How to prangent?
At a woman's 35-37 week prenatal visit which screening test should be done?
-Self GBS (Group B Strep) swab, if pos tx with IV ampicillin/penicillin during labor
24-28 weeks: Screen for gestational diabetes
First visit: Rh type, STIs, basic bloodwork/UA
Your patient is a 35 year old female with a PMH of DVT and HTN. She smokes 2 packs a day. She presents today because she don't want to get pregnant. She rarely seeks medical care.
What are her options? Which would be best for her?
IUD - localized progesterone
Copper IUD (ParaGard) - 10 years baby!!!
Nexplanon - implanted progesterone
Depo-provera - injected progesterone
"Mini-pill" or norethindrone - oral progesterone
Also: condoms, cycle-tracking, sterilization
CI: combo pill, nuva ring, patches, anything with estrogen!
A 12-year-old boy is brought in to your office by his mother and father. The child has been experiencing swelling of his joints, fevers, and a rash on and off for 7 weeks. What is the most likely diagnosis?
Idiopathic Juvenile Rheumatoid Arthritis
Specifically, this is Still's disease/systemic d/t fever and rash.
Most commonly polyarticular (5+ joints affected)
Clinical diagnosis: labs (ESR, CRP, ANA, can be RF neg or pos)
Treatment: NSAIDS, corticosteroids, methotrexate, biologics
75-80% remit without serious disability
You're pretty sure your patient has reactive arthritis. Which joints are most likely to be affected?
The most common joints involved in reactive arthritis are the large weight-bearing joints of the knees and ankles.
When I say "pulsating mass protruding through cervical os," you say....
Umbilical cord prolapse!
What does the acronym HELLP stand for?
Hemolysis, elevated liver enzymes, low platelets (preeclampsia with these specific liver problems).
Why? Liver issues = abnormalities of erythrocyte membranes, break-down of liver = released liver enzymes, liver produces thrombopoietin so when damaged = dec thrombopoiesis
A patient comes in for a spontaneous abortion at 13 weeks gestation. The mother is Rh negative. What treatment should be given in the ED, if any?
RhoGAM (Rho(D) immune globulin ).
Mother can develop Rh antibodies when exposed to fetal blood cells if fetus is Rh pos. Inc risk of hemolytic disease of the newborn for next child.
When do we usu give RhoGAM?
What is the cute saying to remember reactive arthritis manifestations? What does this actually mean?
"Can't see, can't pee, can't climb a tree"
Conjunctivitis, urethritis, oligoarthritis (arthritis affecting few joints)
BONUS: What is the MCC of reactive arthritis?
A 40yo female comes in for burning in her epigastric region after meals. On PE you note tightened, shiny skin on her hands and neck. When you ask her about her hands, she says she thinks it's because she is sensitive to cold, she notices her fingers often get pale on cold days. What is the best tx for the likeliest dx?
Dx: scleroderma.
Tx: Based on s/s. PPIs for her GERD, vasodilators (calcium channel blockers) for Raynaud's.
CREST: Calcinosis cutis, Raynaud's phenomenon, Esophageal dysmobility, Sclerodactyly (claw hand), Telangiectasias
When I say, "anti-cyclic citrullinated peptide antibody," you say...
Rheumatoid arthritis!
Rheumatoid factor is a good initial test (pos), but this is the most specific.
Describe the difference between an inevitable abortion and a threatened abortion.
Both: bleeding before 20 weeks, fetus may still be "viable" (but if os is open fetus will not make it)
inevitable: open cervical os; retention of viable fetal products
Threatened: closed cervical os; retention of viable fetal products
A 20yoF with a hx of 20 male sexual partners presents to the ED for right-sided abdominal pain and vag bleed. She says the pain feels much worse than her normal period, though she has an IUD and her last "normal" period was when it was placed four years ago, now she just has spotting. She does not use condoms and has a hx of PID (pelvic inflammatory disease). Her last period was 8 weeks ago. Her vitals are WNL. What is the appropriate tx for the likeliest diagnosis?
Stable (unruptured) ectopic pregnancy, IM methotrexate (which stops zygote/blastocyst from further dividing).
CLUES: PID Hx, IUD.
OTHER CLUES: Mass in adnexa (ovary/fallopian tubes), Beta-hCG lower than expected, high Beta-hCG w/o gestational sac on transvag u/s. Cervical motion tenderness + suspicious hx.
Rupture: May have Kehr sign (referred pain in L shoulder).
Explain how to differentiate between gout and pseudogout (four common differences in vignettes). Is the tx the same?
Pseudogout: Positively birefringent, rhomboid shaped calcium pyrophosphate crystals, MC in knee
Gout: Negative birefringent, needle-like shaped uric acid crystals, MC in 1st metatarsal (podagra)
Tx: NSAIDS 1st, steroids, colchicine.
GOUT ONLY: Allopurinol, diet changes
Remember, sudden intense pain that comes on at night! Diff from septic joint, fracture, tendinitis.
A 45yo female presents with c/c of "weird fingers." She says her hands usually feel stiff in the morning and look fat, but she knows this is normal because it happens to her mom and sister. Over the years though they have gotten more deformed looking. Given the likeliest dx, which two deformities might you see on PE?
Boutonniere deformity: flexion at PIP, hyperextension of DIP
Swan neck deformity: flexion at DIP with joint hyperextension at PIP
Rheumatoid Arthritis
Involves MCP, PIP, WRIST, knee, MTP, shoulder, and ankle
Symmetric arthritis: swollen, tender and boggy joint
Ulnar deviation at MCP joint
Rheumatoid nodules
When I say "pregnant women with a hx of HTN who is seizing" you say
eclampsia!
Remember the spectrum: Chronic HTN -> gestational HTN -> preeclampsia -> preeclampsia w/ severe features +/- HELLP syndrome -> eclampsia (MUST HAVE SEIZURE, can occur up to a month after delivery).
Tx???
A woman in her third trimester presents to the ED for vaginal bleeding. She woke up and her pajamas were "covered in blood all the way through." She is having no cramping or pelvic pain. What is the most likely diagnosis?
Placenta previa. NO DIGITAL EXAMS IF THIS CONDITION IS SUSPECTED, speculum and transvaginal u/s OK.
BONUS: The same pt comes in but states they have minimal bleeding and a sharp, ripping pain in their abdomen. Now which is the likeliest dx?
What is the most common cause of postpartum hemorrhage?
Uterine atony (boggy uterus)
Tx: Fundal massage, IV oxytocin, U/S to confirm no retained placenta.
What test(s) can help diagnose Sjogren syndrome?
Suspect if: ocular + oral dryness daily x 3 or more months
Labs: ANA, Anti-SS-A (Anti-RO. Like row a boat. B/C you're so dry), Anti-SS-B (Anti-LA), + RF (MOST COMMON POSITIVE FINDING), elevated ESR
Schirmer's tear test! (<5mm lacrimation in 5 minutes)
Complications: interstitial nephritis, non-Hodgkin's
Name the most common etiology for septic arthritis in adults < 35?
Adults > 35?
<35: N. Gonorrhea (esp if knocking boots)
>35: S. Aureus
IVDU: Pseudomonas
When I say "snow storm appearance on ultrasound," you say....
Molar Pregnancy or Gestational Trophoblastic disease
What are mifepristone + misoprostol?
Medications that can be used to induce an abortion. First give mifepristone, then misoprostol 24-48 hour later.
Mifepristone: progesterone antagonist that softens/dilates cervix and supports placental separation (termination)
Misoprostol (Cytotec): prostaglandin analog that causes uterine contractions and cervical dilation (explusion). Often used to induce labor.
Assistance with spontaneous abortion up to 84 days gestation (12 weeks)
Medication abortion up to 77 days gestation (11 weeks)
Which anti-hypertensives are ok to use in pregnancy?
Methyldopa, labetalol, nifedipine, hydralazine
AVOID: ACE-Is and ARBs (hard for little baby kidneys)
What is the name of the rash associated with Systemic Lupus Erythematosus?
What is the most specific antibody?
What is the most sensitive antibody?
Malar (butterfly) rash. Think cancer pt with joint pain and rash.
The most specific antibody for SLE is the anti-Smith antibody; however, the sensitivity is only 30%-40%. (lots of false negatives)
Antinuclear antibody (ANA) is used for screening and has a sensitivity of 95%. (low specificity - lots of false positives)
Anti-dsDNA antibodies have a high specificity, but a sensitivity of only 70%.
WEIRD TX! Malaria-mariposa??
What is the pathophysiology of scleroderma?
Connective tissue disorder characterized by overproduction of collagen (types I, III) and matrix proteins -> diffuse fibrosis and vascular abnormalities in skin, joints, internal organs
Scleroderma?? More like...sclerodactyl!When I say, "HLA-B27 with back pain" you say...
Ankylosing spondylitis!
It is a protein on the surface of WBCs. This dx most often affects males aged 15-30, or BOYS age 27ish!
(Also seen with reactive arthritis, psoriatic arthritis, IBD)
***Bamboo spine on xray