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578 Cards in this Set
- Front
- Back
- 3rd side (hint)
HPAO
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Hereditary Progressive Arthro-Ophthalmopathy
Stickler’s Syndrome |
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5 A’s
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Ask
Advise Assess Assist Arrange |
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Stages of Change Model To Assess Readiness
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Precontemplation
Contemplation Preparation Active Maintenance |
PC PAM
(do they think it’s PC) to use PAM oil. |
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Stages of bereavement and grief
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Shock 2w
Awareness/Anger Bargaining Depression 6mos Resolution 1-2 y |
SAB DR
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Primary amenorrhea
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No secondary sex characteristics by 13
No menses by 16 |
No TAP 13, No Men 16
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WHI Study
For the group of women on HT. CEE/MPA Small but significant increased risk of: |
DVT
Invasive Breast Cancer Stroke Heart Attack (MI) |
DISH
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Behcets triad:
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Immigrant
Genitalia Eyes Oral |
GEO
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effect of Pagets of vulva
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“Cake for the Pageant”
Cake icing |
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Bisphophonate
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B = Both prevents and treats
I= Inhibits osteoclasts sph = spine and hip |
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SAIL THE FEMORAL TRIANGLE
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Sartorius
Adductor longus Inguinal Ligament |
The SAPHENOUS ROUTE The Pirates have large PECS, to scrub the FLOOR (Pectineus muscle is the floor of the triangle) |
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PEACH Study
PID Evaluation And Clinical Health |
PID treated as inpatient v. outpatient
No diff in CPP, infertility, TOA, ectopic, IUP, recurrence, persistent infection |
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High risk level for DVT in gyn surgery
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>40yo
DVT/PE Immobilization postop/Inherited thrombophilic disease Malignancy ERT Varicose Veins Obesity Prolonged Surgery |
DIME VOPS
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Chorioamnionitis pathogens
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Bacteroides
Prevotella E. Coli GBS |
BPrEG
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Cholecystitis pathogens
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BEcK Serratia (Ec,Enc)
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Postpartum hemorrhage
Management |
Assess/Stabilize
Mechanical Pharmacological Blood products Surgery Emergent measures |
“Ass, mech, Phar, blood, surg, emerg”
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Carpenter-Coustan
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95, 180, 155, 140
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5-year survival by stage for Cervical Carcinoma
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85, 65, 35, 12%
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cho,fat,prot
DM in pregnancy |
50, 30, 20
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Ecclampsia
MgSO4 |
4g to 6g load in 100 mL IV over 15–20 minutes
maintain at 2 g/hr IV 6g IV/IM over 15 – 20 minutes. Maintain 2g/hr IV |
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Eclampsia management
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Injury – prevent maternal
Stabilize medically Convulsions – treat/prevent (Mg or phenobarb) Antihypertensive Respiratory/cardiac Fetus |
ISCARF
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An abdominal circumference within the normal range reliably excludes growth restriction with a false-negative rate of less than ___%
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10%
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A measurement of what abdominal circumference identifies more than 90% of newborns with a birth weight greater than 4000.
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AC >35 cm
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TAH v. TVH
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S Size uterus
S Shape uterus C Caliber vagina L Length vagina I Infrapubic angle P Parity/SVD#/birth weights Prolapse PID/endometriosis/pelvic surgery and… Malignancy and other abdominal surgery needs to be done |
SS CLIPS
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APPY
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Dissect/ligate mesoappendix/vessels
Clamp/cut base Purse string suture at base Paint stump with betadine Invert (before finish purse) and embed |
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Perform u/s in ECV for:
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D Dorsum
V vaginal exam T Type breech P placenta location E extended or flexed P position A AFI C cord length/nuchal U uterine anomalies |
DVT PE PACU
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Leopold’s
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North pole what’s at fundus
South pole what’s in pelvic pole Back where is back Attitude extended or flexed head? |
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WHI
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For the group of women on HT. CEE/MPA
Small but significant increased risk of: DISH DVT ***same for ET Invasive breast cancer (8 per 10,000 women) ***no significance in ET Strokes ***same for ET Heart attacks ***ET did not “prevent” HT offered health benefits as well. Lower risk of spine and hip fractures. ***same for ET with Hip Reduced risk of colon cancer |
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FFN requirements:
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Intact membranes
<3 cm 24-35 weeks |
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Pneumonia types
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F Flu
A Atypical V Varicella A Aspiration B Bacterial |
FAVA B
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Velocimetry?
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Assess Vascular Impedance.
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Seizure etiology
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Idiopathic/Infection/Injury
Congenital Tumors - glioma, hamartoma Alzheimers/Degenerative/Alcohol/Drugs - buproprion,clonidine, lidocaine Lytes/Metabolic |
ICTAL
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Incontinence History
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F Frequency
U Urgency N Nocturia D Dysuria A Aggravating Factors Timing Coincident = GSUI Delayed = DI |
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Meds causing incontinence
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R Reserpine
A Aldomet D Digitalis M Major tranquilizers C Caffeine |
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Urological Physical Exam
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O Obesity
P Prolapse evidence I Impulsivity of cough D Degree of estrogenization of pelvic tissue N Neuro exam Q Q-tip test |
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Postmenopausal mass work up
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C CT
U u/s T tumor markers B Bowel prep I IVP G GI work up |
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Clinical Pelvimetry
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inlet
D Diagonal conjugate R Retropubic space P Pectineal line Mid H Hollow of sacrum I Ischial spines S Sacrospinous ligament Outlet Coccyx Infrapubic angle |
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COHOSH sides
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COntractions
HypotensiOn Seizures |
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Increases Prolactin
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C Craniophayrngioma/adenoma
H Hypothyroid A Antipsychotic/Haldol N Nipple stim T TCA and Reglan |
CHANT
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Bacterial Pneumonia
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Acute fever/chills, productive cough, lobar pattern CXR
Streptococcus rusty sputum gram+ diplococci Hemophilus gram-coccobacillus Uck (productive) Klebsiella gram- rods Staphylococcus gram+ cocci |
SHucKS
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Dilantin
Maternal Side effects |
Gummy, Hairy/hypertrichosis, Acne, Rickety (osteomalacia/vit D def) neuropathy/NTD
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Fetal effects of epilepsy in pregnancy:
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Stillbirth
IUGR Preeclampsia |
SIP
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Conditions associated with Uterine Rupture
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S Scars - c/s, myomectomy
T Trauma R Rupture history I Instrumentation,TOP,Forceps P Perforation,accreta/increta C Cocaine A Anomaly M malpresentation/molar P Prostaglandin/Pitocin M Multiple gestation O Obstructed labor E Endometritis prior pregnancy |
STRIP
CAMP MOE |
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What are the benefits of Autologous Blood transfusion?
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SPA
Safety..... no risk of transfusion reactions due to incompatibility. Purity..... no risk of transmitted disease, such as, among others, HIV/AIDS, Hepatitis B& C, HTLV/ Human T-cell Lymphotropic Virus 1&2, & Syphilis. Availability..... instantly available and requires no cross matching. |
SPA
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Treatment option for Obesity
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DEB MS
Diet (usually requires 500-1000 kcal/day reduction. Refer to nutritionist) Exercise (first focus on exercise consistency, then increase duration and intensity) Behavior therapy ( stress management, stimulus control, problem solving, social support) Medications Surgery |
DEB MS
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Initial Management of hypertension
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Document and classify hypertension
Evaluate for end organ damage Assess overall cardiovascular risk factors Rule out secondary and reversible causes |
DEAR
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Pheochromocytoma Symptoms
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Palp Pallor Pers Pain Pressure…Pancreas
Palpitation Pallor Perspiration Pain (chest, head, abdomen) Pressure (HBP) Pancreas (hyperglycemia) |
“5 P’s”
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Treatment of H. Pylori
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omeprazole
Clairithromyin ampiciilin |
OCLAM
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Thromboprophylaxis in pregnancy. Candidates for therapeutic anticoagulation
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V Valves mechanical
I inherited thrombophilia homozygous FVL, Prothrombin mutation, ATIII deficiency A APS G A Active DVT R Recurrent DVT A Afib from RHD Conditions are at highest risk and should have adjusted-dose heparin prophylaxis |
VIAGARA
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The Physician’s Responsibility to Victims of Domestic Violence
What must the physician do? |
SAD SORE
S Screen A Assess safety/suicide/Acknowledge it’s not her fault D Document S Support subsequent O Offer help/lists/groups R Refer E Escape plan Implement universal screening Acknowledge the trauma Assess immediate safety Help establish an Escape plan Offer educational materials Offer list of community and local resources Provide referrals Document interactions with patient Provide ongoing support at subsequent visits |
SAD SORE
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Classification of Sexual Dysfunction
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- Desire disorders
- Orgasm disorders - Pain disorders - Arousal disorders |
DOPA
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Melanoma findings
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A asymmetry
B Border irregularity C Color variagation D Diameter > 5mm E enlargement/elevation |
ABCDE
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Canavan’s Disease (auto recessive)
Enzyme? |
Aspartoacylase deficiency (storage disease)
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Sparticus cycles.
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What are Symptoms of Hepatitis?
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FARM
Fatigue Anorexia RUQ pain Malaise Jaundice Dark urine/stool Coagulopathy Encephalopathy |
FARM
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Treatment of Thyroid Storm
|
βIG TRIP
β B Blocker I Iodine G Glucocorticoids T Thermoregulation R Rehydration I Iodinated Radiocontrast agent P PTU |
βIG TRIP
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How do you counsel a patient regarding VBAC?
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Sequelae of rupture hyster/death
Rupture rates Success rates of VBAC Failure factors of VBAC Risk rupture 1% with prior LTCS Risk of rupture 7% prior classical Risk of death to mother and baby if rupture Possible need for hysterectomy if rupture and unable to stop hemorrhage. Success rate 66% prior CPD Success rate 75% not for CPD Lower success if obese, >4000g, >40 weeks, prior labor required ind/aug |
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Congenital CMV “symptoms and sequelae”
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90% of infected neonates asymptomatic at birth, 10% will develop late sequelae
10% of infected neonates symptomatic at birth, 90% of survivors have permanent sequelae |
– “90/10” rule:
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Amsel’s criteria: BV
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Clue POD
Need at least three of four. pH >4.5, amine odor on the application of KOH base, appearance of a thin homogeneous vaginal discharge clue cells on wet mount. |
Clue POD
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Gardnerella vaginalis
what are they on path? |
gram-negative rods
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-Adnexal Mass -What are the criteria that assist you determining whether to observe or treat surgically?
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SAC BAGS
S Size A Age C Characteristics B Bilaterality A Ascites G Growth S Symptoms |
SAC BAGS
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-Discuss post operative bladder care in this patient?
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USO
Ureteral integrity Subjectively - Indwelling catheter for 1-3 days dome and at least 7d if trigone Objectively - Obtain a cystogram/VCUG to confirm the injury has healed before removing the catheter |
USO
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What is the lymphatic drainage of the cervix?
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Common iliac
External iliac Internal iliac Obturator – think Point B Presacral – think origin of USL Parametrial – think Stage II Paracervical |
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Define DUB:
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Disabling Uterine Bleeding
Disruptive Uterine Bleeding Drugs with Uterine Bleeding Disabling uterine bleeding that Disrupts lifestyle (ACOG) DUB “Disabling!” “Disrupts!” (ACOG) Unexplained bleeding on HRT (ACOG) DUB “Unexplained!” B = Bleeding |
DUB
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Monopolar devices require what type of media if using electrical current?
|
Electrolyte-poor fluids.
MSG Mannitol/Sorbitol/Glycine Monopolar=Mannitol MSG |
MSG
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What are complications of Dextran 70?
|
Dextran = DIC
Anaphylaxis Glycine = ammonia toxicity |
D=D
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-Discuss (in detail) how you would exhaust conservative options of treatment prior to taking the patient to the OR
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MRS
Multiple visits Relationship doc-pt Secondary gain none Marriage disruption Children – unable to care for Work interference |
MRS
Marriage Children Work |
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Risks of BTL:
|
REF
Regret Ectopic Failure |
REF
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BTL counseling
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Risks REF Regret/Failure/Ectopic
Benefit Permanent – not intended to be reversible Alternatives/Anesthesia Vasectomy/IUD/short term reversible Anticipated outcome Informed refusal STD |
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Amenorrhea -How would you work-up a patient with amenorrhea? First rule out the obvious!
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LMP
Lactation Menopause Pregnancy |
LMP
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-Hirsutism -Discuss the life cycle of a hair follicle
|
Life cycle of a hair follicle: ACT
Anagen actively growing last 3 years Catagen breakdown/transitional phase 3 weeks Telogen resting phase 3 months, then falls out |
ACT
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3 steps to classify individual CHD risk category:
Coronary heart disease (CHD) |
1)Obtain a fasting lipid profile
2)Identify presence of CHD or CHD equivalents (risk factor that places patient at same risk for CHD event as CHD itself) Multiple risk factors that confer 10 year risk of > 20% 3) Identify major CHD risk factors other than increased LDL |
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CHD or CHD equivalents
(risk factor that places patient at same risk for CHD event as CHD itself) |
Diabetes
Symptomatic carotid disease Peripheral arterial disease Aortic abdominal aneurysm |
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major CHD risk factors other than increased LDL
|
Smoking
Hypertension Low HDL (<40) Family hx of premature CHD (1st degree male relative with CHD < 55yo, 1st degree female relative with CHD <65 Age > 55 yo HDL > 60 subtract one risk factor |
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-What is the contraceptive mechanism of action of both the estrogen and progesterone component in the OCP?
|
MAOI
Mucus – thickened cervical Atrophy of endometrium Ovulation Inhibition PCOS – give low dose monophasic – study showed may reduce risk endometrial cancer 100 µg LEvonorgestrel and 20 µg Ethinyl estradiol (ALEsse) |
MAOI
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Failure rate of OCPs.
obesity? |
0.1% failure (4.5% failure in obesity)
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Causes of recurrent pregnancy loss:
|
-MULIGI (eulogy)
M Metabolic poorly controlled DM/PCO (no therapy for PCO)/TSH U Uterine anomalies Septum-poor vascularization, unicornuate , fibroids, ashermans L Luteal phase defect I Immune disorders APS, alloimmune hydrops, SLE G Genetic Balanced Translocation I Infection TORCH, Parvo, ureaplasma, syphilis LFD Not proven |
MULIGI (eulogy)
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Initial incision of VH
|
Incise Supravaginal septum SVS
entry into the Cervicovesical space CVS Grasping the Vesicouterine peritoneal fold VPF |
SVS
CVS VPF |
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Simple screening tool for depression:
|
Ask two questions:
‘During the past month, Have you often been bothered by feeling down, depressed or hopeless?’ ‘During the past month, Have you often been bothered by having little interest or pleasure in doing things?’ |
Down Depressed Hopeless
Little interest or pleasure |
|
Diagnostic Criteria for depression
|
Diagnosis of depression requires 5 distinct criteria be present:
o Concomitantly o For most of the day o On consecutive days o For at least 2 weeks At least one of the criteria must be either: Depressed mood o Markedly diminished interest or pleasure in almost all activities At least 4 other neurovegetative symptoms must be present |
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Diagnostic Criteria for depression:
neurovegetative symptoms |
GUILT SPACE
Guilt feelings of worthlessness or inappropriate guilt Suicide thoughts of death or suicide Sleep insomnia or sleeping too much Psychomotor psychomotor retardation or agitation Appetite significant change in appetite or weight Concentration diminished ability to think, concentrate or make decisions Energy fatigue or loss of energy |
GUILT SPACE
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Depression:
preferred agent for Pregnancy |
Fluoxetine/Prozac
Don’t forget to rule out postpartum thyroiditis |
P=P
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Depression:preferred agent for Breastfeeding
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Sertraline/Zoloft
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PP Depression:
Don’t forget to rule out what? |
postpartum thyroiditis
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Hypoactive sexual desire may be due to other causes
|
SAVED Negative Experiences
S Stress A Anxiety V Vaginismus E Etoh D Depression/drugs Negative Experiences |
SAVED Negative Experiences
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meds that cause hypoactive sexual desire
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BBlockers
OCPs Antidepressants/antiandrogens Tamoxifen |
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ROME II SYMPTOM CRITERIA FOR IBS
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At least 3 months or more, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has II out of three features:
RELIEF FREQUENCY FORM 1) Relieved with defecation; and/or 2) Onset associated with a change in frequency of stool; and/or 3) Onset associated with a change in form of stool. |
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PMS tx: ACOG
FIRST LINE |
SANDS
First line: Supportive Aerobic exercise Nutrition (Ca Mg Vit E) CME Dietary avoid salt, caffeine, fatty food, alcohol Spironolactone |
SANDS
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PMS tx: ACOG
Second line: |
SSRI (either fluox, Sert),
Anxiolytic /Alprazolam if needed |
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PMS tx: ACOG
Third line: |
Suppression (OCPs, GnRH)
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Congenital Toxoplasmosis clinical presentation:
|
Cats (chorioretinitis)
eat liver (HSM), drink milk (calcifications) and water (ascites/hydrops), have small head(microcephaly) |
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Meds that decrease libido
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B B Blocker
O OCP/antiandroges A Antidepressants T Tamoxifen |
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Other Causes of headache
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VMI
Vascular - Aneurysm, AVM Subarachnoid hemorrhage Intracranial hemorrhage Cavernous venous thrombosis Mass lesions – constant, slowly progressive Tumor Abscess Intracranial hematoma Infectious Meningitis/Encephalitis |
VMI
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PseuDOtumor cerebri – Headache
|
PseuDOtumor cerebri – HEADACHE
P-DO TUMOR CEREBRI Pregnancy, Obesity, Diabetes Frequent and prolonged headache Diagnosis with LP (Opening Pressure > 250 mmH20) Optic nerve damage Treatment is with Diuretics |
PseuDOtumor cerebri – HEADACHE
P-DO TUMOR CEREBRI |
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Spironolαctone
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Diuretic and Aldosterone antagonist
Direct inhibition of 5-α-reductase activity |
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Flutamide
|
– Flute receptor
Antiandrogen - blocks testosterone at the receptor |
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Finasteride
|
(inhibits the enzyme 5- -reductase) –
better tolerated FINER, FINAST than Flutamide |
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vestibulitis. Describe your management and treatment.
|
CLEAST
C Calcium Citrate and low oxalate diet L Lubricate/Lidocaine E Eliminate irritants Estrogen cream A Amitriptyline S Surgery T Therapy-biofeedback/sex |
CLEAST
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Erythema and edema of the vulva
|
PDS CV
Psoriasis – calcipotriene, steroid Dermatitis – Irritant, Contact, Seborrheic Steroid overuse (sebaceous hyperplasia) Candida Vaginitis (GBS) - PCN or Clinda |
PDS CV
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Diagnose PCOS Need 2 of 3
|
P Phasting GIR>4.5, Waist to hip ratio >.85 predictive
C Clinical O Ovulation disturbance S Sono |
PCOS
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Contact vulvar dermatitis allergens
Immunogic causes (hypersensitivity reaction) |
Poison SLK
Poison oak Semen Latex KY Jelly |
Poison SLK
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Met formin should not be used with what meds?
|
Cimet idine, trimet hoprim
|
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Vulvar psoriasis. What are the clinical manifestations?
Treatment? |
SILVER SCALES & PITTING NAILS! Hold breast.
Calcipotriene - synthetic vitamin D3, Steroid Phototherapy UVB light Psoralen PUVA |
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Cystometry
Test of detrusor function and can be used to assess: |
Sensation
Capacity Compliance Contractions - presence and magnitude of both voluntary and involuntary detrusor |
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Differential Diagnosis of Urinary Incontinence in Women
|
FILLING
FISTULA FUNCTIONAL CONGENITAL Filling and storage disorders Urodynamic stress incontinence UVJ Hypermobility ISD Detrusor overactivity (idiopathic) Detrusor overactivity (neurogenic) Mixed types Fistula Vesical Ureteral Urethral Congenital Ectopic ureter Epispadias Functional incontinence etiology DIAPPERS |
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Who requires cystoscopy and cytology to exclude bladder neoplasm:
|
Microscopic hematuria (2-5 red blood cells per high-power field),
> 50 yo with persistent hematuria Acute onset of irritative voiding symptoms in the absence of UTI |
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Lifestyle interventions that may help modify incontinence:
|
Curb pounds
Caffeine reduction Carrying physical forces (eg, work, exercise), Cessation of smoking Constipation relief |
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Why is estrogenization important in incontinence?
|
Urethra and bladder contain a rich supply of estrogen receptors
atrophy and replacement of the submucosa (vascular plexus) by fibrous tissue. Important for anatomic repair |
|
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Bulking agents provide what effect to the periurethra?
|
Washer effect
|
|
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Defined as the involuntary loss of urine coincident with increased intra-abdominal pressure in the absence of uninhibited detrusor contraction.
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SUI
|
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Urinary Incontinence w/u in office:
|
Urinalysis and urine culture: UTIs
Urine cytology: Carcinoma in situ of the urinary bladder Chem 7 profile: Blood urea nitrogen and creatinine levels are checked if compromised renal function is suggested. Voiding diary Pad test documents urine loss. Intravesical methylene/ Pyridium Cotton-swab test Cough stress test or Marshall test Standing pelvic examination PVR volume Uroflow test evaluating bladder outlet obstruction. To properly diagnose bladder outlet obstruction, perform pressure-flow studies. Filling cystometrogram |
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|
The only test able to help assess bladder contractility and the extent of a bladder outlet obstruction.
|
voiding cystogram VCUG
aka detrusor "pressure-flow study" simultaneously records the voiding detrusor pressure and the urinary flow rate. |
|
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Can help identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.
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VCUG
|
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GTN Therapy depends on low or high risk category
|
Met CHAP
Mets Lung/vagina Chemo prior HCG < 40,000 Antecedent preg < 4 months ago pregnancy term v SAB |
Met CHAP
|
|
Sexually abused children may develop the following:
|
ABUSE
A Avoidance or interest of all things of a sexual nature B Bodies are dirty or damaged U Unusual aggressiveness S Sleep problems/Seductiveness/Suicidal/Secretiveness E Examples of sexual molestation in drawings/games/fantasies |
ABUSE
|
|
PEP 4 weeks
Post Exposure Prophylaxis |
PEP 4 weeks
Post Exposure Prophylaxis Combivir BID |
PEP 4 weeks
|
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CPP DDx
|
CPP DDx
GUM Gyn G GI U Uro M Musculoskeletal Gyn |
CPP DDx
GUM Gyn |
|
Spigelian hernia?
|
“Spigel semilunaris”
Ventral hernia through the linea semilunaris, Line where the sheaths of the lateral abdominal muscles fuse to form the lateral rectus sheath |
|
|
Sperm analysis
|
50 50% mobility forward within 60 min of ejaculation
40 40 million count/ejaculate 30 30% morphology 20 20 million concentration/ml 2 2 ml |
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|
Lichen Sclerosis also found where?
|
Lichen on my back.
Parchment |
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Memory loss DDx
|
Memory loss = ICTAL Depression
Think of ICTAL, Add Tumor/Trauma/TIA Add depression Hypothyroid! |
Memory loss = ICTAL Depression
|
|
Zoloft traits and sides
|
GI side effects n/v
Most activating of all three SSRI. Zoloft = Zest! Zeal! |
Zoloft = Zest! Zeal!
|
|
Amitriptyline sides
|
Trippy/drowsy/confusion/dizzy
|
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Depression Meds with less sexual sides
|
bupropion
reuptake inhibitor of DA NE SE |
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Medical abortion
What regimen? 95-99% effective decreased rate of continuing pregnancies decreased time to expulsion fewer side effects - vaginal, and lower mife dose improved complete abortion rates lower cost |
EBR 63 days better than FDA ladder 49 days
Mifepristone 200 mg po, then in 24 hours… miso 800 pv…in 2 weeks sono. Mifepristone (RU-486) derivative of norethindrone binds to the progesterone receptor with an affinity greater than progesterone but does not activate the receptor, thereby acting as an antiprogestin necrotizing the decidua, softening the cervix, and increasing both uterine contractility and prostaglandin sensitivity |
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How would you counsel for medical TOP?
|
TOP CEASES
Compliance Importance of compliance and follow up Effective 95-99% effective Access Need access to care Sides Pain, bleeding, septic abortion Early Can be done early Surgery May need surgical procedure anyway/ No anesthesia or surgical risk |
TOP CEASES
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Oft Forgotten risks of D&E
|
R Retained POC
A Ashermans S Stenosis H Hematometra –D&C/methergine |
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Memory loss
|
= ICTAL Depression
Think of ICTAL, Add Tumor/Trauma/TIA Add depression elder abuse Communicating hydrocephalus - dizziness, unsteady walking, increased frequency of urination, and forgetfulness |
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Dizziness
|
mad stamp cabin
M Meds - neuroleptics, antidepressants, hypnotics/sedatives, loop diuretics, antihypertensives A Anemia/arrhythmia/aortic stenosis/abuse/acoustic neuroma D dehydration/Disequilibrium of aging/diverticulitis/diverticulosis S Shy Drager T tumor/trauma/TIA A Acoustic neuroma M Meniere’s P postural hypotension/panic attack/PUD C cervical spondylosis/constipation (valsalva)/communicating hydrocephalus/Colon cancer A Abuse B BPPV I infection (flu) N nutrition |
mad stamp cabin
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Hernia repair
|
Hernias < 3 cm
Mesh plug or Suture repair with primary fascia-to-fascia closure |
|
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Bowel Burn injury? What do you do?
|
Call general surgery
If > 2mm blanching burn area, resect 5 cm both sides If < 2mm blanching, bury area with one or two stitches |
|
|
Oft forgotten vulvar ulcers
|
Behcets
Pagets HIV/Mono/Cicatricial Pemphigoid |
|
|
Lichens Simplex Chronicus
Describe: |
PIPA (post inflammatory pigment alteration) pickers nodule, chronic itch-scratch cycle
|
|
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Lichen Planus
|
PRURITIC PURPLE PAPULES
wickhams striae, look at mouth/tooth loss, obliterates vagina. Purple papules in hair steroids, neovagina, retinoids |
|
|
Modified McCall Culdoplasty
|
Approximates the USL in the midline, incorporating posterior vaginal fornix in the stitch.
Securely close pubocervical and RV fascia, one or two layers across vag apex. Permanent 2-0 through full thickness of peritoneum post fornix/post vag wall, and then bring it through US ligaments |
|
|
PEACH Study
PID Evaluation And Clinical Health |
PID treated as inpatient v. outpatient
No diff in CPP, infertility, TOA, ectopic, IUP, recurrence, persistent infection No difference in outcome with mild to mod PID, clinical sxs. Cefoxitin/Doxy. |
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Outpatient PID: 14 day therapy
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Oflaxacin/Flagyl
Ceftriaxone/Rocephin and doxy with or without Flagyl |
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Inpatient PID x 14 days
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Mefoxin/Doxy
Gent/Clinda |
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Inpatient TOA:
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Meds 75% effective x 14 days
Baseline imaging for size and location Amp/Gent/Flagyl Mefoxin/Doxy |
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Why Probenecid? “For Good Killing”
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A uricosuric (treats gout by lowering uric acid levels)
Blocks urinary excretion, and thereby increases the blood levels and action of many medications |
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Laparoscopic Myomectomy
Two major concerns with laparoscopic myomectomy are: |
LAVH R&R
Removal of large myomas through small abdominal incisions Repair of the uterus. |
LAVH R&R
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What are the vessels at risk during a sacrospinous ligament fixation?
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In Pouring Gusts
Internal pudendal vessels coursing posterior to sacrospinous ligament Inferior Gluteal vessels |
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What is Adenomyosis?
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Stroma and/or heterotopic endometrial glands are located deeper than the endometrial-myometrial junction by more than 1 high-power field.
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Cervical Ca; describe how the radiation is given.
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Transfuse if Hg <12
Teletherapy 5040 cGy Brachytherapy 3,000 cGy four field technique. 7000 cgy Point A 5000 cgy Point B |
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How is cisplatin given / dosed?
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Cross links DNA
Weekly cisplatin 40 mg/m2 IV weekly for 5 wk |
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Benefits of chemosensitization
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Synchronizes cycle/reduces hypoxia/direct effect/higher growth fraction
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How long after MI can you do a surgery?
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Duke’s activity risk – best predictor of cardiac risk. Greater than 4 is moderate function.
6 weeks, need stress test/echo Scar formation and infarct healing is usually completed within six weeks of MI Will be intermediate risk |
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How do you treat Crohns disease
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Combination of corticosteroids and Immunosuppressants:
6-mercaptopurine and azathioprine Ceph/Flagyl – bacterial overgrowth Surgery IV Infliximab Moderate to severe Crohns disease that does not respond to standard therapies Anti –TNF also tx for RA Treatment of open, draining fistulas. |
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History Work up for prolapse
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S Symptoms Urinary/Colorectal/Protrusion/Pain/Sexual/Defecation dysfunction
O Ongoing Risks Constipation/Occupationalstress/Obesity/Chronic cough/Future childbearing/Young age M Medical condition smoking/COPD/arthritis E Estrogen status |
SOME
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Complications/problems with SSLF:
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Resultant fixed vaginal retroversion predisposes to anterior prolapse –
SSLF cystocele risk 16-90% |
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Options for prolapse repair
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Anatomic repair –
good EPF. Repair site EPF to USL/CL complex AP repairs Compensatory repair – bad EPF – SSLF, ASCP, Sling, graft |
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Complications/problems with b/l US suspension:
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Ureters!
Cystoscopy mandated |
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Abdominal route surgery methods to repair apical prolapse include:
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B/L Uterosacral Suspension
ASCP |
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Complications/problems with b/l iliococcygeus suspension:
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Apical recurrence rate high
Limits vaginal depth |
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How do you do a sacro colpopexy?
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Suspending strap (fore and aft) after hyst (autologous/donor fascia, porcine dermis)
Into anterior longitudinal ligament over the promontory |
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How do you repair the bowel?
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Close in 2 layers
First layer full thickness interrupted 3-0 vicryl for mucosa. 0.25 cm apart Second layer running seromuscular stitch 3-0 silk 0.5 cm apart |
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PE The classic radiographic findings
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Hamptons hump -wedge-shaped, pleura-based triangular opacity with an apex pointing toward the Hilus = Hamptons Hump
Westermark sign - decreased vascularity |
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Management of Acute Coronary Syndrome (ACS)
Within first 10 minutes: |
A Airway
B Breathing/Oxygen C Circulation/IV access M Morphine A Aspirin D Draw Enzymes E EKG |
H BANG - MI
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For all ACS: Acute Coronary Syndrome
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H BANG - MI
Heparin or LMWH B-blockers Aspirin Nitroglycerin GP (Glycoprotein) IIa/IIIb if percutaneous intervention (PCI)/Stents anticipated |
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Discuss Cardiac Enzymes:
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Test Onset Peak Duration
CPK 3-12 h 18-24 h 36-48 h Troponin 3-12 h 18-24h 10d |
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Spiral CT is advantageous for a number of reasons:
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Faster 15-25 secs total. Patient can hold their breath for the entire study, reducing motion artifacts,
More optimal use of IV contrast enhancement Higher resolution than conventional CT Can detect other chest pathology Less fetal than radiation than V/Q angiography may miss central mural thrombus |
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Determine if anovaginal or rectovaginal fistula
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Within 3 cm of anus is anovaginal
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Simple RVF
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No need for colostomy, may heal spontaneously in 6 months
Low to mid vag septum <2.5 cm diameter Traumatic/infectious etiology |
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Complex RVF
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Requires 2nd stage procedure/need for colostomy
High vaginal septum 2.5 cm or more in diameter IBD/Crohns, radiation or neoplasm |
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Recurrent vaginitis/cystitis may be what?
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RVF
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Anal u/s evaluates what?
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Sphincters
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Most helpful test for RVF?
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fistulagram/fluoroscopy
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Gene mutations involved in SPORADIC ovarian cancer?
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TP53 (tumor suppressor)
HER-2-neu (oncogene) |
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Common Causes of Transient (Functional) Urinary Incontinence
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DIAPPERS
Delirium Infection Atrophic Pharmacological Psychologic – depression, psychogenic polydipsia Pregnancy Excessive fluid (DM, CHF/vol overload, hypercalcemia, intake) Restricted mobility, Radiation Stool impaction, Surgery |
DIAPPERS
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AMA screening
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STAMP AMA
S Screening Parents T Testing A Abortion M Maternal Risks P Pre-embyro analysis/selection |
STAMP AMA
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Etiology of Early Pregnancy Loss
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M Medical Thyroid, DM
I Immune/Infection APL/Rh/RPR/Ureaplasma C Chromosomal Balanced translocation U Uterine Mullerian/Leiomyoma |
MICU
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Infertility workup
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UTERINE STOPS OBESITY
Uterine Avascular septum, ashermans Sperm Tubal PID, adhesive disease Ovary/Osis PCOS/Anovulation/endometriosis Pituitary PRL, TSH Social |
UTERINE STOPS
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Infertility history
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Coital frequency
Obesity Depo Provera Etoh/smoking/Coffee>4 cups/day Drugs (THC/CCB) heat/sauna exposure |
CODED HEAT
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Contraindications to ECV (ACOG)
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MAOIugr
Multifetal pregnancy Abruption/previa Oligo/marked IUGR |
MAOIugr
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Failure rate condoms when used correctly?
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3%
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Failure rate condoms when used INCORRECTLY?
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12%
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A patient presents with PROM at 18 versus 24 versus 26 versus 34 weeks gestation. Overall survival
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18(30%)
24(50-75%) 26(80%) 34 (98%) |
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Most common adverse effects from high-dose radiation:
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IUGR
Microcephaly Mental retardation |
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Risk of CNS effects is greatest with exposure at ______of gestation, with no proven risk at less than 8 weeks of gestation or at greater than 25 weeks of gestation
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8–15 weeks
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A threshold for this adverse effect may exist in the range of _____rads.
Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree. |
20–40 rad.
Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree. |
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Ionizing radiation can result in the following 3 harmful effects:
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GCC
1) Cell death and teratogenic effects 2) Carcinogenesis 3) Genetic effects or mutations in germ cells |
GCC
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Mastitis pathogens?
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Staph aureus,
Staph epidermis. Streptococcus, E.Coli |
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How do you treat mastitis?
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Dicloxacillin 500 Qid x 10-14 days
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If no response to Dicloxacillin in 24-48 hrs,
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Keflex,
Augmentin (B Lactamase inhibitor) |
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AGC favor Neoplasia
Chance AIS? Chance invasive adenocarcinoma? Chance of coexisting Squamous cell lesion? |
Counsel patient that 5% chance AIS
2% chance invasive adenocarcinoma R/o coexisting squamous lesion (50%) |
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A patient presents at 26 weeks with back pain and fever. What's the differential diagnosis?
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Pyelonephritis
Labor Perinephric abscess Pancreatitis Renal stones Cholelithiasis Cholecystitis PUD |
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How a CXR appears in ARDS.
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Diffuse bilateral alveolar infiltrates/ opacities (consolidation)
Consolidation with air-bronchograms Normal appearing |
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Why CXR normal appearing sometimes with ARDS?
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Changes seen on x-ray often lag many hours behind functional changes, so hypoxemia may seem disproportionately severe compared with the edema observed on chest x-ray
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Pathophysiology ARDS
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Inflammation, then fibrosis
Capillary and alveolar epithelial injury Plasma and blood leak Alveolar flooding and atelectasis Refractory to O2 therapy |
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A patient presents with Size > Dates. Don’t forget this in your differential:
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Uterine fibroid
Adnexal mass |
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How is TTT caused?
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Placental AV shunt
most common is AA shunt!!! TTT=AA |
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Is 20% discordance always pathologic?
which twin type see discordance in? |
No.
If two fetuses are discordant but both have normal estimated weights and grow appropriately on their own growth curves, the discordance may not indicate a pathologic process Discordance=Dizygotic |
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Management: Vaginal Delivery if First Twin Vertex
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Monitor first twin by internal scalp electrode
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In pregnancy, exertion at altitudes of up to ____appears to be safe
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6,000 feet
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SCUBA in pregnancy –
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Compression sickness in fetus,
Barotrauma (lungs, ears, sinus) risky if taking anticoagulants |
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Absolute Contraindications to Aerobic Exercise During Pregnancy
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Hemodynamically significant heart disease
Restrictive lung disease Incompetent cervix/cerclage Multiple gestation at risk for premature labor Persistent second- or third-trimester bleeding Previa after 26 weeks of gestation PTL during the current pregnancy ROM Preeclampsia/Gestational Hypertension |
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What is T&S?
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ABO & Rh, and minor antigens (c,e,Kell,Kidd)
Blood exposed to O, see what antibodies are made |
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What is T&C?
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T&S and crossmatch
Donor red cells exposed to recipient serum to check compatibility |
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• How long does it take to get blood?
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ASAP: type, screen and crossmatch time is 30 minutes
STAT: un-crossmatched blood can be released in 10 minutes |
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GB stones diagnosis in pregnancy:
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GB ultrasound
ERCP |
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Why would someone have recurrent pyelonephritis?
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Resistant organism pseudomonas
Other pathogen not treated Proteus, mycoplasm Vesicoureteral reflux -VCUG Renal calculi Fistula Perinephric abscess Obstruction Diabetes |
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ovarian cyst during pregnancy.
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Luteoma 2/3 regress postpartum
Dysgerminoma midline vertical at 18 weeks, sample ipsi nodes Dermoid Serous Cystadenoma Corpus Luteum Cyst resolves by 16 weeks Theca lutein cysts regress in 6 months Torsion PP due to rapid involution |
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In pregnancy, which masses should be surgically excised?
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> 6 cm beyond first trimester
Large masses can be observed if not highly suspicious for malignancy by u/s evaluation |
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Cervical length <______is PTL
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< 20mm
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Cervical length >_____can exclude PTL
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>30mm
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Pt presents with contractions and 2cm dilated, don’t forget to do three things:
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r/o infection
cervical length FFN |
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FFN, what is it?
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CHORION GLUE
Glue that holds chorion to maternal endometrium Indicates membrane/decidua disruption |
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GBS Would you give any antibiotics and why?
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Reduce “early-onset” neonatal GBS disease.
GBS sepsis, meningitis, neurological damage (CP in chorio) |
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If PCN allergic, but not at high risk for anaphylaxis, what is next choice?
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Cefazolin 2g IV then 1 q 8 hours
98% susceptibility |
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Poor cerclage outcomes after how many weeks gestation?
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22 weeks
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Who gets cerclage?
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13 – 16 weeks
3 mid-trimester losses 3 preterm deliveries |
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What are early and late symptoms of GBS in the neonate?
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Early (24 - 48 hours) respiratory symptoms/Pneumonia.
Late (2 weeks) Meningitis, bacteremia/seizures |
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When do you not use GBS cultures/treat?
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GBS negative within last 4 weeks per ACOG
Planned c/s, not in labor and no ROM |
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A patient is positive culture GBS and is not sensitive to clindamycin or erythromycin. What would you give her?
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PCN - risk of fatal anaphylaxis has been estimated at 1 per 100,000
Cefazolin 2g IV then 1 q 8h 98% susceptibility Vancomycin 1g q 12h |
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What are the signs of Mg toxicity?
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CRAPO
Cardiac arrest Respiratory depression Absent reflexes Paralysis Muscular Oliguria |
CRAPO
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Treatment Mg toxicity. How to you mix it? How slow do you inject?
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I’m not in love with Mg toxicity 10cc
10cc 10% 10 min 1g Calcium Gluconate IV Calcium Gluconate (10 cc of 10% solution over 10 minutes) by slow intravenous injection |
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How would you apply Piper forceps?
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Maintains the head in a flexed position.
Applied to bimalar biparietal region Supports the fetal body in a horizontal plane - savage maneuver by assistant. Direction of the pelvic axis reverse pelvic curve LEFT blade first |
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How do you avoid head extension?
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Suprapubic pressure
Mariceaux-Smellie-Veit maneuver - fetal maxillary prominences. Upper hand on the fetal back Assistant to maintain horizontal while applying forceps Piper forceps |
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nuchal arm and how do you deal with it? Breech delivery.
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Lovset’s maneuver – deliver posterior arm, rotate 180 degrees, deliver new posterior arm.
or rotate the infant so that the fetal face rotates toward the symphysis pubis; this reduces the tension holding the arm around the back of the fetal head. Or:Duhrrsen’s incision 2,6, and 10 o’clock must press antecubital. If press on humerus, will get radial nerve palsy - wrist drop. |
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Twin B breech - deliver vaginally if:
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>1500 g, <36 weeks? Controversial
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When to do ECV:
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COMPLETED 36 weeks
Most of the evidence pertaining to ECV comes from recent studies that selected patients near term. |
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Why not induce successful ECV right away?
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There is no support for routine practice of immediate induction of labor to minimize reversion.
except possibly in persistent transverse lie to avoid cord prolapse, after verting successfully. |
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What are the risk factors for ECV failure?
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Marked oligohydramnios
Small fetus Nulliparity harder Anterior placenta Maternal obesity fetus fixed in pelvis frank breech |
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Most common complication of ECV?
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Fetal/maternal bleed
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ECV tocolytic? Epidural? What studies say:
|
Support the use of a tocolytic agent during ECV attempts, particularly in nulliparous patients.
There is not enough consistent evidence to make a recommendation favoring spinal or epidural anesthesia during ECV attempts |
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Can VBACs can get oxytocin for augmentation/induction?
|
Yes.
In VBAC, the rate of uterine rupture was not different between those who received oxytocin and those who labored spontaneously. |
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Post partum for preeclampsia and develops severe oliguria <10cc/hr. What is the role of a CVP line insertion?
|
Evaluate intravascular volume
If the CVP rises and stays high (14-16mmHg) then volume loading is complete Insert CVP, if low, give IVF If CVP normal, give nitroglycerin to dilate renal artery CVP does not mirror PCWP in severe Preeclampsia Can push PCWP to 12-14mmHg |
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How is true preload measured?
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Pulmonary artery catheter
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If urinary flow is still poor, and the blood pressure is low or marginal, then what?
|
vasopressor, such as norepinephrine.
to increase renal perfusion pressure more potent inotrope, such as dobutamine |
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What is the risk of Asherman’s syndrome after D&C?
|
69%
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• What surgical techniques might increase or decrease risk of Asherman’s syndrome?
|
Antibiotics prior to procedure
Gentle curettage |
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A patient doesn’t bleed after given estrogen and progestin. DDX?
|
Asherman’s
Pelvic TB Outlet obstruction Transverse vaginal septum Imperforate hymen |
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What values appear to be most effective at determining the likelihood of macrosomia and other adverse pregnancy outcomes in patients with GDM?
|
Postprandial glucose values
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Besides R/N 2/3 ½ R/N ½ ½ , what is another GDM method to initiate with:
|
Can start with 10 R or Lispro, 20 NPH in AM , and 5/5 in pm
10/20 5/5 |
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Which GDM regimen is best?
|
No particular insulin regimen or insulin dose has been demonstrated to be superior for GDM.
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What can be used instead of Regular, and will improve postprandial?
|
Lispro instead of Regular (1:1) to improve postprandial
More rapid onset of action than regular insulin |
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Obese pregnant women (body mass index >30) may do well with moderate caloric restriction of what %?
|
Caloric restriction of 30%
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With caloric restriction, what is important to check daily?
|
Should check morning urine ketones
Possibility that it may cause starvation ketosis – |
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Definition of mild and severe CHTN in pregnancy:
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mild (BP >140/90 mmHg) or as severe (BP >=180/110 mmHg)
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Are diuretics okay in pregnancy?
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Diuretics are okay except in settings in which uteroplacental perfusion is already reduced (preeclampsia and IUGR).
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Do women with mild hypertension (140–179 mmHg systolic or 90–109 mmHg diastolic pressure) need meds?
|
No.
Generally do well during pregnancy and do not, as a rule, require antihypertensive medication. There is, to date, no scientific evidence that antihypertensive therapy will improve perinatal outcome. |
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HTN Therapy could be increased or reinstituted for:
|
Blood pressures > 150–160 mmHg systolic or 100–110 mmHg diastolic
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antihypertensive therapy should be initiated or continued in:
|
Severe chronic hypertension (systolic pressure >=180 mmHg or diastolic pressure >=110 mmHg),
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Gestational hypertension
• How would you manage? |
140/90, no proteinuria
Manage like mild HTN |
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PP HTN treatment:
|
Labetalol PO 200 mg every 8 hours (maximum dose of 2,400 mg/d)
Nifedipine is 10 mg orally every 6 hours (maximum dose of 120 mg/d) |
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In Eclampsia, deliver if FHR decels don’t resolve after how many minutes?
|
10 minutes
The patient with eclampsia should be delivered in a timely fashion. |
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Once the Eclamptic patient is stabilized, should base delivery on what factors?
|
Age
Fetal condition decels - greater than 10 minutes Labor Bishop/cervix <30weeks or Bishop < 5 should CD |
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Regional anesthesia contraindicated at what platelet level?
|
plt<50,000
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Besides anterior shoulder entrapment, what other shoulder dystocia is there?
|
Impaction of the posterior fetal shoulder on the sacral promontory. ACOG.
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|
Severe shoulder dystocia may result in:
|
hypoxic-ischemic encephalopathy and even death
|
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|
What percent of Erb’s palsy victims heal completely within a year.
|
90%
Usually takes up to three months |
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What percent of Klumpke’s palsy recover in 1 year?
|
40%
|
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What percent of brachial plexus injuries occur after cesarean delivery. ACOG.
|
4%
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What percent of brachial plexus injuries are not associated with shoulder dystocia?
|
40%
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Is surgery ever warranted in Brachial plexus injury?
|
Cases of severe nerve injury and with avulsion injuries
If clinical or electrodiagnostic evidence of recovery is not present at 4 months surgical exploration should be recommended Clinical examination is a better prognostic indicator than is EMG |
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Patient with IUGR, don’t forget to consider:
|
Infection
Maternal factors Fetal Factors Environmental factors |
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When should IUGR be delivered if premature?
|
An abnormal result from fetal heart rate testing (decreased variability) coupled with abnormal results from Doppler velocimetry suggests poor fetal well-being and a potential need for delivery, despite prematurity
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|
Risk Congenital Varicella infection if exposed 1st,2nd trimesters)
|
1-2% risk
|
1st 2nd trimester = 1-2%
|
|
Congenital Varicella infection findings:
|
Pox warfare lesions
Cutaneous scarring, limb hypoplasia, IUGR, microcephaly like warfare, but has cutaneous scarring |
Pox Warfare lesions
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What to give Nonimmune exposed mother if VZV exposed during pregnancy:
|
VZIG for exposed, give within 72 hours of exposure (if anti-VZV IgG negative) to prevent clinical Varicella,
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|
Does Labial agglutination always need treatment?
|
No often spontaneously resolves in 6 months to 1.5 years
|
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|
When should Labial agglutination be surgically treated?
|
Complete obstruction
Voiding difficulty |
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|
What is the incubation period of HSV?
|
2-14 days
|
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How long will the HSV patient shed for?
|
3 months
|
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|
What are congenital anomalies of syphilis?
|
Microcephaly
Intracranial calcifications Chorioretinitis Just like Toxo! Stillbirth,IUGR, nonimmune hydrops, rhinitis - snuffles, hepatosplenomegaly,"mulberry molars","saber shins", saddle nose deformity, interstitial keratitis, eigth nerve deafness,peg-shaped incisors/hutchinson's teeth |
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|
What are neonatal effects of HSV and mortality of each?
|
Skin, eye, mouth 0%
CNS (Herpes encephalitis) 15% Disseminated 57% |
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Can an amnio be done if HSV outbreak?
|
No if “primary” HSV and systemic symptoms, cannot do amnio, CVS, PUBS until resolve.
Okay if recurrent disease. But avoid transcervical procedures. FSE okay if no lesions. |
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|
Various pre-op holding area scenarios:
|
Patient has:
chest pain high glucose hypertension anemia |
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|
Bacterial Vaginosis
Drug Regimen |
Metronidazole (Flagyl) 500 mg PO BID for 7 days
Clindamycin cream 2% 1 full applicator (5 GMS) per vagina X 7 days @ night Metronidazole gel 0.75% 1 full applicator (5 GMS) per vagina BID X 5 days Metronidazole 2 GMS PO as a single dose Clindamycin 300 mg PO BID X 7 days metronidaole has less effect on return of lactobacillus |
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|
Genital Warts (Condyloma acuminata) Patient-Applied
Drug Regimen |
Podofilox 0.5% solution or gel Applied with a cotton swab or gel with a finger to visible genital warts BID X 3 days followed by 4 days of no therapy. Cycle may be repeated for a total of four cycles
Imiquimod 5% cream Apply cream with finger at bedtime 3 X weekly, up to 16 weeks. Wash with mild soap and water after 6 - 10 hours. Not for use during pregnancy. |
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|
Genital Warts (Condyloma acuminata) Practitioner Applied
Drug Regimen |
Cryotherapy with liquid nitrogen or cyroprobe Repeat applications every one to two weeks. Avoid normal tissue. Wash off in 1-4 hours. Not for use during pregnancy.
Podophyllin resin 10-25% in compound tincture of benzoin Repeat weekly if necessary Trichloracetic acid (TCA) or Bichloracetic acid (BCA) 80-90% Repeat weekly Surgical removal. Scissors or shaving excision, curette, or electrosurgery are possible. |
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|
Parvovirus B19
The illness presents in the mother as |
fever, malaise, polyarthralgia (particularly of the peripheral joints), coryza.
Lacelike rash on trunk , extremities and face. The infection may be mistaken for rubella. |
|
|
Incubation Parvo
|
Incubation is 4 to 14 days.
|
|
|
What is Parvo Rash like in mother?
|
Lacelike rash on trunk , extremities and face.
|
|
|
Discuss IgM and IgG in toxo
|
IgM typically turns positive after 1 week and may remain positive for years. IgG follows same course, but remains positive for life.
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|
|
Varicella (Chickenpox)
rash begins on |
face and scalp then spreads to trunk.
|
|
|
Varicella (Chickenpox)
The incubation period ranges from |
10 to 21 days.
|
|
|
Varicella (Chickenpox)
The patient is contagious for |
1-2 days before the onset of rash until all lesions are crusted. The crusts are not infectious
|
|
|
Varicella (Chickenpox)
The risk of developing the congenital syndrome is |
1% if less than 20 weeks and 2% at 13-20weeks
|
|
|
Why give exposed mother VZIG?
|
"Administration of VZIG to susceptible, pregnant women has not been found to prevent viremia, fetal infection, congenital varicella syndrome, or neonatal varicella. Thus, the primary indication for VZIG in pregnant women is to prevent complications of varicella in the mother, rather than to protect the fetus.
|
|
|
How is the newborn treated if mother exposed?
|
Newborns are administered VZIG if the mother had ONSET of chickenpox < 5 days before delivery to 48h postpartum. should receive another full dose of VZIG.
|
|
|
counseling about BSO
|
SELF Self image
SEX Sexual function-libido/dryness HORMO Hormonal mileu REPRO Reproductive function |
|
|
How is the diagnosis of PMS established?
|
CONSISTENT
LUTEAL EXCLUSION FACET a) symptoms CONSISTENT with PMS; b) restriction of these symptoms to the LUTEAL phase of the menstrual cycle assessed prospectively; c) impairment of some FACET of the woman's life; and d) EXCLUSION of other diagnoses that may better explain the symptoms |
|
|
metabolic syndrome be identified as the presence of three or more of these components:
|
WHHET
• Waist:Hip > .85 • TG> 150 mg/dL • HDL < 50 mg/dL • HTN 130/85 mm Hg • Elevated fasting glucose > 100 mg/dL |
|
|
A 60 year old patient as abnormal cholesterol values.
• What is your differential diagnosis? |
DM
Metabolic syndrome Iatrogenic (testosterone therapy/progestins) Hypothyroid |
|
|
Which lab test is predictive of MI?
|
C-REACTIVE PROTEIN!!!!!
|
|
|
Vaginoperitoneal fistula from endometriosis fulguration, is a risk factor for
|
fallopian tube prolapse.
This problem can be diagnosed and safely managed with a laparoscopic approach. |
|
|
SSL located where?
|
within the coccygeus muscle
|
|
|
Grade a cystocele:
|
Grade-I cystocele is when the bladder drops to the mid vagina with abdominal strain.
Grade-II cystocele is when the bladder drops to the introitus with abdominal strain. Grade-III cystocele is when the bladder protrudes out of the vaginal introitus with abdominal strain. Grade-IV cystocele is when the bladder protrudes out of the vagina at rest. |
|
|
History Work up for prolapse
|
S Symptoms Urinary/Colorectal/Protrusion/Pain/Sexual/Defecation dysfunction
O Ongoing Risks Constipation/Occupational stress/Obesity/Chronic cough/Future childbearing/Young age M Medical condition smoking/COPD/arthritis E Estrogen status |
|
|
hymenectomy, watch for which vessels?
|
lateral pudendal
|
|
|
hematocolpos or mucocolpos. If intend to perform hymenectomy, should it still be done?
|
cruciate incision on hymen at inital procedure but do not remove it.
Allow adequate drainage and then restoration of normal anatomy, prior to reconstruction/excision of hymen. |
|
|
VVF fistula repair
if due to radiation, will need: |
temporary diversion with ileal loop to bring external blood supply to fistula
|
|
|
VVF repair post op drainage with, and how long?
|
Dual cath drainage post op
Foley up to 2 weeks post op SPT up to 3 weeks |
|
|
hymenectomy, watch for which vessels?
|
lateral pudendal
|
|
|
hematocolpos or mucocolpos. If intend to perform hymenectomy, should it still be done?
|
incise hymen at inital procedure but do not remove it.
Allow adequate drainage and then restoration of normal anatomy, prior to reconstruction/excision of hymen. |
|
|
Can you treat uterine prolapse without removing uterus?
|
Posterior LUS to sacrum
|
|
|
Blood supply to ureter
|
Renal artery
Ovarian artery Aorta Common iliac Internal iliac Superior vesical Inferior vesical |
|
|
Rectosigmoid endometriosis symptoms
|
Premenstrual tenesmus/diarrhea
|
|
|
Sutures become permanently encapsulated in tissue
|
silk
|
|
|
blood supply small bowel
blood supply colon |
SMA
SMA IMA |
|
|
Lab for outpatient DVT w/u
|
D-Dimer
|
|
|
Discontinue warfarin 5 days pre-op and let the INR drift down to normal range.
Proceed with surgery if INR is |
<1.3
start heparin when stop coumadin. stop heparin 5 hours preop restart w;in 24 hours post op. start coumadin post op when tol PO. |
|
|
Do what if PE pulmonary work up negative
|
Echo
|
|
|
What is easily seen with CT may be missed at pulmonary angiography.
|
A chronic central mural thrombus
|
|
|
cuff cellulitis caused by
|
Trich
BV |
|
|
Treament SPT
|
heparin AND antibiotics
|
|
|
What type of heparin for SPT?
|
LMWH 1mg/kg BID
|
|
|
What % of simple fistulas heal spontaneously
|
50%
|
|
|
Post op care for RVF
|
low res diet
antibiotics PREVENT CONSTIPATION |
|
|
DIME VOPS
DVT within how much time is high risk? |
< 3 months is considered high risk
|
|
|
Gyn surgery for patient with h/o DVT
|
• Full dose therapeutic IV heparin or LMWH 1mg/kg q 12H should be given 2 days prior to the OR.
• D/C IV heparin 5 hours prior to going to the OR. • LMWH should be held 24 h prior to surgery. • Postop re-start IV heparin without bolus or enoxaparin 1 mg/kg Q 12 H 24 hours post op • warfarin once the patient is taking po meds. Heparin/lovenox can be d/c’d once INR 2-3. |
|
|
? superficial thrombophlebitis v. DVT
|
must do b/l duplex u/s
MRV – noninvasive serial exams r/o PE if symptomatic DVT until proven otherwise |
|
|
Antibiotics should be used whenever the phlebitis involves the
|
proximal thigh
|
|
|
pediatric discharge, don't forget
|
Trauma with necrotizing hematoma/abscess
|
|
|
incidence of underlying carcinoma among women with a community diagnosis of atypical endometrial hyperplasia was ___ % GOG
|
45%
|
|
|
VVF usually occur how many days post op?
|
Usually 10-14 days post op
|
|
|
The coagulation waveform has what characteristic
|
higher peak-to-peak voltage waveform
(producing higher temperatures) to dessicate |
|
|
cutting waveform allow what temp?
|
100 deg C
to evaporate only |
|
|
Type of coagulation in which the active electrode does not touch the tissue but
‘sprays’ multiple sparks between itself and the tissue |
Fulguration
|
|
|
What setting uses a higher peak-to-peak voltage waveform than the other coagulation settings?
|
fulguration
|
|
|
During LEEP, The least amount of power that will effectively perform the electrosurgery should be used, so as to minimize the risk to the patient’s normal tissues and ensure that the excised specimen is in acceptable condition (with a minimum of thermal artifact) for pathological assessment.
|
Hmmm.
|
|
|
If the lesion extends onto the vagina, it is preferable to use the
|
ball electrode for electrofulguration
|
|
|
How wide to Leep?
|
5mm before and aft each transformation zone
|
|
|
Iodine is glycophilic
Lugols |
Iodine is glycophilic
therefore will be taken up by cells that have glycogen - mature, non neoplastic cells |
|
|
A patient is S/P TAH, having had a pre-op Hct of 40. The Hct is now 24, pulse rate is 98 and urine output is 10 cc/hr.
don't forget to consider |
retroperitoneal hematoma
check u/s |
|
|
A 60 year old woman has ovarian cancer.
• How would you counsel her daughter regarding her risk of developing ovarian cancer? Increased risk for first degree relative |
4%
|
|
|
Ovulation induction increases risk of what type of ovarian cancer?
|
LMP Low Malignant Potential/Borderline
|
|
|
BRCA1, auto dominant, lifetime risk ovarian cancer?
|
90%
|
|
|
Reduce risk with OCPs ___% (even if genetically susceptible)
|
50%
|
|
|
Decrease risk of ovarian cancer:
|
OCPs (especially progestin potency)
Oophorectomy 40% 1% (still can be Primary Peritoneal Carcinoma), 2% occult cancer found in specimen. Tubal ligation |
|
|
Who gets Extended Field Radiation
|
bulky stage 1b
Stage IIB |
|
|
radiation bad for vagina how?
|
length
caliber lubrication also bad for ovaries |
|
|
C perfringens sepsis (septic abortion) presents as:
|
Hemolysis
Anuria port-wine colored serum and urine DIC Ultrasonographic presence of air within the uterine cavity RENAL FAILURE!!! |
|
|
plane flights causes hemoconcentration and increases the risk for DVT and PTL. why?
|
Reduction of cabin humidity to less than 25%
|
|
|
Pregnant women should be informed that the most common obstetric emergencies occur in the which trimesters?
|
first and third
|
|
|
antifactor Xa levels
antifactor Xa levels antifactor Xa levels |
antifactor Xa levels
antifactor Xa levels antifactor Xa levels |
|
|
PaO2/FIO2 < 200
|
ARDS
decreased Pa02 despite inspired 02 Refractory to 02 therapy air bronchograms because aerated bronchioles end up to blocked alveolae. no gas exchange can occur. 02 can't get to caps. |
|
|
They asked how a CXR would appear in ARDS.
|
Diffuse alveolar-interstitial infiltrates
Opacities (consolidation) Consolidation with air-bronchograms |
|
|
S>D, don't forget about...
|
Polyhydramnios
|
|
|
Bleeding and IUFD
Fibrinogen and FDP levels can be monitored serially until delivery Delivery can be expedited if |
DIC develops.
avoid c/s!!! replace blood and rupture membranes. |
|
|
• Why would someone have recurrent pyelonephritis?
|
@@@ Resistant organism pseudomonas
Other pathogen not treated Proteus, mycoplasm Vesicoureteral reflux -VCUG Renal calculi Fistula Perinephric abscess Obstruction Diabetes |
|
|
recurrent pyelonephritis
Resistant organism |
pseudomonas
|
|
|
recurrent pyelonephritis
Other pathogen not treated |
Proteus, mycoplasm
|
|
|
Size all masses > ___ cm beyond first trimester should be surgically excised.
|
6
Large masses can be observed if not highly suspicious for malignancy by u/s evaluation |
|
|
Fetal loss in patients with gallstone pancreatitis is
|
10-20%
|
|
|
Discuss cervical lengths on US and significance of findings
utility is in |
excluding PTL
|
|
|
FFN NPV is
|
99% NPV
|
|
|
FFN will be positive < 24 weeks because
|
membranes haven’t sealed
|
|
|
UDCA ursodeoxycholic acid
|
also treats ICP – bile acid to dissolve cholesterol gallstones
|
|
|
Fetal loss in patients with gallstone pancreatitis is
|
10-20%
|
|
|
Laparoscopy in pregnancy
|
When possible, operative intervention should be deferred until the second trimester, when fetal risk is lowest
Pneumoperitoneum enhances lower extremity venous stasis Therefore pneumatic compression devices should be utilized whenever possible. Given the enlarged gravid uterus, abdominal access should be attained using an open/Hassan technique. Dependent positioning should be utilized to shift the uterus off of the inferior vena cava. Pneumoperitoneum pressures should be minimized (to 8 - 12 mm Hg) and not allowed to exceed 15 mmHg |
|
|
cfu/ml
|
colony forming units per ml
|
|
|
severe Mg toxicity, what to do if calcium gluconate doesn't work:
|
May need dialysis if severe
Intubation |
|
|
Contraindicated to delay and vicryl ligate high PPROM Twin B when?
|
Monochorionic
Chorioamnionitis Abruption NRFHT |
|
|
• What are the risk factors for ECV failure
don't forget |
nulliparity
|
|
|
A patient is 2 weeks post partum with heavy bleeding (2 pads/hr)
don't forget |
recurrent invasive mole
avoid D&C/ashermans unless have to. Likely cause of bleeding is infection (fever?). Treat with antibiotics. |
|
|
PP retained POC - D&C. Don't forget...
|
Antibiotics – Doxycycline 100mg BID x 10 days
|
|
|
Treatment Ashermans. don't just say blind D&C, but also add that can do
|
hysteroscopy
|
|
|
ashermans etiology, don't forget
|
Pelvic TB
|
|
|
Drainage of pelvic abscess by vaginal route must meet 3 criteria:
|
Fluctuant abscess (or else adequate drainage cannot be achieved)
Must dissect the RV septum (or else will enter rectum) Must be midline (or else I&D will result in peritoneal spread) |
|
|
After I&D pelvic abscess vaginally, must do this...
|
Place drain in CDS
|
|
|
post op c/s ileus obstruction, could be
|
ureter
hematoma/abscess endometritis ileus |
|
|
seizure, at risk for what pulmonary sequelae?
|
aspiration
pulmonary edema |
|
|
If still another seizure:
give |
Give another 2g MgSO4 over 3-5 minutes
Phenobarbital 250 mg over 3-5 minutes |
|
|
Nifedipine dose for HTN
|
Nifedipine 10mg q 30 min, max 50mg/hr.
|
|
|
What percent of brachial plexus injuries are not associated with shoulder dystocia;
|
40%
|
|
|
What percent of brachial plexus injuries occur after cesarean delivery.
|
4%
|
|
|
IUGR don't for get to inquire about
|
Maternal factors
Fetal factors Environmental factors smoking cocaine how much past babies weighed FAS HTN |
|
|
What is treatment for HSV suppression?
|
Valtrex 400mg qd
ONCE DAILY!!! |
|
|
early stage cervical CA, desires fertility
|
Trachelectomy
Put cerclage in |
|
|
rads to point A
rads point B |
7000
5000 |
|
|
rads bowel can handle
|
5000
rads = cGy |
|
|
If found cerv ca on retrospect path after hyst
|
Do CT
XRT |
|
|
If return with symptoms of recurrence cervical cancer
|
Do exam, CT, refer
|
|
|
biopsy gross cervical lesion where?
|
at periphery/include edge (if just bx center, will just get necrosis)
|
|
|
12 weeks, invasive ca cervix if stage 1b
|
Rad hyst/LAN
|
|
|
Cervical cancer needing surgery/radiation, Up to ___ weeks, don’t need to terminate , baby will die on own
|
Up to 18 weeks, don’t need to terminate , baby will die on own
|
|
|
Cervical cancer, can wait how many weeks for treatment without compromise
|
16 weeks
so, at 22 weeks gestation, can safely wait until term to intervene. |
|
|
XRT how long after CD for cervical cancer?
|
10 days
|
|
|
Paracervical block complications - lidocaine
|
Metallic taste
Tinnitus Arrhythmia Coma |
|
|
s/p cone with bleeding. likely etiology is?
|
infection
|
|
|
Should you do hyst when if found to have “late s/p cone infection/bleeding”?
|
8 weeks later
Don’t want to do hyst if parametrium is infected |
|
|
Leep settings
|
monopolar cut 50 Watts
|
|
|
Lido toxicity management
|
ABC
Wait it out until metabolism Give ephedrine or 1 mg atropine for Lidocaine bradycardia Give thiopental or valium or succinylcholine if convulsions/seizures The recommended doses of lidocaine without epinephrine is 4 mg/kg. If epinephrine is added, the maximum safe dose is 7 mg/kg. Remember that epinephrine is a treatment for lido toxicity/bradycardia |
|
|
HPV takes how long to undergo change
|
3 years
therefore can wait to do first pap then. |
|
|
Takes how long for LGSIL to become invasive cancer if not immunocompromised
|
15 years
|
|
|
film and digital mammography were equally accurate. But for which women digital mammography is significantly better
|
dense breasts
women under age 50 pre- and perimenopausal |
|
|
MRI has been shown to detect small breast lesions that are sometimes missed by mammography, and MRI can successfully image
|
the dense breast
breast implants. doesn’t expose women to radiation |
|
|
Downside to breast MRI
|
hard time distinguishing between carcinoma and benign breast disease (fibroadenoma)
doesn't detect certain types of very small calcifications uses blood flow as a marker instead |
|
|
should breast MRI replace standard screening and diagnostic procedures?
|
No
|
|
|
Breast ca staging
|
I 2.0 cm
II 2-5 cm or ipsi nodes IIIa > 5cm nodes stuck to selves and tissue IIIb skin/wall/mammary IV mets |
|
|
Prognostic tests for treatment in women with dx of breast ca:
|
Est/Prog receptor status
Her 2/neu DNA cytometry |
|
|
mammo will dx what size breast ca
|
1 mm
|
|
|
CBE will palpate what size breast ca
|
1cm
|
|
|
SBE will palpate what size breast ca
|
2cm
|
|
|
BRCA1BRCA2
What % will get breast ca |
90%
|
|
|
BRCA do what px surgeries?
|
Bilateral mastectomy
BSO after child bearing bso (take tubes, too) |
|
|
cheesy nipple discharge =
|
duct ectasia
|
|
|
how to excise duct
|
subaerolar and do duct excision
|
|
|
mastitis, why dicloxicillin?
|
penicillinase resistant abx
|
|
|
treatment breast pain
|
bra
no smoking no OCPs primrose oil Danazol Bromocriptine |
|
|
25 year old lump in breast
management |
Examine after period
Aspirate |
|
|
Fibroadenoma in teenager
Usually< 4cm management |
Don't operate
|
|
|
Remove when in teenager?
|
If > 4cm or phylloides – remove
cystosarcoma phylliodes is benign! hard to differentiate between phylloides and fibroadenoma |
|
|
12 weeks gest and 5 cm Dermoid
|
observe unless torsion
|
|
|
Granulosa cell tumor
require chemo? |
r/o endomet ca
most don’t require chemo Stage III, IV get BEP |
|
|
Inhibin A
|
Quad screen
Early preeclampsia Produced by placenta and CL Sex-cord stromal |
|
|
Inhibin B
|
measured in ovarian reserve
secreted by granulosa cells |
|
|
Be sure to stage ovarian CA within 1 week, or if can’t be staged in 1 week, then
|
give 3 cycles of chemo and stage later.
|
|
|
GnRH sides
|
vasomotor
memory loss osteo |
|
|
addback
|
medroxyprogesterone
EE bisphosphonate |
|
|
If giving addback right away, to minimize sides, give which
|
Norethindrone
|
|
|
How is fibroid affected if given addback right away?
|
shrinks LESS with addback right away.
|
|
|
Sarcoma
three things to look for |
1. Loss architecture
2. Mitosis 3. Necrosis |
|
|
sarcoma mitosis 10-20
management |
hyster
|
|
|
Sarcoma > 20 mitoses
management |
chemo
|
|
|
Hysteroscopic resection myoma
risks |
bleeding - cauterize, balloon
hyponatremia - won't happen with NS fluid overload - can happen with MSG or NS |
|
|
Hyponatremia management
|
stop procedure
stat electrolytes hypertonic saline 3% lasix won't happen with NS distention media can use NS with bipolar |
|
|
Hyponatremia manifested how?
|
HA, coma, encephalopathy
|
|
|
critical level of NA for hyponatremia?
|
125
|
|
|
stop at what fluid deficit
|
1000
|
|
|
Distention media Glycine danger of
|
ammonia toxicity
|
|
|
In preoperative h/h 5
|
Fe
Prempro Oral estrogen D&C Iron therapy Erythropoietin |
|
|
GnRH
describe protein |
decapeptide
Released from the medial basal hypothalamus Modification 6th position agonist Modification 1st position is antagonist |
|
|
SCH advantages
|
Less operating time
Less injury to ureter, bladder, less uterine artery damage If osis, adhesions |
|
|
SCH disadvantages
|
Vaginal discharge
Chronic cervicitis cyclic bleeding Paps cervical prolapse 2% NO DIFFERENCE IN BOWEL, BLADDER, SEXUAL FUNCTION OR PROLAPSE BETWEEN SCH AND TOTAL HYSTERECTOMY |
|
|
will SCH preserve sexual function compared to total hysterectomy?
|
No.
Transudate from vagina is lubrication |
|
|
Cervical myoma
|
Incise/myomectomy
trace ureter or place stents cystoscopy afterwards |
|
|
Broad ligament myoma
|
Ureter posterior
Make incision anteriorly Then dissect wall carefully to isolate ureter Get to pelvic brim common iliac bifurcation if necessary and follow down to uterine artery level Can stent or indigo carmine Or cystoscopy |
|
|
Nec fasc
bugs |
Bacteroides
Anaerobes Debridement until bleeds |
|
|
Vag hyst, entered rectum. Do what?
|
The good news:
In colpotomy you’re below anal-rectal verge. Close 2 layers, irrigate, give antibiotics |
|
|
Vag hyst - Bladder injury
|
Close 2 layers
3-0 vicryl (monocryl is less inflammation) |
|
|
LS in sigmoid colon, feces coming out-
|
Suture it, no colostomy required.
Antibiotics, heals well. |
|
|
VVF after vag hyst
wait how long to repair? |
Delay closure 3 months
Repair vag or abdominally Until then, place foley |
|
|
Incontinence of feces
(see hint for etiology) pudendal nerve S 2,3,4 innervates sphincter Sacral nerve innervates levators |
check anal wink/neuro - dovetail sign
Anal u/s - r/o fistula Fistulagram Anal manometry - sphincter mechanism Rectal physiological studies for neuro - EMG Pudendal Nerve Terminal Motor Latency Testing |
Anatomy defect
fistula - IBD/XRT/HIV/steroids/poor epis repair sphincter disorder - poor repair Neuro defect – MG, MS What studies? |
|
Posterior repair:
Repair perirectal fascia – bring in midline Levators bring in midline may cause dyspareunia if brought together too tightly Dyspareunia due to or didn’t leave enough room for introitus. |
Hmmm.
Make sure can accommodate two fingers comfortably. |
|
|
Deep dyspareunia – tubal prolapse
Pain due to |
granulation tissue
|
|
|
Dyspareunia also due to
|
too tight levator plication from post repair
collision dyspareunia from retroverted uterus pelvic congestion syndrome uterus suspension to encourage venous drainage and to alleviate collision dyspareunia |
|
|
Cystocele - lateral defect
Paravaginal defect due to white line Can repair vaginally by |
dissecting back to white line
|
|
|
Central repair cystocele:
remove excess vagina? |
Don’t remove excess vagina, may cause dyspareunia
?????? |
|
|
Urinary retention post op
|
Intermittent cath self teach – if increased PVR
Or leave foley |
|
|
Epidural and retention of urine due to
|
Overdistended bladder.
|
|
|
diagnose epidural overdistension bladder?
|
Do office cystometrics – no sensation
Takes weeks to get better. |
|
|
Spinal cord injury –neurogenic retention
Keep filling foley, will have no sensation. Management? |
Manage long term, can put SP cath
Leg bag |
|
|
Delivery of women with spinal cord injury:
Findings? Management? |
unattended deliveries
Autonomic dysreflexia Sympathetic dystrophy Hyperactivity severe HTN Can avoid if have epidural at T 10 |
|
|
60 year old nursing home incontinence
|
Think DIAPPERS
|
|
|
ISD h/o
|
anterior repair - denervate the urethra
XRT |
|
|
VLPP low < 60
|
ISD
|
|
|
VLPP
|
the abdomen pressure minus urethral pressure in absence of bladder neck mobility
|
|
|
If has COPD to prepare for surgery do
|
PFT (pulmonary function tests) FEV1/FVC
low FEV1 predicted postoperative complications FEV1 reduced compared to FVC Want to know tidal volume CXR -predictor of perioperative complications Improve lung fct Make sure no respiratory alkalosis Albuterol COPD doesn't do well coming out of anesthesia stop smoking may need post op heparin - if limited reserve Incentive spirometry |
|
|
Obs lung dis
|
Asthma
Emphysema bronchitis COPD |
|
|
SUI post partum
|
R/o fistula
infection voiding diary kegels Progesterone effect during pregnancy Increased abdominal pressure during pregnancy |
|
|
Bleeding when cut incision
|
Meds
Coumadin NSAIDS Herbal meds = ginseng, gingko biloba, ginger VWD – cryo, DDAVP ITP DIC |
|
|
What is Type 1 VWD?
|
most common form
Quantitative deficiency VWF works normally, but there is not enough of it. no symptoms of VWD at all until a bad injury or surgery |
|
|
What is Type 2 Von Willebrand Disease?
|
VWF does not work properly
Qualitative problem less efficient in binding to platelets |
|
|
What is Type 3 Von Willebrand Disease?
|
Most severe
most rare very little VWF in their blood. Because VWF transports Factor VIII, they also have very low levels of Factor VIII. |
|
|
Usually should transfuse how many units platelets
|
8
|
|
|
if have DIC, transfuse and ROM if IUFD.
|
Hmmm.
|
|
|
How does Premarin work?
|
causes proliferation of endometrium to cover open vessels
|
|
|
Sickle cell disease low Hg
Preop |
Give transfusion first then stabilize before surgery
Will have more sickling when hypoxic Hydrate preoperative r/o infection Hg A (Adult) should be adequate. SSD makes more HgS than HgA. b chain has a valine instead of a glutamic acid in the number 6 position of the b globin chain |
|
|
SSD electrophoresis findings:
|
Hg S on Hg electrophoresis
Should have HgA (Adult) instead. |
|
|
SSD what chromosome
|
11
position 6 |
|
|
Sickle cell crisis
|
Sickle cell crisis –
Stroke Acute chest syndrome Bone pain Spleen/liver infarction Auto splenectomy Pyelo |
|
|
Treat sickle cell crisis
|
IVF, MSO4, transfuse if necessary
|
|
|
SSD ob complications
|
infertility
abruption IUGR pyelo Preeclampsia SAB |
|
|
Beta thal
like iron def |
Hmmm.
|
|
|
A thal management
Minor like iron def Barts hydrops fetalis |
Hmmm.
|
|
|
ITP
don't use these interventions on baby |
no scalp pH, no vacuum
|
|
|
Drug induced thrombocytopenia –
|
lithium
|
|
|
Travelers' Diarrhea
|
E coli
shigella salmonella campylobacter vibrio |
|
|
treat travelers diarrhea with
|
Cipro
|
|
|
Viral diarrhea - differentiate how?
|
no blood or leukocytes
|
|
|
what causes c diff
|
clinda
|
|
|
treat cdiff?
|
ORAL flagyl, IV vanco
|
|
|
CP pain relieved with food
|
gastric ulcer
|
|
|
diagnose H pylori
|
endoscopy - biopsy
pH breath test serology |
|
|
Ileus
Why ileus post op |
Manipulation of bowel
blood dried bowel infection |
|
|
Secretion GI tract daily loss ____ml with NGT daily
|
3000 ml
|
|
|
avg fluid required daily
|
2 litres
|
|
|
Treatment of hyponatremia
|
Do not raise serum Na more than 12 mEq/L in 24 hours in asymptomatic patients.
May replace Na with 3% NaCl solution fluid restrict |
|
|
Do not overcorrect hyponatremia. May precipitate
|
central pontine myelinolysis.
|
|
|
Hypermagnesemia treatment
|
1g calcium gluconate 10cc in 10% solution 10 minutes
lasix hemodialysis |
|
|
Diabetic Ketoacidosis treatment
|
supportive
fluid replacement insulin 0.1 u/kg, add D10 when glu 250 potassium bicarb Mg Phos |
|
|
It is preferable to give D10W with the infusion rather than stop the insulin because
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insulin is still required to clear the acidosis and ketotic state
|
|
|
Hypokalemia etiology
|
GI loss - n/v, diarrhea
drugs - diuretics renal loss hyperaldosteronism poor intake |
|
|
Hypokalemia when correcting, ALWAYS REMEMBER TO MAKE SURE ENOUGH OF WHAT???
|
Magnesium
Maggie and Kay - the replacements! |
|
|
If serum K+ concentrations >2.4 mEq/L and no ECG changes, K+ can be given at a rate up to ____mEq/hr with maximum daily administration of ___ mEq.
|
20mEq/hr
200 |
|
|
Do not correct K too rapidly or will get
|
arrythmia
|
|
|
Hyperkalemia treatment
|
calcium gluconate
bicarb insulin |
|
|
to decide if obstruction complete or partial/subacute
|
better in 3 days then subacute
use barium study to distinguish, unless think perforation. |
|
|
treatment bowel obstruction
|
NGT
IVF replacement electrolytes |
|
|
why post op obstruction
|
bowel got kinked in adhesion
suture in bowel. |
|
|
when surgery for obstruction?
|
NGT 2-3 days, no improvement
if NGT output not diminished and repeat KUB shows no improvement no air in rectum on repeat KUB |
|
|
nutritional status labs
|
prealbumin
transferrin t 1/2 20 days |
|
|
TPN amt
|
glucose
lipids aa 35 cc/kg/day fluid replacement 35 kcal/kg day calorie replacement through subclavian electrolyte and B complex |
|
|
s/p LS comes to ER with distention what to do
|
to OR. likely perf
leukocytosis with distention |
|
|
how to tell if first trocar hit bowel
|
feces on trocar when remove
|
|
|
what to do if bowel adhesions likely and concern about trocar placement?
|
1-2 fingerbreadths under subcostal magin in mid clavicular line
|
|
|
small bowel repair in OR, can feed when?
|
right away
|
|
|
large bowel injury with feces, what to do?
|
irrigate then primary closure, abx
|
|
|
what abx for large bowel injury?
|
ofloxacin and flagyl
or unasyn or 3rd gen Ceph |
|
|
Direct coupling –
|
touching dirctely with electrode, crack instrument, or touch another instrument.
What you actually see. |
|
|
Capacity coupling –
|
arc forms somewhere else. Don’t see it.
Arc forms when there’s a defect b/w plastic and metal. Out of field of vision. |
|
|
Unipolar burn - ___ cm beyond what you see.
|
4 cm
|
|
|
treat travelers diarrhea with
|
Cipro
|
|
|
Colon Ca symptoms
|
anemia - dizziness
change bowel habits, stool form bleeding obsruction - late finding |
|
|
test for Colon Ca when if have FH?
|
10 years before
|
|
|
CPP likely
|
depression
somatization |
|
|
Fibromyalgia must find how many tender points?
|
11 of 18
|
|
|
treat fibromyalgia with
|
antidepressants
|
|
|
Back pain how to evaluate
|
flexion/extension
point tenderness lose weight give flexeril- muscle relaxant lifestyle modification |
|
|
symptoms Interstitial cystitis
|
frequency day, night
bladder pain |
|
|
dx IC
|
bladder overdistention
potassium sensitivity test |
|
|
what causes IC?
|
defect in glycoaminoglycan layer
pt sensitive to potassium as it touches the Hunner ulcers |
|
|
COPD test preop
|
PFT
FEV1/FVC don't do well coming out of anesthesia looking for resp acidosis on ABG |
|
|
Written Treatment Plan for out-patient management asthma
|
Green Zone
Yellow Zone Red Zone |
|
|
Green zone =
|
good control (PEF > 80% personal best) no change in regimen
|
|
|
Yellow zone =
|
caution (PEF 50-80% personal best), call MD, needs step-up in therapy
|
|
|
Red zone=
|
medical alert (PEF < 50% personal best), to MD or ER immediately, needs acute treatment
|
|
|
Management of acute asthma exacerbations
|
Oxygen
Albuterol nebulizer q 2 hr prn Add atrovent nebulizer if not responding Systemic steroids - po or IV depending on severity Prednisone start at 60 mg qd OR (Do not use Methylprednisolone (Solumedrol 2mg/kg X 1 dose, then 1mg/kg q 6h) Treat until PEF > 80% personal best CXR needed only in pneumonia suspected Antibiotics only if co-morbid infection ABG needed only if attack severe Initially respiratory alkalosis (PaO2 reduced, PaCO2 reduced) If the attack worsens, PCO2 starts to rise leading to respiratory acidosis |
|
|
why do CXR for r/o pulm embolism?
|
r/o pneumonia
|
|
|
dose for switchover to LMWH in PE after initial adjusted dose with 80u/18u
|
LMWH 1mg/kg BID
|
|
|
Restrictive lung disease
|
sarcoidosis
PE pneumonia |
|
|
hospital acquired pneumonia treatment
|
pip and gent
(covers pseudomonas) |
|
|
treat aspiration pneu
|
clindamycin
|
|
|
pulm edema due to
|
low osmotic pressure
|
|
|
Ventricular fibrillation
and Pulseless Vtac |
cardioversion - 200J 200J 360J
EPI EVERYBODY Shock Lidocaine LITTLE Shock Bretylium BIG Shock Magnesium Sulfate MAMA Shock procainamide PAPA Shock |
|
|
need to empty uterus if need cardiac massage in Vfib if how many weeks and above?
|
32 weeks
|
|
|
what type c/s for trauma?
|
classical
|
|
|
if need to take to OR emergently and patient had full breakfast, then do what?
|
awake intubation
press cricothyroid |
|
|
dx AFE
|
debris in lung
|
|
|
LS patient gets arrythmia, what's going on?
|
CO2 embolus
|
|
|
how to manage CO2 embolus
|
airplane LLD left,
aspirate CO2 out of left ventricle Deflate abdomen hyperventilate patient |
|
|
end tidal co2 should be normally what?
what happens to it in C02 embolism? |
20-30
goes down in CO2 embolism – |
|
|
how does one get HS air embolism
|
tube not purged of air
patient in steep trendelenberg |
|
|
most often used distention agent?
|
sorbitol
|
|
|
which K level will cause cardiac arrest?
|
6.5
|
|
|
treat hyperkalemia with
|
calcium gluconate
insulin bicarbonate |
|
|
Sinusitis –symptoms
|
facial pain
persistent cough tooth pain |
|
|
symptoms sleep apnea
|
EDS - excessive daytime sleepiness
sudden cardiac death |
|
|
describe patient with sleep apnea
|
obese
neck circumference 43 cm |
|
|
management sleep apnea
|
sleep lab
CPAP |
|
|
if depression meds don't work, then what?
|
ECT
|
|
|
DV may lead to
|
homicide
|
|
|
reasons patients don't admit to DV
|
Hope
Shame Fear |
|
|
DM patient on insulin for surgery, how to take meds
|
1/3 NPH in am
|
|
|
DM gyn patient post op management blood glucose
|
SS when 200
above 250 give insulin |
|
|
DM patient on oral hypoglycemic for surgery, how to take meds
|
no meds in AM before surgery
|
|
|
Pt with HTN in preop holding, what to do
|
assess cardiac and pulm function
can do case, but may need to give diuretic or BBlocker |
|
|
HTN crisis, give what?
|
labetolol
hydralazine |
|
|
Pt comes to office with HTN, what to do?
|
head to toe eval of end organ damage
eyes carotid heart lung abd bruits extremities EKG electrolytes lipids glu |
|
|
diets for obese
|
Mediterranean
Calorie restriction |
|
|
Link between body and menstrual function
|
Leptin
Low levels indicate that fat stores not sufficient for growth and reproduction • Low levels correlate with reduced body fat – Leptin levels < 3 ng/ml associated with irregular menses and amenorrhea |
|
|
BP in office 140/90
management |
Lifestyle modification
|
|
|
BP in office 150/95
management |
work up!
DECEL EKG, CXR, electrolytes. lipids, DM |
|
|
BP in office 160/110
management |
needs meds
EKG, CXR, electrolytes. lipids, DM diuretic BBlocker |
|
|
atypical pneumonia
|
mycoplasma
legionnaires chylamydia interstitial |
|
|
spinal cord overflow incontinence management
|
leg bag
bladder drills scheduled voiding bethanecol - cholinergic |
|
|
hematoma s/p hyst (no broad ligament to use as landmark to find ureter)
|
stent or trace
start trace at pelvic brim |
|
|
To prevent complications during uterine access in HS, what are effective for cervical priming.
|
misoprostol
laminaria equally |
|
|
The use of what agent to distend the uterus prevents hyponatraemia, but
hypervolemia may still be a major problem. |
normal saline
|
|
|
Irrigant fluid deficit is best monitored by
|
automated devices.
|
|
|
This type of electrosurgical systems do not require dispersive return electrodes
do not generate stray currents, thus minimizing the risk of electrical burns. |
Bipolar
|
|
|
Hidradenitis Suppurativa treatment =
|
tetracycline = tetra-tiva!
clindamcin accutane |
|
|
CDIFF first line treatment
|
PO Flagyl (can also be given IV)
|
|
|
Vanco for cdiff must be given by what route only?
|
ORAL VANCO ONLY!!!
|
|
|
What is Hidradenitis suppurativa?
|
obese patients
suppurative lesions apocrine sweat glands axilla and groin areas |
|
|
what is Osteoprotegerin (OPG) –
|
cytokine -new drug on the horizon to treat osteoporosis
low levels of OPG also tend to have faster bone turnover, Increasing OPG may help to normalize bone turnover. Blocks resorption. binds to RANKL |
|
|
What is test for preop eval of levator mechanism and cystocele rectocele in constipation
|
defecography
|
|
|
What is arimidex?
|
aromatase inhibitor
treatment postmenopausal breast cancer causes osteoporosis worse than tamoxifen does |
|
|
Pathoophysiology of Sheehans Syndrome:
|
thrombosis of vessels with hypotension from acute hemorrhage
|
|
|
Sheehans Postpartum pituitary necrosis/pituitary insufficiency symptoms:
|
Inability to breast-feed
Fatigue - hypothyroid Loss of pubic and axillary hair - no estradiol, no testosterone Amenorrhea, or lack of menstrual bleeding Low blood pressure |
|
|
Sheehans Syndrome - labs
|
low TSH, ACTH, FSH/LH with low levels of T4, cortisol, and estradiol
MRI of head |
|
|
Sheehans Syndrome - treatment
|
lifelong hormone replacements of
thyroid, testosterone, cortisol, ddAVP, GH, OCPs |
|
|
Why does sheehan's occur in postpartum?
|
Because of the pituitary enlargement during pregnancy, it is vulnerable to ischemia from PPH.
|
|
|
no pulse, what to do
|
chest compression/CPR
200J 200J 360J |
|
|
V. fib
pulseless V. tac |
EVA 360J
EPI can repeat shock 360J Vasopressin (V.) once shock 360J amniodarone-cardioversion eds |
|
|
Asystole
CEA |
Confirm 2nd lead
EPI Atropine (A) |
|
|
PEA
|
PEA
Plenty of things to treat EPI Atropine treat underlying cause hypovolemia hypothermia hypo/hyperkalemia tamponade PE = PEA EPI Atropine |
|