✅F3 (PEDS/PREGNANCY/REPRO/UROLOGY/BREAST) Flashcards
1
Q
Give brief descriptions of each pediatric neoplasm
Neuroblastoma
________________
Rhabdomyosarcoma
________________
Wilms tumor
A
N: extracranial solid tumor of adrenal medulla p/w catecholamine sx: HTN, flushing sweating
___________________
R: malignant soft-tissue tumor of the head/neck
___________________
W: most common ped renal CA presenting < 5 yo with uL PAINFUL abd mass + Hematuria + HTN
N/W mass compresses renal artery ➜ activates renin-angiotensin system ➜ HTN
2
Q
initial tx for Insomnia
A
CBT
_________________
sleep hygiene / sleep restriction / relaxation techniques
3
Q
MDD and Grief have overlapping Symptoms
What are 3 factors of Grief that separate it from Major Depression Disorder?
A
grief (normal rxn to loss):
Intensity ⬇︎ over time
Suicidality NOT common
“waves” of grief at reminders
4
Q
Clozapine’s SE is agranulocytosis
Name the Granulocytes - 3
A
BEN
Basophils
Eosinophils
Neutrophils
Clozapine also causes Metabolic Syndrome X, Seizures and Myocarditis
5
Q
Diagnostic criteria for Persistent Depressive Dysthymia disorder - 3
A
- at least 2 / 6 of SIgeca
- CONSTANT ≥ 2 years (or 1 year in kids)
- No relief > 2 mo
Major Depressive Episodes may also occur with this
6
Q
Vulvodynia cp
________________
tx -2
A
≥3 mo idiopathic raw burning vulvar pain
________________
Tx = [pelvic floor physiotherapy] and CBT
7
Q
Exercise during pregnancy ⬇︎ risk of (⬜3)
A
gestational DM
PreEclampsia
Cesarean
8
Q
What are the contraindications to Exercise during pregnancy? -3
A
- cervical insufficiency
- underlying comorbidity preventing exercise
- active vaginal bleeding
9
Q
How do you manage Patient agitation when it’s escolated to violence? -2
A
- PHYSICAL RESTRAINTS
- INTRAMUSCULAR ANTIPSYCHOTIC
10
Q
[Pyogenic granuloma telangiectaticum]
A
[dome shaped papule with recurrent bleeding] caused by capillary proliferation after trauma during pregnancy
11
Q
Describe [Simple breast cyst]
________________
A
benign fluid filled mass 2/2 breast duct obstruction
________________
12
Q
What are the risk factors for Cervical Insufficiency? -4
A
- Cervical Conization
- Uterine abnl
- Prior obstretric trauma
- congenital (intrauterine DES exposure, collagen abnl)
13
Q
Rett syndrome sx -3
A
- [microcephaly with developmental regression]
- epilepsy
- unique hand gestures
14
Q
patient is diagnosed with breast cyst
Describe your workup -5
A
15
Q
What level of prolactin indicates a Prolactinoma
A
>200
Prolactin inhibits LH release
16
Q
Name the factors of Schizophrenia a/w a good prognosis -6
A
17
Q
Febrile seizures present day ⬜ of illness, are a common complication of high fever a/w ⬜, and onset between ⬜ y/o
_________________
What is the prognosis for children with febrile seizure
A
1 ; viral infection ; [3 months - 6 yo]
_________________
typically [benign course (does not require tx)] but 30% will have ≥1 recurrence and also have INC risk for Epilepsy
18
Q
How do you treat Febrile Seizure? -3
A
- REASSURANCE
- [Abortive tx if ≥5 min]
- [Sx Tx (APAP)]
19
Q
A physician (⬜ can | cannot) unilterally terminate a patient solely for nonpayment \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ When is a physician considered "abandoning" a patient? -2
A
CAN
_________________
Abandoning Patient if:
- Patient terminated whilst in immediate medical need
- Patient NOT given reasonable time to find alternate provider
20
Q
AntiParkinson tx can cause psychosis due to ⬜
How do you manage this? -2
A
+ dopaminergic effects (activation of mesolimbic pathway)
_________________
[DEC AntiParkinson dosage (starting with least potent)]
–(if sx persist)–> [add D2 R Blocker (Quetiapine/Clozapine/PimaVanserin)]
21
Q
What are 2 major signs of tooth decay?
_________________
Name 3 risk factors for a baby developing tooth decay?
A
white spots / discoloration
_________________
- sugary substances frequently
- nighttime bottle/feedings
- Inadequate fluoride
* Dental Home must be established by 1 y/o*
22
Q
What are the 4 major risk factors for [Spontaneous Abortion < 20WG]?
A
PREVIOUS SPONTANEOUS ABORTION
[Maternal Age > 35]
[Maternal Substance Use]
[BMI extremes]
23
Q
Describe the following contraception:
a. Progestin-releasing IUD
_________________
b. Copper-containing IUD
_________________
c. BL tubal Ligation
A
a. long,reversible contraception used in pts with contraindication to estrogen. Also ⬇︎menstrual blood loss in anticoagulated pts
_________________
b. long, reversible contraception but ⇪ menestrual bleeding and dysmenorrhea
_________________
c. irreversible contraception indicated for pts finished with childbearing. Will NOT help menorrhagia
24
Q
Ovarian torsion occurs in ⬜ women and presents with (⬜2 sx)
_________________
how do you diagnose this?
A
reproductive ; [uL pelvic pain + tender adnexal mass]
_________________
[Pelvic Ultrasound with color Doppler]
(will show enlarged edematous ovary with ⬇︎blood flow)
25
Main features of Becker Muscular Dystrophy - 4
1. [Xp21 deletion] *(X-link recessive deletion on Chromo Xp21)*
2. Scoliosis
3. [peds onset **at 5 yo**]
4. [cardiomyopathy ➜ **4****0-50 yo DEATH**]
26
Main features of Duchenne Muscular Dystrophy - 5
1. [**CALF PSEUDOHYPERTROPHY** requiring gower manuever + teenage wheelchair] = [⇪ Creatine Kinase]
------------
2. [Xp21 deletion] *(X-link recessive deletion on Chromo Xp21)*
3. Scoliosis
4. [peds onset **at 2 yo**]
5. [cardiomyopathy ➜ **20-30 yo DEATH**]
27
Why are the **Negative** symptoms of Schizophrenia treated differently?
and what are Negative Schizo sx treated with?
NEGATIVE Schizo Sx **respond poorly to Antipsychotics** so...
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
➜ Negative Schizo symptom tx = [social skills training]
28
*For Women who wish to preserve fertility:*
What is the MOA for the 1st line tx of [Leiomyoma Fibroids]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Whats another tx for this?
[**Progestin-releasing IUD**] *Reversibly* induces endometrial atrophy ➜ [⬇︎ leiomyoma size and ⬇︎ uterine bleeding]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Combined OCP]
29
What are the sx of [Leiomyoma Fibroids] -4
enlarged **irregularly** shaped uterus
regular menorrhagia
dysmenorrhea
mass effect (constipation/pelvic pressure/urinary sx)
30
In neonates, how might Cystic Fibrosis present? -4
**Meconium iLeus** = inspissated GI secretions obstruct meconium excretion in distal iLeum ➜
## Footnote
[**DILATED SMALL BOWEL LOOPS with NARROW UNDERUSED MICROCOLON**]
[**Bilious** emesis]
[R ground glass mass AXR (from iLeum air mixing with iLeum meconium)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*AXR = Abdominal XRay*
*ASK ABOUT FAM HX OF RECURRENT SINUS INFECTIONS*
31
Diagnosis? ; Name the major risk factor for this
HIRSCHSPRUNG DISEASE ; [Mom ≥ 35 yo]
## Footnote
*markedly dilated descending colon*
32
[Advanced Maternal Age ≥35] is a risk factor for ⬜, which is a/w with what 2 neonatal conditions?
Down Syndrome Trisomy 21
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Duodenal Atresia (double bubble)
Hirschsprung disease (dilated colon)
33
Maternal Macrolide use during pregnancy is a risk factor for ⬜ , which typically presents at age ⬜ with (⬜2)
[pyloric stenosis] ; 1 month old ;
**NONBILIOUS** PROJECTILE VOMITING + PALPABLE OLIVE SHAPED ABD MASS (target sign on XR)
34
What is the Doctrine of Implied Consent?
pts who **LACK DECISION-MAKING CAPACITY**
but REQUIRE 911 TX
may be given (wihout their explicit consent) same tx most reasonable people in a similar siutation would expect to receive
35
Physicians should screen for ⬜ in veterans reporting insomnia, substance use and interpersonal conflict
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx for this condition? -3
PTSD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Trauma Focused CBT]
[SSRI/SNRI]
[Prazosin for nightmares]
36
Physicians should screen for ⬜ in veterans reporting insomnia, substance use and interpersonal conflict longer than ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What is the diagnostic criteria -2
PTSD
\> 1 month
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[LIFE THREATENING TRAUMA]
+
**P.A.I.N.** sx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
***P****ysch (sleep* ∆ /*hypervigilance/concentration ⬇︎)*
***A**voidance (avoids distressing thoughts/feelings/external reminds of the event)*
***I**ntrustion (nightmares/flashbacks)*
***N**egative mood (guilt/ anhedonia/detachment/anger/self-esteem ⬇︎)*
37
how does Nephrolithiasis present *during pregnancy*?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
dx?
2nd or 3rd trimester
[Flank pain that radiates to labia + NV]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
dx = renal/pelvic US
38
What are the recommendations regarding Bariatric Surgery and Pregnancy?
After Bariatric Surgery, **Delay Pregnancy x 1 year** to optimize wt loss and nutrition
39
BP Goal for Pregnant patients?
\< 140/90
40
patients with fetal growth restriction (defined as ⬜ ) are at ⇪ risk for ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is this managed?
[estimated fetal **wt \< 10th%tile** for gestational age]; STILLBIRTH
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Serial Antenatal testing]
41
What is the purpose of [Fetal Fibronectin test]?
determines risk of preterm delivery in patients with preterm contractions
42
Describe purpose of [Percutaneous Umbilical Sampling]
high risk procedure that samples fetal blood to confirm severe fatal anemia (hydrops fetalis)
43
What's current recommendation regarding Lyme disease during Pregnancy?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Which 2 abx can be used to treat Lyme disease during Pregnancy?
If mother receive adequate abx (PO amoxicillin vs PO ceFUROxime) = NO ⇪ FETAL RISK
44
*AFP is obtained in pregnant women at 15-20WG*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What does an elevated AFP indicate in a pregnant woman?-3
1. Fetal Open Neural Tube Defects (open spina bifida, anencephaly)
2. Fetal Abd Wall defect (Gastroschisis, Omphalocele)
3. Multiple gestation (twins)
*If ⬆︎AFP --\> GET ANATOMY US!*
45
What is the Prenatal Maternal Quad Serum screening? When is this obtained?
Measures 4 chemical markers for fetal anomalies and down syndrome- 81% accuracy (QUAD = **BUAD**):
1. **β**HCG⬆︎
2. **U**nconjugated EsTriol⬇︎
3. **A**FP⬇︎
4. **D**imeric inhibin A⬆︎ - *only in QUAD screen*
Performed 15 -20WG
*Be sure to f/u abnml results with cell free fetal DNA test and US*
46
What are the Quad BUAD results (obtained 15-20WG) for Edward's Trisomy 18?
⬇︎βHCG
⬇︎**U**nconjugated EsTriol
⬇︎**A**FP
NML **D**imeric inhibin A
47
AFP (*from Maternal serum*) is a protein made by the (⬜3) It is obtained in pregnant women at ⬜ weeks gestation via ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What constitutes as an elevated AFP?
[Fetal Yolk Sac]/GI/Liver
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
15-20WG
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
via Quad BUAD screen
*if AFP \> 2.5 ➜ get anatomical US!*
48
What 2 contraceptives are the most ideal for adolescents teens? Why is this?
[**IUD** or **subdermal implants**] = RELIABLE, SAFE and REVERSIBLE
## Footnote
*long acting reversible contraceptives*
49
*Pt on Valproate, incidentally found to be 14 WG*
How do you manage this?
although [AntiEpileptics Drugs] (especially valproate) are INC risk for congenital anomalies
DO NOT MAKE CHANGES TO AED **AFTER** CONFIRMATION OF PREGNANCY
Instead ➜ start pt on [high dose folic acid] + [obtain AFP with anatomical US] to screen for congenital anomalies
50
**[T or F]**
[AntiEpileptic Drugs] are relatively contraindicated with breastfeeding
FALSE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*Moms CAN breastfeed while on [AntiEpileptic Drugs]*
51
Name the absolute contraindications to breastfeeding? - 7
**BITCHES** *can NOT breastfeed!*
1. [**B**reast has HSV lesions]
2. [**I**nfant has galactosemia]
3. **T**B untreated
4. **C**hemoradiation
5. **H**IV maternally
6. varic**E**lla actively
7. **S**ubstance abuse maternally
* Hep B pts can breastfeed as long as baby receives HepB Immunoglobulin and vaccination*
52
Peds with untreated iron deficiency anemia are at INC risk for what 2 comorbidites?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is this mitigated? -3
psychomotor delay
neurocognitive impairment
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[universal screening starts age 1 yo]
--(if hgb \<11)--\> [PO ferrous sulfate]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*IDA is the most common nutritional deficiency in kids*
53
Explain why some females have ***irregular heavy menstruation*** around menarche
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
endometrium builds 2/2 estrogen, however, without progesterone (common around menarche) the cue to slough endometrium is absent = Anovulation➜ estrogen breakthrough bleeding = *irregular heavy menstruation*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*Estrogen proliferates and repairs Endometrium ➜ Endometrial hemostasis*
54
Name the causes of [Abnormal Uterine Bleeding] in nonpregnant women? -9
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you treat ACUTE heavy [Abnormal Uterine Bleeding]?-3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* HDS*: [combined OCP with **HIGH DOSE ESTROGEN**]
* NPO/Refractory*: [IV Estrogen]
* HD**U**S*: [D&C (endometrium surgical removal)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Estrogen proliferates and repairs Endometrium ➜ hemostasis*
55
What is Pubic Symphsis Diastasis? ; What is the clinical presentation of this after a traumatic delivery?
Physiological widening of pelvis by progesterone and relaxin to facilitate vaginal delivery ; **Postpartum** **suprapubic TTP pain that radiates to the Back and/or Hips**
## Footnote
*worst with weight bearing, walking or position change and resolves by 4 weeks PostPartum*
56
CP for Endometriosis - 5
The 3 Ds and **A**ll
1. **D**ysmenorrhea
2. **D**yspareunia deep pelvic - implants in posterior cul-de-sac
3. **D**yschezia (painful defecation) - implants in posterior cul-de-sac
OR
**(4) A**SX (tx not indicated if so) - otherwise tx = NSAIDs --\> Contraceptives (combined OCP/IUD progesterone)
(5) Infertility of unknown origin
* Findings: Gun Powder Burn lesions, ADHESIONS--\>immobile uterus, Chocolate fluid*
* Dx = Laparoscopy to biopsy & remove endometriotic lesions*
57
Why is it common for adolescents to have irregular and anovulatory menstruation?
**immaturity of hypothalamic-pituitary-gonadal axis** --\> inadequate amounts of GnRH --\> low FSH and LH --\> lack of ovulation --\> lack of Menses
Menses normally occurs when corpus lutem (byproduct after ovulation) produces progesterone and this progesterone drops --\> Menses/shedding. **No ovulation --\> No menses**
* Tx = Progestin-only or Combined OCPs*
* this self-resovles 1-4 yrs after menarche*
58
hCG is secreted by _____ and responsible for what? ; When does hCG production begin?
syncytiotrophoblast ; **preserves corpus luteum** (which secretes progesterone) during early pregnancy until the placenta can take over ; 8 days after fertilization
## Footnote
*hCG also stimulates maternal thyroid and promotes male sex differentiation*
59
Which hormone prepares the endometrium for implantation of a fertilized egg?
**P**rogesterone **P**repares endometrium via decidualization
60
MOD for PCOS
Hyperinsulinemia and Elevated LH --\> ⬆︎ Androgen release from Ovarian Theca which is converted to Estrone--\> **Elevated Estrone** which feedbacks on the hypothalamus --\> ⬇︎GnRH --\> ⬇︎**FSH imbalance** --\> failure of follicle maturation and anovulation --\> No progesterone --\> Endometrial CA
## Footnote
* tx = weight loss and clomiphene citrate*
* Note: if pt has high levels of sex hormone binding globulin, total testosterone may be low. so clinical dx may be necessary*
61
Tenderness along the uterosacral ligament should make you suspicious for what disorder?
Endometriosis
62
Which hormone induces prolactin production during pregnancy?
**E**strogen
63
Which hormone is responsible for myometrium relaxation during pregnancy?
**P**rogesterone
64
*After giving abx*
How do you manage UTI in peds less than 2 yo
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
what about peds \> 2 yo?
after 1st febrile UTI,
in [peds \< 2 yo]= renal/bladder US (to evaluate for anatomic abnl) --(if abnl)--\>VCUG
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[peds \> 2 yo] = No imaging as long as abx tx ➜ resolution
*VSUG = voiding cystourethrogram*
65
How do you manage a pregnant patient who's GBS positive at 14 WG? -2
[Amoxicillin or Cephalexin **STAT**] + [PCN **intrapartum**]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*pregnant patients require abx STAT to prevent progression to upper UTI (like*
66
Tx for Lichen Sclerosis
Clobetasol ointment (high potency topical CTS)
## Footnote
*dx = vulvar punch biopsy*
67
clinical presentation of [Genital wart condyloma acuminata]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx?
**cauliflower**-like, soft and raised lesions
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TriChloroAcetic acid
68
Ectopic pregnancy can be managed medically with methotrexate (⬜*MOA*) unless its contraindicated which ➜ Surgery instead
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the contraindications for MTX in ectopic pregnancy? -5
folic acid blocker
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. liver disease (DEC MTX clearance)
2. renal disease (DEC MTX clearance)
3. ruptured ectopic (free fluid in posterior-cul-de-sac)
4. immunodeficiency
5. high failure probability (fetal cardiac activity, βhCG\>5000 )
69
When is [RhoGam AntiRhD] administered to **Rh NEGATIVE** pregnant women? - 7
DO THIS FOR ALL Rh NEGATIVE mothers
1. 50mcg 1st trimester **if uterine bleeding and/or spontaneous abortion occurs**
2. **300mcg at 28 WG**
3. **[300 mcg within 3 days after delivery** **(*if infant RhD+)*****]**
4. give with any episodes of vaginal bleeding (if indicated)
5. give with External Cephalic Version
6. give with Hydatidiform Mole dx
7. give if Ectopic Pregnancy occurs
70
the 2 diagnostic criteria for [*ruptured* ectopic pregnancy] are ⬜ and ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you manage suspected ectopic pregnancy?
positive UPT
+
HDuS hemoperitoneum
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
71
What's the most common side effect of combined OCP?
**Irregular breakthrough bleeding**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*2/2 thin atrophic endometrium that sheds UNEVENLY*
72
Oligohydramnios --\> ⬜ sequence.
Name the 3 most common causes of Oligohydramnios
Oligohydraminos --\> **POTTER** Sequence
**POSTERIOR URETHRAL VALVES** are the most common cause of obstructive uropathy in newborn **BOYS** (which causes renal damage --\> oligohydramnios during utero)
73
Oligohydramnios --\> ⬜ sequence.
Describe this clinical presentation for this Sequence
Oligohydraminos --\> **POTTER** Sequence
**P**ulmonary hypOplasia
**O**ligohydraminos from renal agenesis/damage (cause)
[**T**wisted Face & Extremities]
**T**wisted Skin
**E**ars set low
**R**enal Failure
74
False labor occurs as a result of Braxton Hicks contractions and causes NO CERVICAL CHANGE
Compare the **Timing** / **Strength** / **Cervix status** of contractions occuring in False Labor to True Labor
Uterine Contractions...
FALSE = irregular + weak + NO CERVICAL CHANGE
True = [Regular with **increasing frequency**] + [**increasing in strength**] + cervical change
75
What is often the cause of Early Decelerations on Fetal Heart Tracing
**Head Compression** of Fetus
## Footnote
*these occur WITH contractions and no tx is required*
76
which pregnant patients should receive ⬜ antibiotic prophylaxis for GBS prevention?
Intrapartum PCN to
[(GBS+)]
\_\_\_\_\_\_\_\_and\_\_\_\_\_\_\_\_
[(GBS unknown) + (≥1 risk factor)]
*RF: [\<37WG] / [maternal intrapartum fever] / [Prolonged Rupture of Membrane ≥18H]*
77
Diagnosis? | Tx?
[Actinic Solar Keratosis] | [topical 5-Fluoruracil]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*diffuse scaly papules on photodamaged (telangiectasia/dyspigmentation/atrophy) background*
## Footnote
*can prorgress to SQC*
78
diagnosis?
Psoriasis
## Footnote
*affects extensor surfaces*
79
What are the potential complications of Subchorionic Hematoma? (6)
spontaneous abortion/
placenta abruptio/
PPROM/
preeclampsia/
preterm labor/
IUGR/
IUFD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*subchorionic hematoma result in placental dysfunction and ➜*
80
what is subchorionic hematoma ?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
management?
abnml blood collection between [Uterus chorion] and gestational sac that presents as 1st trimester bleeding or incidental US finding
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expectant (serial US for reassurance)
*can result in placental dysfunction and ➜ spontaneous abortion/placenta abruptio/PPROM/preeclampsia/preterm labor/IUGR/IUFD*
81
Treatment choices? (3)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What's the prognosis of this condition after treatment?
* treat SD with [topical **CAC**]*
1. topical antifungal (ketoconazole / selenium sulfide)
2. topical CTS
3. topical calcineurin inhibitors (pimecrolimus)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SD is a chronic RELAPSING condition so intermittent **re-treatment may be necessary**!
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Seborrheic DERMATITIS ;
*pruritic erythematous plaques with **oily greasy scaling & flaking***
82
Emergency contraception should be offered within ⬜ days of unprotected intercourse.
⬜ is the most effective therapy and ⬜ is the most effective ORAL therapy.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name all 5 options
5 ; [**COPPER IUD**] ; [Ulipristal (AntiProgestin)]
83
describe Postexposure Px (PEP) management (5)
1. Chlamydia = doxy
2. Gonorrhea = Ceftriaxone
3. Trichomoniasis = Metronidazole
4. [H**I**V (if within 3 days of exposure)] = triple drug regimen
5. [H**B**V (HBV vaccine if not immune [and IG if assailant HBV+])
84
*Most seizures in young children with fever are benign (febrile seizure)*
When is Lumbar Puncture indicated? (4)
1. Nuchal rigidity
2. HA
3. bulging fontanelle
4. prolonged AMS
85
Which contraception is the most effective?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
MOA? (2)
[PSI (*r**3 year*)]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
progesterone
1. thickens cervical mucus and ⬇︎tubal motility ➜ inhibits sperm migration
2. ⬇︎ [FSH and LH secretion] ➜ stops ovulation
[PSI-Progestin Subdermal Implant (long-acting + reversible)]
86
[T or F]
Stimulant therapy for ADHD is associated with ⇪ risk for Substance Use Disorder
FALSE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*Stimulant rx for ADHD does **NOT** increase risk of developing Substance abuse*
87
[Genu Varum] is normal during age ⬜ and presents as (⬜3) . When should this correct by?
0-2 yo ; [BL symmetric bow leg, normal stature, **no** lateral thrust]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
should correct by 2 yo
## Footnote
*obtain XR if \> 2 yo, short stature or uL*
88
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
How do you clinically diagnose Proteinuria for pregnant women - 4
1. ≥300 mg protein on 24 hr urine
OR
2. ≥ 30 mg/dL on dipstick
OR
3. At least 1+ on dipstick
**OR**
4. **Protein:Creatinine ratio \> 0.3**
* Must occur at least 2 times at least 6 hours apart*
89
Preeclampsia is typically diagnosed ____ weeks gestation. What is the exception to the rule?
≥ 20WG! ; Preeclampsia is a complication of Hydatidiform mole which may occur \< 20WG
90
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
Describe timeline for Postpartum preeclampsia
can present up to 12 weeks postpartum
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
**PreEclampsia** --\> **SEVERE PreEclampsia** --\> **HELLP** and at anytime, **Eclampsia** is possible
91
**PreEclampsia** --\> **SEVERE PreEclampsia** --\> **HELLP** and at anytime, **Eclampsia** is possible
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
what is the treatment for HELLP? (3)
DELIVERY
MAGNESIUM SULFATE (SEIZURE PX)
[antiHTN (if ≥ 160/110)]- *labetalol/hydralazine*
92
*Criteria for PreEclampsia is **Gestational HTN** + [**Proteinuria or End Organ Damage]***
How do you clinically diagnose _SEVERE_ PreEclampsia? - 9
**PreEclampsia** --\> **SEVERE PreEclampsia** --\> **HELLP** and at anytime, **Eclampsia** is possible
ANY **ONE** OF THE FOLLOWING:
1. Systolic \> 160
2. Diastolic \> 110
3. **refractory** HA
4. scotoma vision changes
5. Pulmonary Edema (from ⬇︎albumin)
6. RUQ OR Epigastric pain
7. Doubling of LFTs
8. Platelets \< 100K
9. Cr \> 1.1 or doubled from baseline
*although not in criteria, can also include Hyperreflexia*
93
What are the potential CP for Hydatidiform Mole? - 5
1. **HEAVY vaginal bleeding**
2. Hyperemesis Gravidarum
3. Severe Preeclampsia
4. Hyperthyroidism
5. Uterus larger than expected gestational age **but with regular countour**
## Footnote
"Snowstorm with grapes" and/or [Theca lutein ovarian multiseptated cyst from excess bHCG] on ultrasound
HHIIGH LEVELS OF bHCG (\> 100,000)
*Most of the time this is caused by sperm implanting an EMPTY ovum*
94
What are the primary components for the Mechanisms of Disease in Preeclampsia? - 3
**Ab complex mediated endovascular damage --\>**
1. Hemolytic Anemia
2. Platelet aggregation from ⬆︎Thromboxane
3. Vascular constriction pervasively from ⬆︎Thromboxane
95
Although tx for OSA in adults is ⬜ , what's the first line tx for OSA in children?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*OSA = Obstructive Sleep Apnea*
CPAP ;
[Tonsillectomy and adenoidectomy] = 1st line for peds
96
What are the recommendations regarding MD and teenager patients having sex.
Should MD discuss with parents?
MD should maintain confidentiality of sexually active teens and ensure teen access to healthcare and counseling
***MD MUST BREAK CONFIDENTIALITY IF THERE'S RISK OF HARM TO SELF/OTHERS OR CHILD ABUSE***
97
What's the single greatest indicator of a teenager being in an abusive or coercive sexual engagement
sexual partners who occupy **POSITIONS OF POWER OR AUTHORITY** over the teenager is s/f abuse/exploitation
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*MDs are obligated to notify CPS or law enforcement about abuse/exploitation*
98
Nipple discharge is pathologic if it is 1 of what 3 things?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you workup breast nipple discharge?
spontaneous / uL / persistent
99
The most common cause of pathologic breast nipple discharge is ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When is breast nipple discharge considered pathologic? -3
papilloma (from lining of the breast duct )
## Footnote
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
spontaneous / uL / persistent
* pathologic breast nipple discharge requires age-based imaging to r/o CA*
* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
* Papillomas are usually benign but may have associated atypia, DCIS or invasive intraductal carcinoma within the lesion*
100
Which contraception should be given to a patient with PCOS?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
why?
Progesin-containing IUD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
unoppossed estrogen in PCOS ➜ androgen excess, polycystic ovaries and anovulation (which ➜ irregular menses, endometrial hyperplasia/CA).
Progesterone protects the Endometrium
101
What is 1st line tx for Dysmenorrhea in sexually active pts?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What about non-sexually active pts?
Combined OCPs
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
NSAIDs
## Footnote
*Combined OCPs treat dysmenorrhea by ⬇︎endometrial proliferation ➜ atrophy which --\> ⬇︎prostaglandin release --\> ⬇︎painful uterine contractions*
102
Diagnostic criteria for Primary Dysmenorrhea; etx
pelvic cramping during the first few days of menses in the context of a normal pelvic exam; prostaglandin release from endometrial sloughing during menses
103
*Hydatidiform Mole is a precursor to ⬜*
How do you manage Hydatidiform Mole ? (5)
[Gestational Trophoblastic Neoplasia]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
104
What is a Hydatidiform Mole?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is HM related to CA?
abnormal fertilization of [empty ovum] by either 2 sperm or [1 sperm whose genome ultimately duplicates] ➜ [hypertrophic and hydropic trophoblastic villi] that secretes **βhCG \> 100,000**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
HM can develop into [Gestational Trophoblastic Neoplasia]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*tx = [D&C + contraception] ➜ [serial βhCG until undetectable x 6 mo]*
105
in newborns, bilirubin greater than ⬜ ➜ ⬜. Describe this condition
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
management?
[20-25] ➜ [Kernicterus bilirubin encephalopathy] *(mvmnt DO and hearing loss)*
*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
Exchange Transfusion
*exchanging [blood with SEVERE HYPERBILIRUBINEMIA and/or DAT+ maternal Ab] from baby and transfusing baby with replacement RBC*
106
Exchange Transfusion in neonates involves ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When is this indicated? (3)
exchanging [blood with SEVERE HYPERBILIRUBINEMIA and/or DAT+ maternal Ab] from baby and transfusing baby with replacement RBC
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
1. total bilirubin \> 20-25
2. worsening hyperbilirubinemia on phototherapy
3. kernicterus encephalopathy
107
MOD for this condition? | Management? (2)
Psuedofolliculitis barbae
shaving ["nappy" tightly curled hair] below skin surface➜ allows penetration of the resultant [angled tip hair shaft] into interfollicular skin ➜ [**small painful papules in beard**]
*and possibly ➜ [hyperpigmentation / 2º bacterial infection / keloid]*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
D/C SHAVING (or use clippers that leave hair longer)
108
Imiquimod indications (3)
actinic solar keratosis
anogenital warts
superficial Basal Cell Carcinoma
109
Tx for Trichomoniasis is ⬜ . What are the precautions if female patient is breastfeeding?
[2 gm metronidazole PO x 1]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
after taking, breast milk should be expressed and discarded x 24h
110
Based on PECARN rule, name the [high risk Pediatric TBI features] for [2 -18 yo] (5)
*high risk Ped TBI = [noncontrast head CT (or 5h obs if med risk)]*
111
Based on PECARN rule, name the [high risk Pediatric TBI features] for [0 -1y 11m] (5)
112
Give brief descriptions that differentiate Postpartum
Blues vs Depression vs Psychosis
* Blues = onsets PPD1, peaking at PPD5 and subsiding PPD14, worst w/lactation
* Depression = onset between [1 month - 12 months after birth] **Traditional s/s**. Previous Depression hx is RF
* Psychosis = RARE but onsets IMMEDIATELY after birth
113
Why can't Ceftriaxone be used during the 1st month of life?
Ceftriaxone can displace albumin-bound bilirubin ➜ allows free bilirubin to cross blood brain barrier ➜ Kernicterus
114
What microbes are the most common causes of serious bacterial infection in [neonates LOE 28 days]? -3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name abx for each -3
1. GBS = Ampicillin
2. Listeria = Ampicillin
3. E Coli = [Gentamicin {or CefoTaxime/CefTazidime if meningitis suspected}]
115
*neonates \> 28 days old*
what organisms cause sepsis? -3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name the empiric abx -2
1. [Ceftriaxone (*Strep Pneumo + Neisseria meningitidis*)]
2. [+/- Vancomycin (*MRSA or meningitis*)]
116
Explain why Breastfeeding is associated with iron deficiency
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
*thalassemia\< [MIX 13]\< IDA*
Breastfeeding only provides sufficient iron for **first 6 months of life**.
[infants ≥6 months] MUST be introducted [iron-rich solid foods (pureed meats/cereals)] to prevent iron deficiency anemia
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*(thalassemia* \< *[Mentzer Index 13 (MCV/RBC)]\< IRON DEFICIENCY ANEMIA)*
117
*There are 3 types of female Urinary Incontinence*
Describe [Stress Urinary Incontienence]
urinary leakage with **INC INTRAABDOMINAL STRESS** (coughing / sneezing / laughing / lifting)
118
*There are 3 types of female Urinary Incontinence*
Describe [Urgency Urinary Incontienence Overactive Bladder]
**URGE** to urinate Suddenly / Overwhelmingly / Frequently
119
*There are 3 types of female Urinary Incontinence*
Describe [Overflow Urinary Incontienence]
**constant OVERFLOWING DRIBBLE OF URINE** and bladder distension 2/2 incomplete bladder emptying
## Footnote
(either from mechanical outlet obstruction or DM Detrusor hypOactivity)
120
*There are 3 types of female Urinary Incontinence*
dx for [Overflow Urinary Incontienence] -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx for [Overflow Urinary Incontinence] -2
[⇪ post void residual] \> 150 cc + neuropathy
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[intermittent self catherterization] + [correct underlying etx for incomplete bladder emptying]
121
Congenital hypOthyroidism is a common and preventable cause of ⬜ in kids; but may be difficult to detect. Why is that?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
how do you manage congenital hypOthyroidism?
*sx: hypOtonia/poor feeding/lethargy/constipation*
intellectual disability ; because maternal T4 crosses placenta most newborns lack clinical signs of congenital hypOthyroidism (hypOtonia, poor feeding, lethargy, constipation) at birth
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
give infant levothyroxine [**by 2 WEEKS OF AGE**]
## Footnote
*T4 is important for neurodevelopment and myelination*
122
What are the complications of Cryptorchidism? -4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How does Orchiopexy affect the incidence of all these?
1. **TESTICULAR CANCER** (orchiopexy enables increased detection and ⬇︎ testicular CA but it will still remain higher than gen pop)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2. Testicular Torsion (orchiopexy ⬇︎)
3. Inguinal hernia (orchiopexy ⬇︎)
4. Subfertility (orchiopexy ⬇︎)
123
by age ⬜ , full term infants should be able to sleep thru the night without overnight feeds
If they can't, how do you change this?
6 months old
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
AVOID OVERNIGHT FEEDS
(do NOT offer feeding during nocturnal awakenings. Just check on baby)
124
What is the normal age parameters for physiologic genu varum?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
genu valgum?
varum "bow legged" = [onset birth - resolve by 2 year old]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
valGus "Knock Kneed" = [onset 2y - resolve by 7y]
*obtain imaging only if persist beyond upper age limit*
125
If Pap Smear testing reveals [High Grade Squamous intraepithelial lesion], what is the next step in management? -2
**COLPOSCOPY** = cervix magnified to identify and BIOPSY abnormal areas
\_\_\_\_\_\_\_\_or\_\_\_\_\_\_\_\_
LEEP (loop electrosurgical excision procedure) = excision of cervical transformation zone and surrounding endocervix - [only if done with childbearing]
126
*Your infant patient is due for the [Varicella Zoster Virus] Vaccine, but the patient lives with its immunocompromised grandmother*
How do you manage this? (2)
* VZV vaccine CAN be administered to immuno**competent** patients with household contacts who are immuno**COMPROMISED** as long as no RASH develops
* monitor for pt rash --(if rash presents)--\> isolate patient from household contact
127
Major causes of 1st trimester bleeding - 3
1. Spontaneous Abortion (inevitable vs threatened)
2. Acute cervicitis (postcoital bleeding, Friable cervix with discharge)
3. Molar Pregnancy
128
Differentiate the following spontaneous abortions:
Inevitable abortion
Threatened abortion
Missed abortion
Complete abortion
*spontaneous abortion = occurs \< 20 WG*
1. INEVITABLE = vaginal bleeding \< 20 WG **with cervical os dilated** --\>abortion will *inevitably* happen soon
2. THREATENED = early vaginal bleeding \< 20 WG **with cervical os closed** is clearly a threat to a STILL LIVING FETUS
3. MISSED = Fetal death **with cervical os closed**...which is why we *Missed* it - (pt will have pregnancy sx that just suddenly disappear out of nowhere)
4. COMPLETE = ALL PRODUCTS OF CONCEPTION COMPLETELY EXPEL AND THEN CERVIX CLOSES BACK UP
## Footnote
*spontaneous = occurs \< 20 WG*
129
What are the 3 criteria options for diagnosing
Cervical insufficiency
[*pp**:* ≥2 pain**LESS** 2nd trimester spontaneous abortions]
## Footnote
OR
[*C**p:* Ultrasound showing short cervix ≤25 mm]
OR
[*C**p:* (early \< 24WG ) pain**LESS** advanced cervical Dilation]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*pp = previous pregnancy*
*Cp = Current pregnancy*
130
⬜ placement ⬇︎ risk of 2nd trimester loss in pregnant patients with cervical insufficiency.
What is it called when [pregnancy with cervical insufficiency] fails and prolapses? and what's the prognosis for this?
Cerclage;
[Previable Prolapsing amniotic membrane];
POOR PROGNOSIS (PPAM a/w *imminent delivery/high risk preterm*)
131
Is it safe to direct breastfeed if Lactational mastitis is present?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
etx for Lactational mastitis
YES!
(*Interrupting breastfeeding can ➜ ⬇︎maternal milk production*)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
breastfeeding difficulties (can be improved with lactation consultant) ➜ [prolonged engorgement (diffuse BL breast TTP)] ➜ inadequate milk drainage ➜ clogged milk ducts ➜ Bacteria from skin enters stagnant milk ➜ Lactational mastitis
132
Lactational mastitis occurs ⬜ and presents with (⬜:3). What's treatment for it? (3)
[first 3 mo postpartum] ;
## Footnote
***(LIES) L****actational mastitis =*[**I**nduration / **E**rythema / **S**welling & Pain]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
([oral Dicloxacillin] or [oral Cephalexin]) + [frequent milk drainage]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*breastfeeding difficulties (can be improved with lactation consultant) ➜ prolonged engorgement ➜ inadequate milk drainage ➜ clogged milk ducts ➜ Bacteria from skin enters stagnant milk ➜ Lactational mastitis*
133
Breast engorgement presents as ⬜
Tx? (3)
diffuse BL breast TTP
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
BREAST PUMPING / NSAID / Cold Compress
134
[Condyloma acuminata genital warts] is caused by ⬜. How is delivery managed in patients who are pregnant?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What topical medication is typically used to treat CAGW?
[HPV 6 & 11] ; C-section does NOT prevent vertical transmission of HPV so Women with Condyloma Acuminata genital warts can proceed with vaginal delivery *(unless they're large/ obstructive)*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Podophyllum [contraindicated in pregnancy]
135
What are the guidelines for Breast Cancer Screening? (2)
136
Postpartum endometritis cp -4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx (2)
## Footnote
*RF: **CESAREAN** / GBS+ / prolonged ROM / protracted labor / operative vaginal delivery*
postpartum: [**uterine fundal tenderness**] , vaginal discharge, vaginal bleeding, fever
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Clindamycin + gentamicin
## Footnote
*polymicrobial infection*
137
What is Pregnancy induced pruritus?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx? (3)
common benign condition = focal abd pruritus **without rash**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
tx = oatmeal baths | UV | [Histamine R Blocker]
*Intrahepatic Cholestasis of Pregnancy = GENERALIZED PRURITUS INCLUDING PALMS/SOLES, NO RASH, A/W IUFD*
138
*pregnant patient*
Diagnosis?
Tx?
pemphigoid gestationis ; topical Triamcinolone
## Footnote
* [Pregnancy Induced Pruritus (abd pruritus **without rash**)] ➜ gzd urticarial papular RASH starting umbilicus and trunk ➜ eventually tense bullae*
* Pemphigoid gestationis is autoimmune*
139
Pt with severe mania is treated with ⬜. If this patient does not respond to monotherapy, what should you do?
[mood stabilizer (**Lithium**/**Valproate**)]
; add ANTIPSYCHOTIC
140
What regimen is considered in Bipolar pts who DON'T respond to [mood stabilizer monotherapy] ?
ADD [**A**ntipsychotic 2ND GEN]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
## Footnote
Treat Bipolar pts b4 they go **B(****AL****)D**!
**A** + **L**
[**A**ntipsychotic 2ND GEN] + [**L**ithium or Valproate]
141
S/S of Amphetamine and Cocaine withdrawal - 4
Coke/Meth withdrawal hits **HARD**
1. **H**ungry
2. **A**ngry irritable
3. **R**est a lot w/unpleasant dreams
4. **D**epressed (can mimic MDD vs Bipolar)
*can last several days*
142
For Bipolar **I** dx, you need at least [\_\_ mania sx +/- \_\_\_] that last for ___ duration.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the mania sx? (7)
[3 sx +/- major depression]; 1 week duration;
**BIPOLAR**
**B**uying excessively (⬆︎ in pleasurable activity)
**I**nflated self-esteem
**P**sychomotor agitation (pacing)
aw**O**ke - won't sleep
**L**ots of Language
**A**DD distractability
**R**acing thoughts
143
Diagnostic criteria for Bipolar II ? - 3
1. Major Depressive Episodes +
2. **hypO**manic episode +
3. **NOT** functionally impaired
144
Diagnostic criteria for Bipolar I ? - 3
1. Major Depressive Episodes +
2. **Manic** episode +
3. Functionally impairing
145
Tx for Acute Bipolar **Mania** -3
**ALV**
[**A**ntiPsychotics (1st or 2nd gen)] \> **L**ithium \> **V**alproate
NO ANTIDEPRESSANTS
146
Tx for Bipolar I and II - 6
Treat Bipolar pts b4 they go **BALLD**!
## Footnote
**-B**enzos adjunct prn
**-A**ntiPsychotics (Only use 2nd gen for Depressive phase)
-**L**amotrigine (depression phase only)
**-L**ithium or Valproate \*\*
**-D**epakOte \*\*
147
When is it ok for Bipolar pts to discontinue their Rx therapy?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Explain
NEVER!!
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
It is a **lifelong** illness requiring maintenance tx for years (and forever in severe bipolar pts)
148
Antipsychotics (\_\_\_ generation) can be used to treat the depressive phase of Bipolar disorder
Which 2 are the best to be used?
Treat Bipolar pts b4 they go **BALLD**!
2nd generation Antipsychotics for Bipolar *Depression* =
Quetiapine and Lurasidone
149
What is the clinical criteria for **Mania**-2
1. ≥3 [**BIPOLAR**] sx PLUS
2. Elevated or irritable mood \> 7 days
150
What is the clinical criteria for **hypOmania** -2
1. ≥3 [**BIPOLAR**] sx PLUS
2. Elevated or irritable mood 4\< x \<7 days
151
*Adolescent* Depression has different cp than Adult MDD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Name 4 main features
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
***ALL DEPRESSED ADOLESCENTS MUST BE SUICIDE SCREENED!***
1. irritability
2. somatic sx (tension HA)
3. socioeducational decline
4. anhedonia
***ALL DEPRESSED ADOLESCENTS MUST BE SUICIDE SCREENED!***
152
*Patient presents with Suicidal Ideation*
What 2 factors determine if this patient should receive inpatient tx or outpatient tx?
*+Ideation*
[+**PLAN** and +**INTENT**] = Inpatient Tx
[No Plan and No Intent] = Outpatient tx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
153
How should you manage a nonsuicidal teen who cuts themself ?
full psych eval (if suicidal ideation ➜ inpatient)
154
s/s of Anorexia Nervosa (3)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx for Anorexia Nervosa typically includes ⬜ and ⬜ but When should these patients be hospitalized?(4)
1. knuckle calluses *(indicates self-induced vomiting)*
2. [BMI \<15]
3. distorted body image
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx = [CBT + Nutritional Rehab] --(*BESO sx*)--\> HOSPITALIZATION
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*BESO*
**B**radycardia / [**E**lectrolyte ∆] / **S**yncope / [**O**rthostatic hypOtension]
155
In pregnancy, c/f appendicitis can be ruled out using ⬜ and presents atypically with ⬜
graded compression abd ultrasound ; [R abd pain **with NO peritoneal signs or McBurney TTP**]
156
Name the 6 body systems potentially associated with Erectile dysfunction?
157
Pt's Pap Smear reveals Atypical Squamous Cells of Undetermined Significance
Mngmt? - 3
1st: HPV typing, and if high risk (16 or 18) ---\>
2nd: Colposcopy and if abnml --\>
3rd: Cervical biopsy
158
There are several causes of abnormal uterine bleeding. give differentiating factors for each:
Pelvic organ Prolapse
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Cervical CA
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
endocervical polyp
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
endometritits
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
leiomyoma
eroded and bulging mass at introitus +/- incontinence, constipation, dyspareunia
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
exophytic cervical lesion
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
smooth vermiform appearance visibily protruding thru cervical os
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
uterine and cervical motion tenederness
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
enlaged **irregularly** shaped uterus
159
Urethral diverticula etx
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
s/s (3)
repeated infection and urethral trauma (vaginal delivery) ➜ distension of diverticulum with purulent fluid
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. ANT vaginal wall mass
2. postvoid dribbling
3. dysuria
* diagnosis confirmed with pelvic MRI or TVUS*
160
⬜ (caused by hyperactive cremasteric reflex) may present very similarly to Cryptorchidism. How are they differentiated? (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is this condition managed?
Retractile Testes;
1. RT (caused by hyperactive cremasteric reflex) **R**e**T**ains ability to manually manipulate testicle into the scrotal base
* (In cryptorchidism, testicles can not be manipulated back down)*
2. RT **R**e**T**ains scrotal rugae
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Monitor annually
161
What are the 2 *medical* managements for elective spontaneous abortion
1. [MisoPROstol (*PROstaglandin analogue*) 800 mcg vaginally]
2. MiFepristone (*antiprogestin*)
162
For pregnant women in [ACTIVE labor stage 1B], when is the patient considered to be in labor protraction?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you treat this? (2)
*Labor = (LA)PD*
NORMAL: **1B:** **A**CTIVE labor phase = Cervix is now 6 cm Dilated, [growing @ \>1 cm /2 hr] and effacing
PROTRACTED: 1B = [≤1 cm/2hr]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Oxytocin + Amniotomy
*(since most common cause of [ACTIVE labor stage 1B] protraction = contraction inadequacy)*
163
What's the time limit for pregnant women in [Latent labor Stage 1A] if they're nulliparous?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What about if they're multiparous?
*Labor = (LA)PD*
**1A: L**atent labor phase = Strong Contractions q3-5 min **(should be \<20 hrs for nulliparous pts and \<14 hrs for multiparous pts)**
**1B:** **A**CTIVE labor phase = Cervix is now 6 cm Dilated, [growing @ \>1 cm /2 hr] and effacing
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**2** : **P**ushing Time! since Cervix is now 10 cm FULLY DILATED (should be ≤3 hrs for nulliparous and 2 hrs for multiparous)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**3 : D**elivery of Baby! and then Deliver Placenta
164
What's the time limit for pregnant women in [Labor Stage 2] if they're nulliparous?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What about if they're multiparous?
[nulliparous \<3 hr]
[MULTIPAROUS \<2 hr]
(*add 1 hour if +epidural)*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* Labor = (LA)**P**D*
* 2 : PUSH time! since Cervix is now 10 cm FULLY DILATED (\<3 hrs for nulliparous and \<2 hrs for multiparous (add 1 hr if +epidural)))*
165
What are the stages of Labor?
*Labor = (LA)PD*
**1A: L**atent phase = Strong Contractions q3-5 min (should be \<20 hrs for nulliparous pts | \<14 hrs for multiparous)
**1B:** **A**CTIVE phase = Cervix 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**2** : **P**ushing Time! since Cervix is now [**10** cm FULLY DILATED] (nulliparous \<3 hrs | MULTIparous \<2 hrs)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**3 : D**elivery of Baby! ➜ then [Deliver Placenta **(\<30 min)**]
https://www.youtube.com/watch?annotation\_id=annotation\_563008&feature=iv&src\_vid=Xath6kOf0NE&v=ZDP\_ewMDxCo
166
What's the time limit for pregnant women to deliver the Placenta?
Deliver Placenta \< 30 min
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Labor = (LA)PD*
**1A: L**atent phase = Strong Contractions q3-5 min (should be ≤20 hrs for nulliparous pts and 14 hrs for multiparous pts)
**1B:** **A**CTIVE phase = Cervix is now 6 cm Dilated, [growing @ 1-2 cm/hr] and effacing
**2** : **P**USH time! since Cervix is now 10 cm FULLY DILATED (\<3 hrs for nulliparous and \<2 hrs for multiparous (*add 1 hr if +epidural))*)
**3 : D**elivery of Baby! and then Deliver Placenta **(\<30 min)**
167
What are the 4 clinical features for diagnosing [ACTIVE labor stage 1B]?
* Labor = L**A**PD*
1. [**Strong** Contractions **every 3-5 min**] = LATENT
+
2. [Cervix Dilation \> 6 cm]
3. [Cervix growing at 1-2 cm/hr]
4. [Cervix effaced]
* Fetal Heart Tracing is IRRELEVANT to diagnosing active labor*
168
What is the first manifestation of pubety for females?
**BREAST** --(2.5 years later)--\> Menarche by 15 yo
169
What is the workup for Primary Amenorhhea?-3
**girls with no menses by age 15** but who have normal growth and secondary sex characteristics
## Footnote
If no breast --\> FSH
(if FSH ⬇︎)--\> Pituitary MRI
(if FSH ⬆︎) --\> karyotyping
