Mix3 Flashcards
1
Q
Preferred therapies for HBV
A
Entecavir and tenofovir
Due to low resistance and the ability to be used in decompensated cirrhosis
2
Q
Trichinosis
A
Intestinal stage(within 1wk): asymptomatic or abdominal pain, N/V, diarrhea
Muscle stage (within 3wk): fever, subungual hemorrhage, muscle pain/tenderness/swelling/weakness, periorbital edema, chemosis , conjunctival/retinal hemorrhage
Lab: eosinophilia >20%, increased CPK, increased WBC
Triad: periorbital edema, myositis, eosinophilia
3
Q
INH induced peripheral neuropathy
A
Due to excretion of B6 with INH from kidneys
Higher risk if: DM, pregnant, malnourished, uremia, alcoholism, HIV, epilepsy
Numbness and tingling in a stocking-glove distribution
PEx: deficit in vibration and proprioception
Over time: affects touch, pain, temprature sensation
4
Q
The most common behavioral RF for TB
A
Substance abuse
5
Q
INH hepatitis management
A
Immediate discontinuation
More frequent if: alcoholic, liver disease, >50 yo
6
Q
If subclinical hepatic injury by INH
A
No signs/symptoms of hepatitis
Liver enzymes < 100
In10-20% of pts
continue INH with close F/U
7
Q
Next step after positive PPD?
A
CXR
Symptom review
8
Q
Positive PPD in immigrant < 5y
A
10 mm
9
Q
Positive PPD in IDU
A
10 mm
10
Q
Positive PPD in DM
A
10 mm
11
Q
Positive PPD in prolonged CS therapy
A
10 mm
12
Q
Positive PPD in ESRD
A
10 mm
13
Q
Positive PPD in leukemia
A
10 mm
14
Q
Positive TB in children <4y
A
10 mm
15
Q
Positive PPD in malabsorption syndromes
A
10 mm
16
Q
5mm PPD is positive if:
A
HIV Organ transplant ImSup Changes consistent with previous TB on CXR Recent contact of known TB
17
Q
Canadian vs US cutoff value for positive PPD
A
10 vs 15 (US)
18
Q
Latent TB treatment
A
INH+ Rif weekly x 3mo under direct observation (not for HIV)
INH 6-9mo
Rifampin 4mo
INH + rif 4mo
19
Q
Urine culture and gram smear in gonorrhea vs chlamydia
A
Negative smear and culture in chlamydia
Gram stain shows 95% of gonorrhea infection
20
Q
UTI with urease producing bacterium
A
Urinary alkalization (pH>8)
Proteus mirabilis, klebsiella pneumoniae.
High pH reduces solubility of phosphate, raising the risk of struvite stones (Mg ammonia P)
21
Q
Recommendation to pt with vaginal trichononiasis
A
Oral Metro or tinidazole Refrain from alcohol Treatment of partner (testing of partner is unnecessary) Abstain from sexual activity until both partners treated
22
Q
Tx of choice for bacterial vaginosis
A
Oral metro.
Alternative: clinda
23
Q
Autonomic control of erectile function
A
Sympathetic: T11-T12
Parasympathetic: S2-S4
24
Q
Acute AUB in adolescents. Reasons
A
The most common: immature HPO axis resulting unovulatory cycles
Also: hemostasis disorders, pregnancy
25
Tx of acute AUB
If pt is hemodynamically stable:
IV/PO estrogen
High-dose OCP
High-dose progesterone pills (if estrogen contraindicated)
Tranexamic acid (if est and prog contraindicated)
If no response to medical management after 24-36 h: emergency dilation and curettage
Packed cell: if unstable
26
Prepubertal vaginal bleeding etiology
Estrogen withdrawal:
In neonatal period (first 2 wk)
<1 wk duration
Normal PEx (sometimes temporary breast buds, external genitalia engorgement)
Trauma:
Fall, sexual abuse
Malignancy:
e.g. rhabdomyosarcoma
<3 y
Protruding vaginal nodules
27
Dysmenorrhea+ heavy menstrual bleeding in a multiparus woman > 40
Adenomyosis
28
Small ovarian cyst in post menopausal women
Check CA-125
If no suspicion for malignancy (small size, no solid component, no septation) and negative CA-125: observe
29
Mechanism of amenorrhea caused by marijuana
Functional hypothalamic
30
FSH and LH levels in pituitary dysfunction
Very low (<5)
31
Mechanism of anenorrhea caused by obesity
Anovulation
| FSH and LH: nl
32
Time of testis removal in AIS
After completion of puberty
33
The reason for irregular menses at the beginning of menarch
Inadequate FSH and LH, therefore lack of ovulation and lack of progesterone
Menses due to estrogen breakthrough bleeding
34
Tx of bartholin cyst
If asymptomatic: non
If symptomatic: I&D + word catheter
35
Breast abscess Tx
Needle aspiration under US guide
| + AB for surrounding mastitis
36
Trastuzumab (Herceptin)
For HER2 positive breast cancer
Cardiotoxic with other chemo agents
Requires echo before administration
37
The most common side effect of tamoxifen
Hot flashes
Other side effects: VTE, endometrial cancer
38
RFs of breast cancer
```
Alcohol consumption
HRT
Nulliparity
Increased age at first live birth
Genetic mutation
White race
Increasing age
Early menarche, late menopause
Obesity
```
39
Breast engorgement
```
Milk production > release
No fever
No erythema
Usually bilateral
If lactation cessation desired:
Wearing a comfortable, supportive bra.
Avoidance of nipple stimulation and manipulation.
Ice pack
NSAIDs
Breast binding not recommended.
Use of medication not supported.
```
40
Acoustic enhancement is indicative of
Fluid
41
A mass suspicious for fibroadenoma in a young woman (adolescent)
Re-examine over one menstrual cycle. If decreased in size/tenderness after the mense, reassurance.
If older than adolescent or if persistent mass, U/S. If results consistent with fibroadenoma no further W/U for adolescents.
Excisional Bx considered if adult or if very large mass
42
Tx of CIN3
Cervical conization with cold knife or LEEP
43
Mechanism of HTN by OCP
Increased angiotensin synthesis by estrogen during hepatic first-pass metabolism
44
OCP and risk of cervical cancer
Increases the risk
45
OCP and wt gain
No wt gain
46
Contraindicated contraception method in breast cancer
All hormonal methods: pills, rings, patches, IUDs...
47
Adverse effects if DES
Daughters:
Clear cell carcinoma of the vagina/cervix
Cervical/uterine malformations
Difficulty conceiving and maintaining pregnancy
```
Sons:
Cryptorchidism
Microphalus
Hypospadiasis
Testicular hypoplasia
```
48
Ovarian endometrioma on U/S
Homogenous cystic ovarian mass
49
Laparoscopy in endometriosis is necessary if:
Failure of medical Tx
Infertility
Adnexal mass
50
Breast fat necrosis
```
Post-trauma/surgery
e.g. seatbelt injury
Firm
Fixed
Skin/nipple retraction
Calcification on mamo, hyperechoic
```
51
Which ovarian cysts may rupture?
Simple ovarian cysts
| Corpus luteum cysts
52
Typical manifestations of ovarian torsion
```
Lower abdominal pain (often sudden)
Sharp, colicky, intermittent
Sometimes precipitating factors like exercise
N/V
Low-grade fever
Unilateral abdominal/pelvic tenderness
Voluntary guarding
+/-palpable mass
Peritoneal signs (rebound, involuntary guarding) if necrosis
```
53
Manifestations of ruptured ovarian cyst
Sudden onset of unilateral lower abdominal pain
Usually following sex or strenuous activity
Symptoms of hemoperitoneum (rigidity, rebound)
Lower quadrant tenderness
Involuntary gaurding
Pleuritic chest pain
Shoulder pain
+/- Decreased hematocrit
Free fluid
54
Inadequate colposcopy. Next step?
```
Endocervical curretage
(Deferred innpregnancy due to the risk of miscarriage or PTL)
```
55
HSIL on pap testing during pregnancy
Colposcopy
| Bx if high-grade features
56
Screening of chlamydia and gonorrhea in women <25
Annually (sexually active)
57
Fitz-Hugh-Curtis
Perihepatitis as a complication of PID
slightly elevated transaminases
RUQ pleuretic pain
Tx: hospitalization, IV AB
58
Gonococcal pharyngitis symptoms
Asymptomatic
Or
Pharyngeal edema and non-tender cervical LAP
59
If cervical swab for NAAT positive for chlamydia and negative for gonorrhea, Tx?
Azithromycin or doxy
| With smear/culture, treat both chlamydia and gonorrhea
60
Maternal estrogen effect in newborn
Breast hypertrophy
Swollen labia
Physiologic vaginal leukorrhea
Uterine withdrawal bleeding
61
Severe features of preeclampsia
```
SBP 160 or higher or DBP 110 or higher
Thrombocytopenia
Increased creatinine
Increased transaminases
Pulmonary edema
Visual/cerebral symptoms
```
62
If urine dipstick positive for protein during pregnancy, next step?
24h urine protein (gold std)
Or
ACR
```
Preeclampsia in setting of increased BP confirmed
If:
24h protein > 300 mg
Or
Protein/creatinine ratio 0.3 or higher
```
63
Definition of preeclampsia
SBP 140 or higher OR DBP 90 or higher
And
Proteinuria and/or end-organ damage
64
GnRH, FSH, Estrogen in PCOS
GnRH: increased
FSH: Nl
Estrogen: increased
65
GnRH, FSH, estrogen during ovulation
All normal
66
FSH/LH ratio in ovarian failure
> 2
| Due to slower clearance of FSH
67
Adverse effects if SERMs
Hot flashes: both raloxifene and tamoxifen
VTE: both
Endometrial hyperplasia/carcinoma: tamoxifen
All medicines with estrogen agonist activity increase risk of DVT
68
The most common cause of rectovesical fistula
Obstetric injury
69
If strong clinical suspicion but negative RPR/VDRL
Treat empirically with penicillin G
| Repeat non-treponemals in 2-4 weeks for baseline titer. Repeat in 6-12 mo
70
Urethral hypermobility test
Place pt in lithotomy position
Insert a Q-tip in urethral orifice
Angle of 30 degrees or higher from horizontal plane on increased intraabdominal pressure signifies urethral hyper-mobility (stress incontinence)
71
Tx of stress incontinence
LSM
Kegel
If due to urethral hypermobility: urethral sling surgery
If due to internal urethral sphincter deficiency: injection of bulking agents
72
Normal post-void residue
Women < 150 mL
| Men < 50 mL
73
Menopausal GU syndrome
Urgency
Frequency
UTI
stress/urge incontinence
Inv: U/A, U/C
Tx: 1st step: moisturizer, lubricant
If mod-sev: low-dose vaginal estrogen
74
Removal of vaginal foreign body in children
Ca alginate swab or irrigation with warm fluids
If unsuccessful or large, examination under anesthesia
75
Abortion method in unstable pt
Suction curettage
76
Septic abortion Tx
Broad AB
Fluid
Suction curettage
77
The most common RF for abruptio placenta
HTN
78
The reason for hypotension after epidural
Blockage of sympathetic nerve fibers, therefore pooling of blood in veins
Prevention: fluid before anesthesia
Tx: left lateral decubitus, IV fluid, vasopressor
79
Fetal anemia on NST
Sinusoidal
80
Chorioamnionitis on NST
Fetal tachycardia
81
Oxytocin adverse effects
Hyponatremia
Hypotension
Tachysystole (>5 uterine contractions in 10 minutes over a 30 minutes period)
Tetanic contractions
82
Klumpke palsy
Claw hand
Horner
Intact moro and biceps reflexes
83
Erb-Duchenne palsy
```
C5 (deltoid, infraspinatus)
C6 (biceps)
+/- C7 (wrist/finger extensors)
Waiter’s tip
Intact grasp
Decreased moro and biceps reflexes
```
Tx: gentle massage, PT
80% spontaneous recovery by 3 mo
If no improvement by 3-6 mo, surgery considered
84
Breastfeeding contraindications
Active untreated TB (up to 2 wks after starting therapy)
Maternal HIV infection (in developed countries)
Herpetic breast lesions
Varicella (<5days before to 2 days after delivery)
Chemo
Ongoing RT
Active abuse of alcohol/drugs
Infant galactosemia
85
Alcohol consumption and breastfeeding
Occasional use is not absolute contraindication
| Do not breastfeed for at least 2-3 h after intake
86
Inborn errors of metabolism and breastfeeding
The only absolute contraindication: galactosemia
Phenylketonuria: may breastfeed intermittently, but close monitoring of phenylalanine and other metabolites
87
HCV and breastfeeding
Not a contraindication
| Abstain if cracked/bleeding nipples
88
H1N1 and breastfeeding
Mother should be separated from the infant while febrile, but should be encouraged to pump
89
Protraction of active phase of labor definition and Tx
Cervical change that is slower than expected +/- inadequate contractions
Tx: oxytocin
90
Arrest of active phase of labordefinition and Tx
No cervical change for:
4 hour or more with adequate contraction
Or
No cervical change for 6 hours or more with inadequate contractions
Tx: cesarian
91
Definition of adequate uterine contractions
Contractions generating 200 MVUs or more in a 10 minute interval are considered adequate
MVU= No. of contractions in 10 min x contraction strength
92
Chorioamnionitis treatment
Broad AB + delivery (oxytocin if vaginal) + antipyretics
93
Exercise in pregnancy
20-30 min, moderate intensity (able to engage in normal conversation), on most/all days
Avoidance of dehydration
Avoidance of prolonged periods of lying supine
Stop if symptoms such as vaginal bleeding, leakage of fluid, contractions or chest pain develop
94
Contraindications of exercise during pregnancy
```
Absolute:
Amniotic fluid leak
Cervical incompetence
Multiple gestation
Placenta abruption or previa
Premature labour
Preeclampsia/gestational hypertension
Severe heart or lung disease
```
95
Unsafe activities during pregnancy
Contact sports
High fall risk
Scuba diving
Hot yoga
96
Excessive wt gain complications during pregnancy
GDM
Macrosomia
C/S
97
Inadequate wt gain complications during pregnancy
IUGR
| PTB
98
Approach to BPP
0-4/10: urgent delivery
6/10: repeat in 24 h
8-10/10: Nl:continue weekly BPP
99
Antepartum fetal surveillance for gestational HTN
Starting at 32w GA
| Weekly BPP
100
Gradual deceleration definition
30 seconds or more from onset to nadir
| In early and late decelerations
Deceleration is abrupt “<30 sec” in variable deceleration
101
FHR patterns DDx
Early deceleration: fetal head compression
Late deceleration: uteroplacental insufficiency
Variable deceleration: cord compression, cord prolapse, oligohidramnios
102
The first intervention with recurrent variable decelerations
Maternal repositioning
If failed, aminoinfusion
Intermittent variable decelerations (<50% of contractions) are well tolerated by the fetuso
103
The exception to universal GBS screening
Hx of GBS bacteriuria/UTI at any point during the current pregnancy
Or
Invasive early-onset GBS disease in a prior child
Intrapartum AB prophylaxis
104
GDM targets
FPG: <95 (5.3)
1 hpp: <140 (7.8)
2 hpp: <120 (6.7)
105
GDM screen
If high risk: at 1st prenatal visit and at 24-28w if negative
If normal risk: at 24-28
High risk pts: previous GDM, obese, previous macrosomic neonate
106
GDM Tx
1st line: LSM (dietary modification)
| 2nd line: insulin, metformine, glyburide
107
Dietary modification for GDM
Evenly distributed carbohydrates, fat, protein intake over 3 meals and 2 to 4 snacks daily
108
Forceps in management of shoulder dystochia
Not indicated
| Forceps is used for delivery of the head not shoulder
109
DDx of theca-lutein cysts
GTN
Multiple gestation
Infertility treatment
110
ALP in pregnancy
Normally elevated
111
Conditions associated with wernicke encephalopathy
Chronic alcoholism
Malnutrition (Anorexia nervosa)
Hyperemesis gravidarum
112
Ocular manifestations of Wernicke
Horizontal nystagmus
Bilateral abducent palsy
+ encephalopathy, postural and gait ataxia
113
Metabolic abnormalities of hyperemesis gravidarum
Hypochloremic metabolic alkallosis
Hypokalemia
Elevated serum transaminases
114
Tx of Wernicke in context of hyperemesis gravidarum
Antiemetics
Fluids
Thiamine
Glucose (after thiamine)
115
Vitamin B12 deficiency symptoms
Dementia
Subacute combined degeneration due to demyelination of:
Spinocerebellar tract (gait ataxia)
Lateral corticospinal tract (spastic paresis)
Dorsal column (loss of position/vibration sense)
Indolent clinical course
Macrocytic anemia
116
Neurosyphilis manifestations
```
Tabes dorsalis (sensory ataxia, lancinating pain)
Argyll Robertson pupils
```
117
Na and oxytocin
Oxytocin can cause hyponatremia due to similarity to ADH
118
Mg therapeutic range for preeclampsia
5-8 mg/dL
| Toxic: > 8
119
Resumption of menses in non-lactating women
In 10 weeks
120
Intrauterine fetal demise mode of delivery
20-23 wk: dilation and evacuation or vaginal delivery
24 wk or more: vaginal delivery
121
Prolonged second stage of delivery
>3 h in nulliparous
| >2 h in multiparus
122
The most common cause of prolongation of the second stage of delivery
Fetal malposition
123
The optimal fetal position in delivery
Occiput anterior
124
The main cause of low back pain in pregnancy
Increased lordosis
Also
Relaxation of the ligaments supporting sacroiliac and other joints
125
Mx of clavicular fx in newborn
Reassurance
Gentle handling
Analgesics
Place affected arm in a long-sleeve and pin sleeve to chest with elbow flexed at 90 degrees
126
The next step after decreased fetal movement
NST
127
The next step after abnormal NST
BPP
Or
Contraction stress test
128
PPV and NPP of NST
Low PPV
| High NNP
