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578 Cards in this Set

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HPAO
Hereditary Progressive Arthro-Ophthalmopathy
Stickler’s Syndrome
5 A’s
Ask
Advise
Assess
Assist
Arrange
Stages of Change Model To Assess Readiness
Precontemplation
Contemplation
Preparation
Active
Maintenance
PC PAM
(do they think it’s PC) to use PAM oil.
Stages of bereavement and grief
Shock 2w
Awareness/Anger
Bargaining
Depression 6mos
Resolution 1-2 y
SAB DR
Primary amenorrhea
No secondary sex characteristics by 13
No menses by 16
No TAP 13, No Men 16
WHI Study

For the group of women on HT. CEE/MPA

Small but significant increased risk of:
DVT
Invasive Breast Cancer
Stroke
Heart Attack (MI)
DISH
Behcets triad:
Immigrant
Genitalia
Eyes
Oral
GEO
effect of Pagets of vulva
“Cake for the Pageant”
Cake icing
Bisphophonate
B = Both prevents and treats

I= Inhibits osteoclasts

sph = spine and hip
SAIL THE FEMORAL TRIANGLE
Sartorius
Adductor longus
Inguinal
Ligament

The SAPHENOUS ROUTE


The Pirates have large PECS, to scrub the FLOOR
(Pectineus muscle is the floor of the triangle)
PEACH Study
PID Evaluation And Clinical Health
PID treated as inpatient v. outpatient
No diff in CPP, infertility, TOA, ectopic, IUP, recurrence, persistent infection
High risk level for DVT in gyn surgery
>40yo

DVT/PE
Immobilization postop/Inherited thrombophilic disease
Malignancy
ERT

Varicose Veins
Obesity
Prolonged Surgery
DIME VOPS
Chorioamnionitis pathogens
Bacteroides
Prevotella
E. Coli
GBS
BPrEG
Cholecystitis pathogens
BEcK Serratia (Ec,Enc)
Postpartum hemorrhage
Management
Assess/Stabilize
Mechanical
Pharmacological
Blood products
Surgery
Emergent measures
“Ass, mech, Phar, blood, surg, emerg”
Carpenter-Coustan
95, 180, 155, 140
5-year survival by stage for Cervical Carcinoma
85, 65, 35, 12%
cho,fat,prot
DM in pregnancy
50, 30, 20
Ecclampsia
MgSO4
4g to 6g load in 100 mL IV over 15–20 minutes
maintain at 2 g/hr IV

6g IV/IM over 15 – 20 minutes.
Maintain 2g/hr IV
Eclampsia management
Injury – prevent maternal
Stabilize medically
Convulsions – treat/prevent (Mg or phenobarb)
Antihypertensive
Respiratory/cardiac
Fetus
ISCARF
An abdominal circumference within the normal range reliably excludes growth restriction with a false-negative rate of less than ___%
10%
A measurement of what abdominal circumference identifies more than 90% of newborns with a birth weight greater than 4000.
AC >35 cm
TAH v. TVH
S Size uterus
S Shape uterus
C Caliber vagina
L Length vagina
I Infrapubic angle
P Parity/SVD#/birth weights
Prolapse
PID/endometriosis/pelvic surgery

and… Malignancy and other abdominal surgery needs to be done
SS CLIPS
APPY
Dissect/ligate mesoappendix/vessels
Clamp/cut base
Purse string suture at base
Paint stump with betadine
Invert (before finish purse) and embed
Perform u/s in ECV for:
D Dorsum
V vaginal exam
T Type breech

P placenta location
E extended or flexed

P position
A AFI
C cord length/nuchal
U uterine anomalies
DVT PE PACU
Leopold’s
North pole what’s at fundus
South pole what’s in pelvic pole
Back where is back
Attitude extended or flexed head?
WHI
For the group of women on HT. CEE/MPA
Small but significant increased risk of: DISH
DVT ***same for ET
Invasive breast cancer (8 per 10,000 women) ***no significance in ET
Strokes ***same for ET
Heart attacks ***ET did not “prevent”

HT offered health benefits as well.
Lower risk of spine and hip fractures. ***same for ET with Hip
Reduced risk of colon cancer
FFN requirements:
Intact membranes
<3 cm
24-35 weeks
Pneumonia types
F Flu
A Atypical
V Varicella
A Aspiration
B Bacterial
FAVA B
Velocimetry?
Assess Vascular Impedance.
Seizure etiology
Idiopathic/Infection/Injury
Congenital
Tumors - glioma, hamartoma
Alzheimers/Degenerative/Alcohol/Drugs - buproprion,clonidine, lidocaine
Lytes/Metabolic
ICTAL
Incontinence History
F Frequency
U Urgency
N Nocturia
D Dysuria
A Aggravating Factors

Timing Coincident = GSUI
Delayed = DI
Meds causing incontinence
R Reserpine
A Aldomet
D Digitalis

M Major tranquilizers
C Caffeine
Urological Physical Exam
O Obesity
P Prolapse evidence
I Impulsivity of cough

D Degree of estrogenization of pelvic tissue
N Neuro exam
Q Q-tip test
Postmenopausal mass work up
C CT
U u/s
T tumor markers

B Bowel prep
I IVP
G GI work up
Clinical Pelvimetry
inlet

D Diagonal conjugate
R Retropubic space
P Pectineal line

Mid

H Hollow of sacrum
I Ischial spines
S Sacrospinous ligament

Outlet

Coccyx
Infrapubic angle
COHOSH sides
COntractions
HypotensiOn
Seizures
Increases Prolactin
C Craniophayrngioma/adenoma
H Hypothyroid
A Antipsychotic/Haldol
N Nipple stim
T TCA and Reglan
CHANT
Bacterial Pneumonia
Acute fever/chills, productive cough, lobar pattern CXR

Streptococcus
rusty sputum gram+ diplococci

Hemophilus gram-coccobacillus
Uck (productive)
Klebsiella gram- rods
Staphylococcus gram+ cocci
SHucKS
Dilantin
Maternal Side effects
Gummy, Hairy/hypertrichosis, Acne, Rickety (osteomalacia/vit D def) neuropathy/NTD
Fetal effects of epilepsy in pregnancy:
Stillbirth
IUGR
Preeclampsia
SIP
Conditions associated with Uterine Rupture
S Scars - c/s, myomectomy
T Trauma
R Rupture history
I Instrumentation,TOP,Forceps
P Perforation,accreta/increta

C Cocaine
A Anomaly
M malpresentation/molar
P Prostaglandin/Pitocin

M Multiple gestation
O Obstructed labor
E Endometritis prior pregnancy
STRIP
CAMP
MOE
What are the benefits of Autologous Blood transfusion?
SPA

Safety..... no risk of transfusion reactions due to incompatibility.
Purity..... no risk of transmitted disease, such as, among others, HIV/AIDS,
Hepatitis B& C, HTLV/ Human T-cell Lymphotropic Virus 1&2, & Syphilis.
Availability..... instantly available and requires no cross matching.
SPA
Treatment option for Obesity
DEB MS

Diet (usually requires 500-1000 kcal/day reduction. Refer to nutritionist)
Exercise (first focus on exercise consistency, then increase duration and intensity)
Behavior therapy ( stress management, stimulus control, problem solving, social support)
Medications
Surgery
DEB MS
Initial Management of hypertension
Document and classify hypertension
Evaluate for end organ damage
Assess overall cardiovascular risk factors
Rule out secondary and reversible causes
DEAR
Pheochromocytoma Symptoms
Palp Pallor Pers Pain Pressure…Pancreas

Palpitation
Pallor
Perspiration
Pain (chest, head, abdomen)
Pressure (HBP)
Pancreas (hyperglycemia)
“5 P’s”
Treatment of H. Pylori
omeprazole
Clairithromyin
ampiciilin
OCLAM
Thromboprophylaxis in pregnancy. Candidates for therapeutic anticoagulation
V Valves mechanical
I inherited thrombophilia homozygous FVL, Prothrombin mutation, ATIII deficiency
A APS
G
A Active DVT
R Recurrent DVT
A Afib from RHD


Conditions are at highest risk and should have adjusted-dose heparin prophylaxis
VIAGARA
The Physician’s Responsibility to Victims of Domestic Violence

What must the physician do?
SAD SORE

S Screen
A Assess safety/suicide/Acknowledge it’s not her fault
D Document

S Support subsequent
O Offer help/lists/groups
R Refer
E Escape plan

Implement universal screening
Acknowledge the trauma
Assess immediate safety
Help establish an Escape plan
Offer educational materials
Offer list of community and local resources
Provide referrals
Document interactions with patient
Provide ongoing support at subsequent visits
SAD SORE
Classification of Sexual Dysfunction
- Desire disorders
- Orgasm disorders
- Pain disorders
- Arousal disorders
DOPA
Melanoma findings
A asymmetry
B Border irregularity
C Color variagation
D Diameter > 5mm
E enlargement/elevation
ABCDE
Canavan’s Disease (auto recessive)

Enzyme?
Aspartoacylase deficiency (storage disease)
Sparticus cycles.
What are Symptoms of Hepatitis?
FARM
Fatigue
Anorexia
RUQ pain
Malaise

Jaundice
Dark urine/stool
Coagulopathy
Encephalopathy
FARM
Treatment of Thyroid Storm
βIG TRIP

β B Blocker
I Iodine
G Glucocorticoids

T Thermoregulation
R Rehydration
I Iodinated Radiocontrast agent
P PTU
βIG TRIP
How do you counsel a patient regarding VBAC?
Sequelae of rupture hyster/death
Rupture rates

Success rates of VBAC
Failure factors of VBAC

Risk rupture 1% with prior LTCS
Risk of rupture 7% prior classical
Risk of death to mother and baby if rupture
Possible need for hysterectomy if rupture and unable to stop hemorrhage.
Success rate 66% prior CPD
Success rate 75% not for CPD
Lower success if obese, >4000g, >40 weeks, prior labor required ind/aug
Congenital CMV “symptoms and sequelae”
90% of infected neonates asymptomatic at birth, 10% will develop late sequelae
10% of infected neonates symptomatic at birth, 90% of survivors have permanent sequelae
– “90/10” rule:
Amsel’s criteria: BV
Clue POD

Need at least three of four.
pH >4.5,
amine odor on the application of KOH base,
appearance of a thin homogeneous vaginal discharge
clue cells on wet mount.
Clue POD
Gardnerella vaginalis
what are they on path?
gram-negative rods
-Adnexal Mass -What are the criteria that assist you determining whether to observe or treat surgically?
SAC BAGS
S Size
A Age
C Characteristics

B Bilaterality
A Ascites
G Growth
S Symptoms
SAC BAGS
-Discuss post operative bladder care in this patient?
USO

Ureteral integrity

Subjectively - Indwelling catheter for 1-3 days dome and at least 7d if trigone

Objectively - Obtain a cystogram/VCUG to confirm the injury has healed before removing the catheter
USO
What is the lymphatic drainage of the cervix?
Common iliac
External iliac
Internal iliac
Obturator – think Point B
Presacral – think origin of USL
Parametrial – think Stage II
Paracervical
Define DUB:
Disabling Uterine Bleeding
Disruptive Uterine Bleeding
Drugs with Uterine Bleeding

Disabling uterine bleeding that Disrupts lifestyle (ACOG)
DUB “Disabling!” “Disrupts!” (ACOG)
Unexplained bleeding on HRT (ACOG)
DUB “Unexplained!”
B = Bleeding
DUB
Monopolar devices require what type of media if using electrical current?
Electrolyte-poor fluids.
MSG

Mannitol/Sorbitol/Glycine

Monopolar=Mannitol MSG
MSG
What are complications of Dextran 70?
Dextran = DIC
Anaphylaxis

Glycine = ammonia toxicity
D=D
-Discuss (in detail) how you would exhaust conservative options of treatment prior to taking the patient to the OR
MRS

Multiple visits
Relationship doc-pt
Secondary gain none

Marriage disruption
Children – unable to care for
Work interference
MRS

Marriage
Children
Work
Risks of BTL:
REF

Regret
Ectopic
Failure
REF
BTL counseling
Risks REF Regret/Failure/Ectopic

Benefit Permanent – not intended to be reversible

Alternatives/Anesthesia Vasectomy/IUD/short term reversible

Anticipated outcome

Informed refusal

STD
Amenorrhea -How would you work-up a patient with amenorrhea? First rule out the obvious!
LMP
Lactation
Menopause
Pregnancy
LMP
-Hirsutism -Discuss the life cycle of a hair follicle
Life cycle of a hair follicle: ACT


Anagen actively growing last 3 years

Catagen breakdown/transitional phase 3 weeks

Telogen resting phase 3 months, then falls out
ACT
3 steps to classify individual CHD risk category:

Coronary heart disease (CHD)
1)Obtain a fasting lipid profile
2)Identify presence of CHD or CHD equivalents (risk factor that places patient at same risk for CHD event as CHD itself)
Multiple risk factors that confer 10 year risk of > 20%
3) Identify major CHD risk factors other than increased LDL
CHD or CHD equivalents
(risk factor that places patient at same risk for CHD event as CHD itself)
Diabetes
Symptomatic carotid disease
Peripheral arterial disease
Aortic abdominal aneurysm
major CHD risk factors other than increased LDL
Smoking
Hypertension
Low HDL (<40)
Family hx of premature CHD (1st degree male relative with CHD < 55yo, 1st degree female relative with CHD <65
Age > 55 yo
HDL > 60 subtract one risk factor
-What is the contraceptive mechanism of action of both the estrogen and progesterone component in the OCP?
MAOI

Mucus – thickened cervical
Atrophy of endometrium
Ovulation Inhibition




PCOS – give low dose monophasic – study showed may reduce risk endometrial cancer
100 µg LEvonorgestrel and 20 µg Ethinyl estradiol (ALEsse)
MAOI
Failure rate of OCPs.
obesity?
0.1% failure (4.5% failure in obesity)
Causes of recurrent pregnancy loss:
-MULIGI (eulogy)

M Metabolic poorly controlled DM/PCO (no therapy for PCO)/TSH

U Uterine anomalies Septum-poor vascularization, unicornuate , fibroids, ashermans

L Luteal phase defect
I Immune disorders APS, alloimmune hydrops, SLE
G Genetic Balanced Translocation
I Infection TORCH, Parvo, ureaplasma, syphilis

LFD Not proven
MULIGI (eulogy)
Initial incision of VH
Incise Supravaginal septum SVS

entry into the Cervicovesical space CVS

Grasping the Vesicouterine peritoneal fold VPF
SVS
CVS
VPF
Simple screening tool for depression:
Ask two questions:

‘During the past month,
Have you often been bothered by feeling down, depressed or hopeless?’

‘During the past month,
Have you often been bothered by having little interest or pleasure in doing things?’
Down Depressed Hopeless

Little interest or pleasure
Diagnostic Criteria for depression
Diagnosis of depression requires 5 distinct criteria be present:
o Concomitantly
o For most of the day
o On consecutive days
o For at least 2 weeks

At least one of the criteria must be either:
Depressed mood
o
Markedly diminished interest or pleasure in almost all activities

At least 4 other neurovegetative symptoms must be present
Diagnostic Criteria for depression:
neurovegetative symptoms
GUILT SPACE

Guilt feelings of worthlessness or inappropriate guilt

Suicide thoughts of death or suicide

Sleep insomnia or sleeping too much

Psychomotor psychomotor retardation or agitation

Appetite significant change in appetite or weight

Concentration diminished ability to think, concentrate or make decisions

Energy fatigue or loss of energy
GUILT SPACE
Depression:
preferred agent for Pregnancy
Fluoxetine/Prozac
Don’t forget to rule out postpartum thyroiditis
P=P
Depression:preferred agent for Breastfeeding
Sertraline/Zoloft
PP Depression:
Don’t forget to rule out what?
postpartum thyroiditis
Hypoactive sexual desire may be due to other causes
SAVED Negative Experiences

S Stress
A Anxiety
V Vaginismus
E Etoh
D Depression/drugs

Negative Experiences
SAVED Negative Experiences
meds that cause hypoactive sexual desire
BBlockers
OCPs
Antidepressants/antiandrogens
Tamoxifen
ROME II SYMPTOM CRITERIA FOR IBS
At least 3 months or more, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has II out of three features:

RELIEF
FREQUENCY
FORM

1) Relieved with defecation; and/or
2) Onset associated with a change in frequency of stool; and/or
3) Onset associated with a change in form of stool.
PMS tx: ACOG
FIRST LINE
SANDS
First line:

Supportive

Aerobic exercise

Nutrition (Ca Mg Vit E) CME

Dietary avoid salt, caffeine, fatty food, alcohol

Spironolactone
SANDS
PMS tx: ACOG
Second line:
SSRI (either fluox, Sert),

Anxiolytic /Alprazolam if needed
PMS tx: ACOG
Third line:
Suppression (OCPs, GnRH)
Congenital Toxoplasmosis clinical presentation:
Cats (chorioretinitis)
eat liver (HSM),
drink milk (calcifications) and water (ascites/hydrops), have small head(microcephaly)
Meds that decrease libido
B B Blocker
O OCP/antiandroges
A Antidepressants
T Tamoxifen
Other Causes of headache
VMI

Vascular -
Aneurysm,
AVM
Subarachnoid hemorrhage
Intracranial hemorrhage
Cavernous venous thrombosis

Mass lesions –
constant, slowly progressive
Tumor
Abscess
Intracranial hematoma

Infectious Meningitis/Encephalitis
VMI
PseuDOtumor cerebri – Headache
PseuDOtumor cerebri – HEADACHE
P-DO TUMOR CEREBRI

Pregnancy, Obesity, Diabetes
Frequent and prolonged headache
Diagnosis with LP (Opening Pressure > 250 mmH20)
Optic nerve damage
Treatment is with Diuretics
PseuDOtumor cerebri – HEADACHE
P-DO TUMOR CEREBRI
Spironolαctone
Diuretic and Aldosterone antagonist
Direct inhibition of 5-α-reductase activity
Flutamide
– Flute receptor

Antiandrogen - blocks testosterone at the receptor
Finasteride
(inhibits the enzyme 5- -reductase) –
better tolerated FINER, FINAST than Flutamide
vestibulitis. Describe your management and treatment.
CLEAST
C Calcium Citrate and low oxalate diet
L Lubricate/Lidocaine
E Eliminate irritants Estrogen cream
A Amitriptyline
S Surgery
T Therapy-biofeedback/sex
CLEAST
Erythema and edema of the vulva
PDS CV


Psoriasis – calcipotriene, steroid
Dermatitis – Irritant, Contact, Seborrheic
Steroid overuse (sebaceous hyperplasia)

Candida
Vaginitis (GBS) - PCN or Clinda
PDS CV
Diagnose PCOS Need 2 of 3
P Phasting GIR>4.5, Waist to hip ratio >.85 predictive
C Clinical
O Ovulation disturbance
S Sono
PCOS
Contact vulvar dermatitis allergens
Immunogic causes (hypersensitivity reaction)
Poison SLK

Poison oak

Semen
Latex
KY Jelly
Poison SLK
Met formin should not be used with what meds?
Cimet idine, trimet hoprim
Vulvar psoriasis. What are the clinical manifestations?
Treatment?
SILVER SCALES & PITTING NAILS! Hold breast.

Calcipotriene - synthetic vitamin D3,
Steroid
Phototherapy UVB light Psoralen PUVA
Cystometry

Test of detrusor function and can be used to assess:
Sensation
Capacity
Compliance
Contractions - presence and magnitude of both voluntary and involuntary detrusor
Differential Diagnosis of Urinary Incontinence in Women
FILLING
FISTULA
FUNCTIONAL
CONGENITAL

Filling and storage disorders

Urodynamic stress incontinence
UVJ Hypermobility
ISD
Detrusor overactivity (idiopathic)
Detrusor overactivity (neurogenic)
Mixed types

Fistula
Vesical
Ureteral
Urethral

Congenital
Ectopic ureter
Epispadias

Functional incontinence etiology
DIAPPERS
Who requires cystoscopy and cytology to exclude bladder neoplasm:
Microscopic hematuria (2-5 red blood cells per high-power field),
> 50 yo with persistent hematuria
Acute onset of irritative voiding symptoms in the absence of UTI
Lifestyle interventions that may help modify incontinence:
Curb pounds
Caffeine reduction
Carrying physical forces (eg, work, exercise),
Cessation of smoking
Constipation relief
Why is estrogenization important in incontinence?
Urethra and bladder contain a rich supply of estrogen receptors
atrophy and replacement of the submucosa (vascular plexus) by fibrous tissue.

Important for anatomic repair
Bulking agents provide what effect to the periurethra?
Washer effect
Defined as the involuntary loss of urine coincident with increased intra-abdominal pressure in the absence of uninhibited detrusor contraction.
SUI
Urinary Incontinence w/u in office:
Urinalysis and urine culture: UTIs
Urine cytology: Carcinoma in situ of the urinary bladder
Chem 7 profile: Blood urea nitrogen and creatinine levels are checked if compromised renal function is suggested.
Voiding diary
Pad test documents urine loss. Intravesical methylene/ Pyridium
Cotton-swab test
Cough stress test or Marshall test
Standing pelvic examination
PVR volume
Uroflow test evaluating bladder outlet obstruction.
To properly diagnose bladder outlet obstruction, perform pressure-flow studies.
Filling cystometrogram
The only test able to help assess bladder contractility and the extent of a bladder outlet obstruction.
voiding cystogram VCUG

aka detrusor "pressure-flow study"

simultaneously records the voiding detrusor pressure and the urinary flow rate.
Can help identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.
VCUG
GTN Therapy depends on low or high risk category
Met CHAP

Mets Lung/vagina

Chemo prior
HCG < 40,000
Antecedent preg < 4 months ago
pregnancy term v SAB
Met CHAP
Sexually abused children may develop the following:
ABUSE


A Avoidance or interest of all things of a sexual nature
B Bodies are dirty or damaged

U Unusual aggressiveness
S Sleep problems/Seductiveness/Suicidal/Secretiveness
E Examples of sexual molestation in drawings/games/fantasies
ABUSE
PEP 4 weeks
Post Exposure Prophylaxis
PEP 4 weeks
Post Exposure Prophylaxis
Combivir BID
PEP 4 weeks
CPP DDx
CPP DDx

GUM Gyn

G GI
U Uro
M Musculoskeletal

Gyn
CPP DDx

GUM Gyn
Spigelian hernia?
“Spigel semilunaris”

Ventral hernia through the linea semilunaris,


Line where the sheaths of the lateral abdominal muscles fuse to form the lateral rectus sheath
Sperm analysis
50 50% mobility forward within 60 min of ejaculation
40 40 million count/ejaculate
30 30% morphology
20 20 million concentration/ml
2 2 ml
Lichen Sclerosis also found where?
Lichen on my back.
Parchment
Memory loss DDx
Memory loss = ICTAL Depression

Think of ICTAL, Add Tumor/Trauma/TIA
Add depression

Hypothyroid!
Memory loss = ICTAL Depression
Zoloft traits and sides
GI side effects n/v
Most activating of all three SSRI. Zoloft = Zest! Zeal!
Zoloft = Zest! Zeal!
Amitriptyline sides
Trippy/drowsy/confusion/dizzy
Depression Meds with less sexual sides
bupropion
reuptake inhibitor of DA NE SE
Medical abortion
What regimen?

95-99% effective

decreased rate of continuing pregnancies

decreased time to expulsion

fewer side effects - vaginal, and lower mife dose

improved complete abortion rates

lower cost
EBR 63 days better than FDA ladder 49 days

Mifepristone 200 mg po, then in 24 hours… miso 800 pv…in 2 weeks sono.

Mifepristone (RU-486)

derivative of norethindrone

binds to the progesterone receptor with an affinity greater than progesterone but does not activate the receptor, thereby acting as an antiprogestin

necrotizing the decidua, softening the cervix, and increasing both uterine contractility and prostaglandin sensitivity
How would you counsel for medical TOP?
TOP CEASES


Compliance Importance of compliance and follow up
Effective 95-99% effective
Access Need access to care
Sides Pain, bleeding, septic abortion
Early Can be done early
Surgery May need surgical procedure anyway/ No anesthesia or surgical risk
TOP CEASES
Oft Forgotten risks of D&E
R Retained POC
A Ashermans
S Stenosis
H Hematometra –D&C/methergine
Memory loss
= ICTAL Depression
Think of ICTAL,
Add Tumor/Trauma/TIA
Add depression elder abuse
Communicating hydrocephalus - dizziness, unsteady walking, increased frequency of urination, and forgetfulness
Dizziness
mad stamp cabin

M Meds - neuroleptics, antidepressants, hypnotics/sedatives, loop diuretics, antihypertensives
A Anemia/arrhythmia/aortic stenosis/abuse/acoustic neuroma
D dehydration/Disequilibrium of aging/diverticulitis/diverticulosis

S Shy Drager
T tumor/trauma/TIA
A Acoustic neuroma
M Meniere’s
P postural hypotension/panic attack/PUD

C cervical spondylosis/constipation (valsalva)/communicating hydrocephalus/Colon cancer
A Abuse
B BPPV
I infection (flu)
N nutrition
mad stamp cabin
Hernia repair
Hernias < 3 cm
Mesh plug or Suture repair with primary fascia-to-fascia closure
Bowel Burn injury? What do you do?
Call general surgery
If > 2mm blanching burn area, resect 5 cm both sides
If < 2mm blanching, bury area with one or two stitches
Oft forgotten vulvar ulcers
Behcets
Pagets
HIV/Mono/Cicatricial Pemphigoid
Lichens Simplex Chronicus
Describe:
PIPA (post inflammatory pigment alteration) pickers nodule, chronic itch-scratch cycle
Lichen Planus
PRURITIC PURPLE PAPULES

wickhams striae, look at mouth/tooth loss, obliterates vagina. Purple papules in hair steroids, neovagina, retinoids
Modified McCall Culdoplasty
Approximates the USL in the midline, incorporating posterior vaginal fornix in the stitch.
Securely close pubocervical and RV fascia, one or two layers across vag apex.
Permanent 2-0 through full thickness of peritoneum post fornix/post vag wall, and then bring it through US ligaments
PEACH Study
PID Evaluation And Clinical Health
PID treated as inpatient v. outpatient

No diff in CPP, infertility, TOA, ectopic, IUP, recurrence, persistent infection


No difference in outcome with mild to mod PID, clinical sxs. Cefoxitin/Doxy.
Outpatient PID: 14 day therapy
Oflaxacin/Flagyl

Ceftriaxone/Rocephin and doxy with or without Flagyl
Inpatient PID x 14 days
Mefoxin/Doxy
Gent/Clinda
Inpatient TOA:
Meds 75% effective x 14 days
Baseline imaging for size and location
Amp/Gent/Flagyl
Mefoxin/Doxy
Why Probenecid? “For Good Killing”
A uricosuric (treats gout by lowering uric acid levels)

Blocks urinary excretion, and thereby increases the blood levels and action of many medications
Laparoscopic Myomectomy
Two major concerns with laparoscopic myomectomy are:
LAVH R&R

Removal of large myomas through small abdominal incisions

Repair of the uterus.
LAVH R&R
What are the vessels at risk during a sacrospinous ligament fixation?
In Pouring Gusts

Internal pudendal vessels coursing posterior to sacrospinous ligament

Inferior Gluteal vessels
What is Adenomyosis?
Stroma and/or heterotopic endometrial glands are located deeper than the endometrial-myometrial junction by more than 1 high-power field.
Cervical Ca; describe how the radiation is given.
Transfuse if Hg <12

Teletherapy 5040 cGy
Brachytherapy 3,000 cGy

four field technique.
7000 cgy Point A
5000 cgy Point B
How is cisplatin given / dosed?
Cross links DNA
Weekly cisplatin

40 mg/m2 IV weekly for 5 wk
Benefits of chemosensitization
Synchronizes cycle/reduces hypoxia/direct effect/higher growth fraction
How long after MI can you do a surgery?
Duke’s activity risk – best predictor of cardiac risk. Greater than 4 is moderate function.

6 weeks, need stress test/echo

Scar formation and infarct healing is usually completed within six weeks of MI
Will be intermediate risk
How do you treat Crohns disease
Combination of corticosteroids and Immunosuppressants:

6-mercaptopurine and azathioprine

Ceph/Flagyl – bacterial overgrowth

Surgery

IV Infliximab Moderate to severe Crohns disease that does not respond to standard therapies Anti –TNF also tx for RA Treatment of open, draining fistulas.
History Work up for prolapse
S Symptoms Urinary/Colorectal/Protrusion/Pain/Sexual/Defecation dysfunction
O Ongoing Risks Constipation/Occupationalstress/Obesity/Chronic cough/Future childbearing/Young age
M Medical condition smoking/COPD/arthritis
E Estrogen status
SOME
Complications/problems with SSLF:
Resultant fixed vaginal retroversion predisposes to anterior prolapse –

SSLF cystocele risk 16-90%
Options for prolapse repair
Anatomic repair –
good EPF. Repair site EPF to USL/CL complex AP repairs
Compensatory repair –
bad EPF – SSLF, ASCP, Sling, graft
Complications/problems with b/l US suspension:
Ureters!

Cystoscopy mandated
Abdominal route surgery methods to repair apical prolapse include:
B/L Uterosacral Suspension
ASCP
Complications/problems with b/l iliococcygeus suspension:
Apical recurrence rate high

Limits vaginal depth
How do you do a sacro colpopexy?
Suspending strap (fore and aft) after hyst (autologous/donor fascia, porcine dermis)

Into anterior longitudinal ligament over the promontory
How do you repair the bowel?
Close in 2 layers

First layer full thickness interrupted 3-0 vicryl for mucosa. 0.25 cm apart
Second layer running seromuscular stitch 3-0 silk 0.5 cm apart
PE The classic radiographic findings
Hamptons hump -wedge-shaped, pleura-based triangular opacity with an apex pointing toward the Hilus = Hamptons Hump
Westermark sign - decreased vascularity
Management of Acute Coronary Syndrome (ACS)

Within first 10 minutes:
A Airway
B Breathing/Oxygen
C Circulation/IV access

M Morphine
A Aspirin
D Draw Enzymes
E EKG
H BANG - MI
For all ACS: Acute Coronary Syndrome
H BANG - MI

Heparin or LMWH

B-blockers
Aspirin
Nitroglycerin
GP (Glycoprotein) IIa/IIIb if percutaneous intervention (PCI)/Stents anticipated
Discuss Cardiac Enzymes:
Test Onset Peak Duration
CPK 3-12 h 18-24 h 36-48 h
Troponin 3-12 h 18-24h 10d
Spiral CT is advantageous for a number of reasons:
Faster 15-25 secs total. Patient can hold their breath for the entire study, reducing motion artifacts,

More optimal use of IV contrast enhancement

Higher resolution than conventional CT

Can detect other chest pathology

Less fetal than radiation than V/Q

angiography may miss central mural thrombus
Determine if anovaginal or rectovaginal fistula
Within 3 cm of anus is anovaginal
Simple RVF
No need for colostomy, may heal spontaneously in 6 months

Low to mid vag septum <2.5 cm diameter

Traumatic/infectious etiology
Complex RVF
Requires 2nd stage procedure/need for colostomy

High vaginal septum 2.5 cm or more in diameter

IBD/Crohns, radiation or neoplasm
Recurrent vaginitis/cystitis may be what?
RVF
Anal u/s evaluates what?
Sphincters
Most helpful test for RVF?
fistulagram/fluoroscopy
Gene mutations involved in SPORADIC ovarian cancer?
TP53 (tumor suppressor)

HER-2-neu (oncogene)
Common Causes of Transient (Functional) Urinary Incontinence
DIAPPERS

Delirium
Infection
Atrophic
Pharmacological
Psychologic – depression, psychogenic polydipsia
Pregnancy
Excessive fluid (DM, CHF/vol overload, hypercalcemia, intake)
Restricted mobility, Radiation
Stool impaction, Surgery
DIAPPERS
AMA screening
STAMP AMA

S Screening Parents
T Testing
A Abortion
M Maternal Risks
P Pre-embyro analysis/selection
STAMP AMA
Etiology of Early Pregnancy Loss
M Medical Thyroid, DM
I Immune/Infection APL/Rh/RPR/Ureaplasma
C Chromosomal Balanced translocation
U Uterine Mullerian/Leiomyoma
MICU
Infertility workup
UTERINE STOPS OBESITY

Uterine Avascular septum, ashermans
Sperm
Tubal PID, adhesive disease
Ovary/Osis
PCOS/Anovulation/endometriosis
Pituitary PRL, TSH
Social
UTERINE STOPS
Infertility history
Coital frequency
Obesity

Depo Provera

Etoh/smoking/Coffee>4 cups/day


Drugs (THC/CCB)

heat/sauna exposure
CODED HEAT
Contraindications to ECV (ACOG)
MAOIugr

Multifetal pregnancy
Abruption/previa
Oligo/marked
IUGR
MAOIugr
Failure rate condoms when used correctly?
3%
Failure rate condoms when used INCORRECTLY?
12%
A patient presents with PROM at 18 versus 24 versus 26 versus 34 weeks gestation. Overall survival
18(30%)
24(50-75%)
26(80%)
34 (98%)
Most common adverse effects from high-dose radiation:
IUGR
Microcephaly
Mental retardation
Risk of CNS effects is greatest with exposure at ______of gestation, with no proven risk at less than 8 weeks of gestation or at greater than 25 weeks of gestation
8–15 weeks
A threshold for this adverse effect may exist in the range of _____rads.
Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree.
20–40 rad.

Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree.
Ionizing radiation can result in the following 3 harmful effects:
GCC

1) Cell death and teratogenic effects
2) Carcinogenesis
3) Genetic effects or mutations in germ cells
GCC
Mastitis pathogens?
Staph aureus,
Staph epidermis. Streptococcus,
E.Coli
How do you treat mastitis?
Dicloxacillin 500 Qid x 10-14 days
If no response to Dicloxacillin in 24-48 hrs,
Keflex,
Augmentin (B Lactamase inhibitor)
AGC favor Neoplasia
Chance AIS?
Chance invasive adenocarcinoma?
Chance of coexisting Squamous cell lesion?
Counsel patient that 5% chance AIS
2% chance invasive adenocarcinoma
R/o coexisting squamous lesion (50%)
A patient presents at 26 weeks with back pain and fever. What's the differential diagnosis?
Pyelonephritis
Labor
Perinephric abscess
Pancreatitis
Renal stones
Cholelithiasis
Cholecystitis
PUD
How a CXR appears in ARDS.
Diffuse bilateral alveolar infiltrates/ opacities (consolidation)
Consolidation with air-bronchograms
Normal appearing
Why CXR normal appearing sometimes with ARDS?
Changes seen on x-ray often lag many hours behind functional changes, so hypoxemia may seem disproportionately severe compared with the edema observed on chest x-ray
Pathophysiology ARDS
Inflammation, then fibrosis
Capillary and alveolar epithelial injury
Plasma and blood leak
Alveolar flooding and atelectasis
Refractory to O2 therapy
A patient presents with Size > Dates. Don’t forget this in your differential:
Uterine fibroid
Adnexal mass
How is TTT caused?
Placental AV shunt

most common is AA shunt!!! TTT=AA
Is 20% discordance always pathologic?
which twin type see discordance in?
No.
If two fetuses are discordant but both have normal estimated weights and grow appropriately on their own growth curves, the discordance may not indicate a pathologic process

Discordance=Dizygotic
Management: Vaginal Delivery if First Twin Vertex
Monitor first twin by internal scalp electrode
In pregnancy, exertion at altitudes of up to ____appears to be safe
6,000 feet
SCUBA in pregnancy –
Compression sickness in fetus,
Barotrauma (lungs, ears, sinus) risky if taking anticoagulants
Absolute Contraindications to Aerobic Exercise During Pregnancy
Hemodynamically significant heart disease
Restrictive lung disease
Incompetent cervix/cerclage
Multiple gestation at risk for premature labor
Persistent second- or third-trimester bleeding
Previa after 26 weeks of gestation
PTL during the current pregnancy
ROM
Preeclampsia/Gestational Hypertension
What is T&S?
ABO & Rh, and minor antigens (c,e,Kell,Kidd)
Blood exposed to O, see what antibodies are made
What is T&C?
T&S and crossmatch
Donor red cells exposed to recipient serum to check compatibility
• How long does it take to get blood?
ASAP: type, screen and crossmatch time is 30 minutes
STAT: un-crossmatched blood can be released in 10 minutes
GB stones diagnosis in pregnancy:
GB ultrasound
ERCP
Why would someone have recurrent pyelonephritis?
Resistant organism pseudomonas
Other pathogen not treated Proteus, mycoplasm
Vesicoureteral reflux -VCUG
Renal calculi
Fistula
Perinephric abscess
Obstruction
Diabetes
ovarian cyst during pregnancy.
Luteoma 2/3 regress postpartum
Dysgerminoma midline vertical at 18 weeks, sample ipsi nodes
Dermoid
Serous Cystadenoma
Corpus Luteum Cyst resolves by 16 weeks
Theca lutein cysts regress in 6 months
Torsion PP due to rapid involution
In pregnancy, which masses should be surgically excised?
> 6 cm beyond first trimester

Large masses can be observed if not highly suspicious for malignancy by u/s evaluation
Cervical length <______is PTL
< 20mm
Cervical length >_____can exclude PTL
>30mm
Pt presents with contractions and 2cm dilated, don’t forget to do three things:
r/o infection
cervical length
FFN
FFN, what is it?
CHORION GLUE

Glue that holds chorion to maternal endometrium
Indicates membrane/decidua disruption
GBS Would you give any antibiotics and why?
Reduce “early-onset” neonatal GBS disease.
GBS sepsis, meningitis, neurological damage (CP in chorio)
If PCN allergic, but not at high risk for anaphylaxis, what is next choice?
Cefazolin 2g IV then 1 q 8 hours
98% susceptibility
Poor cerclage outcomes after how many weeks gestation?
22 weeks
Who gets cerclage?
13 – 16 weeks


3 mid-trimester losses
3 preterm deliveries
What are early and late symptoms of GBS in the neonate?
Early (24 - 48 hours) respiratory symptoms/Pneumonia.
Late (2 weeks) Meningitis, bacteremia/seizures
When do you not use GBS cultures/treat?
GBS negative within last 4 weeks per ACOG
Planned c/s, not in labor and no ROM
A patient is positive culture GBS and is not sensitive to clindamycin or erythromycin. What would you give her?
PCN - risk of fatal anaphylaxis has been estimated at 1 per 100,000

Cefazolin 2g IV then 1 q 8h 98% susceptibility

Vancomycin 1g q 12h
What are the signs of Mg toxicity?
CRAPO
Cardiac arrest
Respiratory depression
Absent reflexes
Paralysis Muscular
Oliguria
CRAPO
Treatment Mg toxicity. How to you mix it? How slow do you inject?
I’m not in love with Mg toxicity 10cc
10cc 10% 10 min

1g Calcium Gluconate IV
Calcium Gluconate (10 cc of 10% solution over 10 minutes) by slow intravenous injection
How would you apply Piper forceps?
Maintains the head in a flexed position.
Applied to bimalar biparietal region
Supports the fetal body in a horizontal plane - savage maneuver by assistant.
Direction of the pelvic axis
reverse pelvic curve
LEFT blade first
How do you avoid head extension?
Suprapubic pressure
Mariceaux-Smellie-Veit maneuver - fetal maxillary prominences.
Upper hand on the fetal back
Assistant to maintain horizontal while applying forceps
Piper forceps
nuchal arm and how do you deal with it? Breech delivery.
Lovset’s maneuver – deliver posterior arm, rotate 180 degrees, deliver new posterior arm.
or rotate the infant so that the fetal face rotates toward the symphysis pubis; this reduces the tension holding the arm around the back of the fetal head.
Or:Duhrrsen’s incision 2,6, and 10 o’clock

must press antecubital.
If press on humerus, will get radial nerve palsy - wrist drop.
Twin B breech - deliver vaginally if:
>1500 g, <36 weeks? Controversial
When to do ECV:
COMPLETED 36 weeks
Most of the evidence pertaining to ECV comes from recent studies that selected patients near term.
Why not induce successful ECV right away?
There is no support for routine practice of immediate induction of labor to minimize reversion.

except possibly in persistent transverse lie to avoid cord prolapse, after verting successfully.
What are the risk factors for ECV failure?
Marked oligohydramnios
Small fetus
Nulliparity harder
Anterior placenta
Maternal obesity
fetus fixed in pelvis
frank breech
Most common complication of ECV?
Fetal/maternal bleed
ECV tocolytic? Epidural? What studies say:
Support the use of a tocolytic agent during ECV attempts, particularly in nulliparous patients.

There is not enough consistent evidence to make a recommendation favoring spinal or epidural anesthesia during ECV attempts
Can VBACs can get oxytocin for augmentation/induction?
Yes.
In VBAC, the rate of uterine rupture was not different between those who received oxytocin and those who labored spontaneously.
Post partum for preeclampsia and develops severe oliguria <10cc/hr. What is the role of a CVP line insertion?
Evaluate intravascular volume
If the CVP rises and stays high (14-16mmHg) then volume loading is complete
Insert CVP, if low, give IVF
If CVP normal, give nitroglycerin to dilate renal artery
CVP does not mirror PCWP in severe Preeclampsia
Can push PCWP to 12-14mmHg
How is true preload measured?
Pulmonary artery catheter
If urinary flow is still poor, and the blood pressure is low or marginal, then what?
vasopressor, such as norepinephrine.
to increase renal perfusion pressure
more potent inotrope, such as dobutamine
What is the risk of Asherman’s syndrome after D&C?
69%
• What surgical techniques might increase or decrease risk of Asherman’s syndrome?
Antibiotics prior to procedure

Gentle curettage
A patient doesn’t bleed after given estrogen and progestin. DDX?
Asherman’s
Pelvic TB
Outlet obstruction
Transverse vaginal septum
Imperforate hymen
What values appear to be most effective at determining the likelihood of macrosomia and other adverse pregnancy outcomes in patients with GDM?
Postprandial glucose values
Besides R/N 2/3 ½ R/N ½ ½ , what is another GDM method to initiate with:
Can start with 10 R or Lispro, 20 NPH in AM , and 5/5 in pm
10/20 5/5
Which GDM regimen is best?
No particular insulin regimen or insulin dose has been demonstrated to be superior for GDM.
What can be used instead of Regular, and will improve postprandial?
Lispro instead of Regular (1:1) to improve postprandial
More rapid onset of action than regular insulin
Obese pregnant women (body mass index >30) may do well with moderate caloric restriction of what %?
Caloric restriction of 30%
With caloric restriction, what is important to check daily?
Should check morning urine ketones

Possibility that it may cause starvation ketosis –
Definition of mild and severe CHTN in pregnancy:
mild (BP >140/90 mmHg) or as severe (BP >=180/110 mmHg)
Are diuretics okay in pregnancy?
Diuretics are okay except in settings in which uteroplacental perfusion is already reduced (preeclampsia and IUGR).
Do women with mild hypertension (140–179 mmHg systolic or 90–109 mmHg diastolic pressure) need meds?
No.
Generally do well during pregnancy and do not, as a rule, require antihypertensive medication.
There is, to date, no scientific evidence that antihypertensive therapy will improve perinatal outcome.
HTN Therapy could be increased or reinstituted for:
Blood pressures > 150–160 mmHg systolic or 100–110 mmHg diastolic
antihypertensive therapy should be initiated or continued in:
Severe chronic hypertension (systolic pressure >=180 mmHg or diastolic pressure >=110 mmHg),
Gestational hypertension
• How would you manage?
140/90, no proteinuria

Manage like mild HTN
PP HTN treatment:
Labetalol PO 200 mg every 8 hours (maximum dose of 2,400 mg/d)
Nifedipine is 10 mg orally every 6 hours (maximum dose of 120 mg/d)
In Eclampsia, deliver if FHR decels don’t resolve after how many minutes?
10 minutes
The patient with eclampsia should be delivered in a timely fashion.
Once the Eclamptic patient is stabilized, should base delivery on what factors?
Age
Fetal condition decels - greater than 10 minutes
Labor
Bishop/cervix

<30weeks or Bishop < 5 should CD
Regional anesthesia contraindicated at what platelet level?
plt<50,000
Besides anterior shoulder entrapment, what other shoulder dystocia is there?
Impaction of the posterior fetal shoulder on the sacral promontory. ACOG.
Severe shoulder dystocia may result in:
hypoxic-ischemic encephalopathy and even death
What percent of Erb’s palsy victims heal completely within a year.
90%

Usually takes up to three months
What percent of Klumpke’s palsy recover in 1 year?
40%
What percent of brachial plexus injuries occur after cesarean delivery. ACOG.
4%
What percent of brachial plexus injuries are not associated with shoulder dystocia?
40%
Is surgery ever warranted in Brachial plexus injury?
Cases of severe nerve injury and with avulsion injuries
If clinical or electrodiagnostic evidence of recovery is not present at 4 months surgical exploration should be recommended
Clinical examination is a better prognostic indicator than is EMG
Patient with IUGR, don’t forget to consider:
Infection

Maternal factors
Fetal Factors
Environmental factors
When should IUGR be delivered if premature?
An abnormal result from fetal heart rate testing (decreased variability) coupled with abnormal results from Doppler velocimetry suggests poor fetal well-being and a potential need for delivery, despite prematurity
Risk Congenital Varicella infection if exposed 1st,2nd trimesters)
1-2% risk
1st 2nd trimester = 1-2%
Congenital Varicella infection findings:
Pox warfare lesions


Cutaneous scarring,
limb hypoplasia,
IUGR,
microcephaly

like warfare, but has cutaneous scarring
Pox Warfare lesions
What to give Nonimmune exposed mother if VZV exposed during pregnancy:
VZIG for exposed, give within 72 hours of exposure (if anti-VZV IgG negative) to prevent clinical Varicella,
Does Labial agglutination always need treatment?
No often spontaneously resolves in 6 months to 1.5 years
When should Labial agglutination be surgically treated?
Complete obstruction
Voiding difficulty
What is the incubation period of HSV?
2-14 days
How long will the HSV patient shed for?
3 months
What are congenital anomalies of syphilis?
Microcephaly
Intracranial calcifications
Chorioretinitis

Just like Toxo!



Stillbirth,IUGR, nonimmune hydrops, rhinitis - snuffles, hepatosplenomegaly,"mulberry molars","saber shins", saddle nose deformity, interstitial keratitis, eigth nerve deafness,peg-shaped incisors/hutchinson's teeth
What are neonatal effects of HSV and mortality of each?
Skin, eye, mouth 0%

CNS (Herpes encephalitis) 15%

Disseminated 57%
Can an amnio be done if HSV outbreak?
No if “primary” HSV and systemic symptoms, cannot do amnio, CVS, PUBS until resolve.

Okay if recurrent disease.

But avoid transcervical procedures.

FSE okay if no lesions.
Various pre-op holding area scenarios:
Patient has:

chest pain
high glucose
hypertension
anemia
Bacterial Vaginosis
Drug Regimen
Metronidazole (Flagyl) 500 mg PO BID for 7 days
Clindamycin cream 2% 1 full applicator (5 GMS) per vagina X 7 days @ night
Metronidazole gel 0.75% 1 full applicator (5 GMS) per vagina BID X 5 days
Metronidazole 2 GMS PO as a single dose
Clindamycin 300 mg PO BID X 7 days

metronidaole has less effect on return of lactobacillus
Genital Warts (Condyloma acuminata) Patient-Applied

Drug Regimen
Podofilox 0.5% solution or gel Applied with a cotton swab or gel with a finger to visible genital warts BID X 3 days followed by 4 days of no therapy. Cycle may be repeated for a total of four cycles
Imiquimod 5% cream Apply cream with finger at bedtime 3 X weekly, up to 16 weeks. Wash with mild soap and water after 6 - 10 hours. Not for use during pregnancy.
Genital Warts (Condyloma acuminata) Practitioner Applied

Drug Regimen
Cryotherapy with liquid nitrogen or cyroprobe Repeat applications every one to two weeks. Avoid normal tissue. Wash off in 1-4 hours. Not for use during pregnancy.
Podophyllin resin 10-25% in compound tincture of benzoin Repeat weekly if necessary
Trichloracetic acid (TCA) or Bichloracetic acid (BCA) 80-90% Repeat weekly
Surgical removal. Scissors or shaving excision, curette, or electrosurgery are possible.
Parvovirus B19
The illness presents in the mother as
fever, malaise, polyarthralgia (particularly of the peripheral joints), coryza.
Lacelike rash on trunk , extremities and face.

The infection may be mistaken for rubella.
Incubation Parvo
Incubation is 4 to 14 days.
What is Parvo Rash like in mother?
Lacelike rash on trunk , extremities and face.
Discuss IgM and IgG in toxo
IgM typically turns positive after 1 week and may remain positive for years. IgG follows same course, but remains positive for life.
Varicella (Chickenpox)
rash begins on
face and scalp then spreads to trunk.
Varicella (Chickenpox)
The incubation period ranges from
10 to 21 days.
Varicella (Chickenpox)
The patient is contagious for
1-2 days before the onset of rash until all lesions are crusted. The crusts are not infectious
Varicella (Chickenpox)
The risk of developing the congenital syndrome is
1% if less than 20 weeks and 2% at 13-20weeks
Why give exposed mother VZIG?
"Administration of VZIG to susceptible, pregnant women has not been found to prevent viremia, fetal infection, congenital varicella syndrome, or neonatal varicella. Thus, the primary indication for VZIG in pregnant women is to prevent complications of varicella in the mother, rather than to protect the fetus.
How is the newborn treated if mother exposed?
Newborns are administered VZIG if the mother had ONSET of chickenpox < 5 days before delivery to 48h postpartum. should receive another full dose of VZIG.
counseling about BSO
SELF Self image
SEX Sexual function-libido/dryness
HORMO Hormonal mileu
REPRO Reproductive function
How is the diagnosis of PMS established?
CONSISTENT
LUTEAL
EXCLUSION
FACET


a) symptoms CONSISTENT with PMS;
b) restriction of these symptoms to the LUTEAL phase of the menstrual cycle assessed prospectively;
c) impairment of some FACET of the woman's life; and
d) EXCLUSION of other diagnoses that may better explain the symptoms
metabolic syndrome be identified as the presence of three or more of these components:
WHHET

• Waist:Hip > .85
• TG> 150 mg/dL
• HDL < 50 mg/dL
• HTN 130/85 mm Hg
• Elevated fasting glucose > 100 mg/dL
A 60 year old patient as abnormal cholesterol values.
• What is your differential diagnosis?
DM
Metabolic syndrome
Iatrogenic (testosterone therapy/progestins)
Hypothyroid
Which lab test is predictive of MI?
C-REACTIVE PROTEIN!!!!!
Vaginoperitoneal fistula from endometriosis fulguration, is a risk factor for
fallopian tube prolapse.

This problem can be diagnosed and safely managed with a laparoscopic approach.
SSL located where?
within the coccygeus muscle
Grade a cystocele:
Grade-I cystocele is when the bladder drops to the mid vagina with abdominal strain.

Grade-II cystocele is when the bladder drops to the introitus with abdominal strain.

Grade-III cystocele is when the bladder protrudes out of the vaginal introitus with abdominal strain.

Grade-IV cystocele is when the bladder protrudes out of the vagina at rest.
History Work up for prolapse
S Symptoms Urinary/Colorectal/Protrusion/Pain/Sexual/Defecation dysfunction
O Ongoing Risks Constipation/Occupational stress/Obesity/Chronic cough/Future childbearing/Young age
M Medical condition smoking/COPD/arthritis
E Estrogen status
hymenectomy, watch for which vessels?
lateral pudendal
hematocolpos or mucocolpos. If intend to perform hymenectomy, should it still be done?
cruciate incision on hymen at inital procedure but do not remove it.

Allow adequate drainage and then restoration of normal anatomy, prior to reconstruction/excision of hymen.
VVF fistula repair

if due to radiation, will need:
temporary diversion with ileal loop to bring external blood supply to fistula
VVF repair post op drainage with, and how long?
Dual cath drainage post op
Foley up to 2 weeks post op
SPT up to 3 weeks
hymenectomy, watch for which vessels?
lateral pudendal
hematocolpos or mucocolpos. If intend to perform hymenectomy, should it still be done?
incise hymen at inital procedure but do not remove it.

Allow adequate drainage and then restoration of normal anatomy, prior to reconstruction/excision of hymen.
Can you treat uterine prolapse without removing uterus?
Posterior LUS to sacrum
Blood supply to ureter
Renal artery
Ovarian artery
Aorta
Common iliac
Internal iliac
Superior vesical
Inferior vesical
Rectosigmoid endometriosis symptoms
Premenstrual tenesmus/diarrhea
Sutures become permanently encapsulated in tissue
silk
blood supply small bowel

blood supply colon
SMA

SMA IMA
Lab for outpatient DVT w/u
D-Dimer
Discontinue warfarin 5 days pre-op and let the INR drift down to normal range.
Proceed with surgery if INR is
<1.3

start heparin when stop coumadin. stop heparin 5 hours preop restart w;in 24 hours post op. start coumadin post op when tol PO.
Do what if PE pulmonary work up negative
Echo
What is easily seen with CT may be missed at pulmonary angiography.
A chronic central mural thrombus
cuff cellulitis caused by
Trich
BV
Treament SPT
heparin AND antibiotics
What type of heparin for SPT?
LMWH 1mg/kg BID
What % of simple fistulas heal spontaneously
50%
Post op care for RVF
low res diet
antibiotics

PREVENT CONSTIPATION
DIME VOPS

DVT within how much time is high risk?
< 3 months is considered high risk
Gyn surgery for patient with h/o DVT
• Full dose therapeutic IV heparin or LMWH 1mg/kg q 12H should be given 2 days prior to the OR.
• D/C IV heparin 5 hours prior to going to the OR.
• LMWH should be held 24 h prior to surgery.
• Postop re-start IV heparin without bolus or enoxaparin 1 mg/kg Q 12 H 24 hours post op
• warfarin once the patient is taking po meds. Heparin/lovenox can be d/c’d once INR 2-3.
? superficial thrombophlebitis v. DVT
must do b/l duplex u/s

MRV – noninvasive

serial exams

r/o PE if symptomatic

DVT until proven otherwise
Antibiotics should be used whenever the phlebitis involves the
proximal thigh
pediatric discharge, don't forget
Trauma with necrotizing hematoma/abscess
incidence of underlying carcinoma among women with a community diagnosis of atypical endometrial hyperplasia was ___ % GOG
45%
VVF usually occur how many days post op?
Usually 10-14 days post op
The coagulation waveform has what characteristic
higher peak-to-peak voltage waveform

(producing higher temperatures) to dessicate
cutting waveform allow what temp?
100 deg C
to evaporate only
Type of coagulation in which the active electrode does not touch the tissue but
‘sprays’ multiple sparks between itself and the tissue
Fulguration
What setting uses a higher peak-to-peak voltage waveform than the other coagulation settings?
fulguration
During LEEP, The least amount of power that will effectively perform the electrosurgery should be used, so as to minimize the risk to the patient’s normal tissues and ensure that the excised specimen is in acceptable condition (with a minimum of thermal artifact) for pathological assessment.
Hmmm.
If the lesion extends onto the vagina, it is preferable to use the
ball electrode for electrofulguration
How wide to Leep?
5mm before and aft each transformation zone
Iodine is glycophilic

Lugols
Iodine is glycophilic

therefore will be taken up by cells that have glycogen - mature, non neoplastic cells
A patient is S/P TAH, having had a pre-op Hct of 40. The Hct is now 24, pulse rate is 98 and urine output is 10 cc/hr.

don't forget to consider
retroperitoneal hematoma

check u/s
A 60 year old woman has ovarian cancer.
• How would you counsel her daughter regarding her risk of developing ovarian cancer?
Increased risk for first degree relative
4%
Ovulation induction increases risk of what type of ovarian cancer?
LMP Low Malignant Potential/Borderline
BRCA1, auto dominant, lifetime risk ovarian cancer?
90%
Reduce risk with OCPs ___% (even if genetically susceptible)
50%
Decrease risk of ovarian cancer:
OCPs (especially progestin potency)

Oophorectomy 40%  1% (still can be Primary Peritoneal Carcinoma), 2% occult cancer found in specimen.

Tubal ligation
Who gets Extended Field Radiation
bulky stage 1b
Stage IIB
radiation bad for vagina how?
length
caliber
lubrication

also bad for ovaries
C perfringens sepsis (septic abortion) presents as:
Hemolysis
Anuria
port-wine colored serum and urine
DIC
Ultrasonographic presence of air within the uterine cavity

RENAL FAILURE!!!
plane flights causes hemoconcentration and increases the risk for DVT and PTL. why?
Reduction of cabin humidity to less than 25%
Pregnant women should be informed that the most common obstetric emergencies occur in the which trimesters?
first and third
antifactor Xa levels
antifactor Xa levels
antifactor Xa levels
antifactor Xa levels
antifactor Xa levels
antifactor Xa levels
PaO2/FIO2 < 200
ARDS

decreased Pa02 despite inspired 02
Refractory to 02 therapy

air bronchograms because aerated bronchioles end up to blocked alveolae. no gas exchange can occur. 02 can't get to caps.
They asked how a CXR would appear in ARDS.
Diffuse alveolar-interstitial infiltrates
Opacities (consolidation)
Consolidation with air-bronchograms
S>D, don't forget about...
Polyhydramnios
Bleeding and IUFD

Fibrinogen and FDP levels can be monitored serially until delivery
Delivery can be expedited if
DIC develops.

avoid c/s!!! replace blood and rupture membranes.
• Why would someone have recurrent pyelonephritis?
@@@ Resistant organism pseudomonas
Other pathogen not treated Proteus, mycoplasm
Vesicoureteral reflux -VCUG
Renal calculi
Fistula
Perinephric abscess
Obstruction
Diabetes
recurrent pyelonephritis
Resistant organism
pseudomonas
recurrent pyelonephritis
Other pathogen not treated
Proteus, mycoplasm
Size all masses > ___ cm beyond first trimester should be surgically excised.
6

Large masses can be observed if not highly suspicious for malignancy by u/s evaluation
Fetal loss in patients with gallstone pancreatitis is
10-20%
Discuss cervical lengths on US and significance of findings

utility is in
excluding PTL
FFN NPV is
99% NPV
FFN will be positive < 24 weeks because
membranes haven’t sealed
UDCA ursodeoxycholic acid
also treats ICP – bile acid to dissolve cholesterol gallstones
Fetal loss in patients with gallstone pancreatitis is
10-20%
Laparoscopy in pregnancy
When possible, operative intervention should be deferred until the second trimester, when fetal risk is lowest
Pneumoperitoneum enhances lower extremity venous stasis
Therefore pneumatic compression devices should be utilized whenever possible.
Given the enlarged gravid uterus, abdominal access should be attained using an open/Hassan technique.
Dependent positioning should be utilized to shift the uterus off of the inferior vena cava.
Pneumoperitoneum pressures should be minimized (to 8 - 12 mm Hg) and not allowed to exceed 15 mmHg
cfu/ml
colony forming units per ml
severe Mg toxicity, what to do if calcium gluconate doesn't work:
May need dialysis if severe
Intubation
Contraindicated to delay and vicryl ligate high PPROM Twin B when?
Monochorionic
Chorioamnionitis
Abruption
NRFHT
• What are the risk factors for ECV failure

don't forget
nulliparity
A patient is 2 weeks post partum with heavy bleeding (2 pads/hr)

don't forget
recurrent invasive mole

avoid D&C/ashermans unless have to.

Likely cause of bleeding is infection (fever?). Treat with antibiotics.
PP retained POC - D&C. Don't forget...
Antibiotics – Doxycycline 100mg BID x 10 days
Treatment Ashermans. don't just say blind D&C, but also add that can do
hysteroscopy
ashermans etiology, don't forget
Pelvic TB
Drainage of pelvic abscess by vaginal route must meet 3 criteria:
Fluctuant abscess (or else adequate drainage cannot be achieved)
Must dissect the RV septum (or else will enter rectum)
Must be midline (or else I&D will result in peritoneal spread)
After I&D pelvic abscess vaginally, must do this...
Place drain in CDS
post op c/s ileus obstruction, could be
ureter
hematoma/abscess
endometritis ileus
seizure, at risk for what pulmonary sequelae?
aspiration
pulmonary edema
If still another seizure:
give
Give another 2g MgSO4 over 3-5 minutes

Phenobarbital 250 mg over 3-5 minutes
Nifedipine dose for HTN
Nifedipine 10mg q 30 min, max 50mg/hr.
What percent of brachial plexus injuries are not associated with shoulder dystocia;
40%
What percent of brachial plexus injuries occur after cesarean delivery.
4%
IUGR don't for get to inquire about
Maternal factors
Fetal factors
Environmental factors

smoking
cocaine
how much past babies weighed
FAS
HTN
What is treatment for HSV suppression?
Valtrex 400mg qd

ONCE DAILY!!!
early stage cervical CA, desires fertility
Trachelectomy
Put cerclage in
rads to point A
rads point B
7000
5000
rads bowel can handle
5000
rads = cGy
If found cerv ca on retrospect path after hyst
Do CT
XRT
If return with symptoms of recurrence cervical cancer
Do exam, CT, refer
biopsy gross cervical lesion where?
at periphery/include edge (if just bx center, will just get necrosis)
12 weeks, invasive ca cervix if stage 1b
Rad hyst/LAN
Cervical cancer needing surgery/radiation, Up to ___ weeks, don’t need to terminate , baby will die on own
Up to 18 weeks, don’t need to terminate , baby will die on own
Cervical cancer, can wait how many weeks for treatment without compromise
16 weeks

so, at 22 weeks gestation, can safely wait until term to intervene.
XRT how long after CD for cervical cancer?
10 days
Paracervical block complications - lidocaine
Metallic taste
Tinnitus
Arrhythmia
Coma
s/p cone with bleeding. likely etiology is?
infection
Should you do hyst when if found to have “late s/p cone infection/bleeding”?
8 weeks later

Don’t want to do hyst if parametrium is infected
Leep settings
monopolar cut 50 Watts
Lido toxicity management
ABC

Wait it out until metabolism

Give ephedrine or 1 mg atropine for Lidocaine bradycardia

Give thiopental or valium or succinylcholine if convulsions/seizures

The recommended doses of lidocaine without epinephrine is 4 mg/kg.

If epinephrine is added, the maximum safe dose is 7 mg/kg.

Remember that epinephrine is a treatment for lido toxicity/bradycardia
HPV takes how long to undergo change
3 years

therefore can wait to do first pap then.
Takes how long for LGSIL to become invasive cancer if not immunocompromised
15 years
film and digital mammography were equally accurate. But for which women digital mammography is significantly better
dense breasts

women under age 50

pre- and perimenopausal
MRI has been shown to detect small breast lesions that are sometimes missed by mammography, and MRI can successfully image
the dense breast

breast implants.

doesn’t expose women to radiation
Downside to breast MRI
hard time distinguishing between carcinoma and benign breast disease (fibroadenoma)

doesn't detect certain types of very small calcifications

uses blood flow as a marker instead
should breast MRI replace standard screening and diagnostic procedures?
No
Breast ca staging
I 2.0 cm
II 2-5 cm or ipsi nodes
IIIa > 5cm nodes stuck to selves and tissue
IIIb skin/wall/mammary
IV mets
Prognostic tests for treatment in women with dx of breast ca:
Est/Prog receptor status
Her 2/neu
DNA cytometry
mammo will dx what size breast ca
1 mm
CBE will palpate what size breast ca
1cm
SBE will palpate what size breast ca
2cm
BRCA1BRCA2

What % will get breast ca
90%
BRCA do what px surgeries?
Bilateral mastectomy

BSO after child bearing


bso (take tubes, too)
cheesy nipple discharge =
duct ectasia
how to excise duct
subaerolar and do duct excision
mastitis, why dicloxicillin?
penicillinase resistant abx
treatment breast pain
bra
no smoking
no OCPs
primrose oil
Danazol
Bromocriptine
25 year old lump in breast
management
Examine after period
Aspirate
Fibroadenoma in teenager
Usually< 4cm
management
Don't operate
Remove when in teenager?
If > 4cm or phylloides – remove

cystosarcoma phylliodes is benign!

hard to differentiate between phylloides and fibroadenoma
12 weeks gest and 5 cm Dermoid
observe unless torsion
Granulosa cell tumor

require chemo?
r/o endomet ca

most don’t require chemo
Stage III, IV get BEP
Inhibin A
Quad screen
Early preeclampsia
Produced by placenta and CL
Sex-cord stromal
Inhibin B
measured in ovarian reserve

secreted by granulosa cells
Be sure to stage ovarian CA within 1 week, or if can’t be staged in 1 week, then
give 3 cycles of chemo and stage later.
GnRH sides
vasomotor
memory loss
osteo
addback
medroxyprogesterone
EE
bisphosphonate
If giving addback right away, to minimize sides, give which
Norethindrone
How is fibroid affected if given addback right away?
shrinks LESS with addback right away.
Sarcoma

three things to look for
1. Loss architecture
2. Mitosis
3. Necrosis
sarcoma mitosis 10-20
management
hyster
Sarcoma > 20 mitoses
management
chemo
Hysteroscopic resection myoma
risks
bleeding - cauterize, balloon
hyponatremia - won't happen with NS
fluid overload - can happen with MSG or NS
Hyponatremia management
stop procedure
stat electrolytes
hypertonic saline 3%
lasix

won't happen with NS distention media

can use NS with bipolar
Hyponatremia manifested how?
HA, coma, encephalopathy
critical level of NA for hyponatremia?
125
stop at what fluid deficit
1000
Distention media Glycine danger of
ammonia toxicity
In preoperative h/h 5
Fe
Prempro
Oral estrogen
D&C
Iron therapy
Erythropoietin
GnRH
describe protein
decapeptide

Released from the medial basal hypothalamus

Modification 6th position agonist
Modification 1st position is antagonist
SCH advantages
Less operating time
Less injury to ureter, bladder, less uterine artery damage
If osis, adhesions
SCH disadvantages
Vaginal discharge
Chronic cervicitis
cyclic bleeding
Paps
cervical prolapse 2%

NO DIFFERENCE IN BOWEL, BLADDER, SEXUAL FUNCTION OR PROLAPSE BETWEEN SCH AND TOTAL HYSTERECTOMY
will SCH preserve sexual function compared to total hysterectomy?
No.

Transudate from vagina is lubrication
Cervical myoma
Incise/myomectomy

trace ureter or place stents

cystoscopy afterwards
Broad ligament myoma
Ureter posterior

Make incision anteriorly

Then dissect wall carefully to isolate ureter

Get to pelvic brim common iliac bifurcation if necessary and follow down to uterine artery level

Can stent or indigo carmine

Or cystoscopy
Nec fasc

bugs
Bacteroides
Anaerobes
Debridement until bleeds
Vag hyst, entered rectum. Do what?
The good news:

In colpotomy you’re below anal-rectal verge.

Close 2 layers, irrigate, give antibiotics
Vag hyst - Bladder injury
Close 2 layers


3-0 vicryl (monocryl is less inflammation)
LS in sigmoid colon, feces coming out-
Suture it, no colostomy required.

Antibiotics, heals well.
VVF after vag hyst
wait how long to repair?
Delay closure 3 months

Repair vag or abdominally

Until then, place foley
Incontinence of feces

(see hint for etiology)

pudendal nerve S 2,3,4 innervates sphincter
Sacral nerve innervates levators
check anal wink/neuro - dovetail sign

Anal u/s - r/o fistula

Fistulagram

Anal manometry - sphincter mechanism

Rectal physiological studies for neuro -
EMG
Pudendal Nerve Terminal Motor Latency Testing
Anatomy defect
fistula - IBD/XRT/HIV/steroids/poor epis repair

sphincter disorder - poor repair

Neuro defect – MG, MS


What studies?
Posterior repair:
Repair perirectal fascia – bring in midline

Levators bring in midline may cause dyspareunia if brought together too tightly
Dyspareunia due to or didn’t leave enough room for introitus.
Hmmm.

Make sure can accommodate two fingers comfortably.
Deep dyspareunia – tubal prolapse

Pain due to
granulation tissue
Dyspareunia also due to
too tight levator plication from post repair

collision dyspareunia from retroverted uterus

pelvic congestion syndrome

uterus suspension to encourage venous drainage and to alleviate collision dyspareunia
Cystocele - lateral defect

Paravaginal defect due to white line

Can repair vaginally by
dissecting back to white line
Central repair cystocele:

remove excess vagina?
Don’t remove excess vagina, may cause dyspareunia

??????
Urinary retention post op
Intermittent cath self teach – if increased PVR

Or leave foley
Epidural and retention of urine due to
Overdistended bladder.
diagnose epidural overdistension bladder?
Do office cystometrics – no sensation

Takes weeks to get better.
Spinal cord injury –neurogenic retention

Keep filling foley, will have no sensation.

Management?
Manage long term, can put SP cath

Leg bag
Delivery of women with spinal cord injury:

Findings?
Management?
unattended deliveries

Autonomic dysreflexia

Sympathetic dystrophy

Hyperactivity severe HTN



Can avoid if have epidural at T 10
60 year old nursing home incontinence
Think DIAPPERS
ISD h/o
anterior repair - denervate the urethra
XRT
VLPP low < 60
ISD
VLPP
the abdomen pressure minus urethral pressure in absence of bladder neck mobility
If has COPD to prepare for surgery do
PFT (pulmonary function tests) FEV1/FVC

low FEV1 predicted postoperative complications

FEV1 reduced compared to FVC

Want to know tidal volume

CXR -predictor of perioperative complications
Improve lung fct

Make sure no respiratory alkalosis

Albuterol

COPD doesn't do well coming out of anesthesia

stop smoking

may need post op heparin - if limited reserve

Incentive spirometry
Obs lung dis
Asthma
Emphysema
bronchitis
COPD
SUI post partum
R/o fistula
infection
voiding diary
kegels
Progesterone effect during pregnancy
Increased abdominal pressure during pregnancy
Bleeding when cut incision
Meds
Coumadin
NSAIDS

Herbal meds = ginseng, gingko biloba, ginger

VWD – cryo, DDAVP
ITP
DIC
What is Type 1 VWD?
most common form

Quantitative deficiency

VWF works normally, but there is not enough of it.

no symptoms of VWD at all until a bad injury or surgery
What is Type 2 Von Willebrand Disease?
VWF does not work properly

Qualitative problem

less efficient in binding to platelets
What is Type 3 Von Willebrand Disease?
Most severe
most rare
very little VWF in their blood.

Because VWF transports Factor VIII, they also have very low levels of Factor VIII.
Usually should transfuse how many units platelets
8
if have DIC, transfuse and ROM if IUFD.
Hmmm.
How does Premarin work?
causes proliferation of endometrium to cover open vessels
Sickle cell disease low Hg
Preop
Give transfusion first then stabilize before surgery

Will have more sickling when hypoxic

Hydrate preoperative
r/o infection
Hg A (Adult) should be adequate. SSD makes more HgS than HgA.

b chain has a valine instead of a glutamic acid in the number 6 position of the b globin chain
SSD electrophoresis findings:
Hg S on Hg electrophoresis

Should have HgA (Adult) instead.
SSD what chromosome
11

position 6
Sickle cell crisis
Sickle cell crisis –
Stroke
Acute chest syndrome
Bone pain
Spleen/liver infarction
Auto splenectomy
Pyelo
Treat sickle cell crisis
IVF, MSO4, transfuse if necessary
SSD ob complications
infertility
abruption

IUGR
pyelo
Preeclampsia
SAB
Beta thal
like iron def
Hmmm.
A thal management
Minor like iron def
Barts hydrops fetalis
Hmmm.
ITP
don't use these interventions on baby
no scalp pH, no vacuum
Drug induced thrombocytopenia –
lithium
Travelers' Diarrhea
E coli
shigella
salmonella
campylobacter
vibrio
treat travelers diarrhea with
Cipro
Viral diarrhea - differentiate how?
no blood or leukocytes
what causes c diff
clinda
treat cdiff?
ORAL flagyl, IV vanco
CP pain relieved with food
gastric ulcer
diagnose H pylori
endoscopy - biopsy
pH breath test
serology
Ileus

Why ileus post op
Manipulation of bowel
blood
dried bowel
infection
Secretion GI tract daily loss ____ml with NGT daily
3000 ml
avg fluid required daily
2 litres
Treatment of hyponatremia
Do not raise serum Na more than 12 mEq/L in 24 hours in asymptomatic patients.

May replace Na with 3% NaCl solution

fluid restrict
Do not overcorrect hyponatremia. May precipitate
central pontine myelinolysis.
Hypermagnesemia treatment
1g calcium gluconate 10cc in 10% solution 10 minutes
lasix
hemodialysis
Diabetic Ketoacidosis treatment
supportive
fluid replacement
insulin 0.1 u/kg, add D10 when glu 250
potassium
bicarb
Mg
Phos
It is preferable to give D10W with the infusion rather than stop the insulin because
insulin is still required to clear the acidosis and ketotic state
Hypokalemia etiology
GI loss - n/v, diarrhea
drugs - diuretics
renal loss
hyperaldosteronism
poor intake
Hypokalemia when correcting, ALWAYS REMEMBER TO MAKE SURE ENOUGH OF WHAT???
Magnesium

Maggie and Kay - the replacements!
If serum K+ concentrations >2.4 mEq/L and no ECG changes, K+ can be given at a rate up to ____mEq/hr with maximum daily administration of ___ mEq.
20mEq/hr

200
Do not correct K too rapidly or will get
arrythmia
Hyperkalemia treatment
calcium gluconate
bicarb
insulin
to decide if obstruction complete or partial/subacute
better in 3 days then subacute

use barium study to distinguish, unless think perforation.
treatment bowel obstruction
NGT
IVF
replacement electrolytes
why post op obstruction
bowel got kinked in adhesion

suture in bowel.
when surgery for obstruction?
NGT 2-3 days, no improvement

if NGT output not diminished and repeat KUB shows no improvement

no air in rectum on repeat KUB
nutritional status labs
prealbumin
transferrin t 1/2 20 days
TPN amt
glucose
lipids
aa


35 cc/kg/day fluid replacement
35 kcal/kg day calorie replacement
through subclavian
electrolyte and B complex
s/p LS comes to ER with distention what to do
to OR. likely perf

leukocytosis with distention
how to tell if first trocar hit bowel
feces on trocar when remove
what to do if bowel adhesions likely and concern about trocar placement?
1-2 fingerbreadths under subcostal magin in mid clavicular line
small bowel repair in OR, can feed when?
right away
large bowel injury with feces, what to do?
irrigate then primary closure, abx
what abx for large bowel injury?
ofloxacin and flagyl

or

unasyn

or

3rd gen Ceph
Direct coupling –
touching dirctely with electrode, crack instrument, or touch another instrument.

What you actually see.
Capacity coupling –
arc forms somewhere else. Don’t see it.

Arc forms when there’s a defect b/w plastic and metal.

Out of field of vision.
Unipolar burn - ___ cm beyond what you see.
4 cm
treat travelers diarrhea with
Cipro
Colon Ca symptoms
anemia - dizziness
change bowel habits, stool form
bleeding
obsruction - late finding
test for Colon Ca when if have FH?
10 years before
CPP likely
depression
somatization
Fibromyalgia must find how many tender points?
11 of 18
treat fibromyalgia with
antidepressants
Back pain how to evaluate
flexion/extension
point tenderness

lose weight
give flexeril- muscle relaxant
lifestyle modification
symptoms Interstitial cystitis
frequency day, night
bladder pain
dx IC
bladder overdistention
potassium sensitivity test
what causes IC?
defect in glycoaminoglycan layer

pt sensitive to potassium as it touches the Hunner ulcers
COPD test preop
PFT
FEV1/FVC
don't do well coming out of anesthesia
looking for resp acidosis on ABG
Written Treatment Plan for out-patient management asthma
Green Zone
Yellow Zone
Red Zone
Green zone =
good control (PEF > 80% personal best) no change in regimen
Yellow zone =
caution (PEF 50-80% personal best), call MD, needs step-up in therapy
Red zone=
medical alert (PEF < 50% personal best), to MD or ER immediately, needs acute treatment
Management of acute asthma exacerbations
Oxygen
Albuterol nebulizer q 2 hr prn
Add atrovent nebulizer if not responding
Systemic steroids - po or IV depending on severity
Prednisone start at 60 mg qd OR (Do not use
Methylprednisolone (Solumedrol 2mg/kg X 1 dose, then 1mg/kg q 6h)
Treat until PEF > 80% personal best
CXR needed only in pneumonia suspected
Antibiotics only if co-morbid infection
ABG needed only if attack severe
Initially respiratory alkalosis (PaO2 reduced, PaCO2 reduced)
If the attack worsens, PCO2 starts to rise leading to respiratory acidosis
why do CXR for r/o pulm embolism?
r/o pneumonia
dose for switchover to LMWH in PE after initial adjusted dose with 80u/18u
LMWH 1mg/kg BID
Restrictive lung disease
sarcoidosis
PE
pneumonia
hospital acquired pneumonia treatment
pip and gent

(covers pseudomonas)
treat aspiration pneu
clindamycin
pulm edema due to
low osmotic pressure
Ventricular fibrillation

and Pulseless Vtac
cardioversion - 200J 200J 360J
EPI EVERYBODY Shock
Lidocaine LITTLE Shock
Bretylium BIG Shock
Magnesium Sulfate MAMA Shock
procainamide PAPA Shock
need to empty uterus if need cardiac massage in Vfib if how many weeks and above?
32 weeks
what type c/s for trauma?
classical
if need to take to OR emergently and patient had full breakfast, then do what?
awake intubation
press cricothyroid
dx AFE
debris in lung
LS patient gets arrythmia, what's going on?
CO2 embolus
how to manage CO2 embolus
airplane LLD left,

aspirate CO2 out of left ventricle
Deflate abdomen

hyperventilate patient
end tidal co2 should be normally what?

what happens to it in C02 embolism?
20-30

goes down in CO2 embolism –
how does one get HS air embolism
tube not purged of air

patient in steep trendelenberg
most often used distention agent?
sorbitol
which K level will cause cardiac arrest?
6.5
treat hyperkalemia with
calcium gluconate
insulin
bicarbonate
Sinusitis –symptoms
facial pain

persistent cough


tooth pain
symptoms sleep apnea
EDS - excessive daytime sleepiness

sudden cardiac death
describe patient with sleep apnea
obese
neck circumference 43 cm
management sleep apnea
sleep lab
CPAP
if depression meds don't work, then what?
ECT
DV may lead to
homicide
reasons patients don't admit to DV
Hope
Shame
Fear
DM patient on insulin for surgery, how to take meds
1/3 NPH in am
DM gyn patient post op management blood glucose
SS when 200

above 250 give insulin
DM patient on oral hypoglycemic for surgery, how to take meds
no meds in AM before surgery
Pt with HTN in preop holding, what to do
assess cardiac and pulm function
can do case, but may need to give diuretic or BBlocker
HTN crisis, give what?
labetolol
hydralazine
Pt comes to office with HTN, what to do?
head to toe eval of end organ damage

eyes
carotid
heart
lung
abd bruits
extremities

EKG
electrolytes
lipids
glu
diets for obese
Mediterranean
Calorie restriction
Link between body and menstrual function
Leptin

Low levels indicate that fat stores not sufficient for growth and reproduction
• Low levels correlate with reduced body fat
– Leptin levels < 3 ng/ml associated with irregular menses and amenorrhea
BP in office 140/90

management
Lifestyle modification
BP in office 150/95
management
work up!

DECEL


EKG, CXR, electrolytes. lipids, DM
BP in office 160/110

management
needs meds

EKG, CXR, electrolytes. lipids, DM

diuretic
BBlocker
atypical pneumonia
mycoplasma
legionnaires
chylamydia

interstitial
spinal cord overflow incontinence management
leg bag
bladder drills
scheduled voiding
bethanecol - cholinergic
hematoma s/p hyst (no broad ligament to use as landmark to find ureter)
stent or trace

start trace at pelvic brim
To prevent complications during uterine access in HS, what are effective for cervical priming.
misoprostol
laminaria

equally
The use of what agent to distend the uterus prevents hyponatraemia, but
hypervolemia may still be a major problem.
normal saline
Irrigant fluid deficit is best monitored by
automated devices.
This type of electrosurgical systems do not require dispersive return electrodes

do not generate stray currents, thus minimizing the risk of electrical burns.
Bipolar
Hidradenitis Suppurativa treatment =
tetracycline = tetra-tiva!

clindamcin

accutane
CDIFF first line treatment
PO Flagyl (can also be given IV)
Vanco for cdiff must be given by what route only?
ORAL VANCO ONLY!!!
What is Hidradenitis suppurativa?
obese patients

suppurative lesions

apocrine sweat glands

axilla and groin areas
what is Osteoprotegerin (OPG) –
cytokine -new drug on the horizon to treat osteoporosis


low levels of OPG also tend to have faster bone turnover,
Increasing OPG may help to normalize bone turnover. Blocks resorption.

binds to RANKL
What is test for preop eval of levator mechanism and cystocele rectocele in constipation
defecography
What is arimidex?
aromatase inhibitor

treatment postmenopausal breast cancer

causes osteoporosis worse than tamoxifen does
Pathoophysiology of Sheehans Syndrome:
thrombosis of vessels with hypotension from acute hemorrhage
Sheehans Postpartum pituitary necrosis/pituitary insufficiency symptoms:
Inability to breast-feed
Fatigue - hypothyroid
Loss of pubic and axillary hair - no estradiol, no testosterone
Amenorrhea, or lack of menstrual bleeding
Low blood pressure
Sheehans Syndrome - labs
low TSH, ACTH, FSH/LH with low levels of T4, cortisol, and estradiol
MRI of head
Sheehans Syndrome - treatment
lifelong hormone replacements of

thyroid,
testosterone,
cortisol,
ddAVP,
GH,
OCPs
Why does sheehan's occur in postpartum?
Because of the pituitary enlargement during pregnancy, it is vulnerable to ischemia from PPH.
no pulse, what to do
chest compression/CPR
200J
200J
360J
V. fib
pulseless V. tac
EVA 360J


EPI can repeat
shock 360J
Vasopressin (V.) once
shock 360J
amniodarone-cardioversion eds
Asystole

CEA
Confirm 2nd lead
EPI
Atropine (A)
PEA
PEA

Plenty of things to treat
EPI
Atropine


treat underlying cause

hypovolemia
hypothermia
hypo/hyperkalemia
tamponade
PE = PEA

EPI
Atropine