Spirometry test
• Chest x-ray : Chest distension, increased intracostal space,
hyperinflation.
COMPLICATION AND EVOLUTION
• Complication : Pneumothorax, pneumomediatin
• Asthma in nourrisson (Wheeze> 3times / year) : Persistent to 2-3
years-age.
• Asthma in children (Bradypnea , nocturnal dyspnea and prolong ENT
infection) : Persistent to adolescence.
FORMS OF ASTHMA
• Exercise asthma
• Occupation asthma
• Cardiac asthma
• Triad asthma
CLASSIFICATION
• Benign asthma : No daily, sometime dyspnea a month
• Moderated asthma : A few times a week, but not nocturnal dyspnea.
• Severe asthma : Everyday or nocturnal dyspnea, associated with
cough or infection ENT.
DIFFERENTIAL DIAGNONIS
• Congestive heart failure (Nocturnal dyspnea, JVD, Edema)
• COPD (No reversible, hyper inflation)
• Foreign body aspiration (Stridor)
• Pneumonia
MANAGEMENT
• Bronchodilater test, response with ventolin inhaled after 15mn
• Asthma Attack
- Inhalation Ventolin or Adrenaline : 5drops + 5ml NSS
for 4 times per day
- Dexamethasone : 0.5mg/kg/day IV
- Subcutaneous epinephrine if respiratory distress
0.01mg/kg SC, maybe repeat the dose once
- Oxygenotherapy with cyanosis
• Asthma manifestation
- Ventoline® : 0.1-0.3mg/kg/day in 3 divided oral
or Montigat® 1cp everyday
- Prednisolone 1-2mg/kg/day PO
• Treat at home
- Seretide® 1-2 bouffée with Babyhaler per day
- Or Montelukast (Montigat®) : 1cp PO
• Other drugs : Terbutaline, aminophylline, magnesium sulfate,
cyclosporine, methotrexate.
References
The 5-Minute Pediatric
Pulmonary disease 93
Pediatric disorder D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Obstruction inflammatory of bronchioles by viral
• Children 2months -2years
ETIOLOGY
• Respiratory Syncytial Virus 70%
• Other virus 30%
- Adenovirus
- Rhinovirus
- Myxovirus
- Para-influenza virus
PATHOPHYSIOLOGY
• Virus proliferates in coryza of the nasal epithelium with profuse rhinorrhea.
• Infected secretions are aspirated into the lower respiratory tract.
• There is goblet cell proliferation and mucus hypersecretion. The airway lumen
becomes filled with debris consisting of dead cells and mucus resulting in
plugging, which causes partial or complete airway obstruction, increased
airways resistance, hypoxemia, and decreased lung compliance.
CLINICAL SIGNS
• Onset rhinorrhea
• Initially hoarse cough for 3-5days
• Fever persisted
• Dyspnea persisted
• Physical exam
- Dyspnea persisted
- Respiratory rate < 50b/mn
- Cyanosis
- Ronchi, or ronflant, or wheezing
PARACLINIC
• CBC (Supra infection)
• CRP (N < 6mg/mm³)
• Chest x-ray : Distension thorax, hyperinflation
• Rhinopharyngitis
• Bronchitis (Most common in children > 2years)
• Bronchopneumonia
• Gastroesophageal reflux disease (GERD)
• Foreign body aspiration
• CHF
94 Pulmonary disease
D-ork-L Pediatric disorder
•Cystic fibrosis
•Bronchiolitis Obliterans with Organizing Pneumonia (BOOP)
- Obstruction of bronchi and bronchioles by fibrous tissue
- Causes : Inhalation of toxic gases, chronic pulmonary infection, AIDS,
Stevens-Johnson syndrome, idiopathic.
- Clinic signs : Persistent cough, wheezing, sputum, digital clubbing-rare
- Investigation : Chest x-ray nonspecific, confirmed by lung biopsy
- Treatment : Antibiotic, bronchodilator, corticoids
COMPLICATIONS
• Common complications
- Otitis media
- Broncho-alveolitis
- Pneumonia
• Respiratory Distress Syndrome (Acidosis)
• Aspiration Syndrome (Aspiration pneumonia)
• Hypersecretion of ADH Syndrome (Fluid overload)
• Sepsislike Syndrome (Septicemia)
MANAGEMENT
• Admission Criteria
- Need for supplemental oxygen
- Inability to self-hydrate
- Apnea
- Severe underlying chronic lung disease or cardiac disease
- Persistent severe respiratory distress after several doses of β2-agonists
therapy or 4 hours after corticosteroids
- In the patient premature, immunodeficiency or immunosuppressive therapy
- Strongly consider in infants younger than 8 weeks
• Treat by symptomatic
- Paracetamole 40-60mg/kg/day PO
- Desobstruction : Nasal lavage with NSS for 3 times/day
• Nebulizer Berodual (3drops + 4mL of NSS) : 3times/day
• Respiratory kinesitherapy
• Antibiotherapy
- Not usually indicated
- Other than otitis media, the incidence of concurrent serious bacterial
Infection (Pneumonia, meningitis, sepsis) is < 2% in healthy infants with no
underlying disease who have RSV bronchiolitis.
• Antiviral agents (Ribavirin) : Respiratory Syncytial Virus
References
Acute respiratory infection ( WHO )
Handbook’s pediatric
Pulmonary disease 95
Ngam Punlork, MD.
______________________________________
DEFINITION
• Inflammation of bronchiolar, alveolar and parenchyma
• 5 criteries
- Age < 24 months
- Polypnea > 50/mn
- Chest retraction
- Fever
- Breast sound : Crackle and wheezing
ETIOLOGY
- Respiratory syncytial virus 70%
- Adenovirus , influenza , rhinovirus
- Super infections : Pneumococcal, staphylococcal, streptococcal
PATHOPHYSIOLOGY
• Infected secretions are aspirated into the lower respiratory tract.
• The airway lumen becomes filled with debris consisting of dead cells and
mucus resulting in plugging, and bacterial super infection into parenchyma,
increased airways resistance, hypoxemia, and decreased lung compliance.
CLINICAL SIGNS
• History of upper respiration infection
- Fever > 38° C
- Rhinorrhea or congestion nasal
- Productive cough
• Polypnea expiration (RR > 50b/mn)
• Chest retraction
• Crackle inspiration and wheezing expiration
• Cyanosis
• Physical examination
- Chest in drawing intercostals
- Tachycardia > 140b/mn
- Crackle and wheezing
Gravity signs
- Chest retraction
- Nasal flaring
Air hungry - Balancement thoraco-abdo
- Geignement expiration
Hypoxia - Cyanosis
Respiratory distress - SaO2 < 95%
96 Pulmonary disease
Hypercapnia - Tachycardia > 140b/mn

- Hypertension
- Conscience trouble
PARACLINIC
• CBC (Increase WBC : Bacterial infection)
• CRP positive : Bacterial infection
• Chest x-ray :
- Opacity macro-micro nodular with infiltration
- Thorax distension
• Asthma (Recurrent dyspnea)
• Pneumonia
• Pertussis (Severe isolated cough : toux quinteux)
• Myocarditis
COMPLICATIONS
• Common complications
- Pleural effusion
- Pneumothorax
- Atalectasia
- Empyema
- Pericarditis
• Respiratory Distress Syndrome (Acidosis)
• Aspiration Syndrome (Aspiration pneumonia)
• Hypersecretion of ADH Syndrome (Fluid overload)
• Sepsislike Syndrome (Septicemia)
MANAGEMENT
• Admission Criteria
- Need for supplemental oxygen
- Apnea
- Severe underlying chronic lung disease or cardiac disease
- Persistent severe respiratory distress after several doses of β2-agonists
therapy or 4 hours after corticosteroids
- In the patient premature, immunodeficiency or immunosuppressive therapy
- Strongly consider in infants younger than 8 weeks
• Treat by symptomatic
- Paracetamole 40-60mg/kg/day PO
- Desobstruction : Nasal lavage with NSS for 3 times/day
- Nebulizer Berodual (3drops + 4mL of NSS) : 3times/day
• Respiratory kinesitherapy
• Antibiotherapy if necessary
• Oxygenotherapy (Child < 2months : 0.5L/mn and child > 2months : 1L/mn)
• Corticotherapy : Dexamethasone 0.3mg/kg/day IV or IM
References
Acute respiratory infection ( WHO )
Handbook’s pediatric
Most Common Pediatric 97
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Infectious disease by dengue virus
- Primary infection : Dengue Fever
- Secondary infection : Dengue Hemorrhagic Fever
ETIOLOGY
• Transmission by female Aedes mosquito
- Aedes aegypti (Indoor)
- Aedes albopitus (Around the house)
• Dengue virus-RNA (D1, D2, D3, D4), Flavivirus family
• 3 structural proteins
- Capsid : C
- Membrane protein : M
- Envelope glycoprotein : E
PATHOPHYSIOLOGY
• Extrinsic incubation period about 8-10days
• Intrinsic incubation period about 4-8days
• Primary infection is a dengue fever, which neutralizing, antigen-the
same serotype dengue virus.
• Secondary infection is dengue hemorrhagic fever, causing non-
neutralize other serotype dengue viruses (Ag-Ab complex), that
inflammatory response (Histamine, prostaglanding, IL1, IL6, C3a, C5a)
- Leukopenia : Viral invade to bone marrow, and suppression
- Increased vascular permeability : Ag-Ab complex
- Plasma leakage : Hyperpermeability
- Thrombocytopenia : Bone marrow suppression, platelet
aggregation and immune complex on platelet.
World Health Organization required criteria for diagnosis of DF
• Fever unresponsible to antipyretic
• Flushed face
• Headache
• Myalgia
• Retro-orbital pain
• Cutaneous rash
• Abdominal pain
• Vomiting
• Hemorrhagic manifestation
• Leucopenia
• Platelet count normal
98 Common Pediatric Disotder
D-ork-L Infectious disease
World Health Organization required criteria for diagnosis of DHF
• Fever
• Positive tourniquet test or bleeding phenomenon
• Hepatomegaly
• Shock
• Thrombocytopenia (<100,000/mm3)
• Increased vascular permeability with elevated hematocrit (>20%)
World Health Organization required criteria for diagnosis of DSS
• Rapid or weak pulse
• Narrow blood pressure (< 20 mmHg)
• Hypotension
• Cold skin or extremities
• Restlessness
• Capillary refill time > 3 seconds
Clinical signs Paraclinic
- Fever 39-40°C - Leukopenia
- Flushing - Atypical lymphocyte
DF - Periorbital pain - Platelet normal
- Rash - Hematocrit normal
- Abdominal pain
- The same signs - Platelet <100,000/mm3
I - Tourniquet test (+) - Ht > 20% of normal
DHF --------------- ---------------------------------- ----------------------------------
II - The same signs - The same
- Spontaneous bleeding
- Hypotension - The same test
- Pulse weaknss - Severe bleeding
III - GI bleeding - Ht decreased
- Agitation
DSS …………… ---------------------------------
IV - Profound shock
- Pulselessness
Incubation Fever 2-7days Critic 24-48h
Febrile phase Afebrile phase Convalescent
PARACLINIC
- Leukopenia
- Atypical lymphocyte
- Thrombocytopenia
- Increased hematocrit > 20% of normal range : DHF
• Positive IgM anti-dengue serology test
• PCR serotype finding
• Transaminase, PT, aPTT, glycemia
• Chest x-ray and ultrasound
Infectious disease 99
MANAGEMENT
1. IV fluid for DHF grade I and II
Lactate ringer, Lactate D5% or D5% ½Saline

3mL/kg/h
(1-3h)
Improvement No improvement
3mL/kg/h 6mL/kg/h
(1-3h) (1-3h)
Improvement Improvement No improvement

1.5mL/kg/h 3mL/kg/h
(1-3h)
Stop infusion after 48h DSS
2. IV fluid for DHF grade III (Shock)
Acetate ringer, Normal saline

10mL/kg/h
(1h)
6mL/kg/h 10mL/kg/h
(3h) (1h)
Improvement No Improvement No improvement

3mL/kg/h Still increased Ht Decreased Ht
(6h) (Ht > 50%) (Ht < 40%)
1.5mL/kg/h Colloid Fresh Whole Blood

Stop infusion after 24-48h Dextran 40 10-20mL/kg/dose
10mL/kg/h
Improvement
No improvement Improvement
10mL/kg/h
DHF IV and ABCDEFG

Crystalline (AR)
100 Infectious disease
D-ork-L Pediatric disorder
3. IV fluid for DHF grade IV (Profound Shock)
Acetate ringer or Normal saline
10mL/kg/h
15mn Bolus
5% AC or 5%NSS AC or NSS
10mL/kg/h 10mL/kg bolus
Improvement
No improvement No improvement
Reduce dose
6-3-1.5mL/kg/h Improvement
• Hematocrite, ABG
• Electrolyte, calcemia
• Glycemia, BUN, creatinin
• Transaminase
• SaO2
7 P’s ABCDEFG drugs

1. A-Acidosis problem
• Bicarbonate sodium 8.4% : 1mL/kg/dose infusion
2. B-Bleeding problem
• PT, aPTT and bleeding time
• FWB : 10-20mL/kg/dose
• Platelet < 50 000/mm3 give vitamin K 10mg IV
3. C-Calcium problem
• Hypocalcemia < 2mmoL/L
• Calcium gluconate 10% : 1mL/kg/dose IVL or infusion
4. D-Dextrose problem
• Hypoglycemia and hypothermia
• Dextrose 50% : 1mL/kg/dose infusion
5. E-Electrolyte problem
• Hyponatremia < 120mmoL/L
• Na = 0.6 (Weight in kg) x (140 –Na deficit)
half dose IVL and half dose infusion over 4hours
6. F-Fluid overload problem
• Pulmonary edema and anuria
• Furosemide : 0.5-1mg/kg/dose IV
7. G-General cyanosis problem
• SaO2 < 90% give oxygen mask, if not required to mask
should be inbubation.
4. Treatment by symptomatic in febrile phase
• High grade fever
- Paracetamol : 10mg/kg/dose for 4times a day PO
- Compress cool
- Avoid aspirin or NSAIDs
• Seizure/convulsion : Diazepam : 0.5-1mg/kg/dose IR
• Abdominal pain and vomiting : Domperidone : 0.3mg/kg/dose PO
• GI bleeding : Cimetidine : 20mg/kg/day in 3 divided dose PO or IV
• Cerebral hemorrhage : Vitamin K 10mg IV if needed
• Correct electrolyte imbalance
• Follow up vital signs, urine outup and hematocrit
DIFFERENTIAL DIGNOSI
1. Hyperthermia
• Malaria
• Typhoid fever
• Hematology disorder
• Leptospirosis
2. Purpura
• Aplastic anemia, ITP, leukemia (Purpura ecchymosis > 10mm)
• Purpura rheumatoid (Henoch-Schönlen purpura) : Arthralgia, GI
bleeding, and lower extremities purpura.
• Meningococcemia (Purpura necrosis)
• Septicemia (DIC), Hemophilia, vWD, vitamin k deficiency
3. Thrombocytopenia
• ITP, aplastic anemia, leukemia
• Snake envenom bite (DIC), severe sepsis (DIC)
• Chronic liver disease
• Prolonged Aspirin Therapy (Anti-thrombosan A)
4. Increased hematocrit
• Smoking polycythemia is secondary to increased carboxyhemoglobin.
• Secondary hypoxia : Mountain disease, chronic liver disease, chronic
lung disease, congenital cardiopathy.
• Stress polycythemia
• Severe dehydration (Diarrhea, burn)
COMPLICATIONS
1. Febrile phase
• Viremia
• Meningitis
• Encephalitis
2. Afebrile phase
• Electrolyte imbalance : Hypoglycemia, hypocalcemia, hyponatremia
• Coagulopathy : Vasculitis, DIC
• Massive bleeding : GI bleeding, cerebral hemorrhage
• Fluid overload : Acute pulmonary edema
3. Other problems
• Pruritus
• Hypoalbuminemia, anemia
• Pleural effusion and ascites
• Hepatic, renal failure
Reference
Hospital care for children (WH)
102 Pediatric disorder
D-ork-L Infectious disease
Ngam Punlork, MD.
______________________________________
DEFINITION
• Acute infectious disease caused by Corynebacterium diphtheriae,
affects primarily the membranes of the upper respiratory tract with the
formation of a gray-white pseudomembrane or skin wound.
ETIOLOGY
• Corynebacterium diphtheriae, a Gram-positive pleomorphic bacillus
• Transmitted by air droplets of nose or mouth
PATHOPHYSIOLOGY
• Corynebacterium enter mucus membrane of pharynx and epiglottis,
and 2-4 days of incubation at one of these sites, the bacterium
elaborates toxin.
• Locally, the exotoxin induces formation of a necrotic coagulation of the
mucous membranes (Pseudomembrane) with underlying tissue
edema, respiratory compromise may ensue.
• Elaborated exotoxin may also have profound effects on the heart,
nerves, and kidneys in the form of myocarditis, demyelination, and
tubular necrosis, respectively.
CLINICAL SIGNS
• History of immunization : DTP-absence
• Onset rhinorrhea
• Fever (T : 38° C)
• Sore throat
• Hoarseness
• Other : Anorexia, dysphagia, cervical lymphadenitis
Physical exam
• Nasal diphtheria : Rhinorrhea become serosanguineous
• Tonsil and pharynx diphtheria : Pseudomembrane, cervical lymph
node, low grade fever, anoxia, sore throat.
• Larynx and epiglottis diphtheria : Gray membrane, inspiration
stridor, airway obstruction.
• Cutaneous and mucosa diphtheria : Nonhealing ulcer with gray
membrane, conjunctivitis and vulvovaginitis.
Consequent : Exotoxin
• Myocarditis : Arrhythmia, heart block, heart failure
• Neuropathy : First cranial nerve (Diplopia, slurred speech, swallowing)
Pediatric disorder 103
Infectious disease D-ork-L
PARACLINIC
• Smear and culture from throat
• Fluorescent antibody test
• Examination of a methylene blue-stained lesion : Metachromatic granules
may be helpful if performed by an experienced technician.
• Streptococcal pharyngitis
• Infection mononucleosis EBV)
• Candidasis
• Herpes simplex infection
• Adenovirus infection
• Croup
• Acute epiglottitis
MANAGEMENT
• Prophylaxis with DPT vaccination
- Age 6 weeks : DTP1 : 0.5 mL IM
- Over age 4 months : DTP 2 doses given IM at least 4 weeks apart
and a booster dose 1 year later.
• Diphtheria antitoxin (DAT) antiserum, produced in horses
- Pharyngeal or laryngeal disease of < 48 hours duration :
20 000-40 000 units IV (Mild)
- Nasopharyngeal lesions : 40 000-60 000 units IV (Moderate)
- Extensive disease of 3 days' duration or diffuse neck swelling :
80 000-120 000 units IV (Severe)
• Removal gray membrane
• Severe form : Laryngoscopy
• Oral antibiotherapy for 14days
- PNC V : 250 mg x 4 times a day PO or
- Erythromycin : 40-60mg/kg/day
References
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Inflammatory reaction occurs within brain parenchyma with destruction of
neurons (CSF), parenchymal edema, and petechial hemorrhages.
• Meningoencephalitis is inflammation of the brain and the meninges.
ETIOLOGY
• Mode infections
- Direct invasive
- Infections (Airborne, droplet, and contact precautions)
- Post-traumatism or surgery
- Blood stream
• Causes
- Viral infections : Japanese encephalitis, rhabdovirus/lyssavirus,
enteroviruses, varicella, flaviridae, adenovirus.
- Bacterial infections : Chlamydia, TB, listeria monocytogene, HIB
- Protozoan infections : Cryptococcal, toxoplasmose, cat-scratch
PATHOPHYSIOLOGY
• Acute infections : Direct infection by viral or bacterial risk neural cell
• Chronic infections (Fungal , syphilis) : Obstruct of CSF flow, resulting
hydrocephalus, cranial nerve palsies.
CLINICAL SIGNS
• Prodrome of upper respiratory infection : Cough, coryza, malaise, fever,
anorexia, and digestive symptoms.
• Encephalitis is often heralded by fever, headache, hypersalivary, seizure
but hypotonia, motor weakness and Babinski reflex-positive.
- Meningoencephalitis : Headache, fever, neck stiffness, confusion
- Varicella-zoster encephalitis : Hallucination, ataxia, clonus
- Japanese encephalitis : Parkinsonism, delirium, confusion, coma
- Flavivirus (West Nile virus) encephalitis : Febrile illness, often with
rash, headache, lymphadenitis, polyarthropathy, poliolike syndrome.
- Rabies encephalitis : History of animal bite, fever, hypersalivary,
hydrophobia, paralysis.
- Noviral encephalitis : High fever, headache, vomiting, neck stiffness
• Physical exam
- Hypertension, bradycardia, cranial nerves-facial palsy, papilledema,
apnea maybe brain swelling.
- Neck : Stiffness, Kernig or Brudzinski signs (Meningoencephalitis)
- Adenopathy (Mycobacterium, cat scratch, Bartonella)
- Chest : Signs of pneumonia, rales, rhonchi ( Mycobacterium and
Mycoplasma infections, HIB)
- Abdomen : Hepatosplenomegaly (Epstein–Barr virus, Ehrlichia)
- Skin : Purpura (Rickettsial, meningococcemia) to erythematous or
papular (Lyme disease, Enterovirus)
- Neurologic exam : Confusion to delirium with hallucinations to stupor
and aphasia (Herpes virus), poliolike syndrome (West Nile virus),
hydrophobia (Lyssavirus-Rabies), parkisonian syndrome (JEV).
D-ork-L
PARACLINIC
- WBC usually elevated and CRP positive : Bacterial Infection
- Electrolytes, glucose, BUN, creatinine
- Bacterial and viral blood cultures
- Liver function tests, ammonia level if hepatic failure suspected
• Carboxyhemoglobin level if CO poisoning suspected
• Toxicology screen if ingestion suspected in differential
• Increased intracranial pressure : Cryptococcal suspected
• CSF examination : Cell count and chemistry
- Elevated WBC, predominantly neutrophils (Bacterial infection)
- Normal or elevated WBC, predominantly lymphocytes (Viral infection)
- Elevated protein
- Glucose (Normal in viral infection)
- Gram stain with or without India ink for suspected/confirmed HIV
• Viral and bacterial cultures (Fungi if indicated by history)
• Serum antibody : ELISA
• CSF-PCR
• CT scan
- To rule out trauma, hemorrhagic conditions, and mass lesions
- Cerebral edema may be the only finding consistent with encephalitis.
- HSV may show parenchymal hemorrhagic areas of the frontal and
temporal lobes, along with edema.
• MRI : Hypodense temporal lobes in HSV.
• Meningitis
• Meningo-encephalitis
• Brain abscess
• Stroke (Hemorrhagic or ischemic)
• Head injury
• Subarachnoid hemorrhage
• Encephalopathy (Hepatic, uremic)
MANAGEMENT
• Admit to ICU
- ABCDE resuscitation
- Supporting care
- DON’T : Dextrose, Oxygen, Nalaxone, Thiamine
- Stop seizure with Diazepam, or Phenobarbital
• Treat underlying disorder
- Viral encephalitis : Ganciclovir® or foscanet® and antiretroviral for HIV
- Bacterial encephalitis : Antibiotherapy with antibiogram specific
- Fungal encephalitis : Cryptococcal with amphothericine B and continue
fluconazole or Toxoplasmosis with cotrimoxazole long life.
• Prevention by vaccination : HIB vaccination, JE vaccination.
References
106 Common pediatric disorder
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
•
Diarrhea : Watery stool or semi liquid stool more than 3times or
increased fluid content of the stool >10 mL/kg/day.
ETIOLOGY
• Viral infections 70%(Rotavirus, in children < 18months)
• Bacterial infections (Enterobactery or entero-invasif)
• Protozoan (Amoeba, parasites)
• Other causes : Yeast, lactose intolerant, oil, milk allergy
PATHOPHYSIOLOGY
• Hypersecretions : Submucosa of colon inflammation or damage
• Hyperperistasis : Incomplete bowel obstruction
• Malabsorption : Poorly absorbed or nonabsorbable solute is present
in the intestinal lumen. This can occur with the ingestion sugars,
carbohydrate malabsorption. Usually cause by prolonged antibiotic or
fungal infection.
• Hyperosmolarity : In general, the solute composition of intestinal fluid
is similar to that of plasma. Osmotic diarrhea occurs when poorly
absorbed risk of increased osmolar in the intestinal lumen. Water into
intestinal lumen that cause of acute diarrhea.
CHARACTERISTIC
• Acute diarrhea : < 14 days
• Persistance diarrhea : 14-28 days
• Chronic diarrhea : > 28 days
CLINICAL SIGNS
Evaluation Without Moderate Severe
dehydration dehydration dehydration
Conscious Anxious Agitation, somnolent Lethargy , coma
Drink & thirsty Drink well Thirsty, vomiting No able drinking
Eye Tear No tear, dry eye Sunken eye
Skin pinch Anxious Retardation > 3sec Severe retardation
PARACLINIC
• Completed blood count (CBC)
- Elevated WBC, predominant neutrophils : Bacterial infection
- Normal WBC, CRP negative : No bacterial infection
• Stool test, yearst, oil, lactose
• Stool culture (Coproculture)
• Ultrasound : Intussusception, bowel obstruction finding
Gastrointestinal diseases 107
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COMPLICATION
• Dehydration (Hypovolemic shock)
• Electrolyte inbalance (Hypokalemia)
• Hypoglycemia
• Pseudomembranous colitis
• Necrotizing colitis
• Septicemia
• Hemolytic uremic syndrome
• Renal complications : Kidney or adrenal necrosis, failure
• Pneumonia
• Severe malnutrition
• Diarrhea by vibrio cholerae (Cholera)
• Dysentery (Shigella or entamoeba histolytica)
• Food poisoning (Clostridum botulism)
• Helminthic infections
• Bacterial gastroenteritis
- Temperature >39 °C
- Toxic clinical appearance
- Crampy abdominal pain
- Bloody mucoid stools
• Viral gastroenteritis
- Seasonal epidemics
- Guaiac-negative stool
• Noninfectious
- Milk allergy : Heme-positive stool, vomiting
- Malrotation with midgut volvulus
- Inflammatory bowel disease
- Intussusception: Currant jelly stool, abdominal mass
MANAGEMENT
1. Prevent of diarrhea
• Exclusive breast feeding
• Improvement wearing practice
• Use of plenty of clean water
• Hygiene
• Use of latrine
• Proper disposal of stool young children
• Immunization again measles
2. Treat of dehydration
• Dehydration < 5% (Table A : Without or mild)
- Oral rehydration
- SRO : 15-20mL/kg/h
- Enfant < 2 years : 50-100mL after a diarrhea or vomiting
- Enfant > 2 years : 100-200mL after a diarrhea or vomiting
108 Gastrointestinal diseases
D-ork-L
• Dehydration 5-10% (Table B : Moderate)
- Follow up 4hours : SRO 75mL/kg/4h
- If vomiting or no drinking give IV fluid
• Dehydration > 10% (Table C : Severe)
- First time give lactate ringer : 30mL/kg/h bolus
- Second time give lactate ringer : 70mL/kg/5h
3. Treat underlying of enterobacterial
• Cause : E-coli, salmonella, shigella, helicobacter pyloric, yersinia
• Clinical signs : Fever, abdominal pain, mucus or bloody stool
• Treatment : Ciprofloxacin 30mg/kg/day PO
• Ameba : Metronidazole 30mg/kg/day PO
• Fungal (Leuvur or yeast) : Stop antibiotic and give bioflor®,
nystatin® and vita- B1 per oral.
• Parasite
- Ascariasis : Pyrentel® 12mg/kg/dose PO
- Ankylosis : Albendazole® 400mg/day PO for 3 days
- Taenia solium or saginata : Niclosamide
- Schistosoma : Praziquentel® 40-60mg/kg/day PO
• Lactose intolerance : Free lactose milk
5. Treat by symptomatic
• Antipyretic : Paracetamole 40-60mg/kg/day PO
• Anti-diarrhea : Smecta®, Biolactyl®, Polysilane®, Bioflor®
• Antiemetic : Domperidone®, Promethazine®
• Antispamodic : Dispan®, Buscopan®, Spasfon®
• Absorbant : Carbophos®, Acticarbin®
• Bloating with rhinorrhea : Colicaid®
References
Neonatal disorder 109
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Jaundice in newborn is the clinical manifestation of hyperbilirubinemia
• Yellow pigmentation of tissues due to elevated serum bilirubin
PATHOPHYSIOLOGY
• Bilirubin is formed by destruction of red blood cells and heme protein (
Fe + biliverdin), into circulation (Unconjugate bilirubin) indirect ,
transported to liver (Conjugate bilirubin-water soluble), bilirubin is
excreted in blood 80% and enterohepatic cycle 20% (Converse by
bacterial to urobilin and stercobilin)
• Prehepatic : Hemolysis (G6PD deficiency, AIHA, Malaria), increased
indirect bilirubinemia (Unconjugated bilirubinemia)
• Intrahepatic : Liver disease, liver abscess, malaria (Increased total ,
conjugated bilirubinemia)
• Posthepatic : Gallbladder stone, biliary atresia/obstruct, Budd-chari
syndrome (Conjugated bilirubinemia)
ETIOLOGY
• Most common in premature 80%
• Hyperbilirubinemia in neonate
• Materno-fetal blood incompatibility
• Miscellaneous
- Hemolysis
- Anoxia, hypoxia, acidosis
- Infectious causes
- Hypoglycemia, hypoalbuminemia, polyglobulia
- Gestation Diabetes Mellitus
- Drugs-used : Paracetamole, indometacine, furosemid, diazepam,
tetracycline, chloramphenicole, caffeine, aminoglycosides.
DIAGNOSIS
1. Physiologic jaundice
• Present 24-48h after birth and continue until 7days
• Durant 2-7days
• Bilirubin 6-12mg/dL or total bilirulin < 200 µmoL/L
• No signs of neurologic : No seizure, feeding normal
2. Pathologic jaundice
• Prolonged jaundice > 7days
• Pathology jaundice (Soon after birth)
• Hepatomegalia
• Anemia
• Seizure and neurologic signs
110 Neonatal disorder
D-ork-L
3. Bio-chemic
• Physiologic : Total bilirubin (TB) < 200µmoL/L
• Pathologic : TB > 200µmoL/L for premature, TB > 350µmoL/L neonate
4. Pediatric Considerations
• Intrahepatic cholestasis
• Cardiovascular (Congenital heart disease, congestive heart failure,
shock, asphyxia)
• Metabolic or genetic (Trisomy 18 and 21, cystic fibrosis, Gaucher's
disease, Niemann-Pick disease, glycogen storage disease type IV)
• Infectious (Bacterial sepsis, cytomegalovirus, enterovirus, herpes
simplex virus, rubella, syphilis, tuberculosis, varicella, viral hepatitis)
• Hematologic (Severe isoimmune hemolytic disease)
PARACLINIC
• CBC, blood group, Rhesus
• Total bilirubin, direct and indirect bilirubin
• Liver function, PT and PTT
• Glycemia, calcemia
• Blood film morphology
• Coombs test, G6PD test
• Hypoalbuminemia : Decreased with severe liver disease
• Prothrombin time : Prolonged level is an important prognostic
indicator in patients with acute hepatitis or vitamin K deficiency
• Increased transaminases
- Alanine aminotransferase (ALT, SGPT): primarily in the liver
- Aspartate aminotransferase (AST, SGOT): liver, heart, kidney,
skeletal muscle, and brain.
• Alkaline phosphatas / glutamyltranspeptidase: Biliary tree
obstruction/cholestasis
• Stool color : Acholic (White) stools suggest biliary atresia.
• Imagery : Ultrasound, CT scan
1. Unconjugated hyperbilirubinemia 80%
• Physiologic jaundice : After 24 hours, in premature, 6-12 mg/dL
• Breat milk jaundice : In general jaundice, breat-fed infant can develop
elevations, starting first week of life 15-27mg/dL by the second or third.
• Increased hemolysis : Materno-fetal incompatibility (ABO) , G6PD
deficiency, autoimmune hemolytic anemia (AIHA), newborn hemolytic
syndrome (NBHD)
• Miscellaneous : Hypothyroid, Down’s syndrome, pyloric stenosis,
urinary infection, hemoglobinopathy, Wilson disease, Gilbert disease,
Crigler-Najjar syndrome.
2. Conjugated hyperbilirubinemia 20%
• Etiology
- Intra hepatic : Cholestasis due viral infections (HBV, CMV, herpes
, rubella), E-coli infection, malaria include increased hemolysis
Neonatal disorder 111
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- Extrahepatic diseases : Biliary atresia, cholangitis, Budd-chiari’s
- Metabolic causes : Metabolic abnormalities include in alpha1-
antitrypsin deficiency, cystic fibrosis, and galactosemia
• Clinical signs
- Prolonged jaundice
- White stool
- Hepatomegalia
• Investigation
- CBC, Bilirubin, Transaminase, Coombs test, G6PD test, hepatitis
- Abdominal ultrasound (Hepatic)
MANAGEMENT
• Isotonic IV fluid therapy if dehydrated
• Toxic-appearing patients :
- Supplemental oxygen, cardiac monitoring
- Nasogastric suction and bladder catheterization
• Phenobarbital : Seizure in sepsis and drug-induced causes,
decreases conjugated bilirubin.
• For NBHD give vitamin K and infectious causes give antibiotic
• Phototherapy and transfusion
Therapeutic in jaundice-newborn Phototherapy Transfusion
Healthy full-term Bilirubinemia level > 15mg/dL > 25mg/dL
Sickness full-term Bilirubinemia level 10-15mg/dL 20mg/dL
Premature Bilirubinemia level 5-14mg/dL 14-20mg/dL
• For bacterial cholangitis/sepsis, obtain blood cultures and administer

parenteral antibiotics : Ampicillin, gentamicin, and metronidazole
• Obstructive extrahepatic jaundice : Surgical consultant
• Choledocholithiasis : ERCP papillotomy, balloon or basket retrieval,
or open surgery.
References
Ngam Punlork, MD.
______________________________________
DEFINITION
• Malaria is a protozoan disease caused by the genus Plasmodium and
transmitted by female Anopheles mosquitoes.
ETIOLOGY
• It is characterized by hectic fever and often presents with classic
malarial paroxysm. Four species of genus plasmodium usually infect
humans.
- Plasmodium Vivax
- Plasmodium Falciparum
- Plasmodium Malariae
- Plasmodium Ovale
• Mode transmission
- Female Anopheles
- Blood transfusion, congenital
PATHOPHYSIOLOGY
• Sexual cycle
- Develops in the female Anopheles mosquito providing the
sporozoites to the host.
- Male and female gametocytes are taken up by a female anopheline
mosquito with a blood meal where they fertilize in the mosquito gut
to produce a diploid zygote that matures to an ookinete, haploid
sporozoites are generated that migrate to the salivary gland of the
mosquito to infect another human.
• Asexual cycle
- After bite in the human (Sporozoites in blood steam), first in the
liver producing merozoites and then in the erythrocytes.
- In the hepatocytes, the sporozoites mature to tissue schizont or
become dormant hypnozoites.
- The tissue schizont amplify the infection by producing large number
of merozoites (10,000 to 30,000).
- When merozoites affected to RBC are called trophozoites
- Each merozoite does not replication in RBC, developed to
gametocytes.
CLINICAL SIGNS
• Incubation 1-2weeks
• History of living malaria zone
• Fever frequent evening
- Tertian : Every 3days
- Quatian : Every 4days
- Subtertian : Disease is lethal
• Classic malarial paroxysm characterized by
- Cold stage : Frisson (30-60mn)
- Hot stage : Fever > 41° C (3-4hs)
- Sweating stage : Sweat
1. Plasmodium Falciparum
• Simple malaria (Benign Malaria)
- Frisson, fever, sweating, headaches, myalgia, fatigue
• Severe malaria (Malign Malaria)
- Hypoglycemia
- Hemoglobinuria 4H
- Hepatomegaly
- Hypoxia
- Convulsion
- Colapsus vascular 4C
- Cerebral malaria
- Coma
- Renal failure 2R
- Respiratory distress
- Jaundice
- Anemia 2Pallors
2. Plasmodium Vivax
• Tertian malaria : Fever occurs every 3days
• Incubation period after exposure is 14days (Range: 8 to 27days)
• Hypnozoites may cause relapse of infection after years
• Infects mainly reticulocytes
• Irregularly shaped large rings and trophozoites, enlarged RBC, and
Schüffner's dot are seen in peripheral blood smear
• Pigment color is yellow-brown
• P. vivax from Papua New Guinea have reduced sensible-chloroquine
• Primaquine needed to eradicate the hypnozoites
3. Plasmodium Ovale
• Also known as tertian malaria, fever occurs every other day
• Incubation period after exposure is 14days (Range: 8 to 27days)
• Hypnozoites may cause relapse of infection
• Infects mainly reticulocytes
• Infected RBC seen as enlarged, oval shape containing large ring or
trophozoites with Schüffner's dot. Pigment color is dark brown
• Primaquine needed to eradicate the hypnozoites
• No chloroquine resistance encountered
4. Plasmodium Malariae
• Quartan malaria : Fever occurs every 3 days
• Chronic malarial infection, persist 20 to 30 years
• May cause soluble immune-complex, resulting in nephritic syndrome
• May persist in blood for many years if treated inadequately
• Incubation period after exposure is 30 days (Range: 16 to 60 days)
• Lacks hypnozoites (Intrahepatic stage)
• Infects mainly mature RBC
• Band or rectangular forms of trophozoites are commonly seen in
peripheral blood smear. Pigment color is brown-black
• Chloroquine can be used cautiously for falciparum malaria acquired in
chloroquine-sensitive areas (Chloroquine is more rapidly than quinine)
• Treatment is oral quinine sulfate 10mg (salt)/kg (Usually 650 mg) q8h
for 3 to 7days, followed by pyrimethamine with sulfadoxine (Fansider)
3tablets (Each tablets contains 500mg sulfadoxine and 25mg
pyrimethamine) or doxycycline 200mg loading dose, then 100mg bid
for 7days to eradicate asexual forms of the parasite.
5. Congenital malaria : In the pregnant patient, increased perinatal mortality
has not been reported with malaria in stable, endemic regions. However,
for semi-immune or non immune mothers, transplacental antibodies may
be lacking, and the risk of congenital infection may be higher in this
subgroup.
• Early symptom after birth, jaundice, hepatomegaly, fever, trouble
hemostasis. Cause by occlusion of microvasculature of placenta
(Transplacental antibodies)
• Late symptom after 14-21days, transmitted during at birth.
6. Cerebral malaria are caused by occlusion of the cerebral
microvasculature from infected red cells. It is the most serious
consequence of malaria infection. Prognosis depends on the management
of other complications (Acidosis, renal failure). Cerebral malaria will
manifest with signs of increased intracranial pressure, encephalopathy,
and seizures.
7. Black water fever is due to acute renal failure caused by accumulation of
hemoglobin in the renal tubules resulting in hemoglobinuria with dark
urine. This often occurs after repeated attacks of P. falciparum.
8. Hemolytic anemia, the most common disease finding, can be severe,
especially in P. falciparum, the predominant mechanism is due to
intravascular hemolysis from fragile erythrocytes (G6PD deficiency, Sickle
cell disease, thalassemia) rather than solely rupture from infected cells.
9. Hypoxia : Sequestation, cytoadherance, rosetting, reduce RBC
deformability.
10. Mechanism of hepatomegaly and sphenomegaly
Tropical splenomegaly syndrome seen in chronic infections caused by P.
malariae produces splenomegaly, hepatomegaly, portal hypertension, and
pancytopenia. In P. vivax malaria, acute splenomegaly can induce rupture.
PARACLINIC
• CBC (Hb decrease)
• Blood smear of malaria
• Hypoglycemia
• G6PD test
• Electrolyte
• Liver and renal function
• PCR of malaria
• Dengue Fever, DHF
• Enteric Fever
• Urinary tract infection
• Yellow fever
• Influenza
• Viral hepatitis
• Trypanosomiasis
MANAGEMENT
1. Prophylaxis
• Personal protective measures against Anopheles mosquito bites
• Chemoprophylaxis is strongly advised for travelers in endemic zoon
• Chloroquine is the drug of choice in resistant areas (500 mg once a
week or 5 mg/kg once a week) and 4 weeks after leaving the endemic.
• Mefloquine is recommended in chloroquine-resistant areas (250 mg
once a week.
2. Treat underlying cause
• Severe Plasmodium Falciparum
- Artesunat (Artemather®)
D1 : 3.2mg/kg IM
D2 : 1.6mg/kg/day
---------------------
---------------------
D5 : 1.6mg/kg/day IM
D6 : Mefloquine : 25mg/kg/day PO
- Check malaria test before exit hospital
• Mild Plasmodium Falciparum : Malarine® , or A+M5®
3. Resistant
• Quinine : 20mg/kg infusion follow up every 4h, quinine : 10mg/kg
repeated every 8h oral, associated with tertracycline 250mg x 3 times
for 7days.
4. Severe malaria infectious
• If Hb < 4g/dL : Transfusion packed cell 10-15mL/kg
• Coma and renal failure : Dialysis
5. Hypoglycemia : D10% : 5mL/kg infusion
References
Vademecum clinique (MASSON)
Ferri’s Clinical Advisor
116 Pediatric disease
D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Acute systemic viral illness
• Rubeola, First disease
ETIOLOGY
• Measles virus is a single-stranded RNA paramyxovirus
• Transmission by droplet and highly contagious
• Measles is a highly contagious disease in nonimmune persons
PATHOPHYSIOLOGY
• The virus enters the body through the respiratory tract, incubation 10-
14 days between exposure and onset of symptomatic , multinucleated
giant cell can be recovered from urine, and nasal secretions.
CLINICAL SIGNS
• History of the patient’s nonimmune
• Onset prodrome : Fever, coryza, cough, conjunctivitis, photophobia
• Exanthems after 3 days of prodrome
- Irregular marculopapular rash
- Brick-red on face to trunk extremities
• Koplik’s spots on the bucal mucosa
• Associated : Diarrhea, anorexia, fatigue, sore throat, lymphadenitis
PARACLINIC
• CBC : Leukopenia
• Nasopharyngeal secretions culture
• Smear (Frottis nasal : Warthin-Finekeldey)
• Serologic testing (Measles-specific IgM < 72hours from onset of rash)
• Monoclonal antibody immunofluorescence
• Other acute exanthems fever
- Rubella
- Herpes simplex (HSV1, HSV2)
- Varicella (Herpes zoster : HHV3)
- Epstein-Barr virus infection (HHV 4)
- Cytomegalovirus (HHV 5)
- Roseola (Exanthem subitum : Human herpes virus 6)
- Enterovirus (Coxsackivirus)
• Drug allergy
• Scarlet fever
• Kawasaki disease
Pediatric disease 117
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COMPLICATIONS
• Diarrhea
• Otitis media
• Laryngitis
• Pneumonia
• Encephalitis
MANAGEMENT
• Primary immunization preventive : At age 9 months or after
15months.
• Treatment of patient
- Bed rest and analgesic
- Isolating for 1 week following onset of rash
- For children with ophthalmologic evidence of vitamin A deficiency, a
3rd dose at 4 weeks is indicated.
• Specific treatment
- Passive immunoglobulin : 0.25 mL/kg IM (Max 15 mL)
- Double the dose for immunocompromised persons
- Ribavirin for severe measles pneumonitis
- Secondary bacterial complications by antibiotic
References
Pediatric emergency & medicine (McGrow-Hill)
Current essentials of medicine (LANGE)
D-ork-L Medicine disorder
Ngam Punlork, MD.
______________________________________
DEFINITION
• Inflammation of meninges and CFS infection
ETIOLOGY
• Micro organism (Bacterial, viral, fungi) direct or extension from
- The ear (Chronic otitis)
- Nasopharyngeal infection
- Cranial injury
- Congenital meninges
- Blood stream spread
• Non infections : Drug , malignant cell (Subarachnoid hemorrhage)
PATHOPHYSIOLOGY
• Bacterial meningitis is an inflammation of meninges with increased
intracranial pressure, and pleocytosis or increased WBCs in CSF
secondary to bacteria in the pia-subarachnoid space and ventricles,
leading to neurologic sequelae and abnormalities(Hydrocephalus,
cerebral edema)
- Neonate : Streptococcus B, E-coli, Listeria monocytogene
- Enfant : Haemophilus influenzae B, meningococcal, pneumococcal
- Chronic illness : Mycobacterium TB
• Viral meningitis is acute aseptic meningitis usually with lymphocytic
pleocytosis and negative CSF stains and cultures.
- Lynphocytosis > PMN
- CSF without pus
- Not cerebral edema exception encephalitis
- Gems: Enterovirus (Echovirus, coxakivirus), Mump virus, Herpes
• Fungal meningitis
- Immuno-compromised patient (HIV, Cytotoxic)
- Cryptococcal meningitis
- Gems : Cryptococcus neoformans, Candida, Histoplasma
capsulatum Blastomyces dermatidis (USA)
CLINICAL SIGNS
1. Meningitis Syndrome (Triad)
- Headache
- Neck rigidity
- High fever or vomiting
2. Children and adult
• Vomiting are often present
• Seizure
• Photophobia
Medicine disorder D-ork-L
• Affective on cerebral and cranial nerves

- Venous sinus thrombosis
- Severe cranial edema
- Hydrocephalus
- Cerebral abscess
• Pupil edema (Before lumbar puncture should be find tumor cerebral)
• Mental status change (Deliros)
• Purpura necrosis with meningococcal
• Meningismus : Positive
- Kernig : Flexed knee resists extension (Bilateral).
- Brudzinski : Flexion of neck produces flexion at hips.
3. Neonate
• Fever or hypothermia
• Lethargy
• Weak suck
• Vomiting or no feeding
• Respiratory distress
• Irritability
• Bulging fontanel
• Meningismus : Commonly absent when <12 months old
4. Viral meningitis without sequelae neurological
5. Elderly and Immunocompromised
• Confusion with or without fever
• Less striking symptoms
• Cryptococcal meningitis
- Severe headache
- Increased intracranial pressure
- Lethargy, confusion, coma
6. Diagnosis of meningitis depend upon lumbar puncture
• Routine CT before lumbar puncture (LP) with patient
- Immunodeficiency/HIV
- History of CNS disease (abscess, bleed, mass lesion)
- History of seizure <7 days
- Focal neurologic deficit
- Diminished consciousness/mentation/comatose
- Older than 60 years
- Papilledema
• Do not give antibiotic before lumbar puncture
PARACLINIC
• CBC (Complete blood count)
- Increase WBC, PMN, and CRP(+) : Bacterial infection
- Normal WBC but lymphocytosis : Viral infection
• Hemoculture antibiogram
• CSF (Gram’s stain, count cell)
• CSF culture A/B, Chines ink (Cryptococcal), PCR
D-ork-L Medicine disorder
• Imageries : CT scan, MRI, ultrasound, chest x-ray

1. Sudden headache of subarachnoid hemorrhage (Trauma, tumor)
2. Migraine headache (Unilateral headache)
3. Other meningitis with CSF analysis
• Typical bacterial meningitis :
- WBC > 100 (Usually 1 000-20 000)
- Differential > 80% PMNs
- Protein > 200 mg/dL
- Glucose < 40% of serum
• Typical viral meningitis :
- WBC < 2 000
- Differential : initially polymorphonuclear neutrophils (PMNs), then
after 24 hours, predominantly lymphocytes
- Protein < 200 mg/dL
- Glucose normal
• Typical fungal meningitis :
- WBC < 500
- Differential lymphocytes
- Protein > 200 mg/dL
- Glucose low
• Typical tuberculosis meningitis:
- WBC range, 100-400
- Differential mixed
- Protein variable
- Glucose variable
MANAGEMENT
1. Prevention
• Obligated immunization : BCG, HBV, DTP, Polio, Measles, HIB
• Other : Pneumococcal, meningococcal, MMR
2. Treat by symptomatic
• Fever : Paracetamole 40-60mg/kg/day
• Seizure : Diazepam 0.5-1mg/kg/dose IR or IV or IM
• Bacilla gram negative (Haemophilus influenzae)
- Dexamethasone : 0.15mg/kg x 4 times per day
- Ceftiaxone or cefotaxime : 200mg/kg/day
- Vancomycine : 60mg/kg/day, Durant 10-14days
• Cocci gram negative (Menigococcal : Purpura fulminans)
- Cefotaxime + Vancomycine, Durant 7-14days
- Prophylaxis : Rifampicine : 10mg/kg/day for 2days
or ceftriaxone (Pregnant) or ciprofloxacin (Adult) single dose.
• Cocci gram positive (Pneumococcal)
- Cefotaxime : 300mg/kg/day
- Vancomycine : 60mg/kg/day, Durant 10days
Medicine disorder D-ork-L
4. Neonatal meningitis
• Listeria monocytogene meningitis sensible with Amino-penicillin
• Ceftriaxone + Ampicilline + Gentamycine
5. Tuberculosis meningitis
• Poor prognosis if do not treatment
• Sequellas 10-30 % : Epilepsia, hemiplesia, hydrocephalus, psychiatric
• Corticotherapy if conscious trouble
- Prednisolone or hydrocortisone reduce long-term complication
• Antituberculous therapy until 9-12months but avoid Ethambutol
6. Cryptococcal meningitis
• Premedication
- Hydrocortisone 50mg IV
- Paracetamole 1g PO
- Promethazine 25mg PO
• Treatment
- Amphotericin B : 0.7mg/kg/day with D 5% infusion for 14-21days
• Prophylaxis : Fluconazole : 200-400mg everyday PO
COMPLICATIONS
• Bacterial meningitis
- Acute complications : Hypersecretion ADH syndrome, seizures
occur in up to 1/3 of patients, focal neurologic signs occur in10-15%
- Long-term complications : Mental retardation, hearing defects,
hydrocephaly.
• Viral meningitis
- Acute complication : Hypersecretion ADH in 10%
- Long-term complications : Complications from viral meningitis are
rare. However, neonates (<1 month of age) may develop severe EV
disease and older agammaglobulinemic children may develop
chronic EV meningoencephalitis.
• Tuberculous meningitis
- Acute complications: Most common are cranial nerve findings,
especially 6th cranial nerve palsy affecting the eyes; hydrocephalus
- Long-term complications: Many, including blindness, deafness, and
mental retardation.
References
122 Genitourinary Diseases
D-ork-L Pediatric Disorders
Ngam Punlork, MD.
______________________________________
Acute glomerulonephritis
DEFINITION
• Post streptococcal glomerulonephritis
• Acute glomerulonephritis (AGN) is acute inflammatory damage to
glomerulus, associated with :
- Edema
- Hypertension : Increase afferent artery pressure
- Hematuria : Active urine sediment (RBC casts)
- Proteinuria : Nonselective
ETIOLOGY
• Most common in children between 3-7 years and under 2 years of age
are rarely affected
• Post-streptococcal infection
- 5-10% in pharyngitis : 1-3weeks after infection
- 25% in skin infections : 2-4weeks after infection
• IgA Nephropathy : Most common cause of AGN (>25%)
- Ab-Ag causes immune complex deposition of IgA and C3.
- Complement levels are usually normal
• Noninfectious Causes of glomerulonephritis
- Systematic lupus erythematosus
- Henoch-Schönlein purpura, vasculitis
- Wegener granulomatosis
- Goodpasture syndrome
PATHOPHYSIOLOGY
• Glomerulonephritis probably results from the deposition of circulating
immune complexes in the kidney, theses immune complexes are
deposited on the basement membrane, reducing glomerular filtration.
• Inflammatory complex depend upon :
- Infection by grope A beta-hemolytic streptococci
- Complex Ag-Ab attack of basement membrane of glomerula
- Toxin effect of streptococcal to basement membranous glomerula
• Exact mechanism of AGN unclear :
- Combination of autoimmune reactivity to specific antigens at renal
glomeruli
- Glomerulonephritis comprises 25-30% of end-stage renal disease
CLINICAL SIGNS
• Post streptococcal infection of pharynx (Exposure 1-2weeks)
- Fever
- Sore throat
Genitourinary Diseases 123
D-ork-L
- Malaise
- Abdominal pain
• Acute glomerular inflammation
- Sudden onset 1-7days
- Edema and hematuria (90%)
- Oliguria 80% ( Urine < 400mL/day )
anuria prognosis to acute renal failure in 2% of children
- Hypertension (60-70%)
- Proteinuria non selective (2g/m2/24h)
PARACLINIC
• CBC
• BUN ( Blood Urea-Nitrogen ) and creatinine-elevated
- Creatinine clearance > 200mg/24h
- Ratio protein / creatinine (< 0.2 normal)
• Azotemia
• ASLO positive
• Urinalysis
- Proteinuria non selective
- Erythrocyte cast
- Leukocyturia
- Hyaline, glanular
• Renal ultrasonography, IVP and renal biopsy
• 3 Serologic markers
- Serum C3 level is reduced in 90-100% of children during the first 2
weeks of illness, returning to normal with 3-4 weeks.
- Anti glomerula basement membrane antibody (AGBM antibody)
- Anti nucleo cytoplasmic antibody (ANC antibody)
• Streptococcal antibodies :
- Antistreptolysin (ASO) more reactive in pharyngeal infections
- Antistreptokinase (ASK) elevated in recent hemolytic streptococcus
- Antideoxyribonuclease B (ADNase B), anti-nicotinyl adenine
dinucleotidase (ANADase), and antihyaluronidase (AH) : Skin
COMPLICATION
• Anemia
• Hyperkalemia
• Acute renal failure
• Chronic renal failure evolution to ESRD
1. Nephrotic syndrome
• Proteinuria > 50mg/kg/24 h
• Hypoprotidemioa < 60g/L
• Hypoalbuminemia < 25g/L
• Hypercholesterolemia
2. Henoch Schönlein Purpura (Rheumatoid purpura)
• Purpura rash, arthralgia
124 Genitourinary Diseases
D-ork-L
• GI bleeding
• Glomerular syndrome
3. Wegener’s Granulomatosis : Vasculitis associated with
• Glomerulonephritis
• Respiratory symptoms : Cough, dyspnea, chronic sinusitis, otitis
media, hemoptysis
• Neuropathy, purpura, arthritis, scleritis
• Conformed diagnosis : C-ANCA, large nodular by chest x-ray, biopsy
• Treat by corticoids or cyclosporine and cotrimoxazole
4. IgA Nephropathy
• Most common cause of AGN (>25%), worldwide
• Antibody-Antigen causes immune complex deposition of IgA and C3.
• Complement levels are usually normal.
• IgA-Nephropathy has different presentations :
- Gross hematuria following upper respiratory infection (URI)
- Microscopic hematuria with proteinuria
- Hematuria occurs either during viral illness or after exercise.
- Prognosis is related to serum creatinine, blood pressure, and
proteinuria.
- 50% of patients with proteinuria may develop progressive renal
disease.
• Angiotensin converting enzyme inhibitor or angiotensin receptor
blocker RBS may help.
5. Proteinuria (> 100mg/24h)
• Proteinuria + leukocyturia : Urinary tract infection
• Proteinuria + hematuria : Glomerulonephritis, Alport syndrome,
Berger ’s disease (Ig A nephropathy), HUS, Lupus nephritis
• Proteinuria + edema : Lipoid nephrosis
6. Hematuria (≥ 100 000/mL)
• Nephroblastoma
• Lithiasis
• Urinary tract infection
• Kidney traumatism
• Glomerular syndromes : Glomerulonephritis, Berger’s, Alport’s, HUS
MANAGEMENT
• Fluid and salt restriction
• Supporting diet and vitamin B
• Edema and hyperkalemia are often required to diuretics
Furosemide 0.5-1mg/kg/dose
• Hypertension (Calcium channel blocker)
• Antibiotherapy : Benzathine penicillin or ceftriaxone
• Follow up every months, ASLO test
and Extrancilline® 2.4 millions/month
References
Rosen and Barkin’s 5 minute medicine
Pediatric Disorder 125
Genito-urinary Disease D-ork-L
Ngam Punlork, MD.
______________________________________
DEFINITION
• Endocrinology
• Idiopathic nephrotic syndrome
• Diseases causing defect in glomerular filtration barrier, producing
- Proteinuria >3.5g/day(Protein selective)
- Hypoalbuminemia (Serum albumin < 3 g/dL)
- Peripheral edema due to hypoalbuminemia
- Hyperlipidemia (Fasting cholesterol >200mg/dL)
PATHOPHYSIOLOGY
1. Immunologic factor
• A number of immunologic abnormalities are seen with nephrotic syndrome
that predispose to infection.
• Risk decreased serum levels of complement factors D and B, abnormal
humoral immunity, decreased delayed hypersensitivity and proliferative
responses, and increased suppressor-cell activity and suppressor
lymphokine levels .
2. Mechanic of proteinuria
• Electron microscopy reveals widening and effacement of the visceral
epithelial foot processes, which are reversible, occur in association with
proteinuria, and are not specific for MCNS.
• Plasma protein : Albumins, globulins, and fibrinogens
3. Mechanic of hyperlipidemia
• Hyperlipidenia due to hepatic lipoprotein synthesis stimulated by
decreased plasma oncotic pressure.
• Decreased lipoprotein lipase risk of elevated cholesterolemia
4. Mechanic of edema
• Abnormal glomerular infiltration barrier, producing of large amount of
proteinemia risk of hypoalbuminemia
- Decreased plasma oncotic and increased plasma hydrostatic pressure
- Fluid and plasma move down interstitial space
- Fluid accumulation in body spaces (ascites, pleural effusions, scrotal
swelling)
CLINICAL SIGNS
• Fatigue and general malaise
• Weight gain and facial swelling
• Puffy eyes
• Abdominal swelling or pain
• Pitting-dependent edema
• Fluid accumulation in body spaces (Ascites, pleural effusions, scrotal)
• Hepatomegaly

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• Anatomy and physiology

HOME EDITION D-ork-L

NAVAIDOT of Internal Medicine edited by Ngam Punlork, MD.

NAVAIDOT of Internal Medicine

3. Fluid and electrolytes………………………………….. ..

4. Most common pediatric disorders …………………….

8. Pulmonary diseases ……………………………………..

9. Ear, Nose and Throat disorders ……………………….

10. Stomatology ……………………………………………….

11. Common eye disorders………………………………... ..

13. Neurologic diseases………………………………………

15. Psychiatric disorders……………………………………..

16. Endocrine disorders………………………………………

17. Infectious Diseases………………………………………..

18. Genitourinary diseases………………………………......

19. Congenital malformations……………………………….

20. Gastrointestinal diseases………………………………..

21. Common Surgical Disorders…………………………….

22. Gynecology-Obstetric Disorders……………………….

24. Common Medications……………………………………..

My sincere thanks also to my parent, wife, teachers, friends, participants that

Nerve Arteriole Nenule

Structure of the skin

Structure of the skin

Neurons and Neuroglia

Myelin Functional dendrite

Type of nervous system

Spinal Nerve Autonomic Nervous System Brain Spinal cord

Peripheral Nervous System

Cranial Nerve : 12 pairs

Spinal Nerve : 31 pairs

Autonomic Nervous System

Organ Sympathetic Response Parasympathetic Response

Central Nervous System

The cerebral and spinal cord Terminal of spinal cord

The Digestive System/GI Tract

Structure of the GI tract

Longitudinal section of stomach

Duodenu Pancreatic duct

Hematology and Immunology

Thrombin + Fibrinogen (Inactive) = Fibrin

Fibrin + Blood cells = Clot

Plasma Protein : 6-8 g / dL or 60-80 g / L

Erythroblast Promyelocyte Monoblastocyte Lymphoblast

Basophilic Neutrophilic Eosinophilic

Erythrocyte Monocyte Lymphocyte

Basophil Neutrophil Eosinophil

Macrophage Plasma Cell

The stem cell (Hemocytoblast)

Blood ABO system

Passive ( Serum –antitoxic ) Active ( Immunoglobulin )

Maternal and post infection Vaccination

Left common carotid artery

Left pulmonary artery

Right ventricle Apex

Regulation of Blood Flow

Structure of the muscle tissue

Muscles of the head and neck

Muscles of the back

The muscle of the back