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Clinical Medicine Final
Terms in this set (783)
4 major sources of bleeding in early pregnancy
Ectopic, miscarriage, implantation of pregnancy, and pathology
What is the most common cause of bleeding during the first trimester?
What happens to the uterus during pregnancy?
Enlarges/globular and softens
At what point in the pregnancy does the uterus grow to above the pubic symphysis?
What happens to the cervix during pregnancy?
Vaginal Mucosa and cervix bluish/violet (increased Blood supply)
When can the heart beat of fetus be heard by doppler?
10 to 12 weeks EGA
When can the fetus be seen on U/S?
5 to 6 weeks
Can result in false positive for pregnancy when read after suggested time frame
True or false: HCG can be used to estimate gestation age
False, but is a good indicator of pregnancy progression
What happens to the quantitive HCG?
doubles every 29 to 52 hours during first 30 days
When does HCG peak?
60 to 90k (8 to 10 weeks)
When can the gestational sac be seen with TVUS?
4.5 to 5 weeks
fetal pole/yolk sac never develop, empty sac
FIRST day of LMP + 7 days - 3 Months
If LMP is unknown dating using what trimester U/S is most accurate?
First trimester -- Third trimester can be off +/- 3 weeks
Gravity and parity G_P_ _ _ _
G: how many conceived
P: term, preterm, abortions, living
> 37 weeks
20 to 36 weeks
< 20 weeks
0 to 14 weeks
15 to 28 weeks
29 to 42 weeks
At what week gestation is the fundus of uterus at level of umbilicus
When is the triple/quad screen tested?
15 to 22 weeks (first trimester)
When is Ab Screen conducted?
Whats included in quad screen?
AFP, HCG, inhibin A, Estriol
When is morphologic evaluation and dating ideal?
18 to 20 weeks
How man extra calories should a pregnant woman eat?
Toxoplasmosis in pregnancy
Undercooked meat, cats and cat litter in pregnant women increase risk
Listeria in pregnancy
No lunch meat, hot dog, soft cheese, most susceptible in 3rd trimester
Where is HCG produced?
Rate of weight gain in pregnancy?
3 to 6 lbs in 1st trimester, 1/2 to 1 lbs per week in 2nd and 3rd trimesters
Recommended intake of caffeine in pregnancy?
< 200 mg/day
Fetal Alcohol syndrome
Smooth philtrum, thin vermillion border, small palpebral fissures, microcephaly
What affects can cocaine have on pregnancy?
placental abruption due to vasoconctriction
Class A drugs and pregnancy
Class B drugs in pregnancy
animal studies indicate safety
Class C drugs in pregnancy
No studies to support or refute
Class D drugs in pregnancy
Shows adverse effects
Class X drugs in pregancy
What two types of drugs should be avoided during pregnancy
What immunizations are contraindicated in pregnancy
Smallpox, measles, mumps, rubella, varicella, yellow fever
Normal abnormal findings during pregnancy
systolic murmur, exaggerated S1, S2, S3, spider angioma, and palmar erythema, linea nigra, and stria gravidum
Issues with CMV and pregnancy
No known treatment known during pregnancy, results in progressive hearing/vision loss
OTC meds for N/V in pregnant women
Vitamin B6, Unisom
Severe emesis, Weight loss > 5 percent pregnant body weight
Profuse salivation associated with pregnancy
All vitamins except ____________ are found in breast milk
Vitamin K, has to be given to child after birth to prevent hemorrhagic disease
What hormone stimulates milk production
What hormone stimulate milk ejection
Glucola test is done at what week?
24 to 28 weeks
Group B strep is done at what weeks?
If (+) for Gonocchal or Chlamydia when is the TOC?
unilateral, chills, rigor fever, hard and red
Inhibition of lactation?
breast binder, ice packs, cabbage leaves, oral analgesics (NO BROMOCRIPTINE)
What is a normal weight gain during pregnancy
good guideline for expected progression in labor --
Latent first phase of labor
slow dilation to 3 to 5 cm
Active first phase of labor
faster rate of dilation 1 cm/hr to 1.5 cm/hr if mutlipariou
What is 1st stage arrest disorder?
> 2 hour with no change (ok as long as having active contractions)
Second stage of Labor
Complete dilation (10 cm) until fetal delivery
Third stage of labor
After delivery of fetus until delivery of placenta
Three signs of placental separation
Lengthening of umbilical cord, gush of blood, funds becomes globular more anteverted
What is the most common fetal lie (position)?
Umibilical cord first, BAD
How to determine if membranes have ruptured?
Nitrazine paper, pH normally 4.5 to 5 in vagina. Amniotic fluid: 7.0
Level of fetal part in birth canal compared to where ischial spine, which is 0
Negative station position
Above ischial spine
Positive station position
below ischial spine
Normal fetal heart rate
120 to 160 bpm
Accelerations versus decelerations in fetal monitoring
decelerations pathologic, accelerations not as concerning
Early decelerations of fetal monitoring
Variable decelerations of fetal monitoring
Late decelerations of fetal monitoring
How to assist with placental delivery
20 units of pitocin at 200 cc/hour until uterus contracts then 125cc/hr
loss of >500 cc of blood (vaginal), > 1000 cc (C/S)
What do you do with GBS infection in pregnancy?
Prophylax with PCN
First degree Perineal lacerations
Second degree perineal lacerations
Skin + Mucosa
Third degree perineal lacerations
Skin + mucosa + perineal body + anal sphincter
Fourth degree perineal lacerations
3rd + rectal mucosa
pregnancy ended before 20 weeks gestation, most evident before 12th week
Expulsion of all POC
No gestational sac
Os is closed
Partial expulsion of POC
passed with tissue and blood
Os is open
No expulsion of products but bleeding with dilation of cervix
any vaginal bleeding < 20 weeks
Os is closed
No tissue passed
-No FHR with complete retention of POC
-Usually no vaginal bleeding
Treatment of thrush in pregnancy
diflucan (oral), topical (wash off before feed)
oral nystatin for baby
What is the most common cause of spontaneous abortion?
What should be given to all Rh-neg patients with bleeding?
< 15 weeks gestation, >/= 3 SAb's or >/= 2 SAbs if over age of 35
Uterine anomalies as cause of abortion is usually seen in what trimester?
Second trimister (e.g. ashermans syndrome, DES exposure, fibroids)
What some infectious causes of spontaneous abortion?
Mycoplasma Hominis, Listeria, toxoplasmosis, rubella, HSV, measles, CMV, coxsackie
What is the most common presentation of baby at time of delivery?
LOA (left occiput anterior)
What should be avoided if ectopic pregnancy is suspected?
Pelvic exam, can induce shock, US instead
What are some lab abnormalities seen in one with Ectopic pregnancy?
beta-hCG levels lower than expect compared to gestational age
Progesterone level < 5ng/ml (normal > 25)
What is a Rx for ectopic pregnancy?
methotrexate, but surgical removal is an option
What are some long term effects of an ectopic pregnancy?
recurrent ectopic, infertility risk
What is the most common neoplasm that produces hCG
True or false: Gestational Trophoblastic Disease is sensitive to chemotherapy
Types of benign Gestational Trophoblastic Disease
Complete (class) molar pregnancy
molar degeneration with no associated fetus
Incomplete (partial) molar pregnancy
molar degeneration with an abnormal fetus
Most common pattern for complete molar pregnancy
46, XX (fertilization of an empty egg)
Which has a higher malignancy potential, complete or partial?
Highest rate of complete molar pregnancy see in which population?
Asians (lowest, black women)
Risk factors of Complete Molar Pregnancy
> 20 or < 40 y.o.
diet high in carotene and folic acid
hx of SAbs or GTD
Common symptoms of complete molar pregnancy
irregular or heavy vaginal bleeding, passage of vesicles
Complete molar pregnancy
beta-hCG extremely high (>100,000), snowstorm pelvic US, grape-like molar clusters, no fetus in uterus, lutein ovarian cysts
Complete Mole Treatment
D and E, hysterectomy if done childbearing,
Complete Mole Follow-up
serial beta-hCG weekly until 3 consecutive negatives, then monthly for 1 year, with concurrent contraception
Partial Molar pregnancy
normal egg fertilized by 2 sperm (69, XXX)
What does a partial molar pregnancy usually present with?
Incomplete or missed abortion
Partial mole treatment
Same as complete: beta-hCG until neg x 3 then monthly for 1 year
Malignant GTD classification
Invasive mole, choriocarcinoma, placental site trophoblastic tumor
Follow up malignant GTD treatment
beta-hCG weekly, then monthly x 1 year
plateauing or rising beta-hCG after treatment for molar pregnancy
Malignant necrotizing tumor, metz, 25% after molar, 50% after normal term pregnancy, 25% after SAb, Eab or ectopic
Placental Site Trophoblastic tumors
rare, vaginal bleeding and persistent + beta-hCG, not sensitive to chemo
What is a normal response to pregnancy that is typically concerning?
tachycardia, but >120 to 130 is worrisome, decrease in BP, decreased esophageal peristalsis, delayed gastric emptying, melasma
Oral glucose challenge test in non-fasting state, if positive what is indicated?
What criteria must be met with OGCT in order to initiate treatment for gestational diabetes
If patients 1 hour OGCT is >200, if elevated >134 definitive test is 3 hour OGTT >140
cesarean section should be performed for babies who are what weight?
> 4250-4500 g
Delivery criteria for GDM
If poor control deliver at 38 weeks, if diet-controlled and no other comorbidities @ 40 weeks
Hypertension in pregnancy
2nd leading cause of maternal mortality, associated with intrauterine growth restriction
Chronic hypertension in pregnancy
hx of HTN prior to pregnancy or during 1st half, evident before 20 weeks, lasts longer than 12 weeks postpartum
HTN occuring > 20 weeks
HTN + proteinuria (>300mg/24 hours) +/- edema
pre-eclampsia + seizures
Treatment chronic HTN in pregnancy
Methyldopa (ACEi contraindicated)
If mild manage with anti-HTN, and mg sulfate (for seizure prevention)
If severe, delivery by at least 34 weeks
Pts have few complaints
Diastolic < 110
No epigastric pain
Symptoms more dramatic (HA, vision changes
BP 160/110 and up
Advanced form of severe pre-eclampsia (3rd trimester)
Elevated Liver enzymes
Low platelet count
Most common cardiac complication of pregnancy is what?
What is the most common valvular lesion seen in pregnancy?
s/s of CHF late in pregnancy or early postpartum
function returns to normal in 50% of patients,
decrease after load and increase cardiac
What is the most common extrauterine complication requiring surgery in pregnancy?
appendicitis (2nd 3rd trimester) -- if surgery is needed do in 2nd trimester
Most common pulmonary risk factor during pregnancy?
Aspiration pneumonia -- general anesthesia
Second most common surgical disorder during pregnancy
Cholecystitis treatment during pregnancy
IV fluids and decreased oral intake, and ABX, if doesnt resolve surgery is necessary
Acute fatty liver of pregnancy
3rd trimester, new-onset of N/V, malaise, epigastric pain and jaundice
Difference between HELLP syndrome and AFLP?
Both 3rd trimester with N/V and RUQ pain, AFLP --> low glucose
Antiphospholipid antibody syndrome is associated with what obstetric complications
Recurrent pregnancy loss, fetal death, preeclampsia, IUGR, abruption****, abnormal test results
Antiphospholipid antibody syndrome treatment
w event: anticoags through preg and 6 wks post-partum
w/o event: heparin or LMWH preg and 6 weeks post-partum
Hx of still birth or recurrent pregnancy loss: LDA and heparin
Hypochromic microcytic cells + low retic count
Oval macrocytes + low retic count
megaloblastic anemia (b12 or folate)
evaluation of anemia
Iron defiency versus anemia of chronic infection
BOTH: plasma iron decreases
CI: TIBC decreases
Treatment of intrahepatic cholestatis during pregnancy
B12 vitamin deficiency
Folate deficiency in pregnancy
low folate level, signs of anemia with skin roughness and glossitis
OB complications of sickle cell anemia
preeclampsia, antepartum admissions, PTD, PROM
How to prophylactic treat HSV in late pregnancy?
Valacyclovir the last month
When is cesarean delivery for pregnant women with HSV necessary?
active genital lesion
True or False: primary and secondary are more likely to transmit to fetus than latent
BACH (normocytic anemia)
Blood loss, aplastic, chronic disease and hemolytic
FHPP (macrocytic anemia)
folic, hypothyroidism, B12 perncious
TICS (microcytic anemia)
Thalassemia, Iron deficiency, chronic disease, sideroblastic
Late congenital syphilis
Hutchinson teeth, mulberry molars
Hemolytic disease of Newborn
Rh- mom carries Rh+ fetus, mixing causes Rh+ antibodies, which can affect subsequent fetuses -- Rhogam at 28 weeks, and then w/in 72 hours of delivery
lack of pregnancy after one year of normal sexual activity without the use of contraceptives
Most common cause of 2nd trimester loss
True or False: Abnormal karyotype is a common cause of late abortion
False! most common in first trimester <12 weeks
PAINLESS dilation and effacement of Cx often in 2nd trimester
Infection and vaginal discharge is common
Commonly confused with PTL
Incompetent Cervix Treatment
If pre-vialbe (<23 to 24) elective Termination of pregnancy or expected management with bed rest OR rescue cerclage (13 to 14 weeks subsequent pregnancies)
occurs before 37 weeks, preterm contractions with cervical change
Differs from incompetent cervix (painless dilation)
prevent contractions and progression of PTL, can only delay delivery by 48 hours cannot prevent PTD
Given at <34 weeks with preterm labor to reduce respiratory distress, intraventricular hemorrhage, enterocolitis
Tocolytic, can only be given IV, cannot give orally. avoid if patient is already tachy
Tocolytic, fetal neuroprotechtion in <32 weeks
Tocolytic; Rx of choice for PTL between 28 and 34 weeks, or DM
Tocolytic; rx of choice in PTL </= 28 weeks
What is a common cause of Preterm labor?
Preterm Premature Rupture of Membranes
What are some risk associated with Preterm Premature Rupture of Membranes?
Risk of chorioamnionitis, abruption, cord prolapse
Fluid on microscope shape indicative of PROM
Tx of Preterm premature rupture of membranes
steroids if 23 to 32 weeks
Mercer antibiotic protocol
Inidications of Chorio and/or fetal distress in Mom with PPROM
fetal tachy (>175 bpm and maternal fever)
HTN in pregnancy
HTN early 2nd trimester: molar pregnancy, CHTN
>20 weeks: pre-eclampsia
> 36 weeks: pregnancy induced HTN
< 36 weeks HELLP
BP > 140/90 mm Hg @ least twice
< 300 mg proteinuria (1 to 2+ disptick)
Normal LFT and platelets
Pre-eclampsia symtpoms (some severe some mild)
Visual disturbances, headache epistastric pain
BP > 140/90
Proteinuria > 500 mg/24 hour (3 to 4+ dipstick)
Hemolysis (increased uric acid, LDH, total bilirubin, Elevated LFTs, Low platelets < 100k
Fetal complications of Pre-eclampsia
Prematurity, Acute Uteroplacental insufficiency (stillbirth), Chronic UPI (Oligohydramnios)
Magnesium sulfate dosage for preeclampsia
4gm load, 2 gm/hr mantainence, 12 to 24 hours postpartum
Acute anti-hypertensive Rx Eclampsia
Hydralazine and Labetalol IF diastolic is > 105 to 110 mmhg
True or False: there is a 25% chance of recurrence of pre-eclampsia in subesequent pregnancies
What can reduce the risk of pre-eclampsia, if pre-eclampsia developed at <34 weeks in prior pregnancy?
What is the leading cause of maternal death
What are the two major causes of antepartum hemorrhage?
placenta previa, placental abruption
abnormal implantation of placenta over internal cervical os
Low lying placenta
2 cm or closer to the internal cervical os
Placenta previa accreta
superficial ATTACHMENT and invasion
- increases in risk with C/s
Placenta previa increta
Placenta previa percreta
penetrates myometrium to uterine serosa
Clinical symptoms of placenta previa
sudden profuse PAINLESS vaginal bleeding, usually after 28 weeks, Dx using U/S
premature separation of normally implanted placenta from the uterine wall, usually occur >30 weeks
what is the most common factor associate with placental abruption?
HTN, also risk of abruption in future pregnancies increases with each event.
Clinical Symptoms of Placental Abruption?
3rd trimester bleeding with abdominal pain and/or frequent contractions
Differences between Placenta abruption and placenta previa
Abruption: Abdominal pain
True or false: Placental abruption is a clinical diagnosis
True, if dx with U/s usually too late
Treatment for abruption
If unstable, deliver
Stable: tocolytics, steroid if < 34 weeks
Most associate with prior uterine scar, occur duing labor, sudden onset of pain, poor FHR, immediate laparotomy and delivery, discourage future pregnancy
Antibiotic contraindications in Pregnancy: Fluoroquinolones
Antibiotic contraindications in Pregnancy: Aminogylcosides
CN8 toxicity in fetus
Antibiotic contraindications in Pregnancy: Sulfonamides
Antibiotic contraindications in Pregnancy: Tetraycycline
Tooth/bone problems in infant
Globular or spherical
If pelvic support problem affects anterior wall think.....
If pelvic support issue affects posterior wall think....
Causes of uterine prolapse
vaginal childbirth **, normal aging (decline in estrogen levels and elasticity
Most common cause of rectocele
When are cervical cultures indicated in uterine pelvic support problems?
if ulcerations or discharge is present upon examination
Imaging studies useful in uterine pelvic support problems
pelvic ultrasound, MRI (grade prolapse, not dx)
Managment of uterine pelvic support problems
Kegel exercises, pessary, surgery (bladder suspension, hysterectomy, posterior colporrhaphy)
Pelvic Girdle Pain
between posterior iliac crest and gluteal fold, caused by pregnancy, trauma or injury
aberrant growth of endometrial tissues outside the lining of the uterus (MC found in dependent parts), type A, nulliparous women
What is the most widely accepted cause of endometriosis?
Signs and symptoms of Endometriosis
Pelvic pain, abnormal uterine bleeding, infertility, dyspareunia, rectal bleeding (colonic), hematuria (bladder)
True or false: Most women pelvic with endometriosis will have an abnormal US
False, most will be normal
What is the only way to definitively diagnose endometriosis?
Danazol, Leuprolide acetate
Sx managment endometriosis
Conservative (LAP exploration removal of adhesions)
Total hysterectomy (definite treatment)
two goals of treatment for endometriosis?
Decrease pain and promote fertility
growth of endometrium within the muscular walls of uterus, results in diffuse enlargement
Women 35 to 50
diffuse enlargement of uterus
ACQUIRED uterine abnormality (MC D&C)
MC cause of secondary amenorrhea in younger patients
S/S asherman's syndrome
Inability to create healthy lining for implantation to occur, secondary amenorrhea, infertility
Tx asherman's syndrome
hysterectomy (Gold standard)
MC gyn malignancy in US
50 to 70 y.o. (if younger <40 suspect lynch syndrome)
What is the "warning sign" of endometrial cancer?
abnormal bleeding in post-menopausal female and lower abdominal pain
What increases risk of endometrial cancer?
obesity, late menopause, obesity, nulliparous, diabetes, HTN, PCOS, White, Family HxColon or Gyn Cancer
What decreases risk of endometrial/uterine cancer?
ovulation, progestin, combo OCP's, multiparity, early menopause
Pelvic exam findings: uterine/endometrial cancer
enlarged, boggy uterus
Diagnostic method of choice: uterine/endometrial cancer
endocervical and endometrial biopsy with hysterectomy (atypical glandular cells)
Tx endometrial cancer
total hysterectomy with bilateral salpingo oophorectomy, LN resection, colonoscopy or genetic screening if applicable
What are the most common benign neoplasms of the female genital tract
What are uterine fibroids also known as?
fibromyomas, leiomyomas, myomas
S/S Uterine fibroids
Can be asymptomatic
Heavy/prolonged/irregular menstrual bleeding (anemia)
pelvic pain or pressure
Pelvic exam findings: Uterine fibroids
irregularly shaped uterus or masses, non-tender (always check serum pregnancy)
What test confirms dx of uterine fibroids?
Uterine Fibroid managment
Depo Leuprolide, OCP (shrinks tissue), surgical (myomectomy, hysterectomy)
PID is also known as
What is PID strongly associated with?
N. gonorrhoeae, C. trachomatis
pelvic pain, chills, PID shuffle, menstrual changes/vaginal discharge, CMT tenderness
Fitz-Hugh Curtis Syndome
Associated with PID, RUQ pain, violin string adhension (perihepatitis)
What must you r/o in those with suspected PID
ectopic, appendicitis, septic abortion
Pelvic exam findings: PID
pus, cervical motion tenderness, chandelier sign
Ceftriaxone + doxycycline x 14
(can add metronidazole: BV and trich)
What structures are included in the adenxa?
round ligament, ovary, and fallopian tube
type of ovarian cyst
mature follicle that fails to rupture
Corpus luteum cyst
type of ovarian cyst
results from bleeding into center of corpus luteum
True or False: Ovarian cysts are usually bilateral
False, typically unilateral
Benign, young women, asymptomatic, may be calcified on xray, can occur bilaterally, remove to avoid TORSION
Associated with endometriosis (chocolate cyst)
Failure of the fluid in an incompletely developed follicle to be reabsorbed, asymptomatic, self-limiting
Most frequently seen with Dermoid cysts
severe sudden onset of pelvic pain
Sx: ASAP to preserve function
Workup for Ovarian cysts
Laprocopic if unresolved
Polycystic Ovarian syndrome
Hyperandrogenism (obesity, facial hair, acne, thinning of scalp hair), Infertility, bilateral enlarged polycystic ovaries
Clinical findings: PCOS
hirsutism, obesity, amenorrhea, acanthosis nigricans, abnormal uterine bleeding, insulin resistance, infertility
What is an example of primary amenorrhea
Genetic disorders such as turner syndrome
Female athlete triad
eating disorder, amenorrhea, and osteoporosis
fasting glucose to r/o diabetes
Elevated LF/FSH > 2.5
Elevated Prolactin level
exercise and weight reduction
metformin 500mg TID
Dexamethasone (high DHEA levels)
What is the leading cause of death from reproductive tract cancer?
True or False: women with ovarian cancer are diagnosed with advanced disease?
What age are most women with ovarian cancer?
50 to 75 y.o.
What are some protective mechanisms for Ovarian cancer
OCPs, breat feeding, multiparity
Are fixed or unfixed masses more worrysome?
What are some common symptoms in advanced disease of ovarian cancer
pain, bloating, abdominal mass
What specific lab test should be evaluated if ovarian tumor is found and are looking for malignancy?
What should be conducted if ovarian mass/cancer is confirmed?
genetic testing (r/o BRCA)
What is a good test to conduct to work-up ovarian cysts?
Early stage ovarian cancer carcinoma treatment
TAH w/ BSO
Advanced disease Ovarian cancer
Surgical tumor removal, chemotherapy
What is the MOA of OCP?
MOA of progestin minipill
thickening of cervical mucous to make it hositile to sperm, and inhibiton of implantation
MOA of IUD
spermicidial or inhibitory effects on sperm capacitation and transport
True or False: copper containing IUD can be used as a postcoital contraceptive
True. As long as its inserted within 5 days
Which IUD type is useful in menorrhagia?
hormone releasing IUD (not copper)
What time frame must emergency contraception be used?
within 120 hours after unprotected coitus
(levonorgestrel, ulipristal, ethinyl estradiol)
Mifepristone (RU 486)
oral abortifacient during first trimester
Where do most breast lymphatics drain?
Majority of breast cancers occur in which quadrant
What findings are consistent with Breast malignancy
hard, irregular shape, dimpling of overlying skin, retraction of nipple, non-tender
Where are supernumerary nipples typically found?
along embryonic milk lines
Unilateral: can be sign of cancer: refer to mammography/ductal aspiration
When should mammography screening beginning
50 y.o. and every two years, younger if at higher risk
What kind of microcalcifications may be associated with cancer?
tiny, irregular deposits
Larger, coarser area may be due to anging or fibroadenoma
When are MRI's recommended for breast cancer imaging?
Strong family hx
BRCA1 or BRCA2
Hx of radiation to chest
lifetime risk of 25%
Genetic syndromes (Cowden, lil-fraumen)
Fine needle biopsy
effective in dx of breast cancer without exicisional biopsy in > 90%
When is US useful in the diagnosis of breast cancer?
distinguish cystic from solid mass, used in focal masses found in women < 30
cyclic pain in reproductive aged women
non-cyclical premenopausal and post-menopausal women (large breast size, meds, pregnancy, thrombophelbitis, inflammatory breast cancer
well fitted breast, tamoxifen can be used after careful screening
MC breast condition, Painful, multiple, usually bilateral in breast, fluctuation in size, pain worsens with PMS, age 30 to 50
When does fibrocystic condition increase risk of malignancy?
If hyperplasia is associated with atypical cells
Proliferative breast disease
hyperplasia, dx based on biopsy, link to cancer (atypical)
When is open biopsy required in fibrocystic change disease?
when aspiration is bloody or residual mass after aspiration
common benign tumor, occurs commonly <30 y.o., round, rubbery, discrete, moveable, 1 to 5 cm in diameter
no Tx necessary if dx can be made with core needle biopsy. excision needed if pathologic or lesion grows significantly
benign tumor that grown in milk duct of breast, common cause of nipple discharge
seen in 35 to 55 y.o.
benign process, clogged milk ducts
bloody discharge is concerning for what?
rare mass lesion, skin or nipple retraction similar to carcinoma, trauma is presumed to be the cause, biopsy needed
benign papillary neoplastic growth, occurs just before or during menopause, present as bloody, serous, or turbid discharge
What diagnostic tools are used to determine intraductal papilloma
Mammography and cytologic exam
dilatation of duct with thick milky fluid, presents shortly after lactation, needle aspiration is curative, biopsy may be needed if aspiration doesnt resolve
Mastitis is usually caused by what?
Mastitis with associated abscesses present as what?
usually single, warm, edematous, erythematous, painful, fluctuant, nipple discharge
What are the early findings of breast cancer?
single, non-tender, firm to hard with ill defined margins, mammogram abnormalities, no mass
What are some later findings of breast cancer?
Skin or nipple retraction, axillary lymphadenopathy, breast enlargement, edema, pain, fixation of mass to skin/chest wall
What is the most predictive risk factor of breast cancer?
BRCA 1 and 2
Peau d' orange
blocked lymphatics leading to lymphedema and thickening of skin
Most common kind of breast cancer?
cancer cells that begin in the glands that make milk
rare breast cancer that involves the skin of the nipple and aerola, usually have one or more tumors of same breast Dx: biopsy
Most malignant form of breast cancer, spreads to skin and looks red and swollen, feels warm. May present as peau d'orange
How often should a person with breast cancer be seen within the first two years?
every 6 months, then annually
Special attention should be paid to what in those with breast cancer?
the contralateral breast (20 to 25%)
How does pregnancy affect breast cancer?
May be detrimental to a patient with occult metz
When is male breast cancer typically found?
in men approx. 70 y.o.
what are normal findings in the vaginal environment?
Lactobacillus and Candida in small amts
milk discharge with no odor, or irritation
irritation, pain, unusual odor and discharge, pruritus, dysuria, dyspareunia
Fishy scent: BV
Metallic: After period
Yeast/Bread: yeast infection
Musky: sweat, tight pants
Rotten: infection, FB
what are some personal hygiene issues that may cause vaginitis?
douches, bubble baths, vaginal sprays
Symptoms of Vaginal foreign bodies
vaginal discharge, intermenstrual spotting, foul-smelling
Toxic Shock Syndrome
Caused by retained tampons, blood cultures often negative bc symptoms are from toxin not effects of infection
Non-infectious vaginits TX
stop offending agent, sodium bicarbonate (stiz baths), vegetable oil
Most common cause of infectious vaginitis
BV is an overgrowth of what bacteria?
gardenerella vaginalis, mobiluncus, and a decrease in lactobacilli
True or False: BV is rare in those who are not sexually active
Symptoms of BV
watery, malodorous, white-gray discharge, pruritis, no lesions (hence not vaginitis)
Diagnosis of bacterial vaginosis
white adherent discharge, vaginal ph >4.5, + Whiff test, clue cells
Tx Bacterial vaginosis
Metronidazole 500 mg x 7 days or clindamycin cream
What is seen on the wet prep in Candidiasis?
hyphae and budding yeast
How does this differ from BV?
hyphae and budding yeast, - whiff test, pH < 4.5, no need for culture
Miconazole (single dose) clotrimazole (7 day)
What kind of species is trichomonas vaginitis?
Symptoms of Trichomonas
musty odor, frothy yellow or green discharge, dysuria, pruritis
Physical Exam: Trichomonas
Erthematous vulva and vagina, strawberry cervix
Dx: Trichomonas Vaginitis
Wet prep: flagellated protozoans and large WBC's
pH 5 to 7.0
Treatment of Trichomonas Vaginitis
Metronidazole 2g po x 1 dose
What if your'e pregnant with trichomonas?
only treat if symptomatic, treat > 37 weeks
Causes of Cervicitis
Trauma, Radiation, Infection, Malignancy
Infectious causes of Cervicitis
chlamydia, gonorrhea, trichomonas, HSV, HPV
Suspect cervicitis if:
erythematous, edematous or easily friable cervix, yellow/green discharge
TX of cervicits
Based on microbiology
STI Caused by HPV (types 6 and 11)
HSV types associated with cervical dysplasia/neoplasia
16, 18, 31 (post coital bleeding)
What does Quadrivalent (gardasil) vaccine protect against?
6. 11. 16. 18 (ages 9 to 26)
Gardasil 9 protects against...
6, 11, 16, 18, 31
, 58*, recommended in girls 9 to 26, and boys 9 to 15 years.
Bivalent HPV vaccine protects against....
HPV 16 & 18
When should PAP testing begin?
screening at age 21 every 3 to 5 years
Pap results: ASC- US
low risk of invasive Ca
Pap results: LSIL: HSIL
colposcopy and biopsy
Pap results: AGC
colposcopy with endocervical and endometrial evaluation
Pap results AIS, adenocarcinoma
What is the most common type of cervical cancer?
squamous cell carcinoma
soft, smooth, red growth, protruding from cervical os or seen in the endocervical canal, friable, usually seen in multigravidas > age 20
Symptoms of Cervical Polyps
Abnormal bleeding (postcoital), intermenstrual
Dx and Tx of Cervical polyps?
sample of endocervix and endometrium, tx, removal
Cervical Nabothian Cysts
Mucous-secreting columnar endocervical epithelium covered by squamous cells, appear translucent or yellow
What population is cancer of vulva typically seen?
postmenopausal women > 50 y.o.
cancer of vulva
slow growing, squamous lesion, associated with HPV 16, 18, 31, smoking, prior hx of cervical cancer, presents most often with pruritis, irritation, bloody discharge
Diagnosis of vulvar cancer
biopsy is essential, if + consider pelvic CT or MRI, colposcopic examination
treatment of vulvar cancer (irritative conditions, Lichen sclerosis or VIN)
clobetasol propionate cream
Bartholin duct cyst
found at 5 and 7, secrete mucous to help with lubrication, can become infected (abscess) or obstructed (cyst)
Bartholin Duct Cyst vs Abcess
Cys: painless lump
Infected: very painful, fluctuant swelling,
Tx: bartholin duct cyts
Warm soaks (sitz baths), I&D if abcessed, culture exudate, word catheter to allow drainage, or marsuialization
Fall of estrogen and progesterone
Phase 1: Follicular Phase
Days 1 through 12
Estrogen predominates, increased FSH, and LH
Phase 2: ovulation
Days 12 to 14
LH surge causes release of egg
Phase 3: Luteal Phase (secretory)
Non-pregnant causes of AUB
Structural causes (PALM)
Polyp, Adenomyosis, Leiomyoma, Malignancy & hyperplasia
Coagulopathy, ovulatory dysfxn, endometrial, iatrogenic, not yet classified
Areas of the body that can cause AUB
brain (gns, TSH, prl)
Lower gyn tract/perineum
Uterine causes of abnormal uterine bleeding (AUB)
myometrium: fibroids, adenomyosis
ednometrium: hyperplasia, adenoCa, poylps, endometritis, DUB
vasculature: von willebrand, platelet abnormalities, ITP
True of False: dysfunctional Uterine bleeding is a diagnosis of exclusion
True (no structural abnormality or coagulation disorders)
Anovulatory Dysfunctional uterine bleeding
due to high sustained levels of estrogen -- most common ovarian cause is PCOS
excessive bleeding associated with progesterone withdrawl
What is the most important thing that needs to be r/o in anyone experiencing abnormal uterine bleeding?
malignancy (esp. uterine cancer -- endometrial biopsy needed)
AUB physical exam
BP, weight, acanthosis, acne, hirustism, tumors, s/s of adrenal dysfunction, thyroid, breast exam, pelvic exam
What important structures can be seen using a Transvaginal ultrasound?
uterus and ovaries
Endometrial biopsy should be performed on which patients?
those > 35 y.o. or any age with prolonged anovulation
What are the advantages of Dilatation and Curettage?
more extensive sample, both diagnostic and therapeutic, high sensitivity
avoid in younger patients
What is typically the cause of AUB in those 13 to 18 ?
immaturity of HPO axis, and blood dyscrasias
What is typically managment of Acute AUB in those 13 to 18 ?
estrogen followed by combine OCP
What is typically managment of chronic AUB in those 13 to 18 ?
Birth control pills of any kind or progestin only (medroxyprogesterone/depo OR levonorgestrel/mirena)
What is the typical cause of AUB in those 19 to 39?
PCOS, with treatment of Birth control (>35 y.o. e-containing BC contraindicated)
What is the typical cause of AUB in those 40+ y.o.
anovulatory bleeding due to decreased ovarian reserve
What is the typical management of AUB in those 40+ y.o.
endometrial biopsy, low dose OCP
Iron defiency anemia is seen with a menstrual loss of _________/month
What is the goal with endometrial ablation?
amenorrhea or singificant decrease in quantitiy, frequency, an duration of abnormal bleeding (hysterectomy not necessary in majority of patients)
What is an absolute cure for DUB?
What Rx option can be used for PMS if non-pharmacolocial treatment is not working?
What can be used to help dymenorrhea?
OCP, NSAIDS teh day before menses
Post-menapausal symptoms can be improved with ______
HRT, but is not used often due to fear of breat cancer and may cause vaginal bleeding
What are the 5 P's
Partners, practices, protection, Past Hx, Prevention of pregnancy
PAINLESS chancre at site of transmission after 3 to 6 week incubation
non-pruritic rash, including soles and palms, can also include systemic symptoms like malaise, fever, myalgias
Following resolution of secondary syphilis but patients remain seroactive
1/3 untreated develop this
What is the most common cause of genital ulceration in the US?
chancroid, PAINFUL lesion with irregular borders
Lymphogranuloma venereum (LGV)
PAINLESS and superficial ulcer, usually with unilateral large LN
Treatment of Chancroid
azithromycin 1 gram Oral
Ceftriaxone 250 mg IM
Ciprofloxacin 500 mg BID x 3 days
Erythromycin 500mg TID x 7 days
Treatment of lymphogranuloma venereum (LGV)
doxycycline 100mg BID x 21 days
True or False: neurosyphilis can occur at any stage
True or false: ocular syphilis IS neurosyphilis, so is treated the same way
What are the most common structures affected by ocular syphilis?
posterior uveitis and panuevitis
related to Ocular syphilis
Accommodate but don't react
Common symptoms of ocular syphilis
Blurred/decreased vision, new onset of floaters, redness of the eye, eye pain, photophobia
Ocular syphilis management and treatment
Opthalmologic eval ASAP, CSF
Tx: aqueous penicillin G IV
Report to loca/state DOH
tests to detect T. pallidum directly from lesion exudate, diagnosing early syphilis
Each dx of syphilis needs what?
Nontreponemal test (VDRL, RPR) and a treponemal test (FTA-ABS, TP-PA, EIA, CIA)
EIA+/RPR- test results
past (treated) syphilis, chronic untreated, very early, or false positive
True or False: even if VDRL or RPR is negative, if exposed to syphilis you should be treated prophylactically anyway
Treatment of Syphilis
Benzathine penicillin G
If you are pregnant and receiving treatment of late latent or late syphilis what is not acceptable?
Missing doses -- if missed must have to start over full course of therapy
fibrile reaction occurring within the first 24 hours of syphilis treatment
What to do if allergic to penicillin and contract syphilis?
Doxycycline or ceftriaxone, but if pregnant, no other option other than penicilin, must be densitized.
Any woman who delivers a stillborn infant after 20 weeks should be tested for what?
clinical and serological eval @ 6 and 12 mos following tx, looking for a fourfould dilution decrase
When is syphilis most infectious?
primary and secondary stages
What is the 2nd most notifiable communicable disease in the US
True or False: Most women with gonorrheae are asymptomatic
True, however can commonly cause urethritis in males.
Treatment of Gonorrhea?
Ceftriaxone + Azithromycin
How long should patients wait to have sex following the beginning of STI therapy?
What is the treatment for gonococcal conjuctivitis?
Ceftriaxone 1g IM and saline rinse, refer to opthalmologist
Active individuals with onset of monoarticular arthritis, with concurrent genital symptoms
Treatment for Non-gonococchal Urethritis
Azithromyocin 1gm PO
Or doxycycline PO BID x 7 days
Treatment for perisistant NGU
If azithromyocin was given for 1st episode try moxifloxacin PLUS metronidazole and tinidazole
What is the most frequently reported STD in the US?
Non-pregnant (same as NGU): azithromycin or doxycycline
Pregnant: azithromycin or amoxicillin
Which Herpes infection is more severe? Primary or Non-primary?
How do herpes lesions progess?
papules, vesicles, pustules, uclers, crusts, healed (2 to 4 weeks)
Which HSV infection is more prone to reoccurence? HSV-2 or HSV-I
When is most HSV-2 transmission occuring?
during asymptomatic shedding
Treatment of HSV?
Acyclovir, reduces shedding
What is the gold standard for diagnosing herpes?
What is the dangerous complication of herpes?
The most deadly form of meningitis comes from HSV
seen in bacterial vaginitis/osis, no recognizable cell well
yellow-frothy green adherent discharge, amine odor pH >4.5
what is the most common cureable STI in the sexual active women?
Treatment for Trichomonas
Tinidazole or Metronidazole
Types of scoliosis
Infantile: birth to 2 years
Juvenile (3 to 9 year)
Adolescent (10 years and older) --MC
completely open risser 1, to completely closed risser 4 (iliac crest)
CRITOE (bone age elbow films)
Capitellum, Radial head, Internal epicondyle, trochlea, olecranon, external epicondyle (appear @ 1,3,5,7,9,11 -- close 2 years later)
At what degree of scoliosis okay for observation?
< 20 degrees
When should bracing be considered for scoliosis?
5 degree progression or > 25 degrees
when should surgery be completed in a scoliosis patient?
> 50 degrees
What are the milestones for normal walking gait?
13 mos: independent walking
18 mos: reciprocal arm swing
24 mos: normal knee flexion
36 mos: mature angular rotations
7 years: normal adult pattern, single limb stance
fever, elevated WBC, ESR, CRP
Poor active and passive motion, x-ray usually normal.
Acute hematogenous osteomyelitis
fever + bone pain
Exam findings in an infant with DDH
ortlani and barlow, short let, and decreased hip abduction
hip abduction with relocation of the hip into the acetabulum anterior
hip adducted with posterior force to try and posteriorly dislocate hip
Uneven leg height when bent at hip and knee
3 to 10 y.o., painless or painful limp, knee pain, decreased hip motion
ages 10 to 16 yo. painful limp and knee pain, decreased IR
What are the two common pediatric bone tumors?
Osteosarcoma and Ewings sarcoma
What can we infer about tumor type in pediatrics based on the time course of pain?
long time = benign
wks to months = aggressive
severe, short duration = infection
MC type in children/adolescentssun ray/sunburst appearance, codmans triangle, adjacent soft tissue mass, usually involves long bones
mottled or moth like lesion, lytic destruction common, onion skin appearance
fallen leaf sign
Salter Harris fractures
Transverse lines of park-harris
Growth arrest lines, will parallel physis
> 80,000 PMN
Cavus and Adductus, talus vertical
Infant < 29 days old fever?
Infant 29 to 90 days old fever?
100.4 to 100.7F
What is the gold standard for temperature taking
True or false: a fever is a medical emergency in a child under 2 months
True (UTI, bacteremia, meningitis)
If infant is hospitalized due to fever what is the first line treatment?
empiric antibiotics until cultures return negative
Neonatal meningitis causes
Group B strep, e. coli, strep pneum
Neonatal meningitis diagnosis and treatment
CSF culture, start with broad spectrum (ampicillin/gentamicin) ABX at least 14 days ABX therapy
Neonatal Herpes simplex
Skin, eye, mucous membrane, MC
Disseminated greatest morbidity
Neonatal herpex simplex treatment
acyclovir (14 days SEM, 21 disseminated)
What level goes up significantly in bacterial infection in infants?
Fever in 3 to 36 month old
usually viral, occult UTI remains concern
Who are more likely to get UTIs as an infant? Girls or Boys?
Girls are more likely,
UTIs in infants are commonly caused by what?
e.coli, klebsiella, proteus
Treatment of UTI in infants and children?
augmentin, bactrim, f/u evaluation of bladder and kidness
What is indicated if recurrent UTIs in infant and children?
Community acquired pneumonia in Infants and children
< 3 weeks: GBS, chlamydia
>3 weeks to 4 y.o.: viral, strep. pneum.
School age: mycoplasma
Is pneumonia a clinical diagnosis?
yes, can get CXR, blood work, or cutlutres to help.
When to hospitilize infant of child for pneumonia?
respiratory distress- hypoxemia <90% or infant < 3 to 6 months
Treatment of CAP in infants and children
1st line: high dose amoxicillin
When is tamiflu best used?
started within first 48 hours of flu onset
Barky cough, hoarseness, inspiratory stridor, worse at night
Laryngotracheobronchitis Radiograph finding
Steeple sign (subglottic narrowing)
Corticosteroids if uncomplication
Nebulized epinephrine if stridor at rest
Irritation of teh cilliate of respiratory tract
paroxysms of couging, inspiratory whoop, post-tussive vomiting
Catarrhal stage of Pertussis
similar to URI then worsens
Paroyxysmal stage of Pertussis
coughing develops in classical presentation, long series of cough where there is little to no respriations.
Convalescent stage of pertussis
cough subsides over several weeks to months
Clinical: 2 weeks of coughing + paroxysms of cough, whoop, post-tussive vomiting, or apnea
Macrolide to decrease severity and infectivity, but not duration of cough, if < 3 months = admit to hospital
Bronchiolitis in children
Viral, commonly RSV
exposure to older contact with URI, wheezy cough, upper airway secretions affecting feeding, "happy wheezer"
What is the most common cause of hospitalizations in those < 12 months
Common pathogens that cause sinusitis in children
s. pneumoniae, h. flu, m. catarrhalis (same as otitis media)
Otitis Media Viral causes
Otitis Media Bacterial causes
s. pneum, h.flu, m. catarrhalis (same as sinusitis in children)
What is needed to diagnosis otitis media in children
pnematic otoscope to assess bulging
Treatment of otitis media in children 6 mos or younger with severe symptoms?
high dose amoxicillin
Treatment of otitis media in children 6 months to 23 months with AOM w/o severe symptoms
Antibiotics or observation
Suggestive findings of Group A strep
sore throat, dysphagia, fever, abdominal pain, N/V, absense of cough and rhinorrhea, palate petechiae, anterior cervical lymphadenopathy, scarlet fever rash
Treatment of group a strep in children?
amoxicillin x 10 days
Complications of Group A strep
Rhematic fever, JONES criteria, Post-streptococcal glomerulonephritis (initial tx of infection does not prevent this complication)
JONES critea of GAS
N- nodules (osler and janeway)
E - Erythema marginatum
S - syndenham's chorea
MC cause of mononucelosis
glandular fever with atypical lymphocytes, hepatosplomegaly, rash
monospot test (heterophile antibody)
Complications of Mono
alice in wonderland syndrome, aplastic anemia, guilliain-barre syndrome
Common pathogens causing otitis externa?
p. aeruginosa (MC), enterobacter, proteus
Treatment of Otitis Externa
Neomycin and polymyxin
Cough, coryza, conjunctivitis
maculopapular rash that begins after fever starts back of ears and spreads
treatment of measles?
GAS soft tissue infection types
Impetigo, erysipelas (raised well demarcated borders), cellulitis
Rashes on the hands and palms
5 days of fever + 4 of the following: bilateral conjunctival injection with limbic sparing, oral mucosa changes, extremity changes, polymorphous rash, cervical lymphadenopathy
Complication of kawasaki's disease?
coronary artery aneursym
Kawasaki disease managment
echocardiogram, IVIG, high dose aspirin until fever resolution
Fever without a source
fever lasting one week or less w/o adequate explantation
Fever of unkown origin
Fever of 101 with no dx apparent based on hx, PE and labs that lasts five days to 3 weeks
True or False: neutropenic fever is a medical emergency
True (neutrophil count < 1500, associated with chemotherapy)
Fever in a sickle cell anemic patient should be treated how?
3rd generation cephalosporin until blood cultures are negative
True or False: Atopy has no genetic predisposition
False, likelihood of atopy increases with each parent with atopy. Also person hx of one atopic disease increases your likelihood of others
Three types of allergic rhinitis
seasonal, perennial, episodic
Spring seasonal allergies
Summer seasonal allergies
Fall seasonal allergies
Name some perennial allergies
molds, dust mites, animal dander
Allergic rhinitis hx
congestion, runny nose (usually clear), pruritis of eyes, nose and palate
PE findings in Allergic rhinitis
Eyes: shiners, dennie-morgan folds, cobblestoning of the conjunctiva, conjunctival injection
Nose: transverse nasal crease
Mouth: tonsillar atrophy, post nasal trip
1st line treatment Allergic Rhinitis
intranasal corticosteriods: fluticasone, mometasone
If at high-risk for allergy, introduce foods earlier rather than later.
Oral allergy is often seen in children with what other allergy?
Birch Pollen (oral allergy culprits)
Apple, almond, carrot, hazelnut, kiwi, plum
Ragweed Pollen (oral allergy culprits)
sunflower seeds, zucchini, banana
Grass Pollen (oral allergy culprits)
oranges and tomato
When is serum testing for allergies used?
in patients who skin testing is not possible
Skin allergy tests
must be off antihistamines > 72 hours, histamine release form wheal and flare
vancomycin, give slowly, pretreat with benadryl
high fever, arthralgias, itching, glomerulonephritis, lymphadenopathy, malaise, shock, splenomegaly
Steven Johnson syndrome
fever, sore throat, burning with urination, anorexia, purpuic macules, mucousal lesions, occular involvement, sulfa drugs
What is another name of atopic dermatitis?
where are common eczema distributions?
face, extensor surfaces of arms and legs, moves to flexor as aging occurs
intensely pruritic erythematous papules over reddened skin
Sub acute eczema
excoriated scaling with erythematous papules or plaques
thickened skin with lichenification
Treatment of Eczema
cleansers with pH closer to natural skin, hydration with emollients, anti-inflammatory with topical steriods
3 components of asthma
mucosal edema, smooth muscle contraction, production of mucous
How do diagnosis asthma
What FEV1/FVC indicates airway obstruction related to asthma?
classification of asthma
What asthma medication should you not use as a monotherapy?
LABA (salmeterol, formoterol)
Short acting beta2 agonists (SABA)
work quickly 5 to 10 minutes
used for acute exacerbations
Long acting beta 2 agonsis (LABA)
relax bronchial smooth muscle x 12 hours
used only in combination with inhaled corticosteroid
Used for moderate to severe asthma
used for shorter courses for exacerbations, longer for severe asthma
mainstay treatment for persistent asthma
Side effect of chronic inhaled corticosteroid
thrush -- have patient brush teeth after taking
> 12 y.o. severe persistent asthma
What is the most common finding on a CXR in a child with asthma
hyperinflation with flattening of the diaphragm, peribronchial thickening
Acute managment of an asthma attack
oxygen if hypoxic, nebulized albuterol every 20 minutes, steroids if needed
2x birth weight by _____ months
3x birth weight by ______ months
4x birth weight by _______ months
2x birth weight by 4 months
3x birth weight by 12 months
4x birth weight by 24 months
Think 2, 4, 6
After age of 2 normal weight gain is how many pounds per year until adolescence?
Birth length increases _________% per year
2x birth length by ______ years
3x birth length by _______ years
2x = 4
3x = 13
After 2, average height increase is how many inches/year until adolescence
Familial short stature
Bone age is not delayed vs constitutional growth delay
Constitutional growth delay
delayed bone age, not on correct area of growth chart but height is appropriate for bone age
excessive crying with no indentifiable need:
3 weeks to 3 months
> 3 hours/day
symptoms for > 3 weeks
at least 3 days a week
Treatment of Colic
5 S's: swaddle, side-lying, suck, shh, sway/swing
>10 = exposure reduction
>45 = medical management needed (chelation)
permanent contraindication to vaccinations
severe allergic reaction to vaccine component
encephalopay within 7 days of pertussis vaccine
Rotavirus-SCID or h/o intussception
If child needs PPD and MMR what order should they be completed?
If PPD is needed, must do before or WITH MMR
need to wait 4 to 6 weeks for PPD if given after MMR
What vitamin must be supplemented in exclusively breast fed infants?
Iron supplementation in children
Breastfed infants do not need
Premature infants do
> 24 to 32 ounces of milk can inhibit iron uptake
Children should rear face until AT LEAST what age?
2 years of age
Booster seat until...
at least 4'9" or 40 to 50 lbs
Late preterm infants
34 to 36 wks
very preterm infants
Determining size for gestational age
SGA: < 10th precentile
AGA: 10 to 90th percentile
LGA: > 90th precentile
Low birth weight: <2500
Very low: <1500
Extremely low: <1000
Ridiculously low <500
decreased amniotic fluid
IUGR, kidney abnormalities, potter sequence
Club feet, compressed facies, low set ears, pulmonary hypoplasia
increased amniotic fluid
diabetes, hydrops fetalis, esophageal or duodenal atresia
When does fetal hemoglobin start to decrease?
whitish pinhead-sized concretions found on chin, nose, forehead and cheeks
3 stages: pustules, ruptured pustules, and hyperpigmented macules
red macules with central yellow-white papule, last 7 to 10 days, Eosinophils, benign
Patent ductus arteriosis (PDA murmur)
continous machine-like LUSB, radiates to left shoulder
peripheral Pulmonic stenosis
systolic ejection murmur LUSB, radiates to back and axilla
Early cyanosis in newborn is most likely to present with what?
Transposition of Great Vessels
hernation of abdominal contents to base of umbilical cord
abdominal wall defect resulting in herniation of abdominal content (no sac)
True or false: Bilious vomit in newborn is always pathologic
Causes: malrotation, duodenal atresia
cecum is abnormally positioned in RUQ leading to volvus and ischemia
Double bubble sign, associated with down syndrome
3 weeks to 3 month babies
diffuse swelling of scalp extending across sutures, spontaneously resolves
subperiosteal hemorrhage that never extends across suture lines, resolves spontaneously but should be montiored closely, skull fracture
bleeding below epicranial aponeurosis, may cross suture lines, most severe
Waiters tip (c5, c6)
Wrist and grasp reflex (klumsy)
Respiratory distress sydrome
insufficient surfactant in lungs
CXR: ground glass appearance with bronograms
Tx: steroids, surfactant, O2
Transient tachypnea of newborn (TTN)
Benign shortly after delivery (lasting 3 to 5 days)
C/S, prolonged labor, macrosomia, CXR: hyperexpansion, fluid in minor fissure
Meconium Aspiration syndrome
Common in post-term infants CXR: coarse patchy inflitrates, prevent by intubating and suctioning
Chronic lung disease of the infant
oxygen dependence at 36 weeks CXR: sponge-like cystic appearance, tx: bronchodilators, diuretics
displacement of abdominal contents thru the thoracic cavity (typically on Left), CXR loops of bowel in chest Tx: immediate intubation and decompression
Patent ductus arteriosus treatment
Indomethacin (inhibits prostaglandins, which keep ductus open) or surgical ligation
IgG freely crosses the placenta but Ig __ does not.
IgM does not cross placenta
Type O mothers produce what kind of antibodies, versus type A, b, and AB
Type O - IgG
Type A, B, AB, IgM
RH incompatibility may result in....
Premature Infant complications
Retinopathy of prematurity: retinal detaachment due to oxygen toxicity
Intraventricular hemorrhage: bleeding from germinal matrix
Necrotizing enterocolitis: free air/sentinel loops on ABXray
Other: syphilis, Hep B, EBV
NOT prevented by topical prophlaxis, eye discharge @ 1 wk of life, giemsa staining
1 to 2 weeks of rhinorrhea, cough, dx nose culture
Opthalmia neonatorum gonorrhea
prevent with prophylaxis, may lead to corneal perforation or blindness
HIV can be transmitted to infant via....
placenta, vertical or breast milk
What is done after delivery?
silver nitrate or erythromycin to eyes and vitamin K administration
What is done prior to discharge in an infant
Hep B vaccination, hearing screen, newborn screen, cyanotic congential heart disease screen
What kind of baths should be done if the cord is still attached?
none- wait until cord has fallen off
closure of mitral valves
Systolic ejection murmurs are tyipcally heard loudest where?
at the base of the heart
louder in lower heart
Grades of murmurs
Which murmurs are always pathologic in peds?
Peripheral pulmonic stenosis murmur
common in newborns
disappears by 3 to 6 months
radiates to back and axilla
if back murmur in newborn = PPS
children between 3 and 6 years
heard only when upright
right and left infraclavicular areas
uncommon before age of 2
Mid left sternal border
lying supine makes louder
resolves with no complication
shunts blood into the IVC bypassing the portal system
shunts blood from right atrium to left atrium to bypass lungs
oxygenated blood from placenta to fetus
carries waste and deoxygenated blood back to the placenta
Rales and crackles on a a neonate with suspected CHD is suspicious for....
Left heart failure
Hepatomegaly found in the evaluation of a neonate with suspected CHD is suspicious for?
Right heart failure
infant is placed on 100% oxygen and arterial blood gas is obtained, if PaO2 < 100 ---likely heart disease
Types Left to right shunts
Ventricular septal defect
patent ductus arteriosus
atrial septal defect
Left to right shunts
Systemic blood is circulated through pulmonary circut, oxygenated blood flows back into pulmonary system, no cyanosis or abnormal oxygen levels
what is the most common form of CHD?
Ventricular septal defect
VSD; muscular vs. membranous
muscular more likely to close spontaneously
What kind of Murmur is associated with VSD?
Heart failure in babies:
poor weight gain, tachycardia, quiet tachypnea, diaphoresis during feeds
VSD not managed correctly, no murmur, right ventricular hypertrophy, flow is reversed from left to right and becomes right ot left. irreversible
Atrial Septal defect
fixed split S2
associated with Trisomy 21 and at risk for eisenheimers
present with heart failure by 2 months of age
5 cyanotic lesions
1- truncus arteriosis
3- Tricuspid atresia
4- tetrology of fallot
(2,3,5: ductal dependent)
VSD are present in which cyanotic heart issues?
tertrology of fallot
Transposition (if not present will see soon after birth)
Associated with Digeorge syndome
What makes up the Tetralogy of fallot
Right ventricular hypertrophy
Tetralogy of fallot
boot shaped heart, due to right ventricular hypertrophy
cyanosis due to decreased oxygenation, fixed by increasing venous return and SVR, increasing oxygenation
Treatment for tetralogy of fallot
What is the most common cyanotic lesion?
transposition of the great arteries
Transposition of great arteries
Pulmonary artery off left ventricle and aorta off of right, makes two separate systems that do no mix, need VSD and ductus opened to help with mixing. Fixed by greating ASD give prostaglandins
Total anomalous pulmonary venous return
venous return drain other places than left atrium. all have an atrial septal defect
Coarctation of the aorta
associated with Turners syndrome, happens commonly next to ductus, presents after ductus has closed.
CXR; rib notching
What is the most common cause of death from CHD during first month of life?
hypoplastic left heart syndrome
Hypoplastic left heart syndrome
left ventricle doesnt from, associated with small aorta, RV forced to do all work
Hypertrophic obstructive cardiomyopathy
harsh SEM at the LLSB, gets louder when patient stands from sitting or squating
what is the diagnostic for Hypertrophic Obstructive cardiomyopathy?
Early disease Measles (rubeola) rash
Blanchable vs. late disease which is not blanchable
Scarlatina (scarlet fever)
White tongue --> beefy red, sandpapery rash sparing palms and soles
What happens following scarlatina rash?
dequamation, no treatment to prevent
Rubella (german measles)
Rash begins on face, fever and symptoms before exanthem
slapped cheek after prodrome resolves, net like xanthem.
Slapped cheek appearance spares what facial areas?
follows slapped cheek phase of erythema infeciousum (parvovirus B19), seen in arms and legs
HHV 6 and 7
High fever proceeds, lymphadenopathy, starts at trunk and moves up
Hand foot and mouth disease
coxsackie virus A16
painful mouth enanthem
cloudy vesicles with red halo (palm soles, fingers toes)
poxvirus, flesh colored dome shaped papules with central umbilication
disrupt skin lines, black dots, mosaic pattern
HPV 1, 2, 4, 7
HPV types 3, 10
HPV types 1, 2, 4, 7
goose pimple flesh
resolves on its own
Adult: flexor surfaces
Child: extensor surfaces
Treatment of impetigo
Limitied localized: mupirocin
Comedolytic treatment of Acne
Anti-inflammatory treatment of acne
topical antibiotics, medicated wash
Tx: use topical antibiotic NOT STEROID
If perioral dermatitis is treated with a steroid what complication can occur?
perioral granulomatous dermatitis
Common cause of viral diarrhea in children
Common causes of bacterial diarrhea
Sometimes EVE: e.coli, vibrio, e. histolyitica
Intestinal mucosa secretes fluids
NPO- diarrhea continues
MC- exchessive juice/carbohydrates
Constipation in neonate consider....
hirschprung's diease or cystic fibrosis
overflow soiling due to constiption, produce large stools that can plug a toliet, unable to sense urge to defecate due to stretching of internal sphincter
Which are more common upper or lower GI bleeds?
lower GI bleeds
MOST common cause of GERD in young children
hypertrophy of the pyloric muscle, affects infants 4 to 6 weeks in age. More common in first born, projectile vomit, non-billious, olive sized mass, reverse perstalsis
What is the study of choice for pyloric stenosis?
dermatitis herpetiformis, IgA deficiency and trisomy 21 should be consider in any child with chronic abdominal complaints
What is needed for a definitive diagnosis of celiac disease
small bowel biopsy
What is the most common form of intussusception in children?
9 to 18 months old, currant jelly stools, bilious vomiting
TX: NG tube to decompress
Rule of Two's
2% of population
Age 2 most common
2" in length
2 feet from ileocecal valve
2 types of tissue (gastric and pancreatic)
When is the exception to the rule of melena and the ligament of trietz?
Gastric mucosa is most common tissue seen in meckel's and will present with melena even though below the ligament of trietz
What is the most common presentation of Mecklel diverticulum?
painless rectal bleeding
failure of ganglionic cells of the myenteric plexus to migrate down distal colon.
Obstructs flow of feces, suspect if infant fails to pass meconium within first 24 hours of life. bilious vomiting
PE clues for hirschsprung disease
feel stool throughout abdomen, but none in rectum
Coins in esophagus will present their circular face on what kind of film
Coins in the trachea present their circular face on what kind of film
syndrome of acute mental change that develops over short time, includes alteration of attention
Impairment of memory, social withdrawl, cognition, judgement, dishinibition, usually irreversible
Lewy body dementia
often misdiagnosed as AD or PD, 2nd most common dementia, early onset of paranoid and hallucinations, sensitive to the EPS of antipsychotics (akathisia, tardive dyskinesia)
What is the greatest risk factor for falling
muscle weakness, followed by history of falls
What test can be used for a formal gait evaluation?
Get up and go test (normal < 10 seconds)
Common causes of abnormal gait: Difficulty arising from a chair?
Common causes of abnormal gait: Inability on first standing
Hypotension and weakness
Common causes of abnormal gait: Instability with eyes closed
Common causes of abnormal gait: step height/length
What are some risks of those >65 after not being able to get up after a fall?
dehydration, rhabdomyolysis, pressure ulcers, pneumonia
Whats the biggest risk modification for fractures?
fastest growing population?
persons over 85 years of age
Names some ADL's
Bathing, dressing, transferring, toileting, grooming, mobility (MORNING ROUTINE)
Name some Instrumental activities of daily living?
using phone, preparing meals, managing finances, doing laundry, housework, transportation, med managment
what's included in a mini-cog
3 items (repetition and registration)
3 item recall
Fitzpatrick Skin Types
I-Always burn, never tan
II-burns easily, tans minimally
III- Burns moderately, tans gradually
IV: burns minimally; always tans well
V-rarely burns; tans darkly
VI-never burns, deeply pigmented
sunburn, cataracts, photoaging
DNA mutation (tumor initiator and promotor)
4 factors that determine degree of photoaging
Fitzpatrick skin type, lifetime UV light exposure, intensity of exposure, how long ago they occured
dorsal surface affected, ventral surface spared
warty -stuck on appearance, keratin pearl
white or yellow greasy scale on erythematous base, hair baring areas. Goal is control, not cure
Treatment seborrheic dermatitis
Salicylic acid shampoo, zinc shampoo
5th cranial nerve involvement HZ ophthalmicus
sun bearing areas
may be precancerous squamous cell
Tx: liquid nitrogen
What is the most common cancer in humans?
Basal cell skin cancers
most common form, pearly surface, telangiectasias, nose is most common site
Superficial Multicentric BCC
least agressive, trunk and extremities, resemble eczema or psoriasis
may extend well beyond visible borders
Indications for MOHS surgery
Large skin cancers
Poorly defined borders
High risk locations (eyelids, nasal alae, auricular areas)
Common locations for SCC
Dorsum of hands
BCC rarely found here
completely contained in the epidermis
Sun exposed areas
red and scaly
Most common type of melanoma?
superficial spreading melanoma
pigmented band that involves proximal nail fold, suspcious for Acral lentiginous melanoma
Medicare Part C
Combined A, B, D, provided drug coverage before part D was implemented
Medicare Part D
Prescription drug plan
True or false: Percentage of fat increases as age increases
What respiratory measures are incresed in normal parts of aging?
Residual volume and Compliance
Tx of ametropia
eyeglasses, contact lenses, laser refractive surgery
begins after age 40, hardening of lens
age related macular degeneration
impaired central vision, blurred vision, difficulty reading
most common form, Drusen or geographic atrophy, Drusen usually asymptomatic other usual cause of blindness
causes severe loss of vision, abnormal leakage blurring vision
TX; VEGF inhibitors
Complete blindness is not associated with what condition?
most prevelant form of glaucma?
primary open angle
loss of peripheral visual fields
what is the most common cause of blindness worldwide?
blurred vision, glare, monocular diplopia
What is the leading cause of NEW blindness?
What can prevent diabetic retinopathy?
Tight glycemic control A1C <7 and BP control
Symptoms of diabetic retinopahy
blurred vision, floaters, poor night vision, asymptomatic
Non-proliferative diabetic retinopathy
microaneurysm, retinal hemorrhage, exudate
Proliferative diabetic retinopathy
neovascularization of the retina and disc, vision loss due to vitreous hemorrhage or retinal detachment
Most common sensory impairment of old age
How to control for whisper level when doing whisper test?
whisper at the end of exhalation to ensure it's as quiet as standardized voice as possible
Sound intensity levels
whipser 20 db
loud music 80-120
jet engine 140 to 180db
Presbycusis begins with progressive loss of hearing starting with _______ frequency sounds
high frequency, such as speech
Pallative care: dyspnea
Opiods (morphine) most effective)
Ativan/lorazepam (2nd line)
Pallative care: nausea
Pallative care: chemo induced nausea
Pallative care: gastroparesis
pallative care: delirium treatment
haldol, use anxiolytic (benzo/barbs) in alcohol withdrawl and terminal delirum
what is the most common barrier to treating pain?
Caregiver's failure to ask about and assess pain
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