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FSH level to check for amonrrhea when uterus present and pregnancy test
negative. High fsh means turner, low fsh means kallman confirm kallman
(hypogonadotropic hypogonadism, failure to start puberty, infertility, alt
sense or absent smell, GnRH neurons fail to migrate into hypothalamus)
with brain MRI
Preeclampsia eleated bp, proteinuria after 20 weeks gest. Patient first needs 24
hour urine quantitative measurement for protein, bp monitor, and lab eval of hb,
hct, plate count, serum transaminase, Cr, albumin, LDH, uric acid. Definative tx is
delivery.
Anemia if mircocytic with normal RDW its a thalassemia. In hemorrhage RDW is
high with normal MCV. In b12 and folate high rdw and high mcv. In mixed iron def
and b12 high rdw and mcv can be high low or normal.
Placenta Previa common finding in 2nd trimester, but few carry to term. In absence
of bleeding repeat ultrasound in 3rd trimester. Decision regarding delivery shoud not
be made until ultrasound performed at 36 weeks. Digital exams no done on women
with placenta previa, might make bleeding worse. In patients with hx of c-section
who have previa at site of previous incision a color flow Doppler should be done to
evaluate for placenta accrete. MRI is helpful to confirm dx.
Post Op fever 5 Ws wind (pneumonia/atelectasis), water ( UTI), Wound
infections, walking ( can help reduce dvt and pe), wonder drugs especially
anesthesia. Occur on post op days 1,3,5,7, and anytime respectively. Wind at 1,
water at 3 etc..
Post meningitis MCC of meningitis in 5 year olds include Pneumococcus
pneumonia, meningococcal men, H influenza. bacterial menigntis especially at risk
if not properly immunized. Sensorineural hearing loss is found in 20-30% of H.
influenza meningitis survivors. Audiologic assesments in pateints 4 to 6 weeks after
needed for hospitalized patients not for outpatient. Initial tx of CAP is empiric, and
macrolides and fluoroquinolones or doxy are used (not so much fluoroquinolones.)
Amoxi/clavulanate and b-lactams are alternatives.
Gastroenteritis pediatrics first dietary changes to rest gi tract and oral hydration.
Stool culture and sens after 7 days of diarrhea or if bloody stools. Parasite/ova if hx
of travel. No oral antidiarrheals, no antibiotics if its viral.
Pneumothorax if small and hemodynstable without parenchymal disease then it
will resolve spontaneously, breathing 100% o2 helps. Simple aspiration and defer
hospitalization in primary spontaneous if patient is stable. CT of lung in complicated
cases, or lung disease.
Postpartum Hemorrhage MCC is uterine atony. Less frequent include lacerations,
hematomas, and uterine rupture. These occur immediate after birth. Delayed
hemorrhage, occurring beyond the first 24 hrs is due to retained placental
fragments. Placenta accrete mcc of bleeding needing hysterectomy.
EKG changes due to occlusion circumflex occlusion changes in I and AVL, and
maybe V5,V6. LAD occlusion changes in V1 to V6. Right coronary occlusion changes
in II, III, AVF.
Remember to add K+ to IV fluid when treating DKA or hyperosmolar due to shift
of K+ from extracell back into the cells after insulin is given.
Bacterial vaginosis mcc of acute vaginitis, more than 50% of cases. Due to shift in
normal flora. Mixed vaginal flora is second mcc of discharge.
Labial adhesion of vagina in peds affects 3 mo to 6 year olds. Harmless resolves
once puberty starts. If they are severe or interfere with urination need tx. Tx
options: estrogen cream applied bid for 2-8 weeks. Side effects self limited.
Surgery is last resort. Antibiotic cream bust me applied to labial edges to stop them
from sticking together while they heal.
Sensitivity and specifity Sensitivity = a/(a+c) = dz&tst+ / all dz+. Spec = (neg,neg
/ (all with no dz).
Preeclampsia patiants with pre eclampsia require magnesium sulfate as soon as
dx is made, then deliver at 34 weeks or when deterioration of maternal or fetal
status or fetal lung maturity occurs. Always deliver if they have a seizure and severe
hypertension.
Genital wards hpv Imiquimod, podophyllin and podofilox are not recommended
during pregnancy. For tx during preg use cryotherapy with liquid nitrogen and not a
cryoprobe. Alternative is trichloroacetic acid
Sensitivity snout rule out measure of true positives. High sensitivity means if
you are negative you probably dont have the disease.
Specifity ability to correctly ID patients who do not have the disease. True negative
rate. Spin - rule in.
PE In patients with high clinical probability of PE do CTa. Normal D-dimer rules out
PE only in low or moderate clinical probability patients.
Oligohydramnios - Potter syndrome typical appearance due to dramatically
decreased amniotic fluid or absent fluid, secondary to renal agenesis. Causes fetus
to become compressed in uterus. Leads to potter facies and lower extreme
deformaties like clubbed foot / bowing of legs.
Neuroleptic malignant syndrome Hypermetabolic rxn to antipsychotics especially
dopamine receptor antagonists (thiothixene). Occurs early in tx after an inc in
dosage. Signs/sx lead pipe rigidity, hyperpyrexia, tachycardia, htn, ams, confusion,
and diaphoresis. Can lead to MI, aspiration, resp failure, acidosis, rhabdo.
Weight changes with psych drugs - Bupropion antidepressant least likely to cause
weight gain, may induce some weight loss. Among SSRIs paroxetine will cause most
weight gain and fluoxetine least. Mirtazapine causes more weight gain than SSRIs.
Heart failure vasopressin worsens heart failure by causing vasoconstriction of a.
and v., causes fluid retention and worse hyponatremia.
Ginseng can cause hypoglycemia and has anticoag properties must be stopped
before surgery.
OCD, ADHD, Tourettes in children all 3 commonly seen together. If one found
screen for the other 2 .
Shaken baby syndrome retinal hemorrhages, broken bones/ribs, mioght be
sleeping well/calm due to brain injury/swelling, sometimes from subdural
hemorrhages.
Aortic regurg diastolic decrescendo murmur best heart in left 3 rd intercoastal. Also
wide pulse pressure in valvuar lesions.
Spontaneous bacterial peritonitis sbp PMN > 250 is diagnostic. Protein > 1g is
evidence against sbp.
Lead poisoning peripheral neuropathy may occur after chronic exposure seen as
extensor muscle weakenss with minimal sensory loss. First sign usually painless
wrist drop.
Meningococcal caused by n. meningitides. Sx include high fever, severe headache,
dyspnea, stiff neck/back, painful joins and vomiting. Tx with penicillin or ceftriaxone.
Spreads to close contact through saliva or nose/throat secretions. Close contacts
shold be given prophylaxis either rifampin or ceftriaxone.
Chlamydia infection MC reported std. maybe asypm or mucopurulent discharge
endocervical, urethral syndrome (like uti, with abacterial pyuria), pelvic pain,
dyspareunia, post coital bleeding. Cannot be ID on saline wet mount or gram stain.
NAAT Is best. Doxy is drug of choice (100 mg PO BID 7 days). Can also do
azithromycin 1g PO single dose.
triggers. Ocular problems occur in half of patients. Mgmt includes avoid factors and
use sunscreen. Oral metronidazole, doxy and tetracycline can also be used. Low
dose clonidine and beta blockers can be added to help with flushing.
HIV screening newborn recommended that pregnant women receive anti-retroviral
therapy and infants with positive screening should ge zidovudine asap. Early hiv
infection is if present w.in 48 hours after birth and associated with rapid progression
to sxtomatic AIDS. Preferred screening is HIV DNA PCR. Sensitivity and specifitiy is
highest and increase with time the highest being after 6 monmths. Test 48 hours
after birth, then after 1 month then again after another 4 months.
Drug Side effects psychiatry antipsychotic meds parkinsonism tremor,
increased muscle tone, bradykinesia or akinesia, postural instability, loss of
spontaneity, micrographia.
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But cardio and weight training before bed time is bad. Iron and vitamin deficiency
can cause RLS, check all RLS patients for iron def. if cant manage sx with warm
baths, reducing stress, etc .. then use gapapentin or low dose pramipexole.
Drug induced esophagitis in elderly tetracyclines mc is doxy causes esophigits
decreased peristaltic clearance in old people can lead to pill retention and leads to
esophageal in jury due to prolonged contact. Aspirin and nsaids can also da mage
the esophagus. Others include KCl, quinidine, iron, alendronate.
Renal cyst simple renal cysts are found incidentally in older people, and in many
autopsies. No further evaluation needed if its a simple thin walled, homogenous,
fluid filled cyst. If its complex need renal CT with contrast. MRI is better to find
benign lesions and can be helpful if the CT results are not good enough.
Ophthalmology - Amaurosis fugax transient loss of vision inone or both eyes.
Patients present after it has resolved and neuro and opth exam is normal. Scotoma
is an area of depression vision in the visual field, surrounded by area of normal
vision (blind spot). Strabismus where visual axes of the eyes are not parallel and
the eyes appear to be looking in different directions. Esotropia cross eye a form
of strabismus. Nyctalopia night blindness, due to impaired function of specialized
cells in retina.
Fetal dev division of embryonic discs before day 4 di-di. Days 4-8 diamniotic,
monochorionic. Days 8-12 mo-mo. Division after day 12 conjoined.
Acardiac twins happens in monochorionic with delayed cardiac function in one
twin, with arterial anastomosis leading to reversed arterial perfusion and absence of
development of the heart tube TRAP twin reversed arterial perfusion. So the
heart of one twin does not develop.
Pheochromocytoma catecholamine secreting tumor of chromaffin cells in the
adrenals. Causes persistent or paroxysmal hypertension. The triad of sx is episodic
headache, diaphoresis, tachycardia. Dx is by measuring catecholamine products in
blood or urine. CT or MRI to localize tumors. Tx includes removal of tumor if
possible. Drug Tx for control of bp includes a-block, +/- b-block. Labs will show
hyperglycemia, hypercalcemia, erythrocytosis.
Menieres disease inner ear disorder that produces vertigo, fluctuating
sensorineural hearing loss, tinnitus. Sudden attacks of vertigo that last up to 24
hours, with n/v. no dx test. Treat vertigo and n/v with anticholinergics or bzds.
Vestibular system can be ablated with topical gentamicin or surgery in severe
cases. Thought to result from accumulation of excessive fluid in inner ear. Fluid
pressure stretches the mmembranes that divides the compartments of the inner
ear. As the membranes stretch, hearing decreases and tinnitus worsens. If they are
too stretched they will rupture leads to mixing of fluids (Na in one and K+ in the
other) and this mixture brings about the vertigo.
G6PD hemolytic anemia presents with decreased hb and increased retic count. For
g6pd recent treatment with tmp-smx, pyridium (both cause oxidative stress). Rapid
fluorescent blood spot test, the test detects the generation of nadph from nadp and
if it is positive (failes to fluoresce under uv light) then patient has g6pd.
Diabetes diagnosis sx of diabetes plus a casual glucose level of 11.1 ; fasting
plasma level of 7 ; or a 2 hour postprandial level of 11.1 after 75 gram glucose load
or hba1c >6.5%.
Risks for preterm delivery 3-4x more likely in a woman with prior preterm delivery.
Multiple gestation also makes it more likely. Known risk factors include 2,3 rd
trimester bleeding. Chronic conditions like DM, HTN. Being under or overweight,
gaining too little or too much. Cigg, alcohol, illicit drugs.
Diabetes treatments biguanides and thiazolidinediones are insulin sensitizers that
decrease hepatic glucose production andincrease insulin sensitivity. Sulfonylureas
and meglitinides stimulate pancreatic insulin secretion. DPP-4 inhibitors prevent
GLP-1 breakdown and slow the breakdown of some sugars. GLP-1 mimetics
stimulate insulin secretion, supress glucagon secretion, promote beta cell
production. Amylin analogs act with insulin to delay gastric emptying, inhibit
glucagon release.
Patietal lobe lesion parietal lobe has 2 areas sensation and perception and the
other is integrating sensory input with the visual system. Damage to the left parietal
lobe can lead to gerstmanns syndrome: right-left confusion, agraphia, acalculia.
Can produce disorders aphasia, and inability to perceive objects normally (agnosia).
Damage to the right parietal lobe leads to neglect of the body contralateral. Can
also cause difficulty making things (constructional apraxia), denial of deficits
(anosagnosia) and drawing ability.
Heat exhaustion and heat stroke evidence of CNS dysfx means heatstroke, even if
other sx are not severe. Heastroke is medical emerg. Heastroke is defined as temp
higher than 41.1 (106) associated with neuro dysfx. However, sometimes patient is
allowed to cooldown, measured temp might be lower than 41. Similar some pateints
may retain the ability to sweat in heatstroke.