Chapter 9-32 !! Flashcards
classification system for AUB
PALM-COEIN
structural- PALM polyps adenomyosis leiomyomas malignancy
nonstructural- COEIN coagulopathy ovulatory dysfuction endocrine iatrogenic Not yet specified
most likely diagnoses for vaginal bleeding in prepubescent girls
vaginitis foreign bodies sexual abuse tumors trauma
most likely diagnoses for vaignal bleeding in adolescent girls
anovulation due to immaturity of HPA axis
bleeding disorders
STIs
most likely diagnoses for vaginal bleeding in reproductive age women
structural lesions - polyps, fibroids
PCOS
most likely diagnoses for vaginal bleeding in perimenopausal women
anovulatory cycles become common as ovarian function declines
most likely diagnoses for vaginal bleeding in postmenopausal women
endometrial atrophy
endometrial cancer
DDX for structural causes of vaginal bleeding in nonpregnant females
polyps fibroids malignncy hyperplasia endometriosis
DDX for nonstructural causes of AUB in non pregnant fmeales
coagulopathies: vWD, factor XI deficiency, thrombocytopenia, ITP
endocrine: PCOS, hypothyroidism, hyperprolactinemia, adrenal hyperplasia, Cushing’s disease
hypothalamic: weight loss, extreme exercise, stress
obesity
trauma / sexual abuse
infections: TOA, vaginitis, STI
systemic disease: liver, kidneys
foreing bodies
medications: anti epileptics, antipsychotics, anticoagulants, hormonal medications, steroids
IUD
DDX for pregnant vaginal bleeding before 20 weeks gestation
ectopic pregnancy GTD abortion/miscarriage implantation bleeding ruptured corpus luteum cyst
DDX for pregnant vaginal bleeding after 20 weeks
placenta previa vasa previa placental abruption uterine rupture AVM
risk factors for ectopic pregnancy
smoking IVF previous ectopic use of IUD prior tubal surgery PID endometriosis
important symptoms to clarify on history in patient with vaginal bleeding
amount of bleeding, presence of clots dizziness, syncope, or weakness abdo pain fever vaginal discharge or odor postcoital bleeding hx of trauma
physical examination in vaginal bleeding
determine hemodynamic status
performing complete abdominal and pelvic exam
pelvic exam may reveal source of bleeding because masses, polyps, ulcers, foreign bodies and evidence of trauma or inflammation may be visualized
lab /tests in pt with vaginal bleeding
pregnancy test
hemodynamically unstable pts - CBC, type and cross matching, coags, and if pregnant a quantitative B-hCG
bedside US for IUP
hemodynamically stable- as outpt TSH and other hormone levels, complete pelvic US
in pregnant patients over 20 weeks GA, what needs to be done before pelvic
US to make sure no placenta previa
treatment of hemodynamically unstable vaginal bleed
IV crystalloid bolus
blood transfusions if not response to bolus
high dose IV conjugated estrogen (25mg) is first line, q4-6h for up to 24 hours
if bleeding continues can pack vagina with long continuous gauze, or insert foley into uterus to tamponade bleeding
treatment of stable non pregnant patent with vaginal bleedign
NSAIDs
OCP -ie. alesse or other low dose under 35ug of ethanol estradiol, one pill BID for 5 days and then one pill daily for remainder of pack OR if contradicted can use medroxyprogresterne acetate 10mg daily x 10days
OR (not in rosen’s)
TXA 1g PO TID x 5 days
contraindications to use of estrogen
hx of thromboembolic events or stroke pregnancy active liver disease severe uncontrolled htn women older than 35 who smoke
critical chest pain diagnoses
acute MI
acute coronary ischemia
aortic dissection
cardiac tamponade
PE
tension pneumo
esophageal rupture (Boerhaave’s syndrome)
emergent chest pain diagnoses
unstable angina
coronary spasm
prinzmetal’s angina
cocaine-induced pericarditis or myocarditis
pneumothorax
mediastinitis
esophageal tear (Mallory-Weiss)
cholecystitis
pancreatitis
nonemergent chest pain diagnoses
valvular heart disease
AS
MVP
HCM
pneumonia
pleuritis, tumuour, pneumomediastinum
esophageal spasm
esophageal reflux
peptic ulcer, biliary colic
muscle strain, rib # arthritis, tumor, costochondritits, nonspecific chest wall pain
spinal root compression, thoracic outlet, herpes zoster, PHN
psychological, hyperventilation
risk factors for ACS
past or family hx of CAD age men > 33, women >40 diabetes mellitus hypertension cigarette use or possible passive exposure elevated cholesterol or triglycerides sedentary lifestyle obesity postmenopausal LV hypertrophy
risk factors for PE
prolonged immobilzation surgery > 30 min in last 3 mos prior DVT or PE pregnancy or recent pregnancy pelvic or lower extremity trauma oral contraceptives + smoking CHF obestiy PMHx or famhx of hypercoagulability
risk factors for aortic dissection
htn congenital dz. of aorta or aortic valve inflammatory aortic dz. CTD pregnancy arteriosclerosis cigarette use
risk factors for pericarditis or myocarditis
infection autoimmune dz. (lupus) acute rheumatic fever recent MI or cardiac surgery malignanct radiation therapy to mediastinum uremia drugs prior pericarditis
risk factors for pneumothorax
prior pneumothorax
Valsalva’s maneuver
chronic lung disease
smoking
chest pain described as crushing pressure, substernal, exertion, radiation to jaw, neck, shoulder, arm
acute MI, coronary ischemia, unstable angina, coronary spasm
chest pain described as tearing, severe, radiating to or located in back, maximum at onset, may migrate to upper back or neck
aortic dissection
chest pain that is pleuritic
esophageal rupture, pneumothorax, cholecystitis, pericarditis, myocarditis
chest pain described as indigestion or burning
acute MI, coronary ichemia, esophageal rupture, UA, coronary spasm, esophageal tear, cholecystitis
chest pain associated with syncope or near-syncope
aortic dissection, PE, acute MI, pericarditis, myocarditis
chest pain associated with dyspnea (SOB, DOE, PND, orthopnea)
acute MI, coronary schema, PE, tension pneumothorax, pneumothorax, UA, pericarditis
chest pain associated with hemoptysis
PE
chest pain associated with nausea, vomitting
esophageal rupture, acute MI, coronary schema, UA, coronary spasm, esophageal tear, cholecystitis
chest pain + acute respiratory distress
PE, tension pneumothorax, acute MI, pneumothorax
chest pain + diaphoresis
acute MI, aortic dissection, coronary ischemia, PE, esophageal rupture, UA, cholecystitis, perforated peptic ulcer
chest pain + hypotension
tension pneumothorax, PE, acute MI, aortic dissection, coronary schema, esophageal rupture, pericarditis, myocarditis
chest pain + tachycardia
acute MI, PE, aortic dissection, coronary ischemia, tension pneumothorax, esophageal rupture, coronary spasm, pericarditis, myocarditis, mediastinitis, cholecystitis, esophageal tear
chest pain + bradycardia
acute MI, coronary schema, UA
chest pain + hypertension
acute MI, coronary ischemia, aortic dissection
chest pain + fever
PE, esophageal rupture, pericarditis, myocarditis, mediastnitis, cholecystitis
chest pain + hypoxemia
PE, tension pneumothorax, pneumothorax
chest apin + diffrence in UP BPs
aortic dissection
chest pain + narrow pulse pressure
pericarditis with effusion
chest pain + new murmur
acute MI, aortic dissection, coronary ischemia
chest pain + S3,S4 gallop
acute MI, coronary ischemia
chest pain + pericardial rub
pericarditis
chest pain + audible systolic “crunch” on cardiac auscultation
esophageal rupture, mediastinitis
chest pain + JVD
acute MI, coronary ischemia, tension pneumothorax, PE, pericarditis
chest pain + unilateral diminished or absent breath sounds
tension pneumo, pneumo
chest pain + pleural rub
PE
chest pain+ subQ emphysema
tension pneumo, esophageal rupture, pneumo, mediastnitis
chest pain + rales
acute MI, coronary ischemia, UA
chest pain + epigastric tenderness
esophageal rupture, esophageal tear, cholecystitis, pancreatitis
chest pain + LUQ tenderness
pancreatitis
chest pain + RUQ tenderness
cholecystitis
chest pain + unilateral leg swelling, warmth, pain, tenderness, erythema
PE
chest pain + focal neuro findings
aortic dissection
chest pain + stroke
acute MI
nonneurologic causes of weakness
alterations in plasma volume (dehydration)
alterations in plasma composition (glucose, lytes)
derangement in circulating RBCs (anemia or polycythemia)
decrease in cardiac pump function (MI)
decrease in SVR (vasodilator shock from any cause)
increased metabolic demand (local or systemic infection, endocrinopathy, toxin)
mitochondrial dysfunction (severe sepsis or toxin-mediated)
global depression of CNS (stimulant withdrawal, sedatives)
