STEP2-UW-OBGYN-19'

Causes of hypercalcemia

#1 Malignancy #2 Hyperparathryroidism Vitamin D Toxicity Granulomatous disease Drugs e.g. thiazides, lithium Milk alkali syndrome Thyroid toxicosis Vitamin A toxicity Immobilization

Management of PPROM at < 34 weeks

(*Abx, +/- steroids --> delivery*) *1. expectant* *2. signs of intraamniotic infection* e.g. fever, and fetal tachycardia, *delivery is indicated*

Management of shoulder dystocia during delivery

*"BECALM"* *B*: breathe, no pushy *E*: elevate legs to *McRoberts position* - to flatten the sacral promontory *C*: call for help *A*: apply suprapubic pressure - downward and lateral *L*: en*L*arge vaginal opening- episiotomy *M*: maneuvers

28 y/o primigravida woman at 30 weeks gestation comes in for routine prenatal care. Patients niece recently died from neonatal group B streptococcal infection, preterm delivery at 36 week gestation and is concerned this could happen to her kid. Next step?

*"Check for bacterium 3-5 weeks before your EDD"* -*rectovaginal culture 35-37 weeks* gestation *Indications for intrapartum prophylaxis: (IV PCN)* -GBS bacteriuria or -GBS UTI, GBS swab -unknown GBS status PLUS: < 37 weeks, intrapartum fever, ROM >18 hours -*prior infant w/ early onset neonatal GBS* -*early-onset neonatal GBS* infection sepsis, pneumonia -*screening 3-5 weeks before the estimated delivery date* -most women deliver 40-42 weeks gestation (screen35-37wks)

When is deep fascial wound dehiscences most likely to occur? (timeframe)

*1-2 weeks* post-op (30 days)

Tamoxifen mechanism of action

*1. Estrogen antagonist in the breast* *2. Estrogen agonist in the uterus*(polyps)

Adverse effects of Oxytocin

*1. Hyponatremia* - sz *2. Hypotension* *3. Tachysystole* -*similar to ADH*, at high doses causes *water retention, hyponatremia*, and resultant seizures.

ddx for intermittent vaginal leakage or wetness in pregnant woman

*1. PROM* *2. stress urinary incontinence* note: veiscovaginal fistulas present w/ continuous leakage and follow gyn surgery or prolonged labor

Type of leiomyoma that causes most pronounced symptoms

*1. Subserosal* *2. pedunculated fibroids*

Tx of vaginal foriegn bodies

*1. warm irrigation* *2. vaginoscopy* under sedation/ anesthesia *Signs/ sx* -prepubertal girls -vaginal spotting -malodorous vaginal discharge -no signs of trauma -toilet paper most common

Tx for gestational DM

*1st line: Dietary modifications* *2nd line: Insulin, metformin* Target glucose levels: -*Fasting:* 95 mg/dL or less -1hr postprandial 140 mg/dL or less -2hr postprandial 120 mg/dL or less

1st stage of labor

*1st stage* *Latent* -<6 cm cervical dilation

Diagnosis of acute pancreatitis

*2 of the following:* 1. Severe epigastric pain 2. Amylase or lipase 3x upper limit 3. CT, MRI, US findings

Percent of patients that have inhibitor development when chronically transfused for Factor VIII deficiency

*25 %* w/ severe factor VIII deficiency

2nd stage of labor

*2nd stage* -cervix completely dilated e.g. 10 cm -deliver of baby

Best method to reduce vertical transmission of HIV?

*3-drug ART therapy* -2 NRTs (zidovudine, tenofovir) -1 NNRT of PI -reduces transmission to <1% -*Zidovudine* to neonate for at least 6 weeks.

Causes of fetal tachycardia

*> 160/min* -*Maternal fever* -*Meds* e.g beta agon -Hyperthyroidism -Tachyarrhythmia

A 38 y/o nulligravid woman comes in for abnormal uterine bleeding. For the past 8 months she has had intermenstrual spotting and bleeding lasts 3-7 days. She started OCPs 4 months ago, which has not improved the bleeding pattern. Speculum exam shows dark red blood in the posterior vaginal vault, but no cervical or vaginal lesions. Pregnancy test negative, US wnl. Next step ?

*Abnormal uterine bleeding* -uncontrolled endometrial proliferation -women < 45 y/o, endometrial cancer risk is low, so start on OCP -continued irregular menstrual bleeding while on OCP (failed medical management) = *Endometrial Biopsy*

36 y/o G2P1 mom at 35 weeks gestation comes in due to vaginal bleeding and constant back pain. PMHX of HTN controlled on labetolol. BP 104/70, pulse 118. Speculum shows small amount of bleeding and a closed cervix. Fetal US shows FHR 160, 3 late decelerations, and uterine contractions q1-2 min. Dx?

*Abruptio placentae*

Active phase of delivery

*Active* -6 cm cervical dilation -cervical dilation *1cm/2hr*

Charcot triad

*Acute cholangitis* 1. RUQ pain 2. Jaundice 3. Fevers

37 y/o women G1P0 at 34 weeks gestation come to the ED for n/v and severe epigastric pain. Pain now involves the RUQ. FHR shows 170/min, no contractions on tocodynamometer. Hgb 10, Plt 80,000, glc 40, T bili 4, AST 69, ALT 44, Amylase 130, Lipase 32. Dx?

*Acute fatty liver of pregnancy* -*3rd trimester* -*microvesicular fatty infiltration* of hepatocytes -liver inflammation e.g RUQ pain -n/v -*RUQ/ epigastric pain* -Fulminant liver failure (profound hypoglycemia, *thrombocytopenia*) -*labs: profound hypoglycemia, high AST, high T bili, low Plt*, DIC

53 y/o woman with "strange, itchy rash" over her left breast present for the last month. Pt applied OTC corticosteroid ointment onto this rash w/o sx relief. LMP 2 years ago. Hx of HTN. Exam shows eczematous plaque on the left nipple and areolar. What condition is most associated with this finding?

*Adenocarcinoma of the breast* -*dx: Mammary Paget disease* -*eczematous, and or ulcerating rash* localized to the nipple and extends to areola. -other feat.: vesicles, *scales, bloody discharge, and nipple retraction* -*Pt experiences pain, itching, and burning* of the affected nipple and no resolution with topical steroids -*Majority of pts have an underlying breast adenocarcinoma *

Middle-aged multiparous woman w/ hx of previous OB surgery has heavy menstrual bleeding and a bulky, tender uterus that is uniformly enlarged.

*Adenomyosis*

*46 y/o female* presents with *heavy* menstrual bleeding. Menses has become heavy, consisting of 5 days of heavy bleeding (4 normal). Her menses has also become very *painful* that is unrelieved by ibuprofen, and she now has constant, dull pelvic pain between menses. Pt has hx of *3 c-sections*, and b/l tubal ligation. BP 110/70, pulse 92. Bimanual exam shows soft, *tender, symmetrical, globular uterus* that measures 11 weeks in size. pregnancy test is negative. Dx?

*Adenomyosis* -abnormal endometrial tissue -within the uterine myometrium -> 40 y/o -*multi-parity* -*prior uterine surgery* -dysmenorrhea -*heavy menstrual bleeding* -chronic pelvic pain -diffuse *uterine enlargement, symmetrical, boggy, globular* -*dx: clinical* presentation, MRI & US: *thickened myometrium* -confirm via pathology -*Tx: Hysterectomy*

42 y/o G2P2 presents with pelvic pain. Menses are painful with heavy bleeding that requires her to change tampons every hour for the first 2 days. This started a few years ago. Pelvic pain subsides after menses but has become constant over the past few months. Pt had tubal ligation after her last child. Exam shows boggy uterus that is tender to palpation. Dx?

*Adenomyosis* -*chronic pelvic pain* -heavy menstrual bleeding -endometrial glands/stroma collect abnormally in myometrium -*multiparous women >40 y/o* -*dysmenorrhea* -entrapped endometrial tissue = *boggy, tender uterus* -*symmetrically enlarged uterus*

When to stop Pap testing

*Age 65 or hysterectomy* *plus* -No hx of cervical intraepithelial neoplasia 2 or higher *and* 3 consecutive negative pap test *or* 2 consecutive negative co-testing results

Pertussis treatment & post-exposure prophylaxis

*Age <1 month:* Azithromycin x 5 days *Age >/= 1 month:*Azith x5 or Clarith x 7 or Eryth x 14 days *Pertussis* -highly contagious -transmitted via respiratory droplets -natural infection + vaccination = transient immunity, *immunity wanes* -*prophylaxis recommended for close contacts*

Ovarian hyperstimulation syndrome

*An exaggerated, abnormal response to ovulation induction* -e.g. clomiphene -over-expression of *VEGF* in the ovaries -results in *b/l enlarged, cystic ovaries* with increased vascular permeability -causes third spacing e.g. *ascites, pulmonary edema*

32 y/o obese woman presents w/ abnormal uterine bleeding. Menses was regular until a year ago, now occurs 45-60 days w/ heavy bleeding. No LMP for 4 months. No hot flashes, acne, or hair growth. Pregnancy test negative. Dx?

*Anovulation 2/2 obesity * -x's adipose tissue affects HPA axis -aromatized androgens by adipose to estrone -high levels of estrone -high freq, short GnRH pulses -imbalance of LH/FSH (preference LH) -lack of LH surge (anovulation)

35 y/o G1P0 women at 35 weeks gestation comes to the office for eval of wetness of her undergarments. She has leakage with laughing and coughing for the past 6 weeks, but has gotten more frequent in the past 2 days. Scheduled for routine GBS screen in 3 days. Speculum exam shows pool of nitrazine-positive clear fluid in the vagina and a closed cervix. US shows low amniotic fluid index. Next steps?

*Antibiotics* -*preterm premature rupture of membranes* -ROM *<37 weeks* prior to labor onset -some have gush of vaginal fluid -others have *intermittent leakage or vaginal wetness*, sx of urinary incontinence -*penicillin should be given for pts who are GBS positive or status is unknown *

Focal nodule hyperplasia of the liver

*Associated with anamalous arteries* -*benign tumor* of the liver -arterial flow and *central scar* on imaging -*women 20-50 y/o* -*tx rarely required, OCP can be continued*

Management of fibroids

*Asx: observation* sx: combined hormonal contraception, surgery

Tx for chlamydia infection w/ negative gonorrhea NAAT test?

*Azithromycin or doxycycline only*

25 y/o woman presents with increasing amounts of malodorous vaginal discharge for 4 days. She has a history of chlamydia at age 19. Exam shows no vulvar or vaginal erythema or lesions. There is an off-white discharge throughout the vaginal vault with no discharge from the cervical os. Dx?

*Bacterial vaginosis* -lactobacilli decreases -overgrowth of anaerobic bacteria e.g. Gardnerella -*risks:* w-on-w, douching, tobacco -*pH >4.5* -*amine odor w/ KOH* -*clue cells*

36 y/o with left sided facial droop that she woke up with 4 hours ago. She states that the left side of her face was sagging and she was drooling from the corner of her mouth. No facial numbness, but has had increased sensitivity to noise. Pt has history of migraines, seasonal allergies, and gestational diabetes. Face appears asymmetric with los of the left nasolabial fold. When asked to smile, the left side of her face does not move. Facial sensation to touch and pain is normal bilaterally. Most likely etiology?

*Bell palsy* -*CN VII (facial nerve)* -unilateral mouth drooping -disappearance of the nasolabial fold -*involvement of the upper face* -*reactivation of neurotrophic virus, HSV* -inflammation and edema of the facial nerve, resulting in compression and degeneration of the myelin sheath -*Tx: glucocorticoids +/- valacyclovir* (not as monotherapy)

8 mo old girl brought in for f/u. She was admitted last week due to fatigue and anemia requiring transfusion. Spleen is palpated 2cm below the costal margin. Electrophoresis shows 5% Hb A2, 95% Hb F. Management?

*Beta-thalassemia* -absent beta globin -*increased Hb F* -microcytic anemia -*splenomegaly*

Jaundice at 3-5 days of life, peaks at 2 weeks, due to high levels of b-glucuronidase in the breast milk deconjugates intestinal bilirubin & increase enterohepatic circulation. Normal examination, adequate breast feeding.

*Breast milk jaundice*

Jaundice appear in first week of life due to insufficient intake of breast milk resulting in decreased bili elimination and increased enterohepatic circulation. Signs of dehydration, and suboptimal breast feeding.

*Breastfeeding jaundice* -breast feed q2-3 hours

39 y/o woman G3P2 comes to ER at 37 weeks for leakage of fluid for last 2 hours. Fetal movement is normal. Pt immigrated to US 6 months ago and has had no prenatal care. Exam shows PROM, and patient has small blood clots on cervical os. US shows active fetus in cephalic presentation whose growth is appropriate. Fetal HR is 150/min. Tocodynaomic shows contraction every 3 minutes. Tx?

*C-section* *Placenta previa* -*painless vaginal bleeding* *during labor*, contractions or manipulation can result in massive maternal hemorrhage therefore *even w/ stable vital signs, c section is indicated*

Young pt missing eye tissue, heart defects, atresia choanae, growth retardation, genital abnormalities and ear abnormalities. Dx?

*CHARGE syndrome* -may have choanal atresia

CXR of rheumatoid effusion

*CXR shows interstitial lung disease, pulmonary nodules*

Definition of postpartum urinary retention

*Can't pee >6 hr s/p vag delivery* -*risks: primiparity, regional neuraxial anesthesia, vaginal delivery, perineal injury, c-section* -overflow incontinence due to pudendal nerve injury and *bladder atony* -small volume voids -inability to void -dribbling of urine -*tx: self-limited condition* -*intermittent catheterization* dx & tx!, esp in pts unable to void

A 1-day old boy is evaluated. Patient was born via vaginal delivery to a primigravida woman at 39 weeks gestation. Pregnancy uncomplicated, she had adequate prenatal care. Vacuum assistance was required during delivery due to difficult extraction. After birth, boy was noted to have a symmetric molding of the head. There is a notable, firm, well-demarcated swelling on the right parietal scalp with no discoloration and no apparent tenderness. Parents are concerned that the boy's head was symmetrical at birth but now appears "lopsided". Dx?

*Cephalohematoma* -*subperiosteal* hemorrhage -neonates due to trauma -*forceps or vacuum-assisted* -limited to surface of 1 cranial bone -scalp swelling *Features* -firm, nontender, *does not cross suture lines, no skin discoloration* -occurs slow -often not visible until hours after birth

23 y/o primagravida presents at 38 weeks to L&D for ROM and painful contractions. Est fetal wt. 8lbs. Cervix 8 cm dilated and 90% effaced with fetal vertex at 0 station. She has increasing rectal pressure, contractions q2-3 min, and contraction strength is 240 Montevideo units over 10 min. 4 hours later the cervix is unchanged. Fetal HR is category 1. Next step?

*Cesarean delivery* -this is *active phase arrest* -cervical dilation *at least 6cm* -*no cervical change 4 hours* -*adequate contractions* Montevideo units (200/10min) -or no change in cervix for 6 hours with inadequate contractions -*tx: cesarean delivery*

Placenta accreta is delivered via

*Cesarean hysterectomy*

Chorioamnionitis

*Chorioamnioitis* *Ascent of normal vaginal flora into uterus* -*tx: broad spectrum abx, delivery*

38 y/o G1P0 presents for her first prenatal visit. LMP 12 weeks ago. Has had n/v, not seen provider in years, supine BP 142/96. Exam shows anxious woman with mild b/l ankle edema and enlarged uterus. US confirms pregnancy consistent w/ date. Urine dipstick is negative for protein and glucose. Pt returns to office for BP reading a week later and her BP is 152/106 mmHg. Dx?

*Chronic hypertension* ->/= *140 mmHg* &/ or >/= *90 mmHg* diastolic -predates pregnancy -2 measures at least 4 hours apart -prior to conception -or *20 weeks gestation* -*complications:* FGR, M&M, preterm, oligohydram *Gestational HTN:* new HTN at 20 wks *Preeclampsia:* new HTN at 20 wks + proteinuria *Chronic HTN w/ preeclampsia:* cHTN + new onset proteinuria or worsening of proteinuria at 20 weeks

4 day old newborn term via vaginal delivery to a 30 y/o woman. length at birth 10th %, weight and head circ 25th %. On exam baby had ambiguous genitalia. Exam shows severe curvature of an underdeveloped phallus. Urethral meatus is at the base, gonads are not palpable. Labs: Testosterone 850, 46, XX, 17-HPG 3740, AMH nl. Dx?

*Classic congenital adrenal hyperplasia* -*autosomal recessive* -*21-hydroxylase deficiency* -salt-wasting syndrome neonates -hypotension, dehydration, vomiting -*ambiguous genitalia in girls* (46, XX) -clitoromegaly or *underdeveloped phallus* -ectopic urethral meatus (*hypospadias*) -*nonpalpable gonads* -boys have normal genitalia w/ palpable testes

Treatment for postpartum endometritis

*Clindamycin & gentamicin*

Passage of products of conception through the cervix at < 20 weeks gestation. On exam cervix is closed, and a small amount of blood pooled in the vaginal vault. b-HCG positive. Scant free fluid in the posterior cul-de-sac. Dx?

*Complete abortion*

27 y/o women comes in due to vaginal spotting. She recently learned she was pregnant and estimates she is 9 weeks gestation based on a very regular menstrual period. The patient has dark vaginal spotting for the past day, no ab pain, cramping, or passage of tissue. Pelvic exam shows a 14 week sized uterus, visibly closed cervix, and dark red discharge from the cervical os. pregnancy test is positive. US shows a "Swiss cheese"/ snowstorm appearance. Dx?

*Complete hydatidiform mole* -uterine size > GA -vaginal spotting -fertilization of empty ovum by 2 sperms or 1 sperm that subsequently duplicates. -*trophoblastic proliferation and hydropic villi* -no fetal development -*first trimester bleeding* -B-hCG > 100,000

Hepatitis C in pregnancy

*Complications* -Gestational DM -Cholestasis of pregnancy -Preterm *Management* -*Ribavirin is teratogenic* -no indication for barriers if partners doesn't have * monogamous* *Prevention* -vertical transmission strongly associated with maternal viral load; 2-5% -*C section not protective* -Scalp electrodes should be avoided -Breastfeeding encouraged note: up to 80% of pt infected with Hep C develop chronic hepatitis -*all pts should be immunized against hepA/B*

34 y/o woman comes to office for vulvar lesion that have worsened over the past 3 months. She's had 2 sexual partners in the last year. PMHX of genital infections with HSV at 23 y/o, and at 25 y/o her sexual partner was diagnosed with syphilis. Exam shows non-tender, freshly, verrucous growth clustered at the vestibule of the vulva over the labia majora. The lesions bleed on manipulation. Dx?

*Condylomata acuminata*(anogenital warts) -persistent infection -low risk strains -*risks: tobacco use or immunosuppression* -*HPV 6 & 11* -multiple pink or skin-colored lesions -lesions ranging from smooth, flattened papules to exophytic/cauliflower-like growths

1 hour old boy is evaluated for microcephaly. He was born to 26 y/o women who did not receive prenatal care, Occipitofrontal circumference is > 3 SD below mean. Anterior fontanelle is closed, and the skull is partially collapsed. Multiple contractures and a right club foot are noted. He also has hypertonia, and imaging shows thin cerebral cortices, and multiple intracranial calcifications within the cerebral cortex. Dx?

*Congenital Zika syndrome* -single-stranded RNA Flavivrus -transplacental transmission -transmitted via *Aedes mosquito bite* or sexual transmission -targets neural progenitor cells -*feat: microcephaly, craniofacial disproportion, neurologic abnormalities, ocular* abnormalities -*dx: calcifications, ventriculomegaly, cortical thinning, Zika RNA detection*

Newborn girl develops respiratory distress. She was born 37 weeks gestation via vaginal delivery. US shows polyhydramnios. T 98F, BP 70/40, pulse 176/min, pulse ox 82% on room air. Exam shows nasal flaring, grunting, and a barrel-shaped chest. Auscultation shows absent breath sounds on the left and fair aeration of the right lung. Heart sounds are loudest in the right chest. Abdomen appears scaphoid. Dx? Next step>

*Congenital diaphragmatic hernia* -life-threatening diaphragmatic defect -abdominal viscera to herniate into chest -*pulmonary hypoplasia, pulmonary hypertension* -*85% on the left* -*polyhydramnios* occurs, esophageal compression -*concave abdomen/ barrel-shapped chest* - deviation of abdominal viscera into thorax

1 day old girl is evaluated for swollen hands and feet. She was born term via emergency C-section, because her mother had preeclampsia w/ severe features complicated by pulmonary edema. Exam shows short, webbed neck, dysplastic nails, and b/l, non-pitting carpal and pedal edema. US shows horseshoe kidney. Cause of swelling?

*Congenital lymphadema* -*lymphatic network dysgenesis* -causes accumulation of protein rich interstitial fluid in hands, feet -obstruction can result in *cystic hygroma*

2 month old with flat head on the right. Pt was born via c-section. Exam shows flattening of the right occiput with anterior displacement of the right ear and forehead. Pt tilts her head to the left while rotating the chin to the right. When head is turned to the right, there is a firm mass in the inferior portion of the L SCM. Dx?

*Congenital muscular torticollis* -*Postural deformity* -SCM is tight and contracted -likely due to intrauterine crowding eg. breech position -*assoc. w/ developmental dysplasia of the hip, club foot*, metatarsus adductus -*positional plagiocephaly* - flattening of head on preferred side, anterior displacement of ears and forehead -SCM thickening or "mass" from fibrosis

1 day old boy is admitted to NICU due to macrocephaly and jaundice. Born at 41 weeks to a 38 y/o G4 w/ good prenatal care. Mother taught in Zambia during 1st trimester, during which she developed fever for 2 weeks, swollen glands, and muscles aches that resolved spontaneously. Infants wt and lg are 25th %, head circumference is >95th %. Exam shows jaundice, liver palpable 4 cm below CM. CT head shows hydrocephalus and diffuse intracranial calcifications. Dx?

*Congenital toxoplasmosis* -raw or undercooked meat -unwashed fruits/ vegetables -cat feces -*signs/ sx: Macrocephaly, intracranial calcifications, jaundice*, blueberry muffin spots -asymptomatic at birth, get *chorioretinitis as adult* -*dx: serology*, IgM or IgA

25 hour full term boy presents with bilious emesis. He has not had a b/m yet. Maternal prescreen was positive for a copy of the CFTR-delta-508 mutation. On exam the boy has abdominal distention, X-ray shows dilated loops of bowel with no rectal air and no free air. Next step?

*Contrast enema* -concern for *meconium ileus* -hyperosmolar *enema* e.g. Gastrografin can *potentially break up the inspissated meconium* and dissolve the obstruction. -indicates bowel obstruction -contrast study needed to *determine level of obstruction* and need for surgery

Efficacy of emergency contraceptives

*Copper IUD -99%* Ulipristal pill - >85% Levonorgestrel pill - 85% OCPs - 75%

Placenta accreta often results in

*Cord avulsion* w/ necessitates manual extraction

52 hour girl develops emesis and abdominal distention. Delivered 40 wks gestation to a 30 y/o woman via C-section. Pt has not yet passed meconium. She has spit up all feeds and now has bilious emesis. X-ray shows multiple dilated loops of small bowel w/ paucit of air in the large intestine and rectum. Lap is performed. Viscous meconium is irrigated and evacuated, colon is found to be diffusely narrow. Dx?

*Cystic fibrosis* -meconium ileus is virtually diagnostic for CF -*thick, inspissated meconium* difficult to propel -life threatening *obstruction at ileum* (@ rectosigmoid for Hirsch)

Management of 4-mm stone in pt w/ sudden onset, severe, colicky right flank pain.

*D/c home, strain urine, drink 2L/day*

37 y/o woman presents for BP f/u. Over past 12 months, pt BP ranged from 145/90 - 150/95. Her BP at a health fair 2 weeks ago was 145/90. Current meds include OCP for the past 5 yrs. No tobacco or ETOH. No fhx of HTN, stroke, DVT, or MI. ECG is wnl. labs are unremarkable. Tx?

*D/c oral contraceptive and switch to another birth control* -OCP can cause mild elevations in BP -women w/ HTN during pregnancy, or FHX of HTN -estrogen mediated increase in hepatic angiotensin synthesis -effects on RAAS

28 y/o G2P1 woman is admitted at 38 weeks gestation for PROM. After oxytocin is infused for labor augmentation, patients starts having painful contractions that require epidural anesthesia. Fetal heart tracing shows 6 contractions per 10 min. Next step?

*D/c uterotonic agent* -*uterine tachysystole, >5 contractions/ 10 min* -fetal compromise/ hypoxemia, acidemia -interruption of intervillous blood flow -inadequate recovery time between contractions/ *late decelerations* -*tx: supportive measures* -*d/c uterotonic* agents

58 y/o woman evaluated for increasing leakage of fluid from her abdominal incision s/p total abdominal hysterectomy and b/l salpingo-oophorectomy for ovarian cancer 5 days ago. After walking in the hallway, she had increasing fluid leakage and a bulge at her incision site. After skin staples are removed, fatty tissue and a loop of bowel are seen protruding from a separation of the rectus abdominal muscles. A moist dressing is placed over the wound. Dx? Next step?

*Deep fascial wound dehiscences* -rectus fascia nonintact, exposure of intraabdominal organs -common w/ large incisions -pts w/ risk factors: cancer, chronic steroids, hypoalbuminemia, cough, obesity -*complication: evisceration* - herniation of ab organs -1-2 weeks after surgery (30 days) -*tx:* deep fascial/ evisceration = *emergency surgery* -*superficial dehiscences:* SQ tissue, intact rectus; *tx conservatively*

32 y/o woman presents at 14 weeks gestation for initial prenatal care. PHX T1M w/ multiple daily insulin injections. BP 154/94, pulse 86/min, FHR 152/min. Hb 12.1, Plt 154,000, K 4.3, Cr. 1.4, UA: 2+ protein, no RBC or WBC. Dx?

*Diabetic nephropathy* -proteinuria -elevated Cr (*14 weeks gestation*) -*significant proteinuria (>300, 1+ protein) prior to 20wks* (suggest underlying renal disease preconception) -normal preg changes: high GFR, *acceleration of renal disease* -*HTN common complication of diabetic nephropathy* notes: gestational HTN- new-onset 20 wks normal pregnancy- trace protein, Cr declines (not increase), BP declines

Management of hemorrhoids

*Dietary:* -increase fluids -increase fiber (psylliium husk) -reduce fats -moderation of ETOH *Behavior:* -limit time sitting on toilet -limit defecation to once daily -avoid straining during defecation *Topical agents:* -*analgesics (e.g. benzocaine)* -*astringents (e.g. witch hazel)* -hydrocortisone *Aggressive tx* -refractory cases or prolapsed, will not reduce (grade IV) -rubber band ligation -surgical hemorrhoidectomy

Human papillomavirus disease associations and vaccine indications

*Disease associations* -cervical cancer -vulvar & vaginal cancers -penile cancers -oropharyngeal cancer -genital warts *Vaccine indications* -*All girls & women 11-26 y/o* -Boys & *men 9-21 y/o* -9-26 y/o for M on M or HIV

Diagnosis of cystinuria

*Dx: cyanide-nitroprusside test*; elevated cystine levels

dx/tx of preeclampsia

*Dx:* -*3rd trimester (28-40wks)* -*BP >140/90 + proteinuria* -BP on 2 occasions, at least 4 hrs apart -*>300mg/24-hr* -*>/= 0.3 urine protein/ creatine ratio* *Tx:* -w/o severity: delivery 37 weeks -w/ severity: delivery 34 weeks -MgSO4 sz ptx -antihypertensives

Central precocious puberty

*Early activation of HPG axis* -pulsatile GnRH secretion -elevated FSH and LH levels

Evaluation of precocious puberty

*Early secondary sex features* 1. check *bone age* advanced bone age 2. check *LH* *normal bone age* -isolate breast = premature thelarche -isolated pubic hair = premature adrenarche *advanced bone age + high LH* -*central precocious puberty* *advanced bone age w/ low LH* -3. *GnRH stimulation* test: low LH - peripheral precocious puberty -3. GnRH stimulation test: high LH - central percocious puberty

42 y/o woman G4P3 presents at 37 weeks gestation and is brought to the ED after falling to the ground and having a 2 min seizure. She was unresponsive during the event, and had a lethargic state s/p. She does not remember the fall, but said she experienced the "worst headache of my life". Has PMHX of depression and anxiety, not sure which meds she's on, also has hx of migraines which she takes Tylenol, drinks cola, and smokes. BP 200/105, pulse 112/min, UA shows 2+ protein. Dx?

*Eclampsia* -seizure during pregnancy -HTN -proteinuria -*severe headache* -visual disturbances -RUQ/ epigastric pain -3-4 min of tonic-clonic sz, usually self limited -*Tx: MgSO4, antihypertensives, deliver fetus*

Micrognathia, microcephaly, large weird feet, overlapping fingers, and absent palmar creases, VSD.

*Edwards syndrome* (trisomy 18)

68 y/o woman w/ femoral hernia that is asymptomatic. Tx?

*Elective surgical repair* -femoral hernias: contents thru femoral ring, below inguinal lig -medial to femora artery and lateral to inguinal ligament -*nonpulsatile mass* in older women -*tympamic to percussion* when bowel loop is present. -associated w/ substantial risk of *incarceration & strangulation* -thus elective surgery is indicated

Treatment for deep fascial wound dehiscence

*Emergent surgery*

Postmenopausal bleeding with normal-size uterus

*Endometrial hyperplasia*

16 y/o girl comes in for evaluation of acne that appeared around the time of her menstrual period at age 10. It has spread to her chest and back. She quit the soccer team bc of it and has gained 20 lbs, Not sexually active, exam shows cystic nodular acne over the face, back, and upper chest. Tanner stage V. Normal testosterone and DHEAS. What malignancy is she at greatest risk for developing?

*Endometrial* -*PCOS* -androgen x's -*androgens may be normal* in some; decreased levels of sex-homone binding globulins. -*assoc:* DM, HTN, OSA, NASH, *endometrial hyperplasia/ cancer* -*tx: wt loss, OCP* -*clomiphene* for ovulation induction

28 y/o woman comes in for infertility evaluation. She has had unprotected intercourse with her husband for past year. LMP was 3 weeks ago. Patient describes "tearing pelvic and back pain" that is only partially relieved by NSAIDs. Exam shows uterus adherent to the right with tenderness on mobilization. Dx?

*Endometriosis*

Treatment of epiglottitis

*Endotracheal intubation & Ceftriaxone* -prevention: Hib vaccine

Neuraxial anesthesia effect on labor

*Epidural* -*lengthens the 2nd/active* stage of labor -not the first stage of labor

5 y/o boy is brought in to ED with sudden onset difficulty breathing. He has had difficulty breathing and has been sitting in bed leaning forward refusing to lie down. Pt is unvaccinated. T 102.4F, BP 100/65, pulse 130, O2 sat 92%. On exam pt is anxious, drooling , and has inspiratory stridor. Lung exam shows upper airway noises without wheezing or crackles. Dx?

*Epiglottitis* -*Haemophilus influenza type B*

53 y/o G2P2 woman comes to office for right-sided pelvic pain that has worsened over past 3 months. She has had bloating and hot flashes since LMP a year ago. Recently sexually active and not using condoms. Hx of chlamydia in her 40s, b/l tubal ligation at age 35 after c section. US shows 7 cm right ovarian mass with solid components, thick septations, and a moderate amount of peritoneal fluid. Dx?

*Epithelial ovarian carcinoma* -abnormal proliferation of tubal epithelium -US is 1st line -*ovarian mass* -*thick septations* -solid components -*free fluid* (ascites) -malignancy note: endometriosis is common in premenopausal women, and US shows homogenous cyst w' "ground glass".

Diagnosis of premenstrual syndrome

*Eval: sx/ menstrual diary* over 2 menstrual cycles -shows sx during luteal phase 1-2 weeks prior to menses -resolution during follicular phase (onset of menses or after)

Progesterone withdrawal test

*Evaluate secondary amenorrhea* -no menses in >6 months -pts w/ previous irregular menses -if no bleeding after progesterone = *LOW ESTROGEN*

60 y/o G3P3 woman w/ SOB. over past 6 months has progressive difficulty with deep breathes. Also has gained weight despite decreased appetite and nausea. Pt sister has BRCA mutation. Pelvic exam shows firm, nodular, non-mobile mass in left adnexa. US confirms mass. Next step?

*Exploratory laparotomy* -epithelial ovarian carcinoma -FMX of *breast cancer e.g. BRCA mutation* -*acute sx: SOB, obstipation, emesis, ab distention* -later sx: pain, bloating, early satiety -labs: high *CA-125* -*tx: Exploratory laparotomy*

24 y/o woman G2P0A1 presents 26 weeks gestation for an initial prenatal visit, prior to this visit the only visit her only prenatal care was a visit to the ER. Previous pregnancy resulted in SAB at 8 weeks. Fundal height is 32 cm. Blood type O, Rh negative. Transabdominal US shows female fetus with biparietal diameter and head circumference that are consistent with 26 weeks. Abdominal circumferences measures 34 weeks gestation, FHR 180, pericardial effusion, b/l pleural effusion, and polyhydramnios noted. Etiology?

*Exposure to kid with Parvo virus e.g. Slapped cheek rash* -*Dx: Hydrops fetalis* -*path: high CO*, high fluid into interstitial spaces -*pericardial effusion, pleural effusion*, ascites, skin edema, polyhydramnios *immune cause:* Rh(D) alloimmunization *nonimmune causes:* -*Parvovirus B19* infection -Fetal aneuploidy -Cardiovascular abnormalities -Thalassemia e.g. hemoglobin Barts

24 y/o G2P1 women presents at 37 weeks gestation. Cervical exam reveals a closed cervix and unengaged fetal presenting part. US shows fundal placenta, single deepest vertical pocket of amniotic fluid of 3 cm, and a fetus in incomplete breech presentation. Next step?

*External cephalic version*

41 y/o female G2P1 at 35 weeks comes to ED for contractions that began 5 hours ago. They began after a day at the beach. She is now having 3-5 contractions every hour, sometimes painful. Uterus is nontender between contractions, cervix is closed. NST shows 120/min, moderate variability, and multiple accelerations. Tocodynamometry reveals irregular uterine contractions. Next step?

*False labor* -can occur due to mild *dehydration* -mild -*irregular contractions* -no cervical chnage -reactive nonstress test e.g. moderate variability, accelerations -*discharge home with labor precautions*

36 y/o woman G1P0 presents at 26 weeks gestation for routine care. US at 19 weeks revealed fetal wt consistent with 18 weeks gestation and ASD. Pt has hx of depression tx w/ citalopram. She quit smoking prior to conception and does not use ETOH or drugs. BMI 23. BP 138/89. Fundal height measures 22 cm. US shows head, abdominal and fetal wt at 4th%. BPP is 8/8. Umbilical artery dopplers wnl. Dx?

*Fetal chromosomal anomalies* -*symmetric fetal growth restriction* -during first trimester -asymmetric FGR is consistent w/ placental insufficiency -*Pts age and ASD suggest trisomy 21*

intrauterine fetal demise

*Fetal death, 20 wks* gestation aka *stillbirth* -*maternal, fetal, or placental* in origin -1/2 of cases have no known cause -*absence of fetal cardiac activity* -*labor induction can be delayed until pt is ready*x

31 y/o G3P2 presents at 40 weeks gestation is in active labor. Pt had normal prenatal course. First pregnancy was uncomplicated, second pregnancy ended in emergency c-section. She had an epidural and is feeling mild pelvic pressure. ROM occurred 15 min ago w/ blood-tinged amniotic fluid. Fetal heart rate tracing shows early decelerations. Dx?

*Fetal head compression* -slow onset -symmetric w/ contractions -*uniform, shallow decelerations* -*nadir at the peak of contraction* -*early decelerations = fetal head compression* -*tx: no intervention indicated*

Transverse Lie (shoulder presentation) tx

*Fetal spine is perpendicular to long axis of uterus* -early gestational ages -most *spontaneously convert to longitudinal lie* and -cephalic presentation by term -manage expectantly

15 y/o girl comes in for self-palpated breast lump. Mass discovered 2 days ago while taking a shower. Exam shows 3-cm mass in the superior outer quadrant of the right breast. No lymphadenopathy. Dx?

*Fibroadenoma* -most common breast mass in *adolescence*

24 y/o woman with breast lump that she noticed 2 days ago. She is sexually active and recently started using OCPs. She is an avid jogger and wears a sports bra almost daily. Exam shows 2-cm firm, round, mobile mass in the superior outer quadrant of the right breast. Dx?

*Fibroadenoma* -solitary -well-circumscribed -mobile mass -cystic premenstrual ttp -*women < 30 y/o* -*prior to menses due to estrogen stimulation* -*dx: "triple diagnostic" approach* (exam, imaging studies, biopsy) -*only a biopsy will confirm the dx* -needle aspiration is performed for a small cystic or solid lesion, while core biopsy is preferred for larger solid masses.

Management of migraine headaches

*First line: Tylenol, NSAIDs, supportive* *Triptans:* if refractory

Primary inciting event of acute cholecystitis

*Gallstone obstructing the cystic duct* w/ subsequent inflammation and infection

60 y/o woman with urinary urgency. Pt has also had involuntary loss of urine 2-3x/day. She has dysuria and nocturia and sometimes awakens to find her undergarments wet. PMHX reveals recurrent urinary tract infections. On exam the vulvar skin shows reduced elasticity with labia minora retraction. Vaginal epithelium is smooth and has areas of patchy erythema. No loss of urine with valsalva. Postvoid residual urine test are normal. Dx?

*Genitourinary syndrome of menopause* -vulvovaginal dryness, irritation, pruritus, *urinary incontinence*,*recurrent UTI* -pelvic pressure *PE*: narrowed introitus, pale mucosa, *low elasticity*, low rugae

Bell palsy treatment

*Glucocorticoids* acyclovir or valcyclovir -per some studies

Treatment of pyoderma gangrenosum

*Glucocorticoids* (Local or systemic)

Peripheral precocious puberty

*Gonadal or adrenal release of x's sex hormones*

3 day girl brought into clinic with copious, purulent eye drainage. She was born vaginally to a 31 y/o woman G3P3. Family declined prophylactic medication including vitamin K, erythromycin ointment, and hepatitis B vaccination for the newborn. Exam shows b/l eyelid edema, conjunctival injection and purulent discharge. The rest of the exam is benign. Dx?

*Gonococal conjunctivitis* -*2-5 days* of life -gram stain with gram negative intracellular diplococci -positive culture on modified MTM -*tx: IM ceftriaxone* (one dose) -prevent w/ erythromycin ointment note: C trachomatis can cause neonatal conjunctivitis but this occurs 5-14 days after birth, is milder, and was more watery dishcarge

Extensive & progressive non-painful ulceration lesions without lymphadenopathy, base may have granulation-like tissue.

*Granuloma inguinale* -donovanosis -*Klensiella granulomatis* -deeply staining gram negative intracytoplasmic cysts (Donovan bodies)

8 day old boy is brought to ED due to hypothermia and poor feeding. He was cool to touch this morning and would not breastfeed. Mom was rubella non-immune in 1st trimester, GBS positive, but received intrapartum abx was deferred due to planned c-section. Family has 2 dogs and a cat. T 95.2F. Exam shows hypotonic, lethargic infant with full anterior fontanelle. WBC 2,000 w/ 20% bands. Infant becomes apneic and requires intubation. Dx?

*Group B Streptococcus* -most common cause of neonatal sepsis *Late-onset GBS sepsis* -*hypothermia, lethargy, low WBC, L shift = neonatal sepsis* -*dx: CSF cultures* -*tx: empiric parenteral abx therapy* -prevention: maternal screening, intrapartum abx

35-37 week prenatal visit labs

*Group B streptococcus culture*

Origin of most arterial thrombosis (PVD)

*Heart*

management of spontaneous abortion

*Hemodynamically stable* -Expectorant/ medical management; *misoprostol* *Hemodynamically unstable* -Inevitable abortion -vaginal bleeding -cramping -dilated cervix -*surgical suction curettage*

Typically presents with prolonged bleeding after minor trauma e.g. hemoarthrosis. History of bleeding issues on mom's side. Dx?

*Hemophilia A* -x-linked recessive -prolonged PTT -normal platelets -*tx desmopressin and factor VIII*

33 y/o female with dull, aching right upper quadrant pain for several weeks. PMHX unremarkable. She takes OCP for the past 12 years. Exam shows hepatomegaly with moderate discomfort on deep palpation in RUQ. Alk phos 215, AST 45, ALT 40, GGT 92. US shows solitary hyper echoic 7-cm lesion in right lobe of the liver. dx?

*Hepatic adenoma* -benign epithelial tumors -young, middle-aged women -*risks: anabolic androgen use* and pregnancy -*US: shows well-demarcated, hyperechoic lesions* -*contrast CT:* early peripheral enhancement. -needle biopsy not advised (risk of bleeding)

Labs for primary ovarian insufficiency

*High GnRH* *High FSH* *Low estrogen* -women <40 y/o -amenorrhea, oligomenorrhea -hot flashes, fatigue (decreased estrogen)

Histological evaluation for newborns with fetal growth restrictions

*Histopathologic examination of the placenta* -assess for infection and/or infarction

15 y/o girl brought to the ER for severe HA n/v, and ab pain She has occipital HA 4 days ago that has worsened. n/v began a day ago. no chills, photophobia, changes in vision, or dizziness. There is a nontender palpable mass that extends from the suprapubic bone up to the umbilicus. Neuro exam shows b/l LE 3+ DTRs, and sustained ankle clonus. Serum B-hCG is elevated. Dx?

*Hydatidiform mole* -HTN, hyperreflexia, and positive pregnancy = *preeclampsia w/ severe features* *Molar pregnancy assoc.* -abnormal vaginal bleeding -+/- hydropic tissue -uterine enlargement > GA -Theca lutein ovarian cysts - due to ovarian stim via b-HCG -*hyperemesis gravidarum* -*preeclampsia, severe* -hyperthyroid -dx: "snowstorm" on US, qty B-hCG, histological contents -*tx: D&C, serial b-HCG post evacuation, contraception 6 mo*

37 y/o G2P1 women comes to ED for painful contractions. She is 24 weeks gestation, hasn't received prenatal care. Delivers a male fetus w/ no cardiac activity. Exam shows edematous, peeling skin. Scalp is edematous, but palate appears normal. No dysmorphic facial features. Abdomen is tense and fluid filled. Mom's labs: Hb 11.2, O, Rh negative, Antibody screen: neg, HIV: Neg. Dx?

*Hydrops fetalis* note: Her antibody screen is neg, meaning she doesn't have anti-D antibodies to cause Rh (D) alloimmunization

28 y/o primagravida is admitted at 10 weeks gestation. T 98.2F, pulse 96, RR 12/min, pH 7.49, PaCo2 54 mmHg, Bicarb 44. Dx?

*Hyperemesis gravidarum*

37 y/o woman comes in for persistent nausea and vomiting for 2 days intermittently. She is now unable to tolarate solids or liquids. No f/c/s, ab pain, diarrhea, constipation, or sick contacts. Sexually active and uses condoms inconsistently. Pt smokes 1/2 ppd. BP 130/88, pulse 108/min. Mucous membranes are dry and cap refil is delayed. Urine pregnancy test positive. UA has ketones. Dx?

*Hyperemsis gravidarum* -feat: severe, persistent emesis, >5% loss of pregnancy, dehydration, orthostatic hypotension -*tx: admission to hospital, antiemetics & IVF* note: twin gestations elevate hCG and progesterone higher

39 y/o woman G10 presents at 34 weeks gestation. She was dx w/ HTN 5 years ago for which she takes labetalol. She drinks 2 cups of coffee daily, no tobacco, alcohol or drugs. BP 142/ 82, fundal height is 30 cm, US shows biparietal diameter consistent with 32 weeks, abdominal circumference consistent with 27 weeks, and est fetal weight is 8th percentile. Etiology of findings?

*Hypertension* -fetal growth restriction is wt <10th percentile -2nd and 3rd trimester placental insufficiency (e.g. HTN) -*restriction of abdominal growth >> restriction in head growth*. -symmetric FGR is due to congenital disorders or 1st trimester infections

Patient with recent large volume blood transfusion who develops n/t around the lips and forceful flexion of the wrist with abduction of the thumb while taking blood pressure. Dx?

*Hypocalcemia* -*chelation of calcium by citrate* -*citrate* binds ionized ca2+ -citrate is rapidly metabolized btesy the liver -hypocalcemia is more likely to occur in pts w/ liver failure or *liver damage*

14 y/o girl is brought in to the office for heavy vaginal bleeding. Menses started a year ago and have been irregular but not painful. LMP 6 weeks ago, she soaks through a thick pad every 2-3 hours and bled through her clothing overnight. On exam there is dark red bleeding from the cervical os. Etiology?

*Hypothalamic-pituitary-ovarian axis immaturity* -*abnormal uterine bleeding* -menstrual bleeding <21 days or >45 days apart -immature HPO axis fails to produce appropriate qty/ratios of gnRH -first few years post menarche, cycles are *anovulatory* and present as *painless, irregular, heavy bleeding*

27 y/o nulligravid woman comes to office due to inability to conceive after a year of trying with her husband. Patient has regular periods, and has brief pelvis pain 14 days before her period starts. no dyspareunia. Patient has hx of PID. Best next step in management?

*Hysterosalpingogram* (laparoscopy)

Treatment for Wernicke encephalopathy

*IV thiamine followed by glucose*

Treatment of Wernicke's encephalopathy

*IV thiamine followed by glucose*

25 y/o woman presents due to heavy menses. Her periods have lasted 7 days rather than her usual 3 days for the past few months. Her periods have also been unusually heavy to the point that she has bled through her clothing while at work. She has noticed easy bruising and exam shows scattered petechiae across the body with a few large ecchymoses on the forearms. Labs: Hct 37%, Plt 24,000, Pt/PTT wnl. Peripheral blood smear shows normal and large platelets. Dx?

*Immune thrombocytopenia* -commonly acquired form of thrombocytopenia -*autoantibody* formation -*mucocutaneous bleeding* -ecchymoses, petechiae, purpura -*dx:* dx of exclusion, normal coag tests, platelet morphology, *HIV & HCV testing (commonly induce ITP)* -*tx:* observation if no bleeding. -*Corticosteroids* if plts <30,000. -*IVIG* & platelet transfusion if hemorrhage. -additional tests e.g. *ANA* are advisable if there appears to be another disorder present.

13 y/o girl brought to the office with lower ab pain for 4 days. She has had rectal pain with b/m, no melana, no frank blood. This has occurred several times over the past year and resolves after 2-3 days. No menarche, and never sexually active. No f/c/s, n/v, or abnormal vaginal discharge. Exam shows tenderness to deep palpation in the midline. External genitalia are Tanner III. Pelvic exam shows firm mass protruding between the labia majora. Dx?

*Imperforate hymen* -common anatomical cause of amenorrhea -hymen fails to fenestrate during development -infants present w/ bulging membrane due to mucus collection -resolves and pt is asymptomatic until menarche -adolescence present w *cyclic lower abdominal pain* in absence of apparent vaginal bleeding -when menstruation occurs, blood collects in the vagina behind the hymenal membrane (hemotcolpos) -*tx: incision of the hymen and drainage* of hemotocolpos

12 y/o girl with lower abdominal pain that was initially colicky and was relived with ibuprofen. Now pain is constant and has pain with defecation and sense of incomplete bowel evacuation. She has decreased appetite, no f/c no n/v/d. BMI 19. Exam shows symmetric suprapubic mass to the level of the umbilicus. There is a blue-tinged bulge between the labia. Rectal exam shows anterior tender, central mass. dx?

*Imperforate hymen* -incomplete degeneration of hymen -cyclic lower ab pain -*bulk sx e.g. defactory, urinary* -primary amenorrhea -*suprapubic mass (uterus)* -*blue-tinged vaginal mass* -*tx: hymenal incision and drainage*

25 yo G2P1 woman presents at 8 weeks gestation to initiate prenatal care. Her blood type is O negative, father is type O positive. First pregnancy had placental abruption. She received a dose of anti-D immune globulin at 28 weeks during her first pregnancy and again 1 day postpartum. Her anti-D antibody titer is currently 1:32. Explanation?

*Inadequate dose of anti-D immune globulin after first delivery* -1:32 shows she is alloimmunized e.g. sensitized -alloimmunization occurs when *mom Rh- w/ Rh+ fetus* -*blood type O negative = Rh negative* -*tx: anti-D immune globulin 28 weeks, and w/i 72 hours delivery*' -the Kleihauer-Betke test is used to determine the dose -risk of fetal blood cells entering maternal circulation -note: if father was Rh negative/ O negative, the fetus is not at risk for hemolysis

42 y/o G3P3 woman comes in with left breast swelling and pain. She weaned her youngest child from breastfeeding ~2months ago. She had mastitis 1 month ago and received abx. BMI 46.6. Exam shows left breast diffusely warm with erythematous with some dimpling. Dx?

*Inflammatory breast carcinoma* -aggressive breast cancer -*"peau d' orange"* (superficial dimpling, fine pitting) -*edematous, erythematous, painful* -*axillary lymphadenopathy* common = mets. -*dx: mammography and US, biopsy to confirm* -note: infiltrating ductal carcinoma or lobular breast carcinoma may cause dimpling, but erythema, edema, and peau d' orange are absent

52 y/o woman w/ pruritic rash on the inguinal region and vulva. OTC moisturizing cream does not improve sx. Exam shows beefy red plaques within the inguinal folds w/ mirror image pattern across the skin fold and multiple satellite lesions near the infection. Dx?

*Intertrigo* -satelite lesions in intertriginous area e.g. axilla and inguinal -*Candida albicans* -systemic corticosteroid use -*tx: clotrimzaole, ketoconazole*

34 y/o woman G3P2 at 33 weeks gestation comes to the ER due to continued leakage of fluid. Pt has has vaginal spotting, nl fetal movements. GBS positive in first trimester. T 102.5F, BP 90/56, pulse 109, fundal height 30 cm, speculum shows pooled fluid in the posterior fornix that turns nitrazine paper blue. Fern pattern is visualized on microscopy. Fetal HR 170. US shows fetus in transvere lie; deepest vertical pocked is 1cm of amniotic fluid. dx?

*Intraamniotic infection* -*risks factors: PROM*, PPROM -prolonged labor -internal fetal/uterine monitoring -repetitive vaginal exams -presence of genital tract pathogens -*dx: maternal fever, leukocytosis, purulent am* -*tx: broad spectrum abx* -*delivery* *Complications* -mom: postpartum bleed, endometritis -baby: preterm, PNE, encephalopathy

42 y/o nulligravid women with intermittent blood staining the left side of her bra. Hx of T2DM, currently on insulin and metformin. Exam shows no palpable breast masses, mammography shows no masses or calcifications. Dx?

*Intraductal papilloma* -*unilateral bloody nipple discharge* -no mass -no lymphadenopathy

48 y/o woman has "copper-colored" fluid from her right nipple first noticed last week during breast self-exam. Hx of schizophrenia dx at 20 y/o, takes acetaminophen for HA. Plans tennis regularly, denies tobacco, ETOH, or illicit drug use. Exam shows 1 mL or reddish brown fluid expressed from right breast. No masses or lymphadenopathy present. Dx?

*Intraductal papilloma* -unilateral bloody nipple discharge -no associated mass or lymphadenopathy -*tx: mammography & US, biopsy* note: fat necrosis - firm, irregular, NO discharge fibroadenoma - round, firm, NO discharge infiltrating ductal carcinoma - discharge w/ mass & lymphadenop

37 y/o G2P1 women comes to ED for decreased fetal movement for the last 2 days. No issues with pregnancy until a few weeks ago when she developed general itching that is worse in her hands and feet. She has also had nausea for 3 days, no v/d. Pt immigrated to the US and had no prenatal care. Fundal height is 38 cm. RUQ ttp, no rebound guarding. b/l 1 + pitting edema. Diffuse excoriations are noted on skin. Labs: Plt 140,000, T. bili 2.4. AST 516, ALT 884. total bile acid 110 (4-16). Dx?

*Intrahepatic cholestasis of pregnancy* -*3rd trimester* -general *pruritus* -*pruritus worse on hands and feet* -no associated rash -RUQ pain -*labs: high total bile, high AST/ ALT, high T.bili*

Asherman syndrome

*Intrauterine adhesions* ("Asher - Adhesions") -symptomatic *intrauterine synechiae* -due to infection -severe endometriosis -D&Cs, ablations, resection, *hysteroscopic resection* -*progesterone withdrawal test does not cause bleeding* -not a complication of cervical conization

3 day old boy is in the NICU for prematurity. Past 2 hours he has shown decreased spontaneous movement and decreased tone. He has been having seizures. Delivered vaginally at 28 weeks by a multiparous woman with cervical incompetence. Exam shows lethargic neonate with weak cry, tense fontanelle, and generalized hypotonia. CBC shows anemia. CRP wnl. Head US shows increased echogenicity in the b/l lateral ventricles. Dx?

*Intraventricular hemorrhage* -prematurity -low birth weight -vasculature less developed -majority are asymptomatic -*sx:* neurological changes; lethargy, hypotonia apnea, sz -bulging fontanelle -increased head circumference. -*dx:* cranial US

2 y/o boy is brought to clinic for routine wellness exam. His diet consists of cheese and yogurt. Family immigrated from Greece. No allergies, immunizations UTD. conjunctivae and mucous membranes are pale. Lungs are clear to auscultation bilaterally. 2/6 systolic murmur present. Hg 8, MCV 70. Dx?

*Iron deficiency anemia* -*risks:* premature, lead exposure -<1 y/o -*cows, soy or goat milk* -delayed introduction of solids ->1 y/o: >24 oz/day cows milk, Fe lacks in diet -*Dx:* Hb at age 1 -*Hgb <11, low MCV, high RDW* -RBC distribution varies bc amount of iron available for RBC synthesis varies throughout the day.

Single most common nutritional deficiency in infants and children

*Iron deficiency anemia* -often asymptomatic -*Risks:* maternal Fe def, *prematurity*, early *cow's milk <1 y/o* -human breast milk only has small amounts of vitamin D -All exclusively breastfed infants: *Vitamin D 400 IU daily* w/i first month of life.

Signs of hypogonadotropic hypogonadism in women

*Irregular menses and infertility* -*low FSH* -*low estradiol* -loss of GnRH secretion 2/2 *wt. loss, stress, or chronic sick* -1st line tx is management of underlying cause

15 y/o girl presents for primary amenorrhea. No changes in weight or nipple discharge, but has difficulty identifying various odors. Height is 3rd%. No breast tissue present, no axillary or pubic hair. US confirms uterus and 2 ovaries. FSH low, LH low. Dx?

*Kallman syndrome* -failure of migration of olfactory and GnRH neurons -46XX (karyotype consistent w/ phenotype) -*anosomina* (inability to distinguish odors) -hypogonadotropic hypogonadism -*low FSH/ low LH*

36 y/o woman G2P2 comes to office for 2 days of right breast pain. Recently replaced nursing w/ pumped milk. She has had f/c, aches, and fatigue. T 101.8, BP 110.60, Pulse 84. Exam shows 5-cm area of erythema, induration, and tenderness at the upper outer quadrant of the right breast as well as the right axillary lymphadenopathy. Dx?

*Lactation mastitis* -skin flora e.g. *staph A* -enters duct via nipple *risks:* -mastitis hx -engorgement -inadequate milk drainage -sudden increase in sleep -replacing nursing w/ formula or pumped milk -weaning -pressure on duct -poor latch

Late & post-term pregnancy

*Late-term: 41 wks* or more *Post-term: 42 wks* or more

24 y/o G1P0 woman comes to the office for her first prenatal visit. LMP 9 weeks ago. Prior to conception, she had regular 28-day cycles with heavier and longer periods after stopping oral contraceptives. She says voiding is uncomfortable and often feels incomplete bladder emptying. Exam shows 15-week sized, mobile uterus with irregular contour. What most likely explains the size-date discrepancy?

*Leiomyomata uteri*

36 y/o AA woman G2P0 comes in with "heavy feeling" in her lower abdomen for the last year. Menses occur at 28 day intervals and last 9-10 days. She has had 2 first trimester miscarriages in the last year. Exam shows mobile, globular mass with several protuberances located below the umbilicus. Urine pregnancy test is negative. dx?

*Leiomyomata uteri* -most common pelvic tumor seen in women -prolonged women

Non-injectable birth control w/ amenorrhea

*Levonorgestrel intrauterine device* -highly efficacious -long-acting -reversible contraception -thickens cervical mucus -impaired implantation -*amenorrhea* -minimal side effects

35 y/o male w/ gynecomastia, has 1-cm nodule in right testes. Labs show LH, FSH are low, Testosterone nl, Estradiol 115. B-hCG & AFP undetectable. Dx?

*Leydig cell tumor* -sex cord stromal tumor -*estrogen (gynecomastia)* -*testosterone (acne)* note: Sertoli: rare, sometimes assoc w/ x's estrogen Seminoma: B-HCG, AFP are negative Nonseminoma: yolk sac, TT, B-HCG, AFP are positive

58 y/o postmenopausal woman presents with vulvar pain for several months. She also has odorless, pink-tinged vaginal discharge and pruritus .On exam she has gingival lace-like, reticular appearance, and there are multiple white plaques on the tongue and palate. The labia minora have glazed, brightly red erosions with white striae along the margin. Vaginal introitus is stenotic, and speculum exam shows friable, red vaginal epithelium with serosanguinous discharge. Dx?

*Lichen planus* -women 50-60 y/o -vulvar pain, pruritus -*glazed, bright red vulvar erosions w/ white striae* (wickham striae) -*serosanguinous vaginal discharge* -*lace-like reticular erosions on the gums* and palate cause oral ulcers -dyspareunia -erosive variant -papulosquamous variant -*dx:* vulvar biopsy *punch biopsy* -*tx: high potency corticosteroids*

54 y/o woman with vulvar pruritus and burning that prevents sleeping that is worsening. Patient also has painful defecation. PMHX of alopecia areata and hot flashes since menopause. Exam shows b/l labia majora w/ excoriated, pale, thin, skin, and the labia minora are not visible. She also has pale white wrinkled skin around the perianal region and a small anal fissure. Dx?

*Lichen sclerosus* -*workup: punch biopsy* of adult-onset to r/o malignancy -*tx:* superpotent corticosteroid ointment e.g. *clobetasol*

Cause of abdominal pain in patient with HELLP syndrome?

*Liver swelling* with distention of hepatic (Glisson's) capsule -centrilobular necrosis -hematoma -thrombi in portal system

Breast feeding benefit to infant

*Lower rates* -AOM -URI, GI -UTI -necrotizing enterocolitis *Lower rates of* -T1DM -*childhood cancer* *only contraindication = galactosemia*

32 y/o G2P1 mom presents at 18 weeks gestation for new facial hair and acne for the past few weeks. No bleeding or pain. No n/v. BMI 24, gained 5 lb over past 2 months. Exam shows chest and back acne and coarse hair on the upper lip, chin, and periareolar area. US shows b/l 7 cm solid masses in the ovaries. dx?

*Luteomas of pregnancy* -benign ovarian tumor -*b/l masses* -*hyperandrogenism* -theca lutein cysts -*spontaneous regression* of masses after delivery -*Tx: observation and expectant*

Small & shallow nonpainful ulcer w/ large painful, coalesced inguinal lymph nodes.

*Lymphanogranuloma venereum*

Treatment for a 16 week gestation mother who is Rubella non-immune?

*MMR vaccine postpartum* -prevents future infection -avoids risk of congenital rubella

Diagnosis of Cerebral Palsy

*MRI brain* (hypoxic/ischemic lesions) -EEG -genetic/ metabolic testing

Treatment for spinal cord compression

*MRI, IV glucocorticoids* -rad/onc & neurosurgery consult

32 y/o primigravida comes to the hospital 28 weeks gestation due to painful contractions. Began 2 hours ago, occur every 5 minutes. Patient had pelvic pressure a few days ago and cervix was closed at the time. Current exam shows cervix 3 cm dilated and 90% effaced with a bulging bag. US shows vertex presentation. FHR wnl, contractions q5min. Betamethasone and indomethacin are administered. Next step?

*Magnesium sulfate*: <32 weeks preterm labor

42 y/o woman in post op unit 15 min after surgery develops sudden-onset tachycardia and dyspnea. Pt required 2 units of PRBC, has 10pack smoking hx. T 100F, BP 160/110, Pulse 134, RR 38. Pt appear diaphoretic, has shallow breathing. lungs are clear, b/l LE have generalized rigidity. Foley produces brown-appearing urine. Dx?

*Malignant hyperthermia* -genetic mutation alters control of intracellular calcium -triggered by volatile anesthetics, succinylcholine, x's heat -masseter muscle/ generlized rigidity -sinus tachycardia -hypercarbia resistant to increased minute ventilation -rhabdomyolysis hyperkalemia -*tx: resp/vent support*, cessation of anesthetic, *Dantrolene*

Evaluation for breast mass

*Mammorgaphy is first line imaging* -woman > 30 -paplable mass US preferred if < 30 y/o

33 y /o G7P6 mom presents at 39 weeks gestation undergoes induction of labor for new onset HTN. She has a history of severe lower uterine fibroids, BP 160/90, pregnancy wt 253, she gained 30 lbs during pregnancy. Fundal height is 43 cm. 22 hours after labor induction, the fetal head delivers and retracts into the maternal perineum. Gentle traction fails to deliver the anterior fetal shoulder. What is the greatest risk factor for this pathology?

*Maternal age* -*shoulder dystocia* -failure of usual obstetric maneuvers to deliver fetal shoulder -*risks:* fetal macrosomia, maternal obesity, x's pregnancy wt. gestational DM, post term pregnancy -*warning signs:* protracted labor, *retraction of fetal head into the perineum after delivery (turtle sign)*

Neonate born 9lb 14 oz presents w/ shoulder dystocia. Likely etiology?

*Maternal hyperglycemia* -hyperinsulinemia -macrosomic neonates (risk of shoulder dystocia)

Most common cause of vaginal bleeding and discharge in the neonatal period

*Maternal withdrawal of estrogen* -lasts < 1 week -exam is otherwise wnl -may lead to temporary breast bud and external genitalia engorgement during first month of life -provide reassurance this is normal

14 y/o girl brought in for facial puffiness, decreased appetite for a few days. Pt recently immigrated from China. Vitals wnl. Exam shows periorbital and pretibial edema. Labs shows albumin 2.2. HBsAg positive, HBeAg positive. Anti-HBsAg negative. Anti-HVC negative. Anti-HIV negative. Urinalysis shows 4+ proteinuria, no RBC, no casts. Dx?

*Membranous nephropathy* -hep B is a risk factor -vaccination has reduced rates of *hep B associated* membranous nephropathy -*immigrants* from endemic areas should be screened for Hep B note: MPGN can cause nephrotic or nephritis syndrome and is associated w/ hep B, but is much less common.

37 y/o woman G2P1 at 8 weeks gestation comes for follow up. Initial visit US showed intrauterine gestational sac with a yolk sac but no fetal pole. B-hCG was 27, 325 IU/L. She has had appropriate prenatal care. Exam shows closed cervix and no vaginal discharge or bleeding. Bimanual exam shows normal-sized, retroverted uterus with no cervical motion or adnexal tenderness. US is unchanged, B-hCG is 25, 659 IU/L. Dx?

*Missed abortion* -intrauterine pregnancy -demise at <20 weeks -prior to expulsion of pdts of conception -asymptomatic, *no bleeding "abortion missing blood"*(the only abortion w/o) -decreased pregnancy sx (n/v breast tenderness) -*closed cervix* -*embryo without cardiac activity or empty gestational sac w/o fetal pole* (e.g. no embryo) -B-hCG normally increase until the end of the first trimester -*decreasing B-hCG indicates demise*

Breast cancer risk factors

*Modifiable* -nulliparity -HRT -Increased age at first birth -ALCOHOL --> dose dependent Nonmodifiable -genetic mutation or breast cancer in 1st degree relative (BRCA, HER2, breast ca <50 y/o) -Caucasian -increasing age -early menarche, late menopause OCPs decrease risk of OVARIAN cancer (NO EFFECT ON BREAST CANCER!!!)

Monochorionic diamniotic twin gestation complications

*Monochrionic twins c/b* -*twin-twin transfusion syndrome* -heart failure, morbidity -unbalanced ateriovenous anastomoses, shared placental vessels

3 week old boy in NICU for emesis that is *bilious* and non-bloody. Born at 28 wks, *weighed 900g*. Has had continuous *NG formula feeds* and is gaining wt. abdominal distention w/ hypoactive bowel sounds. Dx?

*Necrotizing enterocolitis*

3 week old boy presents to ED for a seizure. Born term to 23 y/o woman who had no prenatal care and delivered baby at home. Mom says he was healthy until this morning. He had a 4-min generalized tonic-clonic seizure w/ mild perioral cyanosis. T 101F, child is lethargic but arouses to painful stimuli. Pupis reactive, anterior fontanelle full. Brain imaging reveals patchy areas of increased attenuation in the cerebral cortex, and edema and hemorrhage in the left temporal lobe and brainstem. No intracranial calcifications noted. Dx?

*Neonatal herpes simplex virus infection* -vertical transmission e.g. perinatel, postnatal, IU -*feat:* keratoconjunctivitis, seizures, fever, *temporal lobe hemorrhage/ edema*, sepsis, hepatitis, PNE -note: VSV can have sz/ CNS path, but cortical atrophy occurs -*encephalitis, seizures, full fontanelle* -*dx:* viral surface cultures, HSV PCR blood/CSF -LP often yields bloody tap -*tx: acyclovir*

19 day old girl is brought in to the ED due to difficulty feeding. Mom is 24 G2P2, she has not been waking for feeds and seems sleepier. T 35.1C, BP 78/52, Pulse 150/min, RR 62. Infant has full fontanelle, jaundice of the chest, scleral icterus, and dry mucous membranes, infant also has decreased tone. Dx?

*Neonatal sepsis* -*fever or hypothermia* -poor feeding -*jaundice* -CNS signs e.g. *lethargy* -abnormal WBC -left shift -*dx: blood/urine culture, CSF* -*tx: parenteral abx*

Pellagra

*Niacin deficiency* -Vitamin *B3* -*a*lcoholism -*a*norexia nervosa -malabsorption disease e.g. Crohn disease -Dietary niacin deficiency -*sx: D*iarrhea, *D*ermatitis, *D*ementia, *D*eath -depression, distractibility -*associated with malabsorptive bowel disease* "*Allegra* Cole has *AADDD*" - 3 D for vit B3

management of preeclampsia (when to deliver & meds)

*No severe* feat: *37 weeks* delivery *w/ severe* feat: *34 weeks* delivery MgSO4 *Antihypertensives:* - Labetalol not recommended if pt has bradycardia < 60bpm - *Hydralazine* - Nifedipine is PO and thus not tolerated by pts w/ emesis.

7 y/o boy with severe facial acne that developed over past few months that is resistant to topical agents. He also has significant growth, sever cystic acne over face and shoulder, testicular volume of 2mL. Bone age is 2 SD above his age. Baseline LH is low and does not increase to GnRH stimulation. Dx?

*Non-classic congenital adrenal hyperplasia* -*peripheral precocious puberty* -advanced bone age -LH levels distinguish between peripheral and central. -low/normal LH levels are due to inhibition of the hypothalamus by high levels of androgens. -*21-hydroxylase deficiency*/CYP21A2 -impaired conversion of 17HP to 11DC, *shunting 17HP to androgen pathway*

Pt that recently started breast feeding now develops pain with intercourse, hot flashes, night sweats, and vulvovaginal atrophy. Tx?

*Non-hormonal lubricants and moisturizers* -refractory cases may require vaginal estrogen -elevated prolactin in breast feeding suppresses GnRH causing hypoestrogenism

27 y/o man presents with cough, chest discomfort, and dyspnea. He has lost 10 pounds over the past 2 months. 10-pack-year smoking history. No illicit drug use. CXR shows large anterior mediastinal mass. He has elevated b-HCG and AFP. Dx?

*Nonseminomatous germ cell tumor* -elevated *b-HCG, and AFP* (non produced by seminomas) -large anterior mediastinal mass -*Dx: biopsy* testicular US r/o small primary tumor -almost all germ cell tumors of anterior mediastinum are primary note: benign teratomas do not produce tumor markers

Next step in pregnant patients with decreased fetal movement.

*Nonstress test* -maternal sensation of decreased fetal movement -fetal hypoxemia -acidemia -increased risk of fetal demise -must be further investigated with nonstress testing

26 y/o nulliparous woman w/ severe pain during intercourse. Menses are painful, and occur every 30 days and last 5 days. She has pain w/ passing stool, and sporadic pelvic pain that waxes and wanes with no discernible triggers. She and her husband are not planning to have children for another few years. Tx?

*OCP* -*Endometriosis* -*chronic pelvic pain* (> 6 months) -*adnexal mass* or fullness -women of repro age -*"3 Ds"* -*d*ysmenorrhea -*d*yspareunia -*d*yschezia -*infertility is commonly the sole presenting sx* -*tx:* NSAIDs or combined OPC -1st -reduces pain by ovulation suppression, may result in atrophy of endometrial tissue -*failure of OCP, adnexal mass, and infertility = LAPROSCOPY*

Treatment for PCOS

*OCP* for menstrual regulation *Clomiphene citrate* for ovulation induction

Tx for Bartholin duct cyst

*Observation* *expectant management if asymptomatic* -soft, mobile, nontender, cystic mass -located at base of the labia majora -4 and 8 o'clock positions -resultant obstruction causes proximal duct distention/ cyst formation -*causes:* accumulation of mucus or secondary to edema and trauma, many are idiopathic

13 day old boy is brought in for a well-newborn exam. Infant was born 38 weeks gestation and is doing well postpartum except both eyes have mild eyelid swelling, conjunctival injection, and a scant amount of watery, slightly mucopurulent discharge. Treatment?

*Oral azithromycin* -Chlamydial conjunctivitis -mild eyelid swelling -*watery*, serosanguineous or *mucopurulent* eye discharge -*tx: PO macrolide* note: gonoccocal conjunctivitis has marked eyelid swelling, profuse purulent discharge and corneal edema/ ulcerations (tx: IM ceftriaxone)

19 y/o w lower abdominal pain that started this morning during yoga. Pain has intensified over past 10 hours. She has vomited 3 times. LMP 1 week ago. No sexual activity. PE shows diffuse lower abdominal tenderness, L>R. Pelvic US shows complex left adnexal mass without doppler flow. Best next step?

*Ovarian torsion* *Risks* -ovarian mass -women of repro age -infertility tx w/ induction *Signs/sx* -sudden-onset unilateral pelvic pain -n/v -palpable adnexal mass US shows *adnexal mass w/ absent doppler flow* to ovary *Tx* -*Laproscopy* w/ -*detorsion* -ovarian *cystectomy* -oophorectomy if necrosis or malignant

28 y/o woman GOPO presents for infertility for over a year. Menarche age 13, irregular menstrual cycles, LMP 8 weeks ago. Had tirchomoniasis as a teen. BMI 28, vitals normal. Pelvic exam unremarkable. Free testosterone is elevated. Dx?

*PCOS* -androgen x's -menstrual irregularities -polycystic ovaries on US -high testosterone -high estrogen -LH/FSH imbalance -can lead to *endometrial cancer* -*tx: weight loss, OCP, Clomiphene for ovulation induction* -*lack of LH surge results in failure of follicle maturation*

Infectious genital ulcers

*Painful * -*HSV: small vesicles or ulcers*, mild lymph nodes -H. ducreyi: large, deep ulcer, severe nodes *Painless* -T. pallidum: single ulcer, regular border -Chlamydia trachomatis: small, shallow ulcer

46 y/o nulliparous woman comes in for a routine exam. LMP a week ago. No surgical hx, no smoking or ETOH. Sexually active with her husband, and they do not use protection as he had a vasectomy. Exam shows 5-cm irregular, right adnexal mass. Pregnancy test is negative. Next step?

*Pelvic US to r/o malignancy* -adnexal mass arising from ovary or fallopian tube requires further investigation -adnexal mass may be the only sign of *ovarian cancer* *Epithelial ovarian carcinoma* -*Acute: SOB, obstipation/ constipation w/ n/v, ab distention* -labs: *elevated CA-125* -*US: solid mass, thick septations, ascites* -*tx: exploratory laparotomy*

54 y/o woman G3P3 comes to the office due to difficulty voiding for the past few weeks. Difficulty initiating stream and emptying completely, no dysuria or hematuria. Pt had 2 episodes of nocturia every night, but no involuntary leaks. 10 months ago had b/l salpingo-oophorectomy + hysterectomy for ovarian cancer. Exam shows protruding soft, non-tender mass at the level fo the hymen that descends past the introitus with Valsalva maneuver. Dx?

*Pelvic organ prolapse* - cystoele - bladder - rectocele - rectum - enterocele - small intestine - procidentia - apical prolapse - uterus, vaginal vault *risks:* obesity, multiparity, *hysterectomy, postmanopausal* *signs/sx: pelvic pressure, obstructed voiding, urinary retention* -urinary incontinence, constipation, fecal urgency, sx dysfunction *tx: weight loss, pelvic floor exercises, vaginal pessary, surgery*

Treatment for 13 y/o girl with signs of Rheumatic fever?

*Penicillin prophylaxis* -prevents future infections -limits the progression of heart disease

6 hour hold boy is evaluated in the nursery. Mom was previous IV drug user. Third trimester labs showed, HbsAg: positive, Anti-HbsAg: negative. Next step?

*Perinatal hepatitis B* -90% risk of vertical transmission w/o prophylaxis -<2% risk after prophylaxis -chronic infection in 90% or perinatally infected -*Tx:* -*1. HBV vaccine* -*2. HBIG*

Lacerations that causes perineal edema and pain with urination s/p vaginal delivery?

*Perineal lacerations* *tx:* NSAIDs an supportive care, sitz baths

45 y/o woman comes in for irregular menstrual bleeding. She has had intermenstrual spotting. Bleeding occurred 1-2 days between menstrual cycles but has now become progressively prolonged and heavy. Previous progestin-releasing intrauterine device for contraception was removed 2 year ago. BMI 38, exam shows dark red blood at the cervical os. Endometrial biopsy shows endometrial hyperplasia. Cause?

*Peripheral aromatized estrogen* -*obese women have high estrogen* -high adipose tissue -high estrogen causes chronic an-ovulation, which results in continued stimulation of the endometrium -adipose tissue increases peripheral conversion of androgens to estrone -causes *unopposed uterine estrogen exposure*

Patient with seizure disorder recently treated for UTI presents with signs of cerebellar dysfunction: horizontal nystagmus, broad based gait, overshooting finger-nose testing, and hyperreflexia. Dx?

*Phenytoin toxicity* -*acute toxicity:* horizontal nystagmus, ataxia, dysmetria, slurred speech, n/v, hyperreflexia -*severe toxicity:* AMS, coma, seizures, death -*rapid infusion:* hypotension, bradyarrhythmia -highly protein bound and *metabolized by CYP450* -meds that inhibit CYP450 e.g. TMP-SMX or displace from plasma proteins (valproate) increase toxicity

24 y/o woman G1P0 presents at 26 weeks gestation due to increased urinary frequency and back pain. She also has a sharp, pulling pain in her right groin. No n/v/d or bleeding. She has had recurrent nephrolithiasis in the past. Renal/ pelvic US shows b/l enlargement of the kidneys (R>L), and dilation of the renal pelvis and proximal ureter on both sides. Dx?

*Physiologic hydronephrosis of pregnancy* -starts *1st trimester*2/2 high *progesterone* levels -progesterone = *ureteral dilation*/ decreased peristalsis -more pronounced in the *2nd/3rd trimesters* -urinary frequency -nocturia -back pain -renal US shows *b/l dilation of renal pelvises* -occurs due to *increased maternal blood volume* -increased renal filtration -greater renal vasculature and interstitial tissue -*tx: no additional treatment*

37 y/o G7P2A4 presents with labor pains. She delivered her first child vaginally at 16 y/o, uncomplicated. She has 4 elective terminations followed by a c-section at term for breech presentation. She dilates quickly to 10 cm and delivers a healthy boy. The umbilical cord avulses from the placenta, requiring manual extraction in pieces. During the removal, the pt develops profuse vaginal bleeding unresponsive to uterotonic meds. Dx?

*Placenta accreta* -uterine *villi attach directly to the myometrium*

40 y/o woman G2P1 comes in for prenatal visit. 10 weeks gestation, no PMHX. Her husband and her son are healthy, but she has a cousin with Down syndrome. B-hCG and fetal heart tones present. Next step?

*Plasma cell-free fetal DNA testing*- maternal plasma -women > 35 are increased risk fo fetal aneuploidy -performed at 10 weeks -99% sensitivity and specificity for trisomy 21 -identifies fetal sex and sex chromosome disorder -*definitive karyotypic diagnosis: chorionic villus sampling* (invasive, risk of SAB), amniocentesis -*quad screen:* 2nd trimester, neural tube defects, not dx

6-hour old girl is evaluated in the newborn nursery for respiratory distress. Born at 37 weeks via spont vag delivery after induction of labor 2/2 severe preeclampsia. Birth weight <3rd percentile, vital stable, exam shows plethoric infant with tachypnea, and CLTA b/l. CXR wnl. Hct 71%, Glc: 35. Dx?

*Polycythemia* -Hct > 65% (2 SD above mean) -x's transfusions -intrauterine hypoxia -*maternal DM* -genetic conditions (*Trisomy 21*) -high blood *viscosity limits organ perfusion* and can cause *respiratory distress* -*hypoglycemia*, and poor feeding. -*signs/ sx: lethargy, irritability, and jitteriness, RDS*, ta -exam shows *ruddy/plethoric appearance*, otherwise asymptomatic -*tx: hydration by PO or glucose*-containing parenteral fluids

21 y/o woman is evaluated for nausea, vomiting, and severe headache. HA developed last night after getting out of bed and walking to the newborn nursery. Tried Tylenol and ibuprofen to no avail. Her sx occur whenever she gets out of bed. No dizziness, changes in vision, or loss of consciousness. She had a spontaneous vaginal delivery 2 days ago for which she underwent induction of labor ad had an epidural placed. Neck stiffness evident, pt cannot sit up due to severe nausea. B/L LE edema up to the knees. Dx?

*Postural puncture headache* -after LP or neuroaxial anesthesia -within 72 hours of procedure -*positional (worse when upright, improves when supine)* -neck stiffness -photophobia -diplopia -hearing loss, tinnitus

Spontaneous abortion

*Pregnancy loss < 20 weeks* -*risks: older, previous SAB, substance abuse* -*tx: expectant, misoprostol, D&C if infection or hemodynamically unstable* -Rho (D) immune globulin -*Path report* -*comp: bleeding, retained pdts* of conception, septic abortion, uterine perforation, intrauterine adhesions

5 y/o girl with pubic hair, also has dark axilla. No HA, visual changes, or abdominal pain, or behavioral changes. She is obese and is currently on a diet/ exercise program. She has facial acne. no breast buds, and bone age is normal. Dx?

*Premature adrenarche* -obese children -early activation of adrenal androgens -acne -pubic and axillary hair -bone age normal

2 day old girl develops seizures and bulging fontanelles. T 36.8. Pulse 180. Cap refill >4 sec. Tachycardic. Cranial US shows bilateral hemorrhage involving the germinal matrix, lateral ventricles, and surrounding brain parenchyma. Dx?

*Prematurity* -*intraventricular hemorrhage* due to germinal matrix vessel rupture -many premies are asymptomatic and should be screened by *cranial US*.

42 y/o woman presents with recurrent abdominal bloating, fatigue, and hot flashes that improves after menses. These sx have been occurring for the past 4 days and make her "cranky."Pt has missed work due to sx. PMHX of migraines w/ aura for which she takes beta blockers. She is in a monogamous relationship w/ her BF and uses spermicidal foam for birth control. Dx? Next step?

*Premenstrual syndrome* -bloating, fatigue, HA, flashes, breast ttp -anxiety, irritability, mood swings -*estrogen-containing med contraindicated* in pt w migraines w aura

Presentation and Pathophysiology of AAA

*Presentation* -minimal sx until drastic expansion or ruptures -*pain* is most common sx -proximal aneurysm: upper ab pain/flank/ *back pain* -distal lesions: lower ab pain or groin pain *Rupture* -*Retroperitoneum bleed* -may temporarily contain within retroperitoneum -pts can remain hemodynamically stable -delayed presentation

Strongest risk factor for preterm labor

*Previous pregnancy with preterm labor* -other risks: cervical surgery e.g. cold knife conization -*eval w/ transvaginal US* -*measurement of cervical length* in 2nd trimester -short cervical length is a strong predictor or preterm -cervix </= 2 cm or </= 2.5 w/ hx of preterm

14 y/o girl is brought into the office by her mother because she has not started menstruating. There is no breast development or axillary hair, Pelvic exam reveals normal external female genitalia and no pubic hair. US confirms the presence of a uterus. Next step?

*Primary amenorrhea* -at least 13 y/o w/o 2nd sex characteristics -initial pelvic US: presence or absence of uterus -*In those with uterus: next check FSH level* -central causes of amenorrhea have a low to normal FSH level -peripheral causes of amenorrhea have a high FSH level note: GnRH stimulation test is not performed in evaluation of primary amenorrhea bc it cannot distinguish between hypothalamic and pituitary etiologies and provides no additional info

15 y/o girl comes in for changes in period. Over the past 3 months she has developed malaise and dizziness 2 days prior to menstrual period w/ associated continuous lower abdominal pain that radiates to her thighs. Sx resolve on the second day of menses. Pt is not sexually active, LMP a week ago. Treatment?

*Primary dysmenorrhea* -*x's prostaglandin* production -*< 30 y/o* -*BMI <20* -tobacco use -menarche age <12 y/o -*heavy/long menstrual periods* -sexual abuse -*sx: pain 2-3 days of menses, n/v/d, normal exam* -*tx: NSAIDs, combined-OCP*

33 y/o woman G2P2 presents with abnormal uterine bleeding. 10 months ago she has SAB complicated with postpartum hemorrhage requiring PRBC and suction curettage. She has had increasingly irregular menses and has been amenorrheic for 3 months. Not on contraceptives. Pt lost 30lb since delivery. BMI 22. Exam shows minimally rugated vagina; uterus is small and non-tender. Urine pregnancy test negative. TSH, prolactin are normal. FSH is elevated. US shows thin endometrial stripe. Dx?

*Primary ovarian insufficiency* -*amenorrhea < 40 y/o* -*accelerated ovarian primordial follicle depletion* - lack of eggs -hypoestrogenic sx e.g hot flashes -high FSH -low estrogen

39 y/o woman G1P0A1 comes in for f/u of abnormal Pap test that showed atypical glandular cells. 2 years ago pt had 1st trimester SAB after conceiving via ovulation induction. Since then, she had menses every 2-3 months with frequent spotting. She doesn't use contraception bc she's trying to conceive. BMI 41, exam shows dark, velvety lesions on her neck folds and axilla. UA negative. Endometrial biopsy shows atypical endometrial hyperplasia. Most likely cause of condition?

*Prolonged unopposed estrogen exposure* -obesity (peripheral conversion of androgens to estrogen) -chronic anovulation e.g. PCOS -estrogen causes proliferation of endometrium to allow implantation -progesterone decreases endometrial proliferation (ovulation) -*women 35 y/o require colposcopy w/ endometrial bx* -*risks:* nulliparity, early menarche, late menopause, tamoxifen

35 y/o woman here for her first prenatal visit. Her LMP was 2 months ago. She has had morning sickness, and abdominal distention and breast fullness. US shows thin endometrial stripe. Two office urine pregnancy tests are negative. Dx?

*Pseudocyesis* -sx of pregnancy -belief of pregnancy -*thin endometrial stripe* -negative pregnancy test -*somatization of stress* -affects HPO axis -nonpsychotic patient that believes she is pregnant

38 y/o G5P5 woman evaluated for painful ambulation postpartum day 1. No pain w/ lying down but has sharp lower midline abdominal pain radiating down legs while walking. Received epidural during pregnancy. Pregnancy complicated by shoulder dystocia relieved w/ MR maneuver. Exam shows ttp inferior to bladder, b/l LE edema, no erythema. Vitals wnl. Dx ?

*Pubic symphysis diastasis* -*risks:* macrosomina, multiparity, operative delivery -*signs/sx: difficulty ambulating, radiating suprapubic pain* -*tx:* conservative, NSAIDs, PT, pelvic support

Pathophysiology of respiratory distress in patients with preeclampsia

*Pulmonary edema* in preeclampsia -generalized *arterial vasospam* -*high SVR*/afterload -*hyperdynamic heart* to try to overcome the systemic HTN -additional factors: poor renal, low albumin, endothelial damage/ increased capillary permeability

Skin lesions associated with inflammatory bowel disease

*Pyoderma gangrenosum* -begins as small pustule -*rapidly progressive, painful ulcer with purulent base & violaceous border* -precipitation of ulceration at site of injury -40-60 y/o -women > men

29 y/o G1PO presents at 34 weeks gestation. Pt has SLE with positive anti-Ro/SSA aby but no flares during pregnancy. Meds include hydroxychloroquine, low-dose asa and a prenatal vitamin. Nonstress test at 10 minutes shows no accelerations. Dx?

*Quiet fetal sleep cycle* -*nonreactive NST = no accelerations* -most common cause: quiet fetal sleep cycle (<40 min) -typical NST is 20 min, but *a nonreactive NST is extended* -ensures that fetal activity outside of quiet sleep is captured

36 y/o G2P1 patients presents at 32 weeks gestation with dull, low back pain that is radiating to the b/l LE. Pain is minimal in the morning but increases with activity and at the end of the day. She also notices ankle edema and numbness in her feet at the end of the day. She also has nocturia and urinary frequency. patient has wide lateral gait. Treatment?

*Reassurance and conservative management* -low back pain during pregnancy -enlarged uterus causes exaggerated lordosis -joint/laxity from high progesterone/ relaxin -weak abdominal muscles -decreased lumbar support -*risks: x's weight gain, chronic low back pain*, back pain in previous pregnancy, multiparity -imaging: not indicated -*tx: behavior modification, heating pads, analgesics*

14 y/o boy presents for breast lump. Has had a lump for the past 2 months. No PMHX, smokes 1-2 cigarettes per day. Exam shows tender, galndular, right subareolar breast tissue that is 3 cm in diameter. Tanner 3 genitalia. There is no redness or warmth, the left chest is flat w/ masses. Next step?

*Reassurance and observation* -*pubertal gynecomastia* -*imbalance of estrogens & androgens* during mid-puberty -tanner stage 3-4 -small, firm, unilateral or bilateral subareolar mass -no pathologic feat. (no discharge, axillary lymph nodes, systemic illness) -*tx: reassurance and observation, resolves w/in 1 year*

Normal physiologic changes in pregnancy

*Renal/Urine* (high CO/UOP) -high GFR -low BUN -low Cr -urinary frequency -mild hyponatremia (Na excretion, high ADH) *Heme* (high volume/ hormone reg) -anemia (dilutional) -prothrombotic (low total protein S/high fibrinogen/ CFs) *CV (high CO/ low SVR)* -tachycardia

18 month old girl presents with UTI. She is treated with abx and her sx resolve. Next step?

*Renal/bladder US* -*risks:* F, uncircumsized, vesicoureteral, anatomic defects -+/- renal US & voiding cystourethrogram

14 y/o boy comes in for 2 days of fever and nasal discharge. He has malaise, fatigue, and myalgia. FHX negative for kidney disease. incidental urine dipstick testing shows 2+ proteinuria but no hematuria, pyuria, or active urine sediment, Next step?

*Repeat dipstick testing on two subsequent occasions* -transient proteinuria, most common cause of isolated proteinuria in children -re-evaluate to r/o persistent proteinuria, which requires further eval for underlying renal disease

39 y/o woman G1P0 presents at 32 weeks gestation. She has a hx of HTN dx at 26 weeks gestation, managed w/ labetalol weekly and biophysical profiles. Her BP is 135/85. UA shows trace protein. Non-stress test is reactive, showing baseline of 140 bpm and 3 accelerations. Biophysical profile for BMTA shows 2,2,2,2 for a total score of 8. What is the most appropriate next step in management?

*Repeat testing in 1 week* -*normal BPP is 8-10* -*normal NST - at least 2 heart rate accelerations* -normal BPP rules out fetal hypoxia -*pt has gestational HTN* -she needs *weekly BPPs starting at 32 weeks* gestation -maternal comorbidities eg. HTN require antepartum fetal surveillance to screen for fetal compromise

52 y/o women presents to ED with worsening chest pain and SOB for the past week. Pt has right-sided "stabbing" pain with breathing. Has frequent pain in her hands and feet, pain in morning while walking, and unable to bend her fingers to hold her coffee. No meds/ pmhx. BP 142/80, BMI 30. Wrist and small joints mildly swollen. Hct 32, LDH 70, ANA negative, CXR shows pleural effusion, thoracentesis shows 4 g/dL protein, and LDH 950, glucose 10. Dx?

*Rheumatoid arthritis* (Rheumatoid effusion)

Lung pathology in rheumatoid arthritis

*Rheumatoid effusions* -*exudative effusion (inflammation)* -very low glucose e.g. < 50 -very high LDH e.g. > 700 -low pH resembles bacterial empyema

11 month old girl presents with a rash. She had a low grade fever for the past 3 days which was controlled with Tylenol. The rash started on her face but then spread to her chest, abdomen, and extremities. No cough, rhinorrhea, nasal congestion, v/d. T 100.4F, BP 100/50, pulse 88/min, rr 18/min. Pt also has ttp of sub-occipital, posterior auricular, and posterior cervical areas. Also has a patchy erythema of the soft palate. Dx?

*Rubella (German measles)* -*congenital:* hearing loss, cataracts, PDA -*children:* fever, *cephalocaudal spread of maculopapular rash* -*dx: serology* -*prevention: live attenuated rubella vaccine* note: palatal lesions and inflammation of the *posterior auricular/ sub-occipital nodes* are not expected in parvoB19/ erythema infectiosum.

Tx for ER visit migraine refractory to NSAIDs, Tylenol and associated with n/v? (SQ med and IV med)

*SQ triptan* *IV entiemetic - prochlorperazine* -*avoid* triptans and ergots in pts w/ *significant coronary artery disease*; risk of coronary vasospasms

34 y/o woman G2P1 at 34 weeks gestation presents to est care. Had previous prenatal care out of state. Hx of classic c-section at 25 weeks 2/2 eclampsia + FGR. Vitals are wnl. FHR 145/min. Fundal Ht. 38cm. US shows posterior placenta, normal amniotic fluid volume, and fetus in frank breech position. Pt request vaginal delivery. Next steps?

*Schedule C-section at 37 weeks* -external cephalic version (ECV) *contraindicated (CI) due to prior classic c-section (risk of uterine rupture)* -ECV CI: uterine myomectomy, placenta previa -ECV c/b: abruptio placentae, intrauterine fetal demise

26 y/o woman with infertility with her husband, age 30. They have been trying to conceive for 12 months. Periods are regular. LMP 6 days ago. 3 previous sexual partners w/o pregnancy. Both her and her partner had normal puberty, no medical conditions or previous surgery. BMI 23. Exam is unremarkable. Next step?

*Semen analysis* -infertility: failure to get prego >12 months (>6 mo if >35 y/o) -*male factor* - 25% of cases -*semen analysis* - sperm conc, motility, morphology, id azoospermia -severe oligospermia can cause infertility

29 y/o woman G1P1 is evaluated for recurrent fevers on day 5 after C-section. Given gent and clinda on POD1, and amp on POD3 for persistent fever. Today she has no n/v, dyspnea, hematuria, dysuria, or diarrhea. T 102.2F, BP 120/88, pulse 108/min. Exam shows mild b/l LQ ttp and an incision with serosanguineous drainage. CT abdomen unremarkable. Dx?

*Septic pelvic thrombophlebitis* -*C-section*, surgery, endometritis, PID, pregnancy, malignancy *Pathophysiology* -*hypercoagulability*, venous dilation, vascular trauma, infection *Presentation* -*fever not responsive to abx* -no localized signs of infection *tx: anticoagulation, abx*

62 y/o nulligravid woman comes in for right adnexal enlargement. US shows 5-cm right ovarian cysts. Menopause age 50, abnormal pap test in her 20s. No surgeries, no FHX of cancer, most recent mammogram was wnl. Next step?

*Serum CA-125*- epithelial ovarian cancer -ovarian cancer risk: age, nulligravid, and BRCA mutation -postmenopausal women specificity for CA-125 greater -use in conjunction with US findings -high CA-125 w/ mass on imaging, highly suspicious malignancy note: endometrial biopsy investigates endometrial carcinoma: post menopausal bleeding, abnormal uterine bleeding, thickened endometrial stripe

Sinusoidal fetal heart rate tracings

*Severe fetal anemia* *Smooth wave-like oscillation* -fixed amplitude -*category III tracing*

Patient in labor develops sudden hypotension following epidural anesthesia. Dx?

*Side affect of epidural* -L2-L5 level -sympathetic nerve fibers responsible vascular tone are blocked -results in *vasodilation/ venous pooling, decreased venous return* to right heart -can result in fetal acidosis -prevent by aggressive IVF -*Tx: L uterine displacement, patient on side, improve venous return*

Indication for urgent urological surgery in patient with acute kidney stone?

*Signs of urosepsis* -f/c/s -tachycardia -anuria -refractory pa in *Kidney stones > 10 mm* -most stones ~5mm pass -*alpha blockers* can help stone pass

44 y/o woman presents with 6 months of painful sexual intercourse. Menstrual periods are regular, and not associated with pain. No hx of gynecologic surgery or PID. She takes saline eye drops for chronic dry eyes. Vitals are wnl. Patient has mild dental caries. Pelvic exam shows dry vaginal mucosa. No cervical motion tenderness. dx?

*Sjogren Syndrome* -*Keratoconjunctivitis sicca* -dry moth, salivary hypertrophy -xerosis (dry skin) -*Raynaud phenomenon* -cutaneous vasculitis -arthralgia/arthritis -interstitial lung disease

62 y/o woman presents with progressive gait unsteadiness, legs stiffness, and she stumbles while descending stairs. N/t in the hands and occasional electric shock-like sensation in the spine. No b/b dysfunction. She has fibromylagia w/ continued shoulder and neck pain despite tx w/ duloxetine. Exam shows CN wnl, upper extremity strength is decreased w/ mild wasting of intrinsic hand muscles. LE tone and reflexes are increased bilaterally. Sensation is grossly intact. Dx?

*Spinal cord compression* -myelopathy - cervical spondylosis -spinal canal narrowing -15% of pts w/ spondylosis develop myelopathy -c spine damage: neck pain, LMN signs e.g. atrophy, weakness -damage to descending tracks: unsteady gait, UMN signs -*electrical shock-like sensation*- down the spine w/ FF of neck (Lhermitte sign) -*dx: MRI c-spine 1st line, myelography is often required* -*tx: surgical decompression* for moderate/severe sx or neuro dysfunction

28 year old G1P1 women comes in for 10 day follow s/p c-section. Patient received epidural analgesia during labor. She still has some lower back discomfort, and het legs feel weaker, and she has n/t in her LE. Back exam shows ttp over lumbar, weakness of quadriceps and decreased left knee reflex. Sensation to light touch is decreased over b/l dorsum of feet.Dx?

*Spinal epidural abscess* -Staph A (65%) -source: cellulitis, epidural cath, IV drugs -several days of: -*focal/severe back pain, neurological findings* e.g. m/s changes, b/b dysfunction -*dx: high ESR, cultures, MRI spine*

49 y/o woman with 2 weeks of worsening left sided abdominal pain, fever and chills. Pain is constant and radiates to the back. 2 weeks ago she underwent a laproscopic cholecystectomy. T 103.1F, BP 130/80 mmHg, Pulse 102/min. Spleen is enlarged and tender. Dx?

*Splenic abscess* -recent lab chole -high fever -splenomegaly -rare, life-threatening complication of bacteremia from *distant infection e.g. endocarditis or cholecystitis*. -*risk:* DM, HIV, infection e.g. *infective endocarditis* -*Dx: CT abdomen* -*Tx: abx & splenectomy*

Pt has pelvic pain for 2 days after menstrual period has hx of heavy menstrual periods. On exam has irregular enlargement of uterus, cervix is 5-cm dilated with spherical mass visible through external os. Mass is firm, smooth, and slight bleeding noted.

*Submucous fibroids* -myometrium -protrude into uterine cavity -can prolapse through cervical os -presenting with typical-labor like pains due to cervical distention by solid mass

32 y/o woman comes to the ER with abdominal pain and nausea for 2 days that is now severe over last 3 hours. Passed several clots vaginally. Has hx of irregular menstrual cycles, unsure of LMP. BP 90/55, pulse 120. Exam shows moderate vaginal bleeding. Pregnancy test is positive, TVUS shows gestational sac at upper left uterine cornu and free fluid in the posterior cul-de-sac. Tx?

*Surgical exploration* -*dx of cornual ectopic pregnancy* US showing gestational sac at upper outer corner of uterine fundus

Treatment for hydatidiform mole

*Surveillance for the developement of gestational trophoblastic neoplasia* -after suction curettage, *B-hCG evals* are followed *weekly* until d/undetectable -during surveillance period, *contraception for 6 months* is prescribed as pregnancy would make it hard to determine the significance of a rising B-hCG level and to treat

2-cm ulcer with a nonexudative base and a raised, indurated margin in young female pt w/ mild burning with urination.

*Syphilis*

Indications for Raloxifene vs Tamoxifen

*Tamoxifen:* Adjuvant tx of *breast CA* *Raloxifen:* Postmenopausal *osteoporosis*

Vaccines recommended during pregnancy

*Tdap* Inactivated influenza Rho(D) immunoglobulin

Manifestations of Selenium deficiency

*Th*yroid dysfunction *I*mmune dysfunction *C*ardiomyopathy "Selina's *ThIC*k but she gotta big heart"

40 y/o women presents to ED with n/v and dizziness. Pt has not been able to tolerate any PO intake. No f/c/ diarrhea or constipation. Takes preventative med for migraines, LMP was 8 weeks ago. BP 90/80, pulse 112, BMI 32, exam shows dry mucous membranes, 12-week sized uterus w/ b/l adnexal masses. US shows uterus filled with many small cysts. Ovaries are 10 cm bilaterally with multilocular cystic appearance, pregnancy test positive. Dx?

*Theca lutein cyst* -*multilocular* -*bilateral 10-15 cm ovaries* -*ovarian hyperstimulation* (gestational trophoblastic disease; multifetal gestation, infertility) -*tx: expectant management* -course: resolves w/ decreasing B-hCG levels -*Hydatidiform mole can present with theca lutein cyst*, which can resolve after treatment of mole when B-hCG level lowers

Pathophysiology of Wernicke's encephalopathy

*Thiamine deficiency*

Treatment of E. coli UTI in child or infant?

*Third-generation cephalosporins* -Cefixime

The most common cause of congenital hypothyroidism worldwide.

*Thyroid dysgenesis* -aplasia -hypoplasia -ectopic gland note: maternal iodine deficiency can cause neonatal hypothyroidism; iodine in diet can reverse this condition; *rare in the developed world*, and w/ mom proper nutrition

Thyroid changes in pregnancy, first trimester

*Total T4 - increased:* B-hCG stimulates TH *Free T4 - unchanged/ slight high:* Estrogen stim TBG; thyroid increases hormone pdt to maintain steady T4 levels *TSH - decreased:* B-hCG and TH suppress TSH

12 y/o girl is brought into ED for confusion and rapid breathing. Three days ago she had an URI which has since resolved. She has had increased urination, abdominal pain, and fatigue progressing to somnolence. Exam shows tachycardia, tachypnea w/ subcostal reetractions and dry mucous membranes. Labs show HCO3 9, Glc 450. What electrolyte is most likely to be decreased?

*Total body potassium* -*dx: DKA*

Digital cervix exam shows 4-cm dilatation, 90% effacement, and a taut, bulging bag is palpable with no presenting fetal parts. Next step?

*Transabdominal US* -*no palpable presenting fetal parts* -confirm presentation and help -*determine routing route of delivery*

23 y/o female presents with 3 days of intermittent lower abdominal pain and vaginal spotting. Pain was initially mild but has gotten worse. She takes no meds, vitals unremarkable. Exam shows closed cervix, urine pregnancy test is positive. Transabdominal US shows untrauterine gestation. Dx? Next step?

*Transvaginal ultrasound* -*dx: ectopic pregnancy* -*sx: vag bleeding, lower ab pain, adnexal ttp* -most at fallopian tube -related to prior infection w/ NG/CT -*dx is made with transvaginal US* -*increased Doppler flow e.g. "ring of fire"* -dx r/o if TVUS shows intrauterine gestation w/ + B-hCG

40 y/o woman with abdominal pain for 2 weeks that is not relieved by ibuprofen. She has a fever, but no n/v/d. Currently sexually active and uses condoms for contraceptives. T102F, BP 100/60, pulse 92/min. Abdomen is diffusely tender and worse in the RLQ. WBC 22,000, CRP and CA-125 elevated. US shows a large, thick-walled, multiloculated mass filled with debris obliterating the right adnexa. Dx?

*Tubo-ovarian abscess* -c/b PID -sx: fever, ab pain, *complex multiloculated adnexal mass* -polymicrobial infection

Management of Nephrolithiasis in pregnancy

*US kidneys and ureters* (low risk of radiation) -normal tx is CT abdomen/ pelvis -*tx: supportive e.g. pain control, hydration* -c/b sepsis, obstruction: cystoscopy, stents placed

Diagnosis of leiomyoma

*US pelvis* (size, #, location) -may dx for the 1st time during pregnancy -*size-date discrepancy*

Stress urinary incontinence

*Urethral hypermobility* -intrinsic *sphincteric deficiency* -leakage with valsalva e.g. coughing, sneezing, intercourse -*risks:* prego, obesity, chronic high-impact exercise -*tx: Kegel exercises, wt loss, continence pessary, midurethral sling procedure*

24 y/o woman G1P1 comes in after not having a period for 2 months. Gave birth to a healthy boy 8 months ago. Breastfed for a month and then switched to formula-feeding. Pt had 2 medroxyprogesterone injections since delivery, last given 4 months ago. Over the last 2 weeks she has had breast soreness, weight gain, and increasing fatigue. Menses has been irregular since starting medroxyprogesterone. Pt is requesting a different contraception due to these sx. Next step??

*Urine pregnancy test* -depot medroxyprogesterone (DMPA) are given *every 3 months* -DMPA causes menstrual irregularities -*side effects:* weight gain, fatigue, breast tenderness -*absence of menses, mistiming of injections, must r/o pregnancy*

39 y/o G1 PO comes to the hospital for induction of labor. After a *prolonged labor*, she delivers a 9 lb healthy baby boy via forceps-assistance. During delivery of the placenta, excessive traction is placed on the cord, causing it to avulse, and the placenta must be extracted in pieces. 1 hour *after delivery*, she soaks her perineal pad, exam shows *300 mL of clotted blood* in the lower uterine segment. Dx?

*Uterine atony* -postpartum hemorrhage (PPH), an *OB emergency* -*PPH ddx:* 1. Uterine atony 2. Genitourinary trauma 3. Retained pdts -*PPH < 24 hour after delivery* -uterus becomes fatigued -*prolonged labor* -*induction of labor* -> 8.8 lbs -*forceps-assistance* -uterus *soft ("boggy") and enlarged*

34 y/o woman with precipitous spontaneous vaginal delivery at 39 weeks GA. After 20 min the placenta does not delivery. Traction on umbilical cord and fundal massage are implemented. The cord avulses, after which the patient develops severe abdominal pain, SOB, and copious vaginal bleeding. Exam shows smooth, round, pale mass protruding from the vagina. Uterine fundus is no longer palpable. Dx?

*Uterine inversion* -potentially fatal -postpartum bleed -nulliparity, fetal macrosomia, placenta accreta, and rapid labor and delivery -results from *x's fundal pressure on umbilical cord* before placental separation -*fundus collapses into the endometrial cavity* and prolapses throught the cervix and vagina; fundus no longer palpable. *Tx: manual replacement of the uterus*

28 y/o G2P1 woman comes to the hospital in active labor at 37 weeks gestation with *severe abdominal pain* and back pain. Pt had prior c-section. BP 90/60, and pulse 120/min. Exam shows palpable, *irregular protuberance in the lower abdomen* and moderate vaginal bleeding. Cervix is 3 cm dilated and 80% effaced. A bulging bag is palpated at the cervical os, but there is no fetal part present. Fetal heart decelerations present. Dx?

*Uterine rupture* -prior uterine surgery e.g. *prior c-section* -induction of labor/ prolonged labor -congenital uterine anomalies -fetal macrosomia -*feat:* vaginal bleeding -*FHR decelerations* -loss of fetal stations -*palpable fetal parts* on abdominal exam, loss of intrauterine pressure -*tx: laparotomy for delivery & uterine repair*

68 y/o woman presents with blood tinged vaginal discharge. She has had slightly malodorous discharge for the past several weeks. PMHX of DES in utero exposure resulting in infertility. Mother dx w/ endometrial cancer at 54, uncle dx w/ CRC at 70. She smoked daily for 40 years. BMI 32. Exam shows 3-cm ulcerated lesions posterior vaginal wall, biopsy shows squamous cell carcinoma. Risks?

*Vaginal cancer* -Age >60 -HPV (high risk types 16 & 18) -Tobacco use -In utero DES exposure = clear cell adenocarcinoma only -*sx:* vaginal bleeding, malodorous discharge, irregular lesion -*upper third of posterior vagina* -*dx: biopsy* -*tx: surgery +/- chemoradiation*

Delivery of nonviable fetus

*Vaginal delivery* -(lower risk for maternal complications) -no fetal monitoring -palliative care if infant not stillborn

30 y/o woman G1P0 is admitted in active labor and undergoes forceps assisted delivery for recurrent late fetal heart decelerations. Pt delivers 9.3lb infant. Hr later pt feels lightheaded, BP 90/50, pulse 120/min. Uterus is firm, and palpable at umbilicus. There is minimal blood on perineal pad, and a large purple mass protrudes into the vagina. Dx?

*Vaginal hematoma* -risks: operative delivery, Lg baby, nulliparity, prolonged labor -pt w/ protruding *vag mass* have *minimal bleeding*

Impaired adaptation to darkness, photophobia, dry scaly skin, dry conjunctiva, dry cornea, and a wrinkled, cloudy cornea. There are dry, silver-gray plaques on the bulbar conjunctiva.

*Vitamin A deficiency* -bitot spots - dry, silver-gray plaques

3 y/o boy from refugee camp is brought to clinic for evaluation of a rash. He is "hungry all the time." His weight and length are < 5th percentile for age and sex. Exam shows malnourished boy with scaling and fissures present at the mouth corners and his lips are cracked and inflamed. There are erythematous scaly patches on his eyebrows, cheeks, and nose. Pts tongue and oropharyngeal mucous membranes are swollen and hyperemic. There is also a scrotal rash that extends to the medial aspect of both thighs. Labs show normocytic-normochromic anemia. Dx?

*Vitamin B2/ riboflavin deficiency* -participates in oxidation-reduction rxns for energy pdts -Riboflavin is present in *meat, eggs, yeast, dairy products, green vegetables*, and enriched foods. -*sx: angular cheilitis, glossitis, stomatitis, normocytic-normochromic anemia, and seborrheic dermatitis*

52 y/o postmenopausal woman presents for vulvar irritation. She uses sanitary napkins for stress urinary incontinence and occasionally notices streaks of blood on the napkin. PSHx of hysterectomy & b/l salpingo-oophorectomy. Had abnormal pap, but negative colposcopy. Currently uses nicotine patch for smoking cessation. Exam shows multiple vulvar excoriations w/ surrounding erythema. There is a red friable plaque on the left labium majus. No lesions or discharge. Dx?

*Vulvar cancer* -*Squamous cell carcinoma* -*persistent HPV infection*, chronic inflammation -tobacco use -*vulvar lichen sclerosus* -immunodeficiency -prior cervical cancer -vulvar/cervical intraepithelial neoplasia -*dx: biopsy*

70 y/o women with vulvar pruritus, that is increasing over past 4 months, and not responsive to topical emollients. No pain, bleeding, or discharge. Pt had similar sx 20 years ago, that responded to corticosteroid cream. No sexual activity for past 10 years. Normal Pap/HPV testing 5 year ago. Exam shows firm, white plaque with overlying excoriations on the left labium majus. Mild atrophy of the b/l labia minora is noted. vagina has minimal rugation, and no lesions. Next step?

*Vulvar cancer* -persistant HPV infection -chronic inflammation *Risks:* tobacco, vulvar lichen sclerosis, immunodeficiency, prior cervical cancer *Signs/sx:* vulvar *pruritus*,*vulvar plaque*/ulcer, bleeding *Dx: Vulvar biopsy*

Patient with pruritic, white labial lesions that appear thin and wrinkled and result in obliteration of the normal vulvar architecture. dx?

*Vulvar lichen sclerosus*

Rectus abdominis diastasis

*Weakening of the linea alba* -keeps rectus abdominis muscles close -*risks:* pregnancy, multiparity, prior c-section, -constipation (increased pressure) -*tx: reassurance* and observation

38 y/o female with new onset confusion. She has a hx of Crohn's disease and was admitted recently due to n/v/d 2/2 c. diff. Pt had recent small bowel resections due to strictures and fistulas, and has lost 22 pounds over the past 6 months. BMI 19.5. On exam, she is AOx1, right eye is limited and elicits b/l horizontal nystagmus, and she has a wide based gait. Dx?

*Wernicke encephalopathy*

Patient with recent bout of hyperemesis gravidum now presents with disturbed gait, frequent falls, nystagmus and increased confusion and incoherence. Dx?

*Wernicke encephalopathy* -Thiamine deficiency

Androgen insensitivity syndrome genetics

*X-linked mutation in androgen receptor* -46,XY

Diagnosis of epiglottitis

*X-ray: "thumb sign"* -flex laryngoscope if possible

Women exposed to diethylstilbestrol (DES) are at risk for what cancer?

*clear cell carcinoma of the cervix and vagina*

Fetal complications of severe anemia in utero

*complications: fetal exsanguination* and deterioration

what causes uterine distention in abruptio placentae

*concealed bleeding*

Complications of deep fascial wound dehiscence

*evisceration* - herniation of ab organs

Phenytoin birth defects

*fetal hydantoin syndrome* -in utero exposure to antiepileptic e.g. *phenytoin, carb, val* -cleft lip and palate -distal phalange hypoplasia -microcephaly

Guidelines regarding influenza vaccinations in pregnancy

*influenza associated morbidity and mortality*- all pregnant women w/o contraindications should get inactivated vaccination

Nonstress test shows *late decelerations, fetal HR decelerations* that gradually nadir after the peak contraction.

*intermittent hypoxemia* -decreased placental function -increased placental vascular resistance -age-related placental changes -*late-term pregnancies*

Intrapartum abx effect on late-onset GBS sepsis

*intrapartum abx does not eliminate colonization e.g. does not decrease risk of late-onset GBS sepsis (>7 days)* -mom is still colonized and can expose infant at home

Tool for assessing possible acute PE

*modified Wells criteria* -pretest prob of acute PE -*CT angio*- best test in stable pt w/ likely PE. -Empiric anticoagulation is indicated unless contraindicated

Prognosis of placenta previa

*most cases resolve by 3rd trimester*

Treatment of placenta previa

*no intercourse/cervical exam, admit for bleeding*

Features of placenta previa

*painless vaginal bleeding >20weeks gestation*

Etiology of postpartum endometritis

*polymicrobial*

Risks for cerebral palsy

*prematurity, low birth weight*

Routine newborn screening and preventative care

*preventative* -IM vit K -Erythromycin eye ointment -Hep B *Screening* -Newborn screen -Hyperbilirubinemia -Hearing screen -*Pre- & post-ductal pulse ox*; congenital heart disease -hypoglycemia

second-trimester quadruple screening interpretation

*quad test* - *2nd trimester: 15-20 weeks* -age 35 and up, high risk for fetal aneuploidy -pts w abnormal quad screen: *cell-free fetal DNA* test -CDNA test: measures circulating free maternal DNA w/ sens/spec 99% -US performed to eval for fetal anomalies

Heavy bleeding postpartum

*retained placenta* *uterine rupture*

ABO hemolytic disease

*risks:* infants with blood *A or B to mother with O* *feat:* jaundice within 24 hours, anemia, high retic, *coomb+* *tx:* serial bilirubin levels, oral hydration, *phototherapy* -*exchange transfusion* for severe anemia/ hyperbilirubinemia

Treatment for sinusoidal fetal heart rate tracings

*urgent cesarean delivery* (fetal anemia)

loss of fetal station

*uterine rupture*

17 y/o girl w/ heavy menstrual bleeding. Periods usually have 4 days of heavy bleeding, often requiring 5-6 pads/day, and she often soaks through her clothing and bed sheets. Labs show microcytic anemia, normal plt, PT/PTT wnl. Dx?

*von Willebrand disease* -*heavy, regular menses* -normal coagulation studies -*impaired platelet adhesion* -activated PTT can be normal or prolonged PTT

34 y/o G1P1 woman presents with sudden onset heavy vaginal bleeding. She's had heavy bleeding soaking 2 pads/hour for the past 4 hours. 2 weeks ago pt had forceps-assisted vaginal delivery complicated by vaginal laceration. Cervix is slightly dilated and has active bleeding from the os, but no additional vaginal lacerations present. CBC: Hct 30%. PT/ PTT wnl. Dx?

*von Willebrand disease* (VWD) -*postpartum hemorrhage* -prolonged bleeding time -normal coagulation studies -pts w/ mild VWF deficiency have adequate factor 8 levels to maintain aPTT wnl. -VWF and factor 8; acute-phase reactants, stress/ inflammation -VWF synthesis is increased by estrogen, thyroid hormone, *pregnancy, OCP*, which normalizes aPTT. -*Platelet count and PT are normal* in VWD -*dx: VWF level and factor 8 levels* -*tx: Desmopressin (DDAVP) potentiates release of VWF*

Contraindications to rotavirus vaccine

- Anaphylaxis to vaccine ingredients - Hx intussusception - Hx uncorrected congenital malformation of GI (Meckel's diverticulum) - SCID

Complications of shoulder dystocia

-*Claw hand* -*Horner syndrome* (ptosis, miosis)

Features of Wernicke's encephalopathy

-*Encephalopathy* -*Oculomotor dysfunction* -Postural & gait *ataxia*

Risks for abruptio placentae

-*HTN* -*cocaine* -trauma

Indications for cesarean delivery

-*Late decelerations* -*Breech*

Treatment of cerebral palsy

-*PT/OT* -speech therapy -nutritional -*antispastic meds*

Signs/ sx of abruptio placentae

-*abdominal pain* -back pain -*vaginal bleeding* -frequent contractions -uterine distention

Treatment for necrotizing enterocolitis

-*bowel rest* -parenteral nutrition (TPN) -*broad spec abx*

Causes of folate deficiency

-*chronic hemolysis/ sickle cell* -poor dietary intake -malabsorption -*medications* -adequate folic acid intake is recommended in pts w/ sickle cell

Signs/ sx of hereditary spherocytosis

-*hemolytic anemia/ high retic count* -*Coombs negative* -jaundice -*splenomegaly* -*high MCHC*

Diagnostic test for hereditary spherocytosis

-*high osmotic fragility* on acidified glycerol lysis test -*abnormal eosin-5-maleimide* binding test

Mom needs GBS strep ppx in pts w/ PCN allergy

-*low risk for anaphylaxis e.g. maculopapular rash - Cefazolin* -lower risk of cross-reactivity -achieve same high bactericidal conc in amniotic fluid

Hypothyroidism effect on HPO axis

-*low thyroxine*, increases hypothalamic TRH -*stimulates TSH and prolactin* -hyperprolactin *suppresses ovulation* -abnormal bleeding, *oligomenorrhea*

Symptoms of chorioamnionitis

-*maternal fever* -maternal and fetal tachycardia (sustained baseline *FHR >160*) -FHR- moderate variability, accelerations -*uterine fundal ttp* -maternal leukocytosis

Magnesium sulfate toxicity

-*neuromuscular depression* -decreased respiratory effort -apnea -*muscle paralysis* -somnolence -visual disturbances -*decreased or absent DTR* -pulmonary edema can occur

Cause of infertility in endometriosis

-*pelvic adhesions* -interfere w/ *oocyte release* -*block sperm* entry

Pathophysiology of neonatal thyrotoxicosis

-*plancental passage of TSH receptor-aby* -aby binds infant's TSH receptor -x's thyroid hormone release

Risks of necrotizing enterocolitis

-*premature* -*low birth wt* -*enteral feeds*

Treatment of vaginal hematoma

-*tx: nonexpanding: obs; expanding: embolize, surgery*

Features of fat embolism

-24-72 hrs s/p event: -RDS -confusion -petechial rash* (<50% pts) -thrombocytopenia (plt adhering to fat globules)

Diagnosis of DKA

-Anion gap >14 -Bicarb <15 -pH <7.3 -serum/urine ketones

Copper deficiency

-Brittle hair -*Skin depigmentation* -Neurologic dysfunction (ataxia, peripheral neuropathy) -Sideroblastic anemia -Osteoporosis "arnold running to the chopper, retarded, shot at from the side, war paint, broken leg"

Causes of Wernicke Encephalopathy

-ETOH -*malnutrition* -hyperemesis gravidarum

Associations with Wernicke encephalopathy

-ETOH -malnutrition -*hyperemesis gravidum*

Signs/ sx of Wernicke encephalopathy

-Encephalopathy -oculomotor dysfunction (*horizontal nystagmus*) -postural & gait ataxia

Amphetamine use during pregnancy causes...

-Fetal growth restriction -preeclampsia -abruptio placentae -preterm delivery -intrauterine fetal demise -increased risk of maternal mortality

Contraindications to combined hormonal contraceptives

-HA/Migraine w/ aura -smoking 15 cig/day + > 35 y/o -HTN (160/100) -Heart disease -DM+organ damage -VTE -CVA -CA (breast, liver) -Cirrhosis Major surgery w/ immobilization -<3weeks postpartum -antiphospholipid-aby syndrome HC^3, DMV

Risk factors for cervical cancer

-HPV 16,18 -hx of STI -early sex -multiple partners -immunosuppression -OCP -low SES -tobacco use signs/sx: heavy vaginal bleeding, friable cervical mass

Etiology of hydrops fetalis

-Immune: *Rh(D)* -Nonimmune: Parvovirus B19, *aneuploidy*, thalassemia

Risks for chorioamnionitis

-PPROM or PROM (> 18 hours) -*repetitive vaginal examinations*

Rho(D) immune globulin indication

-Rh(D)-negative patients -*28 weeks for prophylaxis* -*after delivery* if infant is Rh(D) positive

Complications of external cephalic version

-abruptio placentae -intrauterine fetal demise

Breast feeding contraindications

-active, untreated TB -HIV -herpetic breast lesion -active varicella -chemo/radiation -*active substance abuse* -*galactosemia*

Clinical features suggestive of secondary cause of dysmenorrhea

-age > 25 at onset -unilateral pelvic pain -lack of systemic symptoms -abnormal uterine bleeding

Preterm labor management at *32-33 weeks*

-betamethasone -tocolytics -*pencillin* if GBS+ or unknown

Preterm labor management at *<32 weeks*

-betamethasone -tocolytics -*MgSO4* -*penicillin* if GBS+ or unknown

Causes of active phase arrest (labor)

-cephalopelvic disproportion -fetal head too large to fit thru pelvis -later term pregnancies -fetal anomalies e.g. occiput posterior -*maternal obesity*, x's wt gain, old age

Preterm labor

-cervical changes *< 37 weeks gestation* -*intermittent pain* (preterm birth) -uterus relaxes/softens between contractions

Hidrandenitis Suppurativa

-chronic inflammatory condition -*occlusion of hair follicles* in groin and axilla -women 20-40 y/o -*spontaneous draining* abscess -sinus tract and scar formation eg. fibrotic bands, acneiform scars

Cervical mucus due to ovulation

-clear -elastic -thin in consistency -*uncooked white egg* -thought to facilitate sperm transport into the uterus for conception -after ovulation, mucus becomes thick and less hospitable to sperm -*can be perceived by patients as vaginal discharge*

Tx of Diamond-blackfan anemia

-corticosteroids -RBC transfusions

Labs for CMV colitis

-cytopenias 2/2 bone marrow involvement -peripheral smear shows *atypical lymphocytes*

Signs of epiglottitis

-distress -tripod position -sniffing -stridor -drooling -high fever

Immediate routine neonatal resuscitation e.g. right after birth

-drying -stimulating -warming -place on mother's chest for *skin-to-skin*; provides warmth and allows early breastfeeding initiation

Treatment of late and post-term pregnancy

-fetal monitoring -delivery before 43 weeks

Pathophysiology of gestational diabetes

-fetus has increased demands for glucose (accelerated growth/ metabolic demand) -*beta cell hyperplasia* -increased insulin secretion -peripheral *insulin resistance* -*human placental lactogen* -high in 3rd trimeter

Tx of Shigella gastroenteritis

-fluid and electrolyte replacements -abx if immunocompromised, bacteremic or severely ill.

androgen insensitivity syndrome treatment

-gender identity/assignment -counseling -*gonadectomy* -malignancy prevention

Features of hydrops fetalis

-high CO demand(HF) -pleural effusion (3rd spacing) -pericardial effusion, pleural effusion, ascites, polyhydramnois

Lab finding for tubo-ovarian abscess

-high WBC -high CRP -high CA-125 (infection)

Signs of leiomyomata uteri

-history of heavier/ longer menses -pelvic pressure -irregular uterine contour -stress urinary incontinence- increased ab pressure

Precipitating factors of myasthenia crisis

-infection -surgery -pregnancy -meds

Complications of late/post-term pregnancy for mom

-lacerations -c-section -bleeding

Substances/ meds that chelate calcium

-lactate -*foscarnet* -EDTA

Pathophysiology of acid-base disturbance in hyperemesis gravidarum

-loss of gastric acid (met alk) -volume depletion also causes *contraction metabolic alkalosis* w/ activation of RAAS.

Labs for PSGN

-low C3 & possible low C4 -high Cr -high Anti-DNase B & high AHase -high ASO & anti-NAD (from preceding pharyngitis) -immune complexes are deposited w/in the GBM and mesangium

Complications of late/post-term pregnancy for the baby

-macrosomia -dysmaturity syndrome -oligohydramnios -demise

Treatment of intraductal papilloma

-mammography & US -r/o carcinoma -biopsy, +/- excision

Dx Neonatal thyrotoxicosis

-maternal anti-TSH receptor aby >500% of normal

Maternal eclampsia complications

-morbidity -*abruptio placentae* -DIC -MI -*magnesium sulfate is the treatment of choice for ongoing seizures 2/2 eclampsia* (calcium gluconate is the antidote for Mg toxicity)

Treatment for strawberry hemangioma, superficial infantile hemangioma

-most pts require no intervention -*beta blockers* e.g. propranolol are recommended for complicated hemangiomas that are disfiguring, ulcerating, disabling e.g eye lid hemangiomas or life threatening (tracheal issues) -propranolol works by promoting *involution through vasoconstriction and inhibiting growth factors*

Ddx for elevated maternal alpha-fetoprotein screening.

-open neural tube defects -ventral wall defects e.g. omphalocele, gastroschisis -*multiple gestation*

Androgen insensitivity syndrome features

-phenotypically female -*breast development* -absent or minimal axillary & pubic hair -female external genitalia -*absent uterus*, cervix, & upper one-third of vagina -*cryptorchid testes*

Risks for placenta accreta

-prior c-section -hx of D&C -mom >35 y/o

Risk for late and post-term pregnancy

-prior post term -nulliparity -obesity -age 35 -fetal anomalies

Deep fascial wound dehiscence

-rectus fascia nonintact, exposure of intraabdominal organs -common w/ large incisions -risk factors: cancer, chronic steroids, hypoalbuminemia, cough, obesity

Hyperemesis gravidarum

-severe vomiting -1st to early 2nd trimester -weight loss, volume depletion, ketonuria -Metabolic alkalosis often due to loss of gastric acid

Treatment for ectopic pregnancy

-stable: methotrexate -unstable: surgery

Immediate postsurgical fever

-tissue trauma -*mismatched blood* -drug reactions -cytokine release in response to tissue trauma, blood cell lysis, or infection

Features of vaginal hematoma

-vaginal mass -rectal/vag pressure -hypovolemic

Features of necrotizing enterocolitis

-vital instability, lethargy -*bilious emesis, hematochezia* -abdominal *distention* -x-ray: *pneumatosis intestinalis*, portal vein gas/*pneumoparitoneum*

Pathophysiology of low K in DKA

-x's glucose exceeds threshold for absorption by kidneys resulting in glucosuria and osmotic diuresis, which is followed by depletion of total body K+ stores, but the levels may appear normal or high due to acidemia and decreased insulin activity

Preterm labor management at *34-36 weeks*

1. +/- betamethasone 2. penicillin if GBS positive or unknown tocolysis is contraindicated: -indomethacin = oligohydramnios, closure of ductus arteriosus -nifedipine = hypotension/tachycardia

Treatment of postpartum uterine atony

1. Bimanual uterine massage & high dose Oxytocin 2. Tranexamic acid (persistent bleeding) Carboprost, methylgonovine Intrauterine balloon tamponade Surgical intervention

TVUS shows in intra or extrauterine pregnancy, b-hCG 1000 IU/L. Differential?

1. Intrauterine pregnancy 2. Ectopic pregnancy 3. Nonviable intrauterine pregnancy (aborted)

Pathophysiology of AKI in rhabdomyolysis

1. Muscle cell lysis 2. intravascular fluid shifted into damaged muscle cells 3. Intravascular volume depletion - initial insult 4. Direct tubular toxicity - heme/ pigment nephropathy

Fetal complication of preeclampsia

1. Oligohydramnios 2. Fetal growth restriction 3. Small for gestational age all due to chronic uteroplacental insufficiency

Pulmonary pathology that cause V/Q mismatch

1. PE 2. *atelectasis* 3. pleural effusion 4. pulmonary edema *A-a gradient is elevated* A-a gradient = PAO2 - PaO2 A-a wnl <15 (values increase w/ age) A-a > 30 is considered high regardless of age

Treatment of struvite stones

1. Removal of stone e.g. lithotomy 2. possible nephrectomy 3. abx to eradicate organism

First step in postmenopausal bleeding

1. TVUS endometrium -->obs (benign) 2. Endometrial bx (>4mm) 3. Progestins, surgery (atypia, neoplasia)

risk factors for infantile hypertrophic pyloric stenosis

1. first born boy (3-5 weeks) 2. erythromycin 3. bottle feeding suspect in infant w/ nonbilious, projectile vomiting w/ dehydration and weight loss. "Crow bottle feeding infant that keeps projectile vomiting"

Tx for DKA

10 ml/kg isotonic fluid bolus over 1 hour Insulin infusion Isotonic fluids with potassium

HPV vaccination doses

15 yrs and older = 3 doses <15 yrs = 2 doses (6 mo apart)

Normal vaginal pH

3.8-4.5 If >4.5, may be trichomonas or bv

low levels of what neurotransmitter is associated with suicidal behavior

5-hydroxyindoeacetic acid (5-HIAA)

Treatment of hepatic adenoma

<5cm: stop OCPs >5cm: resection, due to increased risk of rupture and hemorrhage

smoking cessation recommendation prior to elective sugery

>4-8 weeks prior

Medications associated with lichen planus

ACE inhibitors thiazide diuretics beta blockers hydroxycholorquine

AIS vs 5-alpha-reductase deficiency

AIS have *breast development* at puberty -defective receptor is unable to inhibit breast tissue proliferation -5alpha has clitoromegaly during puberty due to increased testosterone levels

High urine sodium > 40, and a normal BUN/Cr ratio resulting in hyperkalemia, metabolic acidosis, lung crackles (volume overload) in elderly patient with hypercalceima

ATN due to multiple myeloma

Fetal heart tracing shows persistent bradycardia in patient taking hydrocodone for joint pain

AV block -pt with SLE have increased risk for neonatal lupus

Urinary frequency and urgency, nocturia, or incontinence, sx related to bladder filling and urine storage

Abnormal detrusor overactivity

Preterm infants immunization schedule

According to chronologic age (not corrected age) -corrected age is only used for determining growth and development

Cause of pain in endometriosis

Accumulation of cyclically shed blood from ectopic endometrial tissue

First line treatment for idopathoic intracranial hypertension

Acetazolamide +/- furosemide

Patient with cyanosis and feet but remainder of skin is pink

Acrocyanosis -universal screen w/ pre-ductal and post-ductal oxygen saturation -pulse ox

Contraindications to progestin IUD

Active breast cancer Active liver disease

Contraindications to levonorgestrel

Active liver disease Breast cancer Acute pelvic infection

Treatment of severe hypercalcemia (>14)

Acute -Normal saline -calcitonin Long term -Bisphosphonate

23 y/o G1P0 mom presents at 12 weeks gestation for vaginal bleeding after intercourse. She noticed blood in the toilet after urinating after having sex 12 hours earlier. Vitals stable. FHR wnl. Exam shows thick, yellow malodorous discharge in the vagina that is tinged with blood. Uterus is enlarged, no ttp, no masses. Dx?

Acute cervicitis -postcoital bleeding -thick, mucopurulent discharge -friable cervix -bleeds easy on contact -sx: dysuria, dyspareunia, vulvovaginal pruritus -women >25 y/o

Measles precautions

Airborne precautions

Patient with painless, rapid, and transient monocular visual loss

Amaurosis fugax -retinal ischemia -anterosclerotic emboli from carotid

Side effects of levonorgestrel-containing IUD

Amenorrhea Breast ttp mood changes headaches

Anal bleeding, pain, sensation of fullness, and 3cm ulcer at posterior anal verge with indurated base. 3 cm lymph nodes in groin. Sx resistant to sits bath and laxatives.

Anal cancer

causes of low maternal alpha-fetoprotein

Aneuploidies e.g. Trisomy 18,21

24 y/o woman has SAB at 10 weeks gestation. Blood type AB negative. Anti-Rh antibody titer: Negative. Next step?

Anti-D immune globulin (RhoGAM) -w/i 72 hours of any precedure or incident in which there is any possibility of feto-maternal blood mixing

Diagnosis of placenta accreta

Antinatal U/S -irregular or absent placental-myometrial interface -intraplacental villous lakes

Livedo reticularis in patient with acute leg swelling

Antiphospholipid (APL) syndrome -thrombosis -prolonged PTT -normal PT

Patient with TIA and or recurrent miscarriages requires and anti-beta2-glycoprotein antibody

Antiphospholipid syndrome -requires chronic anticoagulation

Women with hypothyroidism and recurrent pregnancy loss

Antithyroid peroxidase (anti-TPO) antibodies -Hashimoto thyroiditis -increased risk of progression to hypothyroidism -increased risk of miscarriages in euthyroid and hypothyroid women

18 y/o woman comes in for fractured distal radius after falling from a chair. She had ambiguous genitalia at birth, normal uterus/ fallopian tubes, nl follicles. Had not started menses. BP 120/78. Pt has nodulocystic acne over chest and back, no breasts, normal pubic/ axillary hair, and marked clitoromegaly. 46XX, normal glucose, electrolytes. Estradiol and estrone are undetectable. FSH, LH, testosterone, and androstenedione are high. US shows multiple ovarian cysts. Dx?

Aromatase deficiency -prevents conversion of androgens to estrogens -*normal internal genitalia* -*external virilization* e.g. clitoromegaly -in utero: inability of placenta to convert androgens into estrogens, leading to transient masculinization of the mother that resolves after delivery -high levels of gestational androgens -adolescence: delayed puberty, osteroporosis, *undetectable estrogen levels, high levels of FSH, LH = polycystic ovaries*

Pulsatile mass with audible systolic bruit over vascular access site in patient who underwent cardiac catheterization

Arterial pseudoaneursym

Patient with mild localized pain and swelling and a continuous bruit accompanied by a palpable thrill over the site of cardiac catheterization insertion

Arteriovenous fistula

Management of simple breast cyst

Aspiration - clear fluid RTC 2-4 months - check for reaccumulation, then annual f/u

Function of hysterosalpingogram

Assess fallopian tube patency -infusion of radio contrast into cervix under fluoroscopy -MIS -can also ID uterine cavity anomalies e.g. bicornuate uterus

Risk factor for preterm prelabor rupture of membranes

Asymptomatic bacteriuria

Medications that trigger G6PD

Avoid -Dapsone -Isobutyl nitrite -Primaquine -Rasburicase Caution -Tylenol/ ASA -Benadryl -Chloramphenicol -Chloroquine -Colchicine -Glyburide -Isoniazid -L-dopa -Quinine -SMX-TMP -Vitamin K Safe -Pencillin-class meds e.g. -amoxicillin -Cephalosporins "RIP Dapsone- G6P"

Dx of acute lymphoblastic leukemia

BM biopsy >25% lymphoblasts

Blood pressure med associated with impaired glucose control and increased weight gain

Beta blockers -effects on skeletal muscle leads to reduced insulin sensitivity

Patient with fever, nausea, vomiting, and vague abdominal pain 2-10 days after a lap chole.

Bile leak

Neonate with direct hyperbilirubinemia, pale stools, and hepatomegaly.

Biliary atresia -Kasai procedure/ hepatoportoenterostomy; diverts bilt to small intestine, best done <2 mo old

Tx of uterine atony

Bimanual uterine massage oxytocin/ uterotonics IVF O2 IU balloon tamponade uterine artery embolization hysterectomy

Uterotonic effect

Blood causes uterus to firm up resulting in low amplitude but frequent contractions (abruptio placentae)

Side effects of OCP

Breakthrough bleeding HTN Increased risk for VTE -note: wt gain is not an AE

Middle mediastinal masses

Bronchogenic cysts Tracheal tumors Pericardial cysts Lymphoma Lymph node enlargement Aortic aneurism of the arch

Prematurity, low birth weight, respiratory distress syndrome, persistent oxygen requirement and mechanical ventilation

Bronchopulmonary dysplasia -Surfactant therapy does not prevent

Signs of child abuse scald injury

Burns *spare flexural creases* (due to ankle, knee, and hip flexion at time of forced immersion) -stocking or glove burn distribution -sharp line of demarcation -uniform burn depth -absence of burn in the distribution of splash marks

Management of vasa previa

C-section 34-35 weeks (prior to spontaneous labor) -ROM will likely rupture fetal vessels -ROM = obstetric emergency

Risks for postpartum endometritis

C-section, Chorioamnionitis, GBS, PROM, vaginal delivery

Etiology of acute cervicitis

C. Trachomatis, N. Gonorrhea

infant with unilateral neurosensory hearing loss

CMV infection

Rare complication of CO2 insufflation during laparoscopy in which inadvertent insertion of insufflation needle directly into artery, vein or liver causing patient to develop hypotension and or obstructive shock

CO2 gas embolization

60-70 y/o patient with foot pain and swelling, x-ray shows joint effusion, and chronic calcification of the articular cartilage.

Calcium pyrophosphate dihydrate crystal arthritis (pseudogout) -inflammatory effusion -rhomboid-shaped, weakly positively birefringent CPPD crystals

Pseudohyphae with budding yeast forms (blastoconidia)

Candida

Patient's FHR has absent variability and recurrent late decelerations

Category III FHR tracing -increased risk of severe fetal hypoxia -tx w/ repositioning and IVF d/c uterotonics -c-section for patients not completely dilated or not improved with initial tx

Complications of the treatment for cervical intraepithelial neoplasia (CIN)

Cervical conization -indicated for CIN 2 & 3 Complications -cervical stenosis -preterm birth -pPROM -second trimester pregnancy loss

Active phase arrest (labor)

Cervix *doesn't dilate 1 cm Q2H* = *active phase protraction* (APP)

Pregnant women with HIV viral load >1,000 copies/mL in labor, next step?

Cesarean delivery -intrapartum zidovudine

Treatment for condylomata acuminata

Chemical: -podophyllin resin, trichloroacetic acid Immunologic: -Imiquimod Surgery: -Cryotherapy, laser therapy, excision Prevention: -vaccination, barrier contraceptions

Patient with SAB 6 months prior now was significant bleeding, exam shows red, vascular nodule in posterior fornix that bleeds when touched

Choriocarcinoma

Postpartum woman with enlarged uterus, irregular vaginal bleeding, pulmonary symptoms, and multiple infiltrates on chest x-ray

Choriocarcinoma -dx confirmed by elevated B-hCG

Diagnosis of complex regional pain syndrome

Clinical -x-ray w/ patchy demineralization -bone scintigraphy w/ high uptake

Microcephaly and periventricular calcifications, hepatosplenomegaly, thrombocytopenia

Congenital cytomegalovirus infection -shed in body fluids e.g. saliva

Most effective means to prevent acquisition of genital herpes

Consistent condom use

Complication of monochorionic monoamniotic twin pregnancies

Cord entanglement/ fetal demise -pts require inpatient monitoring -delivery via c-section 32-34 weeks

Patient with history of migraines, has self-resolving episodes of emesis triggered by the beginning of the school year; patient is asymptomatic between episodes.

Cyclic vomiting syndrome

Common congenital infection that presents with jaundice, petechiae, and hepatosplenomegaly, as well as periventricular calcifications & intrahepatic calcifications, and fetal growth restrictions

Cytomegalovirus

Management of IUFD at 20-23 weeks

D&E or Vaginal delivery

Complication for patients with functional hypothalamic amenorrhea

Decreased bone mineral density -estrogen deficiency

Calcium changes during respiratory alklaosis

Decreases -less H+ ions binding albumin, more Ca binds Albumin

Genetics of Beckwith-Wiedemann syndrome

Degregulation of *imprinted gene* expression in chromosome 11p15

Treatment for intrahepatic cholestasis of pregnancy

Delivery at 37 weeks Ursodeoxycholic acid Antihistamines

Pathophysiology of lupus nephritis

Deposition of anti-double-stranded DNA immune complexes in the glomerulus

Tx of von Willebrand Disease

Desmopressin

Dx of chronic granulomatous disease

Dihydrohodamine 123 test nitroblue tetrazoium test

Anemia of prematurity

Diminished EPO levels, short RBC lifespan, and blood loss, low Hb low Hct low Retic

Patient oozing from venipuncture and surgical sites and reduced urine output after a serious traumatic injury.

Disseminated intravascular coagulation -low fibrinogen -low plts -high PT/PTT -high D-dimer

Patient with epigastric discomfort, nausea, and worsening emesis one day after blunt abdominal trauma

Duodenal hematoma -hematoma expansion = obstruction -CT abdomen shows homogenous density with C-shaped duodenum

17 y/o girl with burning sensation while urinating, spotting on toilet paper. She is sexually active with 3 male partners and use condoms inconsistently; hx of PID last year. recently completed a course of abx for GAS pharyngitis. Pelvic exam shows clear cervical discharge and no cervical motion tenderness. UA reveals positive nitrites, positive leukocyte esterase. B-hCG is negative. Etiology?

E coli-UTI -E.coli most common -hematuria may occur -pyuria (WBC) -clear discharge is likely physiologic

Treatment for patient with signs of postpartum hematoma BP 80/50 mmHg

Emergency laparotomy -no time for CT, she aint stable

57 y/o G1P1 women comes in for routine checkup. She walks 30 min each morning, sexually active with her husband, no pain with intercourse. She has a light menstrual period a month ago after a lapse since age 53. Father had colon cancer. Mam/pap wnl 2 years ago. BMI 28. Next best step?

Endometrial biopsy (or transvaginal US) -postmenopausal bleeding (PMB), most common presentation of endometrial cancer -risk increases w/ age and BMI -all women w/ PMB require further evaluation

Presents with regular monthly menses and additional intermenstrual bleeding

Endometrial polyps -symptomatic polyps get polypectomy

Patient with dyspareunia, cervical motion tenderness, and cervical displacement on exam

Endometriosis

Women with chronic pelvic pain and infertility

Endometriosis

Posterior mediastinal masses

Esophageal leiomyomas Neurogenic tumors Lymphoma Diaphragmatic hernias Aortic aneurysms MRI for imaging

27 y/o G2P1 at 40 weeks gestation has a *forceps-assisted* vaginal delivery over 2nd degree lacerations after pushing 4 hours w/o epidural. First pregnancy ended w/ low transverse c-section at 39 weeks. Thirty minutes after perineal laceration is repaired, pt has blood soaking through her pad and bedsheets. T 99F, BP 120/70, pulse 112. Bimanual exam expresses 300 mL of clots from vagina, *firm fundus* is felt at the level of the umbilicus. Dx? Etiology?

Etiol: Operative vaginal delivery (vacuum/forceps) -PPH ddx: genitourinary injury, uterine atony, retained pdt -*indications:*2nd stage labor, FHR abnormal, maternal contraindication to pushing -dx: maternal comp: genitourinary tract injury, urinary retention, hemorrhage

Labs for severe preeclampsia

Evidence of end-organ dysfunction at 20 weeks. BP 160/ 110* or higher AND proteinuria &/or end-organ damage low plts high creatinine high transaminases pulmonary edema visual or cerebral sx

Treatment of theca lutein cyst in molar pregnancy

Expectant management -course: resolves w/ decreasing B-hCG levels

Management for patient at term with asymptomatic polyhydramnios

Expectant management -obstetric outcomes are unchanged by surveillance or intervention -note: patients with severe symptomatic polyhydramnios = amnioreduction

Management of threatened abortion

Expectant with observation and repeat US

Neurologic complications of sarcoidosis

Facial nerve palsy Central Diabetes Insipidus Hypogonadotropic hypogonadism

Features of cerebral palsy

Features of CP -delayed motor, abnormal tone -hyperreflexia -seizures -intellectual disability

Nonstress test (NST)

Fetal Heart Monitoring for 20-40 min -normal = Reactive -baseline 110-160/min -moderate variability 6-25 min' -2 accelerations in 20 min, peak 15/min above baseline -last at least 15 seconds

Fetal evaluation of IUFD

Fetal autopsy Gross & microscopic exam of placenta, membranes, cords Karyotype/genetic studies

Causes of fetal bradycardia

Fetal bradycardia *<110/min* -*Maternal hypothermia* -Meds e.g. BB -Hypothyroidism -*Heart block*

Nonstress test shows *early decelerations, gradual heart rate decelerations* that nadir at the peak contraction, normal biophysical profile.

Fetal head compression

Physiology of fetal bradycardia during initial descent of delivery

Fetal head descends closer to the cervix, which contracts and causes narrowing of the fetal anterior fontanelle, causing vagal response, slows HR -benign, physiologic finding -does not indicate fetal hypoxia

US assessment of gestational agge

First trimester US -crown-rump length measure -less accurate as pregnancy progresses

Antibiotic associated with retinal detachment, increased collagen degradation, and aortic aneurysm

Fluoroquinolone

Patient with significant weight loss and low BMI, progesterone challenge results in no bleeding

Functional hypothalamic amenorrhea

Heinz bodies and bite cells indicate what?

G6PD deficiency

Occurs weeks to months after stopping breastfeeding, due to resulting milk accumulation.

Galactocele

Young infant with failure to thrive, bilateral cataracts, jaundice and hypoglycemia

Galactosemia -galactose-1-phosphate uridyl transferase deficiency -risk for E.coli neonatal sepsis

Postpartum hemorrhage and a firm uterus after an operative vaginal delivery

Genital tract injury -most common cause of PPH s/p forceps delivery

55 year old female, LMP 4 years ago, presents with occasional bloody spotting on her toilet paper, sparse pubic hair, fissures along the vestibule, and multiple areas of petechiae.

Genitourinary syndrome of menopause -atrophic vaginitis -vulvar and vaginal atrophy -loss of epithelial elasticity (low estrogen) -makes more susceptible to injury e.g. petechiae

Other name for atrophic vaginitis

Genitourinary syndrome of menopause -low estrogen -decreased vulvovaginal tissue elasticity and blood flow -tx w/ lubricants or moisturizers, vaginal estrogen if severe

Gestational diabetes

Gestational DM -24-28 weeks gestation/ 3rd trimester -50 g PO glucose load; if >140 mg/dL (1 hour screen) -100 g PO glucose load; > 120 mg/dL (3 hour screen) dx: fasting >95, 1hr 180, 2hr >155 3hr >140

Cause of uterine size discrepancy in patient with 1-hour glucose challenge of 200 mg/dL

Gestational diabetes mellitus

Treatment for exacerbation of multiple sclerosis

Glucocorticoids

Treatment for 21-hydroxylase deficiency

Glucocorticoids/ mineralo, high salt diet -genital reconstructive surgery for girls

Glucose and LDH in rheumatoid effusions

Glucose - very low (<50) LDH - very high (>700)

Ovarian tumor that causes precocious puberty and or breast tenderness, uterine bleeding, post menopausal bleeds

Granulosa cell tumor

Patient with abnormal uterine bleeding, found to have high estradiol and high inhibin levels

Granulosa cell tumor

Ovarian mass in patient with new onset bilateral breast tenderness

Granulosa cell tumor -high Estradiol -high Inhibin -thickened endometrial stripe

42 y/o nulliparous woman w/ abnormal uterine bleeding. Pt has had irregular bleeding and spotting for the past 8 months. Now she also has abdominal bloating and breast tenderness. Exam shows b/l breast ttp, no masses. Fullness in the LLQ w/o guarding. Large, non-tender left adnexal mass. Pregnancy test negative. US shows 10-cm, complex ovarian mass and irregular endometrial stripe. Dx?

Granulosa cell tumors (sex cord-stromal) -Call-Exner bodies (rosette pattern) -tx: endometrial biopsy, surgery (tumor staging)

24-28 week prenatal visit labs

H&H Aby screen if Rh(D) negative *50-g 1-hour GCT (oral glucose challenge test)*

Vaccines contraindicated during pregnancy

HPV MMR *Live attenuated influenza* Varicella

Vaccines indicated for high-risk pregnancies

HepB HepA Pneumococcus H. influenzae Meningococcus Varicella-zoster immunoglobulin

Woman on OCP with solid liver mass on US develops hypotension at 80/50, HR 120.

Hepatic adenoma

Hemodynamics of Cardiogenic Shock

High preload (high LVEDV) High afterload Low CO

Initial treatment of plaque psoriasis

High-potency glucocorticoids (topical) Vitamin D analogs Tar Retinoids Calcineurin inhibitors Tazarotene

Pregnancy in patient with UC

High-risk period for patients with UC -there is often worsening disease activity -can lead to fetal complications e.g. preterm, small for GA

Most significant risk factor for spontaneous preterm delivery?

History of spontaneous preterm delivery -manage w/ *progesterone supplements* and serial *cervical length* measurements

18 y/o female presents to ED with signs PID and severe emesis. Next step?

Hospitalization -Fitz Hugh Curtis Syndrome -management based on sx -(parenteral abx) - pt vomiting can't tolerate PO -cefotetan plus doxycycline

SIADH lab findings

Hyponatremia Serum osmolality <275 (275-299) Urine osmolality >100 Urine sodium >40 (>20 means kidneys not fxn properly) expect inappropriately high urine osmolality, and euvoemia, high urine sodium bc kidneys do not retain sodium in setting of euvolemia

Hypothyroidism and carpal tunnel syndrome

Hypothyroidism causes soft tissue thickening and mucinous infiltration, which can lead to compression of the median nerve within the carpal tunnel

Complications for small for gestational age

Hypoxia Polycythemia Hypoglycemia Hypothermia Hypocalcemia

Definitive treatment of endometriosis

Hysterectomy and oophorectomy

Management of submucosal fibroids causing recurrent pregnancy loss

Hysteroscopic myomectomy

Patient at 34 weeks gestation with positive fetal fibronectin test. Next step?

IM betamethasone -fetal fibronectin associated with delivery within next week

Initial management for patient with narrow-QRS-complex tachycardia

IV adenosine -used to identify P waves to clarify a-aflutter or a tachy -can also terminate PSVT

Cause of irregular and anovulatory in adolescence

Immaturity of the developing hypothalamic-pituitary-gonadal axis -inadequate quantities and proportions of GnRH; -progesterone tx helps stabilize uncontrolled proliferation by estrogen, by differentiating into secretory endometrium

Treatment of emphysematous cholecystitis, e.g air in the gallbladder wall

Immediate cholecystectomy

Treatment of acute fatty liver of pregnancy

Immediate delivery

Management of acute fatty liver of pregnancy

Immediate delivery -high maternal and fetal mortality rate

Neonate with conjugated hyperbilirubinemia and hepatomegaly. Next step?

Immediate evaluation for *biliary atresia* Early tx w/ *Kasai procedure improves outcomes*

Chromium deficiency

Impaired *glucose* control in diabetics

Changes to thyroxine medication during pregnancy

Increase dose pregnancy increased TBG, requiring increase amounts of TH needed to saturate the binding sites

Ventilator settings changes to treat acute hypercapnic respiratory failure respiratory acidosis.

Increase respiratory rate Increase tidal volume

Indications for external cephalic version?

Indicated for breech, >37 weeks -decreases cesarean delivery

Purulent discharge and enlarged, boggy, tender uterus on pelvic examination and an U/S showing intrauterine echogenic material with blood flow in patient with recent elective abortion

Inflammation and infection from retained products of conception

Most common cause of POP hematoma

Insufficient hemostasis

17 y/o girl is admitted to the hospital for purging behavior, weight loss, and syncope. On day 2 she has severe SOB and ventricular tachycardia. BP 82/55, HR 112, rr 22/min, BMI 14. K 2.1, Mg 1 mg. Which hormone best explains this deterioration?

Insulin -refeeding syndrome -result of surge in insulin -body resumes *anabolism* -carb ingestion: insulin secretion and cellular uptake of PO4, K+, and Mg+ -cardiac arrhythmia -cardiopulmonary failure

Blunt trauma to lower abdomen e.g. patient got up to use the bathroom after a night of heavy drinking and fell now has inability to void, a positive fluid wave, and elevated BUN and Cr.

Intraperitoneal bladder rupture -urinary ascites -increased BUN -increased Cr

Urge incontinence

Involuntary detrusor contractions -tx: pelvic floor exercises/ bladder training

13 year old with heavy bleeding menses, Hb 7.9, HCV 65, erythrocytes 3.1,

Iron deficiency -low RBC -low iron -high TIBC

Small, painless papules, on posterior surface of upper arms, roughened skin texture, and mottled, perifollicular erythema; may be exacerbated by cold, dry weather

Keratosis pilaris -tx w/ emollients and topical keratolytics e.g. salicylic acid, urea

Differentiating hyperemesis gravidarum from typical n/v or pregnancy

Ketonuria

Labs in hyperemesis gravidarum

Ketonuria, hypocholermic MA, hypokalemia

Maternal evaluation of IUFD

Kleihauer-Betke test for fetomaternal hemorrhage Antiphospholipid antibodies Coagulation studies

Fetal complications of forceps assisted vaginal delivery

Lacerations Caphalohematoma Bell's ICH Shoulder dystocia

17 y/o nulligravid girl comes to the office due to 2 months of colicky LLQ pain. The pain worsens with intercourse and exercise but resolves spontaneously. Menses occur monthly and last 5-6 days with 2 days of heavy bleeding. Pelvic exam shows tender left adnexal mass and small, mobile uterus. Pregnancy test is negative, urine CT/ GC negative. US shows 8-cm left ovarian cyst with calcifications and hyperechoic nodules. Next step?

Laparoscopic ovarian cystectomy (reduce risk of ovarian torsion) -dx: mature cystic teratoma -benign ovarian germ cell tumor -endoderm, mesoderm, ectoderm tissue -sx: asymptomatic mostly, ovarian torsion, struma ovarii (hyperthyroidism) -unilateral adnexal mass -US: complex, cystic calcifications -Tx: ovarian cystectomy or oophorectomy

Management of endometriosis

Laparoscopy when NSAIDs and OCPs have failed -allows direct visualization, biopsy, and removal -Asx pts who have endometriosis found incidentally while performing another procedure may be observed; powder burn lesions, chocolate cysts, nodules.

Pathophysiology of Horner syndrome

Lesion anywhere along the 3-neuron sympathetic pathway (hypothalamus to C8-T2)

Emergency contraceptives in adolescents

Levonorgestrel pill -Plan B -may receive confidential w/o parents

Pruritic, purple/pink, polygonal papules and plaques on flexural surface of wrists and ankles, often associated with hepatitis C

Lichen planus

Follow-up management for cancer relate chronic pain when short acting morphine is not working

Long-acting opioid

Lab values for primary adrenal insufficiency

Low cortisol Low aldosterone High ACTH Hyper-pigmentation High K Low Na Low BP

Dx adenomyosis

MRI, US workup; definitive w/ biopsy after hysterectomy

Postoperative patient with hypotension, jugular venous distension, and new-onset right bundle branch block.

Massive pulmonary embolism

Acquired hyperpigmentation disorder during pregnancy that commonly occurs during pregnancy, typically presents with bilateral, symmetric macules on sun-exposed areas of the face

Melasma -UV radiation triggers melanocyte proliferation and pigment deposition in sun-exposed areas -requires no further evaluation

Causes of peripheral neuropathy

Met: DM, hypothy,Vitb12 def Toxic: ETOH (symmetrical, stocking and glove), phenytoin, disulfiram, platinum Infect: HIV, Lyme Hereditary: Charcot-Marie-Tooth, porphyria Others: plasma cell dx e.g MM, MGUS

Medications for postpartum uterine atony and their contraindications

Methylergonovine - c/i pts w/ HTN Carboprost - c/i in asthmatics Tranexamic acid - c/i in hypercoagulability

Peritoneal irritation from follicular fluid released during ovulation resulting in mild cramping

Mittelschmerz

Complications to mom due to HTN

Mother complications due to HTN -preeclampsia -postpartum bleed -gestational DM -abruptio placentae -cesarean delivery

Bilateral trigeminal neuralgia

Multiple sclerosis -demyelination of the nucleus of trigeminal nerve or nerve root

Diagnosis of acute cervicitis

NAAT

6 hour old boy with tachycardia. Born 40 weeks gestation to 30 y/o woman w/ Grave's treated w/ surgical resection 6 mo before pregancy. Mom took levothyroxine during pregnancy. Birth wt. 4lb 9oz, T 99F, pulse 190/min. Infant is warm with flushed skin. Dx?

Neonatal thyrotoxicosis

Warm, moist, tachycardia, poor feeding, low birth weight in preterm infant

Neonatal thyrotoxicosis

Postpartum period is associated with what behavioral disorder

New onset, recurrence, or exacerbation of obsessive-compulsive disorder -fears of contaminating and harming the baby

Women in postpartum period develops transient rigors, chills, peripheral edema, lochia rubra, breast engorgement, and uterine contraction & involution

Normal findings

Vaginal delivery with prior transverse c-section

Not-contraindicated -only prior classical c-sections e.g. vertical incisions are contraindication to vaginal delivery

Tx for adenomyosis

OCP progestin-releasing intrauterine device hysterectomy

The most common risk factor endometrial adenocarcinoma

Obesity

Next step in pt who wants abortion in clinic that does not offer pregnancy termination due to religious beliefs.

Obligated to refer pt in a timely fashion to another provider

Management of asymptomatic endometriosis

Observation and reassurance

Patient with polyhydramnios are at high risk of...

Obstetric complications e.g. preterm prelabor rupture of membranes -uterine overdistension -increased risk of intraamniotic pressure

Most common cause of vesicovaginal fistula worldwide

Obstructed labor -dx w/ bladder dye testing

Causes of vesicovaginal fistula

Obstructive labor (POP) pelvic radiotherapy

Labs show low FSH, low LH, and normal Prolactin and TSH in patient with amenorrhea

Ovarian failure

Patient undergoing ovulation induction presents with 2 weeks of abdominal pain; ascites; bilateral enlarged, cystic ovaries, and intravascular volume depletion causing hemoconcentration, can include VTE, multi-organ failure and death

Ovarian hyper-stimulation syndrome

Ovulation resumption after delivery

Ovulation resumes 6-12 weeks postpartum (nonlactating) menses resumes 8-14 weeks postpartum

*PCOS vs. sertoli cell tumor*

PCOS is Bilateral multiple cysts - increased Testosterone and DHEAS - WILL NOT cause voice deep/clitoromegaly vs Sertoli cell tumor is unilateral - 1 mass - increased Testosterone only -deep voice -clitomegaly

Pathophysiology of neonatal lupus

Passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) antibodies -patients get AV block -fetal HR persistent bradycardia

Initial treatment of fibromyalgia

Patient education -regular aerobic exercise -good sleep hygiene

Uterine procidentia

Pelvic organ prolapse in which the entire uterus herniates through the vagina along with the anterior and posterior vaginal walls tx - pessary placement

Episodic vertigo occurring after head trauma triggered by sudden pressure change e.g. riding an elevator, Valsalva OR loud noises

Perilymphatic fistula -leakage of endolymph from semicircular canals and cochlea

Why is afterload high in cardiogenic shock

Peripheral vasoconstriction to compensate low BP

Insufflation of CO2 during laparoscopy resulting in bradycardia, AV block, and sometimes asystole

Peritoneal stretch receptors -increased vagal tone

Bilateral brown, gray non-bloody nipple discharge that is guaiac negative

Physiologic galactorrhea -lactation in men or non-breastfeeding women -hyperprolactinemia 2/2 hypothyroidism

29 y/o woman G3P2 comes to the ER due to sudden onset heavy vaginal bleeding soaking through clothes. She has had some non-painful contractions. 4 years ago had low transverse C-section. Smokes 1 ppd, takes no meds. BP 96/70, FHR 150/min, moderate variable accelerations, and no decelerations. Tocodynamometry shows irregular contractions every 10-15 min. Dx?

Placenta previa -risks: older mom, prior c-sections w/ painless bleeding > 20 wks gestation -dx: transabdominal followed by TVUS

Intrapartum vaginal bleeding that causes constant ab pain, uterine ttp, FHR decelerations

Placental abruption

28 y/o G3P2 woman presents at 30 weeks gestation, brought to ED with vaginal bleeding following MVA. Pt was restrained, but steering wheel struck her abdomen. Underwear and pants are soaked with blood. BP 95/65, pulse 116/min, RR 22/min, 98% O2 sat. Spectulum exam removes 150 mL blood from vagina. Hb 7.6, Blood type O. FHR shows contractions every 5 min. No acel/decel. Next step?

Placental abruption/abruptio placentae = IVF -blunt trauma e.g. MVA -antepartum hemorrhage -fetal and maternal morbidity and mortality -tx: aggressive IV fluids w/ crystalloids -pts should be placed in left lateral decubitus position- displaces uterus off the aortocaval vessels and maximize CO -complications: hypovolemic shock, DIC -don't blood transfuse yet, transfusion indicated if bleeding persists/ hypotension unresponsive to fluid resuscitation

Polycythemia definition

Polycythemia *Hct:* *> 49% men* *> 48% women*

31 y/o woman G1P1 is seen on POP2 due to lower ab pain, chills and pain with siting. Patient had spontaneous rupture of membranes and a primary c-section after a 26 hour induction of labor. T 101F, BP 100/60, pulse 96/min. Uterine fundus is firm and ttp. There is scant serosanguineous drainage from the lower aspect of the incision. Pelvic exam shows small amount of blood on the perineal pad with mildly foul-smelling discharge. Dx?

Postpartum endometritis

24 y/o female with fevers and chills day 2 following forceps-assisted vaginal delivery. Had second-degree laceration repair. Has bl pitting edema of the feet, uterine fundal ttp, and moderate amount of lochia. Dx?

Postpartum endometritis -infection of decidua -risk include operative delivery -Tx broad spec IV abx

Contraindications to copper and progestin IUD

Pregnancy Endometrial or cervical cancer Unexplained vaginal bleeding Gestational trophoblastic disease Distortion of endometrial cavity Active infection e.g. PID

Risk factors for NARDS

Prematurity Maternal diabetes mellitus

Indications for hormone replacement in postmenopausal women

Presence of vasomotor symptoms e.g. hot flashes women <60 y/o undergone menopause w/in past 10 years

18 y/o woman w/ ab pain that radiates to her back and thighs during menses. Patient recently stopped taking OCPs. Menstrual periods now occur every 30 days with 5 days of bleeding. Pain and bleeding are worse on 2nd day requiring her to change her pads every 4 hours. Pelvic exam is wnl. Dx?

Primary dysmenorrhea (cramps before menses) -x's prostaglandin production -<30 y/o -BMI <20 -tobacco use -menarche <12 y/o -heavy/long periods -sexual abuse Signs/ sx :pain first 2-3 days of menses, n/v/d -normal pelvic exam Treatment: NSAIDs, combo OCPs -prognosis: sx typically decrease w/ age

Normal respiratory physiology of pregnancy

Primary respiratory alkalosis -hypocapnia is a normal -stimulatory effect of progesterone on CNS -increased respiratory drive -hyperventilation

MRCP shows multifocal, short, narrowing of the bile ducts with segmental dilations

Primary sclerosing cholangitis -most asymptomatic -fatigue pruritus -90% of pts have IBD, mainly ulcerative colitis

Most ectopic pregnancy are related to...

Prior infection with NG/CT causing tubal damage

Hormonal contraceptive for adolescent with cerebral palsy

Progestin-releasing subdermal implant

Treatment of PDA-dependent congenital heart disease

Prostaglandin E1 - vasodilator, keeps the PDA open

Treatment of adjustment disorder

Psychotherapy, target maladaptive responses to stress -address dysfunctional thought pattern contributing to mood -avoid adverse effects from medication

Respiratory changes in pregnancy and hormone responsible for it

Pulmonary (progesterone) -respiratory alkalosis(high O2 for high met demand) -high TV/ minute ventilation/ PaO2 -no metabolic compensation

Osteosarcoma associations

RB1 gene (retinoblastoma) TP53 gene ( Li Fraumeni syndrome) Paget's disease (bone t/o)

Management of trauma patient with hemorrhagic shock

Rapid replacement of intravascular volume with type O blood transfusion -Give RBC, Plt, FFP in 1:1:1 ratio -resuscitate first, then evaluate for urethral injury

Tx for fibroadenoma

Re-examine after menstrual period for a decrease in mass size of tenderness

Treatment of hidrandentis suppurative

Reduce frequency of new lesions Clindamycin intralesional glucocorticoids

Hypophosphatemia, hypokalemia, and hypomagnesemia , and muscle weakness, arrhythmias, and congestive heart failure occurring after period of anorexia

Refeeding syndrome

Next step in evaluation of infant with absent cervix or uterus on examination with otherwise normal secondary sex characteristics?

Renal US -mullerian agenesis -causes primary amenorrhea -failed uterus, cervix, and upper 1/3 of vagina -urogenital development is from a common embryonic source

Insidious onset flank pain and systemic symptoms e.g. fever and weight loss, in patient with recent UTI, urinalysis shows pyuria, bacteriuria, and proteinuria.

Renal and perinephric abscesses -risk factors: stones, uncontrolled DM

Patient at increased risk for Mg toxicity

Renal failure -Mg is renal excreted

TVUS shows no intra or extrauterine pregnancy. B-hCG 1000 IU/L. Next step?

Repeat B-hCG in 2 days -should increase every 2 days (rise slower in ectopic) -intrauterine pregnancy B-hCG: 1500-2000 IU/L

Pathology commonly seen after second trimester deliveries, failure of the placenta to deliver within 30 minutes of fetal delivery, and postpartum hemorrhage

Retained products of conception

Initial prenatal visit labs

Rh (D) type, aby screen H&H, MCV HIV, VDRL/RPR, HBsAg Rubella & varicella immunity Pap test Chlamydia PCR Urine culture Dipstick for urine protein

Maternal risks for breech presentation

Risks for breech -age >35 -multiparity -uterine anomalies (didelphys, septate) -uterine leiomyomas (submucosal) -fetal anomalies -preterm -oligohydramnios/polyhydramnios -placenta previa

80 yo female brought in for increasing ab pain, n/v, can't keep anything down since yesterday. PMHX afib on metoprolo and apixaban. T98.8F, BP 150/80, pulse 96/min and regular, RR 16/min. Abdomen is distended and tympanic, no ttp, bowel sounds are increased and high pitched, no rectal masses. Fullness and ttp in the right groin. Abdominal x-ray shows distended bowel loops with air fluid levels. Dx?

SBO due to incarcerated femoral hernia -prog ab pain n/v -high-pitched bowel sounds -x-ray: air-fluid levels -presence of fullness and ttp within R groin = incarcerated hernia *femoral hernias* more common in elderly women -femoral hernias: more likely to have complications -complications: incarceration (ischemia/necrosis, strangulation); -Tx: elective surgical repair, even if asymptomatic*

Management of major depression in pregnant patients

SSRI -untreated MDD poses risks to mom and baby -SSRI are low risk -paroxetine has slight risk of cardiac malformations

Treatment of premenstrual syndrome

SSRI, combined OCP are another tx option

Diagnostic test for leiomyomata uteri

Saline infusion ultrasound -bc fibroids distort endometrial cavity

Fever; lower abdominal pain; heavy vaginal bleeding, and malodorous, purulent vaginal discharge, bloody discharge from cervical os in patient who recently underwent elective abortion

Septic abortion -unsterile and/or incomplete procedure/abortion -medical emergency; broad abx, suction curettage

Which type of shock will have elevated mixed venous oxygen saturation

Septic shock

Tx for ABO hemolytic anemia

Serial bilirubin levels, oral hydration, phototherapy -exchange transfusion for severe anemia/ hyperbilirubinemia

Patient on tramadol and venlafaxine has lower extremity rigidity and tremors, DTR 3+, pupillary dialtion and ocular clonus, T 101F, BP 160/100, pulse 125/min, and she feels nauseated.

Serotonin syndrome -tramadol increases risk of SS

Reynolds pentad

Severe acute cholangitis -AMS -hypotension -RUQ -Jaundice -Fevers

Ingestions that require endoscopic evaluation

Sharp objects; risk of perforation batteries; risk of electrical chemical injury magnets; bowel entrapment, attraction across intestinal segments

Diagnosis of pyoderma gangrenosum

Skin biopsy of ulcer margin - neutrophil infiltrate or mixed cellular infiltrates

Strongly associated with increased severity of Crohn's disease and should be avoided in these patients

Smoking

Displaced fractures of ribs L9-12

Spleen -bleeding that irritates diaphragm may cause referred pain eg. left shoulder pain

The most common complication of twin pregnancy

Spontaneous preterm delivery -due to uterine crowding & uterine over distention Medically induced preterm delivery -maternal (preeclampsia) and fetal (FGR) complications

Patient with recent admission to ICU for septic shock from pneumonia 4 days later has worsening anemia with positive stool occult blood.

Stress ulcer -PPI for ppx

Patient with intermittent loss of urine from jogging has anterior vaginal bulge

Stress urinary incontinence -pelvic floor muscle weakness -increased urethral hypermobility -increased intra-ab pressure = cystocele

Recurrent upper UTI, increased urine pH in patient with fever, flank pain, and evidence of obstruction of the collecting system

Struvite stone -large staghorn calculi

55 y/o woman with fever left flank pain, and dysuria for 2 days. Hx of 2 UTIs in the past 3 months. UA: blood, LE +, Ntx+, US 1.3 cm irregular shaped stone in left renal pelvis. Dx?

Struvite stones -urease-pdt organisms e.g. klebsiella, proteus -path: Urea --> NH3 + CO2, NH3 --> OH- -ppt of magnesium ammonium

Fever >38C more than 24 hours after delivery with incisional induration and erythema

Superficial surgical site infection -risks: obesity and emergent surgery

Tx of intraventricular hemorrhage of newborn

Supportive Repeat scans

Treatment of congenital Zika syndrome

Supportive w/ evaluation of sequelae

Thyroid nodules in pregnancy

Suspicious sonographic features should *undergo FNA bx* (even if pt is pregnant)

26 y/o primigravid woman presents at 20 weeks gestation to the ER due to joint pain and swelling in her hands and feet for the past day. No bleeding, fluid leakage, or visual changes. PMHX of SLE treated with hydroxychloroquine, d/c before conception. Exam shows 2+ pitting edema of the legs and red macular eruptions on the cheeks. Labs show: Hb 10.2, Plt 120K, UA: 2+ protein, RBC casts, Cr 2.1. Urine protein 1.5 g/ 24 hours. Dx?

Systemic lupus erythematosus flare -edema, malar rash, arthritis, hematuria -labs: nephritis proteinuria, UA w/ RBC & WBC casts, low complement, high ANA titers -dx: renal biopsy -OB complications: preterm, c-section, preeclampsia, fetal growth restriction, fetal demise.

side effects of oral isoretinoin therapy

Teratogenic (e.g. SAB, fetal malform) -pregnancy test prior -2 forms of contraception Hyperlipidemia Chelitis, dry skin Myalgia Pseudotumor cerebri

First step in evaluating asymptomatic elevation of aminotranferases

Thorough history -r/o common hepatitis risk factors e.g. ETOH, drugs, foreign travel, blood transfusions, high risk sex practice

Treatment of anal fissures

Topical nifedipine -reduces anal sphincter pressure -bright red rectal bleeding

Closed fists with overlapping fingers, micrognathia, prominent occiput, large, fat fat

Trisomy 18 -Edwards syndrome

Causes of primary ovarian insufficiency

Turner syndrome Fragile X autoimmune oophoritis chemo/ radiation galactosemia

Highly effective emergency contraception that prevents pregnancy by delaying ovulation and impairing implantation

Ulipristal -progestin receptor blocker -120 hours after sex

Evaluation of biliary atresia

Ultrasound of RUQ -progressive fibrosis and obliteration of extrahepatic bile ducts -2-8 weeks of life

Next step after IVF have been initiated in burn patient

Urethral catheterization -monitor UOP for fluid resuscitation

Painful mass in the anterior vaginal wall in patient with hematuria, incontinence, and recurrent infection

Urethral diverticulum

Fibrotic narrowing of the urethra presenting as weak or spraying urine flow and incomplete emptying, postresidual volume is increased

Urethral stricture -urethra trauma, infection, radiotherapy -dx urethrography -tx urethral dilation

Treatment for patients with complicated urinary incontinence e.g. unresponsive to treatment or who are considering surgical intervention

Urodynamic testing

Patient at 29 weeks gestation with right-sided abdominal pain, uterine tenderness, a palpable, firm, and tender mass, and signs of systemic inflammation e.g. leukocytosis

Uterine fibroid degeneration

Risks of estrogen-progestin contraceptives

VTE HTN Hepatic adenoma CVA MI Cervical cancer

Management of IUFD at >/= 24 weeks

Vaginal delivery

contraindications for vaginal delivery

Vaginal delivery contraindications -prior classical c-section -prior extensive uterine myomectomy -placenta previa

Treatment of genitourinary syndrome of menopause

Vaginal moisturizer & lubricant Topical vaginal estrogen

Tx of genitourinary syndrome of menopause

Vaginal moisturizer & lubricant, topical vaginal estrogen

Vaginal bleeding, malodorous discharge, and irregular lesion in patient over 60 y/o with chronic tobacco use and or persistent HPV infection

Vaginal squamous cell carcinoma -dx biopsy

Indication for amnioinfusion (NST findings)

Variable decelerations -e.g. oligohydramnios -rupture of membranes and subsequent fetal cord compression -however, oligohydramnios can be due to chronic placental insufficiency which has no variable decelerations

Continuous, painless urinary leakage in patient with history of pelvic radiation for cervical cancer

Vesicovaginal fistula

40 y/o G5P5 woman with urine leakage over past 2 months. She has had *constant urinary leakage*, no dysuria, no urgency, or vulvar pruritus. Two years ago she had beam pelvic radiation for cervical cancer. Smoked PPD for 25 years. BMI 43, Exam shows no urethral leakage w/ valsalva. Postvoid residual volume is 20mL. Dx?

Vesicovaginal fistula -abnormal communication between bladder and vagina

Unilateral sensorineural healing loss with imbalance and decreased facial sensation

Vestibular schwannoma -benign tumor of CN VIII -AC > BC; lateralize to unaffected ear

Old patient with chronic antacid has tingling of b/l LE and decreased sensation to light touch

Vitamin B12 deficiency

Patient with recent colon surgery and history of alcoholism presents on POP day 7 with bleeding from veipuncture sites. PT 24, PTT 44 (both elevated)

Vitamin K deficiency -acutely ill patient -underlying liver disease -vitamin K deficient in 7-10 days

Next step in patient with mixed urinary incontinence e.g. symptoms of stress incontinence and urgency incontinence

Voiding diary

Prepubertal girl with vulvar pruritus and thin, white lesions of the vulva and perianal region and small anal fissure noted.

Vulvar lichen sclerosus -tx w/ clobetasol

signs/sx of vulvar cancer

Vulvar pruritus, plaque/ ulcer, bleeding -unifocal friable mass, dyspareunia

Dysparuenia due to sharp, burning pain on the vulvar vestibule often triggered by touch e.g. positive q-tip test, patients may have vestibular erythema

Vulvodynia

Contraindications to copper IUD

Wilson disease Copper allergy Heavy menstrual bleeding Acute pelvic infection

Population affected by endometriosis

Women of childbearing age

Mineral deficiency resulting in alopecia, pustular skin rash (perioral & extremities), hypogonadism, impaired wound healing, impaired taste, and immune dysfunction

Zinc deficiency

42 y/o man with hx of Crohn disease presents for f/u. He had a partial ileal resection due to strictures and also had multiple surgeries to treat enterocutaneous fistula. Pt has received parenteral nutrition for the past several weeks, and recently started PO feeding. He has non-bloody diarrhea, exam shows patchy alopecia and a pustular, crusting skin rash with scaling and erythema around the mouth and extremities. Dx?

Zinc deficiency (obtained from meat, nuts, cereal) -alopecia -pustular skin rash (perioral and extremities) -hypogonadism -impaired wound healing* -impaired taste -immune dysfunction -comorbid diarrhea and malabsorption further increase risk of mineral deficiency in patients on PN

Diagnosis of IUFD

absence of fetal cardiac activity on ultrasound

Dx of nonviable fetus

acardia anencephaly b/l renal agenesis thanotophoric dwarfism

Acute fatty liver of pregnancy vs acute cholangitis

acute fatty liver -fulminant liver -thrombocytopenia -hypoglycemia (profound!) acute cholangitis -charcot triad: fever, RUQ pain, jaundice -high direct hyperbilirubinemia

Antibody in postpartum thyroiditis

anti-thyroid peroxidase autoantibodies (Hashimoto's)

Treatment of septic pelvic thrombophlebitis

anticoagulation, abx

Treatment of acute cervicitis

azithromycin & ceftriazone

Bilateral renal agenesis vs posterior urethral valves

b/l renal agenesis U/S shows absent kidneys and small bladder -posterior urethral valves U/S show signs of obstruction

Diagnosis of vesicovaginal fistula

bladder dye testing may identity small fistula that are difficult to visualize

Treatment of tubo-ovarian abscess

broad spec abx

Diagnosis of hidrandenitis suppurativa

clinical

Complication of IUFD

coagulopathy several weeks of fetal retention

Features of adnexal mass that are concerning for malignancy

complex appearance irregular thickened septations papillary projections

Treatment of pubic symphysis diastasis

conservative, NSAIDs, PT, pelvic support

Tx for lactation mastitis

continue breast feeding dicloxacillin OR cephalexin

Mineral deficiencies in patients on parenteral nutrition

deficiency in Zn, Cu, Se, Cr

Tx for primary ovarian insufficiency

estrogen therapy w/ progestin if intact uterus

Causes of severe fetal anemia in utero

fetal *blood loss e.g. ruptured vasa previa*

Definition of intrauterine fetal demise

fetal death at >/= 20 weeks gestation -decreased or absent fetal movement

Obstetric complications of intrahepatic cholestasis of pregnancy

fetal demise, preterm delivery, meconium-stained amniotic fluid, NRDS

complications of inadequate weight gain in pregnancy

fetal growth restriction preterm

Features of postpartum endometritis

fever >24 hrs *fundal ttp* *purulent lochia*

complications of x's weight gain during pregnancy

gestational DM fetal macrosomia c-section

hCG effect on TSH

hCG stimulates TSH receptors = increase TH production

Risks for hyperemesis gravidarum

hydatidiform mole multifetal gestation prior episodes

Exam findings in endometriosis

immobile uterus, cervical motion ttp, adnexal mass, recto-vaginal-septum, posterior cul-de-sac, uterosacral ligament nodule

Uterine rupture is primarily seen in...

laboring patients prior c-sections myomectomies

Labs for 21-hydroxylase deficiency

low Na low Glc high K high 17-a-HPG

Treatment for patient with recurrent pregnancy loss due to inherited thrombophilia

low-molecular-weight heparin

Paripartum bleeding with pain vs without pain

mom pain = damage to mom (painless = placental unless abruptio placentae)

Patient at risk for preeclampsia

multiple gestation CKD HTN DM autoimmune dz -give low-dose ASA

vulvar lichen sclerosus signs/sx

multiple white papules/ plaques

Tx of choanal atresia

oral airway, surgical repair

Diagnosis of tubo-ovarian abscess

pelvic US, CT

Abruptio placentae

placental separation from the uterine wall before delivery

Lab abnormalities in patients born to diabetic mothers

polycythemia hypoglycemia hypocalcemia

Risks of short interpregnancy e.g. pregnancy 6 months after previous birth

preterm labor preterm prelabor rupture of membranes low birth weight material anemia

Risk for placenta previa

prior episode prior c-section multiple gestations advanced maternal age

Tx for preterm labor

progesterone maintains uterine quiescence

Complications of hepatic adenoma

progressive growth rupture malignancy

Treatment of congenital toxoplasmosis

pyrimethamine sulfadiazine folate

Routine postpartum care for mother

room-in/lactation support serial examination for uterine atony/bleeding perineal care voiding trial pain management

Treatment of postural puncture headache

self limited, epidural blood patch

Treatment for neonatal thyrotoxicosis

self resolves 3 mo Methimazole beta-blockers

Pathophysiology of SIADH

sensitizing the kidneys to ADH through increased # vasopressin-2 receptors in collecting tubules inability of kidneys to excrete adequately dilute urine to maintain normal blood

Female sexual interest/arousal disorder

sexual dysfunction common in postmenopausal women lack of, or significantly reduced sexual interest/arousal

US finding of epithelial ovarian carcinoma

solid mass, thick septations, ascites

Contraception postpartum for breastfeeding mother

subdermal progestin-releasing implant

Reducing sudden infant death syndrome

supine position sleeping reduce prenatal and postnatal smoke exposure *limiting pacifier* use during sleep limit room-sharing w/ caretaker *no soft mattresses*, crib bumpers, and loose bedding

DVT tx in pregnancy

unfractionated heparin low molecular weight heparin

Tx for spinal epidural abscess

vanc + cef, aspiration

postexposure prophylaxis for newborn to mother with varicella developing 2 days after delivery

varicella-specific immunoglobulin

Removal or urinary catheterization post op

within 24-48 hours -reduce risk of UTI -earlier discharge from hospital -reduces mortality

Pathophysiology of hyponatermia in hyperosmolar hyperglycemic state

x's osmotic substance e.g. glucose draws intracellular water and dilutes extracellular fluid sodium - translocational hyponatremia