Module 3 Flashcards
Cholecystitis is
an acute inflammation of the gallbladder wall, which is usually the result of an impacted calculus within the cystic duct, causing inflammation proximal to the obstruction.
Cholecystitis without gallstones, acalculous cholecystitis, is
a very serious disease with high morbidity and mortality rates. It usually occurs in patients who are already critically ill because of trauma, burns, surgery, or sepsis and who have had no oral intake or have been supplemented with hyperalimentation. Patients present with severe pain and tenderness in the epigastrium or right upper quadrant (RUQ) of the abdomen accompanied by nausea, vomiting, fever, and leukocytosis.
percentage of pt with cholelithiasis that don’t require tx
50%
The risk of requiring a cholecystectomy increases with
age as a consequence of complications secondary to the lithiasis.
most common gallstone
cholesterol, account for 75%
six Fs
fat, female, forty (age 40 years), flatulent, fertile, and fat-intolerant
After age 50, the gender distribution of cholelithiasis is
equal.
Pregnancy also predisposes women to cholelithiasis, presumably because of
the increased abdominal pressure and increased cholesterol levels during the third trimester.
The gallbladder is of primary importance in the development of gallstones because it
provides an arena for bile stasis and allows time for the slow crystallization of cholesterol
Biliary cholesterol is increased by ingestion of
estrogen and oral contraceptives, multiparity, and inflammatory terminal ileal disease, which decreases the bile acid pool.
black pigment gallstones
Black-pigmented stones are formed within the gallbladder and are commonly associated with hemolytic diseases, cirrhosis, long-term parenteral hyperalimentation. Black-pigmented stones are more fragile and seem to crush more easily than cholesterol stones.
brown pigmented gallstones
Brown pigmented stones are composed of alternating layers of calcium bilirubinate and calcium fatty acids. Chronic bacterial infections are believed to be partly responsible for the formation of brown pigmented stones because the enzymes the bacteria produce predispose the patient to this type of stone formation. Brown stones are typically found within the intrahepatic ducts and are rarely found within the gallbladder.
acute cholecystitis subjective
indigestion
nausea
vomiting (esp after meal high in fat)
acute, colicky pain RUQ or epigastrium
referred pain in middle of back, right shoulder
acute cholecystitis objective
involuntary guarding of RUQ
positive murphys (painful splinting with deep inspiration or palpation of it causes transient resp arrest)
low grade fever
mild jaundice
hypoactive bowel sounds
suspect gallbladder perforation if
rebound tenderness
shaking chills
increased fever
acute cholecystitis diagnostic testing
mild WBC elevation (15,000)
elevated liver enzymes
alk phos high
bili high
gold standard diagnosis of acute cholecystitis
abdominal US
cholelithiasis tx
avoid foods high in fat
if poor surgical risk- dissolution of stones by po ingestion of ursodiol - typically recur.
acute cholecystitis initial tx
rehydration via IV, abx, analgesics, gi rest
if vomiting persists- NG tube
2nd/3rd gen cephalosporin
tx of choice acute cholecystitis
early surgical intervention
The most common complications of acute cholecystitis are
empyema and perforation.
Acute pancreatitis is defined as a
cute inflammation of the pancreas and the surrounding tissues resulting from the release of pancreatic enzymes. These enzymes cause a chemical burn in the retroperitoneal spaces, which leads to systemic toxicity.
80% of all hospital admissions for acute pancreatitis are the result of
biliary tract disease (passing of a gallstone) or alcoholism
Mild acute pancreatitis normally
improves within 48 to 72 hours and does not involve other organ systems. There is minimal interstitial edema, with only occasional microscopic acinar cell necrosis.
Severe, acute pancreatitis is often
associated with complications and multisystem organ failure. It can be a life-threatening condition, and the patient may require monitoring in the intensive care unit (ICU).
acute pancreatitis subjective
abrupt onset of deep epigastric pain, persists hours- days
radiate straight thru back
aggravated by coughing, lying supine, improves when seated lying forward
pt appears ill
acute pancreatitis objective
epigastric severe tenderness, guarding, no rigidity
decreased bowel sounds
elevated HR
low inspiratory effort
high BP
The diagnosis of pancreatitis is made on the basis of 3 things
the presence of abdominal pain, elevated serum amylase and/or lipase levels, and imaging findings consistent with acute pancreatitis
the gold standard for acute pancreatitis diagnosis is an
elevated serum amylase level (up to three times the normal value);
other lab abnormal acute pancreatitis
WBC btw 12-15
high Hct
decreased Ca
high CRP (esp with pancreatic necrosis)
elevated liver enzymes
ranson’s criteria for assessing severity of pancreatitis
At admission or at time of diagnosis:
1.Age older than 55 years
2.White blood cell count greater than 16,000/mcL
3.Blood glucose greater than 200 mg/dL
4.Base deficit greater than 4 mEq/L
5.Serum lactate dehydrogenase (LDH) greater than 350 IU/L
6.Aspartate transamine (AST) greater than 250 U/L
severe if 3 met
tx acute pancreatitis
maintain fluid status
pain control with demerol
npo with ng tube if vomiting
intro clear liquids when pain free
tx severe pancreatitis
typically in ICU
fast 2-4 weeks, TPN
6-8 L/day IV
correct glucose only if over 250
Chronic pancreatitis is defined as
a slowly progressive inflammatory process that results in irreversible fibrosis of the pancreas with destruction and atrophy of the exocrine and endocrine glandular tissue.
Chronic relapsing pancreatitis is defined as
acute attacks that occur in the setting of chronic pancreatitis and are usually precipitated by a specific event such as binge drinking or the passage of a stone.
causes of chronic pancreatitis
alcoholism
autoimmune dx
genetic mutation
high triglycerides
severe malnutrition
tropical chronic pancreatitis
The tropical, or nutritional, form of chronic pancreatitis is almost exclusively found in tropical countries. In these countries, the disease begins in early childhood and results in death in early adulthood because of complications. This type of pancreatitis also involves large intraductal calculi and a high susceptibility to pancreatic cancer. Malnutrition has a significant role, but it is not the sole cause because many areas with comparable malnutrition do not have equal prevalence of the disease. Key features of tropical pancreatitis include abdominal pain, maldigestion leading to steatorrhea, and diabetes.
Pancreatic insufficiency can be confirmed by the
bentiromide (nitroblue tetrazolium–para-aminobenzoic acid [NBT-PABA]) test
Cirrhosis is result of
hepatocellular injury involving the entire liver, resulting in fibrosis, nodular regeneration, and distorted hepatic architecture. Cirrhosis is considered permanent and irreversible.
In the Western Hemisphere, cirrhosis is a
leading cause of death in individuals older than age 40.
There are three consequences of alcohol abuse:
fatty liver, alcoholic hepatitis, and alcoholic cirrhosis.
fatty liver
fatty liver is a reversible condition where large vacuoles of triglycerides accumulate in the hepatocytes. The accumulation of fat in the liver causes an inflammatory reaction in the liver called steatohepatitis and is a precursor of cirrhosis.
most common type of cirrhosis in USA
alcoholic
Primary biliary cirrhosis (PBC) is a
disease that almost exclusively affects women aged 40 to 60. It is an autoimmune disease that causes destruction of the intrahepatic bile ducts, resulting in cholestasis. Autoimmune disorders such as scleroderma, Raynaud’s syndrome, autoimmune thyroid disease, celiac disease, and Sjögren’s syndrome have been linked to the development of PBC.
Primary sclerosing cholangitis (PSC) is
most common in men aged 20 to 40 and is associated with inflammatory bowel disease (75%), as well as with the histocompatibility antigens HLA-B8, HLA-DR3, and HLA-DR4
other causes of cirrhosis
wilson’s dx
hemochromatosis
Micronodular (Laennec’s) cirrhosis is
characterized by regenerative nodules that are 1 cm in diameter or less, no bigger than normal liver lobules.
normally caused by alcoholic cirrhosis
Macronodular cirrhosis is characterized by .
larger nodules (diameters of 5 cm), which may be multinodular with varying size nodules and may contain central veins. These nodules are surrounded by broad fibrous bands of varying thickness, which correspond to the postnecrotic type of cirrhosis associated with chronic hepatitis
cirrhosis subjective
weakness anorexia weight loss fatigue
menstrual abnormalities
upper GI bleeding
cirrhosis objective
enlarged firm liver edge palpable below right costal margin
spider nevi, muscle wasting
caput medusae- varcisoe veins radiating from umbilical area
cirrhosis labs
macrocytic anemia
increased PT
elevated liver enzymes
GGT elevation
cirrhosis tx- etoh induced
abstinence from etoh
dietary supplementation
irreversible chronic liver dx tx of choice
liver transplant
PBC tx
symptomatic- pruritus tx with cholestyramine
hereditary hemochromatosis tx
weekly phlebotomies until depletion of iron stores
low iron diet
wilson’s dx tx
limit dietary intake of copper (legumes, animal organs, shellfish)
Infertility is defined as
the failure to achieve pregnancy despite regular unprotected sexual intercourse for at least 12 months
woman considered infertile if 35 years and older and
has not achieved pregnancy in 6 months
Primary infertility refers to
a woman who is unable to bear a child, either due to failure to become pregnant or to carry a pregnancy to a live birth.
Secondary infertility applies to
a woman who has delivered at least one child, but subsequently fails to become pregnant or to carry a pregnancy to a live birth.
age at which couples are most fertile
25 yrs
male infertility main cause
Testicular defects in spermatogenesis account for up to 80% of male infertility cases,
female cause of infertility
ovulatory disorders
endometriosis
pelvic adhesions
tubal obstruction
hyperprolactinemia
In general, infertility is caused by one of four conditions:
the inability to produce healthy gametes (sperm or eggs);
the failure of healthy gametes to come into close physical proximity, thus preventing fertilization;
the inability of the fertilized egg to attach to the uterine lining successfully; and the inability of a woman to carry a pregnancy to term postimplantation.
most common genetic defects associated with infertility
turner’s syndrome
Klinefelter’s syndrome
male infertility risk factors
testicular infection
genetic defects
radiation exposure
tobacco smoking
hyperthermia
semen analysis in men
most important diagnostic study in men
should be done before invasive testing of female partner
analyze: sperm concentration, motility and morphology
normal sperm count
between 40-300 million/mL of semen
below 15 indicates infertility
normal motility sperm
40%, at least 25% demonstrate progressive forward mobility
normal morphology sperm
size/shape of sperm
4-14% must have normal to be considered adequate
female infertility testing
progesterone levels at different times to confirm ovulation
LH levels
examination of vaginal discharge
FSH level day 3 of cycle
prolactin level
progesterone challange
The progesterone challenge test, in which medroxyprogesterone acetate 10 mg is given daily for 5 days and the induction of uterine bleeding is monitored in the week after treatment, confirms adequate production of estradiol (estrogen)
infertility lifestyle changes
decrease caffeine to less than 250mg/day
decrease etoh
increase intercourse to 2-3x//wk
achieve ideal body weight
if ovulatory defect during fertility testing
give clomid (SERM)
50mg daily on day 5-9 of cycle
only use on less than six cycles
most effective med to use without intrauterine insemination
injectable gonadotropin
pregnancy with ivf with donor sperm and embryo transfer with donor eggs
higher success rate than regular ivf
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) occur during
the luteal phase of the menstrual cycle
most common symptoms of mild PMS
headache, bloating, breast tenderness, and irritability. Both somatic symptoms (e.g., depression, angry outbursts) and physical symptoms (e.g., breast pain, bloating) are present in patients with PMS
diagnosis of PMS
If symptoms related to the luteal phase lead to economic or social dysfunction (e.g., work absenteeism, decreased work productivity, relationship problems) and have occurred for at least three consecutive cycles, a diagnosis of PMS can be made
PMDD diagnosis criteria
women must have experienced symptoms during most of the menstrual cycles that occurred in the preceding year, and the symptoms must have caused significant distress and interfered with usual activities and quality of life. core symptoms: mood swings, sudden sadness, anger, irritability, depressed mood, tension, and anxiety
risk factor PMS
family history
low education
smoking
PMS patho
deficiency in tryptophan derived neurotransmitter serotonin
pms objective
increased age and parity
most commonly accepted method to diagnose PMS uses
a diary during at least two menstrual cycles (three is preferred). If the intensity of symptoms increases at least 30% in the 6 days before onset of menses (compared with days 5 to 10 of the cycle), and if the symptoms occur in two consecutive months, the patient is likely experiencing PMS.
lifestyle changes PMS
dietary change, regular exercise, relaxation
calcium, magnesium supplements
PMS meds
SSRIs- first line. can be effective if taken only during luteal phase if needed
2nd line- OCP
if failed above, trial ovulatory suppression therapy
spironolactone for fluid retention, nsaids
menopause definition
final menstrual period (FMP) and is reached when there have been 12 consecutive months of amenorrhea
average age of menopause
51.5 yrs
most between 48-55
early menopause transition
can precede menopause by several years
changes in menstrual cycle
late menopause transition
onset of vasomotor symptoms
greater than 60 day interval b/tw periods
average life lived after menopause
30 yrs
menopausal transition can take up to
10 yrs before FMP
all women who cease menses prior to age 40
should be assessed for primary ovarian insufficiency
factors that can lower age at menopause
smoking
nulliparity
menstrual regularity and shorter cycle length
family hx of early menopause
DM1
late menopause occurs
after age 55
FSH levels about this suggest menopause
40
menopause symptoms- thin women
vaginal dryness
menopause symptoms- obese women
AUB, endometrial hyperplasia
most common menopause symptom
hot flashes
subjective menopause
hot flash, insomnia, depression, vaginal dryness, joint pain, low libido, cognitive changes
objective menopause
weight gain, decrease in height, dry skin, wrinkling, peach fuzz facial hair
menopause labs
hcg
lh
fsh
if on OCP (combo) and concern for menopause
draw labs between day 5-7 of placebo pill week
lifestyle modifications for menopause
fans, layers, avoid triggers (stress, caffeine, etoh), weight loss, CBT, soy, black cohash
vasomotor symptoms menopause meds
SSRI or SNRI
HRT
Clonidine
Duavee
vulvovaginal atrophy tx
intravaginal estrogen
HT risks
increased risk of heart disease, stroke, venous thromboembolism, breast cancer
HT contra
hormone dependent cancer
undiagnosed vaginal bleeding
pregnancy
migraine
liver disease
hx of stroke
Primary amenorrhea is
the failure to menstruate by age 15 in girls with secondary sex characteristics (breast development) or within 3 years of thelarche (breast budding)
secondary amenorrhea is
the absence of menstruation for 3 or more consecutive months in a woman who has achieved menarche.
most common cause amenorrhea
pregnancy
secondary amenorrhea more common in
college students
athletes
amenorrhea labs
hcg
dhea
total testosterone
prolactin
fsh
primary amenorrhea tx
estrogen therapy- developed secondary sex characteristics, prevent osteoporosis
secondary amenorrhea tx
progesterone or oral estrogen
dysmenorrhea definition
painful menses
can be with or without pelvic pathology
primary dysmenorrhea
usually begins 1-2 yrs after menses starts
secondary dysmenorrhea
tender to be older, caused by something else- endometriosis, pid, fibroids
most common gyn complaint of women, main cause of missed work, school
dysmenorrhea
primary dysmenorrhea pain
starts within 24 hours of menses, may last 48-72 hours
secondary dysmenorrhea pain
onset of pain a week before menses, continue after cessation of flow for a few days
if complaint of dysmenorrhea with painful intercourse
eval for endometriosis
dysmenorrhea labs
hcg
cbc
ua
sed rate
stool
refer for di with gyn
dysmenorrhea pain tx
nsaids or asa every 4 hours starting 1-2 days before menses
avoid caffeine
exercise
Endometriosis is
a painful, chronic disease characterized by the presence and proliferation of abnormally located endometrial tissue, which responds to hormonal changes in the woman’s body. Abnormally located endometrial tissue has been found outside the uterus, usually in the abdomen, on the ovaries, fallopian tubes, and the ligaments that support the uterus, as well as in the area between the vagina and rectum, on the outer surface of the uterus, and in the lining of the pelvic cavity. Other sites for these endometrial growths may include the bladder, bowel, vagina, cervix, vulva, and in abdominal surgical scars. Rarely, endometrial tissue may be located in the lung, arm, thigh, brain, or other non–reproductive tract locations
which race increase endometriosis risk
Japanese women- twice as likely
endometriosis subjective
abdominal and pelvic pain esp with menses, dyspareunia, fatigue
endometriosis objective
tenderness in posterior fornix
lateral deviation of cervix
diagnosis of endometriosis
direct visualization and patho testing of endo implants via laparoscopy
endometriosis tx
nsaids
ocp
laparoscopy to ablate endometrial implants
uterine fibroids (leiomyomas)
small, often asymptomatic tumor of uterus from smooth muscle cells
AUB most common symptom
uterine fibroids tx
ocp may shrink
surgery for removal
most common cancer in women worldwide
cervical cancer
highest incidence of cervical cancer in USA
hispanic women
grading of cervical cancer
CIN1- mild (1/3 cervical epithelium) dysplasia
CIN2- moderate (2/3 cervical epithelium) dysplasia
CIN3- severe (full epithelium thickness) dysplasia to carcinoma in situ
cervical cancer screening recommendations
start pap at age 21
age 21-29 q 3 yrs, no hpv screening
30-65- q5 yrs
increased cervical cancer risk
history of early intercourse (age 14-15)
having children at early age
history of multiple sexual partners
gardasil recommendations
girls- age 11-26
boys- age 11-21
cervical cancer subjective
vaginal infection, no recent gyn care, brownish discharge
if pap shows AGC
this favors neoplasm
cervical cancer tx
hysterectomy
most common gyn cancer
endometrial cancer
endometrial cancer
avg age: 60
African American highest risk
risk: exposure to unopposed estrogen, early menarche, high fat diet, nulliparity
presents with abnormal bleeding
cure rate high if found early
endometrial cancer diagnosis
refer for endometrial biopsy if AUB
ovarian cancer types
surface epithelial tumor (most life threatening)
ovarian germ cell tumor
ovarian stromal tumor
ovarian ca risk factors
family history
nulliparity
early menarche
late menopause
ovarian ca subjective
pelvic/abdominal pain, bloating, inability to eat or feeling full quickly, urinary urgency
vulvodynia
vulvar pain (burning, stinging) syndrome lasting at least 3 months
. ED is classified as mild if the patient
fails to achieve a satisfactory erection in 2 out of 10 attempts.
severe ED classified as
If all attempts at satisfactory erection fail,
A loss of libido may indicate
androgen deficiency arising from either pituitary or testicular disease
meds that cause ED
methyldopa
clonidine
reserpine
beta blockers
spironolactone
CCB
Normal sexual function in men has five phases:
libido, erection, ejaculation, orgasm, and detumescence.
vascular disease ED risk factors
heart disease
smoking
DM
aging
dyslipidemia
HTN
Priapism,
persistent painful erection, is usually idiopathic but can be associated with sickle cell anemia, chronic granulocytic leukemia, or spinal cord injury
if erections occur outside of attempting intercourse (sleep, early morning)
cause is likely not organic
testes length in hypogonadism
less than 4 cm
ED labs
CMP (fasting blood sugar)
FLP
TSH
testosterone
CBC
PSA
testing for ED
NPTR and color doppler sonography of penis, measure erections during REM
ED treatment of choice
if no bph or prostate cancer and testosterone deficient, testosterone therapy is tx of choice
vasoactive therapy ED
viagra
caverject
cialis
best candidates for penile revascularization surgery
men younger than 45 yrs whose impotence is caused by severe pelvic trauma
epididymo-orchitis
inflammation of testicle that results in unilateral painful testicle
epididymitis risk factors
hx of unprotected intercourse
new sex partner
hx of uti with dysuria or urethral discharge
The causes of epididymitis in males younger than 35 years are usually
sexually transmitted diseases such as Chlamydia or Neisseria gonorrhoeae infections
Causes of epididymitis in men 35 years and older include
coliform bacteria (such as Escherichia coli, which is most common) and sometimes Pseudomonas aeruginosa or Staphylococcus aureus
epididymitis subjective
scrotal pain that often radiates along spermatic cord or to flank, often experience pain at tip of penis as well
epididymitis objective
scrotal swelling, testis not distinguishable from epididymis
epididymitis labs reveal
UA- pyuria, leukocytosis
possible gonorrhea or chlamydia
epididymitis tx
scrotal elevation, ice packs
abx- one time dose of ceftriaxone IM with doxycycline x1- days if sti– must treat partner!
or cipro x2-3 wks
Testicular torsion is
the twisting or rotation of the testes, resulting in acute ischemia. It is a urological emergency.
two-thirds of cases testicular torsion occur between the ages of
10 and 20 years
testicular torsion risk factors
contraction of cremaster muscle- winter, runners, trauma
necrosis can occur in testicular torsion in
6-12 hrs
testicular torsion objective
absence of cremasteric reflex
“blue dot” sign
testicular torsion tx
ED- manual reduction or sx
hydrocele
painless
illuminated fluid in testes
hydrocele tx
none needed unless complications
varicocele almost always appears on
the left or bilaterally,
testicular cancer
most common malignancy in age 15-35 yrs men
one of the most curable solid cancers
testicular cancer risk factor
cryptorchidism
