Rosh Review Incorrect Flashcards
What is May Thurner Anatomy?
It occurs when the left common iliac vein is compressed by the right tcommon iliac artery against the 5th lumbar vertebrae. Very common in pregnant patients and increases likelihood of VTE/DVT.
What should be administered after 4 units of any blood product?
1g of IV calcium chloride
When should patients be referred for multichannel urodynamic testing during the assessment of incontinence?
Unclear dx–sx do not correlate with physical exam
No impvt with sx after tx
Pt has undergone prior incontinence or pelvic floor surgery
What can be used to avoid ureteral injury ina robotic hysterectomy that is complicated by thick pelvic adhesions?
indocyanine green 25 mg dissolved in 10 mL of sterile water can be injected through a 6-F ureteral catheter. The dye reversibly stains the inside lining of the ureter.
What is the cause of postop fever POD1-3? What are the sx, physical exam, and tx?
Sx: Fever, Tachycardia, Tachypnea
PEx: Inspiratory rales at the lung bases
Tx: Incentive spirometry
What number of metabolic equivalents has been associated with positive postop outcomes?
4 Metabolic Equivalents
Name 4 Postop Cardiovascular complications?
Hypotension
Hypertension
Dysrhythmias
Myocardial injury after noncardiac surgery
What are the appropriate dosages for ancef in pts undergoing hyst?
2g for pts <120kg
3g for pts >120 kg
How often do abx used for laparascopic hysts need to be redosed?
Ampicillin/Sulbactam (Unasyn) & Cefotetan 2hrs
Aztreonam and Ancef q4hrs
Clindamycin q6hrs
No redosing for Levofloxacin, Flagyl and vanc
What is the MOA of GnRH receptor agonist and what condition is it used commonly to treat?
Downregulates the HPO axis
Causes an increase in gonadotropin release and increases estrogen production by stimulating gonadotropin receptors until they are desensitized.
This suppresses the HPO axis and leads to a DECREASE in estrogen and causes a pseudomenopause state. Patients can develop hot flashes and insomnia. If sx are severe low dose estrogen can be prescribed.
Dosage
1. 3.75mg IM or SC q1mo
2. 11.25mg IM or SC q3mos
Treatment length: 6mos. Patients should NOT be on it longer than 6 mos
Treatment for fibroids. Serves as a bridge to surgery. It is only approved for presurgical intentions so that one can reduce the size of fibroids so that the pt can avoid a laparotomy and move forward with a minimally invasive approach. Causes a 35-65% decrease in fibroid volume in 3 mos.
PB 221: Mgmt of Symptomatic Uterine Leiomyomas
What is the most common cause of urogenital fistulas in resource-rich countries?
Hysterectomy
How do urogenital fistulas typically present?
Urinary leakage or watery discharge from the vagina.
What is Youssef’s syndrome?
A specific type of vesicouterine fistula
Cause: iatrogenic injury during a LUS Csection
Sx: cyclic hematuria, amenorrhea, urinary continence
What is the flat tire test?
A method of assessing bowel integrity intraoperatively, where the bowel is occluded proximally, the pelvis is filled with fluid, and air is instilled through the rectum. If bubbles appear, full-thickness injury should be suspected.
What is the timeline for initial vaccination and catch up vaccination for the HPV vaccine?
What test for Factor V Leiden cannot be used while the patient is taking anticoagulants?
Activated protein C resistance assay
When is a gestational sac visualized in pregnancy? When is a GS + YS visualized?
GS- 4-5wks
GS + YS - 5-6wks
What is the ROME IV Criteria?
What is the first line treatment for vaginal cuff cellulitis?
Amoxicillin-Clavulanate (Augmentin)
How many days before surgery should antiplatelet agents be stopped?
Stop ASA 7-10 days before surgery.
Plavix should be stopped 5-7 days before surgery
DIscuss the different anticoagulation mgmt ofr warfarin, DOAC, antiplatelet angets.
What drug class is ulipristal?
Selective progesterone receptor modulator
The left ovarian vein drains into which vessel? The right ovarian vein drains into which vessel?
Left ovarian vein–> Left renal vein–> IVC
The LEFT side takes the LONG way
Right ovarian vein–> IVC
What is the difference between ileus and SBO?
Which are the most common organisms encountered in posthysterectomy abscesses?
Gram-negative bacilli, enterococci, streptococci, and anaerobes.
Describe Lichen Sclerosis–Dx, Clinical, Mgmt, Follow Up
Describe Chron Disease–Clinical, Extraintestinal manifestations., buzzwords
“knife cut ulcers in the perianal skin folds “
What is febrile morbidity?
Most common complication of myomectomy procedures. It affects up to 38% of patients. It occurs due to tissue damage and repair within the myometrium. it is not infectious in origin.
Discuss Necrotizing Fasciitis
Definition, cause, Tx
Definition: Acute infection of the subcutaneous connective tissue that spreads along the fascia of surrounding muscles.
Caused by group A streptococcus
Tx: surgical exploration and debridement
Healing by secondary intention is preferred over delayed closure. The wound should be left open to heal by granulation, contraction, and reepithelization.
Which antibiotic works as an antitoxin?
Clinidamycin
What are the risk factors for interstitial pregnancy?
IVF
Hx of PID
STIs
Tubal surgery
Ectopic pregnancy
How is a wedge resection performed? When does it need to be performed?
Wedge resection should be performed in the setting of cornual rupture.
The pregnancy, surrounding myometrium, ipsilateral fallopian tube are excised en bloc.
What is an interstitial pregnancy?
Interstitial pregnancy occurs in the most proximal part of the fallopian tube.
Cornual rupture can lead to significant hemorrhage because the uterine and ovarian arteries anastomose at this location.
What is interstitial line sign?
Echogenic line connecting the gestational sac to the endometrial cavity. The gestational sac is surrounded by a thin layer of myometrium.
Interstitial line sign has a high sensitivity and specificity for interstitial pregnancy.
Discuss sx, lab results, and tx for hyponatremia.
How should full thickness bowel injuries be repaired?
Double layer closure repaired PERPENDICULAR to the lumen.
It is NOT repaired parallel because it can cause constriction of the bowel.
Discuss thermal injuries.
More difficult to recognize intraoperatively.
Usually occur with monopolar energy.
Tissue that is blanched and contracted should be removed along with a margin of several millimeters d/t likelihood of less apparent damage beyond the injury.
What results in adhesion formation and connective tissue scarring?
Decreased fibrinolytic activity.
List out the type of fibroids on the FIGO system
Type 1–pedunculated, intracavitary
Type 2: <50% Submucosal
Type 3: >50% Submucosal, Intramural and is in contact with the endometrium
Type 4: Fully intramural and is NOT in contact with the endometrium
Type 5: <50% subserosal
Type 6: >50% Subserosal
Type 7: Pedunculated
Type 8: Other-cervical
How is a foreign object retained in the abdomen/pelvis described on imaging?
Fine, linear, radiopacity, with mottled air
Mass effect over the adjacent soft tissue
What changes should be made to a patients insulin the night before surgery?
Reduction in their insulin by approximately 25% the night before
This helps promote euglycemia
What is the preop target hgbA1c for patients undergoing surgery?
7-8%
Femoral Nerve
Nerve root
Sensory Deficit Presentation
Motor Deficit
Obturator Nerve
Nerve root
Sensory Deficit Presentation
Motor Deficit
Ilioinguinal/Iliohypogastric Nerve
Nerve root
Sensory Deficit Presentation
Motor Deficit
Pudendal
Nerve root
Sensory Deficit Presentation
Motor Deficit
Genitofemoral
Nerve root
Sensory Deficit Presentation
Motor Deficit
Ulnar Nerve
Nerve root
Sensory Deficit Presentation
Motor Deficit
Radial Nerve
Nerve root
Sensory Deficit Presentation
Motor Deficit
Ovarian torsion tx in premenopausal vs postmenopausal patients.
Premenopausal – detorsion and cystectomy
Postmenopausal– detorsion and unilateral SO
Which side is ovarian torsion more likely to occur?
Right side due to the protective presence of the sigmoid colon on the left
What is a Maylard incision?
The Maylard incision requires transection of the rectus abdominis muscles. This affords more space in the operative field. It is technically more difficult because it requires identification and ligation of the deep inferior epigastric arteries.
Patients that have compromised aortoiliac blood flow rely on collateral blood flow through the epigastric vessels. Ligation of the deep inferior epigastric arteries can cause claudication and leg ischemia
There are also concerns regarding postoperative pain, decreased abdominal wall strength, and increased operative times.
What is the Cherney incision?
The Cherney incision is a type of transverse incision that involves removing the most inferior tendinous insertion of the rectus muscle bellies in order to gain more operative space in the space of Retzius. The Cherney incision may be initiated if a Pfannenstiel incision has already been initiated, but more operative space is required.
What are catamenial seizures and what causes them?
Seizures that are exacerbated during a certain phase of the menstrual cycle.
Occurs 3 days before menses and first 3 days of menses.
The progesterone level drop causes seizure
What is the pathophysiology of estrogen in COCs in the management of PCOS?
Estrogen - Increases production of SHBG in the liver. SHBG binds to free testosterone, which lowers androgen levels and improves acne/hirstutism.
Takes 6 mos to show impvt in sx.
What are the different types of nec fasc?
1 - polymicrobial – associated with diabetes, immunocompromised, PVD
- monomicrobial (group A strep) usually caused by group 2 strep
- Vibrio – associated with marine exposure
- Fungal – Immunocompromise
Discuss management of straddle injury.
Determine extent of injury–vaginal injury vs vulva vs periuretheral .
Give tetanus ppx
Consult specialist if needed
Vulvar hematoma–expanding? yes–place foley catheter, drainage and ligation of bleeding sites. no–conservative mgmt.
What cystopic findings are seen in patients with interstitial cystitis?
Hunner ulcers are reddened mucosal areas with small vessels radiating toward a central scar, and glomerulations are pinpoint hemorrhages in the bladder wall, both of which are suggestive of painful bladder syndrome (interstitial cystitis).
What is the role of D mannose in recurrent cystitis?
D-mannose is a natural sugar that mimics the host uroepithelial receptors and competitively binds to bacterial surface ligands. This theoretically results in fewer bacteria attaching to the bladder mucosa. Some studies have shown that daily use of D-mannose for 6 months reduces the frequency of UTIs.
Discuss management of abnl pap smears in pts 21-24yrs.
Is it recommended to send unrine cx’s for uncomplicated lower UTIs?
if udip is positive for leuks and nitrites then it is highly suggestive of UTI. No additional testing is needed. Patient can be started on abx.
However, if patient does not improve in 48 hrs or if there is recurrent infection then abx should be started
How long do you leave a word catheter in place for bartholin gland abscess?
4-6wks
What is the methotrexate dose of the single- and two-dose regimens versus the fixed multi-dose regimen?
50 mg/m2 versus 1 mg/kg.
PB 193 : Tubal Ectopic Pregnancy
What are the causes of primary ovarian insufficiency?
What is the definition of primary and secondary amenorrhea?
