Empa Mem 6224

Front 1

What does dysphagia, odynophagia, and ingested FB immediately implicate?

Back 1

The esophagus

p. 548

Front 2

How long is the esophagus?

Back 2

20-25 cm

p. 548

Front 3

T/F: The esophagus is lined with stratified squamous epithelium and evidence of secretory function.

Back 3

False, while the esophagus is made of stratified squamous epithelium, there is NO secretory function of the cells.

p. 548

Front 4

What is the function of the upper esophageal sphincter of the esophagus (2)?

Back 4

1. To prevent air from entering the esophagus
2. prevent food from refluxing out of the esophagus and into the pharynx.

p. 548
- what is its resting pressure?

Hint 4

100 mmHg

Front 5

What about the lower esophageal sphincter, what is its function?

Back 5

Allows food to pass into the stomach, but prevents stomach contents from refluxing into the esophagus

p. 548
-what is its resting pressure?

Hint 5

25mmHg

Front 6

What are the three anatomic areas of "constriction" in the adult esophagus with regard to a suspected foreign body or food bolus?

Back 6

1. Crichopharyngeus Muscle (C6)
2. At the level of the Aortic Arch (T4)
3. Gastroesophageal Junction (T10,11)

p. 548
- What 2 additional sites of constriction must also be considered in pediatric patients?

Hint 6

1. Thoracic inlet (T1)
2. Tracheal bifurcation (T6)

p. 548

Front 7

What makes up the blood supply of the esophagus?

Back 7

1. Inferior thyroid artery
2. small branches of the thoracic aorta
3. Ascending branches from the left gastric and inferior phrenic arteries

p. 548

Front 8

What is dysphagia?

Back 8

REALLY?!?!
- difficulty with swallowing. Most commonly patients with this will have an identifiable, organic cause.

p. 548

Front 9

There are two broad pathophysiologic groups of dysphagia, what is transfer dysphagia?

Back 9

MC this occurs early in swallowing, as food moves from the oropharynx into the upper esophageal sphincter. THis is commonly reported as difficulty with initiating swallowing.

p. 548

Front 10

There are two broad pathophysiologic groups of dysphagia, what is Transport dysphagia?

Back 10

MC reported as impaired movement of the bolus down the esophagus and through the lower sphincter. This is perceived later in the swallowing process. "getting stuck" sensation.

Front 11

What is odonyphagia?

Back 11

painful swallowing

p. 549

Front 12

When asking a patient about symptoms of transport dysphagia, some individuals will have difficulty with swallowing solids only. Others with solids as well as liquids. Which does this imply?

Back 12

1. Solid dysphagia implies mechanical or obstructive process
2. Solid and liquid dysphagia implies motility issue

p. 549

Front 13

You are seeing a cachectic old guy in the ER with complaints of dysphagia, he has anterior, superior lymphadenopathy. What are you thinking?

Back 13

Cancer

p. 549

Front 14

While most often the diagnosis and work up of dysphagia is not made in the ER, what should be obtained as a part of the work up for transport dysphagia?

Back 14

CXR

P. 549

Front 15

What type of dysphagia (Transfer or Transport) is associated with Neoplasms?

Back 15

Both

p. 549

Front 16

95% of esophageal carcinoma are what type?

Back 16

Squamous cell carcinoma

p. 549
- what are the 4 provided risk factors for this?

Hint 16

1. EtOH
2. smoking
3. achalasia
4. ingestion of caustic material such as lye

Front 17

A 50 y/o M is in your ED with c/o new sxs of dysphagia. Uncontrolled HTN, Reflux. + hx of EtOhism- but stopped in last year, but is still trying to quit smoking. States that he ran out of his medications and has not seen PCM. NKDA. No surgeries. States that he has been really annoyed with the symptoms. No CP/SOB/Difficulty breathing. no fevers, chills. What is at the top of your differential.

Back 17

Cancer until proven otherwise.

p. 549- needs endoscopy

Front 18

What 2 things identified in the reading can lead to esophageal stricture?

Back 18

1. GERD
2. Chronic Inflammation

p. 549

Front 19

What is the MC cause of intermittent dysphagia with solids?

Back 19

schatzki's ring

p. 549

Front 20

What is the progressive outpouching of pharyngeal mucosa, just above the upper sphincter, caused by increased pressures during the hypopharyngeal phase of swallowing?

Back 20

Zenker's Diverticulum

p. 549- this is an acquired dz that MC will not occur until after age 50 y/o.
MC c/o: neck mass, transfer dysphagia or halitosis.

Front 21

What is the event in the esophagus whereby normal peristaltic activity is disrupted by intermittent interruption of nonperistaltic contraction?

Back 21

Diffuse Esophageal Spasm

p. 550

Front 22

T/F: Differentiating esophageal pain from ischemic cardiac dz can be difficult. If chest pain is determined to be non-cardiac in nature, treatment aimed at esophageal disease is often initiated emperically.

Back 22

True

p. 550

Front 23

What affects do the folowing have on GERD, how?
High Fat foods
Nicotine
Ethanol
Caffeine
meds: nitrates, CCB, anti-cholinergics, progesterone, and estrogen
Pregnancy

Back 23

Decreased Pressure of the lower esophageal sphincter

p. 550, Table 80-2

Front 24

What affects do the folowing have on GERD, how?
Achalasia
Scleroderma
Presbyesophagus
Diabetes mellitus

Back 24

Decreased Esophageal Motility

p. 550, Table 80-2

Front 25

What affects do the folowing have on GERD, how?
Medicines (Anticholinergic)
Outlet obstruction
Diabeteic Gastroparesis
High Fat Foods

Back 25

Prolonged Gastric Emptying

p. 550, Table 80-2

Front 26

T/F: Symptoms of GERD can be very similar to cardiac and vise versa...some cardiac patients report relief in sxs following administration of antacids, while some GERD patients report pain in the chest that is "squeezing" and "pressure like" pain" that has its onset following activity.

Back 26

True

p. 550

Front 27

What disease process has been implicated in: dental erosion, vocal cord ulcers, granulomas, laryngitis, chronic sinusitis and chronic cough? It is also common in many patients with asthma and bronchospasm.

Back 27

GERD

p. 550

Hint 27

Of note: identifying patients with asthma who could benefit from antireflux therapy is difficult.

Front 28

What are 3 medications/types provided in the Tintinalli's that are regarded as "common" offending agents for inflammatory esophagitis.

Back 28

1. NSAIDS/anti-inflammatory medications
2. Potassium Chloride
3. Abx (Doxycycline, tetracycline, and clindamycin)

p. 550

Hint 28

Risk factors for pill induced esophageal injury: swallowing position, fluid intake, capsule size, and age.

Front 29

A patient is seen by you with a hx of GERD sxs. States that it has been increasing in severity over the past few weeks and is no unbearable. + hx of HTN, HLD, DM and CA. Medications: non-compliant. NKDA. PE: unremarkable. What is the most likely reason for reflux base don hx? Causes?

Back 29

1. Infectious Esophagitis.
2. Candida species is the MC cause of esophagitis in patients with hx of immunodediciency. Additionally, HSV, CMV, aphthous ulcers; generally fungal, mycobacteria, viral, varicella zoster, EBV.

p. 551

Front 30

50 y/o obese man is evaluated by you for sxs of chest pain, started at rest and has been colicky. Last he recalls prior to sxs was drinking ice cold drink. After the intense pain set in, he has had dull, achy, residual discomfort. + relief with nitro. Following a consult with cards, they think this is not cardiac but esophageal. What? THey can't be serious?! What are they talking about?

Back 30

Esophageal dysmotility disorder

p. 551

- What is the name given to the dismotility disorder in which there is a high-amplitude, long-duration peristaltic contractions in the distal body of the esophagus or lower esophageal sphincter?

Hint 30

Nutcracker esophagus

Front 31

What is the MC cause of esophageal perforation?

Back 31

iatrogenic

p. 551

Front 32

Where is the MC location of spontaneous esophageal perforations?

Back 32

left posterolateral wall of the distal esophagus

p. 551
- where is the MC site of instrumentation induced perforations?

Hint 32

Proximal aspect, tends to be less severe than distal esophagus

Front 33

20 y/o AD M patient reports to you with CP, persisting/constant, radiating to back and left shoulder. States that the pain was uncomfortable this AM following three episodes of uncomplicated vomiting. Noticed that the pain got worse following chow, then went to do PT, when the pain got to be "so intense" he almost fell out. Minimal to no improvement since arrival. no distress and unimpressive PE. CXR reveals subcutenous emphysema. What is up with that?

Back 33

Esophageal Perforation


p. 551

Front 34

What takes time to develop...is less commonly detected by examination as well as radiogrpahy in lower esophageal perforation and its absence does not rule out perforation?

Back 34

Mediastinal Emphysema.

p. 551

Hint 34

Hamman's Crunch: caused by air in the mediastinum that is being moved by the beating heart...sometimes this can be auscultated.

Front 35

You take fluid off a patient's lungs (thoracentesis), after noting a pleural effusion on chest x-ray. The lab calls you and tells you there is an elevated amylase. What is the source of the pleural effusion?

Back 35

Esophageal perforation

p. 551

Front 36

What is a full thickness tear in the esophagus after a sudden rise in intraesophageal pressure, such as occurs after forceful emesis, coughing, straining, seizures, and child birth.

Back 36

Boerhaaves Syndrome

p. 551

Front 37

Children of ages 18-48 months account for what percentage of ingested foreign bodies?

Back 37

80%

p. 552

Front 38

T/F: In most patients, adults and children, once an ingested foreign body passes the pylorus it usually passes through the GI tract w/o issue.

Back 38

True

p. 552
- however, there are some measurements which can still pose a risk.

Hint 38

Wide > 2.5 cm, long >6 cm- may become lodged in the distal pylorus

Front 39

A 2 y/o child is brought to you by his mother. "He refuses to eat, vomits and seems at times to gag and choke for the last 2 days. Sometimes it even looks like he is drooling. when I asked him, he tells me his throat hurts". You observe a largely healthy, afebrile child. post oropharynx no obstructed, no swelling. No cervical lymphadenopathy. Heart RRR, NML S1,S2. Lungs clear, except stridor at the apices b/l. What are you thinking is the most likely source?

Back 39

Foreign body ingestion.

p. 552

Front 40

What are the 7 reasons for urgent endoscopy for esophageal foreign bodies, even if the patient is stable?

Back 40

1. Ingestion of sharp or elongated objects (toothpicks, aluminum soda can tabs)
2. Ingestion of multiple FB's
3. Ingestion of button batteries
4. Evidence of perforation
5. Coin at the level of the cricopharyngeus muscle in a child
6. Airway compromise
7. Presence of a Foreign Body for > 24 hours.

p. 552

Front 41

Some providers have suggested providing glucagon to patients with suspected foreign body, why is this believed to be helpful? Is it?

Back 41

1. Glucagon is proposed for distal esophageal objects, since glucagon relaxes the lower esophageal sphincter allowing passage.
2. Success rates of glucagon therapy for FB are poor. It may be no better than watchful waiting without other interventions. (so, in short...no, not useful)

p. 553

Front 42

What is the MC cause of food impaction in the esophagus?

Back 42

Bolus of meat.
- if bony fragments are present, needs endoscopy.

p. 553

Front 43

T/F: IF a patient has a meat bolus, have them ingest proteolytic enzymes, such as meat tenderizer, to aid indigestion.

Back 43

FALSE: the use of proteolytic enzymes (adolph's meat tenderizer, which contains papain) to dissolve meat bolus is CONTRAINDICATED, because of the potential for complications and availability of superior alternatives.

p. 553

Front 44

Why is a button battery trapped in the esophagus an emergency requiring prompt removal?

Back 44

because the battery may quickly induce mucosal injury and necrosis. Perforation can occur w/in 6 hours of ingestion

p. 553

Front 45

What do the American Society of Gastrointestinal Endoscopy guidelines recommend regarding the removal of

Back 45

Removal of sharp objects by endoscopy while they are in the stomach or duodenum, because intestinal perforation from ingested sharp objects that pass distal to the stomach is common (~35%). if intestinal perforation does occur it is MC ileocecal valve.

p. 554

Front 46

When transported drugs, many drug packers store drug in condoms. How much can one condom commonly hold?

Back 46

5 grams of narcotic

p. 554
- next slide? Endoscopy to remove, yes or no?

Hint 46

If these condoms with drug rupture, it could be fatal. Endoscopic removal is contraindicated, because of the risk of iatrogenic rupture. Observation as long as transit is appreciate may be appropriate as well as whole bowel irrigation.

Front 47

What is caused by an infectious, toxic or metabolic injury to hepatocytes?

Back 47

Acute hepatitis

p. 566

Front 48

The liver is responsible for both anti-coagulation and coagulation factors. What are the coagulation factors the liver is responsible for?

Back 48

Vit-K dependent clotting factors: 2, 7, 9, 10, protein C&S; as well as other elements of the clotting and thrombolytic processes.

p. 566

Hint 48

- this can be a dramatic presentation in the patient with liver disease...uncontrolled bleeding is one of the life threatening features of liver disease...this can be a dramatic complication of hepatic failure

Front 49

What leads to ascitis in cirrhotic patients?

Back 49

1. Portal HTN
2. hypoalbuminemia
3. poor renal management

p. 566

Front 50

What are the two outcome risks associated with excess fluid in the peritoneum?

Back 50

1. respiratory compromise
2. spontaneous bacterial peritonitis.

p. 566

Front 51

Why does sponatoeus bacterial peritonitis occur in the ascitic patient?

Back 51

it can occur when normal flora translocate across the bowel wall and into the peritoneum.

p. 566

Hint 51

- bowel flora translocate across the bowel wall 2/2 edema and poor production of immunologically active proteins in the liver. bacteremia and infection of pre-existing ascitic fluid ensures.

Front 52

Portal hypertension...explain it.

Back 52

Caused by increased hydrostatic pressure in the portal veins as well as the feeder vessels- caused by resistance blood flow through the cirrhotic liver. This is what leads to esophageal varices and portal systemic shunting.

p. 566

Front 53

How does portal systemic shunting contribute to hepatic encephalopathy?

Back 53

Portal systemic shunting deprives the hepatocytes of substrate for ammonia metabolism.

p. 566

Hint 53

Encephalopthy is a pivitol element in chronic liver dz, but is poorly understood
AMMONIA is often presumed to be the cause of the confusion and lethargy- though the truth is, the cause is not wholely known.

Front 54

Jaundice is caused by all forms of liver failure. What is it caused by?

Back 54

Deposition of bilirubin in the circulation, leading to bile pigment deposits in the skin, sclerae, and mucous membranes.

p. 566

Front 55

What are three reasons for hyperbilirubinemia to occur?

Back 55

1. overproduction
2. inadequate circular processing
3. decreased excretion of bilirubin

p. 567-nxt slide

Hint 55

ie.
- prehepatic
- hepatic
- posthepatic

Front 56

Explain prehepatic jaundice.

Back 56

Caused by any form of hemolysis (including inborn errors of metabolism)- which are overwheming the livers ability to conjugate it

p. 567

Front 57

Explain hepatic jaundice.

Back 57

The MC causes of hepatic jaundice are viral infection, ingested toxin, and alcohol. As hepatocytes necrose, livers ability to conjugate is impaired ...

p. 567

Front 58

Explain post-hepatic jaundice.

Back 58

Is caused by obstruction of the excretion of conjugated bilirubin. MC: gallstones in the bile duct or pacreatic tumor.

Front 59

What should you be thinking in the patient with the following potential chief complaints: jaundice, nausea, vomiting, diarrhea, RUQ or epigastric pain, pruritis, bruising or bleeding, altered mental status?

Back 59

Liver disease.

p. 567

Front 60

What are the following past medical hx risk factors for, with regard to biliary disease: chronic hepatitis, transfusion of blood products, + HIV, frequent use of pain medications, vitamin A, Isoniazid, PTU, phenytoin, and valproate, as well as many herbal supplements?

Back 60

Liver Disease

p. 567

Front 61

What are the following social hx risk factors for, with regard to biliary dz: injection drug use, chronic EtOH abuse, sexual promiscuity, or travel to other countries with endemic parasitic risks?

Back 61

Liver disease

p. 567

Front 62

What are some physical examination findings that are regarded as "hallmarks" of liver dz? (8)

Back 62

Acute hepatitis: liver enlargement and tenderness with or without jaundice
Chronic liver disease:
a. sallow or jaundiced complexion
b. extremity atrophy
c. dupuytren's contracture
d. palmar erythema
e. cutaneous spider nevi
f. distended abdomen with a fluid wave
g. enlarged veins on the surface of the abdomen (caput medusae)

p. 568

Front 63

What form of hepatitis will typically present with the following: N/V and RUQ abdominal pain. Can also have fever, jaundice, bilirubinuria, and an enlarged tender liver.

Back 63

Acute heptitis


p. 568
- what is the MC cause (3)?

Hint 63

1. viral
2. Toxic Ingestions: APAP
3. Toxic Ingestions: EtOH

Front 64

What type of liver failure is: cirrhosis, portal htn, abdominal pain and distention, abnormal bleeding, and edema. May also have ascitis, encephalopahty, signs of infx, and electrolyte derangement. Skin may reveal spider nevi, caput medusa

Back 64

chronic hepatitis

p. 568

Front 65

What is the final pathway of both acute and chronic liver disease.

Back 65

Fulminant liver failure.

p. 568

Front 66

What are the three most prevalent viral hepatitis d/o's encountered in the ED?

Back 66

1. Hep A
2. Hep B
3. Hep C

p. 568

Front 67

What is the MC route of transmission of Hep A?

Back 67

(Fecal oral yes!)- but MC contact will be from asx infected child to adult.
Additionally, from oysters

p. 568

Front 68

A patient is presented to you who had recently had N/V anmd malaise, she knew was AGE. However, in spite of her efforts to remain hydrated, has had REALLY dark urine and clay colored stools. She appears WDWN, but sick (non-toxic) with a hint of yellow color. PE NML. Social hx: Occasional EtOH, tob 1 ppd. + Sexually active, married- does not question fidelity. G0. LMP- current, "seems more than usual" but not too concerned. Last travel: 3 months ago...went to Maine, by flight w/o problems. "THey have the best sea food. oysters, cod, etc. " What do you think is the problem

Back 68

Hep A

P. 568

Front 69

What form of hepatitis is transmitted by "Bootie", "Blood" and "Buddies (needle sharing friends)" "The B's"

Back 69

Hepatitis B

p. 568

Front 70

Which form of hepatitis is >75% chance of being "chronic"...hint C-hronic

Back 70

hepatitis C


p. 568

Front 71

What of hepatitis is needed to get Hep D. THough you can have this hepatitis w/o D, you cannot have hep D w/o this form of hepatitis?

Back 71

Hep B

P. 568

Front 72

What form of hepatitis can result in a rapidly progressive or fulmanant form of liver disease that carries a high short term mortality rate and is commonly associated with IV drug use?

Back 72

Hepatitis D Superinfection

p. 568

Front 73

What is the MC cause of toxic insult to the liver?

Back 73

APAP overdose

p. 568

Front 74

T/F: APAP overdose is the only drug known to dramatically contribute to liver failure.

Back 74

FALSE:
in fact, there are a variety of prescription medications (antibiotics and statins prominent among them), herbal remedies, and dietary supplements that have been associated with acute hepatitis and liver failure.

p. 568 (however, table 83-3 lists a ton!)

Front 75

What form of liver disease carries a 35% 5-year survival rate, and can range from an incidental finding to cirrhosis.

Back 75

Alcoholic liver disease

p. 569

Front 76

How many drinks daily are typically thought to bring enough of an insult to cause significant alcoholic liver disease?

Back 76

6-8 drinks per day

p. 569

Front 77

A 68 y/o M is brought to you for complaints of "numbness in both hands". States that it has been there for the past few weeks. No recent traumas. You see a disheveled appearing man, who appears much older than suggested age, emaciated. he has a salmon colored rash on the skin, and what appears as harold patch on abdomen. What is the reason for the neuropathy? Are you concerned about anything else?

Back 77

1. Alcoholic liver disease
2. EtOHic- worsening disease as well as additional comorbidities/social risks/coagulopathy/nutrition deprivation, etc.

p. 569

Front 78

A coroner friend of yours is telling you about a case he is seeing. A teenager who was trying to get high on shrooms, ended up taking "amanita phalloides" instead. What is the other name of this? What was the source of this kids death?

Back 78

1. Death Caps (Very Lethal)
2. Acute Liver Failure

p. 569

Front 79

T/F: Spontaneous Bacterial Peritonitis is a "subtle" yet crucial finding, because it carries a very high mortality rate.

Back 79

True

p. 569

Front 80

Why is Sponatneous Bacterial Peritonitis (SBP) difficult to diagnose?

Back 80

Because signs of abdominal pain and fever are not always present, and physical examination does not always demonstrate abdominal tenderness.

p. 569

Hint 80

Occurs in ~30% of ascitic patients every year.

Front 81

What should happen for all patients with the following: fever, abdominal pain, GI bleeding, encephalopathy and ascitis?

Back 81

Paracentisis

- to check for SBP

p. 570

Front 82

What is heralded by complications of spontaneous bacterial peritonitis and is an additional complication of cirrhosis? The patient has histologically NML kidneys, known liver disease, but declining renal function.

Back 82

Hepatorenal syndrome.


p. 570- there are two types. Explain. (which one is worse)

Hint 82

Type 1 is the worst: progressive oliguria with doubling Creatinine (usually over 2 weeks)
Type 2 gradual impairment in renal function- which does not often advance beyond moderate

Front 83

What is caused by CNS accumulation of nitrogenous waste products normally metabolized by the liver?

Back 83

Hepatic encephalopathy

p. 570

Front 84

Hepatic encephalopathy is very common after what procedure?

Back 84

Transjugular Intrahepatic Portosystemic Shunt (TIPS)- a procedure of shunting portal blood pass the liver into the inferior vena cava...

p. 570

Front 85

There are different stages of hepatic encephalopathy. What is the following?
General Apathy

Back 85

Stage I

p. 570

Front 86

There are different stages of hepatic encephalopathy. What is the following?
Lethargy, drowsiness, variable orientation, asterixis

Back 86

Stage II

p. 570

Front 87

There are different stages of hepatic encephalopathy. What is the following?
Stupor with hyperreflexia, extensor plantar reflexes

Back 87

Stage III

p. 570

Front 88

There are different stages of hepatic encephalopathy. What is the following?
Coma

Back 88

Stage IV

p. 570

Front 89

You have a patient who has lost use of his arms, so you have him stick out his tongue and notice a back and forth movement. What is this sign called? What is it a sign of?

Back 89

1. Asterixis
2. Stage 2 hepatic encephalopathy

p. 570

Front 90

T/F: Hepatic Encephalopathy is a diagnosis of exclusion, even in the presence of elevated ammonia levels.

Back 90

True

p. 570 (they can be at risk, and sometimes even more risk, for regular disease as anyone else)

Front 91

What is the clinical hallmark of acute liver failure? (2)

Back 91

hepatic encephalopathy and coagulopathy

p. 570

Front 92

Hepatobiliary disease lab test can be divided into 4 tests, what are they?

Back 92

1. markers of acute hepatocyte injury or death (ALT/AST/Alk Phos)
2. measurements of hepatocyte synthetic function (PT/PTT/albumin)
3. indicators of hepatocyte catabolic activity (direct/indirect bili)
4. tests to diagnose specific disease entities.

p. 571

Front 93

What does an increased level of total and indirect bilirubin signify?

Back 93

Either an overwhelming supply of unconjugated bilirubin to the hepatocytes (hemolytic anemia) or an injury to the hepatocytes themselves that damage their capacity to conjugate a normal supply of bilirubin.

p. 571

Front 94

What happens to the bilirubin when there is an obstruction preventing the secretion of the conjugated bilirubin that is produced normally functioning hepatocytes.

Back 94

Elevation in the total and direct bilirubin.

p. 571

Front 95

An AST:ALT ratio of greater than 2 is common in alcholic hepatitis. Why?

Back 95

Alcohol stimulates AST production.

p. 571

Front 96

T/F: ALT is more specific to the liver, where as AST is also found in: heart, smooth muscle, kidney and brain.

Back 96

true

p. 571

Front 97

You are evaluating a pregnant female and as a part of the work up obtained LFT's. When reviewing the labs, you note that the ALK PHOS is up. You recall that this is present in the bone, placenta, intestines and kidney, and leukocytes. Her is twice the value of NML. Whatcha think?

Back 97

NML for pregnancy

p 571

Front 98

T/F: Hemolysis can produce elevations of the LDH as well as the unconjugated bilirubin.

Back 98

True

p. 571

Front 99

T/F: Elevated serum ammonia levels do not reliably correlate with acute worsening of hepatic function in the cirrhotic patient, and more serve more as a marker of generalized decline than as a useful diagnostic tool or therapeutic end point.

Back 99

True

p. 571

Front 100

Coagulation panel: 2,7,9,10- vitamin K dependent clotting factors. Is this the PT or the PTT on the panel?

Back 100

PT

P. 571

Front 101

What should be ordered when ascitic fluid is obtained? (5)

Back 101

1. cell count
2. glucose
3. protein
4. gram stain
5. culture

p. 571

Front 102

Ascitic fluid: wbc >1000/mm^3 or neutrophil count >250/mm^3, what does this suggest?

Back 102

Spontaneous Bacterial Peritonitis

p. 571

Hint 102

(intersting to note, of course low glucose and high proteins suggest infection. However, cultures actually have a false + rating of 30-40%)

Front 103

Why does one not get LFT examinations just because of + urobilinogen on urine dipstick?

Back 103

blood tinged urine will give false +

p. 572

Front 104

NAC is provided for APAP overdose. But what is provided for most/all other forms of liver failure?

Back 104

Supportive care

p. 572

Front 105

When choosing to provide a therapeutic paracentesis, what is the limit to remove? Say you wanted to stat albumin, how would you dose and when?

Back 105

1. No more than 1 liter off
2. Dose albumin: 1.5 gm/kg IV prior to the paracentesis

p. 572- check coags prior.
Plts 42,000 and INR 1.4-2.2 are OK

Front 106

What is the MC accepted first line treatment for SBP?

Back 106

Cefotaxime

P. 572

Front 107

What is commonly prescribed for hepatic encephalopathy? Why?

Back 107

1. Lactulose
2. binds the ammonia, fecally removed.

p. 572

Front 108

What is the route of lactulose administration (2)? How is it dosed and provided (2)?

Back 108

1. PO route: 20 gms diluted in a glass of water/fruit juice/carbonated drink
2. PR route: 300mL syrup with 700 mL of water or normal saline. Enema should be retained for 30 minutes

p. 572

Front 109

Coagulopathy from liver failure, how is this treated?

Back 109

Vitamin K 10 mg IV or PO
- if needed, FFP as well.

p. 573

Front 110

Why is BiPAP in patients with respiratory complications regarded as not an option in ascitis patient?

Back 110

these patients are somnolent MC and very likely to aspirate.

p. 573

Front 111

Patients with liver disease often have low BP 2/2 poor nutrition, bleeding, vomiting, diarrhea, and third spacing. What should be done cautiously in these patients?

Back 111

Fluid resuscitiation

p. 573

Front 112

Pregnant female in THIRD TRIMESTER reports to the ER with c/o HA, malaise, nausea and vomiting. She is HTN with HA and showed proteinuria. You obtained an CMP and CBC, and discovered, evidence of increase in indirect and total bili, ALT/AST 322/297, and PLT: 120,000. What is up? What do you do?

Back 112

- HELLP syndrome
- call Ob/Gyn, if over 34 weeks- baby needs to be delivered. If less than 34 weeks- let OB decide...either way- inpatient mgt is a must.

p. 573

Front 113

T/F: Nasogastric aspiration is for the use of removal of liquid contents as well as for decompression of the stomach. Additionally, should also be used for adynamic ileus.

Back 113

FALSE. The first sentence is true. However, it is no longer recommended for adynamic ileus. Removal of liquid contents is useful in cases of GI bleeding, but not all patients with GI bleeding require NG aspiration.

p. 601

Front 114

What are some common complications of nasogastric and nasoenteric tubes?

Back 114

1. Epistaxis
2. Intracranial placement
3. Bronchial placement
4. Pharyngeal placement
5. Esophageal obstruction or rupture
6. Bronchial, alveolar perforation
7. PTX
8. Charcoal instillation into the lungs and pleural cavity
9. Gastric, duodenal rupture
10. Vocal cord paralysis
11. Pneumomediastinum
12. Laryngeal injuries
13. Knotting (preventing removal)

p. 602 (Table 89-2)

Front 115

What instrument can be used to identify the cause of bleeding in patients with hematachezia?

Back 115

Anoscopy

p. 602

Front 116

You are wanting to perform an anoscopy on a patient, knowing that it is fairly safe, though uncomfortable. What are the 2 contraindications?

Back 116

1. rectal foreign bodies
2. suspected rectal perforation

p. 602
- What is the least uncomfortable position for a patient to be in for anoscopy?

Hint 116

lateral decubitus

Front 117

You have a patient who may have ingested a potentially toxic substance, you want to perform OG lavage to removal the pill fragments. But remember there is a time limit, what is it?

Back 117

OG lavage from pill fragments is appropriate only with in 1 hr of presentation.

p. 603

Front 118

You are working with a new clinician in the department. he had a patient with overdose. States that it was within the hour of ingestion, but has not received any pills back from the lavage. You walk over and seen an NG (nasogastric tube) in the right nares. What is the problem?

Back 118

Nasogastric tubes are too small. Need a large bore OG tube.

p. 603

Front 119

You have a patient who suspect is hemorrhaging from known esophageal varices. What is the name of the tube used for tamponade the bleed?

Back 119

Sengstaken-Blakemore, esophageal ballon

p. 603

Front 120

T/F: Secondary to the development and use of octreotide, somatostatin, and vasopressin the use of sengstaken-blakemore balloon has been rendered obsolete.

Back 120

False- while its use has been significantly reduced, it is still favorable when endoscopy and/or medication/conservative therapies have failed.

p. 603

Front 121

T/F: Sengstaken-blakemore tube is only appropriate in patients with esophageal varices, known hx of frank hematemsis as well as cirrhosis.

Back 121

True

p. 603

Front 122

Why is esophageal balloon (blakemore tube) so effective?

Back 122

MC esophageal varices are at the gastroesophageal junction. Pulling the balloon ti tamponade is appropriate- and effective.

p. 603

Front 123

What complications are common during Large-volume paracentesis?

Back 123

1. hyponatremia
2. renal impairment
3. encephalopathy
- many of the these patients require additional treatment...therefore this is often performed by the admitting team.

p. 604

Front 124

When performing a paracentesis, why is the lower abdomen considered an ideal location?

Back 124

because this avoids the liver...may choose left or right lower quad.

p. 604

Front 125

There are many types of transabdominal feeding tubes. What is a G-tube, J-tube, and gastrojejunostomy?

Back 125

G-Tube: a gastrostomy tube
J-Tube: a jejunostomy
and gastrojejunostomy is exactly what it sounds like.

p. 604

Front 126

What is done for transadbominal tube placement occlusion?

Back 126

irrigation and most often, just replace.

p. 604

Front 127

You have a patient who had their transabdominal tube dislodge, you have gently replced it. Now what?

Back 127

X-ray to confirm placement.

p. 604

Front 128

Transabdominal tube, g-tube, is clogged. How do you irrigate it?

Back 128

Flush with water or carbonated beverage (cola) let sit for 20 minutes.

p. 604

Front 129

In order to remove a transabdominal tube with the "bolster" in place, what should be done to remove this?

Back 129

Endoscopy or by the GI or Surgeon who placed it

p. 605

Front 130

Transabdominal tube has been dislodged or fallen out, how is this managed?

Back 130

It needs to be replaced as quickly as possible (within a few hours) to prevent closure of the tract. Most tracts mature after 2-3 weeks. Do not attempt to replace a tube with an immature tract.

p. 605

Front 131

T/F: it is easy to determine if a patient has had a J-tube or G-tube by placement of the area on the abdominal wall.

Back 131

False- the patient will have to tell you, cause the site it is not helpful.

p. 605

Front 132

The mneumonic for common causes of postoperative dever, are "wind", "water", "wound", "walking" and "wonder drug", what do these stand for?

Back 132

Wind: atelectasis, PNA
Water: UTI
Wound: Infx at at site
Walking: DVT
Wonder Drug: drug fever or pseudo membranous colitis

p. 606

Front 133

What are the MC postoperative complications occuring with in 72 hrs after surgery?

Back 133

Atelectasis, IV catheter related problems, thrombophlebitis- w/in 72 hrs
Atelectasis is MC in 24 hrs- though strep and clostridia are sources too.

p. 606

Front 134

How are patients with atelectasis managed?

Back 134

1. Mild dz w/o evidence of hypoxemia- often managed with pain control and increased deep breathing
2. Admission is for aggressive pulmonary toilet and supplemental oxygen in debilitated patients, patients with underlying lung disease, patients with hypoxemia, and those when the dx is in question.

p. 606

Front 135

Patient presents with dyspnea, chest pain, productive cough, fever, and tachypnea 24-96 hrs after surgery. What is the likely source?

Back 135

PNA

p. 606

Front 136

What can occur in the past operative patient following thoracic wall surgery, breast bx, laparoscopic abdominal surgery, abdominal paracentesis, nasogastric and feeding insertion, thoracic surgery, central venous catheter insertion, endoscopic procedures, shoulder arthroscopy, and tracheostomy?

Back 136

PTX

p. 606

Front 137

What pulmonary complication can occur at anytime following a surgical procedure?

Back 137

pulmonary embolism

p. 606

Front 138

Why does urinary retention occur postoperatively?

Back 138

As a result of catecholamine stimulation of the alpha adrenergic receptors of the bladder neck and urethral smooth muscle.

- this is MC in elderly men, patients receiving excessive fluid administration during surgery, those undergoing anorectal surgery and those with spinal anesthesia.

p. 607

Front 139

70 y/o M patient presents following anorectal surgery; c/o abdominal pain, urinary dribbling, as well as inability to "pee" . Seems to be in moderate distress. What do you want to do?

Back 139

1. Obtain a urinary/bladder scan
2. insert a foley catheter.

p. 607
- what to do?

Hint 139

If no relief with catheter insertion...etc. Call Urology

Front 140

Who should be notified about all postoperative wound complications?

Back 140

The Surgeon

p. 607

Front 141

MC hematomas can be successfully drained and managed with outpatient care/follow-up. What about those who have a hematoma of the neck or those with hematoma following vascular surgery?

Back 141

call consultant

p. 608

Front 142

What are the risk factors associated with Necrotizing Fasciitis? (4)

Back 142

1. Diabetes Mellitus
2. EtOHism
3. Immunosuppression
4. Peripheral Vascular Dz
- but it can occur in an otherwise young and healthy individual

p. 608

Front 143

What is the tx for suppurative thrombophlebitis?

Back 143

Excision of the effected vein

p. 608

Front 144

You are evaluting a patient at turn over and told this was a superficial thrombophlebitis patient and that warm compresses, NSAIDs and pressure support stockings were all that were needed for tx. However, when you examine the patient you discover: erythema, a palpable tender cord, lymphangitis and pain. What do you suspect of this LE pain following surgery?

Back 144

Suppurative thrombophlebitis

p. 608
This patient has this in the LE. What should be done if regular thrombophlebitis?

Hint 144

Ultrasound. if doppler study reveals negative findings- what should be done. Repeat in 3 days, if if worsening sxs: repeat immedately.

Front 145

Why does pseudomembranous colitis occur in patients taking abx?

Back 145

Because the abxs destroy NML enteric bacterial flora, allowing the overgrowth of clostridium difficile

p. 608

Front 146

What are the sxs associated with pseudomembranous colitis?

Back 146

- watery, sometimes bloody stool
- fever
- abdominal cramps/pain

p. 608

Front 147

How is the dx of c.diff made?

Back 147

Obtaining lab specimen for c.diff cytotoxin in the stool, which can be obtained in as little as 2-3 hours.

p. 608

Front 148

What is a functional obstruction of the bowel, caused by stimulation of splanchnic nerves, which leads to neuronal inhibition of coordinated intrinsic bowel wall motor activity- and occurs after operations in which the peritoneal cavity is violated.

Back 148

Ileus

p. 609

Front 149

After a GI surgery, how long is it before the bowels return to normal? How long before the colonic function is restored?

Back 149

24 hrs

3-5 days

p. 609

Hint 149

General anesthesia can also cause an ileus, should still return to NML w/in 24 hrs.

Front 150

What can a prolonged ileus be caused by?

Back 150

1. peritonitis
2. intra-abdominal abscess
3. hemoperitoneum
4. pneumonia
5. electrolyte imbalance
6. sepsis
7. medications

p. 609

Front 151

A 54 y/o M comes to see you following an abdominal surgery. States that he has had N/V, constipation, abdominal pain and distention. Patient appears uncomfortable and reports sxs for 3 days- since his surgery, and "getting worse". What do you do? What is it?

Back 151

1. Chest and Abdominal film, CBC, CMP, and UA- to look for causes of ...
2. proloned ileus

p. 609
- adynamic ileus would respond well to IV hydration as well as nasogastric suction and bowel rest. BUT in the scenario above, it has been prolonged.

Hint 151

SOMETIMES MAY NEED TO GET A CT. IF MECHANICAL OBSTRUCTION OR ADYNAMIC OBSTRUCTION- MAY BE DIFFICULT TO TELL. CT may help in determining this...such as if the bowel has some strangulation

Front 152

What is the MC cause of mechanical ileus?

Back 152

Adhesions

p. 609

Front 153

What is the treatment for mechanical obstruction?

Back 153

Surgery

p. 609

Front 154

What causes intra-abdominal abscesses?

Back 154

-preoperative: contamination
- intraoperative: spilling of bowel contents during surgery
- contamination: hematoma, or postoperative anastomatic leaks


p. 609

Front 155

45 y/o F c/o abdominal pain, n/v, fever, chills, no appetite with weight loss, and abdominal tenderness. She is very apprehensive about a abdominal exam- x-ray reveals multple air- fluid levels, and dilated loops of bowel. What is the source of this ileus? What tests should be ordered and what is the treatment.

Back 155

1. Intra-abdominal Abscess
2. Abdominal CT or U/S
3. Broad spectrum abx
4. call surgery

p. 609

Front 156

Patient presents to the ER following ERCP a few days ago. C/o abdominal pain, nausea, and intractable vomiting. Labs show a leukocytosis. States that the pain began midepigastrum and now feels more diffuse. What do you suspect?

Back 156

Pancreatitis


p. 609

Front 157

You have a patient who c/o lumbar pain, who has a Gray-Turner sign as well as cullen's sign. What is going on with this patient?

Back 157

Hemorrhagic pancreatitis

p. 609

Front 158

Serum amylase is elevated in acute pancreatitis, but can also be elevated in other patients, who?

Back 158

- cholecystitis
- renal insufficiency
- intestinal obstruction
- perforated ulcer
- ischemic bowel

p. 609

Front 159

Serum lipase is believed to be a more accurate reflection of pancreatic insult. However, can also be elevated in what patrients?

Back 159

perforated viscous

p. 609

Front 160

57 y/o M with abdominal pain, localized to the RUQ. You, being such an astute clinician, obtain and RUQ u/s. You see gallbladder enlagement, gallbladder wall measures ~5mm, and and there appears pericholecystic fluid. You do not see any stones. What is it?

Back 160

Acaclulous cholecystitis

p. 609

Front 161

36 y/o M is presented to you because of sxs of trismus and opisthotonos, which first began as abdominal pain, fever, and abdominal rigidity. He lives by himself, so the family did not know but what had been told them, until the patient was found this way. Last they saw him physically was following his abdominal surgery 3 months ago. He otherwise has no significant medical or social history. He is usually healthy, and with the exception of surgery does not believe in anything but "natural" healthcare. Based on this, what is this man's likely dx?

Back 161

Tetanus

p. 610

Hint 161

~1% have C. Tetany in their intestines, that spills in the abdomen leading to sxs in 3 months after surgery

Front 162

What is opisthotonos?

Back 162

from the greek meaning "behind", "tension"- or a state of extreme hyperextension. (example, extreme tetanus posturing)

Front 163

What is paucity?

Back 163

Small in number, fewness or scant

p. 610

Front 164

What anastomatic leaks occur MC w/in 10 days postop?

Back 164

Intrathoracic esophageal

p. 610

Front 165

You have a patient who appears toxic, had complained of fever, chills, chest pain, tachycradia, tachypnea, and appears in shock. CXR shows PTX and pleural effusion. Had esophageal anastomosis 7-10 days ago. What happened?

Back 165

Anastomosis leak

p. 610
- can be confirmed with contrast esophagogagraphy, however, call surgery. Even with operation, mortality is high...don't waste time with studies w/o their call.

Front 166

What are the four bariatric surgeries?

Back 166

1. Lap Banding
2. sleeve gastrectomy
3. Roux-en-Y gastric bypass
4. Biliopacreatic Diversion

p. 610

Front 167

What type of gastric bypass surgery is MC associated with dumping syndrome?

Back 167

Roux-en-Y

p. 610
Why?

Hint 167

Because the surgery requires bypassing the pylorus, the hyperosmolar chyme will then get emptied into the jejenum...with rapid influx of extracellular fluid.

Front 168

What is a rare but serious complication associated with bariatric surgery? Patients often present with cerebellar signs, ophthalmoplegia, weakness and/or memory disturbances.

Back 168

Wernicke Encephalopathy

- occurs MC with Roux-en-Y and biliopancreatic diversion. It is a vitamin B12 deficiency

p. 610

Front 169

What are the two MC stomas?

Back 169

Ileostomy and Colostomy

p. 611

Front 170

What is the MC complication of a colonscopy and is secondary to polypectomy procedures, biopsies, lacerations of the mucosa by the instrument or tearing of the mesentery or spleen.

Back 170

Hemorrhage


p. 613

Front 171

Patients who undergo rectal surgery will often experience urinary retention. However, there are three additional complications that will often present themselves as well?

Back 171

1. constipation
2. rectal bleeding
3. rectal prolapse

p. 613

Front 172

T/F: Fourniers gangrene is a possible complication of anorectal suergy.

Back 172

True

p. 613

Front 173

Charts not implemented from the surgical complications chapters...should review these...pp. 606-613

Back 173

table 90-1
table 90-2*
table 90-3
table 90-4
table 90-5*
table 90-6
table 90-7*

Front 174

What results from acute necrosis of skeletal muscle and the leakage of cellular contents?

Back 174

Rhabdomyolysis

p. 622

Front 175

What is the MC rhabdomyolysis in adults?

Back 175

drug and etoh abuse

p. 622
- this is followed by: medications, seizures, immobility, infx, strenuous activity, heat related illnesses.

p. 622

Hint 175

Ilicit drugs: coacine, LSD, meth, heroin, etc
Rx drugs: antipsychotic, statins and fibrates, SSRI's, narcotics, colchicine, lithium, antihistamines

Front 176

How does EtOH have an impact on rhabdo?

Back 176

it causes coma-induced muscle compression as well as directly toxic effects.

p. 622

Front 177

What drugs when mixed with statins can cause rhabdo?

Back 177

1. Other statins
2. cyclosporin
3. macrolides
4. warfarin
5. digoxin

p. 622

Front 178

What are the MC infectious causes, viral and bacterial, of rhabdomyolysis?

Back 178

1. Influenza
2. Legionella

p. 622

Front 179

What are the following sxs associated with: myalgias, stiffness, weakness, malaise, low grade fever, and dark brown urine?

Back 179

Rhabdomyolysis

p. 623

Hint 179

Nausea, vomiting, abdominal pain and tachycradia can also occur in severe rhabdomyolysis

Mental Status changes can occur from urea induced encephalopathy...

Front 180

MC muscle sites of rhabdomyolysis?

Back 180

postural muscles: thighs, calves, lower back

p. 623

Front 181

What is the most sensitive and reliable indicator of muscle injury?

Back 181

elevated serum CK level.

p. 623
- important point, next page

Hint 181

While the degree of muscle injury is reflected in the elevation of the CK, it does not reflect the level of potential renal risk or other morbidity

Front 182

What is the requirement for dx of rhabdomlyolysis- as it pertains to the CK?

Back 182

Serum CK greater than 5 times the upper limit of normal, in the absence of cardiac or brain injury

p. 623

Hint 182

CK levels begin to rise 2-12 hours after muscle injury, peaks w/in 24-72 hrs, then declines at a relatively constant rate- if no decline, continued muscle necrosis should be suspected

Front 183

What causes the reddish brown discoloration of the urine in rhabdo?

Back 183

Myoglobin

p. 623

Front 184

You have a patient who has complained of increasing weakness over the past few days. UA reveals + RBC's on dipstick, but none in urine microscopy. What? Why?

Back 184

Myoglobin contains heme, but is not RBC's. So it will show + on dipstick, w/o showing evidence of bleeding. Even w/o CK- this person is likely experiencing rhabdo. This is myoglobinuria

p. 623

Front 185

What are the complications associated with Rhabdo?

Back 185

1. Acute Renal Failure (occurs in up to 46%)
2. Metabolic Derangements
3. DIC
4. Mechanical complications

p. 623

Front 186

The need for dialysis, serum potassium and calcium levels, and mortality appear to be similar in rhabdo and non-rhabdo induced acute renal failure. What effect does rhabdo have on uric acid level and anion gap?

Back 186

increases it

p. 623

Front 187

What are the initial electrolyte abnormalities in rhabo?

Back 187

Hyperkalemia
Hyperphosphatemia
Hypocalcemia

additionally
hyperuricemia

p. 623

Hint 187

Later, hypercalcemia and hypophosphatemia.
Initially, phos is leaked from the cell while calcium is retained- leading to cellular death

Front 188

T/F: Compartment syndrome can be a complication of rhabdo.

Back 188

True

p. 623

Front 189

T/F: DIC caused by Rhabdo can cause significant hemorrhage, but usually resolves w/in days

Back 189

True

p. 624

Front 190

What form of IV solutions should not be given to patients with rhabdo?

Back 190

Potassium or Lactate solutions

p. 624

Front 191

How long should IV rehydration be provided for a patient in rhabdo?

Back 191

24-72 hrs.

pts should receive: 2.5mL/kg/hr of crystalloids, with a goal to maintain a minimum urine output 2 mL/kg/hr...(curry and colleagues)

p. 624

Front 192

What patients should have a urinary catheter placed, when in rhabdo?

Back 192

those in critical condition and w/acute renal failure
- to monitor urine output

p. 624

Front 193

Where does not sympathetic innervation of the bladder, responsible for control of the lower urinary tract and urine storage originate from?

Back 193

T10-L2


p. 640

Front 194

Somatic innervation by what nerve maintains sensory input and pelvic muscle tone?

Back 194

Pudendal Nerve (S2-S4)

p. 640

Front 195

Urinary retention can be categoized into what causes(8)?

Back 195

1. obstructive
2. infectious
3. pharmacologic
4. traumatic
5. neurogenic
6. psychogenic
7. childhood
8. extraurinary causes

p. 640
see Table 95-1 for causes
see Table 95-2 for gender specific causes

Front 196

What is the MC cause of urinary retention in men?

Back 196

BPH

p. 640

Front 197

What are some important questions to ask in hx with regard to urinary retention?

Back 197

Bladder and urethral hx: bladder/prostate CA/treat- surgery, radiation or catheter insertion. Additionally ask about medications: cold preparations, anticholinergics, sympathetic agents, and psychogenic agents. Additionally, ask about injury (back etc) as well as recent surgeries in general.

p. 641

Front 198

You have an elderly woman who at presentation has a fever, tachycardia, as well as tachypnea and hypotension. In the days prior to becoming obtunded had been complaining of vague abdominal pain and dysuria. What is it?

Back 198

Urosepsis

p. 641

Front 199

Why, when a woman has symptoms of urinary retention, should you also do a pelvic examination?

Back 199

Because she may have adnexal masses, or pelvic inflammatory processes.

p. 641

Front 200

What should be done with a patient who has had urinary retention but then is decompressed with urinary catherization?

Back 200

Repeat physical examination to determine is an ongoing process is to blame...ex. Appendicitis

p. 641

Front 201

What is the goal with urinary retention in the ED management of the patient?(6)

Back 201

1. decompression of bladder
2. identification of the cause
3. prevention of catheter related complications
4. promotion of successful voiding after catheter removal
5. initiation of indicated meds
6. urologist follow-up

p. 641

Front 202

Once urethral retention is identified, what is the primary method of tx

Back 202

immediate decompression of the bladder by catherization:
- urinary
or
- suprapubic

p. 641

Front 203

How long prior to urethral catherization should anesthetic viscous lido be provided?

Back 203

5-10 minutes

p. 642

(10-15 mL lido)

Front 204

When should you consult with a urologist prior to providing a urethral catherization?

Back 204

1. When a patient recently underwent urologic surgery
2. When one suspects the creation of a false passage by traumatic urethral catherization

p. 642

Front 205

What are the two conditions needed to justify the placement of a suprapubic catheter?

Back 205

1. After several attempts at a urethral catherization have been attempted
2. When there is no obvious source of pelvic trauma or abnormal anatomy

Front 206

What form of suprapubic urinary catheter placement has a low complication rate?

Back 206

U/S guided placement of the urinary catheter.

p. 642

Front 207

What are patients with long standing urinary retention/obstruction at risk for following for?

Back 207

Post obstructive diuresis as well as postobstructive renal failure

p. 642
- next card

Hint 207

It is therefore imparitive that the patient be observed for: 4 hours- observe for <200 cc/hr output.

Front 208

Where do alpha blockers exert there effects, making them useful in urinary retention?

Back 208

Bladder neck and prostate and may relax bladder smooth muscle, reducing outlet resistance to urinary flow

p. 643

Front 209

T/F: Urinary retention in women is common.

Back 209

False

p. 643

Front 210

Gross hematuria can lead to clot retention, resulting in pain and HTN, as well as tachycardia from acute bladder distention.

Back 210

Placement of 20-24 F triple lumen cath, irrigate until clear to evacuate clots. May need cystoscopy to clear, however, either way- admit, as even if improvement, may recurr.

p. 644

Front 211

T/F: a patient is c/o urinary leakage around the catheter. THis is effectively improved with replacement with a larger catheter.

Back 211

False, there is no established/proven way to change this

p. 645

Front 212

You have improved an individual with urinary catheter, and have observed for 4 hours. No evidence of decline. How soon following this should a patient be seen by urology?

Back 212

3-7 days

p. 645

Front 213

What patients with urinary retention hx definately need to be admitted?

Back 213

1. clot retention
2. hematuria and coagulopathy
3. septic patients
4. possible neurologic causes and those with significant comorbidities

p. 645

Front 214

What is the procedure whereby there is an application of repetitive high intensity sound waves to fragment GI calculi?

Back 214

Excorporeal Shock Wave Lithotripsy

p. 657
What are the common postlithotripsy complications?

Hint 214

1. Nausea
2. Vomiting-esp occur 48 hrs after the procedure
3. abdominal pain
4. flank pain
5. ecchymosis
6. uretal colic
7. fever
8. hematuria (self limiting w/in 24 hrs)

Front 215

What is steinstrasse

Back 215

Stands for "street of stone"- refers to the dispersal of stone fragments, usually within the ureters

p. 657- can be visualized on a plain film
Can obstruction occur?

Hint 215

yes, one large fragment can get lodged in the ureter and produce obstructive sxs. Can have flank or groin pain, urinary obstruction, and superimposed infection.

Front 216

T/F: Bowel perforation, GI mucosal erosions and hemorrhages, ureteric perforations, and splenic subcapsular hemorrhage, abscesses to psoas muscle, and pseudoaneurysm of a superior mesenteric artery branch have all occurred following lithotripsy.

Back 216

True

p. 657

Front 217

Many complications can occur following the adult circumcision, but what is the MC?

Back 217

Infection

p. 657

Front 218

You have a patient, who following prostate surgery, presents with sxs of obstruction. You have a triple lumen catheter placed, and begin irrigation for hematuria. What should be done if these begins to be prolonged irrigation?

Back 218

Monitor electrolytes.

p. 657

Front 219

What has fewer rates of infx, suprapubic or urethral urinary catheters?

Back 219

Suprapubic has few rates of infx

p. 657

Front 220

What is available for urinary catheterization for patients allergic to latex (which is MC what catheters are made of)

Back 220

Silicone Catheters

p. 657

Front 221

What are the most common causes of nosocomial UTI's?

Back 221

Urinary Catheters

p. 657

Front 222

What is the rate/risk of bacturia incidnce per day of indwelling catheter use?

Back 222

3-10% per day (100% guarenteed by day 30)

p. 658

Front 223

What are some common risk factors for catheter associated UTI?

Back 223

1. female sex
2. BPH
3. Renal Dz
4. DM
5. Advanced age
6. debilitation

p. 658

Front 224

In non-catherized urinary system, bacteria are effectively eliminated, however, in the catherized urinary tract, the bacteria gain access to urinary system via what route?

Back 224

gain access via the catheter lumen or along the catheter surface. (especially risk, is when the bag is not effectively drained)

p. 658

Hint 224

See p. 658 for monomicrobial and polymicrobial sources of UTI

Front 225

In a patient with short term indwelling catheter use and asx bacteria, is abx tx recommended?

Back 225

No, unless the patient is pregnant or immediately pending a urologic procedure

p. 658

Hint 225

Recommended tx for symptomatic UTI's

Front 226

T/F: Pyuria is universally expected as NML for patients with known indwelling catheters for >1 month.

Back 226

True

p. 658
Next card

Hint 226

In fact, pyuria should NOT be used to dx a symptomatic infection
Hematuria is a better indicator of infection than and may also suggest urinary obstruction

Front 227

What is the MC complication of catheter associated UTI with fever?

Back 227

Pyelonephritis

p. 658
Next slide!

Hint 227

Additional complications:
-prostatitis
-epididymitis
-scrotal abscess

Front 228

A patient you are seeing is a 30 y/o F with hx of indwelling catheter, fever, back pain. BP: 89/40, P: 120, RR: 22, SaO2:98% RA Temp: 102. Appears sick and in gross pain with movement. What is going on? How do you treat? She has to have a catheter

Back 228

1. THis is likely Pyelonephritis
2. Obtain UA, UA cx, Blood cx(she is septic)- at least 2 SIRS and likely identifiable source, CBC
- start abx
- replace the catheter, esp if > 7 days
- call urology

p. 658

Front 229

When d/c'ing a patient from the ER for uncomplicated urinary retention, why is it important to provide d/c instructions with proper foley care and foley bag emptyiing procedures?

Back 229

because failure to empty bag can increase risk of infx, acute renal retention, and hydronephrosis

- make sure f/u with urology in 2-3 days

p. 658

Front 230

A nurse inserted a urinary catheter into a patient, w/o awaiting for the urine return, the patient began screaming...nurse continued to inflate the balloon- why is the patient understandly angry and why should you intervene?

Back 230

1. the nurse inflated the balloon while in the urethra
2, THis can cause significant urethral injury

p. 660

Front 231

T/F: During foley catheter insertion, a false lumen can be created, and the catheter may kink, esp in known urethral stricture patients, proatate enlargement. Patients may bleed, c/o pain or lack of urine output, clot, or urethral disruption.

Back 231

True

p. 660

Front 232

What direction should the coude-tipped catheter be pointed when inserting it? Why?

Back 232

Should be pointed with the tip up, so as to anatomically be poised to go over the prostate.

p. 660

Front 233

You have inserted a urinary catheter into an uncircumcised patient, what should always be sure to be accomplished after this?

Back 233

make sure foreskin is returned.

p. 660

Front 234

A patient appears toxic after urinary catheter insertion, they have peritoneal signs, pyuria, hematuria, and oliguria-anuria. What happened?

Back 234

Bladder perforation.


p. 660
- what should be done?

Hint 234

Diagnostic cystourethrogram and urgent urology consultation

Front 235

What is percutaneous nephrostomy used for? What is it?

Back 235

1. A urinary drainage procedure used for suprvesicular or ureteral obstruction 2/2 malignancy, pyonephrosis, GU stones, and ureteral strictures.
2. It is an adjunctive procedure to lithotripsy and uretal stents.

p. 661

Front 236

What is the percutaneous procedure used to remove renal calculi?

Back 236

Percutaneous Nephrolithotomy

p. 661

Front 237

Patient with hx of nephrostomy tubes placed a few months ago. C/o fever, chills, rigors, pain, and purulent drainage from tube site. What are you thinking?

Back 237

Infection

- common infectious complications from nephrostomy tubes include simple bacteria, pyelonephritis, renal abscess, bacteremia, and urosepsis.

Obtain: Urine and wound cx's. Begin abx therapies and contact urology

p. 661

Front 238

What is an artificial urinary sphincter?

Back 238

An artificial urinary sphincter is a device that is used for urinary incontinence secondary to sphincter disturbance, postsurgical incontinence, trauma to urethra, congenital conditions associated with bladder dysfunction such as exstrophy and epispadias.

p. 661

Front 239

What is the most serious complication of the artificial sphincter?

Back 239

Infection

p. 661

Front 240

What is the source of early sphincter infections?What is the source of late sphincter infections?

Back 240

1. Skin flora
2. gram negative organisms of the urinary tract sources

p. 661

Front 241

What is the tx for periprosthetic infections of sphincter?

Back 241

Abx treatment and Removal of the sphincter

p. 661

Front 242

T/F: Patients with artificial sphincters should receive abx prophylaxis anytime they undergo any tx that risks hematogenous seeding of the device.

Back 242

True

p. 661

Front 243

What are some mechanical complications of artificial sphincter?

Back 243

1. retained air bubbles
2. tube kinking
3. fluid leaks
4. perforation of the cuff

p. 661

Front 244

T/F: Plain films of the pelvis are of no utility in the examination of the patient with artificial sphincter.

Back 244

False. It can be useful in the examination for continuity of mechanical components.

p. 662

Front 245

It has been several months since 70 y/o patient has had his artificial sphincter placed s/p complete prostectomy and incontinence. However, he recently has developed: pain and swelling along the urethra and perineum, stating, "it hurts doc through my pecker and my taint". Additionally c/o incontinence returned and feverish. Additionally reports sxs of hematuria. You immediately realize what it must be and know he will need a cystourethroscopy and removal of harware. Why?

Back 245

Urethral Erosion 2/2 infection and possibly excessive cuff pressure.

p. 662

Front 246

Recurrent incontinence after artificial sphincter placement can have many causes, what are the 4 listed in the book?

Back 246

1. infection
2. cuff erosion
3. fistulas due to surgeries
4. mechanical failure

p. 662

Front 247

Acute urinary retention following sphincter placement, this may be caused by what (3)?`

Back 247

1. bladder neck contracture
2. urethral sticture
3. cuff erosion

p. 662

Front 248

what should you NEVER do when a patient has an artificial sphincter?

Back 248

NEVER introduce a urethral drainage catheter into an artificial urinary sphincter. Consult w/a urologist

p. 662

Front 249

Why do stents increase the risk of UTI's?

Back 249

Because they introduce a foreign body reaction

p. 662

Front 250

How are stent patients managed with UTI sxs?

Back 250

outpatient abxs

p. 662

Front 251

How are stent patients managed who have sxs c/w pyelonephritis and systemic infxs?

Back 251

IV abx's as well as radiographic studies to determine the position of the stent and urology consultation

p. 662

Front 252

T/F: mild flank pain, irritative bladder sxs, dysuria, urgency, incontinence are common in those patients who have uretal stents.

Back 252

True

- However, do get a UA to ensure not UTI related
- Analgesia and sometimes anticholinergic therapies as well...

p. 662

Hint 252

Severe pain or distressing acute change in sxs require work-up to ensure no stent migration or complication

Front 253

34 y/o F with hx of nephrolithiasis and depression reports to the ER with sxs of syncope, hematuria and HoTn. She appears ill. Has taken no medications recently. NKDA. Has hx of C-Section x 2, uretal stent placement x 3 placed. She is lucid but appears ill. no recent illnesses, but unremarkable PE. VS: 86/46, HR: 99 RR: 22 SaO2: 98% RA. Temp- pending. Anything that you are thinking about now- what MUST be ruled out?

Back 253

Vascular fistulation 2/2 eroding stent

p. 662

Front 254

What do the following have in common, with regard to being the MC causes of: DM, priapism, vascular dz, peyroine's dz, pelvic trauma/surgery, spinal cord injury or psychogenic complications?

Back 254

ED (Erectile Dysfunction)

P. 662-663

Front 255

What defines prolong erections?

Back 255

4-6 hrs

p. 663

Front 256

What are the organisms MC implicated in causing penile prosthesis infections?

Back 256

Staph epidermitis
Staph Aureus
Gram Negative

p. 663
infections are the most devastating complications or prosthetic penile devices, MC occur early, but can be late too
Treatmen t is consultation with urologist, abx treatment and arrangements for surgical removal of device.

Front 257

What is a rare, but serious complication of penile implants and is most likely in patients with hx of vascular disease and DM?

Back 257

Penile ischemia and necrosis

p. 663

Hint 257

Read: Urinary Diversion and Orthotopic Bladder> p. 663

Front 258

T/F: Regardless of the medical reasons for ED evaluation, the possibility of pregnancy must be considered on every women of reporductive age.

Back 258

True

p. 691

Front 259

What are the three reasons for unintended pregnancies?

Back 259

1. No use of contraception
2. In consistent use of contraception/inappropriate use/non-compliance (imperfect use)
3. contraceptive failure

p. 691

Hint 259

48% of all unintended pregnancies occur in the month of contraceptive use
30% of oral contraceptive users are non-compliant
Failure rates with implants (implanon) increases with time

Front 260

What denotes the number of pregnancies?

Back 260

gravida

p. 691

Front 261

What denotes the number of births?

Back 261

parity

p. 691

Front 262

How would you annotate a pregnancy in a women who is pregnant now, with 5 priors, and 2 living-at term?

Back 262

G6P2(2-0-3-2)

p. 691

Front 263

How long is pregnancy?

Back 263

40 weeks

p. 691

Front 264

What week is the start of the fetal period?

Back 264

9 weeks

p. 691

Hint 264

fertilization in ampulla, 6 days to uterus, 2-8 weeks= embryo period

Front 265

What happens to maternal BP in the second trimester?

Back 265

Decreases
systolic decreases: 5-10 mmHg
diastolic decreases: 10-15 mmHg

p. 691

Front 266

T/F: Hemodynamic measuring in pregnancy can be influenced by the patients position and their measurements should be done in the left lateral decubitus positions.

Back 266

True

p. 691

Front 267

Review of the effects of pregnancy: Table 103-1, page 691

Back 267

systemic effects

Front 268

What is the NML CO2 of pregnancy?

Back 268

NML Value: 30 mmHg

p. 691

Front 269

Why GERD in pregnancy?

Back 269

Delayed gastric emptying, decreased gastric motility, decreased lower esophageal sphincter tone

p. 691

Front 270

T/F: pregnancy increases the risk of cholesterol gallstones.

Back 270

True

- gallbladder emptying is delayed

p. 691

Front 271

What is the reason for increased susceptibility to infection after the second trimester of pregnancy?

Back 271

Leukocyte function is depressed

p. 692

Front 272

T/F: Platelet counts may decrease a little in pregnancy, this requires further evaluation.

Back 272

False
- plt count decreases, but thrombocytopenia requires work up

p. 692

Front 273

When does the uterus exceed the the capacity of the pelvis and expands into the abdominal cavity? (What gestational age)

Back 273

12 weeks

p. 692

Front 274

When do most pregnant women note breast tingling and tenderness?

Back 274

First trimester.


p. 692
They enlarge, become nodular, Nipple size and pigment increase. Striations on breasts may occur, as similar on abdomen.

Front 275

What is quickening in prengnancy? When is it relevently experienced?

Back 275

The first maternal perception of fetal movements.

- nullip: 18-20 weeks
-multip: 16-18 weeks.

p. 692

Front 276

What should be considered as a pregnancy complication for abdominal pain in the first trimester?

Back 276

Ectopic pregnancy and threatened abortion

p. 692
What should be considered in the late second and third trimester?

Hint 276

- premature labor
- abruption
- uterine rupture

VERY IMPORTANT!!! However, pregnant patients are still at risk for appendicitis, cholecystitis as well as pancreatitis. Atypical presentations- 2/2 changes in anatomy.

Front 277

in the first trimester of pregnancy, some women will experience a sharp pain that is considered NML and can be unilateral or b/l, and is produced by movement what is this pain

Back 277

broad ligament tension

p. 692

Front 278

What occurs in the third trimester of pregnancy and are irregular, palpable contractions?

Back 278

Braxton-Hicks Contractions

p. 692

Front 279

Pregnant patients can experience palpitations, dizziness, near-syncope, or syncope. What are is in the differential?

Back 279

- anemia
- electrolyte imbalance
- dehydration
- pulmonary embolism
- arrhythmia

p. 692

Front 280

When can fetal heart tones be heard with a fetal stethascope? What is the NML fetal heart rate?

Back 280

16-19 weeks
120-160 bpm

p. 692

Front 281

What week of gestation should the uterus be at the level of the umbilicus?

Back 281

20 weeks

p. 692

Front 282

T/F: + serum of urine HCG confirms intrauterine pregnancy.

Back 282

False...this does not confirm intrauterine pregnancy

P. 692

Hint 282

Can also have + results in ectopic pregnancy as well as molar pregnancy (HCG secreting tumor) and recent spontaneous abortion. Therefore need both HCG as well as pelvic ultrasound

Front 283

When are HCG levels doubled?

Back 283

1.4 to 2.0 days

p. 692

Front 284

What is the earliest ultrasound finding in pregnancy?

Back 284

Gestational Sac

p. 693

Front 285

When using the transabdominal u/s and transvaginal u/s, how many weeks can a gestational sac be detected?

Back 285

Transabdominal u/s: 5-6 weeks gestation
Transvaginal u/s: 4-5 weeks gestation

p. 693

Front 286

When us the yolk sac detectable by transvaginal u/s?

Back 286

5-5.5 weeks

p. 693

Front 287

When is the fetal pole detectable by transvaginal u/s?

Back 287

5.5-6 weeks

p. 693

Front 288

When should pregnant women initiate prenatal/natal care?

Back 288

NLT 6-8 weeks gestation

p. 693

Front 289

What are the symptoms/signs of pregnancy that need prompt eval?

Back 289

1. change in fetal movement
2. fever, chills
3. refractory emesis
4. visual disturbances
5. abdominal pain
6. significant HA
7. Anasarca
8. dysuria
9. Vaginal bleeding and fluid loss
10. Abnormal vaginal d/c.

p. 694

Front 290

What gestational age is the developing fetus most susceptible to teratogenesis?

Back 290

4-12 weeks (this is the organogenesis period)

p. 694

Hint 290

- the heart and neural tube

INTERSTING, prior to 4 weeks the fetus is all or none. When exposed to teratogen, it either survives w/o complications/defects, or does not survive

Front 291

What us the agent of choice for analgesia and antipyretic therapies in pregnancy?

Back 291

APAP

p. 694

Front 292

ASA and NSAID use in pregnancy is not safe in pregnancy, why?

Back 292

Early on: congenital defects
Late stage: coagulation complications, premature closure of the PDA, cardiovascular complications in neonate, may prolong labor. Has also been associated with oligohydramnios, intestinal perforations, hydrops fetalis, and renal failure

p. 694

Front 293

What are the two antiemetics that are presumed "safe" in pregnancy?
H2 blocker, which is safe?

Back 293

Reglan and Zofran

p. 694
- Phenergan may be

H2: Tagamet and zantac

Front 294

T/F: First trimester exposure to detramathorphan is associated with fetal defects.

Back 294

False

p. 694 (No harm has been established in the first trimester)

Front 295

Can tetanus toxoid alone or in combination with diphtheria be given to pregnant patients?

Back 295

Yes

p. 694

Front 296

What is the avg total weight gain in pregnancy?

Back 296

28 pounds

p. 695

Front 297

Caffeine risks in pregnancy are conflicting, however, what is known about caffeine and pregnancy? qty for those who smoke and those who don't.

Back 297

1. if a patient smokes and drinks, there is increased risk of miscarriage when caffeine consumption is >200-300 mg/d
2. If non-smoker/drinker, increased risk when caffeine intake is >800 mg/d

p. 695

Front 298

What is one of the greatest threats to NML pregnancy?

Back 298

Substance abuse

p. 695

Front 299

What are some pregnancy related complications that occur in the prehospital setting?

Back 299

1. preeclampsia
2. eclampsia
3. maternal hemorrhage
4. complications of labor, such as:
- cord prolapse
- malpresentation
- shoulder dystocia
- fetal distress

p. 703

Front 300

When assessing the pregnant patient, especially one greater than 20 weeks who is in labor, a history should include what things?

Back 300

1. frequency of contractions
2. fetal membrane status
3. presence of absence of vaginal bleeding
4. presence of absence of fetal movement

p. 704

Hint 300

- in addition to AMPLE hx, also ask: OB hx, including prior pregnancies, deliveries and complications, prenatal care and est delivery dates

Front 301

In every patient presenting with active labor, what should immediately be monitored/assessed?

Back 301

maternal vital signs (particularly BP) and fetal HR


p. 704

Front 302

When assessing a patient in active labor, what use is the doppler u/s as it pertains to the baby?

Back 302

Determining fetal HR:
NML: 120-160 bpm
Brady: < 110 bpm
Tachy: >160 bpm

p. 704

Front 303

You are evaluating a woman with signs of active labor, HR of fetus is 109 bpm. What does this mean?

Back 303

Fetal distress

- bradycardia is fetal distress in labor

p. 704

Front 304

What is false labor?

Back 304

Uterine contractions that do not lead to cervical changes. It is characterized by irregular, brief contractions usually confined to the lower abdomen.

It persists often for days and is treated with hydration and rest

p. 704

Front 305

What are braxton hicks contractions?

Back 305

irregular in both intensity as well as duration.

p. 704

Front 306

What is characterized by painful, repetitive uterine contractions that increase steadily in intensity and duration, leading to progressive cervical dilation and effacement. Often the pains begin in the fundus/upper abdomen and the radiate to the pelvis and in the lower back. These pains lead to the progressive descent of the fetus into the pelvis in preparation for delivery, cervical dilation and effacement.

Back 306

True labor

p. 704

Front 307

When performing a physical examination on the pregnant patient, what type of physical examination should be performed when there has been NO vaginal bleeding?

Back 307

Sterile pelvic examination: speculum as well as gloves

p. 704

Front 308

A pregnant patient presents with feelings of contractions and abdominal pain. + vaginal d/c appears as some blood. What should be done prior to the pelvic examination?

Back 308

Ultrasound- to ensure that this is not a placenta previa.

p. 704

Front 309

What medications are given in pregnancy to induce uterine contractions?

Back 309

1. Oxytocin
2. Misoprostol
3. Methylergonovine
4. Carboprost

p. 704, Table 105-2

Front 310

What medication is given in pregenancy to stop uterine contractions?

Back 310

Terbutaline

p. 704

Front 311

What medications are given in pregnancy for HTN?

Back 311

1. Hydralazine
2. Labetalol

p. 704

Front 312

What medications are given for seizures in pregnancy?

Back 312

1. magnesium sulfate
2. phenytoin

p. 704

Front 313

What medication is given for magnesium toxicity?

Back 313

Calcium Gluconate

p. 704

Front 314

What acceptable analgesias in pregnancy?

Back 314

1. Local anesthesia- lidocaine
2. Fenatyl

p. 704

Front 315

What is the appropriate opiate antagonist in pregnancy, for narcotic overdose?

Back 315

Naloxone

p. 704

Front 316

What antiemetic is often used in pregnancy?

Back 316

Zofran

p. 704

- though prior chapters have also suggested safety with reglan

Front 317

Why is lubricant in a pelvic examiantion generally avoided for pregnancy?

Back 317

It can cause a false + nitrazine test...

p. 705

Front 318

Why, if there is suspicion of ruptured membranes, should a sterile examination be performed and digital examination avoided?

Back 318

Because there is increased risk of infection after even one single digital examination.
It is particularly important to avoid a digital examination in the preterm patient in whom prolongation of gestation is desired.

p. 705

Front 319

What are the three means by which a sterile speculum examination allows confirmation of rupture of membranes?

Back 319

1. verification of pooling amniotic fluid in the vaginal vault
2. a positive nitrazine test result
3. evidence of ferning on a microscope slide of fluid recovered from the vagina

p. 705

Front 320

What cultures should be obtained from the pregnant female pelvic exam, and where should cx's be from?

Back 320

- Chlamydia Trachomatis and Neisseria Gonorrhae-testing for cervical infxs.
- Group B Streptococcus- cx swabs of the vagina, perineum, and perianal area

p. 705
- additional exam visually should be performed, lokking for what?

Hint 320

lesions- such as those caused by genital herpes

Front 321

What is the centimeter range of the cervical os- when measuring for dilation?

Back 321

0-10 cm

p. 705

Hint 321

Ten centimeters suggests for dilation ~ size of a bagel

Front 322

What does effacement of the cervix mean?

Back 322

it is the process of thinning that occurs during labor

p. 705

Front 323

What is the "station" in delivery of fetus?

Back 323

The location of the fetus during the delivery process.

p. 705

Front 324

When describing "station" of the delivering fetus, what is ground "zero" of station?

Back 324

The fetus is at the level of the mothers ischial spines.

p. 705

Front 325

If the child is above the level of the ischial spines, what is station? What about below the level of the ischial spines?

Back 325

1. Negative station if above the level
2. Positive station if below the level

p. 705

Front 326

What station is the baby, when the head is visible in the introitus?

Back 326

3+

p. 705
- pending delivery.

Front 327

You have a 32 week pregnant woman who came to the ER, + hx of HTN. She reported in for abdominal cramping, but appeared well. At presentation: 130/80, HR88, RR 22, Temp: 98. Nurse tells you, "she's just lying down. Ill let you know if there's anything". You go seen other patients and after a while return to check on her, and note she is 88/40, HR: 106, RR and Temp unchanged. she does not appear to be indistress and has no bleeding. What is th e problem? How do you fix it?

Back 327

THis was likely HoTn 2/2 lying on her back too long andf compressing the inferior vena cava. have her lay on her left lateral side and observe for improvement.

p. 705

Front 328

MC after premature rupture of membranes, the child is delivered w/in what time?

Back 328

28 hrs

p. 705
- 50% w/in 5 hrs, 95% w/in 28 hrs

Front 329

pregnant patient reports following "gush" of clear, blood tinged fluid. What happened/

Back 329

spontaneous rupture of membranes

p. 705
- sometimes patients report clear fluid/dampening of under garments when standing, sneezing or coughing

Front 330

22 y/o F reports after noting spotting of clearfluid with coughing or standing. VS: 100/60, HR: 120, RR: 24, Temp: 102, SaO2: 97%. FHT: 200 bpm. She has had no surgeries, she is G1. + prenatal care, only medications are PNV's. NKDA. She is more concerned about the pain and fever and chills. States feeling "sick". Appears ill, non-toxic. Lungs CTAB, Heart: RRR-tachy, no MGR. Abdominal TTP, particularly over the fundus. On pelvic examination, using sterile speculum, you note no significant findings except a foul smelling d/c. What is the likely source?

Back 330

Chorioamnionitis

p. 705

Front 331

What is the pH of the amniotic fluid and what affect does this have on nitrazine paper?

Back 331

7.0-7.4 pH
- turns nitrazine dark blue

p. 705

Hint 331

Vaginal fluid is more acidic: 4.5-5.5, and the nitrazine remains yellow

Front 332

What can cause a false + on nitrazine strips?

Back 332

1. blood
2. semen
3. lubricant
4. trichomonas vaginalis
5. cervical mucus

p. 705

Front 333

What is another test, aside from nitrazine, that can confirm rupture of membranes? The test uses sodium chloride crystals on a slide where the amniotic fluid has dried.

Back 333

Ferning

p. 705

Front 334

You do the vaginal examination on a pregnant patient concerned about contractions. You note the presence of thick, greenish brown fluid. What is this?

Back 334

the presence of meconium

p. 705

Front 335

What is the term given to rupture of membranes proceeding labor?

Back 335

premature rupture of membranes

p. 705

Front 336

What is the term given to rupture of membranes that takes place priorm to 37 weeks?

Back 336

preterm rupture of membranes

p. 705

Front 337

What some indicators of fetal distress?

Back 337

1. late decelerations in HR
2. persistent drop in fetal HR during contractions lasting > 30 seconds after a contraction

p. 706

Front 338

What duration of bradycardia signifies fetal distress as too prolonged and in need of c-section?

Back 338

> 5 minutes

p. 706

Front 339

What are some treatments to improve fetal distress, initially, particular when evidence of decel's?

Back 339

1. Lateral decubitus position, right decubitus and maternal knees to chest- to improve fetal HR to baseline
2. Bimanual, sterile fetal scalp stimulation
3. Maternal IV hydration
4. Maternal oxygen administration via facemask
5. Terbutaline injection may halt uterine contractions and increase blood flow

p. 706

Front 340

You have a female with 10 cm dilated and 100% effacement, with fetus at > 3+ station in the emergency department with safety net established. Delivery is imminent. Go to OB?

Back 340

NO! Have OB provider come to the ED, rather than risk precipitous delivery during transport to their delivery suite

p. 706

Front 341

Why is it important to ensure that the cervix is fully dilated prior to patient "pushing" when they feel the urge?

Back 341

Failure to fully dilate can result in cervical lacerations

p. 706

Front 342

How often does a women push with contractions?

Back 342

3 pushes, each lasting 10 seconds during contractions

p. 706

Front 343

What are the six cardinal movements of fetal descent?

Back 343

1. engagement
2. flexion
3. descent
4. internal rotation
5. extension
6. external rotation

p. 706

Front 344

What form of episiotomy is greater risk for extension tear into the anal sphincter and/or rectum?

Back 344

medial episiotomy

p. 706

Front 345

When delivering an infant, if the nuchal cord is wrapped around its neck loose, what do you do? What is tight? (occurs in 25-35%)

Back 345

- loose: Reduce over the infants head and proceed with deliver
- tight fit: Clamp it, in its two most accessible areas and transect it. Deliver the child

p. 706

Front 346

What do you do with the infant who you fear/suspect has mecomium aspiration?

Back 346

If meconium is present at delivery and the patient is in a depressed condition, intubate and suction (tracheal suctioning)

p. 706

Front 347

T/F: At the time of the delivery, it is imperative to take extra caution not to drop the baby- which is a huge risk

Back 347

True

p. 707

Front 348

How far away from the infants umbilicus is the cord clamped prior to transection?

Back 348

3 cm

p. 707- use sterile scissors to cut

Front 349

Why is it important to use antiseptic on the umbilicus following delivery/transection of the cord?

Back 349

To avoid/minimize the risk of:
1. omphalitis
2. neonatal mortality

707

Front 350

When are APGAR scores figured?

Back 350

1 and 5 minutes

p. 707

Front 351

What is APGAR?

Back 351

Activity
Pulses
Grimace
Appearance
Respirations

p. 708

Front 352

What is the score of the following infant: Arms and legs are flexed, pulses < 100 bpm, Sneezing/coughing and crying, normal color over entire body.

Back 352

1-1-2-2-2 (8)

p. 708

Front 353

You deliver a child who is blue, not active, not responsive to stimuli. What should you do?

Back 353

Intubate and begin resuscitive measures

p. 708

Front 354

How long after delivery does the placenta get delivered?

Back 354

10-30 minutes

p. 708

Front 355

After delivery of the placenta, for which gentle (if any traction is applied), what do you do- perform uterine massage and dose of medication, what?

Back 355

10 mg Oxytocin IM

p. 708

(May provide 10-40 in 1 Liter NS, at a rate of 250cc/hr, ie 10 cc IV an hr).

Front 356

You are supervising a resident who is performing a sterile examination of a imminant delivery, when he looks at you and says he feels a cord..."I feel a pulsating cord...is that normal". What do you tell this guy/girl to do?

Back 356

Do not remove the hand. Elevate the presenting part away from the cord to prevent compression. Then tell him to keepm doing that while in transport with the patient on the way to surgery. "Do not remove the hand or stop elevating that part. And do not try to reduce the cord".

p. 708

Front 357

A childs delivery is going well, up until you see a turtle head sign. At this, you have a colleague note the time. Flex mothers knees into the extreme lithotomy position, insert foley catheter, perform mediolateral episiotomy, and then have an assistant applu suprapubic pressure the symphysis pubis. Why?

Back 357

THis is shoulder dystocia; never apply pressure to the fundus- this will force more pressure of the shoulder against the symphysis pubis.
This is called the McRobert's Maneuver
p. 709

Front 358

What if the McRoberts Maneuver does not work for shoulder dystocia patient?

Back 358

Attempt wood's corkscrew

p. 709

Front 359

When are breech deliveries most common?

Back 359

Preterm infants, < 28 weeks

p. 709

Front 360

What are the four forms of breech delivery?

Back 360

1. Frank breech
2. Complete breech
3. Incomplete Breech
4. Footling

p. 709

Front 361

What is the main point for a frank and complete breech delivery that the ED clinician needs to remember?

Back 361

Keep your hands away and let the delivery happen.

p. 709

Hint 361

refrain from touching until the umbilicus appears.

Front 362

Footling and incomplete breech positions are NOT considered safe for vaginal delivery. Why?

Back 362

There is a risk of cord prolapse or incomplete dilation of the cervix

p. 709

Front 363

T/F: even premature infants of 18-22 weeks gestation should receive initial resucitative measures until a determination of viability is made.

Back 363

True

p. 709

Front 364

What is the chance of survival for an infant 21 weeks? What about 25 weeks?

Back 364

- 0%
- 75%

p. 709

Front 365

Third world/scarce reources in delivery. In unclean conditions, what is a major cause of newborn mortality?

Back 365

Neonatal tetanus

- boil water and use only sterilized crap.

p. 709

Front 366

Vaginitis is a spectrum of dz causing vulvovaginal sxs, burning, itching and d/c. What are the factors associated with acute vulvovaginal d/c?

Back 366

1. Infections
2. Irritant or allergic contact
3. Local response to vaginal FB
4. Lack of estrogen in perimenopausal and postmenopausal women (atrophic vaginitis)
5. Postirradiation changes

p. 711

Front 367

What are the three MC causes of infectious symptomatic vaginal irritation?

Back 367

1. bacterial vaginosis
2. vaginal candidiasis
3. trichmoniasis

p. 711

Front 368

What are some factors associated with vaginitis in prepubescent females?

Back 368

1. less protective covering of the introitus by labia majora
2. low estrogen concentration
3. exposure to irritants- bubble bath
4. poor hygiene
5. presence of specific agents

p. 711

Front 369

T/F: Thick, white opaque vaginal d/c can be NML

Back 369

True

- can also be thin and watery, each lady may know her NML

p. 711

Front 370

NML gainal pH is?

Back 370

3.8-4.5

p. 711
(Uterus is general alkaline, when d/c during menses descends, can set up for infx)

Front 371

T/F: The vagina is deeply innervated with nerves and is sensitive to mild irritants, provoking itching.

Back 371

False, actually the vagina is scant on nerve endings and burning irritation is MC not detectable until after the vulva are irritated as well.

p. 711

Front 372

T/F: Wet mounts can be negative even in the presence of candida and trichomonas infx.

Back 372

True

p. 711
- additionally, signs of vulval inflammation and minimal d/c suggests possible mechanical, chemical, allergic and non-infx causes as possibility

Front 373

What is the MC cause of vaginitis?

Back 373

bacterial vaginosis

p. 711

Hint 373

thin, whitish gray d/c
fishy odor

Front 374

Why, when obtaining a sample for bacterial vaginosis is it imperative to obtain sample from the mid vaginal wall?

Back 374

Because obtaining from the posterior fornix may yield inaccurate results, because of cervical mucus, blood, semen, douches, and vaginal medications can elevate the pH.

p. 711

Hint 374

Can use the Amsel criteria to dx"
1. thin, homogenous vaginal d/c
2. more than 20% clue cells on a wet mount
3. + results on test for amine release, whiff test (most specific)
4. vaginal pH level >4.5 (most sensitive)

p. 712

Front 375

What conditions can posses yellow d/c?

Back 375

1. Gardenella or other bacteria
2. Trichomonas

p. 711

Front 376

T/F: Treatment effective strategy with Metronidazole 2 gm for BV

Back 376

False, not recommended by CDC.

- best to treat with 500 mg bid x 7 days
p. 713- see Table 106-4

Front 377

Is it recommended to treat male sexual partners to prevent BV?

Back 377

No, there is no benefit or need in treating male partners

p. 713

Front 378

How long should someone taking flagyl d/c EtOH consumption?

Back 378

For 24 hrs or more following last dose

p. 713

Front 379

Can Vaginal Cadidiasis be transferred sexually?

Back 379

Yes, tho naturally not a sexually transmitted illness

p. 713

Front 380

What are some factors that increase the risk of vaginal candidiasis?

Back 380

1. pregnancy
2. oral contraceptives
3. uncontrolled DM
4. frequent visits to STD clinics (2/2 frequent abx tx)

p. 713

Front 381

What is the most common and specific tx of vaginal candidiasis?

Back 381

Vaginal Pruritis

p. 713

Hint 381

- leukorrhea
- severe vaginal irritation, d/c
- external dysuria
- dysparunia

sxs MC are worse prior to menstruation and with intercourse
Odor- very unlikely, suggests more BV if present

Front 382

Why is 10% KOH used to test for vaginal candidiasis?

Back 382

It dissolves the epithelial cells while sparing the yeast buds and pseudohyphae

p. 713

Front 383

What are more effective topical vaginal candidiasis tx, azoles or nystatins?

Back 383

Azoles

p. 713
topicals are >80%-90% effective

Hint 383

however, vehicle of delivery is contingent on the patient requests: creams, lotions, sprays, vaginal tablets, suppositories, and coated tampons- as they are all equally effective.

Front 384

Single dose treatment with oral fluconazole is just as effective as topical therapies, but who can NOT use it?

Back 384

Pregnant females

p. 714

Hint 384

Complicated patients who receive antifungal tx: 5-7 days may be appropriate with topicals or oral agents- fyi!

Front 385

What defines recurrent vulvovaginal candidiasis?

Back 385

four or more in 1 year

p. 714

Front 386

oral anti-fungal treatment for vaginal candidiasis can cause what sxs? (3)

Back 386

GI
HA
Rash

p. 714

Front 387

Trichomonas Vaginalis- common STD, 15-20% of cases of vaginitis. Infx can lead to adverse health outcomes, like what (4)?

Back 387

1. preterm birth
2. low birth weight
3. PID
4. cervical cancer

p. 714

Front 388

What other infx's have been associated with trichomonas vaginalis?

Back 388

1. HSV
2. HPV
3. HIV

p. 714

Hint 388

Also associated with:
- increasing # of sex partners
- early initiation of sex
- lower education levels
- poverty

Front 389

What infx is MC associated with a frothy, white, malodorous d/c?

Back 389

Trichomonas Vaginalis

p. 714

Hint 389

50% of patients are asx

Front 390

How soon following specimen attainment should the specimen be examined, when looking for trich?

Back 390

w/in 10-20 minutes, or the trichmonads will lose motility

p. 714

Front 391

When treating Trichomonas Vaginalis, why is the one time dosing the most efficacious tx?

Back 391

Because: lower cost, fewer side effects, greater patient adherence to the regimen

p. 714

Front 392

What is more common for the vulva, irritant or contact dermatitis?

Back 392

Irritant Dermatitis

p. 715

Hint 392

Common irritants: douches, soaps, bubble baths, deodorants, perfumes, dyes, and scented toilet paper; feminine hygiene products, topical vaginal abx, tight slacks, pantyhose, synthetic underwear.

Front 393

23 y/o F presents with c/o vaginal sense of "swelling", itching and burning. VSS, no significant hx and she is in a monogamous relationship- married. PE NML, Vaginal examination reveals subtle, but + edema, erythema. + TTP over the minora and majora of the labia. Vaginal exam is free of discomfort or d/c. What do you suspect is the reasons she is TTP over her genitals externally.

Back 393

Contact Vulvovaginitis

(Actually more like Vulvitis alone, but what the heck)
p. 715

how do you treat.

Hint 393

R/O and tx infx causes/relations (can develop candidal infx). However, may also recommend topical steroid/ie. sx relief.

Front 394

What should you consider in a patient with chronic vaginal d/c, esp when bloody and/or associated with a foul odor?

Back 394

Vaginal FB

P. 715

Front 395

Child with vaginal d/c, esp when bloody or brown, should be examined for what?

Back 395

vaginal foreign body

p. 715
- but what are some other causes?

Hint 395

1. fecal contamination from poor perineal hygiene
2. spread of respiratory bacteria from hand or perineal contact
3. exposure local irritants

Front 396

When looking for vaginal FB, in children. How is this accomplished?

Back 396

1- saline irrigation in children who are able to tolerate this > 7 y/o
2- general anesthesia- vaginoscopy

p. 715

Front 397

What is associated with vaginal dryness, soreness, itching, dyspareunia, spotting or discharge; and is common w/in 4 yrs postmenopause? D/c is scant, thin and yellowish. PE reveals vaginal epithelium that is thin, inflammed, and even ulcerated.

Back 397

Atrophic Vaginitis

p. 715

Front 398

What is the tx for atrophic vaginitis?

Back 398

Topical vaginal estrogen cream

p. 715

Hint 398

SE: AUB, breast pain, perineal pain, endometrial hyperstimulation
Contraindication: Hx of CA of reproductive organs

Front 399

Where are the Bartholin Glands located?

Back 399

Labia Minora

p. 716
When presenting with an abscess, where MC is it?

Hint 399

In the posterior introitus: 4 and 8 o'clock positions.

Front 400

When suspected Bartholins Abscess, how tx'd?

Back 400

Local anesthesia, a stab incision with an 11 blade, insertion of a word catheter...for 4-6 weeks. Abx and Analgesia. This should be done by gyn 2/2 consideration for further work up etc.

p. 716

Front 401

What are the MC breast concerns in the ED (5)?

Back 401

1. breast pain
2. breast mass
3. nipple d/c
4. infx
5. postoperative complications

p. 720

Front 402

Where is the sensory innervation of the breast innervation?

Back 402

Dermatomal

p. 720

Front 403

Where is the arterial blood supply to the breast from (4)?

Back 403

1. Internal Mammary Artery
2. Lateral Thoracic
3. Thoracodorsal
4. Subscapular Arteries

p. 720

Front 404

Where does the lymphatic drainage of the breast go?

Back 404

Axilla

p. 720
- small portion to the inferior mammary lymph nodes

Front 405

What suggests a benign course with the breast eval?

Back 405

1. Sx variation with menstruation
2. Sxs in the contralateral breast


p. 720

Front 406

Where do most of the breast carcinomas originate in the breast?

Back 406

Upper outer quadrant and in left more than right

p. 720

Front 407

What is the term associated with inappropriate secretion of milk from the breast?

Back 407

Galactorrhea

p. 721

Hint 407

MC too much prolactin

Front 408

What is associated with galactorrhea, amenorrhea, hirsutism, facial acne, visual field defect, and HA's?

Back 408

Prolactinoma

p. 721

Front 409

What is associated with glactorrhea and an inability to clear circulating prolactin?

Back 409

Chronic Renal Failure

p. 721

Front 410

What results in increased pituitary secretion of prolactin, 2/2 increased levels of thyrotropin-releasing hormone?

Back 410

Hypothyroidism

p. 721

Front 411

What shared anomaly with the breast do: hypercortisolism and acromegaly have?

Back 411

associated with galactorrhea

p. 721

Front 412

What occurs in the 3-5th postpartum day, possessing sxs of painful, hard, and enlarged breasts. May also have a low grade fever?

Back 412

breast engorgement

p. 721
What helps to reduce the sxs?

Hint 412

Breast pumping.
- remember, candidal growth into the lactiferous ducts is possible 2/2 to the carbohydrate rich milk. In cases where candidal growth is suspected, provide topical candidal tx's with the pumping

Front 413

Breast feeding (for weeks) patient reports w/concerns of pain in the right breast. Has had fever, chills, fatigue and bodyaches, as well as FLS. THe breast exam reveals a erythematous region on the breast, that is well localized area of reproducible pain. What is it?

Back 413

Puerpal mastitis

p. 721

Hint 413

MC cause: Staphylococcus Aureus and E. Coli., as well as Streptococcal Species
TX: breast emptying, routine hand washing prior to breast manipulation, as well as analgesia. If sxs severe: abx.
DO NOT routinely interrupt breast feeding

Front 414

While the differentiation of mastitis vs. breast abscess may be difficult, why is it important?

Back 414

Because cessation of breast feeding is imperative to prevent neonatal infx with breast abscess.

p. 722

Hint 414

Bactrim or clindamycin may be appropriate for staph and anaerobic species may be appropriate

Table 108-2, p. 722

Front 415

What is the differential of inflammatory breast conditions:

Back 415

1. infectious mastoiditis
2. breast abscess
3. periductal mastitis
4. ruptured breast cyst
5. inflammatory neoplasm
6. metastatic CA
7. TB
8. paget's disease

p. 722

Front 416

What does the failure of an inflammatory breast condition to improve with abx suggest?

Back 416

The need for urgent surgical consultation and possible bx to exclude the presence of inflammatory breast causes

p. 723

Front 417

When might general anesthesia be needed for a breast abscess?

Back 417

For large periareolar or retroareolar abscesses

p. 723

Front 418

T/F: Mastitis and/or breast abscess can cause systemic toxicity.

Back 418

True

p. 723

Front 419

What are the following, with regard to mastitis/abscess of the breast: sepsis, hemodynamic instability, immunocompromise/immunosuppression, failure of outpatient abx, rapidly progressive infx, failure of outpatient abx.

Back 419

Reasons for admission or immediate surgical consultation

p. 723

Front 420

What is the benign breast condition by which the breast has dilated ectatic ducts with retained secretions, surrounded by significant tissue inflammation?

Back 420

Periductal Mastitis (Mammary Duct Ectasia)

p. 723

Front 421

What is the chronic condition by which there is obstruction of the sweat glands associated with polymicrobial colonization with Staph A and Strep species implicated in pathogenesis of infx.

Back 421

Hidradenitis Suppurativa

p. 723

Front 422

What form of breast CA is the one with the highest mortality as well as the longest delay from presentation to definitive dx?

Back 422

Inflammatory breast CA

P. 724

Front 423

A 60 y/o F presents with: mastalgia, gross breast inflammation, w/a peau d' orange appearance of the overlying skin, nipple retraction and edema. THe breast is tender and warm; without a palpable mass. Possible axillary lymphadenopathy. What is the worst thing this patient can have?

Back 423

Inflammatory breast CA

P. 724

Front 424

You saw a patient a week ago who appeared to have a breast abscess vs cellulitis and at that time was treated once prior to your exam with abx. You provided more abx, only changed the therapies to cover MRSA. Patient returns because she feels no improvement and maybe even worse. What should you consider?

Back 424

Inlfammatory breast CA

P. 724

Front 425

When during menstruation is breast pain most severe?

Back 425

Premenstrual

- mastalgia, mastodynia

p. 724

Hint 425

Pain is b/l and MC most severe in the upper, outer quadrants

Front 426

What does the following nipple d/c suggest: originates from a single breast, emanates from a single duct, is either clear, pink, bloody, or serosanguineous?

Back 426

Carcinoma

P. 724

Front 427

A pt presents with a palpable, superificial cordlike mass in the outer lower quardrant of breast, with overlying pigment change and dimpling. + Discomfort. No recent, though very remote hx of possible trauma. What is it and how is it treated?

Back 427

Mondor Disease

- Tx conservatively, NSAID or Narcs if needed

p. 724

Front 428

What is a benign proliferation of the lactiferous ducts presenting with eczema or an erosion of the nipple; requiring a referral to breast specialist for surgical excision?

Back 428

Erosive Adenomatosis

p. 724

Front 429

A patient seen for breast problem: weeping, eczematous lesion of the nipples- it almost always associated with breast CA?

Back 429

Paget's Disease

p. 724

Front 430

T/F: Fibrocystic breast disease includes: skin thickening, edema, discoloration, nipple retraction and occasional d/c.

Back 430

FALSE- it is never associated with these things

p. 725

Front 431

Breast CA is rare in patients < 20 y/o and uncommon < 30 y/o. However, what are some risk factors for breast CA?

Back 431

1. Inheritence of BRCA1 and BRCA2 genes
2. hx of childhood malignancy
3. hx of chest irradiation
4. First degree relative with known malignancy
5. exposure to endogenous estrogen- delayed childbearing > 30 yrs old
6. bx confirmed atypical breast hyperplasia increases risk women > 30 y/o.

MC breast CA occurs in women > 50 y/o and only two risk factors

p. 725

Front 432

What are the following signs: palpable breast mass with or w/o: lymphadenopathy, skin ulcerations, mass fixation to the chest wall, fixed axillary nodes, and the presence of isilateral arm edema?

Back 432

Reasons to urgently refer to breast surgeon

p. 725

Hint 432

Reasons for delayed dx and poorer survival rates:
- black
- lower socioeconomic status
- unmarried
- NML or false neg mammogram
- presentation with nipple lesions or axillary mass
- younger age at the time of dx

Front 433

What should you be thinking in a patient with isolated breast injury?

Back 433

1. Abuse
2. Cancer

p. 725

Front 434

Up to 1.5 L of blood can extravasate into the traumatized breast parenchyma. If expanding hematoma, may need to be evacuated by a surgeon, may have a bleeding vessel. but that is for acute findings. What about later presentations of hematomas?

Back 434

Analgesia, compressive bra, and correction of any underlying coagulopathy.

p. 725

Hint 434

Remember too, following injury one can have fat necrosis. This will often be a palpable mass with dimpling- remote/recent hx of trauma. However, CA has to be ruled out.

Front 435

What are the most common reasons for ED eval following a gyn procedure?

Back 435

1. pain
2. fever
3. vaginal bleeding

p. 725

Front 436

What are the important "key questions" to ask a patient following their gyn procedure and reporting to the ED for concerns?

Back 436

1. surgical procedure
2. route of procedure: vaginal, abdominal, lap
3. reason for the procedure
4. time of the onset of sxs
5. proximity of sxs to the surgery
6. complications already experienced
7. other surgical hx
8. medications prescribed

p. 725

Front 437

Why is the interval between the onset of post op gyn surgeries and the onset of sxs important?

Back 437

Because is < 24 hrs after the surgery, infection is unlikely. However, causes may be:
- pulmonary atelectasis
- hypersensitivity rxns to the abx
- pyogenic rxns to the tissue ot trauma
- hematoma formation

p. 726

Front 438

T/F: Abdominal pain radiating the shoulder following gyn lap procedure is common 2/2 CO2 bubbles from the insufflation of the surgery. THis pain is concerning only if associated with nausea/vomiting and a change in bowel habits

Back 438

True

p. 726

Front 439

T/F: If a post-op patient presents for abdominal pain following a gyn procedure, the vaginal exam with speculum and gloves should be performed with sterile technique.

Back 439

True

P. 726

Front 440

Why should a pelvic examination in a women undergoing fertility treatment be deferred to the OB/Gyn provider?

Back 440

Because there is a risk of rupturing an enlarged ovarian follicle.

p. 726

Front 441

When is air absorbed by following air or insufflated CO2, what post-op day?

Back 441

Post op day 3

p. 726

Front 442

What are some common indications for gyn laparoscopy(8)?

Back 442

1. Sterilization
2. Lysis of adhesions
3. CO2 laser ablation endometriosis
4. Uterine surgery
5. Tubal surgery
6. Ovarian surgery
7. paraovarian cyst excision
8. laparoscopic vaginal hysterectomy retropubic urethropexy

p. 726

Front 443

What is the MC gyn surgical procedure performed in the US?

Back 443

female sterilization

p. 726

Front 444

What are the MC complications associated with laparoscopy (7)?

Back 444

1. Thermal injury to the bowels
2. Perforation of viscous
3. Hemorrhage
4. Vascular Injury
5. Ureteral or bladder injuries
6. Incisional hernia
7. Wound dehiscience

p. 726

Front 445

Patient reports to the ER with diffuse lower abdominal pain, fevers. Appears to be ill and in considerable pain. Last abdominal surgery was lap hysterectomy 2weeks ago. No other surgeries. PE c/w peritonitis. Labs reveal leukocytosis. Decided to get AAS- which revealed air under the diaphragm. What happened?

Back 445

THermal perforation of the bowels

p. 726

Front 446

What should be considered until proven otherwise, when a patient present with greater than expected pain after laparoscopy?

Back 446

Bowel Injury

p. 726

Front 447

What presents ~1-14 days postop lap procedure w/flank pain, peritonitis, fever. Elevated WBC count and requires IV pyelogram or CT scan which may reveal extravasation of urine or uroma?

Back 447

Thermal injury to the Ureter

- can happen to bladder too
p. 726

Front 448

What is a hysteroscopy? Why is it done?

Back 448

1. It is a direct visualization of the uterine cavity using a fiberoptic scope
2. dx and therapeutic examiantions.

p. 727

Front 449

Which is associated with more postop complications: operative hysteroscopy or diagnostic hysteroscopy?

Back 449

Operative Hysteroscopy

p. 727
- what type of concerns is this procedure MC associated with

Hint 449

AUB
Uterine Fibroids
intrauterine adhesions
proximal tube obstruction
removal of intrauterine devices
mullerian anomalies
removal of small polyps
endometrial ablation of menorrhagia

Front 450

What are the complications associated with hysteroscopy?

Back 450

Fluid overload
uterine perforation
post-op bleeding
gas embolism
infx
toxic shock syndrome
anesthesia reaction

p. 727

Front 451

T/F: Patient is at risk for CO2 induced embolism with hysteroscopy, 2/2 insufflation. The treatment for this is trendelenberg positioning/left lateral decubitus position and resuscitative measures. Aspiration of gas as well a hyperbaric tx options are also available too as well as admission to ICU.

Back 451

True

p. 727

Front 452

What gyn surgery is the MC "major" surgery in the US?

Back 452

Hysterectomy

p. 727

Front 453

T/F: Total hysterectomy is the removal of the uterus and part or all of the cervix. It has no association with the ovaries. Subtotal is removal of the uterus w/o cervix

Back 453

True

p. 727

Front 454

What remains a significant risk of morbidity with gyn procedures with postop infx risks as high as 50-60%?

Back 454

Hysterectomy

p. 727

Front 455

What is a common complication following abdominal and vaginal hysterectomy?Signs and sxs are common days 3-5 postop. Pt c/o back pain, pelvic pain, abdominal pain, fever, abnormal vaginal d/c. Pelvic exam reveals erythema and induration of vaginal cough; possibly even purulent d/c and labial edema. Leukocytosis. CT scan may be neded.

Back 455

Cellulitis of the vaginal cough

p. 728

Front 456

What is a common complication following abdominal and vaginal hysterectomy?Signs and sxs are common days 3-5 postop. Pt c/o back pain, pelvic pain, abdominal pain, fever, abnormal vaginal d/c. Pelvic exam reveals erythema and induration of vaginal cough; possibly even purulent d/c and labial edema. Leukocytosis. CT scan may be neded.

Back 456

Cellulitis of the vaginal cough

p. 728

Front 457

Patient has had a hysterectomy a few days ago, now c/o fever, chills, abdominopelvic pain and rectal pressure. + TTP vaginal cuff. (May actually feel a palpable mass near the cuff and possible purulent drainage)

Back 457

Vaginal Cuff Abscess

p. 728

Hint 457

Vaginal cuff hematomas, which can become infected, may present later. Usually associated with low H/H

Front 458

Patient has had a hysterectomy a few days ago, now c/o fever, chills, abdominopelvic pain and rectal pressure. + TTP vaginal cuff. (May actually feel a palpable mass near the cuff and possible purulent drainage)

Back 458

Vaginal Cuff Abscess

p. 728

Hint 458

Vaginal cuff hematomas, which can become infected, may present later. Usually associated with low H/H

Front 459

Define Dehiscience and Evisceration- how are they different?

Back 459

Dehiscience: disruption of all layers, including fascia and peritoneum.
- this can be heralded by serosanguinous drainage, between days 5-8 and may feel "pop" or tearing
Evisceration: complete breakdown of the healing processes through all levels of the abdominal wall, and the omentum or bowel presents through the incision.
- 1/3 of dehiscence will go to evisceration. Cover with moist, sterile towels. Take to surgery

p. 728

Front 460

Define Dehiscience and Evisceration- how are they different?

Back 460

Dehiscience: disruption of all layers, including fascia and peritoneum.
- this can be heralded by serosanguinous drainage, between days 5-8 and may feel "pop" or tearing
Evisceration: complete breakdown of the healing processes through all levels of the abdominal wall, and the omentum or bowel presents through the incision.
- 1/3 of dehiscence will go to evisceration. Cover with moist, sterile towels. Take to surgery

p. 728

Front 461

T/F: MC urinary retention following gyn procedures are transient and will resolve with time.

Back 461

True

p. 728

Front 462

You walk into a procedure where a urology collegue has a cotton tampin in a patient and puts a urinary catheter in and instills methylene blue/indigo dye into the catheter. States that the patient had an abdominal hysterectomy x 2+ weeks ago and had c/o clear vaginal d/c. He then pulls the tampon out and it has methylene blue on it. What has he proven?

Back 462

Vesicovaginal fistula.

p. 728

Hint 462

tx urinary catherization 1-2 months to allow closure, if none- then surgical repair.

Front 463

A patient had an abdominopelvic surgery x 3 months ago. She has worsening pelvic pain worse when walking. Fever and chills. Pain is over symphisis pubis. + WBC and ESR. Blood cxs are drawn, what do you think it is?

Back 463

Osteomyelitis of the pubis

p. 728

Hint 463

- abx tx and surgical debridement

Front 464

What is the tx for retained products of conception?

Back 464

Dilatation and Curretage

p. 729

Front 465

patient had an elective abortion. No retained products of conception, closed cervical os and firm, but very tender abdomen- uterus. So what's up?

Back 465

Endometritis

p. 729

Front 466

What do women who are Rh Negative require after spontaneous or induced abortion?

Back 466

300 mcgs IM of Rhogam

p. 729

Front 467

Complications associated with induced abortion:
What complication is immediate, w/in 24 hrs post procedure and is associated with uterine perforation, cervical lacerations?

Back 467

Bleeding and pain

p. 729

Front 468

Complications associated with induced abortion:
Delayed complications, between 24 hrs and 4 weeks postprocedure and is associated with retained products of conception, postabortive endometritis?

Back 468

Bleeding

p. 729

Front 469

Complications associated with induced abortion:
Late complication > 4 weeks postprocedure

Back 469

Amenorrhea, psychological problems, Rh Isoimmunization

p. 729

Front 470

How long is postoperative fatigue following gyn surgery common for?

Back 470

10 weeks, occasionally 6-12 months

p. 730

Front 471

T/F: U/S guided retrieval and preparation for retrieval of oocytes are rare and include: ovarian hyperstimulation syndrome, pelvic infx, intraperitoneal bleed and adnexal torsion.

Back 471

True

p. 730

Front 472

T/F: OVarian hyperstimulation syndrome can be a life-threatening complication of induction ovulation.

Back 472

True

p. 730

Front 473

What are the following sxs c/w abdominal distention, ovarian enlargement, and weight gain.
Aggressive/severe dz: rapid weight gain, tense ascitis, pleural effusion, tachypnea, orthostatic HoTn, tachycardia, oliguria, and electrolyte abnormalities- as well as coagulopathy?

Back 473

ovarian hyperstimulation syndrome

p. 730

Front 474

Why is the bimanual pelvic examination contraindicated in ovarian hyperstimulation syndrome?

Back 474

The ovaries are fragile and are at high risk for rupture and hemorrhage.

p. 730