Index: 1.
CARDIOLOGY
a. b. c. d. e. f. g. h. i. 2.
Gallbladder Disease Esophagitis Esophageal Disorders Peptic Ulcer Disease Misc. Gastric Disorders Acute Diarrhea Chronic Diarrhea Cirrhosis and Ascites Cirrhosis Etiologies Malabsorption Diverticular Disease Colon Cancer Gi Bleed Acute Pancreatitis
Inammatory Bowel Disease Jaundice Viral Hepatitis
12 13 14 15 15 16 16 17 18 19 19 20 21 22 22 23 23
Acute Kidney Injury Sodium Calcium Potassium Kidney Stones Cysts and Cancer Acid Base
24 25 25-26 27 27 28 28
HEMATOLOGY O NCOLOGY
a. b. c. d. e. f. g. 6.
8 8 9 9 10 10 11
NEPHROLOGY
a. b. c. d. e. f. g. 5.
Asthma Lung Cancer Pleural Effusion DVT PE COPD ARDS Interstitial Lung Disease
GASTROENTEROLOGY
a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. 4.
1 2 3 4 4 5 5 5 6
PULMONARY
a. b. c. d. e. f. g. 3.
Coronary Artery Disease Congestive Heart Failure Valve Disease Cardiomyopathy Pericardial Disease Syncope Hypertension Cholesterol ACLS
Macrocytic Anemia Microcytic Anemia Normocytic Anemia Leukemia Lymphoma Plasma Cell Dyscrasia Bleeding, Thrombocytopenia
30 30 31 32 32 33 34
I NFECTIOUS DISEASE
a. b. c. d.
Antibiotics HIV TB Sepsis
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36 36 37 37
Index: e. f. g. h. i. j. k. l. 7.
Anterior Pituitary Posterior Pituitary Thyroid Nodules Men Syndromes Thyroid Disorders Adrenals Diabetes
42 43 43 43 44 45 46
NEUROLOGY
a. b. c. d. e. f. g. h. i. 9.
Lung Infection UTI Genital Ulcers Skin Infections Endocarditis Antibiotics Surgery
38 38 39 39 40 41 41 41
E NDOCRINOLOGY
a. b. c. d. e. f. g. 8.
Brain Inammation
Stroke Dizziness Seizure Tremor Headache Back Pain Dementia Coma Weakness
48 48 49 50 50 51 52 52 53
R HEUMATOLOGY
a. b. c. d. e. f.
Approach To Joint Pain Lupus Rheumatoid Arthritis Other Connective Tissue Dz Monoarticular Athropathies Seronegative Arthropathies
54 55 55 56 56 57
10. DERMATOLOGY
a. b. c. d. e. f. g. h.
Blistering Disease Papulosquamous Dermatoses Eczematous Dermatoses Hypersensitivity Reactions Hyperpigmentation Hypopigmentation Skin Infections Alopecia
58 58 59 59 60 61 61 62
11. PEDIATRICS
a. b. c. d. e. f. g. h. i. j. k. l. m. n.
Constipation Neonatal Jaundice Vomiting Seizures Gi Bleed Allergies Peds Rash Peds Preventable Trauma Vaccinations ENT Pediatrics CT Upper Airway / Stridor Lower Airway
Immunodeciencies
64 64 65 65 66 66 67 68 68 69 70 71 71 72
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Index: o. p. q. r. s.
Ortho Peds Pediatric Ophtho Urology Peds Sickle Cell Abuse
73 74 75 76 76
12. PSYCHIATRY
a. b. c. d. e. f. g. h. i. j. k. l. m. n. o.
Defense Mechanisms Anxiety Disorders Impulse Control Disorders Eating Disorders Mood Disorders I And II Delusional Disorders Personality Disorders Peds Psych Dissociative Disorders Addiction Drugs of Addiction: Intoxication and Withdrawal Sleep I And II Psych Pharm Psych Cognition Psych Somatoform – DSM-IV
78 79 80 80 81 82 83 84 85 85 86 87 88-89 90 90
13. GYNECOLOGY
a. b. c. d. e. f. g. h. i. j. k. l. m. n.
Gynecologic Cancers Gestational Trophoblastic Disease Incontinence Adnexal Mass Pelvic Anatomy Gyn Infections Vaginal Bleeding 1: Premenarche Vaginal Bleeding 2: Reproductive Years Vaginal Bleeding 3: Reproductive Age Primary amenorrhea Secondary Amenorrhea Infertility Menopause Virilization
92 93 93 94 95 96 97 97 98 99 100 101 101 102
14. OBSTETRICS
a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r.
Physiology Of Pregnancy 1st Visit Labs And Initial Care Quad Screen Third Trimester Labs Medical Disease Normal Labor Abnormal Labor Third Trimester Bleeding L&D Pathology Advanced Early Testing Eclampsia Multiple Gestation Post-Partum Hemorrhage Early Antenatal Testing Isoimmunization Perinatal Infections OB Operations Contraception
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104 104 105 105 106 107 108 108 109 110 110 111 111 112 112 113 114 115
Index: 15. SURGERY: GENERAL
a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p.
Pre-op Evaluation Post-op Fever Chest Pain Altered Mental Status Abdominal Distention Wound Fistula Decreased Urinary Output Obstructive Jaundice Esophagus Small Bowel Pancreas Leg Ulcers Colorectal Breast Cancer Pediatrics First Day
116 116 117 117 118 118 119 119 120 121 121 122 122 123 124 125
15. SURGERY: SPECIALTY
a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q.
Pediatrics Weeks To Months Surgical Hypertension Endocrine CT Surgery Pediatrics CT Vascular Adult Ophtho Skin Cancer Pediatric Ophtho Neurosurgery Bleeds Neurosurgery Tumors Urologic Cancer Urology Peds Urologic Miscellaneous Ortho Injury Ortho Hand Ortho Peds
126 126 127 128 129 130 131 132 133 134 134 135 136 137 138-139 140 141
15. SURGERY: TRAUMA
a. b. c. d. e. f. g. h.
Shock Head Trauma Neck Trauma Chest Trauma Abdominal Trauma Burns Bites Toxic Ingestion
142 143 143 144 145 146 146 147
16. PREVENTATIVE MEDICINE
a. b. c. d. e. f.
Biostats Prevention
Condence Interval Bias Vaccines Screening
148 149 149 149 150 150
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C
CARDIOLOGY
Coronary Artery Disease MYOCARDIAL INFARCTION
ACUTE TREATMENT OPTIONS
Path:
Occlusion of a coronary vessel
ASA
FIRST drug to give
Pt:
Chest pain that is worse with exertion, better with rest, relieved with nitrates in a hypertensive, diabetic, dyslipidemic smoker, who is old
Nitrates
Second
Angioplasty
No Clopidogrel needed, only in single-vessel disease
Bare-Metal Stent
Clopidogrel x 1 month, only in single-vessel disease
Drug-Eluting Stent
Clopidogrel x 1 year, only in single-vessel disease
CABG
Left Mainstem equivalent or multi-vessel disease
tPA
No PCI is available within 60 minutes transport time
Door-to balloon
90 minutes
Dx:
Tx:
ST segment changes = STEMI Biomarker Elevation = NSTEMI Stress Test = CAD Coronary Angiogram = best test Morphine, Oxygen, nitrates, Aspirin (MONA) Beta-Blocker, Ace-inhibitor, Statin, Heparin (BASH) Coronary Angiography with Stent (single vessel disease) CABG (multi-vessel disease) tPA if no transport available (60 minutes) R IS K F ACTORS
Prasugrel = Clopidogrel CHRONIC T REATMENT OPTIONS
AN D G OALS
Beta-Blocker
BP < 140 / < 90, HR < 70
Hypertension
<140 / < 90
Ace-inhibitor
BP < 140 / < 90
Diabetes
A1c < 7.0
Aspirin
Anti-Platelet
Smoking
Cessation
Clopidogrel
Anti-Platelet
Dyslipidemia
LDL < 100, better < 70 HDL > 40, better > 60
Statins
LDL < 100 (prefer < 70)
Age
Woman > 55 Man > 45 STORY
STRESS TESTING
Imaging EKG
Test of choice, no baseline abnormality
PHYSICAL
Left sided / Substernal
Nonpositional
Echo
EKG abnormalities, no CABG
Worse with exertion
Nonpleuritic
Nuclear
Better with rest
Nontender
CABG, Baseline wall defects, LBB Testing
STABLE
UNSTABLE NSTEMI
STEMI
ANGINA
ANGINA
Pain
Exercise
@ rest
@ rest
@ rest
Relief
Rest + Nitrates
Ø
Ø
Ø
Trops
Ø
Ø
↑
↑
ST ∆s
Ø
Ø
Ø
↑
Exercise
Test of choice, no contraindication to exercise with feet
Pharm
Any reason why they can’t get on a treadmill, of any kind. Dobutamine and Adenosine essentially identical COMPLICATIONS OF MI
RV Failure
Right Sided ECG No Nitrates
Aneurysm
Diagnosed by Echo
Arrhythmia
Vtach / Vb – ventricular ectopy from dying cells Brady / Blocks – AV nodal dysfunction
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1
A R D I O
CHAPTER 1 :
CARDIOLOGY
ACLS R HYTHMS
TO TREATMENT
Rhythm
Drug
Electricity
Vb Vtach
Amio Amio
Shock Shock
Torsades
Mag
Shock
SVT 1° Block
Adenosine Atropine
Shock Pace
2° Type 1
Atropine
Pace
2° Type 2 3° Block
Vb
Vtach
Torsades
Pace Pace SVT CODES
No pulse
CPR
Shock delivered Anything
CPR CPR
All codes
Epi
VT/VF Codes PEA, Asystole
Epi, Amio Epi AFIB
Stach
WITH RVR
Path:
Underlying stressor Ischemia, Infection, Structural heart
Pt:
Palpitations, Asymptomatic
Dx: Tx:
ECG NO HEART FAILURE: BB or CCB HEART FAILURE: Dig, Amio Shock: Shock AFIB
Path:
Sbrady
Pt:
PIRATES mnemonic Ischemia, Infection, Structural heart Palpitations, Asymptomatic
Dx:
ECG
Tx:
Rate control = Rhythm Control (AFFIRM) Rhythm: Cardioversion after TTE, TEE, one month of anticoagulation Rate: BB, CCB Rate: Anticoagulate with CHADS2 C CHF H HTN A Age > 75 D Diabetes S Stroke S Stroke Score 0 – Aspirin Score 1 – Rivaroxaban, Apixaban Score 2 + Coumadin or -axabans
1 ° Block
2 ° Type 1
2 ° Type 2
3 ° Block
Ab
Autter
Idioventricular
Asystole
6
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CHAPTER 3 :
GASTROENTEROLOGY
Cirrhosis Etiologies WILSON’S DISEASE
Path:
Copper secretion deciency, deposits in
PRIMARY BILIARY CIRRHOSIS
Path:
Women, Intrahepatic, Microductal disease
eyes, basal ganglia, and liver Pt:
Chorea, Kaiser-Fleischer Rings, Cirrhosis
Pt:
Asymptomatic 40 year old female who gets cirrhosis
Dx:
Multiple tests available. NEVER: Serum Copper Option: Ceruloplasmin low Option: Urine Copper high 1st: Slit Lamp looking for eye ndings Best: Biopsy
Dx:
Serology = AMA Biopsy shows disease
Tx:
Transplant
Tx:
Penicillamine → Transplant
Path:
Women with autoimmune disease
Free:
Picture of an eye + question about cirrhosis
Pt:
May be insidious, or may be acute with AST, ALT in the 1000s
Dx:
Serology = Anti Smooth Muscle, Anti-LKM Biopsy = best test
Tx:
Steroids initially Transplant
AUTOIMMUNE HEPATITIS
HEMOCHROMATOSIS
Path:
No “off” signal for iron absorption
Pt:
Bronze Diabetes = Diabetes, Cirrhosis, and Hyperpigmentation.
♂: Amenorrhea, ♀ Dx:
Iron Tests First Test: Ferritin – very elevated Best: Biopsy showing elevated iron
Tx:
NASH/NAFL
Path:
Fatty liver from Fatty People
Pt:
Diabetes, Dyslipidemia, Obesity, and cirrhosis without evidence of another disease causing cirrhosis
Dx:
Ultrasound 1st Biopsy best
Tx:
Weight loss, diabetes control, transplant
Deferoxamine (Desferal) or phlebotomy Transplant will result in recurrence ALPHA-1 ANTITRYPSIN DEFICIENCY
Path:
Elastase goes unchecked because Antitrypsin is trapped in liver. Genotype PiMM normal, PiZZ worst form
Pt:
Cirrhosis and Emphysema
Dx: Tx:
Pt: Dx:
Tx:
18
“VW HAPPENS” V
Viral Hepatitis (B, C)
Biopsy = PAS positive macrophages Best: genotype
W
Wilson’s Disease
Protease (emphysema) Transplant (liver)
H
Hemochromatosis
A
Alpha-1 Antitrypsin
P
Primary Sclerosing Cholangitis
P
Primary Biliary Cirrhosis
E
Ethanol
PRIMARY SCLEROSING CHOLANGITIS
Path:
ETIOLOGY ADVANCED ORGANIZER
Autoimmune disease in men, extrahepatic disease, macroductal disease Biliary stasis and cirrhosis, may also have ulcerative colitis, men Serology = p-ANCA ERCP = Beads on a string Biopsy = Onion Skinning Fibrosis Cholestyramine symptomatic relief Stents maybe, make transplant harder Transplant , but may/will recur
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N S
Non-Alcoholic Steatohepatitis Something else… fulminant diseases Autoimmune Hepatitis
Aa-toxin Acetaminophen Budd-Chiari Shock Liver Portal Vein Thrombosis
CHAPTER 7 :
E NDOCRINOLOGY
Anterior Pituitary 3 LEVELS OF FEEDBACK AND ENDOCRINE R EG
Hypothalamus Portal Circulation
GnRH
TRH
CRH
GHRH
↓
↓
↓
↓
FSH/LH
TSH
ACTH
GH
↓
↓
↓
↓
Ovaries Estrogen Progesterone Ovulation
Thyroid T3 T4 Metabolism
Adrenals Cortisol
Liver ILGF
Stress
Growth
Pituitary Systemic Circulation Target Organ Metabolic Effect
OF THE ANT PITUITARY
PROLACTINOMA
CUSHING’S SYNDROME
Path:
Autonomously secreting prolactin Most common pituitary lesion
See Adrenal
Pt:
Women: Galactorrhea, Amenorrhea, Microadenomas, No Vision Change Men: Decreased libido, Gynecomastia, Macroadenomas, Vision Changes,
Dx:
Medication list 1st: TSH Then: Prolactin Levels Best: MRI
Tx:
Bromocriptine or Cabergoline Surgery
f/u:
Surgery is NOT rst line therapy for
ACUTE P AN HYPOPITUITARISM
Path:
Infection, Infarction, Surgery, Rads
Pt:
TSH: Lethargy, Coma ACTH: Hypotension, Tachycardia GH/LH/FSH: Irrelevant
Dx:
Clinical Hormone (Cortisol and T4)
Tx:
Replace end hormones
f/u:
Sheehan’s: Pregnancy, bloody delivery Apoplexy: Tumor outgrows blood supply and dies, necrosis
prolactinomas; it is for all other secreting pituitary tumors and macroadenomas ACROMEGALY
Path:
Growth hormone = things that can grow Child = Long bones (Gigantism) Adult = visceral organs
Path:
Diabetes Wide-spaced teeth Hat/ring/shoe size increases Coarse features, CARPAL TUNNEL Big hands Dx:
Tx:
Autoimmune, Deposition, Cancer
GH / FSH / LH sacriced so that TSH and ACTH can persist Pt:
↓ Libido, changes in menstruation ↓ Growth
Dx:
Insulin Stimulation Test ˗ Growth Hormone fails to rise MRI
Tx:
Reverse underlying cause Replace hormones as needed
Cardiomegaly → DIA heart failure
Pt:
Growth Hormone ILGF-1 Glucose Suppression Test MRI
Path:
Normal variant
Surgery rst
Pt:
Asymptomatic
Dx:
MRI
Tx:
Reassurance
Octreotide or Cabergoline (adjunct) f/u:
Glucose Suppression Test = give glucose, test is positive (abnormal) if the GH does not change
Wait
Carpal tunnel is more associated with RA than Acromegaly… don’t be tricked
42
CHRONIC P AN HYPOPITUITARISM
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EMPTY SELLA SYNDROME
CHAPTER 9 :
R HEUMATOLOGY
Approach To Joint Pain SINGLE JOINT
MULTIPLE JOINTS
VS
Septic Crystals
Osteoarthritis, Lupus, Rheumatoid Scleroderma, Myositis, Seronegatives ACUTE
CHRONIC
VS
Septic, Trauma, Crystal, Reactive
Osteo, Lupus, Rheumatoid, Scleroderma, Myositis, Seronegatives
ISOLATED
SYSTEMIC MANIFESTATIONS
VS
Septic Crystal
Seronegative (IBD) Lupus (Face, CNS, Renal, Heart, Lung) Rheumatoid (Nodules, Serositis) Reactive (Oral + Genital Ulcer) DEGENERATIVE
INFLAMMATORY
VS
Osteoarthritis
Everything Else
NORMAL
Appearance
NONINFLAMMATORY
INFLAMMATORY
SEPSIS
Clear
Clear
Yellow, White
Opaque
WBC
<2
<2
>2, <50
>50
Polys
<25%
<25%
≥ 50%
≥ 75%
-
-
-
+
None
Osteoarthritis
Everything Else
Infection
Gram/Cx Dz
ANTIBODY
INTERPRETATION
Antinuclear Antibodies
Sensitive Lupus
Anti-Histone Antibodies
Specic Drug-Induced Lupus
Anti-ds-DNA Antibodies
Specic Lupus + Renal Involvement
Anti-Smooth Muscle Ab
Autoimmune Hepatitis
Anti-Mitochondrial Antibodies
Primary Biliary Cirrhosis
Anti-Centromere Antibodies
Scleroderma (CREST)
Anti-Ro+La Antibodies
Sjogren’s
Anti-CCP Antibodies
Rheumatoid Arthritis
Anti-RF Antibodies
Rheumatoid Arthritis
Anti-Jo Antibodies
Polymyositis
Anti-Topoisomerase Antibodies
Systemic Scleroderma
54
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CHAPTER 11:
PEDIATRICS
Pediatric Ophtho TYPE
TIME
PURULENT
PROBLEMS
TX
Chemical
24 hrs
Non-purulent
Bilateral
Caused by ppx
Bilateral,
Topical Erythro then IV ceftriaxone
Gonorrhea
Day 2-5
Chlamydia
Day 7-12
Purulent can turn to blindness
Silver Nitrate Ppx
Unilateral
Oral + Topical Erythro
Can turn into pneumonia
Silver Nitrate PPx
Muco-purulent
R ETINOBLASTOMA
Path:
Rb gene mutation
Pt:
Newborn screen in the neonatal unit
CONGENITAL CATARACTS
Path:
Present at birth → TORCH infections Not present at birth → Galactose Deciency
Pt:
White cloudy lesions in front of their eye “white thing in FRONT of the eye”
Dx:
Clinical
Tx:
Surgical Removal
with an abnormal light reex Red reex (normal) = Pure White Retina
Dx:
“white thing in the BACK of the eye” Tx:
Surgery Radiation Therapy (NEVER)
f/u:
Osteosarcoma R ETINOPATHY AMBLYOPIA
OF PREMATURITY
Path:
Premature baby, oxygen toxicity
Pt:
Suspect in any premature neonate especially if any of the “other 3” are present
Path:
Cortical Blindness
Pt:
Strabismus, Cataracts, another cause, leads to cortical blindness
Dx:
None
Dx:
Ophtho Exam = growths of retina
Tx:
None Fix the problem that could lead to cortical blindness
Tx:
Laser Ablation
f/u:
The “other three” Necrotizing Enterocolitis Bronchopulmonary Dysplasia Intraventricular Hemorrhage
STRABISMUS
Path:
“Lazy eye”
Pt:
Baby with one eye that focuses while the other does not Almost ALWAYS a photograph question
Dx:
Light reects at different points on both eyes
Tx:
74
If present at birth ˗ Patch the good eye ˗ Surgery if all else fails Glasses if developed after birth
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This is a duplicate from surgery.
CHAPTER 1 2:
PSYCHIATRY
Psych Pharm ANTI-DEPRESSANTS
SSRIs
Fluoxetine Paroxetine Sertraline Citalopram
↓ Libido Serotonin Syndrome = fever, myoclonus, altered mental status GI, Insomnia
Atypicals
Bupropion Venlafaxine Mirtazapine Trazodone
Minimal Sex SE, ↑ Risk of Seizures Diastolic HTN Weight Gain Sedation, Priapism
TCAs
Amitriptyline Nortriptyline Imipramine Desipramine
Used for enuresis Seconds as neuropathic pain Can be Lethal (Convulsions, Coma, Cardiac) → Wide QRS → EKG! Has Anti-Ach properties (dry mouth, sedation, Uretention, Constipation)
Phenelzine Tranylcypromine Selegiline
HTN Crisis when mixed together, lack of washout or eating of tyramine (red wine/ cheese) Orthostatic HoTN + Weight Gain
Safe
Most Dangerous
MAO-Is Rarely used
MOOD STABILIZERS
Lithium
First-Line, Drug of Choice Bipolar, Acute Mania, Depression Augmentation
Teratogen Nephrotoxic > 1.5 Causes Nephro DI Narrow TI
Valproate
First Line if Li contraindicated Bipolar, Seizures
Teratogen
(Spina bida) Thrombocytopenia Agranulocytosis Pancreatitis
Carbamazepine
Second Line Stabilizer Trigeminal Neuralgia
Teratogen (Cleft palate) Rash, SJS AV Block
Lamotrigine
Second Line Stabilizer Newer anticonvulsant
Blurred Vision SJS ANXIOLYTICS
Benzos
Abort panic attack Treats EtOH withdrawal
Addictive Withdrawal Seizure
SSRIs
First-Line long term treatment for chronic anxiety: OCD, PTSD, AD
See Anti-Depressants. Ø useful in acute attack
β-Blockers
Performance Anxiety
Bradycardia, Asthma
Bupropion
Backup to SSRI
Avoid in bulimia (causes seizures)
Haloperidol Diphenhydramine Lorazepam
Depot form Enhances Sedation Anxiolytics
Called a “B52”
88
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PSYCHIATRY
Psych Pharm ANTIPSYCHOTICS
Typicals
Haloperidol Fluphenazine Thioridazine Chlorpromazine
Are more potent so have better effect but also more side effects D2 only so good for + sxs only For noncompliance, use depot (Haloperidol)
NMS (fever, ↑ CK, rigidity, AMS)
Less potent but also has less side effects Both D2C and 5-HT1 so work on - and + sxs
EPS, Gynecomastia, Sedation, Anti-Ach (small risk) QTc prolongation DM and Weight Gain
Stop drug Give Dantrolene Highest risk of EPS Gynecomastia, Sedation, Anti-Ach
Atypicals
Risperidone Quetiapine Olanzapine Aripiprazole Ziprasidone
Currently “rst line” for psychosis
Clozapine
Unique to itself
The best antipsychotic The most selective for D2C and 5HT1 (+ and -) Drug of last resort
Agranulocytosis Requiring CBC q week
EXTRAPYRAMIDAL SIDE EFFECTS
Akathisia
A Feeling of Restlessness
↓ Dose
Acute Dystonia
Involuntary muscle contractions, hand ringing, torticollis, and oculogyric crisis
Anti-Cholinergic
Dyskinesia
Parkinsonism
Anti-Cholinergic
Tardive D yskinesia
Irreversible hyper-sensitization of dopamine-R = suppressible oral-facial movements
Stop Drug, sxs initially worsen
CHOOSING
THE R IGHT DRUG
Compliant Young Adult, Any atypical po without complications
↓ SE prole
Combative ER patient
Haloperidol + Benzo + Diphenhydramine The “B52”
Sedating
Noncompliant Psychotic
Haloperidol depot
q 1wk
Old Psychotic
Atypical or High-Potency Typical
↓ Sedation
Hospitalized and off their meds
Atypical, ↑ Dose q Day until maxed, then try
Everything else has failed
Clozapine
Best, most dangerous
Fever, Rigidity, AMS,
Dantrolene , order CPK, ICU
NMS
P
S Y C H
another
↑ CK
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CHAPTER 1 4:
OBSTETRICS
Advanced Early Testing PROCEDURE
WEEK
GOAL
R ISK OF LOSS
Conrm IUP Ultrasound
All
Transcranial Doppler
> 20 weeks
1st Tri = + 1 wk 2nd Tri = + 2 wk 3rd Tri = + 3 wk
Fetal Age, Well- None Being Fetal Anemia
EXTRA
No risk
NO ACCESS
1 / 200
> 16 weeks: Genetic > 24 weeks: Anemia > 36 weeks: L:S
> 16 weeks
AFP, Genetic Material
Chorionic Villus Sampling
10-12 weeks
Genetic Screens, Karyotypes, ?? Abortion
1/100
Elective abortion still possible in 1st tri
PUBS
> 20 weeks
Fetal Anemia
1/30
Access for transfusion
Amniocentesis
Eclampsia DISEASE
Chronic HTN
BP
> 140 / > 90
TIMING
U/A
Sustained BEFORE 20 weeks
Ø
Sustained AFTER 20 weeks
Ø
SXS
Ø
TREATMENT
α-methyldopa Hydralazine Labetalol
Ø
α-Methyldopa,
Transient HTN
> 140 / > 90
Mild PreE
> 140 / > 90
Sustained AFTER 20 weeks
> 300mg/dL
Ø
> 36: Mg + deliver < 36 Develop
Severe PreE
> 160 / > 110
Sustained AFTER 20 weeks
> 5g/dL
+
Mag + Deliver (C/S)
Eclampsia
----
-----
----
Seizing
Mag + Deliver (C/S)
HELLP
Hemolysis
Elevated Liver Enzymes
Low
Platelets
Mag + Deliver (C/S)
Hydralazine, Metoprolol Returns to normal 12 weeks after
Path: ?? Vasoconstriction Alarm Sxs:
Hemoconcentration, Edema Epigastric / RUQ Abdominal Pain Headache, Vision Δs
→ 3 rd Spacing → Glisson’s Capsule Stretch → Vasospasm
Labs: CBC, LFT, U/A
˗ Proteinuria → Eclampsia ˗ HELLP → HELLP Syndrome Seizing
→ Eclampsia
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CHAPTER 1 5:
SURGERY: GENERAL
Breast Cancer BREAST CANCER
Path:
Estrogen - Obesity, Nulliparity, Early Menarche, Late Menopause, HRT Genes – BRCA ½, Radiation
Pt:
Asymptomatic Screen Breast Lump, Breast Mass
Dx:
Mammogram Core Needle Biopsy
Tx:
Lumpectomy + radiation = Mastectomy Sentinel Lymph Node Biopsy Axillary Lymph Node Dissection if positive Chemo ˗ Her 2 Neu + ˗ Trastuzumab ˗ ER/PR + ˗ Tamoxifen (pre-menopausal) ˗ Anastrozole (post-menopausal) ˗ All ˗ Doxorubicin or Daunorubicin (anthracycline) based regimen BREAST CANCER SCREEN
PICK THE
TREATMENT
Local Surgical Therapy Disease: Lumpectomy + Radiation OR Mastectomy Sentinel Lymph Node Biopsy and then Axillary Lymph Node Dissection if + Spread Systemic Therapy Disease: Chemo: Doxorubicin, Paclitaxel Her2neu: Trastuzumab ER/PR: SERMS (Pre-Menopausal) ER/PR: Aromatase-I (PostMenopausal) K NOW YOUR TREATMENTS
Tamoxifen:
Better, ↑ DVT, ↑ Endo Ca
Raloxifene:
Worse, ↓ DVT, ↓ Endo Ca
Trastuzumab:
Heart Failure, Reversible, EARLY
Doxorubicin:
Heart Failure, Irreversible, LATE
USPTF:
50q2, start at 50, every 2 years
Daunorubicin:
The other Doxorubicin
ACS:
40q1, start at 40, every 1 year
ALND:
Sentinel Lymph Node First
All:
Mammogram → Core Needle Biopsy
BRCA:
MRI
DIAGNOSTIC DILEMMA: THE YOUNG WOMAN
< 30 gets a different set of rules Then Then Then
OR OR OR
< 30 = Reassurance x 2-3 cycles < 30 + persists = Ultrasound < 30 + cyst on ultrasound = FNA < 30 + cyst resolves = reassurance Mammogram and Core Needle Biopsy if… > 30 Ultrasound shows mass Aspirate is bloody Cyst recurs after aspiration
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PREVENTATIVE MEDICINE
Prevention
Bias
LEVELS
Primary
Prevent onset of dz Vaccines, diet/exercise
Secondary Tertiary
OF PREVENTION
Prevent progression of dz Screening, hypertension meds
BIAS
Lead Time
Condence Interval
Length Time
CI includes 1
Effect Size
Furthest from 1
Power
Narrowest range
Deadly dz is found less often,
bias that assumes nding dz means it’s less dangerous,
articially makes screening ↑ Overdiagnosis Diagnosis is ↑ but has Ø effect on mortality, is meaningless.
Articially ↑ survival stats Selection
Pt group isn’t chosen at random, can’t get meaningful comparisons, skews outcome
ASSOCIATIONS
Null
Pt of diagnosis changes, but no
effect on outcome, articially ↑ survival time
Prevent complications of dz Surgery, rehab
All medicine falls under 1 of these 3.
IN STUDIES/SCREENS
Measurement Using different tools to measure same thing, can’t get meaningful comparisons, skews outcome Information
Pts know something that affects their actions, skews outcome
Publication
Null/negative results less likely to be published, skews available data
Confounding
3rd variable that has a noncasual relationship with exposure AND outcome, why correlation doesn’t = causation
METHODS
TO ELIMINATE BIAS
Randomization
Blinding
Standardization
Statistical Controlling
**Bias is addressed in study design.**
P
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