Random Flashcards
define adenomyosis
endometrial glands trapped in myometrium
adenomyosis
presentation
physical exam
female ^40 yo
dysmenorrhea w
heavy menstrual bleeding
progression to chronic pelvic pain
boggy tender uniformly enlarged uterus
define heavy menstrual bleeding
soaking a pad or
changing tampon q2h
synonymns for boggy
soft
flaccid
adenomyosis
dx
tx
pelvic us and/or mri initially
bx amd histopath definitively
ocp, levonorgestrel iud
hysterectomy if these unsuccessful
levonorgestrel moa
thickens cervical mucus against sperm
inhib ovulation
inhib fsh and lh
alters endometrium against implantation
bladder pain syndrom aka
interstitial cystitis
bladder pain syndrome
pain over anterior vaginal wall
discomfort w bladder filling
dysuria
urinary freq
is post coital bleeding from cervical cancer assoc w pain?
no
painless
fibroids aka
uterine leiomyomata
tf
depression often presents to pcp with physical complaints such ad headaches, aches and pains, insomnia, fatigue
t
explain weight loss in cancer
v po intake
systemic inflammation ~ hypercatabolism
CACS
cancer-related anorexia cachexia syndrome
treat CACS
cancer-related anorexia cachexia syndrome
progesterone analogue
(megestrol acetate)
if longer life expectancy
can consider corticosteroid if shorter expectancy (more SEs)
- stim apetite, weight gain, possibly assoc w some antiinflammation
tf
dronabinol tx CACS cancer-related anorexia cachexia
f
some clinical effectiveness for HIV cachexia
not cancer cachexia – use megestrol acetate or corticosteroid if short expectancy
tf
nutritional education amd supplementation iv or po is effective for tx of cacs cancer-associated anorexia cachexia
f
not very effective.
megestrol acetate long expect (progesterone analogue)
or corticosteroids short expectancy (more SE’s)
child refusal to speak in certain situations for more than a month, but normal interactions in other situations
selective mutism
a social anxiety disorder
at what age does stranger anxiety typically begin and end
6mos - 3yrs
tf
selective mutism does not need to be treated
f
treat early to avoid education and social impairment
sympx w blood loss of
100ml 20%
150ml 30%
200ml 40%
- orthostasis hr100+ rr20+ agitation cool
- hypotension hr120+ rr30+ confusion cool
- severe hypotension hr140+ rr40+ obtunded cold
hyper igM aka
cd40 ligamd deficiency
cd40 liganf deficiency aka
hyper igM
normal b cell count
high igM
low igGAE
dx
hyper igM
aka cd40 ligand deficiency
normal b cell count
low igMGAE
dx
common variable immunodeficiency
common variable immunodeficiency
b cell count
and ig quantities
normal b cell count
low igMGAE
job synndrome aka
hyper igE
hyper igE aka
job syndrome
normal b cell count
high igE but other igs normal
dx
hyper igE
job syndrome
nl b cell count
nl igMGE
low igA
dx
selective igA deficiency
low b cell count
low igMGAE
dx
x-linked agammaglobulinemia
aka
bruton agammaglobulinemia
how to calc b cell count from total lymphos and t lymphos
subtract that shit
bruton agammaglobulinemia
aka
x linked agammaglobulinemia
bruton x linked agammaglobulinemia
pathogenesis
sympx
tx
tk mut in b cells
failure of pre b lympho dev in bone marrow
so low circulating mature b lymphos
low igMGAE
maternal passive imm wanes 3-6 mos
recurrent severe / chronic sinopulmonary otitis media pna gi salmonella campylo infections
pe older kids underdev tonsils lns lymphoid tissue… but not normally very prominent anyway
ivig and ppx abx
presentation of cvid vs xla
common variable immunodef same but less severe sx after adolescence w dec serum ig’s but norm b cell count
x linked (bruton) agammaglobulinemia severe recurrent sinopulm or gi infections in late infancy, low/absent ig’s AND b cells
22q11.2 deletion syndrome aka
digeorge syndrome
digeorge syndrome aka
22q11.1 deletion syndrome
classic triad digeorge
congenital heart defect
t cell deficiency
hypocalcemia
xla vs 22q11.2 keys
xlinkedbrutonagammaglob recur sinopilmonary gi inf late infancy no B cells no igs
digeorge recurrent bact fung inf no T cells
scid
presentation
labs
scid recurrant bact fung viral inf in infant, from t cell developmental impairment not stimulating b cells so low T AND B
transient hypogammoglobulinemia of infancy
pres
pathogenesis
milder recurrent sinopulm and gi inf in infancy dec igg variable igm normal igA and b cells normalizes typically 9-15mos old
sudden onset hypotention tachycardia and back pain hours post cardiac cath suggests
retroperitoneal hematoma due to bleeding from arterial access site
most common complications of cardiac cath
local at catheter insertion site:
bleeding, hematoma local or with retroperitoneal extension, arterial dissection, thrombosis, pseudoaneurysm, av fistula
most hemorrhage or hematoma formation occurs within __ hours of catheterization
within 12 hours
quad screen
trisomy 18
trisomy 21
neural tube or ab wall defect
18 - everything down
21 - BhCG and Inibin A up, MSAFP and Estriol down
NTD AWD - MSAFP up
quad screen is done when
2nd trimester 15-20 weeks
next step after failure of nsaids / ocps for endometriosis
laparoscopy
typical ultrasound finding of dermoid cyst / cystic teratoma
hyperechoic nodules and calcifications
adnexal mass due to ovarian stimulation by high B-hCG levels (e.g. molar pregnancy) that resolves after levels decline. Do not present outside pregnancy. On ultrasound, multiseptated bilateral cystic masses, No calcifications or hyperechoic nodules
Theca Lutein cyst
young female with known dermoid cyst presents down the line with unilateral lower quadrant abdominal pain – tenderness to deep palpation and voluntary guarding… suspect __ not ___
Torsion - higher risk from mass
not rupture – that would have peritoneal signs, INvoluntary guarding… and much more common with Simple Ovarian and Corpus Luteum cysts… dermoid cysts Don’t typically rupture
Pelvic Pain in a patient with a Known Ovarian Mass should be suspected for ____ until proven otherwise
pelvic pain with known ovarian mass should be suspected for OVARIAN TORSION until proven otherwise
woman trying to conceive and attentive to… stuff… otherwise healthy notices 2 days clear vaginal discharge like uncooked egg white – it is…
peri-ovulatory cervical mucus - increases close to ovulation for sperm facilitation, thickens afterward… some women notice as “vaginal discharge”
what does a passed cervical mucus plug look like and what was its function in pregnancy
brown red or yellowish thick mucus
typically shed before or during labor
barrier to ascending infection during pregnancy
icu pt on pressors with symmetric duskiness and coolness of all fingertips - explain, and what else at risk
ischemia from pressor (such as norepi) - induced vasospasm in already hypotensive pt
at risk for mesenteric ischemia and renal ischemia as well
what is SVC syndrome
Compression of SVC by e.g. lung cancer, thrombi, or fibrosing mediastinitis causing Upper Extremity Edema
fetal Position vs Presentation
Position - relationship of presenting part to maternal pelvis
Presentation - lowest/presenting part of fetus
arrest of 2nd stage of labor due to transverse lie of fetal head in pelvis… call this malposition or malpresentation?
MalPosition - relationship of presenting part to maternal pelvis
(malpresentation refers to lowest/presenting part of fetus, e.g. vertex, face, breech)
vertex, breech, face
refer to position or presentation?
presentation (lowest/presenting part of fetus)
position is relationship of lowest part to pelvis
optimal fetal position
what is risk of alternate positions with same presentation
occiput anterior (occipital bone forward toward pubis, face back toward coccyx – facilitates cardinal movements of labor
cephalopelvic disproportion and arrest of labor a risk with occiput transversus or occiuput posterior
occiput anterior, posterior, transversus
refer to position or presentation?
Position - relationship of presenting part to maternal pelvis
(presentation is lowest/presenting part of fetus)
most common cause of arrest of 1st stage of labor and 2nd stage of labor
1st stage arrest - insufficient contractions
2nd stage arrest – cephalopelvic disproportion
ominous possible explanation for decreased fetal movement despite normal fetal heart tone
benign explanation
central nervous system hypoxia
fetal sleep cycle
contraindications to contraction stress test
contraindications to labor
placenta previa, prior myomectomy, etc
normal Amnionic Fluid Volume on biophysical prophile
single pocket ^2x1cm
AFI ^5
amnionic fluid index
normal fetal Movements, Tone, and Breathing Movements on biophysical profile
3 or more general body movements
^1 flexion/extension of fetal limbs or spine
^1 breathing episode for ^30sec
a score of 0-4/10 on BPP biophysical profile suggests
you should
Fetal Hypoxia due to Placental Dysfunction
aka Placental Insufficiency
Deliver promptly to avoid fetal demise
when to stop pap testing
age 65 or hysterectomy AND no hx CIN2 or higher or immunocompromise or maybe smoking 3 consecutive negative Paps OR 2 consecutive negative co-tests
TF
in patient with vulvovaginal atrophy and urinary incontinence the cause of both is estrogen deficiency
T
urinary incontinence because urethra has estrogen receptors and atrophies as well, losing tone
mechanism of urinary incontinence in vulvovaginal atrophy
estrogen deficiency
-urethral mucosa atrophies and loses tone
TF
postmenopausal woman with vulvogavinal atrophy and urinary incontinence… incontinence likely due to urethral hypermobility
F
estrogen deficiency
-urethral mucosa atrophies and loses tone without estrogen input
inheritance pattern of HOCM
mutated proteins
Autosomal Dominant
myocardial sarcomere contraction protein mutations
EKG changes in HOCM
LVH - tall R wave aVL, deep S wave V3
Repol changes in anterolateral leads I aVL V456
diagnostic test for pancreatic cancer according to jaundiced or not
jaundiced - Ultrasound - likely pancreatic head mass
not jaundiced - CT - body or tail tumor
when to start fertility investigation in couple trying to conceive
1 y mom v35yo
6 mo mom ^35yo
kussmaul sign
lack of decrease (or increase) in JVP during inspiration
ekg in PE
sinus tachy
or nonspecific ST changes or T wave changes, new RBBB, S1Q3T3 pattern (acute cor pulmonale)
ekg changes with fluconazole and moxifloxacin
QT prolongation
risk of Torsades
treat Torsades in hemodynamically stable vs unstable pt
unstable - immediate Defibrillation
stable - Magnesium IV
treat paroxysmal supraventricular tachycardia
Adenosine
use of Atropine for ekg abnorm
Atropine for Symptomatic Sinus Brady or AV Block
ekg changes with hyperkalemia
peaked T waves
P-R elongation
eventual widening of QRS
eventualll Sine Wave
woman with epigastric pain and right shoulder pain for 4 hours after eating a cheeseburger = classic….
biliary colic
“hollow organ contraction and outlet obstruction” in setting of epigastric pain and shoulder pain for 4 hours in a women after eating a cheeseburger refers to
biliary colic
TF
pain from fat necrosis from acute pancreatitis can resolve spontaneously after a few hours
F
not usually spontaneously resolving in a few hours…. think more biliary colic
biliary colic caused by contraction against obstructed cystic duct usually lasts less than __ hours
biliary colic lasts less than 6 hour usually
a PE might seem like a MI of what ventricle at first presentation
may seem like Right Ventricle MI
(PE causes backup into RV and RV dysfunction)… but more dyspnea and syncope with PE and more arrhythmia and bradycardia with RVMI
postmenopauseal bleeding, breast tenderness, and 10cm adnexal mass and thickened endometrial stripe on ultrasound – next step CT or endometrial biopsy?
endometrial biopsy
estrogen secreting Granulosa Cell Tumor high risk for causing Endometrial Carcinoma… must rule out
CT to stage after that
cardioselective beta blockers (B1)
A-M
TF
metroprolol is a cardioselective beta blocker (B1)
T
A-M are cardioselective
FEV1
FEV1/FVC
FVC
obstructive vs restrictive lung disease (including obesity)
Obstructive
FEV1 v70%
FEV1/FVC v70%
FVC normal to decreased
Restrictive
FEV1 v80%
–Fev1/FVC ^70%
FVC v80%
TF
55yo with new asthma symptoms and asthma PFTs on metoprolol probably caused by metoprolol rather than adult-onset asthma
F
metoprolol is A-M cardioselective (B1)
rarely causes asthma symptoms
Adult Onset Asthma is a thing not that uncommon even though asthma typically diagnosed younger
worsening cough and wheezing in old guy preceded by refractory chronic rhinosinusitis with nasal polyposis could be due to what drug
aspirin
aspirin-exacerbated respiratory disease
2 key PFT findings diagnostic of asthma regardless of age
^12% increase FEV1 reversible obstruction with beta agonist
with normal diffusion capacity for carbon monoxide
elderly pt with “abdominal pain” limited to severe pain with brushing skin in a local area with negative TTP etc in setting of recent cancer treatment “chemo” likely attributable to ___
treat with ___ to accomplish ___
shingles, herpes zoster
even without rash, as pain may precede rash. often arises with severe physical stress (cancer treatment) or immunocompromise
treat with acyclovir valacyclovir or famciclovir to shorten duration and decrease risk of post-herpetic neuralgia
adult respiratory distress symptoms presents very similarly to ___ but lacking the history and risk factors that would make you think ___
similar to CHF
without hx and risk factors
renal effects of CHF
RAAS activation in response to decreased cardiac output, to increase contractility, peripheral vasoconstriction, and extracellular fluid volume
specifically
— ATII constricts EFFERENT glomerular arteriol more than afferent arteriol, and stims SODIUM resorption in CORTICAL COLLECTING TUBULE and adrenal ALDOSTERONE secretion
pellagra is due to ___ and characterized by…
seen in populations…
pellagra is due to NIACIN deficiency (niacin from diet or synthesized endogenously from Tryptophan)
characterized by 3 Ds
- Dermatitis - sun-exposed, rough, scaly, hyperpigmented
- Diarrhea
- Dementia - neuronal degeneration… memory, affective symptoms, psychosis
CORN diets (tryptophan unabsorbable) MALNUTRITION (alcoholism, illness) CARCINOID syndrome (depletion of tryptophan) HARTNUP disease (congenital tryptophan malabsorption) ISONIAZID therapy (eg TB) can interfere with tryptophan metabolism
___ causes episodic not chronic abdominal pain, vomiting, diarrhea, often with neurologic agitation, paresthesias, confusion, may be triggered by isoniazid, with chronic transaminase elevation, more common in women than men
AIP
acute intermittent porphyria
_____ is characterized by erythematous scaly plaques affecting scalp face chest intertriginous areas, can be associated with dementia/Parkinsons, does not typically affect the hands does not typically cause GI symptoms
seborrheic dermatitis
skin findings with UC
erythema nodosum and pyoderma gangrenosum
presentation classic for aortic dissection – diagnostic steps?
CT angio preferred if hemodynamically stable and normal creatinine
TEE (transesophageal echocardiogram) if Cr elevated Renal Insufficiency or hemodynamically Unstable
MR angio not preferred - contrast required and time-consuming in possibly emergent setting (type A aortic dissections are emergencies with mortality rates 1-2%/hour following onset
probable aortic dissection with Cr 2
why Cr elevated?
diagnostic test?
dissection may extend to renal arteries
(or CKD)
TEE transesophageal echocardiogram for dissection with renal disease (no contrast)…. otherwise CT angio
50yo heavy alcohol user, smoker, with compensated CHF, no cad, MCV ^100, thrombocytopenia, AST:ALT^2:1
diagnosis
best treatment for heart
-ACEI/ARB? Smoking cessation? Alcohol cessation? Salt restriction?
Alcoholic (dilated) Cardiomyopathy
STOP ALCOHOL improves or normalizes LV function over time
smoking contributes to CAD not CHF
Salt restritction, ACEI/ARB, BB, diuretics, possible aldosterone antagonists, digoxin etc all part of treatment per CHF but Alcohol Abstinence best for Alcoholic Dilated Cardiomiopathy
time to ARDS onset after clinical insult
v1wk
vent settings to treat ARDS
low TV, high PEEP, high FiO2
hypoxia with PaO2/FiO2 v300 suggests
how to calculat PaO2/FiO2
suggests ARDS
e.g. 60mmhg/1.0 = 60
1.0 = 100% FiO2
90mmhg/.1 = 900
90mmhg/.2 = 450
90mmhg/.3 = 300
TF
massive transfusion can cause ARDS
T
Pleural fluid analysis in Uncomplicated vs Complicated Parapneumonic effusion
sterile or bacteria? free or loculated? pH, glucose, WBC, protein gram stain culture treatment
Uncomplicated - sterile, free-flowing, pH^7.2, glucose^60, WBCv50, low protein, negative cultures, antibiotics
Complicated - bacterial invastion, loculated vs empyema, pHv7.2, glucosev60, WBC^50, high protein, negative cultures still (bacterial load there but low), antibiotics and drainage
difference between complicated parapneumonic effusion and empyema?
negative cultures vs gross pus or bacteria on gram stain
parapneumonic effusion with continued fever and pleuritic pain despite abx suggests…
Complicated parapneumonic effusion (persistent bacterial invasion but low enough for negative cultures) or Empyema (gross pus / positive cultures)
requiring Drainage in addition to abx
quantify “low protein” in a transudative effusion
v3g/dl
consider that normal serum total protein is 8
the most frequent underlying arrhythmia responsible for sudden cardiac arrest in setting of acute MI
pathophys
Ventricular Fibrillation
Reentrant ventricular arrhythmia (predominant, If within 10 minutes of MI, from distorted conduction patterns)
abnormal automaticity if 10-60min post mi, less common
pt with variceal bleed with hematemesis hemodynamically unstable with altered mental status - being transfused… next step NG tube to decrease hematemesis?
INTUBATE - protect airway (AMS, hematemesis, aspiration risk, cannot protect airway)
once protected, can move on to NG suction to improve EGD visualization, EGD for sclerotherapy/banding… also do octreotide (SS analogue) to decrease GI blood flow in meantime
calculate cardiac index
cardiac output / body surface area
CO / BSA
underlying cause of ascending vs descending aortic aneurysms
ascending - cystic medial necrosis (elderly) connective tissue disorders (marfan, ehlers danlos)
descending - ATHEROSCLEROSIS htn hld smoking
TF
done diagnosing aortic aneurysm with a cxr?
F
could just be tortuous aorta… CT to confirm
pt with fever, chills, malaise, headache, myalgias, dry cough
mediastinal or hilar lymphadenopathy with focal reticulonodular or miliary infiltrates on cxr
granulomas with narrow-based budding yeasts on biopsy
dx and risk factor?
treatment?
Histoplasma Capsulatum
Bird/Bat droppings - CAVES, Ohio/Mississippi river valleys, Northeast
complete spontaneous resolution in weeks
Itraconazole or Amphotericin B if not
chest pain, cough, fatigue, fever
normal cxr or unilateral infiltrate with ipsilateral hilar LAD
spherules with endospores on biopsy
dx? risk?
Cocccidioidomycosis
Arizona
Mononucleosis-like lymphadenopathy, fevers, malaise in cat owner think…
toxoplasma gondii
fit preggy gymnast wants exercise advice
continue jogging, swimming, walking, stop gymnastics (as long as pregnancy uncomplicated by multiple gestation, placental concerns, heart or lung disease, prematurity concerns…)
(avoid contact sports, FALL RISK, scuba diving, hot yoga)
physical activity to avoid in healthy pregnancy
contact sports
fall risk
scuba diving
hot yoga
TF
bilateral wheezing can occur in acute PE
T
bronchoconstriction in response to hypoxia and infarction
most common cause of mitral regurge, e.g. in otherwise healthy middle-aged person in a developed country
Mitral Valve Prolapse
(Myxomatous Degeneration)
MVP most common cause of MR
in developed countries
pathophys of Mitral Valve Prolapse
myxomatous degeneration
why avoid spillage of mature cystic teratoma / dermoid cyst contents during laparascopic cystectomy
can cause chemical peritonitis
most common risk factors for aortic dissection
htn #1
marfan
cocain
pathogenesis of exercise-induced bronchoconstriction (athletic asthma)
treatment
mast cell degranulation triggered by passage of high volumes of dry cold air
SABA before exercise if a few times per week
can substitute ICS or AntiLeukotriene if exercise daily
most common cause of adult-onset diarrhea due to malabsorption presenting between age 20-40
lactose intolerance
30yo with chronic crampy abdominal pain bloating and watery diarrhea after meals likely has ___
Lactose Intolerance (brush border enzyme deficiency)
normal function and location of intestinal lactase
process lactose into glucose and galactos on the Brush Border of the Duodenum
quality of diarrhea in Lactose Intolerance, why
mechanism of bloating
watery diarhea
-undigested lactose draws water into intestinal lumen and decreases transit time
colonic bacteria ferment lactose producing hydrogen gas
diagnose lactose intolerance
treat
diagnosed by resolution of symptoms with lactose-free diet
or lactose breath hydrogen test if above inconclusive
treat by avoiding lactose or supplementing lactase
acute onset watery diarrhea and low-grade fever and positive FOBT with PPI therapy think…
C Diff
- associated with PPI use
- FOBT often positive
- diarrhea is ACUTE with Low Grade FEVER
quality of diarrhea in Celiac
foul-smelling, greasy
escalating symptoms of magnesium toxicity
treatment
nausea flushing headache hyporreflexia
areflexia, hypocalcemia, somnolence
respiratory paralysis, cardiac arrest
stop mag
give IV calcium gluconate bolus
2 uses of mag sulfate in OB
prevention of eclamptic seizures
preterm delivery – decreases risk of cerebral palsy in premies
magnesium excretion
how does that inform your OB practice
renal
so watch out if renal failure or increased Cr, check levels and signs of toxicity always
how does mag therapy cause hypocalcemia
mag temporarily suppresses PTH secretion
TF
LEEP and Cervical Laser Ablation increase risk of preterm delivery
Fish
knife conization definitely
LEEP maybe
Laser definitely not
this trumps all other risks for preterm delivery
history of preterm delivery
trumps multiple gestation, short cervicle lenth, cervical conization surgery, cigarette use, obesity, etc
OB risks associated with gastric bypass surgery
risk for preterm delivery?
anemia in pregnancy
cesarean delivery
Not a risk for preterm delivery
manage history of preterm delivery in currently pregnant mama
cervical length measurements by TVUS
progesterone administration
maybe cerclage placement if diagnosie cervical insufficiency
hypotensive chest trauma patient has normal/high PCWP that elevates with fluid bolus, don’t think hemorrhage now think…
get…
think myocardial dysfunction, possible contusion
get an urgent echocardiogram
most common infective endocarditis organism
staph aureus
valve involvement in infective endocarditis
tricuspid more than aortic
fever cough chest pain in IV drug user with systolic murmur that increases with inspiration and scattered round lesions in the peripheral lung fields bilaterally think..
infective endocarditis with tricuspid involvement and septic emboli to lungs
describe paradoxical split S2
and 3 examples that cause it
reversed, A2 follows P2, with split increased during Expiration and decreased with inspiration
seen with Fixed Left Ventricular Outflow Obstruction
-Aortic Stenosis
-LBBB
Right Ventricular Paced Rhythm
TF
inadequate pregnancy weight gain, e.g. from hyperemesis gravidarum, can cause fetal growth restriction
T
congenital malformation caused by lymphatic system obstruction in the fetal neck
aka
association
aka Cystic Hygroma
assoc with Aneuploidy eg Turner Syndrome
RhD antii-D immunoglobulin is given in OB Only After…
only after delivery of baby an blood type checked (Rh pos baby to Rh neg mom), within 72 hours of delivery
can get a FAST for an altert and hemodynamically stable trauma pt…. what SBP indicates hemodynamically stablility?
SBP^90
is a sign of hemodynamic stability
woman with HTN COPD and OSA has swollen legs and varicose veins with medial ankle ulcer…
diagnosis
recommend treatment
if fail treatment
chronic venous insufficiency
(nothing to do with COPD OSA or HTN… risk factors are age, obesity, family history, pregnancy, sedentery, prior trauma)
elevate legs and compression stockings
if fail this, get venous duplex ultrasound to demonstrate venous reflux and confirm diagnosis
TF
diuretics for chronic venous insufficiency
F
will just dehydrate
-elevate legs and compression stockings
TF
smoking cessation for chronic venous insufficiency
F
no evidence that stopping helps, though it is known to be a risk factor
-elevate legs and compression stockings
symptoms on presentation of choriocarcinoma
first lab test
treatment
amenorrhea or abnormal uterine bleeding
pelvic pain / pressure uterine mass
mets to lung / vagina and assoc sx
elevated b-hCG is first lab
chemo is treatment
within 6 months of pregnancy, delivery, abortion, molar pregnancy, woman has episodes of vaginal bleeding, large uterus, and lung symptoms
suspect
get
treat
suspect choriocarcinoma (with mets to lungs)
get b-hCG
treat with chemo
most common site of choriocarcinoma mets
choriocarcinoma mets to lungs
when to deliver baby in preeclampsia with severe features vs without severe features
^34 wks severe features
^37 wks no severe features
mag and antihypertensives (Hydralazine, Labetalol, Nifedipine) till then
TF
alpha methyldopa to for blood pressure control in preeclampsia
F
alpha methyldopa for Chronic htn in pregnancy
conrtol Htn in Preeclampsia with IV HYDRALAZINE, IV LABETALOL, or PO NIFEDIPINE
how to choose antihypertensive med for preeclamptic preggy
avoid Labetalol if already bradycardic
avoid Nifedipine (PO) if emesis suggests po intolerance
Hydralazine IV… pretty ok…
why are ACEIs contraindicated in pregnancy
can cause
fetal growth restriction renal failure pulmonary hypoplasia oligohydraminos skeletal abnormalities
why is sodium nitroprusside generally a Last Resort for treatment of hypertension
Cyanide is a metabolic byproduct
predominant Mechanism responsible for rapid anginal pain relief from Nitrates like Nitroglycerin
decreased left ventricular Wall Stress
via venodilation, decreased preload, decreased end diastolic volume resulting in decreased myocardial oxygen demand…
*wall stress more so than decreased contractility from decreased preload, or coronary dilation
pt with amenorrhea and history of chemo… otherwise ROS pretty negative,
suspect
FSH LH PRL TSH levels?
suspect Ovarian Failure from Chemotherapy (targets rapidly dividing cells)
FSH LH up (lack of inhibition from estrogen)
PRL TSH normal
abdominal succussion splash
describe
diagnosis
further diagnostic workup
stethoscope over upper abdomen
rock patient at hips
GOO - retained gastric material ^3 hours after a meal will generate a splash sound in a hollow viscus filled with fluid and gas (most sensitive for GOO, but must follow up with workup below)
NGT suctioning, IVMF, Endoscopy to confirm dx
explain the muscle weakness side effect of albuterol, eg with newbs in treatment of asthma exacerbation
what else can result of this mechanism
first step if occurring
Beta2Agonists like Albuterol can drive K into cells, HypoKalemia, Muscle Weakness, Arrhythmias, EKG changes… also Tremor, Palpitations, Headache
first step BMP to assess K level
treat hypertriglyceridemia
150-500
vs
^1000
and what is initial goal of therapy when triglycerides ^1000
150-500 - lifestyle Weight Loss, Alcohol decrease, Exercise increase, High Dose Statin IF CAD or High Risk
^1000 (initial goal Prevent Pancreatitis)
-Fibrates, Fish Oil, Abstain from Alcohol
triglycerides 465 in CAD patient – what to do other than start high dose statin?
150-500 - lifestyle Weight Loss, Alcohol decrease, Exercise increase, High Dose Statin IF CAD or High Risk
^1000 (initial goal Prevent Pancreatitis)
-Fibrates, Fish Oil, Abstain from Alcohol
most effective pharmacologic therapy for lowering triglyceride levels
when to use it
Fibrates most effective for lowering triglycerides
use for SEVERE Hypertriglyceridemia ^1000 – otherwise risky for myopathy and statins more effective by evidence so statins first-line for most CAD and moderate triglyceridemia
75yo DM and HTN, with cupping of optic disk on exam, loss of peripheral / tunneling of vision, why?
treat
OPEN Angle Glaucoma - cupping of optic disk
BB (Timolol) eye drops initial mgmt
Laser Trabeculoplasty as adjunct
Trabeculotomy if refractory
presentation of open vs closed angle glaucoma
Open - gradual loss of peripheral vision / tunneling, cupping of optic disk
Closed - Sudden onset Blurred Vision, Severe eye Pain, Nausea, Vomiting, Red eye with Hazy Cornea and Fixed Dilated Pupil
20yo with atypical chest pain and short systolic murmur at the apex that shortens with squatting… diagnosis?
MVP mirtal valve prolapse
squat, increase venous return… larger LV volume, delayed prolapse? per UWorld… thinking…. better stretched… less distance to prolapse….
MVP gets SOFTER with squat
MR gets LOUDER with squat
which gets louder with squatting and which gets softer MR vs MVP
MR gets LOUDER with squat
(more LV volume to regurge)
MVP gets SOFTER with squat
(more LV stretch, tighter chordae… less distance to flick back)
1st and 2nd most common Murmurs caused by Rheumatic Heart Disease
RHD
MS Mitral Stenosis #1
MR Mitral Regurge way less often
3 things to do in order for eeclampsia
give mag
give anihtn (hydralazine labetalol nifedipine
deliver baby
4 risk settings for ARDS
vent settings to treat with
how to avoid mortality
infection
trauma
massive transfusion
acute pancreatitis
treat with Mechanical Ventilation
-LOW TV, high PEEP, Permissive HyperCapnia
AVOID alveolar OVERDISTENSION (barotrauma) (low TV)
GOAL SpO2 ^88%
Pt put on vent for ARDS
what is the MOST important treatment strategy to avoid mortality?
Avoid Alveolar OverDistension (barotrauma) (low TV)
GOAL SpO2 ^88%
most common causes of Malignant pleural effusions
lung carcinoma
breast carcinoma
lymphoma
top 4 ddx for hypokalemia with alkalosis and normotension
how does urine chloride help you differentiate
surreptitious vomiting - low urine chloride
diuretic abuse
Bartter syndrome (renal protein mutation)
Gitelman’s syndrome (renal protein mutation)
(all high urine chloride)
what kind of acid/base disturbance in chronic diarreha
metabolic ACIDOSIS
from loss of bicarb in stool
How can COPD exacerbation lead to seizure
and how can over-supplementation of oxygen contribute? Guidelines for use?
Seizure by HYPERCAPNIA (causes brain metabolite signaling changes) and reflex cerebral VasoDILATION
use Oxygen Cautiously with Goal SpO2 90-93% or PaO2 60-70mmHg
Too Much can Worsen HyperCapnia by:
- Loss of Hypoxic pulmonary Vasoconstriction and worsening V/Q mismatch.. increased deadspace perfusion
- Decreased CO2 reuptake because more O2 saturation
- Suppressed Hypoxic Respiratory Drive
Goal SpO2 and PaO2 in oxygen supplementation for COPD exacerbation
In COPD exacerbation, use Oxygen Cautiously
with Goal SpO2 90-93% or PaO2 60-70mmHg
Too Much can Worsen HyperCapnia by:
- Loss of Hypoxic pulmonary Vasoconstriction and worsening V/Q mismatch.. increased deadspace perfusion
- Decreased CO2 reuptake because more O2 saturation
- Suppressed Hypoxic Respiratory Drive
how can Zollinger-Ellison syndrome cause impaired fat absorption?
Gastrin producin tumor
high Acid
Impaired Pancreatic Enzyme Activation by duodenal base and Injury to the Mucosal Brush Border
workup of Zollinger-Ellison Syndrome
Gastrin level ^1000
Gastric pH v4
Endoscopy for ulcers (duodenal and maybe jejunal)
CT MRI SomatoStatin Receptor Scintigraphy to ID Pancreatic tumors (tumor often located in pancreas) and Mets
once confirmed, screen for MEN1 with PTH, Ca, PRL levels
