Mix3 Flashcards
Preferred therapies for HBV
Entecavir and tenofovir
Due to low resistance and the ability to be used in decompensated cirrhosis
Trichinosis
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
INH induced peripheral neuropathy
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
The most common behavioral RF for TB
Substance abuse
INH hepatitis management
Immediate discontinuation
More frequent if: alcoholic, liver disease, >50 yo
If subclinical hepatic injury by INH
No signs/symptoms of hepatitis
Liver enzymes < 100
In10-20% of pts
continue INH with close F/U
Next step after positive PPD?
CXR
Symptom review
Positive PPD in immigrant < 5y
10 mm
Positive PPD in IDU
10 mm
Positive PPD in DM
10 mm
Positive PPD in prolonged CS therapy
10 mm
Positive PPD in ESRD
10 mm
Positive PPD in leukemia
10 mm
Positive TB in children <4y
10 mm
Positive PPD in malabsorption syndromes
10 mm
5mm PPD is positive if:
HIV Organ transplant ImSup Changes consistent with previous TB on CXR Recent contact of known TB
Canadian vs US cutoff value for positive PPD
10 vs 15 (US)
Latent TB treatment
INH+ Rif weekly x 3mo under direct observation (not for HIV)
INH 6-9mo
Rifampin 4mo
INH + rif 4mo
Urine culture and gram smear in gonorrhea vs chlamydia
Negative smear and culture in chlamydia
Gram stain shows 95% of gonorrhea infection
UTI with urease producing bacterium
Urinary alkalization (pH>8)
Proteus mirabilis, klebsiella pneumoniae.
High pH reduces solubility of phosphate, raising the risk of struvite stones (Mg ammonia P)
Recommendation to pt with vaginal trichononiasis
Oral Metro or tinidazole Refrain from alcohol Treatment of partner (testing of partner is unnecessary) Abstain from sexual activity until both partners treated
Tx of choice for bacterial vaginosis
Oral metro.
Alternative: clinda
Autonomic control of erectile function
Sympathetic: T11-T12
Parasympathetic: S2-S4
Acute AUB in adolescents. Reasons
The most common: immature HPO axis resulting unovulatory cycles
Also: hemostasis disorders, pregnancy
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
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
Dysmenorrhea+ heavy menstrual bleeding in a multiparus woman > 40
Adenomyosis
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
Mechanism of amenorrhea caused by marijuana
Functional hypothalamic
FSH and LH levels in pituitary dysfunction
Very low (<5)
Mechanism of anenorrhea caused by obesity
Anovulation
FSH and LH: nl
Time of testis removal in AIS
After completion of puberty
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
Tx of bartholin cyst
If asymptomatic: non
If symptomatic: I&D + word catheter
Breast abscess Tx
Needle aspiration under US guide
+ AB for surrounding mastitis
Trastuzumab (Herceptin)
For HER2 positive breast cancer
Cardiotoxic with other chemo agents
Requires echo before administration
The most common side effect of tamoxifen
Hot flashes
Other side effects: VTE, endometrial cancer
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
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.
Acoustic enhancement is indicative of
Fluid
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
Tx of CIN3
Cervical conization with cold knife or LEEP
Mechanism of HTN by OCP
Increased angiotensin synthesis by estrogen during hepatic first-pass metabolism
OCP and risk of cervical cancer
Increases the risk
OCP and wt gain
No wt gain
Contraindicated contraception method in breast cancer
All hormonal methods: pills, rings, patches, IUDs…
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
Ovarian endometrioma on U/S
Homogenous cystic ovarian mass
Laparoscopy in endometriosis is necessary if:
Failure of medical Tx
Infertility
Adnexal mass
Breast fat necrosis
Post-trauma/surgery e.g. seatbelt injury Firm Fixed Skin/nipple retraction Calcification on mamo, hyperechoic
Which ovarian cysts may rupture?
Simple ovarian cysts
Corpus luteum cysts
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
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
Inadequate colposcopy. Next step?
Endocervical curretage (Deferred innpregnancy due to the risk of miscarriage or PTL)
HSIL on pap testing during pregnancy
Colposcopy
Bx if high-grade features
Screening of chlamydia and gonorrhea in women <25
Annually (sexually active)
Fitz-Hugh-Curtis
Perihepatitis as a complication of PID
slightly elevated transaminases
RUQ pleuretic pain
Tx: hospitalization, IV AB
Gonococcal pharyngitis symptoms
Asymptomatic
Or
Pharyngeal edema and non-tender cervical LAP
If cervical swab for NAAT positive for chlamydia and negative for gonorrhea, Tx?
Azithromycin or doxy
With smear/culture, treat both chlamydia and gonorrhea
Maternal estrogen effect in newborn
Breast hypertrophy
Swollen labia
Physiologic vaginal leukorrhea
Uterine withdrawal bleeding
Severe features of preeclampsia
SBP 160 or higher or DBP 110 or higher Thrombocytopenia Increased creatinine Increased transaminases Pulmonary edema Visual/cerebral symptoms
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
Definition of preeclampsia
SBP 140 or higher OR DBP 90 or higher
And
Proteinuria and/or end-organ damage
GnRH, FSH, Estrogen in PCOS
GnRH: increased
FSH: Nl
Estrogen: increased
GnRH, FSH, estrogen during ovulation
All normal
FSH/LH ratio in ovarian failure
> 2
Due to slower clearance of FSH
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
The most common cause of rectovesical fistula
Obstetric injury
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
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)
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
Normal post-void residue
Women < 150 mL
Men < 50 mL
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
Removal of vaginal foreign body in children
Ca alginate swab or irrigation with warm fluids
If unsuccessful or large, examination under anesthesia
Abortion method in unstable pt
Suction curettage
Septic abortion Tx
Broad AB
Fluid
Suction curettage
The most common RF for abruptio placenta
HTN
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
Fetal anemia on NST
Sinusoidal
Chorioamnionitis on NST
Fetal tachycardia
Oxytocin adverse effects
Hyponatremia
Hypotension
Tachysystole (>5 uterine contractions in 10 minutes over a 30 minutes period)
Tetanic contractions
Klumpke palsy
Claw hand
Horner
Intact moro and biceps reflexes
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
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
Alcohol consumption and breastfeeding
Occasional use is not absolute contraindication
Do not breastfeed for at least 2-3 h after intake
Inborn errors of metabolism and breastfeeding
The only absolute contraindication: galactosemia
Phenylketonuria: may breastfeed intermittently, but close monitoring of phenylalanine and other metabolites
HCV and breastfeeding
Not a contraindication
Abstain if cracked/bleeding nipples
H1N1 and breastfeeding
Mother should be separated from the infant while febrile, but should be encouraged to pump
Protraction of active phase of labor definition and Tx
Cervical change that is slower than expected +/- inadequate contractions
Tx: oxytocin
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
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
Chorioamnionitis treatment
Broad AB + delivery (oxytocin if vaginal) + antipyretics
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
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
Unsafe activities during pregnancy
Contact sports
High fall risk
Scuba diving
Hot yoga
Excessive wt gain complications during pregnancy
GDM
Macrosomia
C/S
Inadequate wt gain complications during pregnancy
IUGR
PTB
Approach to BPP
0-4/10: urgent delivery
6/10: repeat in 24 h
8-10/10: Nl:continue weekly BPP
Antepartum fetal surveillance for gestational HTN
Starting at 32w GA
Weekly BPP
Gradual deceleration definition
30 seconds or more from onset to nadir
In early and late decelerations
Deceleration is abrupt “<30 sec” in variable deceleration
FHR patterns DDx
Early deceleration: fetal head compression
Late deceleration: uteroplacental insufficiency
Variable deceleration: cord compression, cord prolapse, oligohidramnios
The first intervention with recurrent variable decelerations
Maternal repositioning
If failed, aminoinfusion
Intermittent variable decelerations (<50% of contractions) are well tolerated by the fetuso
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
GDM targets
FPG: <95 (5.3)
1 hpp: <140 (7.8)
2 hpp: <120 (6.7)
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
GDM Tx
1st line: LSM (dietary modification)
2nd line: insulin, metformine, glyburide
Dietary modification for GDM
Evenly distributed carbohydrates, fat, protein intake over 3 meals and 2 to 4 snacks daily
Forceps in management of shoulder dystochia
Not indicated
Forceps is used for delivery of the head not shoulder
DDx of theca-lutein cysts
GTN
Multiple gestation
Infertility treatment
ALP in pregnancy
Normally elevated
Conditions associated with wernicke encephalopathy
Chronic alcoholism
Malnutrition (Anorexia nervosa)
Hyperemesis gravidarum
Ocular manifestations of Wernicke
Horizontal nystagmus
Bilateral abducent palsy
+ encephalopathy, postural and gait ataxia
Metabolic abnormalities of hyperemesis gravidarum
Hypochloremic metabolic alkallosis
Hypokalemia
Elevated serum transaminases
Tx of Wernicke in context of hyperemesis gravidarum
Antiemetics
Fluids
Thiamine
Glucose (after thiamine)
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
Neurosyphilis manifestations
Tabes dorsalis (sensory ataxia, lancinating pain) Argyll Robertson pupils
Na and oxytocin
Oxytocin can cause hyponatremia due to similarity to ADH
Mg therapeutic range for preeclampsia
5-8 mg/dL
Toxic: > 8
Resumption of menses in non-lactating women
In 10 weeks
Intrauterine fetal demise mode of delivery
20-23 wk: dilation and evacuation or vaginal delivery
24 wk or more: vaginal delivery
Prolonged second stage of delivery
> 3 h in nulliparous
>2 h in multiparus
The most common cause of prolongation of the second stage of delivery
Fetal malposition
The optimal fetal position in delivery
Occiput anterior
The main cause of low back pain in pregnancy
Increased lordosis
Also
Relaxation of the ligaments supporting sacroiliac and other joints
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
The next step after decreased fetal movement
NST
The next step after abnormal NST
BPP
Or
Contraction stress test
PPV and NPP of NST
Low PPV
High NNP
