Surgery Part 3 and ObGyn Part 1 (202-233) Flashcards
1
Q
Bleeding of middle meningial artery. Dx? CT?
A
Epidural - biconcave disk not crossing suture lines
2
Q
Bleeding of cortical bridging veins. Dx? CT?
A
Subdural - crescenteric pattern extends across suture lines
3
Q
Bleeding from Circle of Willis often at middle cerebral artery branch. Dx? Biggest cause and Sx?
A
Subarachnoid hemorrhage - Caused by berry aneurysm –> severe HA and CN III palsy
4
Q
What does the CSF fluid of a pt with subarachnoid hemorrhage look like? Color? content?
A
Xanthochromia – CSF protein >150
5
Q
What pharmacologic agent do you give pts with subarachnoid hemorrhage? WHy?
A
Nimodipine to prevent vasospasm that could result in secondary infarct.
6
Q
Bleeding from basal ganglia, internal capsule and thalamus. Dx? CT/MRI shows?
A
Parenchymal hemorrhage - CT shows focal edema and hypodensity
7
Q
What could be some causes of parenchymal bleed?
A
hypertension, trauama, AV malformation and coagulopathy
8
Q
What is the most common temporal bone fracture?
A
Longitudinal fracture (80%)
9
Q
After temporal bone fracture, if a CSF leak is noted, what should you do?
A
IV antibiotics and ear drops
10
Q
If a temporal fracture affects the facial nerve, what should you do?
A
Facial nerve decompression
11
Q
What are the 4 ( or 5) classic signs of a basilar skull fracture?
A
raccoon eyes, Battle’s sign, hemotypmpanum, CSF rhinorrhea and otorrhea
12
Q
Dark circles (bruising) under the eyes is what?
A
Raccoon eyes
13
Q
What is Battle’s sign?
A
ecchymosis over the mastoid process indicating fracture.
14
Q
What is the treatment for a basilar skull fracture?
A
Supportive- HOB elevated, monitor ICP
15
Q
Pt with increased ICP, bradycardia with hypotension, Cheyne-Stokes respirations, and papilledema. What general dx?
A
Tumors
16
Q
Small circular lesion, often multiple at gray-white junction
A
metastatic
17
Q
Large irregular ring enhancing lesion due to central infarction (outgrows blood supply) – most common primary CNS neoplasm
A
Glioblastoma multiforme
18
Q
Second mC neoplasm, slow growing and bengin
A
Meningioma
19
Q
Occurs in children (often bilateral) 60:40 sporadic:familial
A
Retinoblastoma
20
Q
Found in cerebellum in the floor of the 4th ventricle, common in children
A
medullablastoma
21
Q
compresses optic chiasm and hypothalamus
A
craniopharyngeoma
22
Q
Sx: bilateral gynecomastia, amenorrhea, galactorhhea and bitemporal hemianopsia
A
prolactinoma
23
Q
MC tumor in AIDS pt (100x incidence) – what does CT look like?
A
lymphoma - ring enhancing lesion
24
Q
Usually affects CN VIII (acoustic neuroma)
A
Schwannoma
25
You excise all brain tumors except which two?
prolactinoma and lymphoma
26
Whats the tx for a prolactinoma?
Bromocriptine (D2 agonist)
27
Whats the tx for a lymphoma?
Radiation therapy
28
Dilated ventricles on CT/MRI with normal ICP. Dx?
Communicating hydrocephalus (either ex vacuo or normal pressure)
29
Why does hydrocephaleus ex vacuo happen? Tx?
Occurs after neuron loss - stroke, CNS dz.
| No treatment
30
Why does normal pressure hydrocephaleus happen? Sx? Tx?
Causes: idiopathic, meningitis, cerebral hemorrhage,trauma, arthrosclerosis.
Sx: wet whacky wobbly
Tx: diuretic, repeated spinal taps and consider shunt placement.
31
What kind of hydrocephalus is associated with increased ICP?
Communicating or non communicating
32
Communicating spontaneous increased ICP commonly seen in obese young females, but can be idiopathic. Also can be caused by massive quntaties of Vitamin A. Dx? CT?
Pseudotumor cerebri
| CT --> no ventricle dilation (may even be shrunken)
33
How to Tx pseudotumor cerebri?
acetazolamide or surgical lumboperitoneal shunt
34
Where is a non communicating hydrocephalus obstructed?
CSF outflow is at the 4th ventricle at the foramina
35
What could be the causes of noncommunicating hydrocephalus?
- Congenital (Arnold Chiari syndrome)
- tumor
- Scarring secondary to meningitis
- secondary to subarachnoid hemorrhage
36
Define aneurysm
Abnormal dilation of an artery to more than twice it's normal diameter
37
What is the Most common cause of an aneurysm?
arthrosclerosis
38
What's the difference between a true and false aneurysm?
True involves with all 3 layers of the vessel wall
False aneurysms are pulsatile hematomas covered only by a thickened fiberous capsule (adventitia)
39
Pt with classic abdominal pain, pulsatile abdominal mass, hypotension. Dx?
Rupture of AAA
40
What is the rate of rupture for a 5cm AAA rupture?
6% per year
41
What is the rate of rupture for a 6cm AAA rupture?
10% per year
42
What is the most difinitive diagnosis of a AAA?
Aortogram
43
Why are CTs done for AAA?
to determine the size of the aneurysm in a stable pt
44
When is surgical intervention for a stable AAA recommended?
infrarenal and juxtrarenal aneurysms >5.5
45
What complication can be seen in patients who have had synthetic grafts placed for AAA disease who have GI bleeding?
formation of a aortoduodenal fistula
46
Where is the most common peripheral aneurysm?
popliteal artery
47
What percent of the peripheral aneurysms are bilateral?
50%
with 33% of pts with popliteal aneurysms have a AAA
48
Where is a type A dissection located?
ascending aorta
49
Where is a type B dissection located?
both ascending and descending aorta
50
Pt presents with classic severe tearing (ripping) chest pain in hypertensive pts that radiates toward the back
Aortic dissection
51
Why does peripheral vascular dz happen?
arthrosclerosis dz in the lower extremeties
52
What are the factors associated with peripheral vascular disease?
smoking
increased homocystiene
elevated levels of C-reactive protein
53
What happens when cellulitis superimposes active infection to necrotic tissue?
wet gangrene
54
What is Leriche Syndrome?
Aortoiliac disease that causes claudication in hip and gluteal muscles, impotence
55
What is the ankle brachial index?
Ratio of BP in the ankle to the BP in the arm.
56
What is a normal ABI?
Greater than 1
57
What is an ABI with severe occlusive disease?
58
What is an ABI in a pt with claudication?
59
What is a normal waveform in an artery?
triphasic
60
Moderate occlusive disease waveform?
biphasic
61
severe disease waveform?
monophasic
62
What kind of lifestyle modifications can be suggested to pt with PVD?
smoking cessation and increase exercise
63
What is the pharmacologic intervention for PVD? (first and second line)
Cilostazol (vasodilator and platelet inhibitory properties)- first
Pentoxifyllin - second
64
What is minimally invasive therapy for PVD?
percutaneous balloon angioplasty and/or arthrectomy + endoluminal stents
65
What are indications for PVD surgery?
rest pain, tissue necrosis, non healing infection and intractable claudication
66
Dilated prominent tortuous superficial veins in the lower limbs
varicose veins
67
What kinds of people get varicose veins? (2) Why?
- pregnancy (progesterone causes dilation of veins)
- prolonged standing professions
- possible inheritance
68
Why do venous ulcers occur?
Seconday to venous hypertension, DVT, varicose veins --> usually located on the medial calf or ankle
69
Are venous ulcers painful or painless?
painless?
70
What is phelgmasia alba dolens?Tx?
milk leg --> venous thrombosis usually occuring in post partum women
Tx: heparin and elevation
71
What is phlegmasia cerula dolens? Tx?
venous gangrene --> venous thrombosis with complete obstruction of arterial inflow
Tx: heparin, elevation and venous thrombectomy if unresolved
72
What are unna's boots?
zinc oxide paste impregnated bandage used to reduce swelling
73
Why do arterial ulcers occur?
secondary to occlusive arterial disease
74
Are arterial ulcers painful or painless
painful in contrast to venous ulcers
75
Where are arthrosclerotic plaques most often seen in carotids?
most commonly the carotid bifurcation
76
What is the indication for carotid endarterectomy in symptomatic patients?
stenosis > 70%
multiple TIAs
Pts with Hx of CVA, amenable to surgery
77
What is the indication for carotid endarterectomy in asymptomatic patients?
carotid steonosis >75%
78
What dz is caused by an occlusive lesion in subclavian arteria or innominate artery that causes decreased blood flow distal to the obstruction?
Subclavian steal syndrome
79
Where does subclavian artery "steal" blood from?
vertebral artery via retrograde flow
80
What is the tx for subclavian steal syndrome?
Carotid-subclavian bypass
81
What causes renovascular hypertension?
Renal artery stenosis and subsequent activation of the renin-angiotensin pathway
82
What causes renal artery stenosis to begin with?
Arthrosclerotic lesions... but can be secondary to fibromuscular dysplasia, subintimal dissections and hypoplasia of the renal artery
83
What's the initial test you would do to test for renal artery stenosis? Gold standard?
renal duplex ultrasound and gold standard is angiography
Can also do renin:vein renin ratio (captopril test)
84
Define chronic intestinal ischemia
secondary to arthrosclerotic lesions of atleast 2 of the 3 major vessels supplying the bowel.
85
Pt with weight loss, post prandial pain and abdominal bruit. dx?
chronic intestinal ischemia
86
Define Acute intestinal ischemia
acute thrombosis of a mesenteric vessel secondary to arthrosclerotic changes or emboli from the heart
87
How do you confirm or rule out diagnosis of acute intestinal ischemia?
Angiogram
88
At how many weeks is a term delivery?
37 weeks
89
How many weeks is a premature delivery
between 20-37 weeks
90
What is Chadwick's sign?
blue-ish discoloration of the vagina due to vascular congestion
91
What is Hegar's sign?
softening of the cervix
92
What hormone do pregnancy tests detect?
hCG or it's Beta subunit
93
At what age is a gestational sac identified?
5wks
94
At what age is a fetal image detected?
6-7weeks
95
At what age is cardiac activity first noted?
8 weeks
96
What is Nagele's rule?
LMP+7 days - 3 months +1 year = estimated due date
97
During first visit, what tests do you do on mom?
```
CPE
Pap smear
cultures for GC
CBC
Blood type with Rh
RPR
Rubella
TB
Skin testing
Offer HIV antibody test
```
98
Teratogen effect of lithium
Ebstein's anomoly
99
Teratogen effect of Carbamazepine or valproate
Neural tube defects
100
Teratogen effect of Retinoic acid
CNS defects, craniofacial defects, cardiovascular defects
101
Teratogen effect of ACEi
Renal failure in neonates, renal tubule agenesis, decreased skull ossification
102
Teratogen effect of Oral hypoglycemic
neonatal hypoglycemia
103
Teratogen effect of warfarin
skeletal and CNS defects
104
Teratogen effect of NSAIDs
Constriction of ductus arteriosus, necrotizing enterocolitis
105
Teratogen effect of thalidomide
phocomelia (underdevelopment of limbs and face)
106
Medication has not shown increased risk for birth defects in human studies. Category?
A
107
Medications are associated with birth defects in humans; however potential benefits in rare cases may outweigh their known risks. Category?
D
108
Animal studies show adverse effects, but no studies available in humans. Category?
C
109
Medications are contraindicated in human pregnancy bc of known fetal abnormalities that have been demonstrated in both human and animal studies. Category?
X
110
Animal studies have not demonstrated a risk and no adequate studies in humans OR animal studies = risk, but human studies = no risk
B
111
If a pregnant pt is not immune to rubella, what should you do?
DO NOT VACCINATE. -- Rubella vaccine is a live virus
112
How much weight gain is recommended during pregnancy?
25-35 lbs
113
In the first trimester, how often should a woman visit the obgyn?
every 4 weeks
114
Why is trace glucosuria seen in normal pregnancy?
increase in GFR.. but anything more than trace protein should be evaluated
115
At what weeks are the following uterine landmarks?
- Pubic symphysis
- midway from symphysis to umbilicus
- at umbilicus
- Correlates with wk of gestation
- Pubic symphysis 12 weeks
- midway from symphysis to umbilicus 16 weeks
- at umbilicus 20 weeks
- Correlates with wk of gestation 20-36 weeks
116
All pregnant women should undergo what testing in first trimester?
Down's syndrome
117
What is the ultrasound test to look for down's syndrome?
Nuchal translucency
118
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Down's syndrome?
AFP and Estriol down
| HcG and Inhibin A is HIgh (in down's ironically)
119
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Turner's syndrome
AFP and Estrio is down
| HcG and Inhibin A are VERY HIgh
120
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Edward's syndrome?
Estriol and HcG is low. (HE is low)
121
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Pateu syndrome?
AFP is high
122
Adding what test to the quad screen increased the detection to >85%?
PAPP-A
123
When is quickening seen in the fetus?
17-19 weeks
124
At what week should glucose screening be done?
24 weeks (1 hr glucola)
125
At how many weeks should you start going to the obgyn more frequently?
Every 4 weeks til 32 weeks, Every 2 weeks from 32-36 weeks and every week til delivery
126
What should you ask when concerned about preterm labor?
Are you having any vaginal bleeding, contractions or rupture of membranes
127
At how many weeks do you screen for GBS?
35-37 weeks
128
If mother is Rh - , at how many weeks is Rhogam administered?
28-30 weeks
129
Why is pregnancy a hypercoagulable state?
increased clotting factors
| venous stasis due to uterine pressure on lower extremity great veins
130
Why is there a relative anemia seen in pregnancy?
Plasma volume increases by about 50% and red cell mass increases later on so relative anemia of 15% seen
131
What happens to cardiac output in pregnancy?
increases by 50%
132
What kind of murmurs are normal in pregnancy?
systolic ejection murmur
133
What murmurs are not normal in pregnancy?
Diastolic murmur
134
Why is there decreased peripheral vascular resistance?
Progesterone mediated smooth muscle relaxation
135
Why is there increased nasal stuffiness and increased nasal secretions in pregnancy?
Increased hyperemia (more vessels growing) = increased congestion
136
What happens to GI motility, esophageal sphincter tone in pregnancy?
decreased --> constipation results in hemorrhoids
137
What happens to bladder tone? Why might this be a problem?
decreased tone, predisposed to UTIs
138
What happens to serum creatinine and BUN?
decreases because increased GFR by 50% which means more gets filtered out
139
What happens to fasting blood glucose? Why?
decreases because of fetal utilization
140
What week does the fetus start making it's own insulin?
9-11 weeks
141
why does hyperpigmentation occur?
Increased estrogen and melanocyte stimulating hormone affects umbilicus, perineum, face (cholasma) and linea nigra
142
What is the #1 medical complication of pregnancy occuring in 2% of pregnancies?
gestational diabetes mellitus
143
What are some risk factors of GDM risk factors
- hx of previous GDM
- maternal age >30
- obesity
- FHx of DM
- previous infant weighing more than 4000 g at birth
- unexplained still births
- repeated spontaneous abortions
144
Why is GDM caused in pregnancy?
Human placental lactogen antagonizes insulin which causes hyperglycemia so fetus can get more.
145
What fetal weight is considered macrosomia?
greater than 4500 g
146
What are 2 complications to mom during pregnancy because of GDM? Why?
Abruption and pre-term labor bc of increased uterine size and post partum uterine atony
147
What is the screening test and diagnostic test for GDM?
1 hour glucola test screens at 24-28 weeks
| 3hr GTT confims
148
Why are oral hypoglycemics contraindicated in GDM?
they can cross the placenta and result in retal and neonatal hypoglycemia
149
What is White's classification?
Class A1 = GDM diet controlled
| Class A2 = GDM insulin controlled
150
When is thromboembolic disease in pregnancy most likely to happen?
During pregnancy 1-2%, post partum 80 %
151
What is the first line for diagnosing thromboembolic disease?
dopplar ultrasound
152
What is the gold standard for thromboembolic disease/?
venography
153
Tx for superficial thrombophlebitis
leg elevation, rest, heat and NSAIDs
154
What do you treat DVT with?
heparin to maintain PTT at 1.5-2.5 times the baseline
155
Why is warfarin contraindicated in pregnancy?
It crosses the placenta -- > teratogenic (bone deformities, abortion, opthomalogic abnormalities) early and causes bleeding later
156
What percentage of DVTs untreated progress to PE?
25%
157
What are some risk factors of pregnancy induced hypertension?
```
nulliparity
age >40
FHx of PIH
chronic HTN
chronic renal dz
diabetes
twin gestation
```
158
What happens to reflexes in pts with pre-eclampsia?
hyperreflexia and clonus
159
Cure for PIH?
delivery of baby
160
What are the 3 criteria for pre-eclampsia?
>140/90 of increased SBP >30 or DBP>15 compared to previous
new onset proteinuria/edema
Generally occuring at >20wks
161
What additional symptoms must be seen to classify as severe pre-eclampsia?
SBP >160 OR DBP > 110
Marked proteinuria (>1g/24h or >11 dip)/ increased creatinine
CNS disturbances
pulmonary edema/cyanosis
epigastric/RUQ pain or hepatic dysfunction
162
What is the hallmark sx of Eclampsia?
convulsions
163
When should you start MgSO4?
in severe pre-eclampsia
164
When should you treat the blood pressure of eclampsia?
to maintain
165
What is a complication of severe PIH?
Hemolysis
Elevated Liver enzymes
Llow Platelets
166
What is the treatment for HELLP?
delivery, transfuse bloos, platelets and fresh frozen plasma as needed, IV fluids, pressors as needed to maintain BP
167
What is peripartum cardiomyopathy?
A type of dilated cardiomyopathy that decreases ejection fraction
168
When does peripartum cardiomyopathy occur?
Last month of preg or first 6 months post partum
169
What are some risk factors to peripartum cardiomyopathy?
```
African american
multiparious
age >30
twin gestation
Pre-eclampsia
```
170
What is the treatment for peripartum cardiomyopathy?
bed rest, digoxin and diuretics along with possible anticoagulation
171
When is intrapartum prophylaxis for GBS indicated?
1. PTL or prolonged ROM or fever in labor
2. GBS + at 36 wks
3. GBS bacteruria or previous baby with GBS
172
What is the drug of choice to treat GBS if pt is allergic to penicillin?
Clindamycin or erythromycin
173
What antibiotics should be used if pt is dx with chorioamnionitis?
broad spectrum *Look up later
174
What is the definition of hyperemesis gravidum?
N/V past 16 weeks of pregnancy
175
What are the causes of hyperemesis gravidum?
increased HcG levels, thyroid or other GI hormones
176
If there is more than a 2cm deviation from expected fundal height during 18-36 weeks, what should you do?
repeat measurement or do ultrasound
177
What is the most reliable tool for assessing fetal growth?
ultrasound
178
What is measured in early pregnancy to obtain gestational age?
crown rump length
179
To get gestational age later in pregnancy, what 4 measurements are done?
biparietal diameter of skull
abdominal circumference
femur length
cerebellar diameter
180
How many fetal movements per hour indicate fetal well being?
4 per hour
181
How many accelerations in a NST are considered normal?
2 within 20 minutes
182
What are the 5 components of a biophysical profile? Scoring?
```
Fetal breathing
Gross body movements
Fetal tone
Qualitative amniotic fluid volume
Reactive FHR
```
Each rated on scale of 0-2. 8-10 is normal, 6 equivocal and
183
What do you test for fetal lung maturity?
Lecithin:sphingomyelin ratio >2
| and phosphatidylglycerol
184
What is lecithin?
a phospholipid found in surfactant and increases as lungs mature
185
What is sphingomyelin?
An agent that remains constant throughout pregnancy
186
What is phosphotidylglycerol?
Marker that appears late in pregnancy, indicates lung maturity
187
After how many weeks are fetal lungs generally mature?
after 34 weeks, but highly variable
188
How are the phospholipids for lung maturity measured?
by amniocentesis because they enter the amniotic fluid from fetal breathing
189
What is normal fetal heart rate?
120-160bpm
190
What's VEAL CHOP
Variable - Cord compression
Early deceleration - Head compression
Accelerations - OK
Late decelerations - Placental insufficiency
191
What is the MCC for fetal tachycardia?
maternal fever
192
Why does head compression cause early decelerations?
Because the vagus nerve stimulated reflex response to release acetylcholine at the fetal SA node
193
Development of maternal immunoglobulin antibodies following RBC exposure is called..
Isoimmunization
194
Why is isoimmunization dangerous to subsequent pregnancies?
cross the placenta, attach to fetal RBCs and hemolyze them causing fetal anemia
195
What is the worst case scenario to isoimmunization and why does it occur?
Hydrops fetalis -- occurs bc significant Abs across placenta causes fetal anemia.. The liver attempts to make new RBCs (fetal hematopoiesis occurs in liver and bone) at the expense of other proteins --> decreased oncotic pressure --> fetal ascities and edema
196
What 2 times during pregnancy is Rhogam given to mother to prevent isoimmunization if she is Rh negative and father is Rh + or unknown
28 weeks and 72 hours after pregnancy
197
Define braxton hicks contractions
False labor = uterine contractions without effacement and dilation of the cervix
198
All lactating women have approximately ____ greater energy requirement than the average pregnant woman.
2/3
199
At what point in gestation does an Rh- mother with Anti-Rh IgG titers greater than 1:16 whos pregnant with Rh+ fetus begin amniocentesis?
16-20 weeks to track amniotic fluid bilirubin levels (which depicts level of fetal hemolysis level)
200
What are the cardinal movements?
```
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation (restitution)
Delivery.
```
201
Hypergonadotrophic hypogonadism is classic of what genetic condition?
Turner's syndrome. nonfunctional gonads so negative feedback doesn't work so increased levels of FSH and LH
202
What are the top 3 DDx to abnormal mid cycle bleeding?
Pregnancy
Hypothyroid
OCP mis-use
203
What is the definition of pre-term labor?
regular contractions at intervals of 10 minutes or less lasting > or = to 30 seconds, occuring between weeks 20-36. Eventual cervical dilation and effacement will occur
204
What time period does missed abortion occur?
205
What are 3 tests done to test for rupture of membranes?
- Pool (speculum exam shoes a pool of fluid in vagina)
- Nitrazine test (fluid is placed onto nitrazine paper, positive if blue-alkaline-aka amniotic fluid)
- Fern = slide shows ferning pattern
206
Untreated hydatidiiform moles become what?
choriocarcinoma
207
What is the most common cause of 1st trimester abortion?
Chromosomal abnormalities?
208
What is the MCC for 2nd trimester abortion?
Cervical incompetence is #1 but other causes include: fetotoxic agents such as warfarin, enalapril, isotretinoin, cocaine
209
What is LGA?
Large for gestational age >90th percentile
210
What is SGA?
small for gestational age
211
What is Beckwith-Wiedemann syndrome?
Pancreatic cell hyperplasia --> risk for LGA
