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49 Cards in this Set

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CASE 26: A 1 cm breast mass is discovered during a routhine physical examination of a 22yo woman. She has no family history of breast cancer. She denies breast leakage or prior irradiation. On examination, her BP is 100/60. Physical examinations are normal. Palpation of her rt breast reveals a firm, mobile nontender rubbery 1 cm mas in the upper outer quadrant. No adenopathy is noted. The left beast is normal to palpation. Next step? Dx?
Next step is fine needle biopsy, most likely diagnois is Fibroadenoma of the breast.
Fibrocystic changes versus fibroadenoma?
Fibrocystic changes are common in premenopausal women but rare following menopause. Fibrocystic changes fluctuate with "hormones" are described as multiple, irregular, lumpiness of the breast. Presentation is cyclic painful engorged, pronounced during menses. Fibroadenoma is the opposite, unilateral, does not change with menstrual cycle.......
Clinical approach to breast mass?
Age, risk factors, breast exam. Low risk, FNA any higher risk will necesitate more tissue, excissional biopsy or core needle biopsy.
34yo complains of unilateral serosanquineous nipple discharge from the breast, expressed from one duct. No mass is palpated.
Intraductal papilloma
27yo woman complains of breast pain, which increases wiht menses. The breast has a lumpy bumpy sensation.
fibrocystic changes
47yo has a 1.5cm rt breast mass wiht nipple retraction and skin dimpling over the mass.
breast cancer
18yo asymptomatic 1cm nontender mobile rt breast mass.
fibroadenoma
CASE 27: 23yo G1P0 at 40 weeks gestation undergoing labor induction with oxytocin for oligohydramnios. She has been at 6cm dilation for 3 hrs. A significant amount of caput is noted on cervical exam. Her uterine contractions are every 2-3 min and palpate firm. Each contraction lasts for 60 sec. The estimated fetal weight is 7.5lb, and the pelvis seems clinically adequate. The fetal heart tones range from 145-150bpm without decelerations. Next step? Dx?
Arrest of active phase, next step is a cesarean delivery. A intrauterine pressure cather (less than 200 montevideo units) may be placed to asses contraction. Here, caput and clinical assesment of "powers" signify that there is enough power. Do a cesarean, if contractions had been inadequate you could try Oxytocin.
Addequate uterine contractions in active phase?
>200 montevideo units or contractions 2-3 minutes that are firm and last 40-60 seconds
Dx of arrest of active phase?
1 Latent phase has completed with a cervical dilation of >4cm. 2 no cervical dilation for 2 hrs. Next asses the 3 P's
3 P'S
PASSENGER, PELVIS, POWERS
The cervix of a 19yo G1P0 at 39 weeks is noted to change from 2 to 3 cm over 4 hrs. Dx?
Normal labor
25yo G2 P1001 at 41 weeks is noted to change her cervix from 6 to 9 cm over 2 hrs. Dx?
Normal labor
30 yo G1P0 at 39 weeks gestation, who does not have an epidural catheter, is completely dilated for 2 hrs at 0 station. Dx?
Arrest of descent (no progress beyond 0 station/full dilation)
38 G3P2 at 38 weeks has changed her cervix from 6-8 cm over 3 hrs. Dx?
Protracted active labor (protracted means some movement but less than adequate)
25yo G1P0 at 39 weeks is in labor. The cervical examination reveals complete dilation and the fetal head at +1 station for 2 hr despite maternal pushing. Which is the most likely etiology for this labor disorder?
Fetal occiput posterior presentation (pelvic inlet disorder or DM would lead to unengagement)
CASE 28: 31yo G1P1 presents wiht a 2yr history of infertility. She states that her menses began at 12 years and occurs at 28 day intervals. A biphasic basal body temperature chart is recorded. She denies sexually transmitted diseases, and a hysterosalpingogram shows patent tubes and a normal uterine cavity. Her husband is 34yo and his semen analysis is normal. Etiology?
Peritoneal factor: Endometriosis is the most common condition
Five basic factors for evaluation?
1 ovulation 2 uterine 3 tubal 4 male factor 5 peritoneal factor
Ovulatory, history? test? therapy?
Irregular menses, obesity test with basal body temp chart, LH surge or progesterone levels, tx clomiphene citrate
Uterine, history? test? therapy?
uterine fibriods, test with hysterosalpingogram showing abnormal uterine cavity tx with hysteroscopic procedure.
Male factor, history? test? therapy?
hernia, varicocele, mumps test with a semen analysis tx is repair hernia, varicocele or in vitro fertilization
Tubal, history? test? therapy?
chlamydia, gono test with hysterosalpingogram tx with laparoscopy in vitro fertilization
Peritoneal, history? test? therapy?
endometriosis 3D's: dysmenorrhea, dysparenunia, dyschezia(deficate) test laparoscopy tx with ablation of endometriosis, medical therapy
explain the "ovulation chart"
Follicular phase - Estrogen.... Ovulation - Estrogen spike->LH surge.... Luteal phase - Progesterone -(15 days)
22 yo G0P0 irregular menses every 30-65 days. Semen analysis is normal. The hysterosalpingogram is normal. Treatment?
Clomiphene
26yo G0P0 has regular 28 day menses. Semen analysis is normal. The patient had a postcoital test revealing motile sperm and strechy, watery cervical mucus. She has been treated for chlamydial infection in the past. Etiology for her infertility?
Tubal factor
28yo G1P1 complains of painful menses and pain with intercourse. She has menses every month and denies a history of sexually transmitted diseases. Which tests would most likely identify the etiology of the infertility?
Laparoscopy
34yo infertile woman is noted to have evidence of a blocked fallopian tube by hysterosalpingogram. Best next step for this patient?
Laparoscopy, a histerosalpingogram is not specific and needs follow up with Lap.
CASE 29: 23yo G2P1 29 weeks compains of a 12hr of colicky right lower abdominal pain and nausea and vomiting. Denies vaginal bleeding or leakage of fluid per vagina. She denies diarrhea or eating stale foods. She has a history of an 8cm ovarian cyst but otherwise has been in good health. She denies dysuria or fever and she has had no surgeries. Her BP 100/70, HR 105bpm, RR 12/min, Temp 99F'. On abdominal examination, her bowel sounds are hypoactive. The abdomen is tender in the rt lower quadrant, with involintary guarding. Cervix is closed. Fetal heart tones are in the 140bpm range. Dx? Best treatment for this condition?
Dx Ovarian torsion treatment is surgery, laparotomy due to pregnancy. Due to young age most likely due to Dermoid Cyst.
Differential diagnosis of abdominal pain in pregnancy?
Appendicitis, Cholecystitis, Torsion, Placental abruption, Ectopic preggers
Appendicitis, time during pregnancy, location associated symptoms, treatment?
anytime, RLQ/RF, nausea vomiting anorexia leukocytosis fever, surgical
Cholecystitis, time during pregnancy, location associated symptoms, treatment?
after 1st trimester, RUQ, nausea vomiting anorexia leukocytosis fever, surgical (simple biliary colic, absence of fever or infection, in pregnancy is usually treated with low fat diet and observed until postpartum)
Torsion, time during pregnancy, location associated symptoms, treatment?
14 weeks or after delivery, Unilateral abdominal or pelvic, nausea vomiting, surgical
Placental abruption, time during pregnancy, location associated symptoms, treatment?
second and third trimester, midline persistent uterine, vaginal bleeding, abnormal fetal heart tracing, delivery
Ectopic pregnancy, time during pregnancy, location associated symptoms, treatment?
1st trimester, unilateral pelvic or abdominal pain, nausea vomiting syncopy spotting, surgical or medical
Describe the movement of the appendix in pregnancy as compared with nonpregnant.
Superior and lateral
Upon performing laparoscopy for a suspected ovarian torsion in an 18yo nulliparous woman, the surgeon sees that the ovarian vascular pedicle has twisted 1 to 1.5 times and that the ovary appears somewhat bluish. Managment?
Unwind the vascular pedicle to asses the viability of the ovary.
Which of the following describes the correct anatomic characteristics of the vessels in the infundibular pelvic ligament to the ovary?
Both ovarian arteries arise from the abdominal aorta. Rt ovarian vein drains int the vena cava, the left ovarian vein drains into the left renal vein.
18yo G1P0 complains of a 2 month history of colicky right abdominal pain when she eats. It is associated with nausea and emesis. She states the pain radiates to her right shoulder. The patient has a family history of DM. Dx?
Cholelithiasis
CASE 30: 19yo G2 Ab1 at 7 weeks gestation by LMP complains of vaginal spotting. She denies the passage of tissue per vagina, trauma, recent intercourse. Medical history significant for pelvic infection approximately 3yrs ago. She had used oral contraceptives 1 yr prior. Appetite is normal. On examination, BP 100/60, HR 90bpm, temp normal. Abdomen is nontender with normoactive bowel sounds. On pelvic examination, the external genitalia are normal. Cervix is closed and nontender. Uterus is 4 weeks size, and no adnexal tenderness is noted. Quantitative b-HCG is 2300mIU/mL. Transvaginal sonogram reveals an empty uterus and no adnexal masses. Next step? Dx?
Next step is laparoscopy, dx is ectopic pregnancy. Risk of extrauterine pregnancy is high, not 100% laparoscopy is indicated not methotrexate. There may still be a viable fetus in the uterus, methotrexate would destroy it. (B-hcg transvaginal ultrasound 1500)
Strategy to rule out ectopic pregnancy?
Prove whether or not an IUP exists
Transvaginal US
>1500 bHCG or >6 weeks.
b-HCG and Progesterone in ectopic pregnancy.
>1500 for transvaginal, if possible follow in 48 hrs rise of 66% above the initial level is evidence of normal pregnancy. Lack of rise indicative of abnormal prenancy. Progesterone > 25ng/ml evicence of normal pregnancy, <5ng/ml abnormal pregnancy.
Methotrexate in ectopic pregnancy.
reserved for less than 4cm, day 3-7 patient may experiance pain due to tubal abortion or rupture.
22yo 8 weeks gestation has vaginal spotting. Her physical examination reveals no adnexal masses. The hCG level is 400ng/mL and transvaginal US shows no pregnancy in the uterus and no adnexal masses. Which of the following is the best next step?
Repeat hCG level in 48hrs
26yo G2P1 7 weeks gestation seen 1 week ago with grampy lower abdominal pain and vaginal spotting. Her hCG level was 1000mIU/mL. Transvaginal US today shows no clear pregnanacy in the uterus and no adnexal masses. Based on the information presented, which of the following can be concluded?
Nonviable pregnancy, location is unclear.
17yo lower abdominal pain and spotting comes to the ER. She has an hCG level of 1000 mIU/mL and a progesterone level of 26ng/mL. Dx?
Normal pregnancy
Primary utility of the transvaginal US in the assesment of an ectopic pregnancy?
assesment of intrauterine pregnancy
29yo complains of syncope. She is 6 weeks pregnant and on examination has diffuse significatn lower abdominal tenderness. Pelvic examination is difficult to accomplish due to guarding. Her hCG level is 400 mIU/mL. and transvaginal US shows no pregnancy in the uterus and no adnexal masses. Best next step?
surgical therapy, she has acute abdomen due to ruptured ectopic pregnancy