Deck 3 Flashcards
How do you dx chorioamnionitis (intraamniotic infection)?
maternal fever ( >100.4) + 1 or more of the following:
- Maternal: tachycardia >/= 100/min, uterine tenderness, malodorous/purulent amniotic fluid or vaginal discharge, WBC > 15,000
- Fetal: Tachycardia - baseline heart rate > 160/min
associated w/ prolonged rupture of membranes
What are possible maternal complications from abruptio placentae?
hypovolemic shock
disseminated intravascular coagulation (due to tissue factor released by decidual bleeding)
What is Todd paralysis?
it is a self-limited, focal weakness that occurs after a focal or generalized seizure.
it presents in the postictal period w/ a partial or complete hemiplegia involving an ipsilateral upper and lower extremity
paralysis usually resolves w/in 36 hrs
in complicated diverticulitis with an abscess, how should you treat the abscess?
if fluid collection < 3cm, tx w/ IV antibiotics and observation
if fluid collection > 3cm, tx w/ CT-guided percutaneous drainage
a child < 8 yrs old presents with erythema chronicum migrans, the classic targetoid rash of Lyme disease. How do you treat him/her?
oral amoxicillin or cefuroxime! (same tx for a pregnant women)
Doxycycline is contraindicated in children < 8 or pregnant women bc it can slow bone growth in exposed fetuses and cause enamel hypoplasia and permanent teeth stains during tooth development in young children.
What is one of the earliest findings in macular degeneration (as may be seen with the grid test)?
distortion of straight lines such that they appear wavy
risk factors = increasing age and smoking
driving and reading are some of the first activities that are affected
What is syringomyelia? and what physical exam findings are associated w/ it?
syringomyelia is a fluid-filled cavity in the spinal cord (commonly associated w/ Arnold Chiari malformation type 1, but may be acquired)
presents w/ loss of pain/temperature sensation in the dermatomes corresponding to the site of spinal involvement (“cape” distribution) - due to disturbance of the crossing spinothalamic tracts in the anterior commissure
as the cavity enlarges, there can be interruption of the anterior horn gray matter, resulting in LMN signs in the upper limbs (decreased/absent DTRs)
What is a Leukemoid reaction? and what lab values help you distinguish it from CML?
Leukemoid reaction occurs as a response to severe infection and is marked leukocyte counts > 50,000
it is characterized by the presence of:
- HIGH alkaline phosphatase score
- a greater proportion of late neutrophil precursors (metamyelocytes, bands)
- a lack of absolute basophilia (seen in CML)
Pts infected with Streptococcus gallolyticus (S bovis biotype 1) are at significantly increased risk of what?
Colorectal cancer! and endocarditis!
bc of this, all pts should have colonoscopy to look for underlying occult malignancy
What are the clinical characteristics of Bronchiectasis? and how do you dx it?
Bronchiectasis is a dz of bronchial thickening and dilation due to recurrent infx and inflammation
pts commonly present w/ large-volume mucopurulent sputum production, hemopytsis, and dyspnea – exacerbations are typically bacterial and require Abx
Dx is made using HIGH-RESOLUTION CT SCAN OF THE CHEST
Penile fracture is a urologic emergency and requires urgent operative repair. What is the only imaging test commonly used in evaluation?
retrograde urethrogram
employed in cases of suspected urethral injury – indications include blood at the meatus, hematuria, dysuria, and urinary retention
What is the recommended treatment for CIN 3? and what are possible complications of the procedure?
cervical conization (excision of the intact transformation zone)
complications include:
- cervical stenosis!! (may cause secondary dysmenorrhea or impaired fertility)
- cervical incompetence leading to preterm delivery
- preterm premature rupture of membranes
- 2nd trimester pregnancy loss
VEAL CHOP
Variable decelerations = Cord compression
Early decelerations = Head compression
Accelerations = Okay!
Late decelerations = Placental insufficiency
what are the first and second line interventions to reduce cord compression (seen w/ variable decels) and improve blood flow to the placenta?
1st tx = maternal repositioning
2nd tx = amnioinfusion – instillation of saline into the amniotic sac may decrease cord compression and eliminate variable decels (in the case of prior rupture of membranes)
bc the facial/ophthalmic venous system is valveless, uncontrolled infection of the skin can result in what? red-flag sxs may include severe HA; bilateral periorbital edema; and CN 3, 4, 5, and 6 deficits.
Cavernous sinus thrombosis
Dx w/ MRI/MR-venography
Tx w/ IV broad-spectrum Abx and prevent/reverse cerebral herniation
a single brain abscess appearing as a ring-enhancing lesion w/ central necrosis on CT scan usually results from direct extension of an adjacent infection (eg, otitis media, sinusitis, dental infection). What are the two most commonly isolated organisms?
Viridans streptococcus
Staphylococcus aureus
a loud S1 and a mid diastolic rumbling murmur at the apex
mitral stenosis
How do you tx chlamydial infx diagnosed by NAAT? gonorrhea was negative.
Azithromycin or Doxycycline (contraindicated in pregnancy)
**concurrent tx is not indicated if the gonorrhea NAAT is negative
Maternal serum alpha-fetoprotein is measured between 15-20 weeks gestation. What are causes of elevated MSAFP?
open neural tube defects (anencephaly, open spinal bifida) abdominal wall defects (gastroschisis, omphalocele) multiple gestations (watch for fundal height in comparison to gestational age)
pleuritic CP in the setting of a long-distance flight, hemoptysis, dyspnea, tachypnea, tachycardia, and OCP use. what does this patient have?
Pulmonary embolism – likely w/ occlusion of a peripheral pulmonary artery by thrombus, causing PULMONARY INFARCTION (pleuritic chest pain and hemoptysis*)
What organisms are most commonly implicated in acute bacterial rhinosinusitis?
Strep pneumoniae (30%) nontypeable H influenzae (30%) Moraxella catarrhalis (10%)
Tx = amoxicillin-clavulanic acid
Aspirin-exacerbated respiratory disease (AERD) is a pseudoallergic rxn to NSAIDs. What pts does it typically occur in?
pts w/ comorbid asthma, chronic rhinosinusitis with nasal polyposis, or chronic urticaria
usually presents w/ asthmatic sxs (cough, wheezing, chest tightness), nasal and ocular sxs (nasal congestion, rhinorrhea, or periorbital edema), and facial flushing w/in 30 mins - 3 hrs after NSAID ingestion
In polycythemia vera, RBC production is driven by a constitutively active JAK2 gene rather than by tissue hypoxia, there EPO levels are ??
EPO levels are LOW
normally EPO activates the JAK2 tyrosine kinase, which differentiates late myeloid cells into erythrocytes. In polycythemia vera, EPO isn’t needed to activate JAK2 so it remains low.
If a pt presents with feature suggestive of Raynaud phenomenon that are asymmetric and accompanied by features of tissue ischemia (numbness, ulcers) and systemic dz (autoimmune or vascular), you should suspect what kind of Raynaud’s?
Secondary Raynaud phenomenon – may be due to SLE, scleroderma, thromboangiitis obliterans
workup includes:
- CBC and metabolic panel
- urinalysis
- ANA and RF
- ESR and C3/C4 levels
Asymptomatic bacteriuria in pregnancy – most common pathogen is E. coli. How do you tx?
1st line Abx =
- Cephalexin
- Amoxicillin-clavulanate
- Nitrofurantoin
What does tx for preterm labor at < 34 weeks include? what additional medication do you add if < 32 weeks?
Tocolytics (indomethacin, nifedipine) to postpone delivery
Corticosteroids (betamethasone) to decrease the risk of neonatal RDS
Penicillin if GBS positive or unknown
If < 32 weeks, MAGNESIUM SULFATE to lower the risk of neonatal neuro morbidities (cerebral palsy)
How do you tx urge incontinence – the sudden, overwhelming, or frequent need to empty the bladder?
voiding is mediated through the PS system, and antimuscarinic drugs (OXYBUTYNIN) increase bladder capacity and decrease detrusor contractions by reducing ACh activity
How do you tx overflow incontinency – the constant involuntary dribbling of urine and incomplete emptying?
cholinergic agonist = BETHANECOL
(and/or intermittent urethral catheterization)
post-void residual volume <150ml in women and <50ml in men is normal.
What is the initial therapy for pts w/ HTN and renal artery stenosis?
ACE-inhibitors or ARBs.
What does an S4 heart sound occurring at the end of diastole just before S1 indicate?
rhythm = “TEN-nes-see”
S4 is an indicator of a stiff left ventricle, which occurs in the setting of restrictive cardiomyopathy or left ventricular hypertrophy from prolonged HTN!!
Pt presents w/ sxs suggestive of a brain tumor and CT/MRI findings of a butterfly appearance w/ central necrosis. What kind of tumor?
Glioblastoma multiforme – classic butterfly!!
the heterogenous, serpiginous contrast enhancement is typical of high-grade astrocytoma
What is the MOA of succinylcholine? and what is a potentially major side effect if used in certain patients?
succinylcholine is a depolarizing neuromuscular blocker that works by binding to postsynaptic ACh receptors to trigger influx of Na ions and efflux of K+ ions through ligand-gated ion channels – depolarization occurs and temporary paralysis ensues (delayed repolarization of the skeletal muscle membrane)
in certain pts it can cause life-threatening cardiac arrhythmia due to severe hyperkalemia!! (pts specifically at risk are those who have experienced extensive muscle injury - rhabdomyolysis, burn injury, disuse muscle atrophy, or denervation – conditions that may cause upregulation of ACh receptors)
How do you treat TTP?
Plasma exchange!!
this removes the pts plasma and replaces it w/ donor plasma – this replenishes ADAMTS13 and removes autoantibodies.
What should you do if a woman in labor has active genital herpes lesions?
Cesarean delivery!!
the risk for neonatal HSV infection is drastically increased if the infant passes through the vaginal canal and is directly exposed to an active HSV eruption
pregnant women w/ a hx of genital HSV should receive prophylactic acyclovir or valacyclovir beginning at 36 wks of pregnancy
what are the clinical features suggestive of biliary atresia?
initially well-appearing, followed by development of the following over 1-8 weeks:
- jaundice
- acholic (pale) stools or dark urine
- hepatomegaly
- conjugated hyperbilirubinemia
- mild elevation in transaminases
for a child with incomplete immunization to varicella, what is post-exposure prophylaxis?
varicella vaccine in immunocompetent!!
if immunocompromised, they get varicella immunoglobulin.
children receive 2 doses of VZV vaccine, at ages 1 and 4 yrs
a pt has an abnormal first-trimester screen, with elevated beta-hCG and increased nuchal translucency (thickness). What follow-up diagnostic testing would you do based on gestational age?
if 10-13 weeks gestation – chorionic villus sampling
if 15-20 weeks gestation – amniocentesis
pt presents w/ fragile, photosensitive skin that develops vesicles and bullae w/ trauma or sun exposure. Healed lesions typically scar and can form both hypo- and hyperpigmented areas. Pt may also have fatigue, elevated transaminases, and arthralgias. What do they have and what is it strongly associated w/?
Porphyria cutanea tarda, which is strongly associated with chronic Hepatitis C
case control and retrospective cohort studies are both retrospective studies. what is the critical distinction between the two?
case control studies determine the OUTCOME and then look for associated risk factors
retrospective cohort studies ascertain RISK FACTOR EXPOSURE and then determine the outcome
pt presents following hysterectomy with clear watery vaginal discharge for two weeks, that occurs in the day and at night. UA shows signs of infection. What does she have?
vesicovaginal fistula
- may occur after pelvic surgery
- present as a painless loss of urine into the vagina
- PE shows pooling of clear watery fluid in the vagina
pts with upper GI bleeding who have a depressed level of consciousness and ongoing hematemesis should have what done prior to endoscopic tx with ligation or sclerotherapy?
endotracheal intubation!! to prevent airway compromise due to aspiration of blood
Pregnant pts w/ asymptomatic bacteriuria are at risk for what?
- ascending infection (eg, acute pyelonephritis)
- preterm labor and low birth weight
