Chapter 9-32 !! Flashcards Preview

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1

classification system for AUB

PALM-COEIN

structural- PALM
polyps
adenomyosis
leiomyomas
malignancy

nonstructural- COEIN
coagulopathy
ovulatory dysfuction
endocrine
iatrogenic
Not yet specified

2

most likely diagnoses for vaginal bleeding in prepubescent girls

vaginitis
foreign bodies
sexual abuse
tumors
trauma

3

most likely diagnoses for vaignal bleeding in adolescent girls

anovulation due to immaturity of HPA axis
bleeding disorders
STIs

4

most likely diagnoses for vaginal bleeding in reproductive age women

structural lesions - polyps, fibroids
PCOS

5

most likely diagnoses for vaginal bleeding in perimenopausal women

anovulatory cycles become common as ovarian function declines

6

most likely diagnoses for vaginal bleeding in postmenopausal women

endometrial atrophy
endometrial cancer

7

DDX for structural causes of vaginal bleeding in nonpregnant females

polyps
fibroids
malignncy
hyperplasia
endometriosis

8

DDX for nonstructural causes of AUB in non pregnant fmeales

coagulopathies: vWD, factor XI deficiency, thrombocytopenia, ITP
endocrine: PCOS, hypothyroidism, hyperprolactinemia, adrenal hyperplasia, Cushing's disease
hypothalamic: weight loss, extreme exercise, stress
obesity
trauma / sexual abuse
infections: TOA, vaginitis, STI
systemic disease: liver, kidneys
foreing bodies
medications: anti epileptics, antipsychotics, anticoagulants, hormonal medications, steroids
IUD

9

DDX for pregnant vaginal bleeding before 20 weeks gestation

ectopic pregnancy
GTD
abortion/miscarriage
implantation bleeding
ruptured corpus luteum cyst

10

DDX for pregnant vaginal bleeding after 20 weeks

placenta previa
vasa previa
placental abruption
uterine rupture
AVM

11

risk factors for ectopic pregnancy

smoking
IVF
previous ectopic
use of IUD
prior tubal surgery
PID
endometriosis

12

important symptoms to clarify on history in patient with vaginal bleeding

amount of bleeding, presence of clots
dizziness, syncope, or weakness
abdo pain
fever
vaginal discharge or odor
postcoital bleeding
hx of trauma

13

physical examination in vaginal bleeding

determine hemodynamic status
performing complete abdominal and pelvic exam
pelvic exam may reveal source of bleeding because masses, polyps, ulcers, foreign bodies and evidence of trauma or inflammation may be visualized

14

lab /tests in pt with vaginal bleeding

pregnancy test
hemodynamically unstable pts - CBC, type and cross matching, coags, and if pregnant a quantitative B-hCG
bedside US for IUP

hemodynamically stable- as outpt TSH and other hormone levels, complete pelvic US

15

in pregnant patients over 20 weeks GA, what needs to be done before pelvic

US to make sure no placenta previa

16

treatment of hemodynamically unstable vaginal bleed

IV crystalloid bolus
blood transfusions if not response to bolus

high dose IV conjugated estrogen (25mg) is first line, q4-6h for up to 24 hours
if bleeding continues can pack vagina with long continuous gauze, or insert foley into uterus to tamponade bleeding

17

treatment of stable non pregnant patent with vaginal bleedign

NSAIDs
OCP -ie. alesse or other low dose under 35ug of ethanol estradiol, one pill BID for 5 days and then one pill daily for remainder of pack OR if contradicted can use medroxyprogresterne acetate 10mg daily x 10days


OR (not in rosen's)
TXA 1g PO TID x 5 days

18

contraindications to use of estrogen

hx of thromboembolic events or stroke
pregnancy
active liver disease
severe uncontrolled htn
women older than 35 who smoke

19

critical chest pain diagnoses

acute MI
acute coronary ischemia
aortic dissection
cardiac tamponade

PE
tension pneumo

esophageal rupture (Boerhaave's syndrome)

20

emergent chest pain diagnoses

unstable angina
coronary spasm
prinzmetal's angina
cocaine-induced pericarditis or myocarditis

pneumothorax
mediastinitis

esophageal tear (Mallory-Weiss)
cholecystitis
pancreatitis

21

nonemergent chest pain diagnoses

valvular heart disease
AS
MVP
HCM

pneumonia
pleuritis, tumuour, pneumomediastinum

esophageal spasm
esophageal reflux
peptic ulcer, biliary colic

muscle strain, rib # arthritis, tumor, costochondritits, nonspecific chest wall pain

spinal root compression, thoracic outlet, herpes zoster, PHN

psychological, hyperventilation

22

risk factors for ACS

past or family hx of CAD
age men > 33, women >40
diabetes mellitus
hypertension
cigarette use or possible passive exposure
elevated cholesterol or triglycerides
sedentary lifestyle
obesity
postmenopausal
LV hypertrophy

23

risk factors for PE

prolonged immobilzation
surgery > 30 min in last 3 mos
prior DVT or PE
pregnancy or recent pregnancy
pelvic or lower extremity trauma
oral contraceptives + smoking
CHF
obestiy
PMHx or famhx of hypercoagulability

24

risk factors for aortic dissection

htn
congenital dz. of aorta or aortic valve
inflammatory aortic dz.
CTD
pregnancy
arteriosclerosis
cigarette use

25

risk factors for pericarditis or myocarditis

infection
autoimmune dz. (lupus)
acute rheumatic fever
recent MI or cardiac surgery
malignanct
radiation therapy to mediastinum
uremia
drugs
prior pericarditis

26

risk factors for pneumothorax

prior pneumothorax
Valsalva's maneuver
chronic lung disease
smoking

27

chest pain described as crushing pressure, substernal, exertion, radiation to jaw, neck, shoulder, arm

acute MI, coronary ischemia, unstable angina, coronary spasm

28

chest pain described as tearing, severe, radiating to or located in back, maximum at onset, may migrate to upper back or neck

aortic dissection

29

chest pain that is pleuritic

esophageal rupture, pneumothorax, cholecystitis, pericarditis, myocarditis

30

chest pain described as indigestion or burning

acute MI, coronary ichemia, esophageal rupture, UA, coronary spasm, esophageal tear, cholecystitis

31

chest pain associated with syncope or near-syncope

aortic dissection, PE, acute MI, pericarditis, myocarditis

32

chest pain associated with dyspnea (SOB, DOE, PND, orthopnea)

acute MI, coronary schema, PE, tension pneumothorax, pneumothorax, UA, pericarditis

33

chest pain associated with hemoptysis

PE

34

chest pain associated with nausea, vomitting

esophageal rupture, acute MI, coronary schema, UA, coronary spasm, esophageal tear, cholecystitis

35

chest pain + acute respiratory distress

PE, tension pneumothorax, acute MI, pneumothorax

36

chest pain + diaphoresis

acute MI, aortic dissection, coronary ischemia, PE, esophageal rupture, UA, cholecystitis, perforated peptic ulcer

37

chest pain + hypotension

tension pneumothorax, PE, acute MI, aortic dissection, coronary schema, esophageal rupture, pericarditis, myocarditis

38

chest pain + tachycardia

acute MI, PE, aortic dissection, coronary ischemia, tension pneumothorax, esophageal rupture, coronary spasm, pericarditis, myocarditis, mediastinitis, cholecystitis, esophageal tear

39

chest pain + bradycardia

acute MI, coronary schema, UA

40

chest pain + hypertension

acute MI, coronary ischemia, aortic dissection

41

chest pain + fever

PE, esophageal rupture, pericarditis, myocarditis, mediastnitis, cholecystitis

42

chest pain + hypoxemia

PE, tension pneumothorax, pneumothorax

43

chest apin + diffrence in UP BPs

aortic dissection

44

chest pain + narrow pulse pressure

pericarditis with effusion

45

chest pain + new murmur

acute MI, aortic dissection, coronary ischemia

46

chest pain + S3,S4 gallop

acute MI, coronary ischemia

47

chest pain + pericardial rub

pericarditis

48

chest pain + audible systolic "crunch" on cardiac auscultation

esophageal rupture, mediastinitis

49

chest pain + JVD

acute MI, coronary ischemia, tension pneumothorax, PE, pericarditis

50

chest pain + unilateral diminished or absent breath sounds

tension pneumo, pneumo

51

chest pain + pleural rub

PE

52

chest pain+ subQ emphysema

tension pneumo, esophageal rupture, pneumo, mediastnitis

53

chest pain + rales

acute MI, coronary ischemia, UA

54

chest pain + epigastric tenderness

esophageal rupture, esophageal tear, cholecystitis, pancreatitis

55

chest pain + LUQ tenderness

pancreatitis

56

chest pain + RUQ tenderness

cholecystitis

57

chest pain + unilateral leg swelling, warmth, pain, tenderness, erythema

PE

58

chest pain + focal neuro findings

aortic dissection

59

chest pain + stroke

acute MI

60

nonneurologic causes of weakness

alterations in plasma volume (dehydration)
alterations in plasma composition (glucose, lytes)
derangement in circulating RBCs (anemia or polycythemia)
decrease in cardiac pump function (MI)
decrease in SVR (vasodilator shock from any cause)
increased metabolic demand (local or systemic infection, endocrinopathy, toxin)
mitochondrial dysfunction (severe sepsis or toxin-mediated)
global depression of CNS (stimulant withdrawal, sedatives)