GI/GU/OB/GYNE Flashcards
Pyoderma Gangrenosum is a sign of:
IBD: Classic skin manifestation of Inflammatory Bowel Dz - Almost never seen without IBD
Large ulcerative lesions that become gangrenous without Rx. Form just about anywhere - not caused by infection or other underlying dz. Its a Dx of exclusion though IBD needs to be high on the DDX list!
Rx is Steroids, can be refractory and difficult to treat but usually resolves, albeit with scarring.
Trichominiasis
Vaginal/ Urethral Infection caused by Flagellated Anaerobic Protozoa. Spread by sexual contact
Often asymptomatic in males or sxs of urethritis
‘Frothy’, greenish vaginal discharge with a ‘musty’ malodorous smell is characteristic in females
“Strawberry Cervix” Pink with red dots, rare
Metronidazole is the drug of choice
Kills it in a single 2gram oral dose or in 7days 500mg BID. OK in Pregnancy
Tinidazole kills it in 2 doses
Treat sexual partners
No Alcohol with either drug. Nausea, Vomiting, Flushing, Tachycardia + SOB
Most common ectopic site?
2nd Most common?
Most common is the fallopian tube
Second most common is the UTERINE INTERSTITIUM where the tube enters the uterus . The egg can implant directly into the myometrium here instead of the endometrium and that causes lots of trouble.
Pregant woman tests negative on her prenatal Rubella Titer. When to get vaccine?
Rubella - German Measels/3-day Measels
Is a mild viral infection with FEVER and RASH that starts on the face and spreads to the trunk and limbs.
It is contagious but self resolves nicely UNLESS the patient is PREGNANT. Early pregnancy infection especially causes birth defects: deafness, cataracts, heart defects, mental retardation, and liver and spleen.
Vaccination itself carries risk of infection to the fetus so pregnant mothers whose titers show no immunity should avoid exposure to the illness.
Proctalgia Fugax
Proctalgia (Rectal Pain) Fugax (comes + goes)
Rectal pain that comes and goes, often wakes pt from sleep. It is a more fleeting version of LEVATOR ANI SYNDROME in which pain lasts 20+ minutes
It is caused by SPASM of the Levator Ani Muscle, a pelvic floor broad muscle through which the anus passes.
Walking, Kegels, Massage, Warm Compress helps. Valium and Botox are last resorts
Ulcerative Colitis Buzz words:
Bloody Mucusy Diarrhea
Mimics Appendicitis in Kids
Mesenteric Adenitis
Lymphadenitis (usually viral) of the Mesentery. Can be distinguished from appendicitis by CT w/contrast so DO that before sending a kid to surgery for appendectomy!
Sr Mary Joseph Node means…
Pancreatic Cancer
Ovarian Cancer
to lesser extent:
colon, gastric, and/or uterine cancers
Bruising and swelling of umbilicus in the absence of trauma
Virchow’s Node
Gastric Cancer, maybe Pancreatic
Swelling above left clavicle
signs of END STAGE LIVER DZ from CIRRHOSIS
Shrunken liver
(at the end, there may have
been hepatomegaly early on)
Gynecomastia
d/t liver’s inability to
synthesize testosterone to
balance estrogen
Testicular Atrophy
d/t lack of testosterone
Lower Extremity Muscle Wasting
d/t liver’s inability to
synthesize enough albumin
Spider Angiomas
Caput Medusa
Elevated Alpha Feto Protein
Liver cancer in an adult
Testicular Cancer in a male +/- 16-25
Spinal closure anomaly in fetus - Spina Bifida
Cirrosis, describe
Cirrhosis is a diffuse histologic abnormality of the liver characterized by hepatocellular fibrosis (regenerative nodules) that ultimately leads to portal hypertension and hepatic insufficiency
The majority of cases stem from either alcoholic liver disease or chronic viral infection
Although many patients may be asymptomatic, others have symptoms such as anorexia, nausea, vomiting, diarrhea, fatigue, fever, yellowing of skin, itching, and reversal of the sleep-wake cycle
Liver biopsy is the gold standard for diagnosis
Cirrhosis is a precancerous condition, and all patients are at an increased risk of developing hepatocellular carcinoma
Development of complications such as ascites, hepatic encephalopathy, variceal bleeding, and hepatorenal syndrome is associated with a poor prognosis
Cirrhosis is generally considered an irreversible process; however, complete abstinence from alcohol and elimination of viral infections (eg,hepatitis B [HBV] and hepatitis C [HCV] viruses) can halt the disease progression and in some cases can even reverse the fibrosis
Liver transplantation should be considered in patients with advanced liver disease and/or the presence of hepatocellular carcinoma
IBD pathopneumonic skin presentation
Pyoderma Gangrenosum
Necrotic ulcers, usually on the legs, that progress from small bug-bite like papules. Some do occur elsewhere but it’s unusual.
Almost never seen w/o Crohns or Ulcerative Colitis
Chadwick’s Sign
Blue/Purple color of vagina and cervix in pregnancy
Hegar’s Sign
Softening of the cervix often seen in pregnancy
McDonald’s Sign
Uterocervical Flexibility seen at 7-8 weeks of pregnancy
Fundal Height @ Umbillicus, weeks?
20 weeks (20-22)
Sign of Polycystic Ovarian Syndrome
Hirsitism
Galacteria, sign of
Nipple Discharge
Hyper-Prolactinemia
Pituitary tumor, Cancer
Functional cysts are
Cycle-related, Fluid Filled and less than 1cm
They usually resolve in 2-3 cycles and are either mildly irritating or asymptomatic.
Non-Functional Cysts are
Not cycle related and fluid/solid or solid. These need to be biopsied by GYN
Chocolate: contains blood and tissue
Dermoid: contains tissue hair teeth skin..
The Gremlin…
Complex: solid and liquid
See endometriosis on sono?
No, need laprascopy
Chart sxs and discomfort locations. Endometriosis is cyclical, even if the tissue lies outside the uterus.
What does KOH wet mount let you see?
KOH destroys cells, bacteria and protozoa.
You get to see Hyphae + Buds of Yeast as well as scabies eggs and ectoderm.
Best Sono for obese women
Trans-Vaginal
Avoids having to penetrate thick adipose
Pt had a painful cyst, now its better. Think…
Rupture
Do another sono and look for
“Fluid in the Culdesac” fluid released from cyst will sink to basement of the pelvic cavity.
Cyst prone women risk:
Ovarian torsion - a GYN 911 so PLAN AHEAD and PREVENT CYSTS with BCP
Wait 2 cycles and re-sono for a solid cyst?
No, only for fluid filled. solids get referred + biopsied- could be cancerous
Definition of menopause
one full year without menses
No going back. Bleeding after this year is NOT break thru bleeding - it is a significant risk of endometrial cancer. Refer for sono AND schedule biopsy asap
Screening for post menopausal females with 3 consecutive negative paps
Annual Breast exams
Bimanual exam every 5 yrs
paps every 5
Post Menopausal female with PE, no underlying DVT AFib or other coagulopathy. Suspicion?
Ovarian Cancer
Get a Sono ASAP. This one Mets to the lungs.
Signs of Ovarian Cancer
often NONE
Vague bloating
Vague ‘not ok in there’
Exam likely normal…. If tender, it’s already advanced.
If it’s vague but pt or you feel something may possibly be amiss, get the SONO. Ovarian cancer is ONLY TREATABLE at VERY early stages.
Sono will ID rice like solids in the abdominal cavity
Biopsy confirms its rogue ovarian tissue
CT is only for staging
CA-125
Ovarian Cancer Marker
Not specific, used more for tracking relapse
Most insurances will not cover though Deb likes it for high risk females with BRCA1/2 or Primary relative with Ov Canc.
Both ovaries and fallopian tubes removed, uterus intact.
Bilateral Salpingo-Oophorectomy
Most Common Cause of dysfunctional uterine bleeding
Fibroids
Though solid, they don’t look like endometrial cancer on sono. EC is a thickening of the endometrial wall, not really a tumor.
They can get so big as to be felt thru the belly and they can press on the ureters/urethra and cause backup, even Hydronephrosis.
Rx is NSAIDS
-Fe++ for anemia
-Combo BCP if nonsmoker
-Progestagin BCP if smoker days 1-25
-Ultrasound Fibroid Destruction
-Radio Frequency Cauterization/Ablation of
Uterine arteries. Renders Uterus unable
to support fibroids and pregnancy
-You can just excise them (Myomectomy) and preserve fertility
Menopause shrinks them d/t lack of estrogen
Most common GYN cancer
Endometrial
Thickening on sono, no tumor
1st sign is POSTmenopausal BLEEDING
- do PAP + Pelvic (will be normal) - do Sono - Schedule Biopsy - ASAP!!!!!!!
If early, biopsy may be (-). Schedule a D+C to clear out the ENTIRE endometrium so pathology can go over every inch of it for aberrant cells. SOMETHING is causing that bleeding.
Mets to the peritoneal cavity and lymph nodes NOT to the lungs
Hormone levels after Menopause
Ovaries stop responding to gonadotropin, so it skyrockets, trying to elicit Estrogen and Prog.
Gonadotropin increases
FSH over 50 (normal is 32-35)
LH rises
Testosterone RISES - no longer suppressed
by Estrogen
Progesterone Plummets
Estrogen Plummets, only estrone on board
FSH is the one you test to confirm menopause.
Vitamin for hot flashes?
E - no more than 400 units or CV at risk
Debs fav non-HRT for Hot Flash/emotional Sxs?
Effexor XR
Venlafaxine, an SNRI
37.5mg ONLY. If its going to work, it will work at that dose. Don’t increase it
HRT
Premarin 50% equine estrone….
Prempro.. has progestegins with its estrogen
No wonder premarin was causing cancer!!!
FSH over 50
Menopause
When to massage prostate?
In chronic bacterial prostatitis (chronic urinary retention, boggy prostate) to obtain a prostatic secretion sample for culture
This will NOT be possible in Acute prostatiasis, wherein the prostate will be a hot hard little apple and your pt will present with Fever Chills Dysuria and PERINEAL PAIN.
Acute Prostatitis Protocol
Pt will present with Fever
Chills
Dysuria and
PERINEAL PAIN.
DRE may be refused - too painful
Get a UA, should be + WBC
PSA will be + in Ac Bact Prost
so this test won't Dx
Still, if (+) retest in 60 days
UTI bugs and GC are the most likely so, unless your pt is sexually inactive, cover both:
Cephrtriaone 250mg IM with a
script for either Cipro 500mg BID or Bactrim DS BID both orals for a FULL 28 days. This area is hard to penetrate with abx!
If you suspect sepsis (hypotension, fever, swelling) hospitalize your patient and run Cephtriaxone with Gentamycin IV until stabilized.
Primary Biliary Cirrhosis
aka
Primary Billiary Colangitis
Bile backs up the liver, damages the ducts.
Test is for antimitochondrial Antibodies, which seem to attack the biliary hepatocytes
Rx is
Syphilis Presentation
Test
Rx
Primary: genital (usually) chancre
w/in 3 weeks
Secondary: Nonpruritic, non-
tender truncal rash 2-10
weeks
\+/- malaise, low fever
neck stiffness
meninigitis possible
Latency: asymptomatic, may last
25 years. Babies may
be born in this stage if
infected in utero, tertiary
sxs being their first signs
Tertiary: 'Gummas' the awful
disfiguring lesions on
face, head, body, bone.
Dementia, Hearing loss
vision loss 3-10 yrs out
Valve vegetation+failure
Early Tests 1-2 weeks post chancre:
VDRL + RPR only 78% sensitive
@ primary stage
FTA-ABS to confirm. This is the definitive serology
Pen G for all stages
Doxy will do it too
Probenecid (for gout) will keep
penicillin from being excreted
in the tubules, maintaining high
serum concentrations
confirm ovulation with mid-luteal testing of…
Progesterone
No ovulation
No luteal body
No progesterone peak- adrenals do produce it but steady + low
Krukenberg tumor
A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast. Gastric adenocarcinoma, especially at the pylorus, is the most common source. Krukenberg tumors are often (over 80%) found in both ovaries, consistent with its metastatic nature.
Lutenizing Hormone rises when?
FSH stimulates the follicle to mature and produce estradiol
The follicle also grows LH receptors
The estridiol peak of the mature follicle stimulates the anterior pituitary to release LH which binds its receptors on the mature follicle and effects rupture/ovlation
It is this rupture/ovulation that signals the creation of the luteal body, which is sustained by LH from the anterior pituitary for two weeks unless a zygote implants, at which point some other hormone directs the anterior pituitary to continue producing LH longer, to sustain the endometrial lining until the placenta can take over progesterone production in 3 months.
Amniotic Fluid comes from…
Before the skin keratinizes (in the 1st trimester) amniotic fluid freely diffuses across the baby’s skin into the amniotic sac and it is essentially plasma.
After keratinization of the skin around 14 weeks, the fluid can’t cross the skin and so it is largely made up of fetal urine and lung secretions made by the fetal kidney and lung.
Mature Follicle about to release egg, AKA…
Graafian follicles can also called “mature vesicular follicles”, “tertiary vesicular follicles” or “ripe vesicular follicles”
Most deadly gynecologic cancer
Ovarian
Silent until untreatable
Endometrial cancer is the most common, but ovarian is nearly always deadly.
Retroverted vs Retroflexed uterus
Verted is just tilted posteriorly
Flexed is actually bent backwards
Endometrioma
Endometrial tissue lying outside the uterus, obviously the result of endometriosis
Chocolate cysts are endometriomas
Anasarca
Generalized Swelling
This can happen to a fetus and is visible on ultrasound as subcutaneous tissue greater than 5mm thick
It’s a component of Hydrops Fetalis, a complication of Homozygous Thassalemia
Teratoma aka
Dermoid Cyst - filled with hair/blood/tissue
Deb’s little gremlin
Usually found in women of child bearing age
Usually benign but 30% are malignant so all of them get removed
Malignancy risk increases if found in a girl as opposed to a woman of child bearing age.
Most common benign cervical abnormality
Nabothian Cyst - essentially a cervical pimple. Epithelial cells grow over a cervical crypt and the mucus secreted by the crypt build up into a hard sometimes white sometimes clear cyst
They are benign unless they get really big, often self resolve but can be frozen off or cauterized.
Nuchal translucency greater than 3 mm in 1st trimester suggests
A Trisomy Developmental Disorder: will become the webbed neck
Placenta takes over progesterone production from the corpus luteum at how many weeks
10-12
That corpus really hangs on a long time if there is implantation - really the entire first trimester!
placenta less than 2 cm from cervical os:
Placenta Previa -
Gestation can continue so long as mother isn’t bleeding and baby isn’t distressed, but is followed very closely.
Usually C-Section. Vaginal birth is possible if at least 2 cm from the os but bleeding could be heavy. If all goes wrong, hysterectomy during C-Section is the fallback to stop the bleed.
enlargement of both parotid glands. He is also found to have failure to thrive with anorexia, weight loss, weakness, and fatigue. Vitals are normalish, mild HTN, tachypnea
Classic Liver Failure
With or without jaundice
Bilateral Parotid Enlargement think…
Cirrhosis - not sure why difficult to get an answer online but it was a sxs.
Frothy Green Vaginal Discharge with itching
Trichonomiasis
Strawberry Cervix
See swimming flagellated protozoa on wet mount
Give Flagyl
Fishy vaginal discharge, burning on urination
Bacterial Vaginosis
Gardnerella Vaginosis (anaerobe)
+ Whiff test
Give Flagyl (Metronidazole) or Clindamycin
Sudden, painless profuse bleeding in 3rd Trimester
Placenta Previa
Bell Clapper Deformity
Testicle is not attached to the scrotum so it can swing like a bell and it can TWIST
High Risk for Testicular torsion
Flank Pain, Hematuria and palpable Renal
Mass, think:
Renal Cell Carinoma
dyspareunia
painful sexual intercourse
Seminoma or Non-Seminoma Testicular Cancers more aggressive?
Nons are more aggressive testicular cancers
Elevated Beta HCG in Seminoma- not so bad
Elevated Alpha Feto Protein in Non-Seminoma- very aggressive
Pancreatic enzyme rises first and stays elevated longer
Lipase lifts first and last longer
don’t even bother with amylase. An elevated serum amylase is not pathopneumonic for anything in particular, if its salivary amylase think parotid gland inflammation but in that case you can probably SEE the problem.
premenstrual pelvic pain, dysmenorrhea, and dyspareunia.
Endometriosis, pain also can move down into the legs.
Fibroids cause heavy bleeding but are typically painless, though very large fibroids can press on nerves and cause pelvic/lumbar issues
Painless Heavy + Prolonged Menstrual Bleeding, low back pain in an middle aged african american
think FIBROIDS white women do get them but
80% of african american women get fibroids of some sort in their life times.
leukocytosis (increased wbc) and low glucose in the synovial fluid of a swollen erythematous joint
Septic Arthritis
Gout would have Uric acid crystals (-) Birefringence/sharp XLs
Pseudo Gout XLs are Calcium (+) Birefringence and rhomboid XLS
Acute Rheumatic Fever arthritis is usually migratory, presenting in varying joints. Strep Antibody test is a good idea here instead of aspirating fluid. Also, this is more likely in kids who had a sore throat that wasn’t treated.
the MOST common cause of respiratory distress in the premature infant. The infant typically presents with tachypnea, cyanosis and expiratory grunting. A chest x-ray reveals hypoexpansion and air bronchograms.
Hyaline membrane disease
Chronic Lung Disease of Prematurity is a complication in about 20% of Hyaline Membrane Disease, so is less prevent then HMD
Sole creases in the term infant cover
The entire sole
In preterm, there will be a portion that is not creased, typically 1/3.
Skin Cancers least to most worrisome
Basal - pearly pink clear/ulcerated papule, with telangectasias
least worrisome
Squamous Cell Red, scaly often ulcerates
Arises from Actinic Keratosis
and that looks like a dark ctr, Keratinized rough
more metastatic
Melanoma - black
ABCDE of Melanoma
A-Assymetrical B-Border, Uneven C-Color, not uniform D-Diamerer larger than pencil eraser E-Evolving appearance, color shape size
Huchinson’s Teeth
Notched teeth of Congenital Syphilis
babies can go through Stage 1 and Early Stage 2 in utero. Latent stage 2 can last over a decade so congenital syphilis is often not picked up until latency ends. The teeth are a sign though.
Bone Scans start
60-65
Breast Mass Biopsy yields bloody fluid with no cancer cells, what to do?…
Take it out.
If fluid were clear and the mass decreased in size with each monthly scan, then you can leave it alone but get that bloody one out.
Infected Bartholin Duct Cyst?
Incise and Drain it
Reserve Abx for cases wherein surrounding tissue is inflamed
Pruritis d/t Biliary Malfunction?
Cholestyramine, A Bile Salt Sequestrant, relieves the itch of cirrhosis
thin grey discharge, unpleasant odor and Clue Cells (stippled epithelia cells) on wet mount of vaginal exudate
Bacterial Vaginosis
Rx is Metronidazole
In pregnancy Leg Edema, Hyper-reflexia, HTN and proteinuria all indicate
Pre-Ecclampsia
Risk of Seizure- seizure is bad as it denies fetus oxygen so PREVENT IT with MgSO4 IV and get this lady to the ER
HELLP Syndrome
Complication of Pre-Eclampsia
H- Hemolysis
EL - Elevated Liver enzymes
LP- Low Platelets
Pt is usually already hypertensive and in the 3rd trimester. Somehow, the coagulation cascade gets activated and fibrin strands in the small vessels mainly of the LIVER start hacking RBCs to bits, creating the HEMOLYSIS. Platelets stick to the fibrin and suddenly we’re low on PLATELETS and of course this creates a blockage in the vessels of the liver and thus tissue downstream becomes ischemic and LIVER ENZYMES RISE as hepatocytes die.
Some say a D-Dimer in the setting of pre-eclampsia is diagnostic.
Others say don’t all it until you have CBC (for platelets), CMP for electrolytes, Coagulation Panel, Lactate Dehydrogenase (leaks out of damaged RBCs and indicates hemolysis) and LFTs
Some say Lactate Dehydrogenase over 600 in the setting of pre-ecclampsia is diagnostic.
Bottom line is baby needs to be delivered. MgSO4 and Fresh Frozen Plasma for the DIC and pRBC for the anemia might work but only for a bit. Get that baby out.
1% maternal mortality, HELLP occurs in +/- 15% of severe pre-eclamptic cases. Fetal prognosis depends on gestational age at the time HELLP develops.
BRCA 1 vs BRCA2
BRCA stands for BR (breast) CA (cancer). They are two genes that, if mutated, increase the risk of developing breast cancer in over 40’s. Their mutation is a familial marker for this risk heralding increased screening and testing for its owner.
BRCA1 mutations are slightly more specific to breast cancer and ovarian cancer
BRCA2 mutations are slightly more specific for breast cancer and prostate cancer.
Thus would a male whose mother and maternal grandmother had breast cancer be wise to get tested and followed for both breast cancer and prostate cancer.
ASCUS Pap Smear Result
Atypical Squamous Cells of Undetermined Significance
Mildly Concerning
For young women, repeat the test in 12 months to see if the atypical cells are still there, if so, then colposcopy
In older women go straight to
Colposcopy: Under strong light and microscopic lenses the cervix is treated with acetic acid highlight suspicious lesions not otherwise visible to the naked eye. Then the cervical canal is curettaged (scraped) and the scrapings “the clot” are removed to be examined by cytology. Biopsies are “bitten out” of the cervix at any suspicious looking spots to be examined for cancer cells by cytology.
CIN
Cervical
IntraEpithelial = CERVICAL CANCER
Neoplasia
CIN I - May be cleared by your immune system, retest 6 mo
CIN II - Confined to the epithelium, get it off with biopsy
CIN III - Cervical Cancer In Situ, LEEP it out with electrical c
cauterization (recall that sausage teaching demo -
YIKE!!!
CIN II + CINIII usually caused by HPV 16 + 18
tocolytic agents…
stop labor
MgSO4
Terbutaline
Nifedapine
menorrhagia
Pds longer than 8 days
diaphragm stays in place…
6 hrs post coitus
Luteal Pseudoneuroendocrine disorder
PMS
Give Fluoxitine 2mg only in days 21-28
or…
put this woman on progesterone from 12-26
Fundus height at 12 weeks
Symphysis Pubis
5 Main Contraindications to HRT
1) Vaginal Bleeding of unknown etiology (could be cancer)
2) Liver Disease (Estrog provokes cholestasis, transdermal
might be an option though as it bypasses liver)
3) Hypercoagulable state (DVT extra likely)
4) Endometrial Cancer still has uterus
5) Breast Cancer
Estrogen and the liver
Interestingly, even pregnancy can incite cholestasis and when BCP came on the market, Jaundice was an unexpected side effect seen in some early users.
Hepatic Osteodystropy - Bone loss d/t liver Dz
Osteoporosis is a leading effect of Hepatic Disease. Unconjugated Bilirubin (which would rise if the liver were diseased and unable to conjugate it for excretion) DEPRESSES OSTEOBLAST activity. Less bone laid down.
Liver damage also causes hypogonadism by interfering with gonadotropic hormone release from the Hypothalamus and FSH/LH from the ant pit. This decreases estrogen production in the ovary and testosterone in the testes. Estrogen in women and Testosterone in men suppress RANK in the bones. Without them, both sexes are subject to increased osteoclast creation and activity: More bone reabsorbed.
With unconjugated bilirubin suppressing osteoblast activity and hypogonadal decreases in estrogen/testosterone allowing increased osteoclast activity, the pt with liver disease is in for a double whammy in the bone loss department.
The liver breaks down estradiol to estrone and then to estriol. If the liver doesn’t work and estradiol is introduced into the portal system either naturally, from functioning ovaries, or unnaturally by ingestion of oral synthetic estradiol, and the liver is diseased, it is unable to break the estradiol down to its less active metabolites and the estradiol continues circulating and endometrial proliferation continues unchecked - this can be the cause of endometrial cancer.
Time in which b-HCG doubles in pregnancy, and keeps doubling !
Every 48 hrs
