Emergency Medicine Final- 2

Front 1

What is the avergae age of menarche?

Back 1

13 years old

Front 2

What is the average age of menopause?

Back 2

51 years old

Front 3

How long is a normal menstrual cycle?

Back 3

28 days ( ranges from 21-35 days)

Front 4

How long is the normal duration of a period?

Back 4

2-7 days

Front 5

What is the normal blood loss for a period?

Back 5

<80 cc

Front 6

Define dysfunctional uterine bleeding

Back 6

any abnormal uterine bleeding pattern without obvious cause

Front 7

Define menorrhagia

Back 7

prolonged (>7 days) or excessive (>80cc) uterine bleeding at regular intervals

Front 8

Define metorrhagia

Back 8

uterine bleeding at irregular frequent intervals in variable amounts

Front 9

Define menometorrhagia

Back 9

prolonged uterine bleeding at irregular intervals

Front 10

At what phase and around what day of your cycle does a woman's body temperature rise about 1 degree C?

Back 10

ovulation

Front 11

Which hormones peak with ovulation?

Back 11

LH
and
FSH

Front 12

Which hormone level is highest with ovulation?

Back 12

LH

Front 13

which hormone peaks just before ovulation?

Back 13

estradiol

Front 14

Which hormone has the highest level during the luteal phase?

Back 14

progesterone

Front 15

which hormone has the highest levels (of all the hormones, not highest level for that hormone ever) during the follicular phase?

Back 15

estradiol

Front 16

around what day of the menstrual cycle is ovulation?

Back 16

about day 13-15

Front 17

Describe all the hormones and how everything works in the normal menstrual cycle

Back 17

Front 18

What causes anovulatory bleeding?

Back 18

hypothalamic-pituitary axis disruption or immaturity

Front 19

What are the undelying causes of anovulatory bleeding?

Back 19

1. perimenacrhal females
2. psychological or physical stress
3. rapid changes in weight/ eating disorders
4. excessive exercise
5. hypothyroidism
6. hyperprolactinemia
7. PCOS

Front 20

What is this showing?

Back 20

PCOS

Front 21

explain what happens to a person with PCOS's hormones

Back 21

Front 22

Which hormones are up-regulated in PCOS?

Back 22

LH
insulin like growth factor
extraovarian androgen

Front 23

What do excesses in LH, insulin like growth factor, and extraovarian androgen along with the effects of ovarian stereogeneis block lead to?

Back 23

dysregulation of androgen secretion which leads to an increase in intraovarian androgen

Front 24

What effects does the dysregulation of androgen secretion and increase in intraovarian androgen lead to?

Back 24

hyperandrogenemia
follicular atresia

Front 25

are most fibroids symptomatic or asymptomatic?

Back 25

asymptomatic

Front 26

Which type of uterine fibroids tend to cause the most bleeding abnormalities?

Back 26

submucosal fibroids

Front 27

What are three causes of disorders of hemostasis in the female uterus?

Back 27

perimenarchal females
inherited systemic disorders of hemostasis
anticoagulant medications

Front 28

List 2 inherited systemic disorder of hemostasis that cause lead to abnormal uterine bleeding

Back 28

von wildebrand disease (13% of women with menorrhagia have this)

hemophilia

Front 29

13% of women with von wildebrand disease have ___________

Back 29

menorrhagia

Front 30

List 4 anticoagulant medications that can lead to abnormal uterine bleeding

Back 30

heparin
lovenox
coumadin
aspirin

Front 31

What is this?

Back 31

a uterus with a submucosal fibroid

Front 32

What are 3 medical treatments for abnormal uterine bleeding? (general)

Back 32

estrogens
estrogens and progestins
progestins

Front 33

With abnormal uterine bleeding, how can you treat an acute event with estrogen?

Back 33

25 mg conjugated equine estrogen IV q4 hours until bleeding is controlled

then start a monophasic OC or progestin

Front 34

With abnormal uterine bleeding, how can you treat it using estrogens and progestin?

Back 34

multidose monophasic OC regimen

1 PO tid x7 days, then daily for 3-6 weeks

Front 35

With abnormal uterine bleeding, how can you treat it using progestin? (one way)

Back 35

medrocyprogesterone 60-120 mg q day until bleeding has stopped for 7 days

then: 20-40 mg q day for 3-6 weeks

Front 36

With abnormal uterine bleeding, how can you treat it using progestin? (the other way)

Back 36

Norethindrone acetate 5-15 mg q day until bleeding has stopped for 7 days

then: 5-10 mg d day for 3-6 weeks

Front 37

What is the #1 rule with acute pelvic pain??

Back 37

Pregnancy test!!!

Front 38

What are the key points in acute pelvic pain?

Back 38

pregnancy test
trust your clinical evaluations and impressions
avoid pain meds prior to evaluation
be systematic

Front 39

What are the important causes of pelvic pain?

Back 39

ectopic pregnancy
ovarian torsion
PID & tuboovarian abscess
endometriosis
ovarian cysts
degenerating fibroids

Front 40

What is this?

Back 40

endometriosis

Front 41

note the anatomy

Back 41

delicious

Front 42

What is this?

Back 42

endometriosis

Front 43

What is this?

Back 43

ovarian cyst

Front 44

What is this?

Back 44

ovarian cyst

Front 45

What is the differential diagnosis for acute pelvic pain?

Back 45

important causes already listed + adhesions
+ (this is what is actually on his slide)
ovarian lesions
-benighn psysiologic ovarian cysts
-benign pathologic cysts
-solid ovarian lesions (rarely a source of pain)
-ovarian torsion
hydrosalpinx

Front 46

List 3 examples of benign physiologic ovarian cysts

Back 46

follicular cysts
luteal cysts
hemorrhagic cysts

Front 47

What can the rupture of a hemorrhagic cyst result in?

Back 47

bleeding and free fluid

Front 48

What are 4 examples of benign pathologic cysts?

Back 48

serous and mucinous cystadenoma
endometrioma
tubo-ovarian abscess
dermoid cyst

Front 49

What type of ovarin lesion rarely is a source of pain?

Back 49

solid ones

Front 50

What is the key phrase with ovarian torsion that should clue you in on it's presence?

Back 50

pain out of proportion to exam

Front 51

What often accompanies ovarian torsion?

Back 51

large ovarian lesions

Front 52

What does US show with ovarian torsion (may show)?

Back 52

lack of blood flow to ovary on US color flow study

Front 53

Because ovarian torsion is a TRUE EMERGENCY, ______________________________

Back 53

do NOT delay surgical intervention if it is suspected!

Front 54

What are some additional differential diagnoses for acute pelvic pain?

Back 54

1. appendicitis
2. UTI
3. cholecystitis
4. diverticulitis
5. inflammatory bowel disease
6. irritable bowel syndrome
7. musculoskeletal causes

Front 55

How do you treat oravian cysts and masses?

Back 55

pain control
immediate surgical management if necessary

Front 56

When do you need to treat ovarian cysts with immediate surgical management?

Back 56

1. hemorrhage
2. bowel obstruction
3. ureteral obstruction
4. uncontrolled pain
5. suspect torsion

Front 57

How do you treat ovarian torsion?

Back 57

with immediate surgery! the ovary can often be preserved.

Front 58

What is PID?

Back 58

a generalized term that refers to infection and inflammation of the upper GI tract and pelvis

Front 59

What can be included in PID?

Back 59

endometritis
salpingitis
tubo-ovarian abscess
peritonitis

Front 60

Describe acute salpingitis

Back 60

Front 61

With PID ___% have lower abdominal pain

Back 61

90

Front 62

With pid, 90% have ____________

Back 62

lower abdominal pain

Front 63

With PID ___% have mucopurulent cervical discharge

Back 63

75%

Front 64

With PID, 75% have _____
(symptom)

Back 64

mucopurulent discharge

Front 65

With PID, __% have a SED rate >15

Back 65

75%

Front 66

with PID, 75% have _______

(lab value)

Back 66

a SED rate >15

Front 67

with PID, __% have WBC >10,000

Back 67

50%

Front 68

with PID, 50% have _____________

Back 68

WBC >10,000

Front 69

Many individuals with PID are ______________

Back 69

asymptomatic

Front 70

What is the Gold Standard for diagnosing PID?

Back 70

lapraoscopy

Front 71

List 6 diagnostic tests you can consider in PID.

Back 71

1. UhCG
2. CBC with diff
3. vaginal culture
4. gonorrhea and chlamydia DNA probe
5. pelvic US
6. culdocentesis

Front 72

What is the outpatient treatment for PID?

Back 72

ceftriaxone 250 mg IM single dose plus doxycycline 100 mg PO BID x 14 days with or without metronidazole 500 mg PO BID x14 days
or
ofloxin 400 mg PO BID x 14 days plus metronidazole 500 mg PO BID x 14 days

Front 73

What are the drugs used in the 3 possible regimens to treat inpatient PID?

Back 73

1. cefoxitin or cefotetan IV +
doxy IV
2. clindamycin IV +gentamycin loading dose + regular dose
3. ampicillin/sulbactam IV + doxy IV

Front 74

This is a possible inpatient treatment for PID:

Cefoxitin ___ q____ IV OR cefotetan _____ q ___ IV +doxy ____ q____ IV

Back 74

2g, 6 hours
2 g, 12 hours
100mg, 12 hours

Front 75

This is a possible inpatient treatment for PID:

clindamycin ___ q ____ IV + gentamicin _____ loading does followed by ______ q _____

Back 75

900 mg, 8 hours
2 mg/kg, 1.5 mg/kg, 8 hours

Front 76

This is a possible inpatient treatment for PID:

ampicillin/sulbactam ______ q ____ IV + doxycycline ______ IV q ___

Back 76

3g, 6 hours
100 mg, 12 hours

Front 77

What are 6 complications of PID?

Back 77

1. pelvic adhesions
2. chronic PID
3. infertility
4. hydrosalpinx
5. ectopic pregnancy
6. chronic pelvic pain

Front 78

Ectopic pregnancies account for ____% of all first time pregnancies and ____% of all pregnancy related deaths

Back 78

2%
6%

Front 79

What is the leading cause of maternal death in the first trimester?

Back 79

ectopic pregnancy

Front 80

Define an ectopic pregnancy?

Back 80

implantation of the fertilized egg outside of the uterus

Front 81

What are possible locations for an ectopic pregnancy?

Back 81

abdomen
cervix
ovary
uterine cornua
fallopian tube

Front 82

What is the most common location for an ectopic pregnancy?

Back 82

the fallopian tube (97%)

Front 83

What is the #1 cause of ectopic pregnancy?

Back 83

abnormal fallopian tube!
ie:
tubal sx
PID
pervious ectopic pregnancy
in utero exposure to DES

Front 84

_____ of all pregnancies after tubal ligation are _________

Back 84

1/3
ectopic

Front 85

What are the risk factors for an ectopic pregnancy?

Back 85

infertility
use of ART
previous pelvic/abdominal surgery
smoking

Front 86

all reproductive age women who present with bleeding or pain should have a ______________-

Back 86

urine pregnancy test

Front 87

At what HCG hormone level should you see a gestational sac in the uterus?

Back 87

Quantitative HCG >1500-2000 mlU/ml

Front 88

What is diagnostic of ectopic pregnancy?

Back 88

pain/bleeding + HCG over 2000 + no sac in uterus on ultrasound

or

pain/bleeding + blood in abdomen + no sac in uterus

Front 89

What percent of pregnancies are complicated by per-gestation diabetes?

Back 89

5-10%

Front 90

DKA in pregnancy is different because _____________

Back 90

it presents at lower levels of hyperglycemia

Front 91

What are the symptoms od DKA in pregnancy?

Back 91

abdominal pain
nausea/emesis
altered sensorium

Front 92

In what trimester of pregnancy is DVT more common?

Back 92

none- it has an equal frequency of occurance in all 3 trimesters

Front 93

When is a pulmonary embolism more common during pregnancy?

Back 93

in the post-partum period

Front 94

What tests can you order for DVT and PE in pregnancy?

Back 94

room air ABG
spiral CT scan

Front 95

How do you treat thromboembolism in pregnancy?

Back 95

heparin

Front 96

How many pregnancies does hypertensive disease complicate?

Back 96

12-22%

Front 97

preeclampsia/eclampsia/ (hypertensive disease?) is responsible for ___ of maternal deaths in the USA

Back 97

17.6%

Front 98

What is the diagnostic criteria for preeclampsia?

Back 98

SBP >140, DBP >90 after 20 weeks gestation in previously normotensive woman
+
proteinuria defined as 300 mg or more in 24 hours

Front 99

What is the treatment of preeclampsia

Back 99

delivery!

Front 100

define eclampsia

Back 100

new onset of grand mal seizures in a woman with preeclampsia

Front 101

What is the differential diagnosis for eclampsia?

Back 101

bleeding AV malformation
ruptured aneurysm
idiopathic seizure disorder

Front 102

How is eclampsia treated?

Back 102

medical stabilization with magnesium sulfate, valium, and anti-hypertensives
+
delivery of fetus

Front 103

How do you manage the injured pregnant woman?

Back 103

-evaluation and stabilization of maternal vital signs
-ABC
-displacement of uterus after 20 weeks
-secondary survery with fetal evaluation

Front 104

In pregnancy, there is a ______ increase in ________ at the expense of __________

(respiration)

Back 104

30-40%
tidal volume
expiratory reserve volume

Front 105

What happens to the diaphragm in pregnancy?

Back 105

it is elevated

Front 106

What happens to minute ventilation in pregnancy?

Back 106

it increases

Front 107

What is going on here?

Back 107

small bowel obstruction

Front 108

What is going on here?

Back 108

the pic on the left is normal
the pic on the right is an obstructed bowel showing trapped air

Front 109

What is a hypersensitivity reaction?

Back 109

a response to an exogenous antigen

Front 110

What are some possible clinical manifestations of a hypersensitivity reaction?

Back 110

itching, hives
angioedema
vasodilation and cardiovascular collapse

Front 111

How are hypersensitivity reactions classified?

Back 111

based on immunologic mechanism

Front 112

What are the steps of a type I hypersensitivity reaction? explain what happens.

Back 112

-initial sensitization (formation of IgE)
-secondary exposure (release of vasoactive amines (histamine)- basophils & mast cells) which leads to recruitment

Front 113

What type of hypersensitivy reaction is true anaphylaxis?

Back 113

type I

Front 114

explain the steps of a type 1 hypersensitivity reaction

Back 114

Front 115

List the primary mediators of a type I hypersensitivity reaction

Back 115

biogenic amines
chemotactic mediators
enzymes
proteoglycans

Front 116

What biogenic amines are primary mediators in a type 1 hypersensitivity reaction?

Back 116

histamine

Front 117

What do chemotactic mediators do as primary mediators of a type 1 hypersensitivity reaction?

Back 117

attract eosinophils and neutrophils

Front 118

List the secondary mediators in a type I hypersensitivity reacion

Back 118

leukotrienes
prostaglandin D2
platelet activity factor
cytokines

Front 119

What do leukotrienes do as secondary mediators in a type I hypersensitivity reaction?

Back 119

increase vascular permeability and smooth muscle contraction

Front 120

What dose prostaglandin D2 do as a secondary mediator in a type I hypersensitivity reaction?

Back 120

causes bronchospasm

Front 121

What do cytokines do as secondary mediators in a type I hypersensitivity reaction?

Back 121

-recruit inflammatory cells
-activate B cells

Front 122

Back 122

apparently that picture is important

Front 123

What are the 3 mechanisms for a type II hypersentitivity reaction?

Back 123

-antibody mediated
-antibody-dependent cell-mediated toxicity
-antibody mediated cellular dysfunction

Front 124

With type II hypersensitivity reactions, the antibody mediated mechanism is ___________

Back 124

complement dependent

Front 125

a transfusion reaction is an examples of a __________-

Back 125

type II hypersensitivity reaction

antibody mediated

Front 126

parasites cause _____________ reactions that are ____________________

Back 126

type II hypersensitivity
Ab-dependent cell mediated cytotoxicity

Front 127

Myasthinia grave is an example of this type of hypersensitivy reaction

Back 127

type II hypersensitivity
Ab- mediated cellular dysfunction

Front 128

What type of reaction is this demonstrating?

Back 128

type II hypersensitivity

Front 129

What is a type III hypersensitivity reaction?

Back 129

immune complex-mediated

Front 130

describe how a type III hypersensitivity reaction takes place

Back 130

Ab-Ag complexes are formed
deposited in tissues
there is an inflammatory reaction

Front 131

What are some possible examples of a type III hypersensitivity reactions that may be post-infectious?

Back 131

glomerulonephritis
endocarditis

Front 132

What are two examples of type III hypersensitivity reactions?

Back 132

SLE
RA

Front 133

What type of hypersensitivity reaction is this picture illustrating?

Back 133

type II hypersensitivity

Front 134

What type of hypersensitivity reaction is this picture demonstrating?

Back 134

type IV

Front 135

type IV hypersensitivity reactions are _______________

Back 135

cell-mediated

Front 136

IN general, what happens in a type 4 hypersensitivity reaction?

Back 136

- sensitized T- lymphs
-delayed CD4 (8-12 hour, peak 24-72 hours. granuloma formation)
-direct C48
-response to intracellular microbes

Front 137

granuloma formation is associated with ______ in the type IV hypersensitivity reaction

Back 137

CD4

Front 138

When does CD4 come into play in a typ IV hypersensitivity reaction?

Back 138

8-12 hours, peaks at 24-72 hours

Front 139

A type IV hypersensitivity reaction can occur in response to intracellular microbes, especially ______________

Back 139

mycobacterium tebuerculosis

Front 140

What is non-immunologic anaphylaxis?

Back 140

a suddne, massive mast cell or basophil degranulation without antibodies present

Front 141

List 4 examples of non-immunologic anaphylaxis

Back 141

Red man syndrome (vanco)
opiates
cold urticaria
ACE inhibitors