Emergency Med EOR

Question 1

Multifocal Atrial Tachycardia

Answer 1

Question 2

Management of Supratherapeutic INR

Answer 2

Question 3

Aplastic Anemia

Answer 3

Question 4

Management of Claudication

Answer 4

Question 5

Ankle Sprain Classification

Answer 5

Question 6

Nerve Palsy Associated with Midshaft Humerus fracture

Answer 6

Question 7

Ischemic Stroke Deficits: Anterior, Middle, and Posterior Cerebral Artery

Answer 7

Question 8

Peak Flow % for Asthma

Answer 8

Question 9

Reactive Arthritis

Answer 9

Question 10

S3 v S4 Heart Sounds

Answer 10

Question 11

Lithium Toxicity Treatment

Answer 11

Question 12

Ischemic Priapism Treatment

Answer 12

Question 13

Red Flags for Complicated acute bacterial sinusitis that requires referral

Answer 13

Question 14

Superior Labrum Anterior Posterior Tear

Answer 14

Question 15

Function of the Rotator Cuff Muscles

Answer 15

Question 16

Wolff-Parkinson-White Syndrome

Answer 16

Question 17

Classification of Antiarrhythmics

Answer 17

Question 18

Alveolar Osteitis

Answer 18

Question 19

Asthma Classification

Answer 19

Question 20

Burn Classifications

Answer 20

Question 21

Leukemia Overview

Answer 21

Question 22

Classification of Febrile Seizures

Answer 22

Question 23

Common Peroneal Nerve Injury

Answer 23

Question 24

Meckel Diverticulum

Answer 24

Question 25

Spontaneous Intracerebral Hemorrhage locations

Answer 25

Question 26

Light Criteria for Pleural Effusion

Answer 26

Question 27

Pellagra

Answer 27

Question 28

Coagulation Cascade

Answer 28

Question 29

Ramsay Hunt Syndrome

Answer 29

Question 30

Acute Coronary Syndrome Management

Answer 30

Question 31

Atrial Fibrillation

Answer 31

Question 32

Dilated Cardiomyopathy: S/sxs

Answer 32

• Sxs:
  
  • pulm congestion (Left HF): dyspnea, orthopnea, rales
  • systemic congestion (Right HF): peripheral edema, JVD, nausea, abdominal pain, nocturia, enlarged liver
  • Low CO: fatigue, weakness
• Other:
  
  • HTN or hypotension
  • tachycardia, tachypnea
  • S3 gallop
  • mitral/tricuspid regurg: papillary muscles stretches with dilation -→ valvular dysnfunction
  • PMI shifted laterally

Question 33

Dilated Cardiomyopathy: Dx

Answer 33

• Diagnostic Criteria:
  
  • inclusion: EF <40%
    
    • LVEDD >177% of predicted
• Labs to order:
  
  • BNP
  • Na, Mg, K
  • BUN, Cr (CMP)
  • Hemoglobin (CBC with diff)
• CXR:
  
  • cardiomegaly
  • pulmonary edema
  • pleural effusion
• EKG:
  
  • wide QRS
  • LBBB
• Echocardiogram:
  
  • L ventricular dilation
  • thin ventricle walls
  • decreased ejection fraction (<50%, but often <30%)

Question 34

Dilated Cardiomyopathy: Dx

Answer 34

• Diagnostic Criteria:
  
  • inclusion: EF <40%
    
    • LVEDD >117% of predicted
• Labs to order:
  
  • BNP
  • Na, Mg, K
  • BUN, Cr (CMP)
  • Hemoglobin (CBC with diff)
• CXR:
  
  • cardiomegaly
  • pulmonary edema
  • pleural effusion
• EKG:
  
  • wide QRS
  • LBBB
• Echocardiogram:
  
  • L ventricular dilation
  • thin ventricle walls
  • decreased ejection fraction (<50%, but often <30%)

Question 35

Dilated Cardiomyopathy: Tx

Answer 35

• tx just like systolic heart failure
  
  • beta-blockers (metoprolol, carvedilol) + [ACE-I (lisinopril, captopril, enalapril) =mainstay of tx] + Loop diuretic (furosemide)
  • Anticoag if EF <30%
• if you need increased contractility = digoxin (digitalis)
• Pt education:
  
  • limit activity
  • salt restriction <2g/day
  • fluid restriction <2L/day
• extreme cases = heart transplant or L ventricular assist device

Question 36

Acute Bacterial Endocarditis Definition and organism

Answer 36

• Definition: infection of a normal valve with a virulent organism (usually S. Aureus).
• Rapidly destructive (fatal < 6 weeks if untreated)

Question 37

Bacterial Endocarditis: General Definition, Risk factors, & Sxs

Answer 37

• General Definition:
  
  • infx of the endocardium (usually the valve) secondary to colonization. Mitral valve = most common valve involved (M> A> T >P)
• Risk Factors:
  
  • >60 yo, males, IV drug abusers, poor dentition
  • pre-existing structural cardiac abnormality, prosthetic heart valve, prior episode, intravascular device (indwelling catheter), congenital heart disease, hemodialysis, HIV, co-morbidities
• S/sxs:
  
  • Fever
  • Chills/sweats
  • Anorexia & weight loss
  • Malaise, fatigue
  • Arthralgias & myalgias

Question 38

Bacterial Endocarditis: PE and tests to order

Answer 38

• PE:
  
  • murmur → new or worse regurg murmur
  • splenomegaly
  • arterial emboli
  • petechiae (appear in crops then disappear in 2-3 days)
  • neurological features, clubbing, arrhythmia, scleral hemorrhage
  • Osler’s nodes (small, painful, purple-red SQ nodules on digits and palms)
  • Roth’s spots (oval retinal hemorrhages with pale center)
  • Janeway Lesions (small, non-tender hemorrhagic macules or nodules on palms & soles)
  • Splinter hemorrhages (linear reddish brown lesions under the nail bed)
• Tests to Order:
  
  • Labs:
    
    • BLOOD CXs : 3 sets > 1 hour apart
    • ESR or CROP: elevated
    • Rheumatoid factor: positive
    • Leukocytosis
    • Anemia
    • Proteinuria, microscopic hematuria
  • Transesophageal Echocardiogram:
    
    • more sensitive than TTE but obtain TTE first → looking for endocardial vegetations

Question 39

Diagnosis of Bacterial Endocarditis

Answer 39

DUKE CRITERIA

• Duke Criteria-Major:
  
  1. Sustained bacteremia: 2 positive blood cultures by organism known to cause endocarditis
  2. Echocardiogram showing vegetation, dehiscence, or abscess
  3. New valvular regurgitation
• Duke Criteria Minor:
  
  1. Predisposition (heart condition or IVDA)
  2. Fever >38C (100.4F)
  3. Vascular: emboli to organs/brain hemorrhages
  4. Immunologic: glomerulonephritis, Osler’s nodes, Roth spots, RF
  5. Positive blood culture not meeting major criteria (1 positive)
  6. Echocardiogram not meeting major criteria
• *Definitive Endocarditis: 2 major criteria; 1 major + 3 minor criteria; 5 minor criteria or histological findings
• *Possible Endocarditis: 1 major + 1-2 minor, 3 minor
• *Rejected Endocarditis: resolution within <4 days of abx, alternate dx made, no evidence of IE at surgery or autopsy, definite or possible criteria not met

Question 40

Prophylaxis of Bacterial Endocarditis: Indicated cardiac conditions, Procedures, & Regimen

Answer 40

**Recommended prior to procedures which may introduce bacteria into the bloodstream of patients who are at high risk of developing bacterial endocarditis**

• Indicated Cardiac Conditions:
  
  • Prosthetic Cardiac Valve, heart repairs with prosthetic material, prior endocarditis, Cyanotic congenital heart disease, cardiac transplant
• Procedures:
  
  • dental:
    
    • (manipulation of gums, roots of teeth, oral mucosa perforation)
  • respiratory:
    
    • respiratory mucosa manipulation, rigid bronchoscopy
  • Skin/MSK tissue procedures
    
    • including abscess I&D
  • GI/GU → NO longer recommended
• Regimen:
  
  • 2g amoxicillin PO 1H before procedure (if allergic: 500mg Azithro, 2g cephalexin, 600mg clinda)

Question 41

Tx of Bacterial Endocarditis

Answer 41

• Duration: 4-6 weeks of high dose therapy (indwelling catheter often used)
• Native:
  
  • anti-staph penicillin (nafcillin, oxacillin) + ceftriaxone or gentamicin
• Prosthetic:
  
  • vancomycin + gentamicin + rifampin
• Fungal:
  
  • Amphotericin B

Question 42

Beck’s Triad

Answer 42

Associated with Cardiac Tamponade

1. elevated JVP
2. muffled heart sounds
3. systemic hypotension

Question 43

Postpartum Hemorrhage (Overview)

Answer 43

• Definition: >1000 cc of blood loss or patient has signs of hypovolemia.
• Causes: “Four Ts”
  
  • -Tone (70%): uterine muscle unable to clamp down on bleeding vessels to stop bleeding (coiled vessels stretch out during pregnancy but need to shrink back down post-birth)
  • -Trauma (20%): wounds, hematomas, uterine inversion
  • -Tissue (10%): retained POCs (membrane, placenta, etc.)
  • -Thrombin (<1%): blood is unable to clot d/t coagulopathy
• S/sxs:
  
  • Prolonged bleeding
  • Hypovolemic shock: hypotension, tachycardia, pale or clammy skin, decreased capillary refill
• PE:
  
  • Soft flaccid boggy uterus with dilated cervix
• Dx:
  
  • CBC: Hgb & Hct
  • US: to detect the bleeding source or retained POCs
• Categories:
  
  • Early: occurs within 24 hours of birth (vast majority)
  • -Late: occurs >24 hours but <6 weeks postpartum
• Tx:
  
  • Women can tolerate blood loss of approximately the volume that’s been added during pregnancy (1500-2000cc)
    *

Question 44

Uterine Atony: Risks & Tx

Answer 44

• Risks:
  
  • overdistension of uterus, conditions that affect uterine contractility, medications that are uterine relaxants, anesthesia
• Tx:
  
  • Fundal massage to maintain firmness & express clots (1^st line)
  • Uterotonics: if “boggy” uterus after massage; includes Oxytocin 20 IU per liter of NS, Misoprostol 800 mg PR, Methergine 0.2mg IM (not w/ HTN)
  • Catheterization: if mother’s bladder is full b/c doesn’t allow uterus to contract down
  • Oxygen & Double IV access: preparation for shock
  • Preparation for surgery: for worst case scenario, hysterectomy

Question 45

Hemorrhage from pregnancy trauma

Answer 45

• Incision or Lac Wounds: C-section, episiotomy, forceps, vacuum, perineal tear
• PE:
  
  • Bleeding at incision or laceration site (can be spurting or pumping)
• Categories of Episeal tear:
  
  • 1^st degree: mucosal layer, stitches
  • 2^nd degree: muscle layer, stitches
  • 3^rd degree: muscle layer & anal sphincter, repair in OR
  • 4^th degree: anal sphincter into rectal mucosa, repair in OR
• Tx:
  
  • suture the affected vessel

Question 46

Pelvic Hematoma

Answer 46

• Definition: bleeding into loose connective tissue while overlying tissue remains intact.
• PE:
  
  • Bleeding from small vessels, outline of hematoma is visible, severe pain
• Tx:
  
  • Supportive care: ice packs
  • *May resolve spontaneously

Question 47

Uterine Inversion

Answer 47

• Definition:
  
  • uterus is pulled inside out
• Causes:
  
  • rushed 3^rd stage management (excessive traction to pull placenta out of uterus), excessive fundal massage after delivery
• PE:
  
  • pain, hemorrhage, shock
• Tx:
  
  • Manual reposition of the uterus
  • -Discontinue Pitocin (Oxytocin) if used
  • -Surgery: hysterectomy
    *

Question 48

Uterine Rupture

Answer 48

• Definition:
  
  • spontaneous complete transection of the uterine wall
• Causes:
  
  • usually occurs at site of a prior C-section delivery
• Fetal mortality of 50-75%. Survival depends upon whether a large portion of placenta remains attached to the uterine wall until delivery is accomplished
• Tx:
  
  • Obstetric Emergency
  • C-section delivery: imperative to ensure neonatal survival & decrease maternal morbidity.

Question 49

Retained Tissue/Placenta

Answer 49

• Risks:
  
  • rushed 3^rd stage (placenta should naturally separate from uterine wall before removal is attempted)
• Causes:
  
  • Placental malformation
  • Placental implantation: accrete (vessels attached to uterine wall), increta (vessels invade uterine muscle), percreta (vessels gone thru the uterine wall & have attached to outside of uterus)
• Dx:
  
  • failure of placenta to detach within 30 minutes
• Tx:
  
  • Non-adherent: manual removal
  • Adherent: surgical removal

Question 50

Causes of Postpartum Fever/Infection

Answer 50

• Benign PP fever (3.8%): 1^st 24 hours PP
• Endometritis (1-2%): infection of uterine lining → abdominal pain & purulent lochia, days 2-7 –> tx: gentamicin + clindamycin (for no GBS colonization, + ampicillin if GBS positive)
• Engorged breasts: days 3-4 (when milk supply comes in, goes away with nursing)
• Mastitis: erythema/heat & flu-like sx, week 2-3
• UTI/Pyelo: urinary sxs, anytime
• URI/Viral: flu-like sxs, anytime
• Perineal wound (0.3%): odor/pus/pain, day 3-7
• DVT: +Homan’s, afebrile, anytime
• Ovarian vein thrombosis: febrile/abdominal pain/leukocytosis, rare

Question 51

Postpartum fever

Answer 51

>38.0 (100.4 F) on any 2 of the 1^st 10 days postpartum, excluding 1^st 24 hours after delivery. If fever lasts <24 hours, then it usually isn’t related to infection.

Question 52

Causes of Fever/inx with C-section

Answer 52

• Post-Op Wound: day 3-7
• -Endometritis (27%): day 2-7
• -URI/lungs: 1^st 24 hours
• -Pelvic abscess
• -Septic pelvic thrombophlebitis: day 2-4
• -DVT/PE: much higher risk than vaginal birth b/c immobile & hypercoagulable state

Question 53

Superficial Vein Thrombosis

Answer 53

• most common form of Postpartum thromboembolic issues
• S/sxs:
  
  • sxs occur 3-4 days postpartum
• PE:
  
  • tenderness at site, heat, erythema
  • fever
  • enlarged hardened vein
• Tx:
  
  • NSAIDs
  • -Rest & elevation of affected leg
  • -Compression stockings
  • -Heat therapy to site

Question 54

Deep Vein Thrombosis Postpartum

Answer 54

• Epidemiology: 2x increased risk after C-section.
• PE:
  
  • -Edema of ankle/leg
  • -Pain in lower leg or lower abdomen
  • -Decreased peripheral pulses
  • -Fever & chills
  • *More likely in left leg
• Dx:
  
  • Clinical diagnosis is notoriously insensitive & non-specific., Doppler ultrasound, d-dimer test
• Tx:
  
  • Anticoagulation until 3 months after resolution
  • -Analgesia
  • -Rest with leg elevated & compression stockings
  • *Safe to continue breastfeeding

Question 55

Pulmonary Embolism Postpartum

Answer 55

• Epidemiology: occurs in 4-5% of treated DVT, 15-25% of untreated DVT.
• S/sxs:
  
  • Dyspnea
  • -Chest pain
  • -Lightheadedness or dizziness
  • -Tachypnea
  • -Tachycardia
• Dx:
  
  • D-dimer test: sensitive but not specific
  • -Doppler ultrasound
  • -MRI (CT = contraindicated in pregnancy
• Tx:
  
  • Anticoagulation for up to 6 months
  • -Prophylactic blood thinners in future pregnancies

Question 56

Perinatal Mood Disorders Overview

Answer 56

• CA Assembly Bill 2193: all women must be screened at least once for mental health issues during pregnancy or postpartum. Most common in early pregnancy for baseline, then again PP. Some clinicians also screen in 3rd trimester and/or based on woman’s comments
• Perinatal Responses:
  
  • Healthy adaptation
  • -Baby blues: common PP, usually goes away after 2-3 weeks
  • -Depression, anxiety, PTSD, panic, OCD
  • -Bipolar Disorder
  • -Psychosis
• Tools:
  
  • PHQ9
  • -EPDS (Edinburgh Postnatal Depression Scale)
  • -GAD7 (General Anxiety Disorder 7)
  • *Each tool has a specific scoring rubric
• Tx:
  
  • Postpartum Psychosis is a Medical Emergency.

Question 57

Baby Blues

Answer 57

• Etiology:
  
  • Rapid decrease in Progesterone levels from pregnancy & Oxytocin from childbirth.
  • Onset 2-3 days PP with peak at day 5 and resolution within 2 weeks
• Epidemiology: 40-80% of women, 1/7 women
• S/sxs:
  
  • Rapid mood swings
  • -Decreased concentration
  • -Irritability
  • -Insomnia
  • -Tearfulness
  • -Concerns about baby & parenting
  • -Feeling overwhelmed
  • -Feelings of dependency
  • -Confusion about new identity
• Tx:
  
  • Symptoms resolve on their own by 4-6 weeks postpartum.

Question 58

Postpartum Depression: Def, Etiology, Risks, Incidence, Pregnancy Depression Med Guidelines

Answer 58

• Definition:
  
  • depression that begins any time after delivery & continues during the 1^st year after birth of child.
• Etiology:
  
  • genetic predisposition, hormonal changes, major life stressors
• Risks:
  
  • hx of depression or anxiety (25% reoccurrence), hx of PP depression (50% recurrence), FMHx, situational life stressors, PMDD
• Incidence:
  
  • 1-23% of pregnant women will experience a depressive disorder while pregnant, 1/7 women
• Pregnancy Guidelines for Depression Meds:
  
  • No evidence to stop medication with positive pregnancy test
  • Choose med with least maternal/ placental transfer & breast milk
  • Avoid new-to-market meds
  • Use as few meds as possible
  • Use as low as dose as possible, but a high enough dose to be therapeutic
  • Titrate up to a therapeutic dose slowly (Q3-7 days)
  • Note that higher doses may be needed in later pregnancy
  • No evidence to taper medication prior to birth
  • -SSRIs are safe during breastfeeding
    *

Question 59

Postpartum Depression: DSM V Dx, Choosing an SSRI, Pt education

Answer 59

• DSM V Dx:
  
  • *5/9 symptoms for dx including either #1 or #2
  • #1 Depressed mood most of the day nearly everyday
  • #2 Markedly diminished interest or pleasure (anhedonia)
  • -Significant weight loss or gain
  • -Insomnia or hypersomnia
  • -Psychomotor agitation or retardation
  • -Fatigue or loss of energy nearly every day
  • -Feelings of worthlessness or significant guilt
  • -Diminished ability to think or concentrate
  • -Recurrent thoughts of death
• Choosing a SSRI:
  
  • If euthymic: continue use of current SSRI
  • -If successful treatment in past year: continue that medication
  • -If no previous treatment history: choose 1) Sertraline OR 2) Citalopram; no transfer to breast milk, best SE profile, generic is available & covered by Medical; start lowest dose QD & book f/u in 4 weeks
• Patient Education:
  
  • Ideal to involve partner when available
  • -Medication SEs are short-lived (usually less than 3 days)
  • -Medication needs to be taken daily & not in response to mood changes; may take 4-6 weeks for patient to see effects
  • -Should remain on medication for 6-12 month for best chance of sustaining remission (decreased relapse)
  • -Discontinuing: titrate slow, decrease dose by 25% Q2-6 weeks, f/u Q2-6 weeks to observe for relapse

Question 60

Cracked/Bleeding Nipples

Answer 60

• Pathophysiology: generally caused by poor latch/position
• S/sxs:
  
  • cracked, bleeding nips
• Dx:
  
  • clinical
• Tx:
  
  • Mild: apply breastmilk to nipples after feeds & leave open to air, use lanolin cream for comfort +/- nipple shield
  • Moderate/severe: all-purpose nipple ointment after feeds, alternate feeding/pumping on affected side as tolerated until healing, engage lactation support

Question 61

Plugged Lactiferous Duct

Answer 61

• Risks: tight bra or underwire
• S/sxs:
  
  • -Hard, tender area on breast +/- lump
  • -More painful before a feeding & less tender after
  • -Nursing is painful on the affected side (esp. at letdown)
  • -Particulate matter in milk
  • -NO flu-like symptoms
• Dx:
  
  • clinical
• Tx:
  
  • feeding or pumping on affected side

Question 62

Breast Yeast Infection

Answer 62

• Risks: infant with thrush, nipple damage, antibiotic use in mom or baby, vaginal candidiasis, DM, immunosuppression
• S/sxs:
  
  • New onset breast or nipple pain
  • -Intense, burning, dry flaky skin
  • -Radiating through breast & sometimes to back
• Tx:
  
  • Antifungals: Nystatin, Clotrimazole, Diflucan
  • -Gentian Violet or Water Vinegar rinse
  • -Wash breast pads, bras, bottle nipples in hot water

Question 63

Mastitis

Answer 63

• **Note: the milk is NOT infected
• s/sxs:
  
  • *Usually 2-3 days PP or 2-3 weeks PP
  • -Unilateral breast pain
  • -Flu-like symptoms
• Dx:
  
  • need to r/o other sources of infection
  • Urine Cx, Milk cx if MRSA is present
• Tx:
  
  • *improves w/i 48H
  • -Bedrest, ice, increased fluids
  • -Feed, pump, or express Q1-2 hours
  • -Massage during expression/feeds
  • -Antibiotics: Dicloxacillin, Cephalexin, Clindamycin
  • -Analgesics: Tylenol or Ibuprofen

Question 64

Breast Abscess

Answer 64

• Definition:
  
  • localized collection of pus, inflammation
• PE:
  
  • Palpable, fluctuant mass with visible indurated area & fluid wave
• Dx:
  
  • US to confirm breast abscess
• Tx:
  
  • Referral to surgery for treatment/drainage
  • *Encapsulation makes antibiotics ineffective

Question 65

How frequently does a preggo need to be seen for an uncomplicated pregnancy?

Answer 65

q 4 weeks up to 32 weeks, q 2 weeks 32-36 weeks, q week 36-40 weeks, twice weekly at 41+ weeks, 6 weeks postpartum, for vaginal delivery or 1 week & 8 weeks for C-section delivery.

Question 66

Physiologic Changes Leading to Labor

Answer 66

(Final 4 weeks): fetal lie (spine position), uterine contractions, cervical dilation, cervical effacement (thinning), fetal station (relation to ischial spine)

• Fetal Lie: by week 36 fetus should be in vertex presentation (longitudinal position) for vaginal delivery
• Uterine Contractions: uterine muscles tighten & shorten assisting in dilation, effacement, & descent of fetus into birth canal; active labor = contractions q 5 minutes each lasting 1 minute for at least 1 hour.
• Cervical Dilation: internal cervical os begins to open, measured by cm or finger widths during cervical check; 1 cm - 10 cm (fully dilated)
• Cervical Effacement; thinning of the cervix leading toward labor; occurs during final week or days of pregnancy; measured in percentages (25%, 50%, 75%, 100% = fully effaced)
• Fetal Station: fetal head (or presenting part) in relation to the pelvic ischial spines; measured as -3, -2, -1, 0, +1, +2, +3, delivered

Question 67

Stages of Labor

Answer 67

(Avg length of all stages is 8 hours)

1. Effacement & dilation: latent phase
2. Active Labor: baby moves through the birth canal
3. Afterbirth: delivery of the placenta
4. Recovery

Question 68

Labor Complications & Indications for C-Section

Answer 68

GDM, hypertensive disorder, HSV outbreak, fetal distress, fetal malpresentation, dystocia

Question 69

Contraction Stress Test

Answer 69

Contraction Stress Test: electronic fetal monitoring with uterine contractions during labor

→ Positive (bad): baby’s heart rate decelerations & stays slow after contractions for > ½ contractions

→ Non-reactive Fetal Monitoring: emergency C-section with goal of <30 minutes from decision to delivery

Question 70

Intrapartum Definitions: Braxton-Hicks Contractions

Answer 70

spontaneous uterine contractions late in pregnancy not associated with cervical dilation

Question 71

Intrapartum Definitions: Lightening

Answer 71

fetal head descending into pelvis → change in abd shape & sensation the baby is “lighter”

Question 72

Intrapartum Definitions: Ruptured Membranes

Answer 72

sudden gush of liquid or constant leaking of fluid

Question 73

Intrapartum Definitions: Bloody Show

Answer 73

passage of blood-tinged cervical mucus late in pregnancy that occurs when cervix begins thinning

Question 74

True Labor

Answer 74

contractions of the uterine fundus with radiation to the lower back & abdomen: regular & painful contractions of the uterus → cervical dilation & fetus expulsion

Question 75

Cardinal Movements of Labor

Answer 75

1. Engagement: fetal presenting part enters the pelvic inlet
2. Descent: passage of the head into the pelvis (“lightening”)
3. Flexion: flexion of the head to allow the smallest diameter to present to the pelvis
4. Internal Rotation: fetal vertex moves from occiput transverse position to a position where the sagittal suture is parallel to the anteroposterior diameter of the pelvis
5. Extension: vertex extends as it passes beneath the pubic symphysis
6. External Rotation: fetus externally rotates after the head is delivered so that the shoulder be delivered
7. Expulsion
8. “Everybody Does Fart In Extremely Egregious Explosions”

Question 76

Maternal Assessment PostPartum

Answer 76

need to perform assessment within a few hours of birth & 6-8 weeks postpartum

→ BUBBLE-HE(EAT): breasts, uterus, bladder, bowel, lochial (vaginal discharge after birth), episiotomy/lac/incision, Homan’s (for DVT), edema, emotions, attachment, transition

→ Breasts: normal findings include intact tender everted nipples, abnormal = abrasion, bleeding, flat, inverted nips

→ Uterus: measurement of postpartum fundal involution (takes ~ 10 days for uterus to return to prepartum size, can do fundal massage); normal = fundus firm, at or below umbilicus, midline, non-tender, uterine cramping relieved with motrin or vicodin, & decreasing with time; abnormal = boggy fundus, above umbilicus, left or right of midline, tender, & uterine cramping that is hard to control with motrin or vicodin & not decreasing in intensity with time

→ Bladder: normal = voiding regularly (no retention/distension), no bladder infection, diuresis, some stress incontinence; abnormal = inability to void, dysuria

→ Bowel: Normal = fear of bowel movement, hemorrhoids, no BM for 2-3 days PP; abnormal = no BM > 3 days PP

→ Lochia: postpartum vaginal discharge, hemorrhage = 1+ liter, tx by 500mL lost or volume status change; types include lochia rubra (red, day 1-3), lochia serosa (pink, day 3-10), lochia alba (white, days 10-14), normal = lochia rubra x 3 days with small clots, menstrual odor; abnormal = soaking >1 pad per hour with large golf-ball sized clots, foul odor.

→ Episiotomy/Laceration/Incision: normal = not bleeding, stitches/staples intact, no signs of inx, edema resolving; abnormal = bleeding, stitches have come out or loose, sxs of infection, edema not resolving

→ DVT (aka Homan’s): normal = negative Homan’s, lower extremity edema is equal bilaterally, no warm or hot spots; abnormal = positive Homan’s, significantly greater edema on one side (esp left), warm/hot spot behind calf

→ Emotions: assess for PP depression at 6-8 week visit using Edinburgh Postnatal Depression Scale (EPDS) - score > 10 suggest minor or major depression; f/u in 4 weeks to check on tx plan

Question 77

Helpful vs. Harmful factors for the postpartum maternal state

Answer 77

• Helpful: oxytocin hormone (feelings of joy & love), support & protecting time with newborn, rest & pain relief (ibuprofen), physical support (assist with walking, ADLs, meal prep), emotional support
• Harmful: sudden hormonal shift with decrease in progesterone (grief, sadness, anxiety, anger), postpartum physical complications, lack of physical & emotional support, separation from baby

Question 78

What is Domperidone?

Answer 78

medication that can be used to produce lactational breast tissue in parents who didn’t carry infant

Question 79

Gestational DM: definition, Pathophys, Epidemiology, s/sxs

Answer 79

• Definition: glucose intolerance or DM only present during pregnancy (subsides postpartum)
• Pathophys:
  
  • -Pregnancy is a diabetogenic state: increased glucose & insulin production, insulin resistance d/t placcental hormones, mild postprandial hyperglycemia
  • -Glucose transport: by facilitated diffusion, concentration of glucose is 15-20% lower in fetus, maternal insulin doesn’t cross the placenta
  • -Fetal Growth: fetGDM, SAB, hx of infant > 4000g at birth, multiple gestations, obesity, > 25 yo
• Epidemiology:
  
  • 80% more common in AA women and more likely to develop complications or disabilities, death rates are 3x higher than in women w/o DM

Question 80

Gestational DM: types, Screening, and Tx

Answer 80

• Types of DM in Pregnancy:
  
  • -Type I DM: autoimmune, 13%
  • -Type II DM: insulin resistant
  • -Preexisting/Overt: diagnosed during 1st T for the 1st time
  • -GDM: diagnosed during 2nd or 3rd T for 1st time, 87% of DM in pregnancy.
• Screening:
  
  • -Fasting blood sugar at 1st prenatal visit for women at high risk OR 1H GGT in 3rd T if low risk
  • -1H glucose tolerance test: if positive (>139) do 3H GTT, if > 190 = GDM
  • -3H glucose tolerance test = gold standard
• 3H GTT: <95 (fasting), < 180 (1 hour), <155 (at 2 hours), < 140 (at 3 hrs) → 2 elevated values = GDM
• HbA1C at 1st prenatal visit, if high then dx pre-existing DM; if prediabetic (5.7-6.2) do 2H GGT, if WNL repeat in 3rd T (24-28wks)
• Tx:
  
  • GDM type A1 (dietary controlled): healthy diet, 30 minutes daily activity, walking after meals, monitoring glucose QID
  • GDM type A2: if >20% of blood sugars are elevated despite diet & exercise begin medication (insulin= 1^st choice, Metformin or Glyburide OK), NST biweekly after 34 weeks, IOL at 39-40 weeks
  • Referral to diabetes educator for nutritional counseling & glucometer education
• Intrapartum Tx:
  
  • maintain euglycemia (70-110 mg/dL), prevent maternal hyperglycemia & natal hypoglycemia
• Encourage breastfeeding after delivery (decreased risk of DM/obesity in baby & DM2 conversion in mom)

Question 81

Postpartum Management of GDM and Complications

Answer 81

• Postpartum Management:
  
  • -Retest for DM at 6-12 weeks postpartum, FBS yearly, continue healthy diet, 30-60 minutes daily exercise
  • -GDM type A2: stop medication after birth
• Complications:
  
  • Spontaneous abortion (SAB), birth defects (cardiac, preeclampsia, fetal organomegaly (liver & heart), polyhydramnios, fetal macrosomia (>8lbs 13oz, 4000g) → should dystocia/operative delivery/birth trauma, C-section, neonatal respiratory problems & metabolic complications (hypoglycemia, hyperbilirubinemia, hypocalcemia), perinatal mortality (20 weeks gestation – 28 days post delivery)

Question 82

Most common medical complication of pregnancy

Answer 82

HTN

Question 83

Chronic HTN in Pregnancy

Answer 83

• Definition: HTN (140/90 mmHg+) before 20 weeks gestation or prior to pregnancy
• S/sxs:
  
  • HA, visual sxs, usually asymptomatic
• Classifications:
  
  • -Mild: 140/90+
  • -Moderate: 150/100+
  • -Severe: 160/110 +
• Dx: BP readings
• Tx:
  
  • Mild: monitor q2-4 weeks, q 1 week from 34-36 weeks
  • -Moderate-Severe: medication (labetalol, nifedipine, or methyldopa)
  • **ACEI & ARBs = contraindicated in pregnancy

Question 84

Gestational HTN

Answer 84

• Definition: onset of HTN (140/90+) after 20 weeks gestation . No proteinuria or organ dysfunction
• S/sxs:
  
  • asymptomatic
• Classifications:
  
  • -Mild: 140/90+
  • -Moderate: 150/100+
  • -Severe: 160/110 +
• Dx:
  
  • -Urine Protein: negative
  • -Platelets
  • -LFTs
  • Complications:
  • -Preeclampsia (10-50% of these pts will develop)
• Tx:
  
  • Mild: biweekly NST, weekly prenatal visits for BP/labs, EFW (estimated fetal weight) q 3 weeks, induce at 38-39 weeks
  • -severe: medication, induce at 34 weeks for seizure prevention

Question 85

Pre-Eclampsia: Def, Pathophys, risks, Epid, & s/sxs

Answer 85

• Definition:
  
  • gestation HTN (140/90+) +proteinuria (>300mg in 24H urine) or evidence of organ dysfunction.
• Pathophys:
  
  • increased BP → decreased placental perfusion → endothelial cell activation → vasoconstriction + intravascular fluid redistribution + activation of coagulation cascade → decreased organ perfusion.
• Risks:
  
  • nulliparity, hx/family hx of preeclampsia, multiple gestation, obesity, maternal age > 40 or < 18, chronic HTN, renal dx, DM, prolonged interpregnancy interval, new partner or limited sperm exposure
• Epidemiology:
  
  • 1 of top 4 causes of maternal mortality (with eclampsia), AA women have higher mortality rates, occurs in 7% of all pregnancies
• S/sxs:
  
  • -HTN
  • -Proteinuria
  • -severe HA
  • -Visual Disturbances
  • -RUQ or epigastric pain (heartburn)
  • -Edema
  • -N/V
  • -decreased urinary output

Question 86

Pre-Eclampsia: PE, Dx, and Tx

Answer 86

• PE:
  
  • -DTR: hyperreflexia or clonus
  • -Clonus
• Dx:
  
  • *BP ≥140/90 on at least 2 occasions at least 4H apart after 20 weeks’ gestation + 1 of the following:
  • -Proteinuria >300mg in 24H urine
  • -Protein/creatinine ratio ≥0.3
  • -Platelet count <100,000
  • -Serum creatinine >1.1mg/dL
  • -LFTs twice upper limit of normal
  • -Pulmonary edema
  • -Cerebral or visual symptoms
• Tx:
  
  • -Mild (<37 weeks): biweekly NST & PN visits with EFW, antenatal steroids (for lung maturation) → dexamethasone
  • -Mild (>37 weeks): induction +/- medication for seizure prevention
  • -Severe >/= 160/110(<34 weeks): inpatient management + medication for seizure prevention + antenatal steroids + BP meds
  • -Severe (>34 weeks): induction + medication for seizure prevention

Question 87

Pre-Eclampsia: HELLP, Induction, and indications for inductions

Answer 87

• HELLP: (Hemolysis, Elevated Liver Enzymes, Low Platelets): antenatal steroids w/ induction of labor after 48 hours + medication for seizure prevention
• Induction:
  
  • birth “cures” preeclampsia; need to balance against gestational age, fetal lung maturity, & indications of fetal well-being
• Indications for Induction:
  
  • growth restriction, non-reassuring testing, oligohydramnios (low amniotic fluid), placental abruption

Question 88

Eclampsia

Answer 88

• Definition: pre-eclampsia + seizure or coma
• S/sxs:
  
  • abrupt onset of tonic-clonic seizures
• Tx:
  
  • IV Mag sulfate for seizures and BP stabilization
  • -Induction of labor once mom is stable
  • -IV labetalol or hydralazine for BP control

Question 89

Spontaneous Abortion

Answer 89

• Definition:
  
  • pregnancy loss occurs spontaneously prior to 20 weeks gestation.
• Categories:
  
  • -Early: 1^st trimester, most commonly due to chromosomal abnormalities
  • -Late: 12-20 weeks, due to chromosomal abnormalities, uterine anomaly (ex. cervical insufficiency), biochemical changes (infection, hemorrhage, uterine overdistension)
• Epidemiology:
  
  • 50-60% of all conceptions end in miscarriage, 15-20% confirmed pregnancies end in miscarriage (risk decreased if cardiac motion seen on US & >10 weeks gestation)
• Assessment:
  
  • Vitals, LMP, OB/gyn hx, emotional state (unplanned vs desired pregnancy)
• Dx:
  
  • -Labs: hCG, H/H, WBC, Blood type & Rh factor
  • -Transvaginal US: if 1^st trimester or early 2^nd trimester we need to see uterine contents closer
• Tx:
  
  • -Anticipatory guidance & education
  • -See management of specific types
  • -D&C/D&E: IV during procedure, hemorrhage prevention with IV Pitocin; dilation & curettage is done prior to 23 weeks gestation; dilation & evacuation is done after 23 weeks gestation
  • Prior to 23 weeks = D&C
  • After 23 weeks = D&E

Question 90

Threatened Abortion

Answer 90

• Definition: cervical os is closed & fetal cardiac motion is present
  
  • Only type that is potentially viable
• S/sxs:
  
  • vaginal bleeding, cramping
• PE:
  
  • Cervical os = CLOSED
• Dx:
  
  • U/S: fetal cardiac motion is present!
• Tx:
  
  • Supportive care: pain management, pelvic rest (no vaginal penetration) or bed rest (if 2^nd trimester)
  • -Cervical cerclage: if cervical dilation is noted & patient is <14 weeks gestation

Question 91

Imminent/Inevitable Abortion

Answer 91

• Definition: cervical os is open & fetal cardiac motion is rarely present
  
  • Concern that the patient is going through a pregnancy loss & fetus is demised
• S/sxs:
  
  • vaginal bleeding, cramping
• PE:
  
  • Cervical os = OPEN
• Dx:
  
  • Ultrasound: fetal cardiac motion rarely present
• Tx:
  
  • Pelvic rest or bed rest
  • -Expectant management: lab work
  • -Misoprostol or D&C: if patient is not expelling the products of conception
  • -Rhogam: if Rh- (patient has experienced mixture of blood products with her own → antibody production)

Question 92

Missed Abortion

Answer 92

• Definition:
  
  • neither fetus nor placenta are expelled
• S/sxs:
  
  • vaginal bleeding, cramping
• Dx:
  
  • U/s = no fetal cardiac motion

Question 93

Incomplete Abortion

Answer 93

• Definition: fetus is expelled & placenta remains inside uterus
• S/sxs:
  
  • vaginal bleeding, cramping

Question 94

Complete Abortion

Answer 94

• Definition: fetus and placenta are expelled
• S/sxs:
  
  • Vaginal bleeding, cramping
• Dx:
  
  • beta-hCG = zero
• Tx:
  
  • No further care needed if woman is stable
  • -Rhogam: if Rh-

Question 95

Habitual Abortion

Answer 95

• Definition: 3+ consecutive SABs
• S/sxs:
  
  • vaginal bleeding, cramping
• Dx:
  
  • chromosomal testing
• Tx:
  
  • -Determine cause → anatomic vs chromosomal
  • -Cervical cerclage: if cervical insufficiency is diagnosed

Question 96

Ectopic Pregnancy

Answer 96

• Definition:
  
  • gestational sac is implanted outside of the uterine cavity. 98% in ampulla of fallopian tubes.
• Risks:
  
  • prior ectopic (#1), hx tubal surgery, tubal ligation, in utero DES exposure, current IUD use
  • **>50% of women don’t have any risk factors
• Epidemiology:
  
  • 2% in general population, causes 10% of maternal mortality, no variation by maternal age or ethnicity
• S/sxs:
  
  • -Dull or colicky pelvic pain
  • -Vaginal bleeding
  • -Amenorrhea
  • Ruptured:
    
    • -shock
    • -lightheadedness
    • -referred pain to shoulder if blood is in the peritoneum
    • *bleeding may not be visible in the vagina
• PE:
  
  • Adnexal tenderness
• Assessment:
  
  • -Vitals
  • -LMP
  • -OBGYN hx
  • -Emotional status
• Dx:
  
  • Labs: serial hCG (q 48H), H/H (hgb & Hct) , WBC, blood type & Rh factor
  • -Transvaginal US: determine location of pregnancy
  • Need to rule out ectopic for every woman who presents in early pregnancy with abdominal pain &/or bleeding
• Tx:
  
  • *Goal: prevent rupture & salvage fallopian tube
  • -Early (<4cm): Methotrexate IM
  • -Late: remove surgically & give Methotrexate post-op
  • Management- Ruptured:
    
    • *Goal: control bleeding & prevent shock
    • -Salpingectomy: remove fallopian tube
• Complications:
  
  • intra-abdominal hemorrhage, DIC, death, impaired fertility, risk of recurrence

Question 97

Gestational Trophoblastic (Molar) Pregnancy

Answer 97

• Definition:
  
  • neoplasm d/t abnormal placental development with trophoblastic tissue proliferation arising from gestational tissue.
• Types: *egg may or may not contain fetal DNA
  
  • -Partial molar pregnancy: with fetal DNA
  • -Complete molar pregnancy: without fetal DNA
• Risks:
  
  • >40 y.o. or <20 y.o.
• Epidemiology:
  
  • 1/2000 pregnancies (rare)
• S/sxs:
  
  • Vaginal bleeding
  • -Enlarged uterus
  • -Pelvic discomfort
• Dx:
  
  • -Pregnancy test: positive
  • -hCG: >100,000 mlU/mL (abnormally high, way higher than a normal pregnancy)
  • -Transvaginal US: shows abnormal pregnancy in the uterus, mosaicism
• Tx:
  
  • -D&C
  • -Methotrexate (stops cells from dividing, causes abortion): if high risk
  • -Follow-Up: follow hCG until 3 normal levels obtained over 8 weeks, then follow for 6 months
• Complications:
  
  • uterine cancer

Question 98

Multiple Gestations

Answer 98

• Types:
  
  • -Diamniotic/dichorionic: 2 ovum + 2 sperm, 2 separate or 1 fused (large) placenta
  • -Diamniotic/monochorionic (identical twins): 1 ovum + 2 sperm, 2 amniotic sacs, 1 placenta
  • -Monoamniotic/monochorionic (identical twins): 1 ovum + 1 sperm, 1 amniotic sack, 1 placenta
  • -Conjoined twins: incomplete division, fetal fusion
• S/sxs:
  
  • Increase in severity of N/V during 2nd trimester
  • -Maternal sxs: uterine contractions, abd pain, increase or thinner vaginal discharge or bleeding
    -Fetal well-being: fetal heart tones, US q4-6 weeks after 20 weeks gestation (if monochorionic Q2 weeks)
• Dx:
  
  • Transvaginal U/S: confirms location, number, viability, & chorionicity
• Tx:
  
  • Average length of twin pregnancy is 36 weeks
  • -US q 4-6 weeks after 20 weeks gestation (if monochorionic q 2 weeks)
    Complications: maternal, fetal & neonatal morbidities

Question 99

Discordant Growth

Answer 99

• Definition: >20% fetal growth difference between larger & smaller fetus
• Tx:
  
  • Additional antenatal surveillance initiated

Question 100

Intrauterine Growth Restriction (IUGR)

Answer 100

• Definition:
  
  • fetal weight is less than 10^th percentile of a specific population at a given gestational age.
• Risks:
  
  • -Maternal Factors: viral infections (rubella, varicella, cytomegalovirus), maternal medical conditions (GDM, renal insufficiency, autoimmune, HTN), substance abuse, teratogen exposure, genetic disorders, placental/cord complications
• PE”:
  
  • Fundal height exam: size < dates by >2cm, limited use in dx but good screening tool
  • Note: small for gestational age (SGA) is used to describe an infant with a birth weight at the lower extreme of the normal birth weight distribution. AKA they are still a normal weight just low.
• Dx:
  
  • US: 4 standard measurements-
    
    • 1. biparietal diameter (ear to ear),
    • 2. head circumference (around forehead) ,
    • 3. abdominal circumference,
    • 4. femur length
  • -Doppler velocimetry of fetal vessels: fetal placental circulation evaluated in the umbilical artery & is measured by a systolic/diastolic ratio
• Tx:
  
  • Goal: identify infants at risk for increased short-term & long-term morbidity & mortality. Deliver healthiest possible infant at the optimal time
• Management:
  
  • -Referral to perinatologist for surveillance (especially if monoamniotic/monochorionic or conjoined)

Question 101

Fetal Macrosomia

Answer 101

• Definition: estimated fetal weight >4,000 gm
• Risks:
  
  • -Maternal Factors: history of previous macrosomia, preexisting diabetes, body composition, pregnancy weight gain, parity
  • -Fetal Factors: genetic potential, specific gene disorders, male sex
• PE:
  
  • Fundal height exam: poor predictor
    
    • Note: large for gestational age (age) is used to describe an infant with a birth weight >90% for gestational age within population-specific norms
• Dx:
  
  • Diagnosis is imprecise & can only be accurately diagnosed at delivery after weighing the infant.
  • Diagnostics:
  • -US: ability to r/o diagnosis but not to rule in
• Tx:
  
  • No interventions designed to treat or curb fetal growth in mother’s w/o diabetes
  • C-section delivery planned for estimated fetal weights:
    
    • >5,000g in women w/o diabetes
    • >4,500g in women w/ diabetes

Question 102

Fetal Malpresentation

Answer 102

• Definition:
  
  • baby is in an unusual position as the birth approaches. Normal position= cephalic.
  • Determine fetal presentation by 36 weeks (confirm via US).
• PE:
  
  • hand on belly to determine position
• Dx:
  
  • U/s to confirm position
• tx:
  
  • External Version: scheduled at 37 weeks at L&D with US guidance

Question 103

Breech Presentation

Answer 103

• Definition:
  
  • fetus whose presenting part is the buttocks and/or feet.
• Risks:
  
  • developmental dysplasia of the hip, torticollis, mild deformations
• Epidemiology:
  
  • occurs in 3-5% of fetuses at term
• PE:
  
  • hand on belly to determine position
• Dx:
  
  • U/S confirms position
• Tx:
  
  • External Version: scheduled at 37 weeks at L&D with US guidance

Question 104

Preterm Birth (Overview): definition, risk factors, categories

Answer 104

• Definition:
  
  • birth occurring b/w 20 weeks – 36 weeks + 6 days. Age of viability is 24 weeks.
• Risk Factors:
  
  • history of preterm birth, short cervix, cervical insufficiency, multiple gestation, infection (UTI, GC/CT, BV, periodontal disease), genetics, smoking, substance abuse, obesity, hispanic & black, teen & advanced maternal age, short inter-pregnancy period
• Epidemiology:
  
  • 10% of babies in the US, 30% spontaneously resolve, 50% of patients hospitalized for PTL will deliver at term
• Categories:
  
  • Extremely Preterm: <25 weeks
  • -Very Preterm: 25 weeks + 1 day - 31 weeks + 6 days; 2% of all babies born but 50% of all infant deaths
  • -Moderately Preterm: 32 weeks – 33 week + 6 days
• Late Preterm: 34 weeks – 36 weeks + 6 days; best preterm outcome but still have 3x mortality rate of term baby

Question 105

Preterm Labor

Answer 105

• Definition:
  
  • onset of regular uterine contractions (labor) before 37 weeks.
• Epidemiology:
  
  • 40-50% of preterm births
• Prevention (hx of previous PTB or short cervix):
  
  • -Progesterone IM or SQ weekly starting b/w 16-20 weeks until 36 weeks
  • -Cervical cerclage: if cervix <2.5cm on TVUS or in high risk patients (stitching the cervix shut)
• S.sxs:
  
  • Uterine contractions: 6+ in 1 hour, lasting 30-60 seconds each
  • -Vaginal bleeding
  • -Intermittent back pain occurring with the contractions
  • -Pelvic pressure
• PE:
  
  • Fetal monitoring: assess fetal well-being
  • -Non-stress test: uterine contractions
  • -VS & PE: maternal well-being
• Sterile speculum exam: to r/o BV and PPROM (looks for amniotic fluid)
• Dx:
  
  • Urine culture: to r/o UTI, pyelo, gonorrhea, chlamydia, substance abuse
  • -Group B Strep (GBS) culture
  • -Fetal fibronectin: protein that the baby releases when they are going through labor
  • -US: measure cervical length, presentation, estimated fetal weight
• Diagnosis:
  
  • -Cervical dilation 3cm or greater + >80% effacement or presence of fetal fibronectin
  • Preterm labor = uterine contractions (4+ q 2o min or 8+ in 60 min AND:
    
    • -cervical dilation 3+ cm OR
    • -cervical length < 20mm on TVUS Or
    • -Cervical length 20 to < 30 mm on TVUS and positive fetal fibronectin)
• Triage:
  
  • drink 2-3 glasses of water, lie down or get in warm bath, empty your bladder, if sxs continue at rate 6+ per hour call provider
• Tx:
  
  • Goal: prevent preterm birth x 48H so underlying conditions may resolve, steroid for lung maturity can work, & woman may be transferred for better care
  • Betamethasone or Dexamethasone IM x 48H: to accelerate fetal lung maturity, can repeat in 7 days
  • Tocolytics: smooth muscle relaxants that decrease uterine contractions; Terbutaline, Mg sulfate, Nifedipine, Indomethacin
  • -Antibiotics: treat infections as needed

Post-Acute Episode Management:

-Pelvic rest: avoid heavy lifting, prolonged standing, intercourse

Question 106

Preterm Premature Rupture of Membranes (PPROM)

Answer 106

• Definition:
  
  • rupture of the amniotic membranes prior to the onset of labor occurring before 37 weeks.
• Risks:
  
  • hx of PPROM, genital tract infection, antepartum bleeding, cigarette smoking
• Epidemiology:
  
  • 33% of preterm births, 3% of pregnancies
• S/sxs:
  
  • Sudden “gush” of clear fluid from the vagina OR
  • Intermittent constant leaking of small amount of fluid from the vagina
• PE:
  
  • -Sterile speculum exam: look for pooling in the vagina, nitrazine strip to look at pH (pH > 6 → paper turns blue which indicates most likely amniotic fluid), fluid sample on microscope slide to look for ferning, amnisure
  • assess for infection & fetal wellbeing
• Tx:
  
  • SEND TO L&D
• Complications:
  
  • -Risk of placental abruption & cord prolapse
  • -Serious infections: chorioamnionitis, endometritis, septicemia
  • -Preterm birth within 1 week

Question 107

Rh incompatibility

Answer 107

• Definition:
  
  • occurs when an Rh(D) negative woman carries a Rh(D) positive fetus with exposure to fetal blood mixing of D-positive RBCs → maternal anti-Rh(D) IgG antibodies
• Pathophys:
  
  • during subsequent pregnancies if mother carries an Rh(D) positive fetus the antibodies may cross the placenta & attack fetal RBCs → hemolysis of fetal RBCs
  • At risk pregnancy= Rh(D) negative mother + Rh(D) positive father
• Dx:
  
  • Antibody screen: done at initial prenatal visit to see if mother is Rh(D)- or Rh(D)+; if Rh(D)- repeat screening at 28 weeks gestation
  • Antibody titers: performed in Rh(D) negative women to determine if unsensitized vs. sensitized (Rh antibodies present)
• Tx:
  
  • Anti-D Rh immunoglobulin (RhoGAM): for any Rh(D) negative women; given at 28 weeks’ gestation, within 72H of delivery of Rh(D) positive baby, and after any potential mixing of blood
    
    • **If mother has already formed Rh antibodies than Rhogam will no longer help

Complications: repetitive miscarriage, fetal anemia, hydrops fetalis, intra-uterine fetal death

Question 108

Shoulder Dystocia

Answer 108

• Definition:
  
  • failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head due to impaction (anterior shoulder is stuck behind the mother’s pubic bone).
• Risks:
  
  • macrosomic infants of diabetes, post-term pregnancy, multiparity, maternal obesity, advanced maternal age, prolonged 2^nd stage of labor, forceps delivery, epidural
• S.sxs:
  
  • Turtle sign: baby retracts head (like turtle retracting into its shell)
  • Red, puffy face
• Complications:
  
  • Fetal: brachial plexus injuries, Erb’s palsy, Klumpke’s paralysis, cerebral palsy, Erb-Duchenne palsy, clavicular fx, fetal asphyxia
  • -Maternal: perineal or vaginal tears, postpartum hemorrhage, uterine rupture
• Prevention:
  
  • C-Section delivery indicated if fetus is >4500g in mother with DM or >5000g in nondiabetic mother
• Tx:
  
  • Obstetric emergency
  • 1st line = McRoberts maneuver: non manipulative, hyperflexion & abduction of the mother’s hips towards the abdomen +/- extending episiotomy
  • Delivery of posterior arm to allow for rotational maneuver
  • Woods corkscrew maneuver: manipulative, rotation of fetal shoulders 180 degrees
  • Zavanelli maneuver: push fetal head back in & go to C-section

Question 109

Placenta Previa: Definition, Types, S/sxs, PE

Answer 109

• Definition:
  
  • a condition in which the placenta is attached close to or covering the internal cervical os
• Types:
  
  • Marginal: placenta is adjacent to the cervical os (2.5 cm or closer), “low lying placenta”
  • -Partial: placenta is partially over the cervical os
  • Total: placenta completely covering cervical os
• S/sxs:
  
  • Painless 3^rd trimester vaginal bleeding (as cervix dilates)
  • Absence of abdominal pain or uterine contractions
  • May be provoked by uterine contractions, examination, or intercourse
  • ***All women >20 weeks who present with bleeding should be presumed to have placenta previa until proven otherwise.
• PE:
  
  • Avoid vaginal exams or sterile speculum (may cause separation resulting in severe hemorrhage)
  • Soft, nontender uterus

Question 110

Placenta Previa: Dx & Tx

Answer 110

• Dx:
  
  • A definitive diagnosis must be avoided in asymptomatic patients before 3^rd trimester because cases of placenta previa identified early in pregnancy will resolve as pregnancy advances (watchful waiting).
  • Transvaginal US: allows location of placenta in relation to internal cervical os with great precision; ~20 weeks this formal US is performed & placenta location commented on; follow-up US at 28-32 weeks, then at 36 weeks (each trimester)
  • Transabdominal US: less reliable → use if TVUS not available
• Tx:
  
  • L&D: vital signs, 2 large bore IVs, Hgb/HCT, Type & screen, cross-match for 4 units, Rhogam (if Rh negative mom), fetal monitoring, then evaluate for placenta previa once stabilized
  • Betamethasone: to enhance fetal lung maturity if <34 weeks’ gestation
  • Beta mimetic drugs & Mg: to decrease uterine contractions, used with success
  • Hospitalization: for 48H post-bleed
  • Home management: if asymptomatic (no bleeding or pain), watchful waiting
  • *If patient has a 2^nd bleed, she will be hospitalized until she delivers
  • C-Section: all women with placenta within 2 cm of cervix as documented by 3^rd trimester TVUS
  • Vaginal delivery: an asymptomatic woman whose placenta >2cm from cervical os

Question 111

Placenta Previa: Causes of Bleeding, Postpartum complications, and Risk Reduction for Hemorrhage

Answer 111

• Causes of Bleeding:
  
  • development of the lower uterine segment, effacement of the cervix, pre-labor uterine contractions, intercourse
• Postpartum Complications:
  
  • PP hemorrhage can occur with low lying placenta d/t lower uterine segment atony
  • With anterior placenta, need to quickly clamp umbilical cord as excessive blood loss could occur
  • Oxytocin, methergine, hemabate, & Misoprostol used to control bleeding
• Risk Reduction for Hemorrhage:
  
  • bedrest or reduced activity, avoid intercourse, education

Question 112

Vasa Previa

Answer 112

• Definition:
  
  • fetal vessels run through the fetal membranes & pass over the cervix → risk for rupture with consequent fetal exsanguination
• Risks:
  
  • placenta previa or lower lying placenta identified during 2^nd T US (60%), in vitro pregnancy, multiple gestation
• Types:
  
  1. Velamentous cord insertion between the umbilical cord & placenta, fetal vessels that run freely within the amniotic membranes overlie the cervix or are in close proximity to it
  2. Placenta contains a succenturiate lobe or is multilobed & fetal vessels that connect the 2 placental lobes course over or near the cervix
• S/sxs:
  
  • Rupture of membranes
  • -Painless vaginal bleeding
  • -Fetal distress: bradycardia
• Dx:
  
  • TVUS: during 2^nd trimester (less effective if done in 3^rd trimester); color pulsed wave Doppler showing rate consistent with fetal heart rate
  • No standardized criteria for how close the fetal vessels must be to the internal os to constitute a vasa previa. Threshold of 2cm has been proposed.
• Tx:
  
  • If diagnosed in the 2nd trimester → 20% resolve by delivery.
  • -Betamethasone: at 28-32 weeks in case of preterm labor to mature the fetal lungs
  • Cervical length testing: starting at 30 weeks, if cervix >2.5cm in length then the patient can remain out of the hospital
  • Antenatal hospitalization: at 30-34 weeks’ gestation with delivery at 34-37 weeks’ gestation via C-section
  • Fetal Lung Maturity Evaluation (amniocentesis) not recommended
  • *Goal: deliver before rupture of membranes while minimizing impact of prematurity

1. 2.

Question 113

Placenta Abruption

Answer 113

• Definition:
  
  • premature separation of a normally sited placenta before birth, but >20 weeks’ gestation.
• Pathophys:
  
  • strongly associated with PPROM (Preterm Premature Rupture of Membranes) in both causal & consequential manner (possibly linking abruption to placental dysfunction & IUGR)
• Risks:
  
  • previous placental abruption (5-17% recurrence), cocaine abuse (10% risk in 3^rd T), cigarette smoking (vasoconstriction), maternal parity, chronic HTN or preeclampsia (5 fold increase), PPROM, rapid uterine decompression, uterine malformation/fibroids, trauma
• Epidemiology:
  
  • peaks at 24-26 weeks’ gestation, causes fetal death in 1/420 deliveries, 10% of all preterm births are due to abruption
• S/sxs:
  
  • Preterm labor
  • -Painful 3^rd trimester vaginal bleeding
  • -Severe abdominal pain
  • -Uterine tenderness deferred to shoulder pain
  • -Dark blood (port-wine) amniotic fluid
  • -Increased uterine tone
  • -Tachycardia, anemia, shock
• PE:
  
  • tender, rigid uterus
  • do NOT perform pelvic exam
• Dx:
  
  • Subchorionic: between placenta & membranes
  • -Retroplacental: between the placenta & myometrium
  • -Preplacental: between the placenta & the amniotic sac
• Tx:
  
  • Management- Mild Symptoms:
    
    • -Betamethasone for <32 weeks
    • -Closely monitor
    • -Quantify blood loss (QBL)
    • -Type & Crossmatch 2 units of blood
    • -Alert NICU
  • Management- Moderate Symptoms:
    
    • -IV access-anticipate central line
    • -O2 at 10L per mask
    • -Frequent VS
    • -Continuously monitor fetus
    • -Blood products/MTP
    • -Anticipate C-Section
    • -Manage pain

Question 114

Umbilical Cord Prolapse

Answer 114

• Definition:
  
  • umbilical lies beside or below the presenting part of the fetus and protrudes into the vagina → reduced fetal oxygenation
• Causes:
  
  • AROM (artificial rupture of membranes), SROM (spontaneous ROM)
• Risks:
  
  • fetal malpresentation (breech or transverse lie), fetal anomalies, IUGR, preterm labor, multiple gestation, PROM, polyhydramnios (overproduction of amniotic fluid → extreme aqueous environment), membranes rupture with high presenting part
• S/sxs:
  
  • Sudden onset of severe, prolonged fetal bradycardia or variable decelerations after a previously normal tracing
  • Prolapsed cord visualize through vaginal opening
• Tx:
  
  • Once the cord is out of the uterus or vagina, the fetal blood and oxygen supply can be blocked because of drop in temperature, spasm of blood vessels, and compression between pelvic brim & presenting part
  • Transfer to hospital: call 911
  • Position:
    
    • knee to chest, Trendelenburg (use gravity to reduce compression)
  • vaginal exam
    
    • If fully dilated → deliver the baby; if not dilated C-section needed
    • Place fingers on either side of cord to relieve pressure on cord, but do not actually handle cord because a vasospasm can occur

Question 115

Uterine Rupture

Answer 115

• Definition:
  
  • a symptomatic disruption and separation of the layers of the uterus or previous scar. May result in extrusion of the fetus or fetal parts into the peritoneal cavity
• Risks:
  
  • uterine scars (C/S), prior uterine rupture, abortion, instrumentation or uterine perforation, Grand Multips, uterine over distension (macrosomia, twins, polyhydramnios, fetal presentation- transverse)
• S/sxs of Fetus:
  
  • Category 2 or Category 3 tracing
  • -An abrupt decrease in fetal HR, late variable decelerations or bradycardia
• S/sxs of Mom:
  
  • Abdominal pain: sudden onset ripping, tearing sensation that is independent of contractions
  • -Decreased or absent uterine contractions
  • -Loss of fetal station or no fetal descent
  • -Palpable fetal parts in maternal abdomen
  • -Vaginal bleeding: bright red
  • -Shock: hypotension, bradycardia
• Tx:
  
  • Life-threatening to mother and fetus.
  • Transfer to hospital: call 911
  • -D/C any medications such as oxytocin
  • -Get patient to the OR
  • -If fully dilated then can attempt to deliver vaginally
  • -IV-Fluid bolus
  • -Oxygen at 10L per mask
  • -Anticipate giving blood products
  • -Place woman on left or right side
  • -Monitor baby continuously

Question 116

Labor Dystocia

Answer 116

• Definition:
  
  • baby doesn’t exit the pelvis during childbirth d/t being physically blocked, despite the uterus contracting normally.
• Causes:
  
  • macrosomia, malpresentation, small pelvis, problems with birth canal (narrow vagina)
• Categories:
  
  • Problems of power: uterine contraction
  • -Problems of passenger: presentation, size (macrosomia), position of fetus
  • -Problems of passage: uterus or soft
• Complications:
  
  • Fetus: not enough oxygen
  • -Mother: infection, uterine rupture, postpartum bleeding

Question 117

Cesarean Delivery

Answer 117

• Definition:
  
  • use of surgery for delivery of the fetus
• Epidemiology:
  
  • ~32% of deliveries in the U.S.
• Reasons for C-Section:
  
  • dystocia, failure to progress to labor (most common), breech presentation, fetal distress
• Low transverse uterine incision: decreased blood loss, ease of repair, lower likelihood of rupture
• Prophylactic antibiotic: up to 60 minutes prior to making the initial incision; IV Cefazolin
  
  • Thromboprophylaxis

Question 118

Incompetent Cervix

Answer 118

• Definition: a weakening of the cervix which causes premature shortening or dilation & miscarriage- causes recurrent 2^nd trimester miscarriages.
• Causes:
  
  • past trauma to cervix (surgery, D&C), previous deliveries, genetic anomalies
• S/sxs:
  
  • Vaginal bleeding
• PE:
  
  • Cervical length <25mm (<2.5cm) before 24 weeks
• Dx:
  
  • TVUS: funneling of the cervix
  • Usually diagnosed after 2^nd or 3^rd T miscarriage occurs but can be detected on routine prenatal US
• Tx:
  
  • Cervical cerclage: placing purse-string sutures in the cervix to draw it closed at 14-16 weeks, removed at 36 weeks to allow for delivery

Question 119

What does GPTAL stand for in OB?

Answer 119

Gravid (pregnancies), Para (births), Term, abortion, living

Question 120

Endometriosis

Answer 120

• Definition:
  
  • presence of endometrial tissue (glands & stroma) outside the uterus
• Pathophys:
  
  • the ectopic endometrial tissue responds to cyclical hormonal changes
• Risks:
  
  • hx of c-section or fibroid removal, family hx, prolonged estrogen exposure (nulliparity, late 1st pregnancy, early menarche)
• S/sxs:
  
  • Classic Presentation: **Progressive dysmenorrhea and deep pelvic pain, deep dyspareunia**
  • Consider endometriosis in patients with dysmenorrhea not responsive to COCs and NSAIDs
• Pe:
  
  • usually normal
    
    • but may have a fixed, tender adnexal mass
• Dx:
  
  • Clinical Dx: dx of exclusion
  • Pelvic US:
    
    • r/o other causes, may show ovarian endometriomas as cysts containing “homogeneous” echoes consistent with old blood or free fluid in pelvis
  • Laparoscopy with biopsy = definitive diagnosis, raised patches of thickened discolored scarred implants of tissue
• Tx:
• -Ovulation suppression: combined OCPs (1st line) &NSAIDs (600-800mg TID for first few days, need to start BEFORE the pain begins)
  
  • → continuous therapy, without taking 7 days of inactive pills that induce withdrawal bleeding, can prevent secondary dysmenorrhea
    
    • (cause medical amenorrhea)
• Surgery: conservative laparoscopy with ablation of ectopic endometrial tissue if fertility desired; total abdominal hysterectomy & salpingo-oophorectomy if no desire for fertility
• **LNP IUDs do NOT help b/c they are not systemic **

Question 121

Leiomyoma (Fibroid)

Answer 121

• definition:
  
  • benign uterine smooth muscle tumors that derive from the muscle cells of the myometrium
• Types: intramural, submucosal, subserosal, parasitic
• Risks:
  
  • increasing age (> 35yo), African-Americans, nulliparity, obesity, family hx
• Pathophys:
  
  • growth is estrogen dependent
• Most common reason for hysterectomy → due to symptoms
• S/sxs:
  
  • mostly asymptomatic
  • heavy period → most common reported symptom: worsen at 40-50 yo & resolves with menopause
  • Abd fullness, increased pelvic pressure: with or without urinary or bowel symptoms
  • Pelvic or lower abdominal pain with sex
• PE:
  
  • irregular large uterus (normal is 6-10cm in length, an upside down pear is normal)
  • Firm, nontender, asymmetric mobile mass(es) in the abd or pelvis on bimanual exam
• Dx:
  
  • bimanual exam as clinical impression
  • transvaginal US: focal heterogenic hypoechoic mass(es) with shadowing
  • saline infused pelvic US or hysterectomy for submucosal fibroids
  • MRI for extremely large fibroids
• Tx:
  
  • Observation: most do not need tx
  • -Hysterectomy = definitive
  • -Myomectomy → preserves fertility
  • Medical Tx: to decrease bleeding and pain
    
    • → Progestin and/or prostaglandin synthetase inhibitors
    • → norethindrone 5-10 mg PO daily (not a contraceptive dose!!)
    • → progestin only LARC; LNG IUD, nexplanon, depo IM
• surgical tx:
  
  • myomectomy/hysterectomy
    
    • →GnRH agonists to debulk fibroid 40-60% prior to uterine sparing surgery
• Uterine Artery Embolization:
  
  • causes acute infarct of targeted fibroid

*

Question 122

Adenomyosis

Answer 122

• Definition:
  
  • islands of endometrial tissue within the myometrium (muscular layer of the uterine wall)
• Risks:
  
  • age 30-50, endometriosis, fibroids
• S/sxs:
  
  • menorrhagia, dysmenorrhea, chronic pelvic pain, infertility
• PE:
  
  • symmetrically enlarged “globular” boggy uterus
• Dx:
  
  • transvagina US: heterogenous cystic structure
  • Pelvic MRI
• tx:
  
  • Conservative: analgesics (NSAIDs), progestins, aromatase inhibitors
  • -Hormonal contraceptives: COCs or progesterone therapy (Depo, nexplanon, LNG (levonorgestrel) IUD→ IUD = great option )
  • -Definitive: total abd hysterectomy

Question 123

Uterine Prolapse

Answer 123

• Definition:
  
  • uterine herniation into the vagina
• Risks:
  
  • multiple vaginal births, obesity, heavy lifting
• S/sxs:
  
  • Vaginal fullness, heaviness, or “falling out” sensation worse with prolonged standing & relieved with lying down
  • low back pain, abd pain, urinary frequency or urgency
  • stress incontinence
• PE:
  
  • Bulging mass esp with increased intraabdominal pressure
• Dx:
  
  • Grading:
    
    • 0: no descent
    • 1: descent into upper ⅔ of vagina
    • 2: cervix approaches introitus
    • 3: cervix outside introitus
    • 4: entire uterus outside of vagina
• Tx:
  
  • Kegel exercises, behavioral modification, weight control
  • Estring–localized ERT (estrogen replacement therapy) replaced q 90 days, vaginal ring, acts as a support structure and has estrogen
  • Pessaries: elevate & support the uterus
  • Estrogen: improves atrophy
  • Surgery: hysterectomy is definitive

Question 124

Uterine Hyperplasia & Cancer

Answer 124

• Epidemiology: 2-3% of women develop uterine cancer
  
  • 97% of uterine cancers arise from glands of endometrium -→ endometrial carcinoma
  • 3% arise from myometrium or stromal components -→ sarcoma
• s/sxs:
  
  • abnormal uterine bleeding → HALLMARK SXS
  • must evaluate in:
    
    • women > 45 yo
    • women < 45 yo with risk factors:
      
      • fmhx of breast, gyn or colon CA, obesity, prior endometrial hyperplasia, chronic anovulation, tamoxifen or ERT use
  • Dx:
  • transvaginal u/s first with endometrial stripe measurement: symptomatic with endometrial stripe > 5mm = have to do an endometrial biopsy
  • Asymptomatic with endometrial stripe > 11mm = have to do an endometrial biopsy
• Tx:
  
  • Goal: reduce risk of malignant transformation and control presenting symptoms
  • Meds:
    
    • Oral progesterone; 1 tablet PO x 10 days → to help them shed
    • -Long acting progesterone: Depo, nexplanon, LNG D
    • -Women on SERM (Tamoxifen/Raloxifene) for breast cancer treatment, therapy should be discontinued
• Surgical:
  
  • dilation & curettage

Question 125

Endometrial Carcinoma: Dx & Tx

Answer 125

• Dx:
  
  • endometrial biopsy
• Tx:
  
  • total hysterectomy with salpingo-oophorectomy and cancer staging
  • Post surgical estrogen replacement: may be used for menopausal symptoms
  • These people are candidates for ERT based on prognostic indicators and pts must be willing to assume the risk

Question 126

Uterine Sarcoma

Answer 126

• Presentation:
  
  • progressive uterine enlargement after menopause
  • Low dose HRT does not increase risk of sarcoma
• s/sxs:
  
  • post-menopausal bleeding
  • pelvic pain with uterine enlargment
  • increased unusual vaginal discharge
• Dx:
  
  • Total hysterectomy (yes for the diagnosis, I know)
• Tx:
  
  • Post-surgical tx:
    
    • radiation & chemo decreases recurrence rate but doesnt change much in terms of survival
  • Prognosis:
    
    • 5 year survival = 29%-76%

Question 127

Peyronie Disease Etiology, S/sxs, Dx, & Tx

Answer 127

buildup of fibrous hardened tissue in the corpus cavernosum → often caused by repeated injury (sex, physical activity) and genetic susceptibility is involved

• S/sxs:
  
  • penile pain worsened with erection
  • curvature of penis on erection
  • interference with sexual function
  • thick circumferential plaque at the coronal sulcus
• Dx:
  
  • hx and penile exam
• Tx:
  
  • stable, mild curvature (≤ 30 degrees) with satisfactory sexual function:
    
    • observation = okay
  • worsening curvature or sexual dysfunction:
    
    • pentoxifylline (vasodilator & anti-inflammatory) = best if initial tx within 3 months of onset
    • > 3 months of deformity?
      
      • intralesional injection with collagenase
    • >12 months and wont respond to other txs?
      
      • surgical management
        *

Question 128

Cystitis S/sxs, PE, Dx, & Tx

Answer 128

infx of bladder

• Most common organisms: E.coli, Klebsiella, proteus, enterobacter, citrobacter
• S/sxs:
  
  • hematuria, dysuria, increased urinary frequency, nocturia
  • no fever, chills or back pain
• PE: NO CVA TENDERNESS
• Dx:
  
  • urine dipstick: nitrites, leukocyte esterase
  • urinalysis: pyuria (WBCs in urine), bacteriuria, +/- blood, +/- nitrites
  • Urine Cx = GOLD STANDARD
    
    • → but do not need for uncomplicated cystitis
      
      • (non-pregnant woman)
• Tx:
  
  • uncomplicated UTIs:
    
    • trimethoprim -sulfamethoxazole (BACTRIM) x 3 days
    • Nitrofurantoin x 5 days
    • fluoroquinolones x 3 days
  • Lower UTI in pregnancy:
    
    • nitrofurantoin x 7 days
    • Cephalexin (Keflex) x 7 days
  • Pediatric Cystitis:
    
    • 1st gen ceph (Keflex) for low risk of renal involvement
    • 2nd gen ceph (cefuroxime) or 3rd gen ceph (cefixime, cefdinir, ceftibuten) for those with high likelihood of renal involvement

Question 129

Epididymitis S/sxs, PE, Dx, and Tx

Answer 129

• Pathogens:
  
  • Men < 35 = chlamydia and gonorrhea
  • Men ≥ 35 = E.coli
• S/sxs:
  
  • dull, aching scrotal pain that gradually increases
  • dysuria, unilateral scrotal pain & swelling
• PE:
  
  • (+) Phren’s sign → relief of sxs with elevation = Classic Sign
  • tender scrotum on posterior
• Dx:
  
  • important to r/o testicular torsion → Rapid onset, higher testis → u/s with doppler
  • urinalysis & cx + GCCT → pyuria (WBCs in urine) and bacteriuria
• Tx:
  
  • <35 or suspected STD: ceftriaxone IM + doxycycline
  • ≥ 35 with suspected enteric organism:
    
    • levofloxacin or double strength Trimethoprim-Sulfamethoxazole (Bactrim)

Question 130

Orchitis s/sxs, PE, Dx, & Tx

Answer 130

• Mumps = most common cuase in kids
• orchitis without epididymitis = very uncommon in adults
• S/sxs: unilateral scrotal pain
• PE:
  
  • tender, swollen testicle
    
    • shininess of the overlying skin
    • scrotal edema with erythema
• Dx:
  
  • r/o testicular torsion with u/s with doppler
  • urinalysis with cxs: pyuria and bacteriuria with cxs positive for suspected organisms
• Tx:
  
  • rest, NSAIDS, scrotal support, ice, and abx (if bacterial)
  • Age <35 or sexuallya ctive post-pubertal males → tx like epididymitis
    
    • → ceftriaxone IM + doxycycline
  • Age ≥ 35 (STI not suspected) →levofloxacin

Question 131

Pyelonephritis S/sxs, PE, Dx, & Tx

Answer 131

infx of the kidneys usually by E. coli

• S/sxs:
  
  • dysuria + fever + flank pain +/- nausea/vomting
• PE: flank pain
• Dx: urinalysis: bacteria and WBC casts
• Tx:
  
  • outpatient: cipro/levo +/- ceftriaxone IM
  • inpatient: cipro/levo or imipenem for more severe disease
  • admit all pregnant patients with pyelo!

Question 132

Prostate Cancer Etiology, S/sxs, PE, Dx, Tx

Answer 132

• most are adenocarcinomas
• associated with the BRCA1 gene
• Risk factors: african american, old age, family hx
• S/sxs: urinary retention (more likely sign of BPH), decrease in urine stream strength
  
  • back pain (metastatic disease)
  • painful ejaculation
• PE: DRE: hard, nodular, enlarged, and asymmetrical prostate
• Dx:
  
  • indications for transrectal biopsy with normal rectal exam → PSA > 10 or abnormal transrectal U/S
  • PSA > 4: U/s with needle biopsy
  • PSA >10: bone scan to r/o metastases
• Tx;
  
  • radical prostatectomy → complication = erectile dysfunction & urinary incontinence
  • with metastases: need androgen deprivation therapy (leuprolide) → type of medical castration, but can be reversible
    *

Question 133

Hypospadias/Epispadias Dx and Tx

Answer 133

• Hypospadias: when the urethral meatus open onto the ventral (bottom/underside) of the penile shaft
  
  • genetic heritability
  • IVF has been associated with increased risk of hypospadias
• Epispadias: when the urethral meatus opens onto the dorsal (topside) of the penile shaft
• Dx: usually made during the newborn exam but imaging studies (excretory urogram) can be helpful
• Tx: surgical repair before 1-2 years of age
  
  • DO NOT CIRCUMCISE → may use foreskin in surgical repair

Question 134

Paraphimosis Dx & Tx

Answer 134

• entrapment of the foreskin in the retracted position → Medical Emergency
  
  • Paraphimosis needs a Paramedic
• ***always remember to reduce the foreskin after urethral catheterization***
• Dx: clinical
• Tx: firm circumferential compression of the glans with the hand may reduce the edema enough to allow the foreskin back to its normal position
  
  • → if not successful, dorsal slit using local anesthetic temporarily relieves the problem → CIRCUMCISION after edema is resolved

Question 135

Phimosis Dx and Tx

Answer 135

• foreskin in normal position and cannot be retracted
• adult phimosis often caused from scarring after trauma, infx (such as balanitis) or prolonged irritation
• Dx: clinical
• Tx: in children, will normally resolve by age 5
  
  • tx not usually required in absence of other issues such as balanitis, UTIs, urinary obstruction
  • betamethasone cream 0.05% BID-TID
  • gently stretch the foreskin

Question 136

Hydrocele PE, Dx, & Tx

Answer 136

• mass of fluid-filled congenital remnants of the tunica vaginalis
• infants: will usually close within the 1st year of life
• PE:
  
  • painless scrotal swelling (most common cause of this)
  • + transillumination vs tumor or varicocele which both do not transilluminate
• Dx: Scrotal U/S
• Tx: in infants → will usually close in the 1st year of life, but may require surgery if clinically indicated
  
  • have parents practice watchful waiting for 1 year

Question 137

Varicocele PE, Dx & Tx

Answer 137

venous varicosity within the spermatic vein

• PE: feels like a “bag of worms’ superior to the testicles
  
  • dilation worse when the pt is upright or with valsalva → decrease in size with elevation of the scrotum or supine position
  • negative transillumination → chronic non-tender mass that does not transilluminate
• Dx: Scrotal U/s
• Tx: surgical repair if varicocele is painful or appears to be cause of infertility

Question 138

Testicular Torsion S/sxs, PE, Dx, & Tx

Answer 138

• Risk Factors: after vigorous activity or minor trauma
  
  • usually post-pubertal boys (65% in boys age 10-20)
  • more common in pts with a hx of cryptorchidism
• S/sxs:
  
  • severe, acute onset lower abdominal pain, sharp pain that may radiate into thigh
  • vomiting
• PE: negative phren’s sign
  
  • loss of cremasteric reflex ( elevation of the testes in response to stroking of the inner thigh)
  • Blue dot sign: tender nodule 2-3mm in diameter of the upper pole of the testicle
• Dx: U/s with doppler = best initial test
  
  • Radionuclide scan demonstrates decreased uptake in the affected testes → GOLD STANDARD
• Tx:
  
  • need to de-torse the testicles in < 6 hours (90% salvage rate)
  • >24 hours? <10% salvage
  • orchiopexy (permanent fixation of the testicle)

Question 139

Aortic Stenosis

Answer 139

CRESCENDO- DECRESCENDO murmur R 2nd intercostal space

• increased murmur when leaning forward (ERBs) and increased venous return (squatting, supine, leg raise)
• pulsus parvus et tardus (weak, delayed carotid pulse)
• Etiology:
  
  • degenerative: calcifications > 70 yo
  • congenital & bicuspid valve <70 yo
• S/sxs: ASH
  
  • angina
  • syncope
  • heart failure
• Dx:
  
  • ECHO = best test
  • ECG = L ventricular Hypertrophy
• Tx: aortic valve replacement = ONLY effective treatment

Question 140

Aortic Regurgitation

Answer 140

Diastolic high-pitched blowing DECRESCENDO murmur along LSB +/- apex

• murmur LOUDER when sitting up and leaning forward
• Etiology:
  
  • acute → MI, aortic dissection, endocarditis
  • chronic → aortic dilation, rheumatic fever, HTN
• Physical Exam:
  
  • Water hammer pulse: swift upstroked and rapid fall of radial pulse accentuated with wrist elevation
  • De-Musset’s Sign: head-bobbing with heart beat
  • Hill’s Sign: popliteal artery systolic pressure > brachial artery by 60 mmHg (most sensitive)
  • Quincke’s Pulses: visible pulsations in the fingernail bed
  • Muller’s Sign: visible systolic pulsations of the uvula
• Dx:
  
  • Echocardiogram → regurgitant jet
  • L ventricular dilation as compensation
• Tx:
  
  • decrease the afterload improves the forward flow (e.g. ACE-I, ARBs, nifedipine, hydralazine)
  • surgery = definitive tx
    *

Question 141

Mitral Stenosis

Answer 141

• Diastolic murmur heard best at the apex
• LOUD S1 (forceful closure of mitral valve) with OPENING SNAP (forceful opening of mitral valve →early diastolic sound followed by a mid-diastolic rumbling murmur.
  
  • → initial rumble during passive filling of ventricle, followed by active rapid filling during atrial “kick”
• Etiology: rheumatic heart disease = most common cause!
• S/sxs: increased L atrial pressure/volume overload → pulm congestion → pulm HTN → CHF
• Dx:
  
  • ECG = L atrial enlargement, A fib, pulmonary HTN (RVH, R axis deviation)
  • ECHO = most useful non-invasive tool
  • Cardiac Cath = most accurate but rarely done
• Tx:
  
  • percutaneous balloon valvuloplasty

Question 142

Mitral Regurgitation

Answer 142

Systolic murmur Blowing Holosystolic murmur heard best at the APEX → murmur radiates to the axilla, can be heard well in the LLD position

• Etiology: Mitral Valve prolapse = most common cause in the US
  
  • rheumatic fever = most common in developing countries
  • MI/ischemia → papillary muscle dysfunction
  • dilated cardiomyopathy → ruptured chordae tendineae
• S/sxs:
  
  • dyspnea = most common, blood backs up into L atrium then lungs
• Dx:
  
  • ECHO = most useful non-invasive test
• Tx: sx control by reducing afterload (ACE-I, ARBs)
  
  • surgery = repair > replacement

Question 143

Mitral Valve Prolapse

Answer 143

Mid-late systolic ejection click best heard at the apex

• → any maneuver that makes the LV smaller (decreases preload) results in an earlier click & longer murmur duration (e.g. valsalva, standing) due to increased prolapse
• MVP = MOST common cause of mitral regurgitation
• Population:
  
  • Most common in young women
• Dx:
  
  • ECHO → posterior bulging leaflets
• Tx:
  
  • MVP is associated with good prognosis → reassurance
  • beta-blockers for pts with autonomic dysfunction
  • mitral valve repair only for severe regurg and CHF

Question 144

Pulmonary Stenosis

Answer 144

harsh mid-systolic crescendo-decrescendo murmur

• murmur increases with inspiration (bigger preload)
• Pathophys:
  
  • Right ventricle encounters more resistance → hypertrophy → less preload→ blood backs up
• epidemiology:
  
  • almost always congenital and in the young
• Tx: balloon valvuloplasty

Question 145

Pulmonary Regurgitation

Answer 145

Diastolic decrescendo murmur best heart at the L upper sternal border

• murmur increases with inspiration and venous return
• Pathophys:
  
  • retrograde blood flow from the pulmonary artery into the Right Ventricle causing R-sided volume overload
• Etiology:
  
  • almost always congenital

Question 146

Tricuspid Stenosis

Answer 146

mid-diastolic rumbling murmur at the lower left sternal border

• blood backs up into the R atrium causing R atrial enlargement which may lead to R-sided heart failure
• Tx:
  
  • decrease R atrial volume overload with diuretics and Na restriction
  • surgery

Question 147

Tricuspid Regurgitation

Answer 147

Holosystolic murmur at 4th ICS left midsternal border

• may radiate to liver
• Pathophys:
  
  • blood flows back into the R atrium
• Etiology:
  
  • functional overload (pulm HTN, RV dilation)
  • dirty needles (staph etc often up on tricuspid valve)
• PE:
  
  • Carvallo’s Sign:
    
    • holosystolic murmur that becomes louder during inspiration
• Tx:
  
  • tx the underlying condition
  • valve replacement

Question 148

What can accentuate mitral murmurs

Answer 148

Left lateral decubitus position with the bell

Question 149

What can accentuate aortic murmurs

Answer 149

sitting up and leaning forward

Question 150

What does increasing venous return do?

Answer 150

increases intensity of all murmurs EXCEPT hypertrophic cardiomyopathy, mitral valve prolapse

“the MVP Hates Conforming to the rules”

Question 151

Pneumonic to remember which murmurs are diastolic

Answer 151

MS. PRARTS DIED

MS = mitral stenosis

PR = pulmonary regurg

AR = aortic regurg

TS = tricuspid stenosis

DIED = diastolic, everything else is a systolic murmur

Question 152

Maneuvers to increase venous return

Answer 152

lying supine

squatting

lifting legs

Question 153

Maneuvers to decrease venous return

Answer 153

standing

valsalva maneuver

Question 154

Inspiration increases venous return to which side of the heart

Answer 154

Right Side: RINSPIRATION

→ increases the sound of murmurs on the R side

Question 155

Expiration increases venous return to which side of the heart

Answer 155

Left side → increases sound of all murmurs on the L side

Question 156

Increased Total Peripheral Resistance & Murmurs

Answer 156

How to: handgrip, phenylephrine

• increased resistance decreases forward flow & increases backward flow → increases aortic regurg, mitral regurg (regurgitant murmurs)
• decreases AS, MVP, hypertrophic cardiomyopathy

Question 157

Decreased Total Peripheral Resistance & Murmurs

Answer 157

How to: Amyl Nitrate

• direct arteriolar vasodilator increases forward flow through the aortic valve
  
  • increases AS, MVP, hypertrophic cardiomyopathy
  • decreases AR, MR (regurgitant murmurs)

Question 158

Pulsus parvus et tardus

Answer 158

weak, delayed carotid pulse

often seen in Aortic Stenosis

Question 159

Infectious Esophagitis

Answer 159

• Risks: immunocompromised (HIV, post-transplant, malignancy)
• Etiology: Candida = most common, CMV, HSV
• S/sxs:
  
  • Dysphagia = difficulty swallowing
  • Odynophagia (Hallmark) = painful swallowing
  • Retrosternal chest pain
• Dx:
  
  • endoscopy:
    
    • candida = linear, yellow white plaques
    • CMV: large, superficial ulcers
    • HSV: small, deep ulcers
• Tx:
  
  • Candida: Fluconazole
  • HSV: Acyclovir
  • CMV: ganciclovir (highly testable on PANCE)

Question 160

Eosinophilic Esophagitis

Answer 160

• Definition: allergic, inflammatory eosinophilic problems of the esophageal epithelium
• Epidemiology:
  
  • most commonly in children, associated with ATOPY
• S/sxs:
  
  • significant Dysphagia and food impaction → food can’t move down esophagus due to ulceration/obliteration
  • odynophagia
  • Reflux or feeding difficulties in children
• Dx:
  
  • Endoscopy
    
    • → normal or multiple Corrugated rings
  • Biopsy → >15 eosinophils/hpf
• Tx:
  
  • Remove foods that cause allergic response → Elimination Diet: 5 day elimination of a single common allergen food
  • PPI + Swallowed steroid Solution (fluticasone, budesonide) → puff steroid from inhaler & SWALLOW IT

Question 161

Barrett’s Esophagus

Answer 161

complication of chronic GERD

• chronic exposure of esophagus to acid → replacement of the squamous epithelium with columnar epithelium
• Precancerous finding
• Need to MONITOR AGGRESSIVELY with regular endoscopy & biopsy
• Tx:
  
  • this pt will always be on PPIs

Question 162

Mallory Weiss Tear

Answer 162

• Definition:
  
  • superficial mucosal laceration of the gastric mucosa that occur from recurrent retching or vomiting
• Risks:
  
  • Alcohol = Strong predisposing factor (persistent vomiting after EtOH binge), bulimia
• S/sxs:
  
  • hematemesis
  • melena
  • hematochezia
  • abd pain
• Dx:
  
  • upper endoscopy = test of choice
• Tx:
  
  • Stop the bleed → will heal well
  • Epi, band ligation, or balloon tamponade
  • if not actively bleeding → supportive care (acid suppression with PPIs)

Question 163

Boerhaave’s Syndrome

Answer 163

• Definition:
  
  • full thickness perforation of the distal esophagus
• S/sxs:
  
  • retrosternal Chest Pain→worsening with swallowing and deep inspiration
  • gross hematemesis
  • hematochezia
  • melena
• PE:
  
  • pneumomediastinum: crepitus on auscultation & shock
  • Hamman’s sign: mediastinal crackling accompanying every heartbeat in LLD position
• Dx:
  
  • CT chest → Pneumomediastinum
• Tx:
  
  • STAT surgery
  • perf of the esophagus is one of the fastest ways to bleed to death

Question 164

Esophageal Web

Answer 164

“The Itsy bitsy spider crawl UP the water spout”

• Definition:
  
  • noncircumferential thin membrane in the upper esophagus
• Etiology:
  
  • congenital or acquired from inflammation (associated with eosinophilic esophagitis
• S/sxs:
  
  • mainly asymptomatic but can have Dysphagia to solids
• Plummer-Vinson Syndrome:
  
  • esophageal webs
  • iron deficiency anemia
  • glossitis
• Dx:
  
  • Barium esophagram:
    
    • ridge above the diaphragm that narrows the esophagus
• Tx:
  
  • endoscopic dilation

Question 165

Achalasia

Answer 165

• Definition: impaired esophageal peristalsis & failure of relaxation o the lower esophageal sphincter → loss of peristalsis into the stomach → food stasis & dilation of the esophagus
• Pathophys:
  
  • degeneration of ganglion cells in myenteric (Auerbach’s) Plexus of the esophagus → Failure of the LES to relax and loss of peristalsis in the distal esophagus ⇒ obstruction
• associated with autoimmune response (latent HSV1 infection)
• S/sxs:
  
  • Dysphagia of both liquids & Solids
  • weight loss/malnutrition
  • regurg of undigested food
  • cough or chest pain
• Dx:
  
  • Manometry = gold standard
    
    • aperistalsis in the distal ⅔rds of the esophagus & incomplete LES relaxation
    • BIRD’s beak on esophagram
• Tx:
  
  • Botox, nitrates, CCBs → to relax the esophagus
  • Pneumatic balloon dilation → at the LES to a diameter of 3-4cm, may cause esophageal perforation

Question 166

• Hamman’s sign:

Answer 166

mediastinal crackling accompanying every heartbeat in LLD position, associated with Boerhaave’s Syndrome

Question 167

Zenker’s Diverticulum

Answer 167

• out-pouches in the esophagus that food can get stuck in
  
  • Sxs: similar to that of obstruction
    
    • will regurg undigested food and liquid into pharynx
• Dx: barium swallow
• Tx: observe if small and symptomatic
  
  • otherwise: surgery

Question 168

Nutcracker Esophagus

Answer 168

• excessive contractions during peristalsis
• manometry shows increased pressure during peristalsis
• tx is the relax the esophagus like achalasia

Question 169

Hyperthyroidism: definition, etiology, s/sxs, & PE

Answer 169

• Definition: excess thyroid hormone synthesis & secretion by the thyroid gland. Thyrotoxicosis is the clinical effect experienced d/t an excess of thyroid hormones in the blood stream
• Etiology:
  
  • Grave’s (#1), iatrogenic thyrotoxicosis, thyroiditis, toxic multinodular goiter, toxic adenoma, TSH-secreting pituitary adenoma, amiodarone, ingestion of thyroid hormone
• Women > men
• S/sxs:
  
  • hyperactivity: anxiety, nervousness, irritability
  • Heat intolerance & sweating
  • fatigue & weakness
  • Weight loss despite increased appetite
  • hyperdefecation, polyuria
  • Oligomenorrhea infrequent periods
  • loss of libido
• Pe:
  
  • **Increased metaboli rate
    
    • tachycardia, palpitations
    • Fine tremor
    • Goiter, warm moist skin
    • muscle weakness, proximal myopathy, eyelid retraction, lid lag or stare

Question 170

Hyperthyroidism: Dx & Tx

Answer 170

• Dx:TSH: good initial screening test, low TSH, high Free T4
  
  • Free T4: helps to evaluate low TSH
  • total T3: detection of T3 thyrotoxicosis
  • Thyroid uptake & scan: can help distinguish b/w causes of thyrotoxicosis contraindicated in preggos/breastfeeding/amiodarone
  • thyroid U/S: used in preggos, evaluation of palpated nodule & to dx amiodarone-induced thyrotoxicosis
• Tx:
  
  • Antithyroid drugs: used in those with higher remission likelihood (women, mild dx, small thyroid glands, negative-low TSH-R ab) b/c only 30% of cases end up in remission:
    
    • Methimazole (1st line, no in 1st trimester preggos)
    • Propylthiouracil (2nd line, warning: hepatic necrosis); follow with TSH AND Free T3 (TSH is a poor response indicator early in tx)
    • 131 Iodine Ablation:avoid in Smokers (TED), no pregnancies x 6 mo post tx, should control comorbidities prior to tx
    • Surgery (Total thyroidectomy): best if done by a surgeon who does this a lot (in order to avoid hypoparathyroidism and laryngeal nerve damage), decreases progression of Grave’s orbitopathy, Do not use in 1st or 3rd trimester preggos

Question 171

Grave’s Disease

Answer 171

MCC of hyperthyroidism in the US

• Pathophys: autoimmune disease in which TSH-R ab target and STIMULATE the TSH-R on the thyroid gland → increased in thyroid hormone production → hyperthyroidism
• S/sxs:
  
  • s/sxs of hyperthyroidism
    
    • Graves Orbitopathy: proptosis, exophthalmos, lid lag, diplopia
    • Graves dermopathy: pretibial myxedema (swollen red or brown patches with non-pitting edema)
• PE:
  
  • Diffusely enlarged but non-tender goiter/thyroid
  • Thyroid Bruit
• Dx:
  
  • Decreased TSH, Increased T4
  • TSH-Receptor Ab: positive
    
    • Thyrotropin binding inhibitor immunoglobulin (TBII): positive
    • Thyroid stimulating immunoglobulin (TSI): positive
  • Thyroid Uptake & Scan: diffuse iodine uptake that is HIGH
• Tx:
  
  • Radioactive iodine (131Iodine Ablation): MOST COMMON
  • Antithyroid drugs: Methimazole or Propylthiouracil
  • Surgery: total thyroidectomy
  • beta blockers to alleviate tremor: Propranolol
  • Smoking cessation (tobacco worsens TED: thyroid eye disease)

Question 172

Thyroid Storm (Thyrotoxic Crisis)

Answer 172

• Definition:
  
  • acute exacerbation of hyperthyroidism that is life-threatening and rare
• Etiology:
  
  • precipitated by illness, inx or surgery. usually associated with Graves, but sometimes toxic multinodular goiter
• S/sxs:
  
  • Severe tremor
  • Hyperpyrexia (104-106F)
  • palpitations & tachycardia
  • n/v, jaundice (d/t acute liver failure)
  • CNS dysfunction: anxiety, delirium, AMS, coma
  • resp failure
• Dx:
  
  • Clinical Diagnosis
    
    • with labs used to support hyperthyroidism
    • Labs: undetectable TSH, markedly elevated free T4 & T3 +/- TSH-R Ab elevation
  • Scoring system: see other flashcard
• Tx:
  
  • Endocrine emergency. Results in death if untreated (Mortality is 10%)
  • IV fluids
  • Propranolol
    
    • (reduce tachycardia & adrenergic sxs → tremor)
  • Anti-Thyroid Med (Propylthiouracil):
    
    • block synthesis of T3 & Y +T4
  • IV glucocorticoids:
    
    • reduced conversion of T4 to T3
  • Oral or IV sodium iodine

Question 173

Myxedema coma

Answer 173

• Definition:
  
  • rare, extreme form of hypothyroidism with a high mortality rate
  • MCC in elder women with long-standing hypothyroidism in winter
• Precipitating Factors:
  
  • HF, PNA, pulm edema, pleural effusions, ileus, excessive fluid admin
• S/sxs:
  
  • coma: progressive weakness, stupor, hypothermia, hypoventilation, hyponatremia
  • Myxedema
• PE:
  
  • bradycardia
  • hypotension
  • Hypothermia (low as 75F)
  • hoarse voice & macroglossia
  • slowed reflexes, ileus, pale & dry cool skin
  • Sallow: yellow skin coloring (decreased carotene → vitamin A)
• Dx:
  
  • clinical diagnosis: labs to support
    
    • TSH: elevated
    • Free T4: low +/- positive thyroid peroxidase ab
    • elevated total cholesterol & LDL
• Tx:
  
  • Endocrine Emergency. Death will occur if untreated (20-40% risk)
  • supportive: airway, rewarming
  • IV levothyroxine +/- T3 supplementation
  • IV glucocorticoids

Question 174

Define Myxedema

Answer 174

boggy or puffy non-pitting edema seen periorbitally on dorsa of hands/feet & in the supraclavicular fossa

Question 175

Thyroiditis Definition

Answer 175

• inflammation of the thyroid gland → group of disorders that cause thyroidal inflammation but they present differently

Question 176

Postpartum Thyroiditis

Answer 176

Occurs 2-12 months after giving birth

• Pathophys:
  
  • immune system is depressed during pregnancy → after birth immune system becomes more active and might attack the thyroid
  • hyperthyroid phase 5-7 months after birth followed by a normal thyroid funx

Question 177

Subacute Thyroiditis

Answer 177

• aka Quervain’s Thyroiditis
• Definition:
  
  • thyroiditis occurring several weeks after a URI (coxsackie, mumps, influenza, adenovirus)
  • MCC of painful thyroid;women > men
• Phases:
  
  • hyperthyroid → euthyroid → hypothyroid → recovery
• Pathophys;
  
  • Destruction of thyroid follicles leads to transient & acute release of thyroid hormone → hyperthyroid. Followed by a period of transient hypothyroidism as the damaged follicles get repaired.
• S/sxs:
  
  • following sxs like: fever, myalgia, pharyngitis
• PE:
  
  • inflamed, painful thyroid, worse with head movement and swallowing, may radiate to jaw or ear
• Dx:
  
  • ESR: high (>50 mm/h)
  • thyroid ab: negative
  • hyperthyroid labs (in early disease): low TSH, increased free T3
  • thyroid uptake & scan: diffuse decreased iodine uptake
• Tx:
  
  • Thyroid fnx usually normalizes within 4-6 months but 15% never regain normal function
  • supportive care: self-limiting in 95%
  • NSAIDs or Aspirin for pain & inflammation

Question 178

Suppurative Thyroiditis

Answer 178

• Definition: bacterial infection of the thyroid gland Staph aureus = most common
  
  • rare
• S/sxs:
  
  • painful thyroid gland
    
    • acute onset with neck pain & tenderness, IMPROVES with neck flexion
  • overlying erythema to the skin
  • fever, chills, pharyngitis
• Dx:
  
  • leukocytosis
  • high ESR fine needle aspiration with gram stain & cx
• Tx:
  
  • abx
  • surgical drainage if fluctuant

Question 179

Drug-Induced Thyroiditis

Answer 179

• Thyroiditis caused by use of certain drugs:
  
  • Antithyroid meds: methimazole and propylthiouracil, lithium, amiodarone, interferon alpha, tyrosine kinase inhibitors
• Dx:
  
  • TSH should be checked Q6-12 months
  • usually causes hypothyroidism , high TSH, low T4/T3
• Tx:
  
  • d/c the offending drug if possible
  • T4 therapy given right away

Question 180

Gastritis

Answer 180

• Definition: inflammatory/infectious process of gastric mucosa
• Acute etiology:
  
  • Most common cause = NSAIDs; EtOH, heavy cigarette use, caffeine
• Chronic Etiology:
  
  • Most common cause = H. Pylori; physiologic stress (burns, infections),, NSAIDs, EtOH
• S/sxs:
  
  • epigastric pain
    
    • Worsened with eating
  • N/V
  • anorexia
  • GI bleed
  • ***most commonly asymptomatic +/- GI bleed (melena, hematochezia, hematemesis)
• Dx:
  
  • Endoscopy = GOLD STANDARD though clinical diagnosis is more frequent
  • H. pylori testing should be done if no other obvious causes are present
• Tx: D/c the offending agents!!
• For H. Pylori: CAP = Clarithromycin, Amoxicillin, and a PPI; BID x 2 weeks, for PPIs continue for an additional 6-10 weeks
  
  • If penicillin allergy = give metronidazole
• If not H. pylori can give a PPI for 8-12 weeks +/- an H2 blocker (famotidine/pepcid)

Question 181

Peptic Ulcer Disease: Definition, Risks, Types

Answer 181

• Definition: break in the gastric or duodenal mucosa >5mm in diameter that penetrates through the muscularis into the submucosa.Most common cause of upper GI bleed.
• Risks:
  
  • H. pylori, NSAIDs, tobacco, alcohol, age >50 yo, family hx of PUD, COPD, CKD
• types:
  
  • Gastric ulcers: more likely to become malignant, peak at the 6th decade
  • duodenal ulcers = Most common, usually benign

Question 182

S/sxs of Gastric Ulcer, Duodenal Ulcer, vs Bleeding Ulcer in Peptic Ulcer Disease

Answer 182

• Gastric Ulcer:
  
  • dyspepsia (burning, gnawing, epigastric pain) worse with food
  • n/v, weight loss
• Duodenal Ulcer:
  
  • Dyspepsia relieved with food or antacids, aggravated by hunger (usually at night, 2-5 hours after a meal)
  • no weight loss b/c no pain with eating
• Bleeding Ulcers:
  
  • hematamesis
  • melena
  • hematochezia (if enough bleeding)

Question 183

Peptic Ulcer Disease: PE, complications, dx, and tx

Answer 183

• PE:
  
  • epigastric tenderness
    
    • tachycardia and orthostasis suggest dehydration
    • severe tender, board-like abdomen suggest peritonitis due to perforation
• Dx:
  
  • Upper endoscopy with Biopsy = Gold Standard
    
    • all gastric ulcers need repeat upper endoscopy to document healing (even if asymptomatic)
  • Other H. pylori testing:
    
    • urea breath test: breathing out labeled urea
    • H. pylori stool antigen: useful for diagnosis & eradication
    • Serologic antibodies: only useful in confirming new dx
• Tx:
  
  • Quadruple therapy: bismuth subsalicylate, tetracycline, metronidazole, & PPI x 14 days
  • Triple therapy: Clarithromycin, amoxicillin, &PPIx 10-14 days (1st line)
• Complications:
  
  • GI bleeding
  • Bowel penetration
  • Perforation: GI emergency, sudden onset of severe abdominal pain, air under the diaphragm, duodenal ulcers = most common (thin wall)
  • gastric outlet obstruction: d/t edema & scarring -→ bloating, early satiety, N/V, pain just after eating
  • Gastric cancer: gastric ulcer (H.Pylori)

Question 184

Zollinger-Ellison Syndrome

Answer 184

aka Gastrinoma

• Definition: gastrin–secreting neuroendocrine tumor → parietal cells release excess HCl → Severe PUD & diarrhea. Most commonly seen in the duodenum & pancreas
• S/sxs:
  
  • severe Peptic Ulcer Disease refractory to tx
  • chronic diarrhea
  • weight loss
• Dx:
  
  • elevated serum gastrin levels
• Tx:
  
  • tumor resection if local
  • if metastatic = lifelong high-dose PPIs
  • *Liver & abdominal lymph nodes = most common sites for METS

Question 185

Pyloric Stenosis

Answer 185

• Pathophys:
  
  • overgrowth/hypertrophy of the pylorus → stomach contents are unable to pass through the gastric outlet → leads to increased pressure → forced vomiting may occur
• S/sxs:
  
  • 3-6 week old baby with non-bilious “projectile vomiting” after meals
  • -after vomiting the child cries from hunger
  • -dehydration
• PE:
  
  • Pyloric sphincter may be palpable→ described as olive shaped
• Dx:
  
  • pyloric US
  • labs to evaluation for dehydration and electrolyte status
• Tx:
  
  • Pyloromyotomy

Question 186

Gastric Carcinoma

Answer 186

• Types:
  
  • adenocarcinoma = most common
  • lymphoma, carcinoid tumors, stromal, sarcomas
• Risks:
  
  • H. Pylori (associated with 90%), males > 40 yo, preserved foods (cured meats), obesity, pernicious anemia, chronic gastritis, smoking,
  • -non-hodgkin lymphoma
• S/sxs:
  
  • * Most patients very advanced at the time of presentation
  • Unintentional weight loss
  • Persistent Abdominal pain
• PE:
  
  • palpable abdominal mass
  • Virchow’s node:
    
    • supraclavicular node
  • St. Mary Joseph’s Node
• Dx:
  
  • upper endoscopy with biopsy
• Tx:
  
  • **usually a poor prognosis**
  • early disease: endoscopy resection
  • late disease: gastrectomy, chemo
• Protective: aspirin & NSAIDs, diet high in fruits and veggies

Question 187

Celiac Disease: Definition, General Info, S/sxs

Answer 187

• Definition:
  
  • inflammation of the small bowel secondary to the ingestion of gluten-containing food
  • villous atrophy occurs as a result of this autoimmune disease trigger → decreased absorptive area → malabsorption (of fat)
• General Info:
  
  • HLA-DQ2 and/or DQ8 loci
  • Autoimmune disorder
    
    • → runs in families
  • Female > Male usually 10-40 years old
  • Most common in N European ancestry
• S/sxs:
  
  • diarrhea, steatorrhea (will have floating stools), flatulence, weight loss
  • weakness, and abd distention
  • infants and children present with FTT
• Malabsorption symptoms:
  
  • weight loss, poor growth, severe anemia, neuro disease from B12 deficiency
    *

Question 188

Volvulus

Answer 188

• Definition:
  
  • twisting of any part of the bowel at its mesenteric attachment site → obstruction & impaired vascular supply. Most commonly occurs in the sigmoid colon & cecum in adults, midgut & ileum in children
• S.sxs:
  
  • crampy abd pain and distention
  • constipation
  • N/V
• PE:
  
  • tympanic abd
  • tenderness to palpation
• dx:
  
  • Adbominal CT = dilated sigmoid colon
  • Abdominal XR = bent inner tube or “coffee bean” sign
• Tx:
  
  • endoscopic decompression with rectal tube left in place to decrease acute recurrence
    
    • decompression often followed by surgery d/t high rate of recurrence

Question 189

Intussusception

Answer 189

• Definition:
  
  • the invagination of a proximal segment of the bowel into the portion just distal to it
• Risk factors:
  
  • ⅔ of cases seen in age 6-18mo of age, esp esp males, esp after viral infections
  • adults = think NEOPLASM!
• S/sxs:
  
  • Classic Triad:
    
    • 1. Vomiting
    • 2. Abd pain
    • 3. Passage of blood per rectum “currant jelly” stool (stool mixed with blood & mucus)
  • sudden onset of significant colicky abd pain that recurs Q 15-20 min often with vomiting
• PE:
  
  • sausage shaped mass in RUQ
• Dx:
  
  • For kids: barium or air enema can be both diagnostic & therapeutic
  • Best initial test = abd U/S looking for target or donut sign
  • then Abd XRay → Crescent sign or Bull’s eye target
• tx:
  
  • Children: barium or air enema
    
    • surgery if refractory
  • Adults = surgery

Question 190

Small Bowel Obstruction

Answer 190

• Definition:
  
  • partial or complete mechanical block of the small intestine
• S/sxs:
  
  • 4 hallmark sxs:
    
    • 1.Crampy abdominal pain, 2. abdominal distention, 3.vomiting (Bilious), and 4.obstipation
• PE:
  
  • High-pitched tinkling bowel sounds with visible peristalsis or ABSENT (SEVERE)
• Dx:
  
  • Abdominal KUB Xray: multiple air-fluid levels in a “step-ladder” appearance, dilated bowel loops.
• Tx:
  
  • Non-strangulated:
    
    • NPO (bowel rest), IV fluids & electrolytes. Bowel decompression if severe vomiting
  • Strangulated:
    
    • surgical intervention

Question 191

Answer 191

Small bowel obstruction

Question 192

Acute Peritonitis

Answer 192

• Definition: inflammation of the visceral and parietal peritoneum
  
  • usually infectious and often life-threatening!!
• Risk factors:
  
  • IBD, appendicitis, PUD, diverticulitis, surgery
• S/sxs:
  
  • acute, severe abdominal pain (diffuse or localized)
  • fever
  • NVD, anorexia, decreased UO, polydipsia, obstipation, fatigue
• PE:
  
  • guarding, rigidity
  • absent or hypoactive bowel sounds
  • hypotension
• Dx:
  
  • no labs needed
  • upright CXR and abdominal series will show FREE AIR under the diaphragm
    
    • → lack of free air does not rule out perforated viscus → need to do CT if you suspect
  • complications:
    
    • more susceptible to adhesions → increased risk of bowel obstruction
• Tx:
  
  • Broad spectrum Abx, ex lap

Question 193

Spontaneous Bacterial Peritonitis

Answer 193

• definition:
  
  • ascites fluid infx seen in patients with cirrhosis (E. coli, Klebsiella)
• S/sxs:
  
  • Suspect in patients with ascites & any of the following:
    
    • temp > 37.8C (100F)
    • abd pain or tenderness
    • AMS
• Dx:
  
  • Paracentesis → take fluid from abd (this will also relieve pressure and therefore pain) → ≥ 250 cells/mm3 of neutrophils
  • send for cx
• Tx:
  
  • Admit for IV abx (3rd gen cephs) cefotaxime > ceftriaxone

Question 194

Mesenteric Ischemia

Answer 194

• Definition: stroke of the gut
• most commonly obstructs the superior mesenteric artery
• full gut necrosis can occur within 6 hours
• Causes:
  
  • CAD, atherosclerosis, Afib, HF, valvular disease
• S/sxs:
  
  • severe colicky pain that is poorly located
  • normal appearing abd and exam
  • **Pain out of proportion to exam**
• Dx:
  
  • abd Xray: may show “thumb-printing”
  • CT Angio → Test of Choice
• Tx:
  
  • Acutely: will need IV fluids and IV abx
  • Immediate surgical intervention for necrotic bowel → if cause is emboli, will get embolectomy
  • if venous thrombus, will require anti-coag
  • If chronic, will require revascularization

Question 195

Appendicitis

Answer 195

• definition:
  
  • obstruction of the lumen of the appendix, results in inflammation & bacterial overgrowth
• Risks:
  
  • 10-30 yrs
• Etiology:
  
  • Fecalith & lymphoid hyperplasia = most common
  • inflammation, malignancy or foreign body
  • Lymphoid hyperplasia due to infx = most common cause in kids
• PE:
  
  • Rebound tenderness at McBurney’s Point
  • Rovsing sign: RLQ pain with palpation of LLQ
  • Obturator sign; RLQ pain with internal rotation of hip
  • Psoas sign: RLQ pain with hip extension while in Left lateral decubitus position
• Dx:
  
  • clinical diagnosis
  • In adults: CT scan of abdomen/pelvis = imaging of choice with u/s and MRI reserved for radiosensitive populations (pregnant women, children)
  • CBC - neutrophilia
• Tx:
  
  • appendectomy

Question 196

McBurney’s Point

Answer 196

⅓ between ASIS to umbilicus

RLQ

deep tenderness = appendicitis

• Also where you test for rebound tenderness
  
  • release the pressure quickly!!

Question 197

Rovsing’s Sign

Answer 197

Palpate on the LLQ and the pt will feel pain on the RLQ

suggests appendicitis

Question 198

Psoas Sign

Answer 198

Have pt lie supine and lift one, straight leg against resistance of your hand

• stretches the psoas muscle which puts pressure on the appendix
  
  • sign is Positive if pt feels more abd pain when lifting leg

Question 199

Obturator Sign

Answer 199

When the pt lies supine and you bend the pts leg moving the knee medially

• this stretches the obturator muscle = puts more pressure on appendix
  
  • this sign is positive if abd pain increases

Question 200

Murphy’s Sign

Answer 200

Press firmly upward on the RUQ and ask pt to take a deep breath

• if gall bladder is enlarged it will push down on the hand and elicit pain.
  
  • sign is positive if pt stops breathing due to pain

Question 201

Fluid Thrill

Answer 201

Tests for Ascites

• requires 3 hands:
  
  • have one person place hand on abdomen and push down
    
    • I will have one hand on each side of abdomen and tap
      
      • if fluid is present I will be able to feel the fluid wave on the opposite side

Question 202

Castell’s Spot

Answer 202

feeling for splenomegaly

• percuss at castell’s spot and have pt inhale and exhale
  
  • if you hear dullness on percussion during this inhale/exhale = positive indication for splenomegaly

Question 203

Rectal Abscess

Answer 203

• definition: bacterial infection of anal ducts and glands
  
  • → strongly associated with Crohn’s disease
• S/sxs:
  
  • severe continuous throbbing pain, fever, malaise, urinary retention
• Pe:
  
  • tender peri-anal and rectal mass
• Tx:
  
  • drain surgically
  • no abx

Question 204

Constipation: Dx & Tx

Answer 204

• Dx:
  
  • clinical
  • History is key! (timing of new drugs and symptoms)
  • Labs: CMP & TSH
  • Diagnostic Studies: RARELY USED → anorectal manometry
    
    • abdominal Xray
  • Alarm features:
    
    • melena/hematochezia
    • weight loss >10 lbs
    • fam hx of IBD or colon cancer, anemia, +FOBT
• Tx:
  
  • If alarm symptoms: tx the underlying issues→ get colonoscopy if unsure
  • 1st line: increased water/dietary fiber (psyllium, methylcellulose or prunes)
  • 2nd line: surfactants (softeners) (docusate
  • 3rd line: osmotic agents that make the body secrete more water (polyethylene glycol [miralax]/ lactulose/sorbitol/glycerine PR, Mg)
  • 4th line: stimulant laxatives (bisacodyl, senna) → CAUTION, body becomes dependent quickly
• Special:
  
  • • idiopathic constipation and IBS → lubiprostone, linaclotide
  • -opioid induced: naloxegol

Question 205

Inflammatory/Invasive Diarrhea (Overview)

Answer 205

• Source: usually caused by invasive or toxin producing bacteria that damage the large intestinal mucosa
• S/sxs:
  
  • Smaller volume diarrhea with blood, mucus +/- leukocytes
  • Tenesmus: “Dry heaving from your butt”
  • abd pain, fever
• Tx:
  
  • supportive care and disease specific
  • DO NOT GIVE antimotility agents as the toxins will remain present longer and worsen the disease

Question 206

Non-inflammatory/ Non-invasive Diarrhea (Overview)

Answer 206

• Source: enterotoxins increase GI secretion of electrolytes → causes secretory diarrhea
  
  • → no cell destruction or mucosal invasion
• S/sxs:
  
  • large volume of diarrhea
  • vomiting
  • no fever or blood in stool
• Tx:
  
  • supportive care and disease specific tx PRN

Question 207

Campylobacter jejuni

Answer 207

• invasive/inflammatory diarrhea
• **Most common bacterial cause of diarrhea in the US**
• Most common antecedent of Guillain Barre Syndrome
• Consumption of undercooked poultry = MCC; Raw milk consumption & Puppies!
• S/sxs:
  
  • bloody diarrhea, fever, abd pain
  • guillain barre syndrome: ascending paralysis, loss of DTRs
• Dx:
  
  • stool cx with S or comma shaped gram neg rods
  • PCR = most practical and most commonly done (but not the answer on BOARDS)
• Tx:
  
  • usually self limiting
  • abx can shorten duration → Macrolides (Azithromycin)

Question 208

Yersinia Enterocolitica

Answer 208

• invasive/inflammatory diarrhea
• Sources:
  
  • contaminated pork products = most common, milk, water, tofu
• S/sxs:
  
  • of inflammatory diarrhea
  • mesenteric lymphadenitis → abd tenderness & guarding known as pseudoappendicitis
  • smaller volume diarrhea blood, mucus +/- leukocytes
  • Tenesmus: “Dry heaving from your butt”
  • abd pain
  • fever
• Dx:
  
  • stool culture = preferred
    
    • “safety pin appearance” of gram neg bacilli
• Tx:
  
  • fluids/electrolytes
  • severe diarrhea → fluoroquinolones or TMP/SMX (Bactrim)

Question 209

Enterohemorrhagic E. Coli

Answer 209

• invasive/inflammatory diarrhea)
• Produces Shiga toxin → damages the endothelial lining and leads to hemorrhage
• Most common in elderly & children
• Sources:
  
  • undercooked ground beef, unpasteurized milk or cider, day care centers
• s/sxs:
  
  • Smaller volume diarrhea with blood, mucus +/- leukocytes
  • Tenesmus: “Dry heaving from your butt”
  • abd pain, fever
  • Watery diarrhea that later becomes bloody + vomiting
• Dx:
  
  • stool cx
  • PCR
• Tx:
  
  • fluid/electrolytes
  • **avoid abx in children due to risk of hemolytic uremic syndrome**

Question 210

Salmonella Typhimurium (non-typhoid)

Answer 210

• invasive/inflammatory diarrhea
• Sources:
  
  • undercooked or raw poultry, eggs, milk, fresh product
  • contact with reptiles (Turtles)
• S/sxs:
  
  • Short incubation: 1-3 days
  • sxs of inflammatory diarrhea + vomiting
  • Smaller volume diarrhea with blood, mucus +/- leukocytes
  • Tenesmus, abd pain, fever
• Dx:
  
  • stool cx
• Tx:
  
  • Fluid/electrolytes
  • severe diarrhea → Fluoroquinolones

Question 211

Salmonella Typhi (Typhoid/Enteric Fever)

Answer 211

• invasive/inflammatory diarrhea
• Most common cause = traveling to or living in an underdeveloped nation
• Source:
  
  • fecal-oral
  • humans are only reservoir for typhoid
• S/sxs:
  
  • Classic (but rare): fever with relative bradycardia
  • “Pea soup diarrhea”
  • Rose spots (faint pink/salmon colored macular rash)
• Dx:
  
  • blood cx & Stool cx
• Tx:
  
  • fluid/electrolytes
  • Severe diarrhea → fluoroquinolonesx2 weeks (2x as long as other diarrhea tx

Question 212

Shigellosis

Answer 212

• invasive/inflammatory diarrhea
• Produces shiga toxin which is neurotoxic, cytotoxic, enterotoxic
• Sources:
  
  • fecal-oral, raw veggies
• s/sxs:
  
  • abrupt onset of explosive, watery diarrhea that becomes progressively bloody
  • tenesmus, abd pain, +/- fever, chills, anorexia, malaise, HA
• Dx:
  
  • Stool cx → positive fecal WBC/RBC
  • CBC with WBC > 50,000 (super high white count
  • Sigmoidoscopy: punctate areas of ulceration
• Tx:
  
  • fluids/electrolytes
  • severe diarrhea → fluoroquinolones

Question 213

Amebiasis

Answer 213

• (invasive/inflammatory diarrhea)
• Entameba histolica → protoza rarely seen in the US, but seen in travelers from endemic areas
• Source:
  
  • ingestion of cysts from food/water contaminated with feces
• S/sxs;
  
  • asymptomatic but may develop liver abscess
• Dx:
  
  • O&P shows cysts and RBCs
    
    • → cysts are not consistently shed so must obtain samples on 3 different days
  • ELISA (rapid & highly sensitive)
• Tx:
  
  • Metronidazole or tinidazole

Question 214

cryptosporidium

Answer 214

• General info: associated with immunocompromised pts
  
  • -fungus
  • transmission: fecal-oral
  • Most common cause of chronic diarrhea in AIDS patients
• Dx: stool O & P
• Tx: ketoconazole, control the AIDs

Question 215

Norovirus

Answer 215

• Non-inflammatory/non-invasive diarrhea
• Most common cause of gastroenteritis in adults
• Source:
  
  • fecal-oral route, contaminated food.water, fomite → associated with cruise ships, hospitals, and restaurants
• S/sxs:
  
  • Vomiting + diarrhea
• Dx: PCR
• Tx: fluids/electrolytes

Question 216

Rotavirus

Answer 216

• Non-inflammatory/non-invasive diarrhea
• Most common cause of diarrhea in unvaccinated infants and young children
• source:
  
  • fecal-oral route, contaminated food/water, fomite → associated with outbreaks in childcare centers
• S/sxs:
  
  • child presenting with fever, vomiting and non-bloody diarrhea
  • **Associated with severe dehydration in babies**
• Dx: PCR
• Tx:
  
  • fluids/electrolytes
  • Prevention: Rotavirus vaccine

Question 217

Enterotoxigenic E. Coli

Answer 217

• Non-inflammatory/non-invasive diarrhea
• Most common cause of traveler’s diarrhea
• Source:
  
  • drinking water/ice, washed unpeeled fruit
• S/sxs:
  
  • abrupt onset of symptoms of non-inflammatory diarrhea
• Dx:
  
  • Stool cx, gram stain
• Tx:
  
  • usually self limited but can prescribe cipro +/- loperamide or bismuth

Question 218

Vibrio Cholerae

Answer 218

• Non-inflammatory/non-invasive diarrhea
• Exotoxin → hypersecretion of water/ions → severe dehydration→ shock and death
• Risk factors:
  
  • overcrowding in areas of poor sanitation
    
    • occurs in outbreaks usually in developing countries
• Source: contaminated food or water
• S/sxs:
  
  • voluminous watery diarrhea
  • rice water stools, mucus flecks, no WBCs No fecal odor, blood, or pus
  • SECRETORY DIARRHEA : inhibition of water, sodium and chloride absorption
  • progressing to SHOCK/dehydration within hours, NO FEVER
• PE:
  
  • rice water-like stools
• Dx:
  
  • stool cultures show gram negative, comma shaped rods
• Tx:
  
  • Oral rehydration solution
  • Doxycycline or cipro for mod-severe cases

Question 219

Listeria

Answer 219

• Non-inflammatory/non-invasive diarrhea
• aka. the 24 hour stomach bug
• source:
  
  • processed/deli meats, hotdogs, soft cheese, pates
• s/sxs:
  
  • acute, watery diarrhea
• tx:
  
  • oral rehydration, self-limited
  • Except in pregnancy → STAT Ampicillin (preggos told not eat those foods to avoid the risk)

Question 220

Giardia

Answer 220

• Non-inflammatory/non-invasive diarrhea
• MOST common intestinal protozoan parasite in the US
• Source:
  
  • streams and wells, constamined still water
  • → associated with beavers
• S/sxs:
  
  • frothy/greasy/foul smelling diarrhea (Steatorrhea)
  • weight loss and low-grade fever is common
  • trophozoite attachment can cause inflammation and villus damage in small intestine and extremely large numbers may lead to a direct physical blockage of nutrient uptake such as Vitamin B12
• Dx:
  
  • O & P cx: trophozoites/cysts in stool
• Tx:
  
  • Oral rehydration + metronidazole, tinidazole,oralbendazole

Question 221

Clostridium Difficile

Answer 221

• Risk Factors: Antibiotics suppress normal flora → especially Clindamycin in adults, amoxicillin in children
• complications:
  
  • toxic megacolon
• S/sxs:
  
  • Mild disease:
    
    • Water diarrhea > 3x/24 hours (Cardinal symptom)
    • cramping, abd pain
    • +/- fever, bloody or mucoid stools, anorexia
  • Severe disease: (plus the above)
    
    • diffuse abd pain & distention
    • hypovolemia
    • lactic acidosis
    • marked leukocytosis
• Dx:
  
  • stool testing (PCR, nucleic acid amplification test)
• Tx:
  
  • CONTACT PRECAUTIONS
    
    • oral vanco (IV is not effective)
    • Fidaxomicin = also expensive but $$$$
    • Metronidazole = 1st line in children

Question 222

Diverticulitis

Answer 222

• Definition: inflammation or infection of a diverticulum. Microscopic perforation of a diverticulum leads to inflammation & focal necrosis.
• Most common in the Sigmoid (left) colon → LLQ pain
• complications:
  
  • bowel perf, fistula formation: bladder, vagina
  • abscess, bowel obstruction
• S/sxs:
  
  • LLQ pain
  • low-grade fever
  • abd distention
  • N/V
  • change in bowel habits: constipation/diarrhea
  • flatulence, bloating
• PE:
  
  • usually normal → may have tender, palpable mass
  • Fistula→ colovesicular (air bubbles in urine, fecaluria
    
    • colovaginal (air or stool via vagina, abd pain, fever)
• Dx:
  
  • CT scan = imaging of choice
    
    • bowel wall thickening
    • *barium enema & endoscopy contraindicated during initial stages because of risk of perforation
  • Labs: leukocytosis, elevated CRP
• Tx:
  
  • Uncomplicated:
    
    • tx outpatient with oral abx (metronidazole & Cipro) x 7-10 days
    • clear liquid diet
  • Complicated:
    
    • fistula/abscess: surgery & abx

Question 223

Hemorrhoid Degrees

Answer 223

• 1st degree: small hemorrhoids protruding into canal
• 2nd degree: prolapse but reduce spontaneously
• 3rd degree: must be manually reduced
• 4th degree: irreducible

Question 224

Hemorrhoids

Answer 224

• Definition:
  
  • internal/external hemorrhoids are separated by anatomically by the dentate line
• Causes:
  
  • increased pressure → dilated submucosal veins due to constipation, straining, sitting too long, bicycling
• S/sxs:
  
  • internal hemorrhoids:
    
    • bring red blood, rectal prolapse, PAINLESS
  • external hemorrhoids;
    
    • BELOW the dentate line → PAINFUL
    • asx until they are thrombosed → BRBPR (minimal bright red blood per rectum), swelling, burning, pruritus, and wetness in anal area/ sudden extreme PAIN lasting for several days, may ulcerate and bleed
  • Dx:
    
    • clinical for both
  • Tx:
    
    • internal:
      
      • high fiber diet, stool softener, topical steroids (hydrocortisone)
      • band-ligation
      • surgical excision for prolapse
    • external:
      
      • hydrocortisone cream
      • sitz bath
      • stool softener
      • witch hazel
      • thrombosed that does not subside within 48 hours must be excised under local anesthesia

Question 225

Crohn’s Disease

Answer 225

• INFLAMMATORY BOWEL DISEASE
• Where: can occur anywhere in GI tract, from mouth to anus (RECTAL SPARING) most common = terminal ileum!!
• Who:
  
  • Females > males, ashkenazi Jews (Eastern European Jewish Ancestry)
• Bimodal Peaks: 15-30, 60-70
• S/sxs:
  
  • abd pain (Esp RLQ due to terminal ileum being most common)
  • diarrhea (usually not bloody)
  • weight loss (lots of weight loss)
  • vitamin deficiency
  • aphthous ulcers
• Complications:
  
  • fistulas, abscess, bowel perf, granulomas
• Dx:
  
  • Colonoscopy/Endoscopy → Transmural lesions, skip lesions, cobblestoning. (DIAGNOSTIC)
  • Labs Cannot diagnose but can point in right direction:
    
    • +ASCA
    • ESR/CRP (vague identification)
• Tx:
  
  • Mesalamine (nsaid) for mild disease
  • steroids for acute flairs only
  • then 6MP(mercaptopurine SEs: liver inflammation, HA, joint pain)/AZA (azathioprine SEs: unusual bruising, changes in hair color and texture)), then anti-TNF (remicade-> infliximab, Humira ->atalinumab; SEs: infection, malignancy, lupus) = immunomodulators → tend to be most successful txs
  • Surgery is NOT curative in crohn’s (only used when meds fail)

Question 226

Ulcerative Colitis

Answer 226

• INFLAMMATORY BOWEL DISEASE
• ONLY OCCURS IN THE COLON : Begins in rectum and then spreads through the colon
• M = F, most common = caucasian, but increasingly fast in asian/hispanic populations
• S/sxs:
  
  • abd pain (most commonly in LLQ)
  • tenesmus
  • bloody diarrhea → due to ulcerations
  • -mucoid stools
  • prei-anal tags
• Complications:
  
  • toxic megacolon
  • primary sclerosing cholangitis, colon cancer: need to get an annual colonoscopy starting 10 years after initial diagnosis
• Dx:
  
  • Sigmoidoscopy → uniform inflammation starting in the rectum, submucosal ulcerations, pseudopolyps
  • Colonoscopy & barium enema CT in acute disease
  • Labs:
    
    • P-ANCA +
    • ESR/CRP
  • Barium Studies → loss of haustral markings (lead pipe sign)
• Tx:
  
  • smoking helps in ulcerative colitis → decreases immune response
  • Sulfasalazine works in colon only (SEs: reversible infertility in males, HAs)
  • steroids for acute flairs only
  • 6MP/AZA if sulfasalazine does not work
  • Anti-TNF = immunomodulators → tend to be most successful treatments

Surgery = curative in UC (only used when other tx fail)

Question 227

Irritable Bowel Syndrome: Info, S/sxs, PE

Answer 227

• Definition;
  
  • chronic, functional, idiopathic pain disorder with no organic cause, not an inflammatory process
• Epidemiology:
  
  • onset most common in late teens, early twenties Most commonly diagnosed GI illness (10-15% of population
• Risks:
  
  • gastric bypass surgery
• S/sxs:
  
  • abd pain: postprandial (occuring after a meal)
  • altered bowel habits: diarrhea, constipation, or alteration between both
  • abd distention (Gas pockets)
• Alarm sxs:
  
  • Gi bleed
  • anorexia/weight loss
  • fever
  • family hx of GI cancer, IBD
  • persistent diarrhea → dehydration
  • severe constipation/impaction
• PE:
  
  • *Normal
  • stable weight (vs IBD which has weight loss)

Question 228

Irritable Bowel Syndrome: Diagnosis & Tx

Answer 228

• Dx:
  
  • Diagnosis of exclusion (after work-up with colonoscopy, abd CT)
  • Rome IV Criteria:
    
    • *Recurrent abd pain at least 1day/week for at least 3 months with ⅔ criteria:
      
      • related to defecation
      • onset associated with change in stool frequency
      • onset associated with change in stool form
  • Tx:
    
    • lifestyle & dietary changes (low FODMAP) are first line (low fat, high fiber, unprocessed foods)
    • avoid drinks with sorbitol, or fructose
    • sleep, exercise, smoking cessation

Constipation symptoms:

• prokinetics: fiber, psyllium polyethylene glycol
• No response: lubiprostone, linaclotide

Diarrhea symptoms:

• loperamide, eluxadoline, rifaximin, bile acid sequestrants (cholestyramine)
• Anticholinergics, antispasmodics (Dicyclomine)

Question 229

Fecal Impaction

Answer 229

• Definition:
  
  • large lump of dry hard stool that remains stuck in the rectum
  • Most common cause = chronic constipation
• Risk factors:
  
  • bed-ridden patients
  • medications: anticholinergics, narcotics, laxatives (overused then suddenly d/c’ed)
• S/sxs:
  
  • abd distention/cramping
  • rectal bleeding
  • small, semi-formed stools
  • suddenly watery diarrhea (only liquid stool is able to pass around fecal obstruction)
• Dx: rectal exam will reveal a hard mass of stool in rectum
• Tx:
  
  • disimpaction

Question 230

Toxic Megacolon

Answer 230

• Definition: non obstructive, extreme colon dilation > 6cm & signs of systemic toxicity
• Etiology:
  
  • complications of IBD, C. diff , infectious colitis, ischemic colitis, volvulus, diverticulitis, radiation, & obstructive colorectal CA
• S/sxs:
  
  • PROFOUND bloody diarrhea
  • abd pain, very tender
  • abd distention
  • N/V
  • toxic appearing
  • fever
• PE:
  
  • abd tenderness & distention
  • systemic toxicity: AMS, fever, tachycardia, hypotension, dehydration
• Dx:
  
  • abd xray: colon dilation > 6cm
  • fever, tachycardia, leukocytosis, anemia (3)
  • hypotension, dehydration, electrolyte abnormalities, AMS (1)
• Tx:
  
  • EARLY surgical consult
  • Supportive: complete bowel rest, bowel decompression with NG tube, broad-spectrum abx, fluid replacement
  • C.Diff? Stop the offending agent, give vanco & metronidazole

Question 231

Acute Cholecystitis

Answer 231

• Definition: inflammation & infx of the gallbladder due to obstruction of the cystic duct by gallstones
• Bugs:
  
  • E.coli (most common)
  • klebsiella, streptococcus
• S/sxs:
  
  • steadily increasing RUQ abd pain: may be precipitated by fatty foods or large meals
  • Fever
  • nausea, anorexia
• PE:
  
  • enlarged palpable gallbladder
  • Murphy’s sign: RUQ pain or inspiratory arrest when the provider hooks their hand under the rib cage and the pt takes a deep breath
  • Boas sign: referred pain to right shoulder, due to phrenic nerve irritation
• Dx:
  
  • US = 1st line imaging → thickened gallbladder wall, pericholecystic fluid
  • Labs:
    
    • Leukocytosis, increased bilirubin, increased alkaline phosphatase, increased LFTs
  • HIDA: = Gold Standard
• Tx:
  
  • NPO, IV fluids
  • IV abx (ceftriaxone + Metronidazole)
  • Laparoscopic cholecystectomy
  • Cholecystostomy drain: consider if the patient is too sick for surgery

Question 232

Cholangitis

Answer 232

• Definition:
  
  • inflammation and infection of the bile duct** **system secondary to the obstruction of the common bile duct (gallstones)
• Bugs:
  
  • E.coli (most common), Klebsiella, Enterobacter
• S/sxs:
  
  • Charcot’s Triad:
    
    • -RUQ abd pain
    • -Fever
    • -Jaundice
  • Reynold’s Pentad: *If severe
    
    • -AMS
    • -Hypotension
    • +Charcot’s triad
• Grade:
  
  • I: symptomatic
  • II: systemic inflammation
  • III: organ dysfunction
• PE:
  
  • light-colored stools
  • dark tea-colored urine
• Dx:
  
  • US = good initial test
    
    • thickened bile duct
  • **in patients with Charcot’s triad and abnormal liver tests, proceed directly to ERCP to confirm the diagnosis and provide biliary drainage
  • ERCP: modality of choice because it is both diagnostic & therapeutic
  • Labs:
    
    • leukocytosis, increased alkaline phosphatase, increased bilirubin
• tx:
  
  • Medical Emergency → Admit pt to the hospital for eval and tx
  • (NPO!!!!)
  • IV abx
  • Endoscopic retrograde cholangiopancreatography: common bile duct decompression and stone extraction, insert a stent, repair sphincter
  • cholecystectomy performed post-acute

Question 233

Choledocholithiasis

Answer 233

• Definition: stones in the common bile duct → cholestasis due to blockage
• S/sxs:
  
  • prolonged biliary colic (episodic RUQ abd pain exacerbated with fatty foods
  • N/V
  • Pale, fatty stool (b/c bile is not absorbing fat)
• PE:
  
  • RUQ tenderness
  • Jaundice
• Dx:
  
  • US: stones, dilated bile ducts
  • Labs:
    
    • elevated AST/ALT, increased alkaline phosphatase, increased GGT, increased bilirubin (conjugated & unconjugated)
  • ERCP: modality of choice b/c both diagnostic & therapeutic
• Tx:
  
  • ERCP for stone extraction

Question 234

Acute Pancreatitis: def, etiology, types, S/sxs, PE

Answer 234

• Definition:
  
  • sudden onset of inflammation of the pancreas → acinar cell injury → intracellular activation of pancreatic enzymes → autodigestion of the pancreas
• Etiology:
  
  • gallstones (40%), EtOH abuse (30%), elevated triglycerides
  • **GET SMASHED: gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion sting, hypercalcemia/hyperlipidemia, ERCP, drugs
• Types:
  
  • interstitial: mild
  • necrotizing: severe, increased risk with smoking, obesity, DM, EtOH
• S/sxs:
  
  • **Acute onset
  • Epigastric pain: radiates to the back, worse if lying supine, relieved by leaning forward
  • N/V, abd distention, FEVER
• PE:
  
  • epigastric tenderness, tachycardia, hypotension, distress/anxious , pulmonary effusion: rales, decreased breath sounds, ARDS
  • Necrotizing → pancreating bleeding:
    
    • Cullen’s sign: periumbilical ecchymosis
    • Grey Turner sign: flank ecchymosis

Question 235

Cullen’s Sign

Answer 235

associated with acute pancreatitis

periumbilical ecchymosis

Question 236

Grey Turner Sign

Answer 236

associated with acute pancreatitis

flank ecchymosis

Question 237

Reyes Syndrome

Answer 237

rash, intractable vomiting, liver damage, dilated pupils

caused by taking aspirin after a viral illness or by kids <18 taking aspirin

Question 238

Spontaneous Bacterial Peritonitis

Answer 238

• Definition: infection of ascitic fluid without perforation of the bowel. Complication of cirrhosis (increases space between tight junctions of epithelial cells)
• Etiology:
  
  • E.coli = #1 cause, pneumococcus, klebsiella
• S/sxs:
  
  • *often subtle signs d/t large amounts of fluid
  • fever, chills
  • abd pain, increasing girth
  • diarrhea
• PE:
  
  • ascites → shifting dullness, fluid wave
  • abd tenderness
• Dx:
  
  • paracentesis = test of choice
    
    • absolute PMN > 250 cells/mm3
    • gram stain, cx (often negative)
• Tx:
  
  • Antibiotics: cefotaxime, ceftriaxone
  • Prophylaxis: lifelong prophylaxis with trimethoprim-sulfamethoxazole (Bactrim) or Norfloxacin

Question 239

Hepatorenal Syndrome

Answer 239

• definition: renal failure in the setting of cirrhosis
• Dx:
  
  • Criteria:
    
    • creatinine > 1.5 or CrCl < 40
    • no improvement of renal function after volume expansion
    • no proteinuria
    • absence of shock/infection
• Tx:
  
  • definitive = liver transplant
  • dialysis, midodrine, octreotide

Question 240

Hepatic Encephalopathy

Answer 240

• Definition: neuropsychiatric abnormalities in pts with portal HTN d/t ammonia release (has neurotoxic effects)
• Grades:
  
  • 0: no clinical signs
  • 1: sleep-wake reversal
  • 2: lethargy, slurred speech
  • 3: stupor
  • 4: coma
• PE:
  
  • Asterixis
• Dx:
  
  • r/o other causes: infx, bleed
  • identify precipitating factor (like worsening liver function)
• Tx:
  
  • dietary protein restriction (ammonia comes from protein)
  • -Catharsis: lactulose (increases fecal nitrogen excretion)
  • -Abx: neomycin, metronidazole, rifaximin

Question 241

PT/INR measures which factors:

Answer 241

I, II, V, VII, & X

Question 242

PTT measures which factors?

Answer 242

VIII, IX, XI, & XII

Question 243

Tx of Acetaminophen overdose

Answer 243

N-acetylcysteine

Question 244

Cluster Headache

Answer 244

• Definition:
  
  • <1% of HAs; more common in young/middle aged males
• Triggers:
  
  • Night (sleep), alcohol, stress
• Usually have 1-2 cluster periods per year (each lasting weeks to months)
• S/sxs:
  
  • severe unilateral periorbital pain, <2 hours with spontaneous remission, sharp, excruciating, searing or piercing pain
  • *Repetitive Clusters of pain
• PE:
  
  • Ipsilateral Dysautonomia:
    
    • -Ptosis (droopy eyelid)
    • -Lacrimation
    • -Conjunctival injection
    • -Rhinorrhea
    • -Nasal Congestion
    • -Restlessness
• Dx:
  
  • Clinical Dx
  • MRI: to r/o lesion
• Tx:
  
  • “Suicide Headache” because so severe
  • 100 % oxygen at 12-15L/min for 15-20 min via non-rebreather → provides relief within 15 minutes
  • -Can give in combo with sumatriptan 6mg SQ , can repeat in hour PRN(Triptan; if possible) (Contraindicated in peripheral artery disease, coronary artery disease, hx of stroke, uncontrolled HTN)
  • For long-term prophylaxis = verapamil, lithium, topiramate, Divalproex, or a combo
  • Anti-migraine medications: Sumatriptan, Ergotamine/dihydroergotamine (MOA: 5HT-1b/d receptor agonists)

Question 245

Red Flag Sxs in a Migraine/HA

Answer 245

• New onset in a pt ≥ 50 years of age
• -Change in established HA pattern
• -Atypical pattern
• -Unremitting/progressive neurologic sxs
• -Prolonged or bizarre aura

Question 246

Migraine: Definition, pathophys, risks, epidemiology, s/sxs

Answer 246

• Chronic Migraine:
  
  • 15+ days/month x 3 months
• Pathophys:
  
  • trigeminal nerve releases neuropeptides (CGRP)→ dural inflammation & pain that is transmitted by the same nerve;aura is an abnormal yet benign electric wave that travels slowly across the cortex to cause sxs
• Risks:
  
  • women (3x), teens, genetics, obesity, frequent HAs, head injury, med overuse (>10day/month), stress, sleep apneas
• Epidemiology:
  
  • 12% of HAs but more likely to be seen in clinic than tension-type because more severe sxs; 1-4 per month on average
• S/sxs:
  
  • Headache: unilateral, throbbing, moderate-severe, increased with exertion, 4-72 Hr duration
  • N/V
  • -Without Aura = most common 80%
  • -photophobia
  • -Phonophobia

Question 247

Subarachnoid Hemorrhage

Answer 247

• Definition:
  
  • bleeding between the arachnoid membranes & the pia mater (The meninges PAD the brain; skull, dura, arachnoid, pia → brain )
• S/sxs:
  
  • -Thunderclap headache: brutally severe, “Worst of life”
  • -N/V
  • -Decreased LOC
  • -Neck stiffness
  • -Sentinel HA
• PE:
  
  • Meningeal Signs: Nuchal rigidity (neck stiffness)
  • -+/- deficits
• Dx:
  
  • -CT scan without contrast:initial study of choice, subarachnoid bleeding
  • -Lumbar Puncture: if CT negative & no papilledema, xanthochromia (presence of bili in CSF)
  • -Angiography: performed after confirmed SAH to identify bleeding source
• Tx:
  
  • Up to 10% mortality & high morbidity
  • -Surgery
  • -Admit to ICU to monitor vasospasms

Question 248

Concussion: Tx

Answer 248

• First Response:
  
  • Remove from any activity, monitor s/sxs, do not give meds, evaluation by provider, no return to play until cleared
• First 24-48 hours:
  
  • rest, avoid strenuous strenuous activity, do not drive x 24H, no EtOH, acetaminophen = okay (no ASA or NSAIDs), no sports
• Return to Learn:
  
  • 1. Daily activities at home
  • 2. Homework/reading
  • 3. Part-time school
  • 4. Full-time school
  • *Parachute’s Protocol: move forward to next stage only when sx free for 24H, if sxs reappear they should go back to previous stage, contact provider immediately if sxs worse
• Return to Play:
  
  • 1. Daily activities
  • 2. Light aerobic activity
  • 3. Sport-specific activity
  • 4. Non-contact training drill
  • 5. Full contact practice
  • 6. Return to sport
  • *Each step takes a minimum of one day

Question 249

Post-Concussion Syndrome

Answer 249

• Definition:
  
  • concussion sxs lasting beyond the expected recovery period after initial injury
• Etiology:
  
  • unknown; structural damage, psychological factors
• **Usually goes away within a few days/weeks. However, persistent sxs may last for months-years
• S/sxs:
  
  • -Mood swings, irritability
  • -Anxiety, depression
  • -Foggy thinking
  • -Memory Issues
  • -Difficulty with attention
  • -Dizziness, nausea
• PE:
  
  • Tinnitus
  • -Balance problems
  • -difficulty making decisions
  • -changes in sleeping patterns
  • -Mild headaches
  • -Photophobia/phonia
• Dx:
  
  • clinical dx
• Tx:
  
  • Headache: sleep/rest, take a break from activities requiring concentration, pain relievers (APAP)
  • Memory Issues: write things in notebook, have family/friends remind you of important things

Question 250

Traumatic Brain Injury Pathology: Types of things that occur in/to the brain/skull

Answer 250

• Subdural Hematoma:
  
  • (typically involve a vein) crescent-shaped mass, venous bleed – slow, crosses suture line
• Epidural Hematoma:
  
  • (typically involve an artery) lentiform (looks like a lense), arterial bleed – fast, does not cross suture lines, ipsilateral dilated pupil; lucid interval after period of unconsciousness, surgery. “Talk and die kids” → need to get them in the OR within an hour of onset of symptoms!!
• Hemorrhagic Cerebral Contusion:
  
  • salt & pepper appearance
• Open Skull Fracture:
  
  • intracranial air
• Brain Herniation:
  
  • non-reactive pupil, extensor posturing, progressive decline in neuro exam, Cushing’s response (HTN, bradycardia, irregular respiration)

Question 251

Glasgow Coma Scale

Answer 251

Eyes opening (4); 4. spontaneously, 3. to speech, 2. to pain, 1. none

• Best Verbal (5): 5. oriented, 4. confused, 3. inappropriate word, 2. incomprehensive sounds, 1. none
• Best Motor (6): 6. follows commands, 5. localizes pain stimulus, 4. withdraws from pain, 3. flexion to pain, 2. extension to pain, 1. none → MOST IMPORTANT SCORE
• Mild (80%): GCS 13-15, need repeat eval
• Moderate (10%): GCS 9-12, need admission
• Severe (10%): GCS 3-8

Question 252

Traumatic Brain Injury: Dx & Tx

Answer 252

• Dx:
  
  • Evaluate damage & severity: x-rays, CT, MRI
  • -CT guidelines: LOC, severe HA, vomiting, age >65yo, drug/EtOH intoxication, GCS < 14, signs of basilar skull fracture, neuro deficits, amnesia, seizure, dangerous mechanism (ie significant MVA),, coagulopathy
• Tx:
  
  • ABCs: Airway, Breathing, Circulation, Disability, Exposure/Environment
  • **No drugs protect the delicate tissue of the brain
  • Limit secondary damage: maintain oxygen supply to the brain, prevent seizures (give Keppra [levetiracetam], prevent fever (meds if > 39C), reducing swelling/inflammation/pressure
  • Surgery:
    
    • if needed to remove blood clots or reduce pressure, need to remove entire skin flap
  • Epidural hematoma:
    
    • operate within an hour of ipsilateral dilated pupil or > 30cm3, >15mm thick, or > 5 mm midline shift
  • Transient hyperventilation:
    
    • decreases ICP by causing vasoconstriction due to decreased serum CO2 levels in the brain → more room to swell
  • Hyperosmolar therapy:
    
    • mannitol or hypertonic saline, fluid shift from intracellular to extracellular → low ICP
  • **Steroid are contraindicated

Question 253

Spongiform Encephalopathy

Answer 253

• Definition:
  
  • group of progressive, invariably fatal, conditions that affect the brain that are caused by the accumulation of misfolded prion proteins giving the brain a “spongy” appearance
• Transmission:
  
  • consumption of infected meat, blood transfusions, corneal transplants, and contaminated surgical instruments
• S/sxs:
  
  • May take decades to become symptomatic but then progresses rapidly and can cause death
  • Dementia
  • -Ataxia
  • -Poor Memory
  • -Behavioral Changes
  • -Dementia
  • -Myoclonus
• Types:
  
  • Creutzfeldt-Jakob Disease:
    
    • -4 main forms:
      
      • 1.Familial CJD: mutation in PRNP Gene
      • 2.Variant CJD: eating the meat of cows with prions in muscle tissue (mad cows disease)
      • 3.Iatrogenic CJD: caused by medical procedures
      • 4.Sporadic CJD: no clear cause
  • Kuru:
    
    • Caused by cannibalism of infected flesh
  • Fatal Familial Insomnia:
    
    • mutation in PRNP gene, prion proteins build up in thalamus and affect sleep, patients develop insomnia, exaggerated startle response
• Dx:
  
  • -MRI
  • -Lumbar puncture = increased levels of 14-3-3 protein
  • Definitive diagnosis = brain biopsy
• Tx:
  
  • No treatment
  • genetic counseling for familial form, restrict blood transfusions

Question 254

Hashimoto’s Encephalopathy

Answer 254

• Definition:
  
  • Syndrome of acute or subacute encephalopathy that is associated with elevated anti-thyroid antibody titers
• Dx:
  
  • Presence of elevated Anti-thyroid antibody titers and the exclusion of the causes of encephalopathy
• Tx:
  
  • Corticosteroids

Question 255

Wernicke Encephalopathy

Answer 255

• Definition:
  
  • complication of Thiamine (Vitamin B1) deficiency
  • acute syndrome requiring emergent treatment to prevent death and neurologic morbidity
• Most common cause = chronic alcoholism
• Risks:
  
  • poor nutrition caused by malabsorption, poor dietary intake (anorexia), increased metabolic requirement (e.g. during systemic illnesses), or increased loss of water-soluble vitamin Thiamine (e.g. renal dialysis)
• S/sxs:
  
  • Ophthalmoplegia: weakness or paralysis of eye muscles
  • -Ataxia
  • -Changes in mental state: confusion, apathy, difficulty thinking
  • -Coma and death
• Dx:
  
  • Thiamine levels and LFTs (AST > ALT)
  • Confirmed by MRI: degeneration of mammillary bodies
• Tx:
  
  • Medical Emergency!
  • Infusion of thiamine over a few days to normalize the thiamine levels → given with Glucose *** must have normal thiamine levels first or will cause metabolic acidosis due to increased lactic acid

Question 256

Hepatic Encephalopathy

Answer 256

• Definition:
  
  • Toxins that are produced by the digestive breakdown of proteins, such as ammonia, and normally cleared in the liver accumulate in the blood and eventually travel to the brain and cause damage.
• Risks:
  
  • chronic liver disease such as cirrhosis or hepatitis
• Triggers:
  
  • infection, dehydration
• S/sxs:
  
  • Early Symptoms:
    
    • -forgetfulness, confusion, breath with a sweet or musty odor
  • Advanced Symptoms:
    
    • shaking of hands or arms (asterixis), disorientation, and slurred speech, coma
• Tx:
  
  • Remove toxic substances from the intestine
  • Lactulose (pulls ammonia into the GI lumen which is then excreted) and rifaximin (decrease intraluminal NH3 production by killing ammonia producing bacteria)

Question 257

Encephalitis

Answer 257

• Definition:
  
  • inflammation of the brain parenchyma
• Etiology:
  
  • arboviruses, HSV-1 (most common), HSV-2, HZV, EBV, CMV, rabies,West nile virus
  • HSV Encephalitis:
    
    • lesions limited to the temporal lobe, necrotizing encephalitis
• S/sxs:
  
  • -Alteration of consciousness
  • -Focal neurologic deficits: hemiparesis, sensory deficits, CN palsies
  • -Seizures,
  • -Fever
  • -HA
  • -Change in personality: hallucinations & bizarre behavior may precede neurological deficits
• PE:
  
  • HSV Encephalitis:
    
    • -Dysphagia
    • -Seizures
  • West Nile Virus Encephalitis:
    
    • -Flaccid paralysis with a clear sensorium
• Dx:
  
  • -MRI/CT: medial temporal & inferior frontal grey matter involvement
  • -EEG: asymmetric sharp waves
  • -Lumbar puncture: normal glucose, lymphocytes, elevated RBCs
  • -PCR testing: HSV identification
  • **Neuroimaging must be done!!
• Tx:
  
  • HSV: IV acyclovir x 14 days

Question 258

Brain Abscess

Answer 258

• Definition:
  
  • a localized, walled-off collection of pus surrounded by a fibrous capsule within the brain parenchyma
• Etiology:
  
  • bacteria (most common), fungi, protozoa; NO viruses
• Predisposing Factors:
  
  • otitis media, sinusitis, dental infection, trauma, neurosurgery, neutropenia, HIV infx
• S/sxs:
  
  • focal neuro deficits
• Dx:
  
  • head CT
• Tx:
  
  • Abx: Ceftriaxone + metronidazole + vancomycin
  • -If prior neurosurgical patient → get MRSA coverage
  • -Steroids: only if cerebral edema
  • -Neurosurgery consult for possible drainage.

Question 259

Bacterial Meningitis

Answer 259

• Definition:
  
  • bacterial infection of the meninges
• Etiology:
  
  • May be bacterial, viral, or subacute
  • -Strep Pneumoniae: most common cause in adults & young kids, G+ cocci
  • -Neisseria meningitidis:Most common in older children (10-19yo), G- diplococci
  • -Group B Strep: most common neonates
  • -Listeria monocytogenes: increased incidence neonates & infants, risk for preggos
  • -Haemophilus influenzae: reduced d/t HIB iz, G- coccobacillus
• Risks:
  
  • age (babies), large group gatherings (college) microbiologists, travel (sub-saharan African, mecca)
• S/sxs:
  
  • Clinical Triad:
    
    • -Fever
    • -Headache
    • -Nuchal Rigidity
  • -decreased LOC
  • -Seizures
  • -Increased intracranial pressure
  • -photosensitivity
  • -Bulging fontanelles in babies
  • Meningismus:
    
    1. Nuchal Rigidity (stiff neck)
    2. Photophobia
    3. Headache
• PE:
  
  • Brudzinski: neck flexion produces knee/hip flexion
  • -Kernig: inability to extend the knee/leg with hip flexion
• Dx:
  
  • -CSF: PMN leukocytosis, decreased glucose, increased protein, increased opening pressure, turbid
  • -CSF pathogen panels: tests for the 14 most common pathogens
  • -Cultures, empirical therapies, neuroimaging
  • *Work-up order: blood cultures, steroids, abx, CT, LP
• Tx:
  
  • Broad Spectrum Abx: Vanco + Ceftriaxone +/- dexamethasone
  • -Droplet precautions for 24 hours
  • -Post-exposure prophylaxis: Ciprofloxain or Rifampin
  • -Listeria: addampicillin; prevent by cooking foods & pasteurizing dairy products

Question 260

Viral Meningitis

Answer 260

• Etiology:
  
  • Enteroviruses, varicella-zoster, HSV2, Epstein-Barr Virus, Arthropod-borne viruses
• S/sxs:
  
  • Clinical Triad:
    
    1. Fever
    2. Headache
    3. Nuchal Rigidity
• PE:
  
  • Decreased LOC, malaise, myalgias, anorexia, n/v/d, abd pain
• Dx:
  
  • CSF exam: lymphocytes,normal glucose & protein, clear
  • -viral culture
  • -Serologic studies

Question 261

Focal Seizures

Answer 261

• Definition:
  
  • abnormal neuronal discharge from one discrete section of one hemisphere
• Classification – Level of Awareness:
  
  • Intact awareness (simple): consciousness fully maintained
  • -Impaired awareness (complex): consciousness impaired
• Classification – Onset:
  
  • -Motor: tonic-clonic, atonic, myoclonic
  • -Non-motor
  • -Unclassified: not enough info to determine onset (unwitnessed seizure)
• S/sxs:
  
  • Types are dependent on brain area
• PE:
  
  • Focal Seizures with retained awareness → no alteration in consciousness, but abnormal movements or sensations (used to be called simple partial seizure)
  • Focal Seizures with a loss of awareness → altered LOC, automatisms (i.e. lip smacking) (used to be called complex partial seizure)
    
    • → Present with a postictal state (confusion & memory loss) which helps to differentiate them from absence seizures
• Dx:
  
  • Initial workup to r/o reversible causes
  • Electrolytes: Na+, Ca2+, Mg
  • -Serum glucose
  • -Pregnancy test → can affect type of antiepileptic therapy the patient receives
  • -toxicology screen
  • -ECG
  • -EEG
  • -Neuroimaging: CT or MRI of the head → should be done all adults with their first seizure
• Tx:
  
  • May evolve into generalized tonic-clonic seizures
  • Tx: phenytoin, and carbamazepine = drugs of choice

Question 262

Generalized Seizures

Answer 262

aka Grand Mal Seizures

• Definition:
  
  • simultaneous neuronal discharge of both hemispheres (diffuse brain involvement)
  • Always have some level of impaired awareness
• Classification – Onset:
  
  • -Motor: tonic-clonic, atonic, myoclonic
  • -Non-motor: absence
  • **Tonic-clonic is most commonly seen in metabolic derangements, drug withdrawal, & head trauma
• S/sxs:
  
  • Tonic Clonic:
    
    • -Generalized body stiffness & rigidity
    • -Arched back
    • -Jerking movements of the trunk, extremities, & head
    • -Associated findings: tongue biting, incontinence, frothing at the mouth, eye blink, cyanosis
    • -Post-ictal phase
• Dx:
  
  • **Initial workup to r/o reversible causes
  • Seizures that develop during adolescence and adult life are usually caused by tumor, trauma, drug use, or alcohol withdrawal → in addition to blood work you should obtain a CT scan
• Tx:
  
  • Those at lower risk may not need medications until further evaluation is completed (or another seizure occurs)
  • -Tx the underlying cause
  • -Anti-seizure meds: phenytoin, fosphenytoin, levetiracetam, Valproic acid, phenobarbital; loading dose → daily dosing

Question 263

Absence Seizures

Answer 263

aka Petit Mal → type of generalized seizure

• Definition:
  
  • generalized seizure character by a brief (4-20 sec) loss of environmental awareness without loss of body tone (Type of Generalized seizure)
• Risks:
  
  • provoked by hyperventilation or flashing lights
• Age of Onset:
  
  • ~4-10 yo (Childhood)
• S/sxs:
  
  • -Sudden, marked impairment of consciousness without loss of body tone
  • -May be accompanied by simple automatisms: eyelid twitching, lip smacking
  • -”Staring into space”
  • -No post-ictal confusion & no memory of the event
• PE:
  
  • May have dozens of seizures per day which often go unrecognized
• Tx:
  
  • 1st line = ETHOSUXIMIDE
  • 2nd line = Valproic acid

Question 264

Status Epilepticus

Answer 264

• Definition:
  
  • 5+ minutes of continuous seizure activity OR recurrent seizure activity without return to baseline OR 2+ seizures within a 5 minute period.
• Etiologies:
  
  • metabolic, sepsis, CNS infx, stroke, TBI, drugs, cardiac arrest, encephalopathies, autoimmune encephalitis, breakthrough seizures, chronic EtOH abuse, CNS tumors, remote CNS pathologies
• S/sxs: Two types:
  
  • 1.Convulsive status epilepticus: presents with a regular pattern of contraction and extension of the arms and legs
  • 2. Non-Convulsive Status Epilepticus: includes complex partial status epilepticus and absence status epilepticus
• PE:
  
  • Untreated generalized seizures lasting >60 min may result in permanent brain damage; longer-lasting seizures may be fatal
• Dx:
  
  • Initial Assessment:
  • -ABCs
  • -Trauma Assessment
  • -Fingerstick Blood Glucose (FSGS)
• Tx:
  
  • Medical Emergency
  • Protect from injury: do not restrain patient & do not put anything in the mouth (but have suction available),
    
    • -Place patient in left lateral decubitus position (suppressed gag reflex ⇒ prone to aspiration of gastric contents)
  • -Immediate seizure control treatment: IV/IO Benzodiazepines (LORAZEPAM, midazolam, diazepam) initially after which you give phenytoin
  • -Closely monitor patient until recovery
  • -Post-Ictal: positioning, airway control, labs & imaging, longer-acting anti-seizure meds, EEG monitoring.

Question 265

Acute Compartment Syndrome: Def, pathophys, Etiology, Risks, & s/sxs

Answer 265

• Definition:
  
  • muscle & nerve ischemia (decreased tissue perfusion) when the muscle compartment pressure > vascular perfusion pressure.
• Pathophys:
  
  • increased compartment pressure → decreased arterial pressure & increased venous pressure → capillary bed collapse → decreased tissue perfusion → tissue death
• Etiology:***Trauma
  
  • Increased volume: long bone fracture (75%), hemorrhage, swelling from the direct soft tissue trauma, burns (increased fluid), post-ischemic swelling (reperfusion), snake bite
  • Decreased volume: tight casts, dressings
  • **Most common: fracture of the tibia, elbow, forearm, femur (leg, forearm, thigh)
• Risks:
  
  • male < 35yo (any age possible, but compartments of younger pts don’t expand as well), unconscious drunk pt, IVDA, underlying bleeding disorder
• Most common location = anterior compartment of the leg
• S/sxs:
  
  • 7 Ps:
  • pain out of proportion to injury = most important
  • -Pallor
  • -Paresthesia (tingling)
  • -Paresis (motor loss)
  • -Poikilothermia (cool skin)
  • -Pressure (tight to palpation)
  • -Pulselessness
  • *Many of these may be normal so depend on pain
• 4 compartments of the lower leg-
  
  • lateral
  • -anterior
  • -deep posterior
  • -superficial posterior
  • *Each contain several muscles surrounded by fascia which has limited ability to stretch

:

*

Question 266

Acute Compartment Syndrome: PE, Dx, & Tx

Answer 266

• PE:
  
  • Pain with passive stretching of the affected muscles
  • -“Wood-like” feeling → d/t tense compartment
  • -Document neurovascular status carefully
  • will have an underwhelming physical exam in comparison to DVT
• Dx:
  
  • Pain is severe, out of proportion, not relieved by rest or meds, focal or referred.
  • -Prior trauma
  • -**Other Ps not reliable
  • -Compartment pressure > 30 mmHg = require emergent fasciotomy, Elevated > 20, Normal 0-10 (measure with solid-state transducer intracompartmental catheter [STIC Monitor]); if >20 it is elevated (repeat measurement)
  • Delta pressure aka P value (diastolic BP - compartment pressure) = <30 mmHg (Emond say <20)
• Tx:
  
  • Medical Emergency!!
  • Up to 15% morality. Tissue death by 8 HOURS → irreversible damage. Nerve damage irreversible after 6 hours.
  • -Loosen tight bandages, casts, splints
  • -Pain medication → IV opioids (but don’t overmedicate)
  • -Elevate extremity to level of heart ONLY
  • -Refer out emergently→ Emergent fasciotomy to decompress
  • *Wounds are left open & delayed closure/skin grafting is performed after swelling subsides

Question 267

Deep Vein Thrombosis

Answer 267

• Etiology:
  
  • venous stasis, endothelial injury, & hypercoagulable state (Virchow’s Triad)
• Risks:
  
  • high-risk surgeries (total joint arthroplasties, internal fixation of hip fracture), trauma, acute illness, Acute HF
• Epidemiology:
  
  • 50% of blood clots are healthcare associated, DVT more common than Pe
• S/sxs:
  
  • Edematous, painful/tender leg
  • -Ankle Edema
  • -Dilated veins
  • -Fever
• PE:
  
  • Homan’s sign: sharp pain in the calf on dorsiflexion of the foot (passive test NOT active test)
  • -Leg tenderness
• Dx:
  
  • U/S with doppler
  • -D-dimer: if unlikely → good to r/o
• Well’s Criteria:
  
  • *DVT likely if score > 2
  • -Active cancer, paralysis, bedridden for 3 days recently or major surgery within last 12 weeks, surgery, localized tenderness, entire leg swollen, calf swelling, pitting edema confined to affected leg , collateral superficial veins, previously documented DVT
• Tx:
  
  • Hospital admission
  • -IV heparinthen oralWarfarinx 3 months once discharged
  • -Alternatives: fondaparinux, dabigatran, rivaroxaban, apixaban

Orthopedic Surgery Prophylaxis:

• IV heparin, IV fondaparinux, oral warfarin or ASA initiated within 24 H of surgery
• Post-op warfarin or ASA x 7-10 days
• Pneumatic compression with foot, calf, & thigh pumps

Question 268

Acute Osteomyelitis: def, Risks, Organisms, S/sxs

Answer 268

• Definition:
  
  • infection/inflammation of the bone & marrow. Most commonly occurs as a primary isolated infection but can occur secondary to systemic infection
• Femur & tibia = Most common bones in children affected
• Risks:
  
  • Local (alter vascularity of the bone): trauma, radiation, Paget’s, osteoporosis, major vessel disease, malignancy
  • Systemic: DM, malnutrition, sickle cell disease, anemia, autoimmune, HIV, immunosuppression (chemotherapy, steroids)
  • Predisposing factors: open fractures = MCC in adults, post-op infections, orthopedic implants
• Organisms:
  
  • -S. Aureus = Most common, ASK if they are a MRSA carrier
  • -E. Coli, Klebsiella: IVDA, GU infx
  • -Pseudomonas: puncture wound, IVDA, GU
  • -Salmonella: sickle cell anemia
  • -H. Flu, group B strep: neonates
  • -Pasteurella multocida: cat bite
  • -Eikenella corrodens: human bite
  • -S. Epidermis: prosthetic joint placement
• S/sxs:
  
  • **Acute Onset
  • -High fever, chills, sweats
  • -bone pain & swelling: acutely painful & skin appears red, warm
  • -Limitation of movement: restricted ROM of the joint near the affected bone

Question 269

Acute Osteomyelitis: PE, Dx, & Tx

Answer 269

• PE:
  
  • Red Flags:
    
    • -Adults: drainage post-op for fracture
    • -Peds: focal tenderness, fever
  • PE-DM:
    
    • -large diabetic foot ulcer with palpable bone → must think of osteomyelitis!!
• Dx:
  
  • Bone Aspiration:
  • -Positive bacterial cx from bone biopsy = preferred diagnostic criteria
  • -Aspirate: Gram stain only positive 50% of the time, need to culture it!
  • Labs:
    
    • -Leukocytosis
    • -Elevated ESR/CRP
    • -Cultures (need to cx before abx initiated)
• Tx:
  
  • Medical emergency
  • -IV abx x 4-6 weeks:
    
    • → MRSA: vancomycin
    • → MSSA: nafcillin or oxacillin
    • → Pseudomonas: Cefepime
  • -Surgical debridement
  • *Abx therapy is only effective before pus formation (soft tissue injury without joint or bone involvement) → deeper infections need surgical drainage
  • *If removal is effective then abx will prevent reformation & primary wound closure is safe

Question 270

Septic Arthritis: Def, risks, Pathophys, joints, organisms, S/sx

Answer 270

• Definition:
  
  • infection of the joint cavity
• Risks:
  
  • >80yo, DM, RA, SLE, prior total joint regional anesthesia (TJRA), recent joint surgery
• Pathophys:
  
  • Contiguous spread: skin infx, cutaneous ulcers (travel deeper & enters joint)
  • Direct inoculation: intra-articular injection, recent joint surgery
  • Hematogenous spread = Most common: DM, HIV, immunosuppression meds, IVDA, RA, osteoarthritis, sepsis, prosthetic joint, sexual activity (gonococcal arthritis)
• Joints:
  
  • mono-articular 80-90%, large peripheral joints such as knee = common in adults, hip = common in children, elbow or wrist
• Organisms:
  
  • staph aureus (MSSA & MRSA)
  • -Pseudomonas: IVDA (IV drug abuse)
  • -Neisseria gonorrhoeae: see other flashcard
  • -Salmonella: African Americans
• S/sxs:
  
  • **Acute onset
  • -Swollen warm, painful, tender joint with decreased ROM
  • -Redness & warmth of joint
  • -Fever
  • -N/V
  • -pain with passive ROM
  • Children:
    
    • -refusal to bear weight
    • -irritability
    • -tachycardia
    • -decreased appetite

Question 271

Septic Arthritis: Key hx points, Dx, & Tx

Answer 271

• Key hx points:
  
  • -Number of joints involved
  • -Underlying joint disease or trauma
  • -Prior illness/infx
  • -Previous intra-articular infx or joint surgery
  • -IV drug abuse
  • -Time of onset
  • **high index of suspicion in young pts presenting with joint pain**
• Dx:
  
  • Arthrocentesis: Synovial fluid
    
    • WBCs > 75K
    • -PMNs > 90%
    • -Clarity: opaque
    • -Color: dirty/yellow
    • -Viscosity: variable
    • -Glucose: low
    • -Protein: elevated
    • -Gram stain (+60-80% of the time)
    • -Analyzed for crystals
  • *Gold standard: cx & sensitivity (3 Cxs: aerobic bacteria, anaerobic bacteria, AFB)
  • *always get cxs before giving abx
  • Labs:
    
    • -Elevated ESR & CRP
  • Xray: usually normal, but may show soft tissue swelling around the joint & widening of the joint space
  • “Are you a MRSA carrier?”
  • REFER OUT EARLY!!
• Tx:
  
  • Medical Emergency. Can rapidly destroy the joint so do NOT wait
  • IV abx: after fluid collection
    
    • → Cx pending: Vancomycin +/- Cefepime (UTI)
    • → Gram + cocci: vancomycin
    • → Gram - rods: Cefepime
    • → Gram - rods: IV Drug Abuse/critically ill: Cefepime + gentamicin
  • -Refer for surgical drainage: arthrotomy (open surgical drainage) or lavage with arthroscopy
  • -If uncomplicated: IV → oral abx x 4-6 weeks
  • *All pts with septic arthritis need surgery except gonococcal

Question 272

Gonococcal Arthritis

Answer 272

• young, sexually active patient who presents with multiple painful joints. Associated with tenosynovitis. Migratory pattern (i.e. ankle → knee → lower back → elbow)
• S/sxs:
  
  • Swollen warm, painful, tender joints with decreased ROM
  • Gonococcal rash
• Tx:
  
  • IV Abx: Cefepime
  • May NOT need surgery

Question 273

Synovial Fluid Analysis Chart

Answer 273

Question 274

Glenohumeral Dislocations: Overview

Answer 274

• Most common joint to dislocate. Anterior is the most common type of dislocation (95%)
  
  • Risks: young male with violent force/trauma (sports), older patient with lower mechanism
• PE:
  
  • Distal neurovascular eval before** & **after reduction
  • -sulcus sign: elbow grasped and traction applied inferiorly→ depression below the acromion)
• Tx:
  
  • conscious sedation, reduction & immobilization (keeping upper extremity internally rotated across chest)
  • -Repeat neurovascular exam
  • -Post-reduction x-rays
  • -PT & referral to ortho
• Complications:
  
  • -axillary nerve injury: this is why we do a neurovascular exam

Question 275

Anterior Glenohumeral Dislocation

Answer 275

• Mechanism:
  
  • most common after a blow to an abducted, externally rotated, & extended extremity
• S/sxs:
  
  • shoulder pain
• PE:
  
  • Inspect: arm held in abduction & external rotation, loss of deltoid contour
  • Palpate: sunken anterior soft tissues +/- humeral head palpable
• Dx:
  
  • Xray: **STAT
  • *axillary & scapular “Y” view
  • -Hill-Sachs lesion: groove fracture of the humerus
  • -Bankart lesion: glenoid rim fracture
• Tx: see glenohumeral dislocations overview

Question 276

Posterior Glenohumeral Dislocation

Answer 276

• Mechanism: posteriorly directed force when the arm is in an adducted and internally rotated position
• Risks: seizures, electric shock, trauma
• Sxs:
  
  • shoulder pain
• PE:
  
  • -Inspect: arm held in adduction & internal rotation
  • -Anterior shoulder appears flat with a prominent humeral head
• Dx:
  
  • Xray: **STAT
  • **Axillary & Scapular “Y” views
  • -”Light bulb” sign: appearance of humeral head looks like a light bulb
• Tx:
  
  • see glenohumeral dislocation overview

Question 277

Anterior Cord Syndrome

Answer 277

• Flexion or vascular cause
• complete loss of motor, pain, and temperature below lesion
• proprioception and vibratory sense intact
• **this has worse prognosis

Question 278

Central Cord

Answer 278

• Forced hyperextension = mechanism
• sensory and motor deficits, upper > lower

Question 279

Brown Sequard Syndrome

Answer 279

• mechanism = penetrating
• ipsilateral vibratory, motor and proprioception loss
• contralateral loss of pain and temperature
• **This has best prognosis

Question 280

When to give blood transfusion?

Answer 280

Transfuse for hemodynamic instability despite fluids, Hgb < 9 in high-risk patients (elderly, CAD), Hgb < 7 in low-risk patients

Question 281

SEs associated with TB tx drugs

Answer 281

• Rifampin (RIF): Orange body fluids, hepatitis - “remember R = red/orange body fluids”
• **Isoniazid ** (INH): peripheral neuropathy (give with B6 - pyridoxine 25 to 50 mg/day)
• **Pyrazinamide ** (PZA): Hyperuricemia (Gout)
• Ethambutol (EMB): Optic neuritis, red-green blindness - “remember E = eyes

Question 282

indirect vs direct inguinal hernia

Answer 282

• Indirect inguinal hernia passes through deep inguinal ring, inguinal canal and superficial inguinal ring and descends into scrotum. The hernia lies lateral to the inferior epigastric vessels
• MDs dont LIe
• Medial to the vessels = direct, lateral to the vessels = indirect