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200 Cards in this Set
- Front
- Back
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Macule
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An alteration in skin color that cannot be felt. It is <0.5 cm
>0.5 cm is a patch |
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Patch
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Same as a macule: an alteration in skin color that cannot be felt, except a patch is >0.5 cm
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Papule
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Palpable solid lesions smaller than 0.5 cm
>0.5 cm is a plaque |
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Nodule
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firm lesion thicker and deeper than the average papule or plaque
rule of thumb: height is deeper than diameter, though depth may be subcu |
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Plaque
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Palpable solid lesion >0.5 cm
<0.5 cm is a papule |
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Vesicle
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raised lesion filled with clear fluid <0.5cm
>0.5cm is a Bulla |
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Bulla
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raised lesion filled with clear fluid >0.5cm
<0.5cm is a vesicle |
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wheal
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palpable flat topped manifestations of dermal edema
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cyst
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enclosed vacities with a lining that contain liquid or semisolid material and are located deep in skin, covered by normal epidermis
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Ersion vs Ulcer
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Erosion: depressed area representing a blister base with the epidermis removed
Ulcer: same as erosion w/ loss of dermis |
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Scales vs Desquamation
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scales are excess of dried epidermis
desquamation is when sheets of skin come off |
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exoriation
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traumatized area of skin caused by scratching or rubbing
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fissues
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linear, we shaped cracks
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petechiae vs purpura
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petechiae: deposit of blood less than 0.5 cm
purpura: deposit of blood >0.5cm |
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Dermoscopy
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non invasive magnification
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Diascopy
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test for blanching under pressure:
press a clear glass slide over a lesion hemorrhagic lesions (peptechiae, purpura) do not blanch urticaria and inflammatory lesions blanch |
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Necrotic Ulcer
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Brown Recluse Bite
No pain on initial bite Toxin is sphingomyelinase D: lyses RBC's Summer, Dark, Dry, Indoor Environments Southern Central region: TX, OK, LA, AR, MO Tx: cold packs, elevation, tylenol, tetanus shots if not up to day --cold reduces the fnx of sphingomyelinase D |
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Brown Recluse Bite
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No pain on initial bite → Necrotic Ulcer
Toxin is sphingomyelinase D: lyses RBC's Summer, Dark, Dry, Indoor Environments Southern Central region: TX, OK, LA, AR, MO Tx: cold packs, elevation, tylenol, tetanus shots if not up to day --cold reduces the fnx of sphingomyelinase D |
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Black Widow Bite
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latrodectus mactans
sharp pinprick of pain neurotoxin α-Latrotoxin, forces release of NT's → @ 1 hour: cramping, muscular rigidity, pain, n/v, anxiety, psychotic behavior presentation is abdominal pin, but hypertensive and hyperactive rather than hypotensive and guarded Tx: cold packs, observation, narcotics, muscle relaxants if spastic, tetanus booster if not to date antivenom available, not given b/c allergic rxn |
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latrodectus mactans
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Black Widow
sharp pinprick of pain neurotoxin α-Latrotoxin, forces release of NT's → @ 1 hour: cramping, muscular rigidity, pain, n/v, anxiety, psychotic behavior presentation is abdominal pin, but hypertensive and hyperactive rather than hypotensive and guarded Tx: cold packs, observation, narcotics, muscle relaxants if spastic, tetanus booster if not to date antivenom available, not given b/c allergic rxn |
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erethematous macules in groups of 3's on lower extremities
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flea bites
fleas can only jump 2 ft can lie dormant >1 yr and creativate upon vibrations of footsteps Tx: antihistamines & steroid creams Rugs, beds, animals must all be treated NB: fleas may transmit typhus and plague |
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itchy red papules around ankles and wasteline, exposure to grass
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Chiggers
Stylostome is tube like structure of larvae in skin Tx: vigorous clensing to detach larvae from skin & topical steroids + antihistamines; wash clothes in hot water |
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expanding erythematous macule
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erythema migrans of Lyme disease (Borrelia burgdorferi)
± multiple ± central clearance (takes days to clear) Ixodes tick must feed >24h w/in 1st mo: Stage I: flu like sx & EM rash Wks-mos: Stage II: Arrhythmias, blockades, neurologic problems mo-yrs: Stage III: arthritis & chronic neurologic problems erythema migrans in an endemic region is sufficient to tx empericlaly w/o lab confirmation Tx: Doxycycline |
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debilitating itching in nursing home pt
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Sarcoptes scabiei mite
burrows in fingerwebs are pathognomonic, but not snsitive ≥7 mo incubation! Tx: permethrin: neck down overnight; all household members if nursing home: all pts, all staff, all freq visitors rx'd, all linens/clothing, carpets cleaned don't have to tx pets |
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itching finger webs
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Sarcoptes scabiei mite
burrows in fingerwebs are pathognomonic, but not snsitive ≥7 mo incubation! Tx: permethrin: neck down overnight; all household members if nursing home: all pts, all staff, all freq visitors rx'd, all linens/clothing, carpets cleaned don't have to tx pets |
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honey crusted
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nonbollous empitigo
Staph aurus or GABHS Tx: mupriocin ointment TID Dicloxacillin or cephalexin po in bullous cases |
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inflammation of hair folliciles
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folliculitis
Staph aureus on face or legs Pseudomonas aeruginosa on trunk if hx of hot tub expsorue Tx:: Bactrobran for less extensive areas No tx for hot-tub folliculitis |
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Carbuncle vs Faruncle
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Faruncle is boil usually an infected hair follicle mostly due to MRSA
Carbuncle are confluent faruncles, will have multiple openings Tx: warm compresses, I&D usually sufficient, send fluid for culture |
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vesicular rash with varying size following a wee of dermatomal pain
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Shingles
rule of 7's: 7 days of vesicles 7 days of crusts 7 more days until resolution Involvement of tip of nose (Hutchinson's sign) pt at risk for serious ocular complications Tx: acyclovir or valacyclovir w/in 72 hours of Sx onset; NSAIDS & Tylenol for pain |
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Zostavax
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to all adults >60
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Involvement of tip of nose in Shingles outbreak
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Hutchinson's sign, pt at risk for severe ocular complications
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Vesicular rash which does not follow a dermtiomal pattern
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Herpes sinplex
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herpes simplex labialis
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recurrent herpes simplex cold sores
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gingivostomatitis
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ulcerative lesions of mouth an thorat
1* HSV infx in young children |
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Whitlow
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herpes infection of distal fingers seen in healthcare workers
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Herpes gladiatorum
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disseminated HSV skin lesions seen in wrestlers
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Tzank prep
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non specific non sensitive test for HSV: looking for multinucleated giant cells
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Apthous ulcer vs HSV
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apthous ulcers is never proceed by vesicles and never outside the mucsoal surfaces
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dome shaped papules w/ central umbilication and cheesy material inside
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Molluscum Contagiousum pox virus (DNA)
Tx: observation & occasionally cryo/curettage |
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Hand foot and mouth disease
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Self limited exanthum-enanthum
exanthum: widespread rash enanthum: rash on mucosal membrane Coxsackie Virus A16 Tx: symtomatic |
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Herpangina
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Coxsackie Virus A2,6, 7, 8 or 10
self limited enanthum of the pharynx Tx: symtomatic |
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small red papules which develop into vesciles and then scab over
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Chicken Pox
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Warts
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verrucae
flesh covered hyperkeratotic papules that have small black dots form trhombosed capillaries caused by HPV transmitted through broken skin Tx: LN2, cautery, trichloracetic acid etc. |
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1) In what types of patients and in what areas of the body should you avoid using a local anesthetic with epinephrine?
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[Known sensitivity to anesthetic, mostly esters]
Avoid using epinephrine in the nose, toes & fingers, penis and ears. Also avoid epi periorbitally in those with narrow angle glaucoma Extreme caution should be used when using epinephrine in peripheral vascular disease, diabetes, hypertension, thyrotoxicosis, or cerebrovascular disease since these patients may respond poorly to a vasoconstrictor. Also use caution with epinephrine in contaminated wounds since decreased blood flow can hasten infection. |
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2) In a patient who is allergic to Novocaine, can you use Xylocaine? Should you use the multidose vial or the single dose vial?
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Yes, there is no cross reactivity between Amides and Esters
Amides: Lidocaine (Xylocaine), et al Esters: Procaine (Novocaine), et al Multidose vials of amides have rpeservatives chemically similar to esters so it is best to use signle dose vials in bts with known ester allergy to avoid sensitivity. |
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3) Does epinephrine extend or shorten the duration of a local anesthetic?
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Increases
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4) Which causes less pain: SubQ or intradermal injection?
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SubQ
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5) What can you do to reduce the pain of an injection?
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Distract teh pt, use a small needle, inject slowly, subcu. add sodium bicarbonate to buffer acidity, warm solution, pinch and shake the skinw hile injecting, and use topical anesthetic or refrigerant/ice cube prior to injecting.
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6) How long does it take EMLA to work and can you use it on broken & unbroken skin?
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Takes 1-2h to work
for use on intact skin only |
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7) How long does it take for a digital nerve block to work?
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(5-10 minutes?)
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8) Describe the direction of pressure used to loosen and lift an ingrown nail. Then describe the way that the nail is split and removed.
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Loosen and lift 1/4 of the nail advancing with continued upward paesussrue waway from the nail and away from the nailbed. split the nail longitudinally via scissors or nail splitter.
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9) What is Phenol used for and what complication can occur with it?
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cautery of germinal nailbed via 3 min application.
(I think pregnants aren't supposed to be in the room) |
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10) How do you differentiate a subungual hematoma from a subungual melanoma, splinter hemorrhages, and green nail syndrome?
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subungual hematoma: collection of blood under nail from trauma. generally horizontal
green nail syndrome: pseudomonas under the nail: discoloration is green-black subungual melanoma: linear longitudinal and pigment may extend into the soft tissue. |
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11) Describe the difference between the procedure for removing a 1-barb versus a 2-barb fish hook.
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1-barb: "back out" method: use local anesthesia over tip of hook, advance it clip the tip off with a wire clipper and back the hook out
2 barb: "push through" method: twist the hook forward until sharp end is visible. cut off eye o the hood and pull on sharp end needle technique : use a needle to cover the barb them back out the hook (not sure if one or two) |
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12) How do you pull out a tick and what should you avoid doing?
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paint the surrounding area with betadine
grasp the tick as close to the skin surface as possible and pull up and out do not twist, jerk, squeeze crush or puncture place tick in EtOH and freeze disinfect bite with iodine for retained moth parts: infiltrate benith with lidocaine, apply bunch perpendicualrlry, encompassing the tick mouth parts, submit the soft tissue for histo evaluation do not place oil on tick to smother it or use a hot match to get the tick to relase: will cause tick to regurtitate at site. |
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13) Know how to perform a punch biopsy and how you know if you are through to the subQ tissue.
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--Prep the area with alcohol; this is a clean, not sterile procedure
--Place a ring of anesthesia around and/or deep to the lesion --Choose the appropriate sized punch (2-mm biopsies may not provide adequate tissue for diagnosis. Try to choose a punch that is 2mm larger than the lesion you wish to remove. It used to be felt that 4-mm biopsies probably needed to be sutured, but a study in 2005 showed that is not the case. --Stretch the skin on both sides of the planned biopsy site away from the site, perpendicular to skin tension lines, using the thumb and index finger of the nondominant hand. --Push the biopsy instrument vertically into the skin and rotate it to cut through the skin to the sub-Q fat. You will feel a decrease in resistance at the point where the dermis is completely penetrated. --Withdraw the punch and push down with the fingers on each side of the biopsy. If the plug goes down with the skin, the biopsy has not gone deep enough. If the plug pops up instead of going down, then the tissue has been freed adequately. --Grasp the specimen with forceps, lift it and cut the sub-Q base with scissors. |
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14) How many mm beyond the margin of the lesion must you freeze for a benign lesion?
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1-3mm
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15) What are the disadvantages to cryotherapy?
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Disadvantages/Complications of Cryosurgery
--Not good for dark skin: destroys melanocytes: repigmentation +- occur with migration of others. --Destroys Hair Follicles --Scars more susceptible to sunburn --Damage to superficial nerves (peroneal, post-auricular) |
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15) What are the contraindications to cryotherapy?
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Absolute contraindications
--Melanoma or lesion with uncertain diagnosis --Areas of end-stage compromised circulation --Patient unable to accept possibility of pigment changes --Recurrent basal or squamous cell cancers Relative Contraindications --Cold intolerance/Raynaud’s --Cold urticaria --Cryoglobulinemia or diseases associated with high levels of circulating cryoglobulins (collagen vascular disease, PSGN, Hepatitis B, Lymphoma, Macroglobulinemia, Severe active UC, EBV, CMV, High dose steroid therapy) --Heavily pigmented skin --Lesions located in pretibial area, eyelid margins, nasolabial fold, and hair bearing areas |
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16) What type of suture is best for skin and what size is used on the body?
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Nylon (Ethilon) that is monofilament and unbraided will best reduce incidence of infection. A 4-0 or 5-0 is used on scalp or body and the smaller 6-0 suture is sued on the face. Approximate, do not strangulate.
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17) What is the preferred technique for biopsy for pigmented lesions?
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Excisional biopsy
sterile procudred with fenestrated drape cut down to subcu & remove entire lesion in elliptical fashion don't corss-hatch incisions at the apices |
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18) Why is a cervical polyp removed?
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not necessary to remove unless large or sx.
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19) When do you need to give tetanus immune globulin?
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Only need Ig if fewer than three doses or uncertain vaccination Hx + wound which is either not clean or not minor.
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20) What is Hutchinson’s sign for fingers?
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extension of pigmentation from nailbed into soft tissue of the finger. indicative of subungual melanoma.
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1) What are the two most emergent conditions that must be considered in a woman of childbearing age who presents with abdominal / pelvic pain?
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Hemorrhagic Shock from ruptured ectopic pregnancy and Septic Shock from PID
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2) What is the relationship of previous episodes of Pelvic Inflammatory Disease to future fertility?
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1 episode 1/10 decrease in fertililty
2 episodes 1/3 decrease in fertility 3 episodes: 1/2 decrease in fertility |
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3) Complete this sentence: The diagnosis of ectopic pregnancy should be considered ....
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in any woman of childbearing age presenting with a complain of lower abodminal pain or pelvic pain
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any woman of childbearing age presenting with a complain of lower abodminal pain or pelvic pain
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The diagnosis of ectopic pregnancy should be considered
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4) What are the important areas of focus in the history of a woman of childbearing age presenting with abdominal / pelvic pain?
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1. Current Pregnancy Status
2. Vaginal Bleeding Amt: pregnancy, PMS, dysmenorrhea, endometriosis or ectopic pregnancy 3. LMP: when was it, was it normal 4. Sexual Activity: Hx of STI's, Contraceptive Techniques, Last Intercourse 5. Gravity/parity: Hx of ectopics and miscarriages 5. Postural Dizziness: hypovolemia/shock 7. Presence of Fever: assoc w/ PID 8. Pain |
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What is the temporal relationship of nausea and vomiting in some of the differential diagnoses discussed?
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Vomitting: N/V occur concerrently with GU/pelvic pain but generally PRECEDES GI pain
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Discuss the history of radiation of pain as it relates to several differential diagnoses.
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--radiation to back: retroperitoneal abscess, bladder infx, dysmenorrhea
--radiation to extremity: fibroids, ectopic pregnancy, dysmenorrhea --generalized peritonitis: benign cysts rupturing into peritoneum, indistinguihsble from ruptured ectopic pregnancy |
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7) Discuss the timing and rate of onset of pain as it relates to several differential diagnoses.
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--pain during/before menses = endometriosis
--Pain during/after menses = salpingitis --Midcycle = Mittelschmerz rupture of follicular cyst --Pain of rapid onset consistent = ruptured viscus or acute infx |
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8) Discuss the duration / intensity of pain as it relates to several differential diagnoses.
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--sudden severe , continuous uniltaeral pain taht rapidly becomes diffuse: ruptured ectopic
--acute or insidious bilateral pain that progresses over Days: PID --PID, torsion typically dull ache --sharp, severe pain late stages of torsion, ruptured ovarian cysts, ectopic pregnancy --pain first associated with exercise or coitus consistent with ruptured ovarian cyst --unilateral pain: adnexial disease, tubal torsion, cystic rupture, tubal inflammation, ureteral stone, pelvic appendixicts |
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9) What are the risk factors for ectopic pregnancy and for pelvic inflammatory disease?
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PID: Teens
Ectopy: 20's, Black Women IUD: ectopic pregnancy, spontaneous and spetic abortions Frequent Sexual Activity: PID Previous PID: Chronic PID, tubo-ovarian abscesses, ectopy, Gitz-Hugh Curtis gonococcal perihepatitis, recurrent UTI PID: 3x increase in ectopy Previous tubal pregnancy: 10% risk for ectopy Tubal surgery: 10x risk of ectopy Dilation and Curettage: minor increase in risk for ectopy |
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10) Discuss the physical exam focus in a childbearing aged female patient with a complaint of severe abdominal / pelvic pain
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Vitals: Orthostatics
General appearance: signs of shock --movement indicative of crampy pain --still indicative of peritoneal signs Abodmainl Exam: peritoneal signs, local tenderness (not bowel sounds) Pelvic Exam: --Bartholin gland cysts --> gonorrheal infection --Internal Genitalia: PID and Ectopy so painful that manipulation of internal genitalia intolerable once speculum inserted insepction made for bleeding, inflam, discharge. endocervical swab should bbe obtained for cultures and gram stain --Bimaunal Exam: localize denderness, reveal abnormal masses. rectovaginal exam to appreciate pelvic viscera in its entirety. PID tenderness usually bilateral, ectopic tenderness in one adnexa. |
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11) Discuss the method of pregnancy testing used today that is most reliable and sensitive.
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7-10 days after conception: betahCG sensitivity near 100%. Sepcificity 96%
2-3 days post-implantation: monoclonal antibody technology |
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12) Discuss the use of a complete blood count in the work-up of a female with abdominal / pelvic pain
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H/H does not necessarily reflect acute hemorrhage
left shift: infection (salpingitis) WBC count may be elevated 2* to stress alone |
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13) Discuss the use of urinalysis in the work-up of the female with abdominal / pelvic pain.
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Can differentiated UTI and ureteral calculi from PID/ectopic.
Presence of a UTI does not exclude the possibility of PID/ectopic pregnancy |
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14) What are the instructions for a “clean catch specimen”?
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Clean catch specimin req's clena area in downward direction 2x, start to urinate in toilet and then stop then start to pee in cup. Cannot obtain? Straight catheterization.
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15) Discuss the use of ultrasound in the work-up of the female with abdominal / pelvic pain.
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Effectively excludes ectopic pregnancy if demonstrates intrauterine pregnancy. Earliest sign at 4 weeks. Best resolution is transvaginal.
Fetal heart not detected before 7 weeks. Ectopic pregnancy: adnexal mass, fluid in cul-de-sac, extrauterine gestational sac |
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16) Discuss the entities listed below, specifically including pain history, precipitating events,
associated symptoms, laboratory findings, and management. |
A) ectopic pregnancy
B) pelvic inflammatory disease C) endometriosis D) ruptured corpus luteum cyst / torsion of ovarian cyst E) degeneration of uterine fibroids / myomas F) mittelschmerz G) Threatened abortion see clinical entities chart |
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17) Understand the patient care / diagnostic flow chart as to work-up for a patient with vaginal bleeding or pain in the stable 1st trimester pregnant patient.
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???
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Signs of Pregnancy:
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Amenorrhea
Nausea/Vomiting at 2wks Breast tenderness enlargement at 6 wks Areolar enlargement and increased pigmentation at 6 wks Urinary frequency, Nocturia, Bladder irritability Chadwick's sign: bluish discoloration of vagina/cervix |
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HCG & pregnancy
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beta is specific
detectable 8-10d post fertilization ~doubles every 2 days until ~wk10 also produced by: hydatiform mole, choriocarcinoma, other germ celll tumors, extopic producing breast cancers and large cell lung carcinoma |
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Fundal Height in Pregnancy
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Detectable above pubic symphysis, at Umbilicus
Above pubic symphysis at 12 weeks at Umbilicus at 20 weeks |
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Prenatal Care:
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Folic Acid
Flu Vaccine good screen for gestational DM, Gonorrhea, Chlamydia, Syphilis, HIV, HepB Do not Give Live Vaccines: MMR or Varicella |
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Prenatal workups
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First Visit: papsmear, Blood Type, Antibody Testing, UA, STD Screening
~wk 17: Ultrasound ~wk 27: Diabetes, H/H, RhoGam wk 26: GBS Postpartum: fetal blood type: Rhogam |
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Chromosomal Screening
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First Trimester: increased beta-HCG, decreased PAPP-A and ultrasound for nuchal translucency T21 & T18
AFP at 20wk for NTD Quad screen: 2nd trimester: HCG, AFP, estradiol, inhibin Tri13: low PAPPA & low hCG Tri21: low AFP & E3, high HCG & In Tri18: low everything ONTD: high AFP |
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Pregnancy and Blood Sugar
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During 1st Trimester watch for hypoglycemia (from increased insulin sensitivity + N/V)
During 3rd Trimester: Increased IR 2/2 hPL human placental lactogen, progesterone, prolactin, and cortisol So: During 7th month 1hr GTT: non fasting 50gm = >130 is positive 3 hr OGTT: 100 gm. at 1h >180 or >85 if fasting, at 3h >140 Desired [glucose]blood ranges ruing pregnancy Fasting 70-105 2h PP: 100-140 Labor: 60-100 |
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Fetal Effects of Gestational Diabetes:
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increased fetal insulin --> excess fetal growth esp adipose ts --> macrosomia & shoulder dystocia
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Non-Gestational DM & pregnancy
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spontaneous abortions
congenital malformations: cardiac defects, CNS anomalies (anencephaly, spina bifida), skeletal malformation (sacral agensis, caudal regression) Test for DM at 6wk pp visit |
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Hyperemesis Gravidarum
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Frequent vomiting early in pregnancy: produces weight loss, dehydration, acidosis (starvation), alkalosis (Loss of HCl), Hypokalemia
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Early Embryogenesis
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First 3 days w/in fallopian tube
D4: solid morula enters uterus D5: fluid filled blastocyst w/ trophoblast and inner cell mass; cell masses muiltply until expanded blastocysts hatches from zona shell D6: blastocyst implants in uterine lining |
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Complications of twins
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(good path card on this one)
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Respiratory changes of pregnancy
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40% Increased Tidal volume w/ same RR
20% Decreased FRC = Decreased ERV & RV 20% increased O2 consumption Increased PO2, PaO2, Decreased PaCO2, PCO2 Respiratory alkalosis: renal excretion of bicarb |
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Physiological changes of prgnancy
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Respiratory alkalosis; No change in Respiratory Rate!
EKG: ST, T, see Q waves, inverted T waves CXR: cardiomegaly w/ heart rotated left Arrhythmias: SVT's Nasal stiffiness, epistaxis Hydronephrosis R>L 8.5L Increased Body Water |
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Metabolic changes of Pregnancy
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Insulin sensity increases in first 20 weeks: decreased fasting glucose
IR and Increased [insulin] last 20 weeks |
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Fasting glucose level in late pregnancy
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less than in nonpregnant
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Managing IUGR
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--deserves more consideration than I'm willing to give it right now
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Risk Factors for and Risks of Macrosomia
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Diabetes, Obestiy, Previous Hx, Post term Pregnancy, Multiparity, AMA
At Risk For: Birth Trauma, Shoulder Dystocia, Jaundice, Hypoglycemia, Low Apgar Scores, C-section |
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Erb's Palsy
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C5 & C6
50% of shoulder dystocia: weakened deltoid, infraspinatus & biceps Hand and wrist movements preserved (unlike Erb's Palsy plus) Eb's Palsy Plus C5, C6 & C7 35% of shoulder dystocia adduction, internal rotation of arm, extension and pronation of forearm, flexion of writsts and fingers. |
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Klumpkey's Palsy:
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Traction on the abducted arm: C8 -T1 injury
(infant being pulled from birth canal via arm above head) isolated hand paralysis and Horner's syndrome (ptosis & meiosis) claw Hand: forarm supinated and writ and fingers flexed paralysis of intrsinc hand muscles, ulnar nerve distribution numbness |
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Risk Categories for Medications while Pregnant
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A: studies do not show risk to fetus
B: animal studdy cannot produce risk, no stides done with human; else adverse effects in animals, but not seen in human studies. C: Animal studies with adverse effects and no studies on humans D: Evidence of human fetal risk, may be acceptable if drug needed for life threatening dz X: Does produce abnormalities. Risks always outweight benefits |
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Teratogenesis Timeline
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1-2 wks: all or non
Organogenesis: 5-10 wks Dose and Duration: varies by genotype & drug, some worse with large dose, others worse with low, prolonged concentrations. |
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Molecular Features of Rx's which Cross the Placenta
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<1k daltons, lipid soluble, non polar, non protein bound
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Fetal Effects of EtOH
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Growth restriction, MR, microcephaly, mild facial hypoplasia, renal/cardiac defects
6/day = increased 40% FAS |
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Fetal Effects of Cocaine
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Bowel Atresias, Heart, limb, facial, & GU malformations. IUGR, cerebral infarct, placental abruption
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Fetal Effects of Lithium
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Ebstein anonaly (malformed tricuspid valve, ASD); toxic to thyroid, kidenys, neuromuscular system, esp in last month. heart malformations in 1st trimester low.
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Fetal Effects of Phenytoin
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IUGR, MR, microcephaly, cardiac defects, hypoplastic nails & phalanges, caraniofacial abnormaliteis; full syndrome in <10% some type in 30%
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Fetal Effects of ACEI's
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Renal tubular dysplasia, RF/olifo, IUGR
Fetal mortality 1/3, increased risk 2nd & 3rd trimester |
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Fetal Effects of Tetracycline
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Tooth enamel hypoplasia, incorportion into bone & teeth --> brown discoloration
Safe for 1st trimester |
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Fetal Effects of Valproic Acid
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NTD, minor facial defects
Worst in first trimester prior to closure of Neural Tube |
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Fetal Effects of Vitamin A derivatives
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increased abortion rates, CNS defects, cleft lip/palate, MR, thymic agenesis
isotretinoin exposure prior to pregnancy not a risk, but etretinate has effects long after discontinuation |
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Fetal Effects of CMV
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Most common congenital infection
--Hydrocephaly, microcephaly, chorioretinitis, cerebral calcifications, symmetrical IUGR, microphthalmos, brain damage, MR, hearing loss --Congenital infection rate 40% after primary infection and 14% after recurrent infection --Of infected, see effects 20% and 8% respectively |
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Fetal Effects of Rubella
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--Microcephaly, MR, cataracts, deafness, heart disease
--Malformation 50% if mom infected in 1st trimester vs 6% by mid- pregnancy --Immunize children and non-pregnant adults but not in pregnancy, (live vaccine) |
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Fetal Effects of Syphilis
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--Fetal demise with hydrops if severe vs if mild see abnormalities of skin, teeth, and bones
--Severity depends on duration of infection, worse if >20wks --Treat with PCN to prevent progression of disease |
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Fetal Effects of Toxoplasmosis
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--Microcephaly, hydrocephaly, cerebral calcifcations, chorioretinitis (most common), severity dependent on duration of time
--Low prevalence in pregnancy (.1-.5%) --Infection during pregnancy to be teratogenic --Transmitted via raw meat or infected cat feces --Fetal infection greater in 3rd trimester but severities greater in 1st trimester --Treat w/ sulfadiazine, spiramycin, or pyrimethamine |
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Fetal Effects of Varicella
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--Chorioretinitis, cataracts, microcephaly, hypoplasia of hands/feet, muscle atrophy
--7-21 wks gestation is time of risk --High neonatal death when mom gets VZV five days --prior to delivery up to 48hrs postpartum |
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Definition & Danger Signs of Pre-Eclampsia
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Systolic BP >140 mmHg OR Diastolic BP >90 (after 20wga)
Proteinuria >300mg on 24hr urine (or 1+ on urine dip) Danger signs of Pre-Eclampsia 3rd Trimester: --HA/Visual Disturbances --Hands and Face Swell --If only feet swell not serious |
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Vasa Previa, Velamentous cord insertion, Placenta accreta, Placenta Increta, Percret
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Vasa Previa: cord vessels pass over internal os
Velamentous cord insertion: fetal vessels insert into the fetal membrane (choriamnionic membrane) b/w amnion and chorion Placenta accreta: placental villa attached to myometrium Placenta Increta: placental villa invade into myometrium Percret: placental villa invade through myometrium |
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3rd Trimester Bleeding
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Painful bleeding with fetal distress: Abruption
Painless but profuse bleeding: Placental Previa: do not do a digital exam |
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Reasons to Induce Labor
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Maternal: Post date, AMA, PROM/PPROM, DM, Heart Disease, Pre-expamspia, HTN, IUGR
Fetal: IUGR, abnromal fetal testing, infex, Rh incompatilibity, oligohydramnios |
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Induction methods for labor
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Oxytocin: 4mλ, worry about water intoxication and uterine tetany
Cytotec: msoprostol PGE1 Cervidil- dinoprostone PGE2 Prepidil Gel: PGE2 Mechanical: Foley, Laminaria |
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Cervical Dilation: visually comparison: 2cm, 4cm, 6cm, 8cm, 10cm
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2cm: penny
4cm: oreo 6cm: soda can 8cm: donut 10cm: roll of cheap TP |
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Fetal station
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relationship of fetal head to mother's pelvis
Zero is at ischial spine, negatives are further up, positives are further down |
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Bishops score:
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The Sum of 0-3 scorings of Dilation, Effacement, Station, Consistency, and Position
<=4 ~=50% failure 5-9 ~= 10% failure 10+ 0% failure >6 favorable for induction |
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Labor
Definition, Staging |
Progressive dilation of uterine cervix associated with repeptive uterine contractions
Stage 1: From Onset to Fill Dilation 2 Phases: latent and active Latent: slow increase in cervical diameter Active: rapid increase in cervical diamter (friedman curve: sigmoidal over time) Difference between nulliparas and multiparas Stage 2: From cervical dilation to fetal delivery nulliparas: 50 min mulitparas: 20 min Variables: size of fetus, maternal expulsive efforts, neuraxial anesthisa, pelvis shape Stage 3: From fetal delivery to placental delivery Usually 5 min, concerning if >30 |
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Signs of placental separation
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uterus become sglobular
gush of blood uterus rises in abdomen cord elongation |
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Friedman Curve:
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the sigmoidal curve of cervical diameter over time, with the major upswing in diameter occuring in the active phase of the frist stage of delivery
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The 3 P's of successful vaginal Delivery
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power, passage, passenger
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Power as one of the 3 P's of Delivery
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spontaneous, augmented, induced
pharmacology: oxygocin, PGE's monitoring: palpation, extenrla transducer, internal pressure catheter Measured in montevideo units; montevideo units: intensity of contractures over baseline; measures sum of all contractions/10 minutes. <180 inadequate, >200 preferred |
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Passage as one of the 3 P's of Delivery
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maternal pelvis
Gynecoird and Anthropoid = Good Shapes Android or Platypoid = Bad Shapes see Obstetric & True conjugates |
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Pelvic Conjugates
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narrowest diameter through which the baby's head must pass: between sacral promontoy and pubic symphysis; should be >=10cm. cannot be directly measured, estimated by subtracting 1.5 cm from diagnoal conjugate
True conjugate: from sacral promintory to top of pubic symphysis Diagonal conjugate: from sacral promintory to bottom of pubic symphysis When measuring: hang in "gun" position you don't want to touch the sacrum or have your thumb tuch the pubic arch. Ischial spines should be at least 10cm apart pubic arch: wider is better: thumbs togeter at top of pubic arch to make triagnel Tuberosities: >10m, make fist and it should fit between them |
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Passenger as one of the 3 P's of Delivery
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Small Enough, Positioned Correctly, Proportioned Correctly, Coming out In the right Direction
Almost all present with cephalic ~3% don't: Breech, Transverse, Compund, Face, Brow Fetal Lie: relation of the longa xis of the ftus to the mother: can be longitudinal, transverse, oblique Fetal Presentation: whatis closest to birth canal: vertex, breech, shoulder, compound Fetal Attitude/Position: relationship of presenting part to right or left side of maternal birth canal: vertex, chin, sacrum |
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Cardinal movements of labor:
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1. Engagement: when the largest transverse diameter of the head (BPD) is below the level of the pelvic inlet = at the ischial spines = 0 station
2. Descent: discontinuous process, occurs at fastest during 2nd stage of labor 3. Flexion: passive motion to optimize diameters presenting to pelvis 4. Internal Rotation: rotation of occiput from original position (ususally transverse) towards symphysis pubis or sacrum 5. Extension: occurs at vulva: head extends around pubis 6. External Rotation "Resitituion": fetus resumes its face forward position wtih occiput and spine lying in same plane 7. Complete Restitution "Expulsion" delivery of anterior shoulder followed by body |
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Engagement
(Obstetrics Jargon) |
first cardinal movement in labor
when the largest transverse diameter of the head (BPD) is below the level of the pelvic inlet = at the ischial spines = 0 station nulliparas occurs prior to labor multiparas can occur in conjugation with step 2: descent |
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Leopold Maneovers
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Abdominal palpation of gravid uterus for the diagnosis of fetal lie and presentation
What is at the fundus where rae the pine and small parts what is presenting in elvis where is cephalic prominence see picture |
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Asynclitism
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based on sagittal suture not mideway between symphsis and sacral promintory
google & draw picture --Anterior: when more of the anterior parietal bone presents itself ot the examining fingers --Posterior: when sagital suture lies more closely to symphysis and more of the posterior parietal bone will be present (may be able to palpate posterior ear) |
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Face presentation:
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head is hyperextended
chin mentum anterior: vaginal delivery still an option mentum posterior: brow is pressed against symphisis must C section Causes: aneencephaly, fetal neck pathology, pelvic inlet contraction, multiparas with pendulous abdomen |
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Brow presentation
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rare, not vaginally deliverable
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montevideo units
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intensity of contractures over baseline; measures sum of all contractions/10 minutes. <180 inadequate, >200 preferred
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Breech position
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Frank breech position: lower extrmeity is flexed at hips and extended at knees; allow delivery wihtout assistance to level of umbilicus if possible
Complete breech: one of both of fetal knees are flexed Footling breech: an incomplete breech where one or both feet below the breech; recommended for C-section |
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Slide 103-118 disorders of labor etc
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also review fetal circulation
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Prematurity Consequences
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Pulmonary Hypoplasia/RDS
Intraventicular Hemorrhage Necrotizing Entercolitis Systemic Infx/Spesis NICU admit Death |
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Postpartum Hemorrhage:
Causes What does: Normal, Low BP, <80 and <70 BP indicate |
Atony, Retained Products, lacerations, Coagulopathy
Normal: ~10% blood loss: palpitations, tachycardia, lightheadedness Low: ~20% blood loss: weakness, sweating, Tachycardia <80: ~30% blood loss: Restlessness, confusion, pallor, oliguria <70: ~ 40% blood loss (2.5 L): Lethargy, air hunger, anuria, collapse |
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Tx: Post Partum Hemorrhage 2* to Atony
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Bimaual Message
Methergine ergot alkoloid Oxytocin PGF2alpha: Corboprost or Hemabate Misoprostol Dinoprostone Bakri Ballon Blood Products |
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Lactation
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Stage I: during 2nd half of pregnancy: differentation o secretory units & slight milk production
Stage II: post partum: copious milk production processes involved: exocytosis, reverse pinocytosis, trasncytosis, apical trasport and paracellular mvmt oxytocin induces myoepithelial contraction to force milk out of ducts |
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Mastitits
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Staph aureus
Mild no MRSA: outpt dicloxacillin/cephalexin Mild maybe MRSA: TMPSMX or Clidamycin or Linezolid Severe infection: vancomycin until C&S results, then specific treatment |
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Vulvar/Vaginal Hematoma
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mostly caused by surgery/episiotomy
conservative management of small non-expanding hematomas promt surgical intervention of expanding hematomas, else arterial embolization hemodynamic instability often first sign of retropeitoneal hematoma |
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Causes of Post-Partum Fever
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Womb: endometriosis
Wind: atelectasis, pneumonia Water: UTI, pyelo Walk: DVT, PE Wound: Infx, wound or epis Weaning: breast engorgement, mastitis, abscess Wonder: drug fever |
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Endometritis
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Dx: >38Cx2 >24h pp or >38.7C at any time
Eval: PE, pelvic (r/o hematoma, retained tissue) CBC w/ dif, UA +c/s, blood cx, CXR, U/S Rx: Ampicillin, Gentamycin, and Clindamycin Tyelnol and Fluids Continue Rx until 24-38h afeb If fever persists consider pelvic abscess, septic pelvic thrombophlebitis |
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Define diagnostic criteria for DMII.
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Must be confirmed on 2 occasions:
Fasting Blood Glucose >=125 Abnormal Glucose Tolerance Test >=200 2 hours after glucose laod Random BG >=200 HgA1c >=6.5 |
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How does HgA1c correlate to EAG (est. avg. glucose).
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5% ~= 100
Every % thereafter equal to +[35 glucose] |
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Define impaired fasting glucose.
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100-125
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What is the connection between obesity and DMII?
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Accumulation of proinflamatory substances
--NEFA's non esterified free fatty acids --Adipokines (promote fatty acid oxidation) Lipotoxicity --Affects B cell fnx of pancreas --Attenuation of insulin signal --Loss of inhibition of GnG decreases Glucagon |
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How effective are lifestyle changes in the management of DMII?
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10% weight reduction will usually reverse the symptoms of new onset T2DM
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Define Macro and Microvascular diseases in DMII.
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Macrovascular Diseases:
MI is most common cause of death in T2DM Strokes, Renal artery stenosis, gangrene of lower extremity Microvascular: diffuse thickening of basement membranes w/ leaky capillaries controlled with bloodsugar Neuropathy: peripheral, or mononeuropathy of obturator, femoral, sciatic Nephropathy: unctonrolled DM: 20 years to renal failure GI dysmotility Foot Ulcers |
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What is the initial treatment of DMII based on HgA1c > 7 vs. HgA1c > 9 with symptoms?
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<7.5% monotherapy
--Metformin, GLP-1 Agonist, TZD, DPP4, Alpha glucosidase inhibitors 7.6-9% dual therapy --Metformin + (GLP-1 agonist, DPP4 inhibitor, Glinide, or Sulfonylurea) >9% aSx start with triple therapy --Metformin + either (GLP1 or DPP4 inhibitor + TZD, glinide, or sulfonylurea) >9% Sx: start with insulin |
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What is the role of lipid lowering and blood pressure control in DMII, what medications are used?
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Blood Sugar Control does not directly affect macrovascular risk
BP Control: Substantial Reduction in microvascular complications (33%) Major Reduction in macrovascular complications (40%) Major Reduction in Kidney Decline (50%) Every 10 mmHg decrease in systolic BP down to 140 will decrease risk for ANY diabetic complication substantially (12%) Lowering diastolic BP from 90 to 80 --> major reduction in macrovascular events (50%) Medications for HTN: ACEI's or ARBs angiotensin receptor blockers. |
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What is the role of lipid lowering and blood pressure control in DMII, what medications are used?
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Blood Sugar Control does not directly affect macrovascular risk
LDL control: major reduction in CV complications (~35%) LDL <100 goal; <70 optional goal in high risk pts (diabetes + existing CVD) HDL: >40 in men, >50 in women TAGs: <150 Total Cholesterol/HDL ratio =<4 |
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most common cause of death in T2DM
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MI
Blood Sugar Control does not directly affect macrovascular risk See cards for BP and Lipid lowering |
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Define clinical findings of hyperthyroidism.
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Hyperthyroidism
Hypermetabolic State, Overactive SNS [lots of stuff] |
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Define clinical findings of hypothyroidism.
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Fatigue, Fluid retention, weigth gain
Dry yellow skin cold intolerance & Hypothermia course/easily lost hair reflex delay constipation goiter hyerlipidemia bradycardia memory and mental impariment Depression Irregular/Heavy menses Infertility Myalgias Myxedema fluid infiltration in tissues |
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What is the most common cause of hyper and hypothyroidism?
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Hyperthyroidism: ?Graves disease, ie stimulatory auto-antibodies
Hypothyroidism: Hashimoto's disease: attacking auto-antibodies |
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What are the lab tests that correspond to hyperthyroidism?
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Hyperthyroidism
TSH: Low (Single Best Screen) Free T4: High Used to Confirm Dx (stop there?) Radioactive iodine uptake: correlates to glandular activity Technicium Tyroid scan: evaluates for mass lesions and Further studies not routinely necessary |
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What are the lab tests that correspond to hypeohyroidism?
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TSH: Low
Free T4: Low Thyroid Autoantibodies: anti-thyroperoxidase, or antithyroglobulin auto-antibodies Thyroid scan, US or both to rule out structural abnormalities |
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What medications are used to treat hyper and hypothyroidism?
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Hyperthyroidism: antithyroid drugs
methimazole or propylthiouracil preffered in pregnancy Hypothyroidism: Levothyroxine; Dose titrated every 6 weeks until stable [Rx] acheived. TSH is most important determining of dosing |
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What is the difference between Cushings Disease and Cushings Syndrome?
|
Cushing Syndrome is the Syndrome and may be caused by endogenous or exogenous causes
Cushing's Disease is a pituitary adenoma esp in 30 yo +-10 women with hypersectrion of POMC |
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Endogenous Causes of Cushing's Syndrome
|
ACTH dependent
--Pituitary Adenoma (Cushings Disease) --Paraneoplastic ACT or CRH secretion |
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ACTH independent causes of Cushing's Syndrome
|
--Autonomous hypersecretion of cortisol
--Micro/macronodular hyperplasia --Adrneal adenoma/adenocarcionma |
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Cushing's Disease
|
a pituitary adenoma esp in 30 yo +-10 women with hypersectrion of POMC by pituitary adenoma
Labs show elevated ACTH plasma levels: need to rule out small cell lung CA MSH prodxn causes hyper pigemntation microadenomas most common macroadenomas >1cm |
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Addison's Disease
|
Adrenal insufficiency: not enough cortisol
Cuases: Most A/im else Mets, TB, AIDS Sx: chonic fatigue, malaise; salt craving, anorexia/abomdinal pain, loss of libido, hypotension, pigementation of skin and mucus membranes; normocytic anemia, elevated TSH Labs Serum cortisol levels: increase starting at 3 am peak after waking >18mg/dL excludes Addisons <6mg/dL suggests Addisons ACTH injection: any increase in cortisol >18mg/dL excludes Addisons Not >18mg/dL: check ACTH levels to confirm the problem is the adrenals, not the brain. Once Dx: determine cause: look for antibodies: look at images, look for plasma VLCFA (Very Long Chain Fatty Acids), and for other autoimmunities Tx: repalce hormones: hydrocortisone, cortisone, prenisolone, dexamethasone and then fludrocortisone |
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Hyperaldosteronism
|
too much aldosterone
Accts for ~8% ("some") of all HTN cases Hyperaldosteronism: suppression Renin activity, HTN, Hypokalemia, Hypernatremia, metabolic Alkalosis, increased CO Aldosterone causes CV problems: stroke, MI's Hypokalmia 40% ("Often")--> weakness, paresthesials, visual disturbances, and possible tetany Labs: Hypokalemia, Hypernatremia, hyperglycemia, metabolic alkalosis, hypomagnesemia, low renin Dx: elevated PCA:PRA ratio ie plasma aldosterone concentration to plasma renin activity if positive procede to confirmatory aldosterone suppression test Tx: spirolactone, amiloride or ACEI's to control BP ad hypokalemia Surgery (unilateral adrenalectomy) |
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Non-Classical Adrenal Hyperplasia
|
("Adult Onset CAH)
AR defect in 21 hydroxylase enzyme: decreases cortisol production. increased ACTH shunts products down to androstendieone production ~6% of women with dx of hyerandogenism (less common than PCOS) |
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Waterhouse-Friderichsen Syndrome
|
acute adrenal insufficiency
catastrophic syndrome w/ overwhelmin bacterial infex most commonly N meningities septicemia rapidly progressive hypotension --> shock, DIC; Adrenal hemorrhage cause of adrenaocortical insufficency. |
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pheochromocytoma
|
catecholamine secreting chromaffin cell tumor: most common tumor of adrenal medulla in adults, M=F 30yo (±10), may also be extra-adrenal paraganglionoma: difference is important (assoc. neoplasms, malignant potential, genetics)
~20 min Spells of the P's: non-exertional Palpitation, Perspiration, HA Pain, Pallor and Tremor, and Tx Resistant HTN (Pressure) There is a genetic susceptibility to Pheo: MEN2, NF1 and VHL Dx: Free metnephrines and catecholamines in 24h urine collection: DA--> HVA homovanillic acid, NE --> VMA Vanillylmandelic Acid, E --> Metanephrine, (Rx's which ↑↓ [Catecholamine, DA] interfere with test); Follow positives w/ Abd CT Rule of 10's: 10% etra-adrenal, bilateral, malignant, not assoc with HTN, calcify, in kids, familial (not all at once) Tx: surgical resection, prepare pts with alpha and beta blockades: -osins, phntolamine, atenolol etc. |
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|
the most common way that HIV is transmitted worldwide
|
heterozexual sex
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|
The virus is transported to regional LN's w/in ? of acquisition
|
48h
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|
HIV RNA levels then approach a steady state between viral production and clearance, called ? within 6 months of infection
|
the viral set point
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|
Most common clinical feature of acute HIV infx is
|
fever
|
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|
1. ELISA +, Western Blot repeatedly negative
2. ELISA +, Western Blot + 3. ELISA +, Western Blot indeterminant 4. ELISA +, Western Blot indeterminate, HIV RNA + 5. ELISA --, Western Blot --, HIV RNA 110,000 |
1. False + ELISA
2. HIV 3 Unknown 4: Acute HIV 5. Acute HIV |
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3. When is a person usually symptomatic in acute HIV and how long does it last?
|
<2wks
>2wks poor Px |
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4. What does the rash of acute HIV usually look like and what is the distribution?
|
Classic Rash = maculopapular & symmetrical, primarily face or trunk, appearing 2-3 days after onset of fever and lasting for about a week. Not usually itchy
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5. Is the risk of sexual transmission higher in acute or chronic HIV?
|
Risk is 30% higher in acute HIV than Chronic HIV
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|
6. What causes a higher susceptibility to transmission?
|
Ulcerative/Inflammatory STD's
Genital/Oral Trauma Menses Uncircumsized Depth of Needle Penetration Hollow bore needles visisble blood on needle Source is in advanced stage of disease, also 30% higher in acute HIV |
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7. Describe some of the most common signs and symptoms of a person presenting with acute HIV.
|
Most Probable Preesenting Sx: Fever, Fatigue, Pharyngitis, Rash
Most Probable Presenting Signs: Lymphadenopathy, Thrombocytopenia, Leukopenia OtherSx: Weight loss, myalgia, HA, Nausea, Night Sweats, Diarrhea, Vomitting, Abdominal Pain, Depression Other Signs: Aseptic meningitis, elevated liver enzymes, oral/genitla ulcers, candidiasis, splenomegaly Nontender lymphadenopathy (appears in 2nd week), oral ulcers, genital ulcers & splenomegaly Gential ulcers likely the portal of entry |
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8. When should a person be tested for HIV antibodies after a needle stick?
|
ASAP with ELISA to establish negative baseline for worker's compensation claims
Follow up at 6 weeks, 3 mo, 6 mo, +-12 mo |
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9. In a high risk exposure setting, when should postexposure prophylaxis be initiated?
|
w/in 2h
|
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|
10. How can you differentiate oral candidiasis from hairy leukoplakia clinically?
|
oral candidiasis on back of throat and scrapes off
hairy leukoplakia on side of tongue and doesn't scrape off |
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11. Is it more common for a person with an acute HIV infection to be symptomatic or asymptomatic?
|
Vast Majority Sypmtomatic (~85%)
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|
12. What is the viral set point and what is the significance of this number?
|
the steady state between viral production and clearance
lower set points have slower progressions to AIDS lowering peak viral load during HIV results in lower set point |
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13. What types of exposures carry the highest risk of transmission from a known HIV source? (Hint: look at bolded items in handout)
|
Receptive anal intercourse
needlestick with infected blood sharing needles |
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14. What is the significance of a CD4 count < 200?
|
A [CD4]<200 is AIDS defining; Also AIDS defining: an AIDS defining condition (disease): very long list
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|
15. What is the median time from +HIV to AIDS in an untreated patient?
|
10 years
|
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|
16. What constitutes a positive PPD in an HIV+ patient?
|
should be tested annually
>5mm induration |
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17. What kind of consent and counseling are required for HIV screening?
|
Routine voluntary HIV screening of all pts 13-64 recommended. Pts should be given an opportunity to ask questions and notified that screening will take place unless they opt out. Written consent no longer required, verbrally declining test should be documented.
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|
18. What immunizations are contraindicated in HIV patients, and in what instance?
|
Live vaccines: MMR & Varicella if (CD4 < 200), still recommended if pt is not immune & has CD4 >200.
Zoster not recommended |
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|
What are the clinical findings in Cushings Syndrome, what are the lab tests used to diagnose?
|
Hypertension
Weight Gain Obesity Proximal myopathy Osteoporosis Amenorrhea Hirsutism Depression Immune Suppression Hypokalemia Hyperglycemia Red, purple striae Thin skin, easy bruising Moon face and Buffalo hump |
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|
What Lab Tests are used to Dx Cushing Syndrome
|
2 step diagnosis:
1st: demonstrate elevated cortisol: 24h urinary free cortisol; 1mg dexamethsone suppression test. midnight salivary cortisol test (confirm with 24h UFC) 2nd ID cause by ACTH level OR Measure urinary cortisol excretion after examethasone high and low doses ACTH <5pg/ML: ACTH independent CS: Adrenal CT ACT >=20pg/mL: ACTH depdendent CS: pituitary MRI, CRH test, 8mg Overnight Dex |
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What is the most common cause of Cushing’s Syndrome?
|
Most commonly caused by exogenous intake for therapy
|
