Right Lower Quadrant Pain (Female)

Front 1

What are 7 factors associated with PID?

Back 1

1. Age < 25
2. First intercourse at younger than 15
3. Lower socio-economic status
4. Single married status
5. Multiple partners
6. frequent vaginal douching
7. Self reported Chlamydia infections

Front 2

What are 3 historical features that should be asked of a female with RLQ pain?

Back 2

1. Presence of IUD
2. Previous history of STD
3. Any risk factors associated with PID?

Front 3

What are the two most frequent organisms associated with PID?

Back 3

1. Neisseria gonorrhoeae
2. Chlamydia trachomatis

Front 4

What are the two most common presenting complaints of patients with PID?

Back 4

1. Lower abdominal pain (98%)
2. Vaginal discharge (45%)

Front 5

What is the current gold standard for diagnosis of PID?

Back 5

Direct visualization of the fallopian tubes by laparoscopy

Front 6

When should empiric treatment be started for suspected PID?

Back 6

Young sexually active women or those with with risk factors associated with STDs who have one of the minimum criteria and no other etiology can be identified

Front 7

5 common presenting symptoms for PID?

Back 7

1. Abdominal pain (98%)
2. Vaginal discharge (45%)
3. Feeling of sickness (30%)
4. Dysuria (27%)
5. Fevers and chills (25%)

Front 8

What is the Chandelier sign?

Back 8

Tenderness with manipulation of the cervix

Front 9

What are the 3 minimum criteria according to the CDC for PID (2006)?

Back 9

1. Abdominal pain
2. Cervical motion tenderness
3. Adnexal tenderness

Front 10

What are the 5 additional criteria according to the CDC for PID (2006)?

Back 10

1. Fever >101 F (38.3 C)
2. Abnormal mucopurulent discharge
3. Elevated ESR or C-reactive protein
4. Present of abundant WBC on saline microscopy of vaginal secretions
5. Postivie cervical cultures with Chlyamidia or Gonorrhoeae

Front 11

PID vs. Appendicitis: What are 3 clinical factors that are low risk for appendicitis?

Back 11

1. No pain migration
2. Presence of bilateral tenderness
3. Absence of nausea or vomiting
(all 3 has 99% sensitivity for excluding acute appendicitis)

Front 12

What is the most practical imaging modality in female patients presenting with lower abdominal pain?

Back 12

Ultrasound (recall that laproscopy is the gold standard).

Front 13

PID vs. Appendicitis: If appendicitis is a true consideration what imaging study should be performed?

Back 13

Focal appendiceal CT: have been found useful in the distinction of appendicitis and TOA/PID

Front 14

What are 3 sequelae of untreated PID?

Back 14

1. Chronic pelvic pain
2. Ectopic pregnancy
3. Infertility

Front 15

Who should be admited with PID?

Back 15

1. cannot r/o surgical emergencies
2. pregnant patients
3. Lack of response after 72 hrs of abx
4. Presence of TOA
5. Severe illness with n/v and/or high fever
6. HIV patients with low CD4 counts or other immuno suppressed pts
7. Patients with IUD
8. Adolescent patients

Front 16

Outpatient Abx recommendations for PID per CDC guidelines?

Back 16

1. Ceftriaxone 250 mg IM x1
2. Doxycycline 100 mg po bid x 14d 3. Flagyl 500 mg po q12 hrs x 14 d
OR
1. Cefoxitin 2 g IM x 1
2. Probenecid 1 g orally x 1
3. Doxycycline 100 mg po bid x 14d 4. Flagyl 500 mg po q12 hrs x 14 d

Front 17

What is the fifth most common surgical gynecologic emergency?

Back 17

Adnexal Torsion (AT)

Front 18

At what stage in a women's life is adnexal torsion most common?

Back 18

Child bearing years (although can take place at any time)

Front 19

What are risk factors for adnexal torsion?

Back 19

1. Ovarian masses (cysts or tumors)
2. Increased ovarian size > 6 cm
3. Hormone injection therapy (increase # of cysts induced)
4. Pregnancy - first trimester and first 6-8 weeks after delievery.

Front 20

Adnexal torsion occurs....

Back 20

because the relative mobility of the supporting pedicles: the ovarian ligament connecting the ovary to the uterus and the suspensory ligament connecting the ovary to the intra-abdominal wall.

Front 21

What are the classic symptoms for ovarian torsion?

Back 21

- acute unilateral pelvic pain
or
- dull, aching pain with acute and sharp exacerbations if torsion is intermittent

Front 22

What imaging study should be used for suspected adnexal torsion?

Back 22

Pelvic ultrasound with color flow Doppler imaging.

Front 23

Treatment for adnexal torsion?

Back 23

1. Gynecologist consult immediately
2. Analgesics
3. IV fluids
4. Anti-emetics

Front 24

What are the most common gynecologic masses to occur in the female pelvis?

Back 24

Ovarian cysts

Front 25

On pelvic ultrasound what is the criteria to identify an ovarian cyst?

Back 25

If the diameter of the cyst is greater than 2.5-3 cm. (Anything less is referred to as a follicle)

Front 26

Common complaint for ovarian cyst?

Back 26

Sharp, intermittent, severe pain that is sudden in onset and associated with nausea and vomiting.

Front 27

What pelvic ultrasound findings should raise suspicion for an adnexal malignancy?

Back 27

1. Masses >7cm
2. Masses persisting beyond one menstrual cycle
3. Masses with solid internal components or complex cystic structure

Front 28

History questions for females with RLQ who may be pregnant?

Back 28

1. LMP
2. HX of STDs
3. Previous or current IUD use
4. Surgical hx, previous pregnancies w/ or w/o complications
5. Presence or absence of vaginal spotting or discharge, and passage of tissue. How much spotting?
6. If pregnant any prenatal visits?

Front 29

What exam (3) should NOT be performed in a pregnant patient after the 20th week of gestation with vaginal bleeding?

Back 29

1. bimanual
2. speculum exam
3. tranvaginal ultrasound
(until r/o suspected previa)

Front 30

What are four risk factors for ectopic pregnancy?

Back 30

1. previous PID
2. previous/current IUD use
3. previous tubal surgeries
4. previous ectopic pregnancies

Front 31

What are additional factors associated with increased risk for ectopic pregnancy?

Back 31

1. In utero DES exposure
2. Infertility
3. Current smoking
4. 3 or more spontenous abortions
5. induced abortions
6. > 1 lifetime sexual partner

Front 32

Classic triad of symptoms in ectopic pregnancy?

Back 32

1. Amenorrhea
2. Abdominal pain
3. Irregular vaginal bleeding

Front 33

What is the diagnostic imaging choice for evaluating ectopic pregnancy?

Back 33

Transvaginal ultrasound

Front 34

At what serum b-HCG level can an IUP be detected on transvaginal ultrasound?

Back 34

1,000-1500 mIU/mL

(Gestational age of 4.5-5 weeks)

Front 35

What is an interstitial pregnancy?

Back 35

Pregnancy that occurs with implantation of the gestational sac in the most proximal aspect of the fallopian tube.

Front 36

What is an cornual pregnancy?

Back 36

An intrauterine pregnancy where implanation occurs in the upper and lateral aspects of the uterus.

Front 37

What 3 u/s findings require further investigation when r/o ectopic pregnancy?

Back 37

1. an empty uterus with b-HCG level >1000 mlU/mL
2. Presence of fluid in teh cul-de-sac
3. Ill-defined adnexal masses

Front 38

What labs should be obtained in the emergent management of an unstable individual with ectopic pregnancy?

Back 38

1. UA
2. CBC and coagulation panel
3. Type and Cross
4. Rh status
5. quantitative serum b-HCG

Front 39

What should be given to all Rh-negative women presenting with an ectopic pregnancy or any vaginal bleeding?

Back 39

50 mcg of anti-Rho immunoglobulin

Front 40

What is a Heterotopic Pregnancy?

Back 40

the presence of both an intrauterine pregnancy and an ectopic pregnancy

Front 41

What percentage of pregnancies end in miscarriage before 20 weeks of gestation

Back 41

15% with most occuring before 12 weeks of gestation

Front 42

Threatened miscarriage

Back 42

Vaginal bleeding during the first 20 weeks of gestation when fetal heart tones are present and WITHOUT dilation of the cervix

Front 43

Inevitable miscarriage

Back 43

Dilation of the cervix with no history of evidence of passage of tissue in the first 20 weeks

Front 44

Incomplete miscarriage

Back 44

passage of parts of the products of conception, in the presence of a closed cervical os, retained fetal or placental tissue visualized on ultrasound

Front 45

Complete miscarriage

Back 45

passage of all fetal tissue and subsequent closure of the cervical os before 20 weeks gestation

Front 46

Septic miscarriage

Back 46

evidence of infection during any stage of miscarriage

Front 47

Physical exam for vaginal bleeding and abdominal pain in the first 20 weeks of pregnancy

Back 47

Pelvic exam - quantify amount of vaginal bleeding, passage of tissue, and cervical dilation
Tissue - send to pathology

Front 48

Laboratory work up for vaginal bleeding in pregnancy <20 weeks

Back 48

1. UA
2. CBC
3. Blood type
4. Rh factor, and antibody screen
5. quantitative b-HCG

Front 49

Treatment for threatened miscarriage?

Back 49

Discharge to home with precautions and follow up with GYN in 2-3 days for repeat b-HCG

Front 50

Treatment for inevitable miscarriage or intrauterian fetal demise?

Back 50

consult gynecology to ED

Front 51

Treatment for complete miscarriage?

Back 51

discharge with obstetric follow up if bleeding is minimal

Front 52

ABX regimen for septic miscarriage?

Back 52

1. Ampicillin 1-2 grams IV q 4-6 hrs
2. Gentamycin 3-5 mg/kg/day q6-8 hr adjusted for renal function
3. Flagyl 500mg IV q 8h or 750 mg IV q12 hr

Front 53

What is the dosing for rh immune globulin?

Back 53

50 mcg gram in the first 12 weeks and 300 mcg after 12 weeks.

When in doubt use 300 mcg dose

Front 54

What are common symptoms for pregnant women presenting with urolithiasis?

Back 54

Hematuria, nausea, vomiting, flank pain, or abdominal pain.

Front 55

What is the first line diagnostic study for a pregnant patient with concerns for urolithiasis?

Back 55

Ultrasound - will not show the stone but features of the disease (hydroutreter and hydronephrosis).

Front 56

Risk factors for placental abruption?

Back 56

1. Maternal HTN (most common)
2. Maternal trauma
3. Smoking, alcohol, and/or cocaine
4. advanced maternal age
5. post-amniocentesis
6. short umbilical cord