Flashcards in Final Exam Deck (247):
At what age should a woman be referred to gynecology /endocrinology if she has not yet had her first menses?
16 years old
Which phase of the menstrual cycle is most likely to vary?
follicular (1st phase) - luteal (2nd phase) is almost always 14 days
What is Tanner Stage I for females?
What is Tanner Stage II for females?
subareolar breast bud and sparse, fine, straight pubic hair
What is Tanner Stage III for females?
elevation of the breast contour/enlargement of the areolae and long, dark, curly public hair
What is Tanner Stage IV for females?
the areolae form a secondary mound above the contour of the breast and pubic hair resembles adult pubic hair in quality but not distribution, having not yet spread to the thighs
What is Tanner Stage V for females?
mature female breast with recession of the secondary mound and a dependent breast contour and pubic hair has adult quality and distribution, with spread to the medial thighs
Which vaccines can be given during pregnancy?
hepatitis B, Tdap, and inactivated influenza
Which diseases are important to assess for in preconception counseling but cannot be vaccinated against during pregnancy?
varicella, HPV, and rubella (pregnant women also cannot receive the live influenza vaccine)
How much folic acid is recommended for pregnancy planning (and for all women of reproductive age)?
400 mg - starting 6 months prior to conception (ideally) and throughout pregnancy
What are the 10 CDC recommendations for preconception counseling?
(1) individual responsibility across the lifespan (reproductive life plan), (2) consumer awareness of healthy behaviors, (3) preventive visits (4) interventions for identified risks (chronic health conditions), (5) interconception care for women who have had a negative perinatal outcome, (6) prepregnancy checkup, (7) health insurance coverage for women with low incomes, (8) public health programs and strategies, (9) research, and (10) monitoring trends toward improving preconception health
What does GTPAL stand for?
G = gravida (# of times pregnant), T = term births (> 37 weeks), P = para (deliveries past 27 weeks), A = abortions (spontaneous or otherwise), L = living (# of children currently alive)
What components should be included at the beginning of every note in women's health?
age and GTPAL
When tracking basal body temperature, what level of temperature change indicates ovulation?
increase of 0.5 degrees F or more over baseline trend
At what age should a woman be referred for specialty consult if attempts at conception have failed (i.e., infertile)?
30 years old
What is the procedure for recording Basal Body Temperature?
monitor 1st temperature in the morning (no movement) for several months to detect trends
What do ovulation predictor kits do?
detect leuteinizing hormone surge via urine test - positive value indicates ovulation (use during the week of expected ovulation)
What is Mittelschmerz?
egg white vaginal discharge that occurs just before ovulation
What are the presumptive signs of pregnancy?
typically reflect symptoms that patient reports => amenorrhea, N/V, urinary frequency, quickening, pigmentation changes, breast tenderness and enlargement, Chadwick's sign, fatigue, chloasma/melasma (tan or dark skin discoloration - "mask of pregnancy"), linea nigra
What are the probable signs of pregnancy?
typically reflect signs that a provider can observe => Goodell's sign, Hegar's sign, ballottement (sharp upward pushing against the uterine wall with a finger inserted into the vagina), Braxton-Hicks contractions, positive pregnancy test, abdominal/uterine enlargement
What are the positive signs of pregnancy?
fetal heart sounds (detectable at around 10-12 weeks), quantitative hCG, and fetal outline/movement on ultrasound
What is Goodell's sign?
significant softening of the vaginal portion of the cervix from increased vascularization due to hypertrophy and engorgement of the vessels below the growing uterus
What is Hegar's sign?
compressibility and softening of the lower uterine segment
What is Chadwick's sign?
bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow that can be observed as early as 6 to 8 weeks after conception
When is human chorionic gonadotropic (hCG) detectable in the blood of a pregnant woman?
at the time of implantation - doubles every 48-72 hours and peaks at 60-90 days post fertilization
What is a qualitative hCG test?
urine dip (99% accurate for predicting pregnancy) - provides a yes/no indicator
What is a quantitative hCG test?
serum (level above 50 is considered a positive sign of pregnancy)
What hCG level is necessary for a pregnancy to be considered viable?
2-3 times the baseline level
How is abortion defined?
pregnancy termination prior to 24 weeks, regardless of cause (spontaneous, induced, or elective)
What are the M and Ms of abortion?
mifepristone (RU486), methotrexate, misoprostol (Cytotec)
What is the mechanism of action of mifepristone (RU486) for abortion?
"antiprogestin" - blocks endometrial growth and causes detachment
What is the mechanism of action of methotrexate for abortion?
prevents placental villi proliferation
What is the mechanism of action of misoprostol (Cytotec) for abortion?
causes uterine contractions
Why should pregnant women avoid arthrotec (used to treat osteoarthritis and rheumatoid arthritis)?
includes diclofenac and misoprostol (Cytotec) - will induce abortion
What is Plan B?
levonorgestrel - makes conditions unfavorable for implantation (*not* a form of abortion) - must be taken within 72 hours (preferably 12 hours) of unprotected intercourse => 85% effective in preventing pregnancy
What is Naegele's rule?
standard way of calculating the due date for a pregnancy - estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP)
What is the typical uterine size at 16 weeks gestation?
halfway between the symphysis pubis and the navel
What is the typical uterine size at 12 weeks gestation?
softball - located above the symphysis pubis
What is the typical uterine size at 20-36 weeks gestation?
20 weeks = at umbilicus, then 1 cm/week (should be +/- 1 cm => no more than 3 cm variation)
Which patients require an early referral to OB/GYN?
advanced age (30 years old or more), Hx of miscarriage, Hx of medical conditions, obese/overweight, "the needy"
What is the best estimate of fetal gestational age?
crown-to-rump length on ultrasound
Which routine tests should be ordered for all prenatal clients?
ABO blood group, Rh factor, CBC (Hb, Hct, MCV, MCH, MCHC), rubella titer, syphilis screening, Hep B, urinalysis/urine culture, chlamydia screening, cervical cytology, HIV screening
What are the best treatments for vomiting during pregnancy?
ginger (500 mg/day) or Vitamin B6 - avoid Zofran or Phenergan in an office-based setting
How should asthma be managed in pregnancy?
patient must be on medications if asthma is not controlled - can take 100 mcg of inhaled steroids => take peak flow 1st thing every morning and adjust steroid dosage up or down as necessary
What does aneuploidy mean?
abnormal number of chromosomes
When is genetic testing generally performed in pregnancy?
When can you determine the baby's sex?
20 weeks via ultrasound
What are Leopold's maneuvers?
systematic way to determine the position of a fetus inside the woman's uterus
When should the practitioner begin to perform Leopold's maneuvers?
20-24 weeks (age of vitality) - perform at every visit thereafter
When is the oral glucose tolerance test (OGTT) performed?
100 g glucose load performed at 24-28 weeks - failure = fail 2 of 3 readings performed at 1 (> 180 mg/dL), 2 (> 155 mg/dL), and 3 (> 140 mg/dL) hours after glucose administration => fasting should be < 95 mg/dL
Can HgA1c be used to monitor blood glucose during pregnancy?
no - pregnancy changes RBC indicators so HgA1c is unreliable
What is RhoGAM?
injected into the muscle of an Rh-negative mother - antibodies circulate in her bloodstream and protect her against any Rh-positive red blood cells from the fetus => performed at 24-28 weeks, if indicated
What is the procedure for kick counts?
perform every night while sitting quietly, start between 28 to 32 weeks - time how long it takes to perceive 10 fetal "kicks" => if > 1 hour, repeat once and if still > 1 hour go to hospital for assessment
What is PAPP-A (performed in 1st trimester)?
pregnancy-associated plasma protein A is a protein that in humans is encoded by the PAPPA gene - used in screening tests for Down syndrome (low value indicates risk for Downs)
What is nuchal translucency (performed in 1st trimester)?
collection of fluid under the skin at the back of the baby's neck - measured using ultrasound => abnormal value is one that is >5-6 mm in thickness (should not be measured after 20.6 weeks)
What is cfDNA testing?
cell-free DNA testing (conducted at 10-12 weeks) - used to detect fragments of the baby's DNA floating through the mother's bloodstream - used to screen for chromosomal abnormalities
What is the difference between chorionic villus sampling and amniocentesis?
CVS samples blood from placenta (performed at 8-10 weeks) while amniocentesis samples fetal cells from the amniotic fluid (performed at 14-16 weeks)
How is preterm labor defined?
cervical effacement/dilation between 20 and 37 weeks gestation - #1 risk factor is preterm labor or repeated pregnancy loss => Tx includes bedrest, cerclage, and tocolytic agents (breathine, MGSO4, indomethacin)
What is cervical effacement?
thinning of the cervix - occurs prior to dilation
Why would a woman experience rhinorrhea during pregnancy?
progesterone causes loosening of mucus membranes (including those in the nose) - treatment includes saline rinses or 5 mg of Claritin (do not give Sudafed) => antihistamines contraindicated in women with low amniotic fluid levels
What are the original FDA pregnancy categories (prior to 2015)?
A = controlled studies show no risk; B = no evidence of risk in humans; C = risk cannot be ruled out/human studies are lacking; D = positive evidence of risk but potential benefits may outweigh risks; X = contraindicated in pregnancy
What are the new FDA labeling rules (passed in 2015)?
Pregnancy and Lactation Labeling Rule - 3 narrative subsections: (1) pregnancy (including L and D), (2) lactation, and (3) females and males of reproductive age => each section contains: registries, risk summary, clinical considerations, and data
What are the recommendations for weight gain during pregnancy?
(1) underweight (BMI < 18.5) = 28-40 total and 1/week in 2nd/3rd trimesters; (2) normal (BMI 18.5-24.9) = 25-35 total and 1/week in 2nd/3rd trimesters; (3) overweight (BMI 25.0-29.9) = 15-25 total and 0.6/week in 2nd/3rd trimesters; (4) obese (BMI > 30) = 11-20 total and 0.5/week in 2nd/3rd trimesters
What is pregnancy induced hypertension?
elevated BP (> 30 mmHg S or > 15 mmHg D) *without* proteinuria - need to perform urine dip stick to test
What is HELLP syndrome?
Hemolysis, Elevated Liver enzymes, Low Platelet count - a life-threatening pregnancy complication usually considered to be a variant of preeclampsia
What is pre-eclampsia?
pregnancy induce hypertention *with* proteinuria - s/s include sudden weight gain (> 2 lbs/week), digital/facial edema (1+), headaches/visual disturbances, HTN (SBP > 160-180 or DBP > 110), proteinuria (5 g or more), hyperreflexia => Tx: bedrest, surveillance, steroids to mature fetal lungs, hospitalization
What is eclampsia?
pre-eclampsia with tonic/clonic seizures
What is placenta abruption?
separation of placenta from the uterine wall - two types: (1) revealed - abruption over the cervix associated with bright red bleeding (80%) and (2) concealed - abruption does not cross cervix with blood pooling between uterus and placenta (20%) => do *not* perform cervical exam in woman with placenta previa - can cause abruption
What is suggested by the phrase "hard, rigid abdomen" in a pregnant woman?
placenta abruption - need to get to the ED within 10 minutes to save the baby
What is the non-stress test?
identifies accelerations in fetal heart rate in response to stimulation - "reactive" is > 2 accelerations of 15 bpm above and 15 seconds beyond baseline in a 20 minute test
What are the components of a biophysical profile?
(1) fetal breathing, (2) gross body movements, (3) fetal tone, (4) amniotic fluid volume, (5) non-stress test - each scored 2 or 0 points => < 4 = delivery, 6-8 = repeat in 24 hours, 8-10 = normal
How is hypothyroidism managed in pregnancy?
titrate levothyroxine levels to keep TSH at < 2.5 mIU/L
What is the procedure for emergency delivery?
check for cord 1st, deliver shoulders (1st pull down then pull hands up), don't lift the baby above the perineum until you have cut the cord (somewhere in the middle - not too short or too long)
What is mastitis?
breast inflammation usually caused by infection (Staph aureus is most common) - Tx: amoxicillin/clavulanate (Augmentin), 875 mg BID => pump and dump to maintain mother's milk supply
What are the various definitions of miscarriage?
threatened (vaginal bleed prior to 20 weeks), inevitable (passage of products of conception [POC]), incomplete (retention of some POC), missed (non-viable pregnancy without bleeding), septic (complicated by infection), recurrent (3 or more consecutive), complete (full expulsion of POC in an intrauterine pregnancy)
What are the s/s of a vaginal yeast infection?
discharge: thick, white, cottage cheese; itching; pseudohyphae; Tx: antifungal (lotrimin or monostat)
What are the s/s of non-infectious vaginitis?
discharge: increased; itching/burning; Tx: avoid irritants
What are the s/s of bacterial vaginosis?
discharge: milky white, thin; fishy odor worse after sex; Clue cells (Cheez-it with black ring around it); Whiff +; Tx: Flagyl (metronidazole)
What are the s/s of chlamydia?
discharge: increased or unchanged; light bleeding after sex; burning on urination; friable cervix; Tx: Zithromax
What are the s/s of trichomoniasis?
discharge: yellow or gray-green, frothy or sticky; itching; painful urination; foul, fishy odor; strawberry cervix; Whiff +; Tx: Flagyl (metronidazole)
What are the s/s of gonorrhea?
discharge: mucopurulent or unchanged; Tx: rocephin IM
What are the s/s of herpes simplex?
discharge: unchanged; pain; viral syndrome; painful vesicular lesions; Tx: antiviral
What is the role of the hypothalamus in the normal menstrual cycle?
produces gonadatropin releasing hormone (GnRH), which stimulates the pituitary to release follicle stimulating hormone (encourages maturation of 1-2 follicles) and estradiol/estrogen (builds up the endometrial lining)
What is the role of leutenizing hormone in the normal menstrual cycle?
causes the release of the dominant follicle out of the ovary - a rise in progesterone hormone indicates to the body that the woman is pregnant and supports the pregnancy until the placenta is strong (decline in progesterone indicates that the woman isn't pregnant and the uterus sheds the endometrial lining)
Which vulvovaginitis diagnosis is suggested by a pH > 5?
What is toxic shock syndrome
colonization of Staph aureus that produces exotoxins and triggers an autoimmune response - characterized by rapid onset of symptoms close to time of menstruation => s/s: fever > 38.9 degrees C, hypotension, diffuse erythroderma, desquamation of palms and soles, involvement of >= 3 major organ systems
What is the treatment for toxic shock syndrome?
removal of retained item (e.g., tampon) and Tx with Flagyl or doxycycline
What is the best treatment for premenstrual dysphoric disorder?
depends on the primary complaint; ibuprofen if pain/cramping, antihistamine (hydroxyzine) if sleep disorder, SSRIs (sertraline/Zoloft) if depression
What distinguishes premenstrual dysphoric disorder from regular depression?
PMDD is more cyclical than depression and associated with the menstrual cycle - prescribe 25 mg Zoloft at bedtime one week before menstruation and off for 3 weeks
What is the weight cut off for low dose contraceptives?
150 pounds - pills will not be effective at this or higher weights
How long after an abortion (due to any cause) should a woman wait before attempting conception again?
6 to 12 weeks
What is justice?
duty to be fair and treat all patients in the same equitable manner => the responsibility of the provider to treat people the same
What is beneficence?
duty to prevent harm and promote good => the obligation of the healthcare provider to help people in need
What is veracity?
duty to be truthful => the healthcare provider must be truthful and avoid deception
What is fidelity?
duty to be faithful => the healthcare provider has an obligation to be faithful to commitments made to self and others
What is autonomy?
duty to respect one's right to their own thoughts/actions => the right of the competent person to choose a personal health plan of life and action by exercising the rights of self-determination, independence, and freedom
What is utilitarianism?
allocation of healthcare resources so that the best is done for the greatest number of people - recognizes that healthcare is a limited resource that needs to be carefully allocated => increased utilization of primary prevention services that are aimed at avoiding health problems can help with healthcare cost savings and help actualize the principle of utilitarianism
What is nonmaleficence?
requirement that the provider do no harm, with or without intention
How is infertility defined?
1 year of unprotected, frequent intercourse that has not resulted in conception - refer to specialist
What is the most common cause of lack of patent fallopian tube?
How is semen analysis conducted?
2 specimens, 1 month apart - specimen must be kept warm and brought to the lab within 30 minutes => call lab first to be sure that they will perform semen analysis
What are the parameters for normal semen?
volume > 1.5 mL; pH 7.2-7.8; count > 15 million/mL; motility >= 32%; forward progression > 2; morphology > 30% with oval heads, midpiece, tail
What precautions should be taken post-vasectomy?
check for bullets in the chamber
What are common features of polycystic ovarian syndrome?
obesity, oligomenorrheic, hirsutism, acne, acanthosis nigricans, polycystic ovaries on ultrasound, hyperandrogenism, oligoovulation/anovulation, insulin resistance => refer to endocrine/gyn
What is the treatment for PCOS?
weight loss, diabetic diet, metformin 500 mg (titrate to 1,500 mg), Clomid (to encourage ovluation if patient is trying to get pregnant), prenatal vitamins
What is the difference between IUI and IVF?
IUI = intrauterine insemination - sperm injected directly into uterus; IVF = in vitro fertilization - egg fertilized outside of uterus and implanted
What is endometriosis?
benign gynecologic disorder in which endometrial tissue grows outside the uterus - can only be diagnosed via laparoscopy
What are the treatments for endometriosis?
minimal - none; mild - NSAIDs; moderate - hormones (Lupron - gonadatropin releasing hormone antagonist); severe - surgery
What are ovarian cysts?
leftover follicles that are not released
What evidence on ultrasound suggests a ruptured cyst?
free fluid in the cul-de-sac - area behind the uterus
What is the classification of ovarian cysts?
simple (contain fluid but no other content) versus complex (contain septum, blood, etc.) => must refer *all* patients with complex cysts, regardless of size
What are the best ultrasonic views for ovarian cysts?
transvaginal *and* abdominal
What are the recommendations for referral for simple ovarian cysts?
< 5 cm - functional (will generally resolve spontaneously - observe/no treatment necessary); 5-7 cm - need to follow-up in 3-4 months; > 7 cm - refer to GYN
What are uterine fibroids/leiomyomas?
benign tumors that grow in the uterus - most common reason for hysterectomy in the U.S.
What are the treatments for fibroids?
NSAIDs, oral contraceptive pills, Lupron, ablation, surgery
What is a Bartholin cyst?
swelling and pain in a Bartholin gland when it become obstructed - Tx: incision/drainage and antibiotic (choice depends on how deep the infection is) => incision/drainage is very painful - do not perform in primary care
What was the finding of the Women's Health Initiative?
prior to 2002, all women were prescribed estrogen hormones at the time of menopause (thought to provide cardiac benefit) - WHI found increased rates of cardiac events in participants => findings led to reversal and refusal to prescribe hormones for any reasons
What is the current recommendation for hormone prescription with menopause?
do not routinely give hormones, but can be given - give the smallest dose for the shortest time possible
If prescribing hormone therapy after menopause, why must women with an intact uterus receive pills with *both* estrogen and progesterone (e.g., Pempro)?
if patient receives estrogen only, uterine lining will continually build up (endometrial hyperplasia with risk of endometrial cancer) - progesterone allows for shedding of the uterine lining
What is recommended for women taking black cohosh for menopausal symptoms?
give a progesterone challenge test - progesterone for 10 days and then stop => patient should have withdrawal bleeding
What is the definition of menopause?
no period for one calendar year - it is *never* normal to have vaginal bleeding after menopause => refer to GYN
How often do cervical cells reproduce?
every 3-4 months
What are possible findings on Pap smear?
normal; ASCUS; CIN 3, 2, or 1; cancer - need to perform colposcopy with biopsy for any patient with CIN 3, 2, 1 or cancer for definitive diagnosis
What is the correlation between PCOS and cardiometabolic risk?
patients with PCOS have increased risk for metabolic syndrome - patients with higher levels of circulating androgens have higher risk for insulin resistance, metabolic syndrome, and Type 2 DM
What are the Rotterdam criteria for diagnosis of PCOS?
2 of the following: (1) hyperandrogenism, (2) oligoovulation/anovulation, (3) polycystic ovaries on ultrasound
Which cardiometabolic screening tests should be performed in patients with PCOS?
BMI, BP, glucose metabolism, lipid profiles, fatty liver (if risk factors present), obstructive sleep apnea (if risk factors present)
What is the timing hypothesis in menopausal hormone therapy?
the time since menopause is a critical determinant of the net benefit versus potential harm of hormone therapy and use - decisions on treatment must be individualized
What is the difference between monophasic and triphasic birth control pills?
monophasic - same dose of estrogen/progesterone for 3 weeks; triphasic - dose of hormones varies to better reflect normal cycle => triphasic likely better option for hormone replacement therapy
What is the benefit of transdermal/local vaginal estrogen therapy?
can treat localized symptoms (e.g., vaginal dryness) without systemic effects (e.g., increased risk for thromboembolism)
What are some lifestyle modifications that women can undertake to manage menopausal symptoms (particularly hot flashes)?
maintain cool environment, wear light clothing, maintain healthy body weight, smoking cessation, relaxation techniques, acupuncture
What was the WHI finding on risk of invasive breast cancer with hormone therapy for menopausal symptoms?
increased risk of invasive breast cancer with 5 or more years use of estrogen plus progesterone; no significant increase in risk with estrogen only therapy, even after 7 years
Which patients are the best candidates for menopausal hormone therapy?
healthy young perimenopausal/early menopausal within 10 years of the onset of menopause
What is the difference between primary and secondary dysmenorrhea?
primary is pain in the absence of underlying pelvic disease (more common in adolescents); secondary occurs as a result of underlying pathology (more common after age 30)
What is the principle cause of pain in primary dysmenorrhea?
increased levels of prostaglandins
How is a diagnosis of primary dysmenorrhea generally made?
following a trial of NSAIDs (block the production and release of prostaglandins) - positive response confirms diagnosis
What is the dosage of Clomid for inducing ovulation?
50 mg daily for 5 days beginning on 5th day of menstrual cycle - maximum of 3 courses (can increase to 100 mg/day for 2nd or 3rd course)
Which gynecological cancers are associated with HPV?
cervical, vaginal, vulvar
What are the symptoms of cervical cancer?
abnormal vaginal bleeding or discharge
What are the symptoms of ovarian cancer?
abnormal vaginal bleeding or discharge, pelvic pain/pressure, abdominal/back pain, bloating, changes in bathroom habits
What are the symptoms of uterine cancer?
abnormal vaginal bleeding or discharge, pelvic pain/pressure
What are the symptoms of vaginal cancer?
abnormal vaginal bleeding or discharge, changes in bathroom habits
What are the symptoms of vulvar cancer?
pelvic pain/pressure, itching/burning of the vulva, changes in vulva color or skin
What are the risk factors for ovarian cancer?
middle age or older; family Hx; personal Hx of breast, uterine, or colon cancer; Eastern European Jewish background; never given birth; endometriosis; positive for BRCA 1 or 2
What are the risk factors for uterine cancer?
age > 50; obesity; take estrogen by itself for menopause; trouble getting pregnant; < 5 periods in a year at any time in a woman's life; take tamoxifen
What are the risk factors for vaginal cancer?
HPV; HIV; abnormal Pap; exposure before birth to DES; smoking
What are the risk factors for vulvar cancer?
HPV; abnormal Pap; HIV; age 50 or older; chronic vulvar itching/burning; smoking
What is the recommended frequency of obstetric visits?
monthly until 30 weeks, biweekly until 36 weeks, weekly until birth
Which assessments should be performed at every obstetric visit?
vital signs (BP and weight), fundal height, fetal heart rate, fetal position/activity
How much iron should be included in prenatal vitamins?
By how much should a pregnant woman of healthy weight increase calories in her diet?
300 calories per day
What is the Consensus Model?
licensure for the APN reflects role (e.g., nurse practitioner versus nurse anesthetist) and population (e.g., family, adult, pediatrics) levels - APNs can conduct their practice beyond the role and population levels in a specialty capacity with additional training
What is Tanner stage I for males?
What is Tanner stage II for males?
enlargement of scrotum and testes; scrotum skin reddens and changes in texture
What is Tanner stage III for males?
enlargement of penis (length at first); further growth of testes
What is Tanner stage IV for males?
increased size of penis with growth in breadth and development of glans; testes and scrotum larger,
scrotum skin darker
What is Tanner stage V for males?
adult genitalia; pubic hair has adult quality and distribution, with spread to the medial thighs
When tracking Basal Body Temperature, what is the indicator for a couple to actively attempt conception?
baseline temperature will drop immediately before LH surge, with a subsequent increase in temperature - begin regular intercourse when the temperature falls
When can you first detect fetal heart tones?
What is the term for cervical thinning (ripening)?
cervical effacement - occurs prior to dilation => cervical length > 30 mm is reassuring that effacement is negative
At what gestational age are Hegar's, Goodell's, and Chadwick's signs all positive?
At what gestational age are fetal movements detected (i.e., quickening)?
At what gestational age are 95% of babies in the vertex position (with head engaged/ballottement)?
When are HgB and STI testing performed?
What is the treatment for placental abruption?
surgical delivery STAT - fetal loss can occur within 10 minutes
What is placenta previa?
placenta is attached over some part of the cervix - do *not* perform vaginal exam => can cause abruption
What is the most common type of anemia during pregnancy?
iron deficiency anemia
What does mean cell volume (MCV) indicate?
size of red blood cells => microcytic < 80, normocytic 80-100, macrocytic > 100
What does mean corpuscular hemoglobin concentration (MCHC) indicate?
color of red blood cells => hypochromic < 32%, normochromic 32-36%, hyperchromic > 36%
What will be the values for MCV and MCHC in a patient with iron deficiency anemia?
microcytic (< 80) and hypochromic (< 32%)
What is the treatment when a patient has multiple ovarian cysts?
birth control pills to suppress ovulation
What were the problems with the design of the WHI study?
goal of the study was to assess cardiac benefits of hormone replacement therapy but study was designed with a sample of patients with average age of 65 (most women receiving hormone replacement are in their early to mid 50s)
What are the causes of post-menopausal bleeding?
*never* normal - indicates either that that endometrial lining is too thick (risk of endometrial cancer) or too thin (indicating atrophy)
What is the most common gynecological problem within the geriatric population?
atrophic vaginitis (s/s: UTIs, pain, itching) => Tx: estrogen cream/suppository or moderate-to-high potency topical glucocorticoids
What is the pontine micturition center?
area in the brainstem that provides for automatic coordinated voiding - urethra opens before the bladder contracts => pons holds the micturition 'reflex' center, which allows the bladder to empty when reaching a certain fullness (important for spinal cord patients)
What is the role of the parasympathetic nervous system in urination?
comes off at S2 to S4 and causes the bladder to contract and the urethra to relax (stimulation initiates voiding)
What is the role of the sympathetic nervous system in urination?
comes off at T10 to L2 and causes bladder neck to tighten and bladder to relax (stimulation contributes to urine storage and promotes continence)
What is the trigone?
smooth triangular region of the internal urinary bladder formed by the two ureteral orifices and the internal urethral orifice - sensitive to expansion => once stretched to a certain degree, sends signal to the brain of the bladder's need to empty (signal becomes stronger as bladder continues to fill)
What is the pathology in patients with urge incontinence?
normally, bladder pressure is NOT greater than urethral pressure and patients may have urgency but not loss of urine - in urge incontinence, bladder pressure is greater than urethral pressure (due to involuntary detrusor contraction) and patient spills urine
What would you suspect in a patient with costovertebral angle (CVA) tenderness/Murphy's punch sign?
What are the most common pathogens for UTIs (cystitis, prostatitis, and pyelonephritis)?
E. coli (85%), Staph saprophyticus (15%), Proteus mirabilis
What is simple/uncomplicated cystitis?
most common symptomatic bladder infection ("traditional UTI") that occurs in otherwise healthy outpatients
What is the treatment for simple cystitis?
trimethroprim/sulfamethoxazole (Bactrim) one double strength tablet (160/800 mg) BID for 3 days (7 to 14 days in men) => can use fluoroquinolone (ciprofoxacin or levofloxacin) in patients with sulfa allergies
What role does the cerebral cortex play in bladder function?
detrusor area directs the micturition centers to initiate or delay voiding depending on the social situation (social continence)
What is the pharmalogical treatment for urge incontinence?
anticholinergics - oxybutinin or tolterodine (preferred)
What is the definition of a urinary tract infection?
an infection of any component of the urinary tract - lower (urethritis, prostatitis, cystitis) or upper (pyelonephritis, peri-nephric abscess)
What are common symptoms of UTIs?
dysuria, increased frequency, hematuria, fever (indicates systemic infection), N/V (pyelonephritis), flank/CVA pain (pyelonephritis), pain with defecation, uretral discharge (urethritis), tender prostate (prostatitis)
What is the most valuable laboratory test to diagnose a UTI?
urinalysis for evaluation of pyuria (presence of pyuria and bacteria confirms the diagnosis) - absence of pyuria in pyelonephritis suggests an obstructing lesion
What does the presence of white cell casts suggest in a patient with pyuria?
renal origin of UTI
What is the treatment from complicated cystitis?
fluoroquinolone (or other broad spectrum antibiotic) for 7-14 days (possibly 2-4 weeks in males)
What is pyelonephritis?
infection of the renal parenchyma - s/s: fever, N/V, headache => diagnose with urinalysis, urine culture, CBC, chemistry
What is the treatment for pyelonephritis?
trimethroprim/sulfmethoxazole (Bactrim) or fluoroquinolone - hospitalization and IV antibiotics if patient unable to take medication PO => 5 days may be sufficient for mild infection while 14 to 21 days may be necessary for severe infection
What diagnosis would you suspect in a patient with UTI (pyelonephritis) who is not improving after 48 to 72 hours of antibiotic therapy?
parenchymal or perinephric/renal abscess - diagnose with CT with contrast and renal ultrasound
What diagnosis would you suspect in a patient with UTI (pyelonephritis) and severe flank pain?
What are possible parenteral regimens for empiric treatment of mild to moderate complicated pyelonephritis?
ceftriaxone (1 g), ciprofloxacin (400 mg), levofloxacin (750 mg), aztreonam (1 g)
What are possible parenteral regimens for empiric treatment of severe complicated pyelonephritis?
cefepime (2 g), piperacillin-tazobactam (3.375 g), ceftolozane-tazobactam (1.5 g), ceftazidime-avibactam (2.5 g), meropenem (500 mg), imipenem (500 mg), doripenem (500 mg)
What is the treatment for prostatitis?
trimethroprim/sulfmethoxazole (Bactrim), fluoroquinolone, or other broad spectrum antibiotic for 4-6 weeks (6 to 12 weeks for chronic prostatitis)
What are the symptoms of prostatitis?
pain in perineum, lower abdomen, testicles, penis, and with ejaculation; bladder irritation; bladder outlet obstruction; blood in the semen; fevers; chills; dysuria; malaise; myalgias; cloudy urine; tender prostate; increased PSA; discomfort on defecation
Which quinolone should be avoided in patients with UTI?
moxifloxacin - does not attain sufficient urinary levels
What are common causes of pyelonephritis?
comorbid medical conditions, indwelling Foley catheters, urosepsis
Why is an indwelling Foley catheter a risk factor for pyelonephritis?
catheter bulb blocks the free passage of urine - patient is colonized with greater numbers of bacteria
What are common laboratory findings in patients with UTI?
+ leukocyte esterase, + nitrities (gram- rods), + WBCs, + RBCs (hematuria)
What is the gold standard for diagnosis of chronic kidney disease?
"true" glomerular filtration rate as tracked by 24 hour urine isotope clearance test (test is expensive and impractical) - serum creatinine clearance is used as common clinical surrogate
What is the definition of acute kidney injury?
abrupt reduction in GFR (potentially reversible) - increase in SCr by 50% within 7 days OR increase in SCr by 0.3 mg/dL within 2 days OR oliguria => may lead to azotemia, disturbed electrolyte and acid-base balance, and abnormal volume status
What is azotemia?
buildup of nitrogenous wastes (e.g., urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood - would otherwise be excreted by the kidney
What is the association of proteinuria in kidney disease?
higher levels correlate with more rapid progression of kidney disease - most common marker of kidney damage in the adult population
What is the definition of chronic kidney disease?
GFR < 60 mL/min per 1.73 m-squared for > 3 months
What are the common markers of acute kidney infection?
serum creatinine and BUN
What is uremia?
constellation of symptoms and signs of multiple organ dysfunction caused by retention of "uremic toxins" in the setting of renal failure
How is oliguria defined?
< 400 mL/day - presence of urine output does not exclude the possibility of AKI
What are the categories of acute kidney injury?
prerenal - decrease in GFR due to reduced renal blood flow/perfusion pressure (Tx; optimize perfusion); intrinsic/intrarenal - result of direct parenchymal injury to the kidney (Tx: directed therapy); postrenal - result of obstruction to urine flow (Tx: relieve obstruction)
What is the definition of acute kidney disease?
AKI or GFR < 60 mL/min per 1.73 m-squared for < 3 months OR decrease in GFR by > 35% OR increase in SCr by > 50% for < 3 months
What is the most accurate measurement of leg length?
true leg length is the distance from the anterior superior iliac spine to the medial malleolus (do not measure from the umbilicus as pelvic obliquity can cause a distortion in apparent leg length)
What type of injury is most common when your tibia strikes the dashboard in an auto accident?
injury to the posterior cruciate ligament
What are the tests for a posterior cruciate ligament injury?
posterior drawer test, posterior sag test, quadriceps active test
What is suggested with fullness in the posterior knee?
Baker's/popliteal cyst - synovial fluid-filled mass located in the popliteal fossa => PT presents with episodic posterior knee pain
What are common signs of prepatellar bursitis?
anterior knee pain upon flexion and fluctuant mass over the anterior knee
Where is true hip pain likely to be felt?
groin or medial thigh
What is the likely cause of pain in the buttocks and/or lateral thigh?
pain radiating from the lumbosacral spine
What is the common complaint for a patient with trochanteric bursitis?
lateral thigh pain
What are possible causes of supraspinatus and infraspinatus atrophy?
large rotator cuff tear (infraspinatus) and compression or rupture of the supscapular nerve
What are possible causes of scapular winging?
weakness of the scapular stabilizers - serratus anterior paralysis due to damage to the long thoracic nerve
What is the sulcus sign?
dimpling of the skin in the area adjacent to the acromion due to subluxation of the humeral head
How is greater trochanteric bursitis assessed?
press directly over the greater trochanter - elicits pain with direct pressure (usually does not radiate)
What is the C sign?
cupping of the anterolateral hip with the thumb and forefinger in the shape of a “C” - indicates impingement (involvement of the hip joint itself)
What are common causes of a positive log roll test?
piriformis syndrome and SCFE
What is the Ober test?
PT cannot passively adduct leg past the midline - external snapping in the hip indicates greater trochanteric pain syndrome
What are s/s of femoroacetabular impingement?
insidious onset of pain that is worse with sitting, rising from a seat, getting into/out of car, or leaning forward; pain located primarily in the groin with occasional radiation to the lateral hip and anterior thigh - test with FABER, FADIR, log roll, straight leg against resistance
What is impingement syndrome?
subacromial bursitis, rotator cuff tendinitis, supraspinatus tendonitis, and painful arc syndrome
What is the rotator cuff?
group of tendons and muscles connecting the humerus to the scapula - tendons provide stability and muscles allow rotation
What are the tests for shoulder impingement?
painful arc (pain from 65 to 120 degrees), Apley scratch test, Neer, Hawkins, empty can (Jobe's) test
What are some tests for a torn rotator cuff?
lift off test and belly press
What are some tests for bicipital tendinitis?
What are some tests of glenohumoral instability?
apprehension test and sulcus sign test
What common UTI symptoms and their causes?
frequency/urgency (spontaneous bladder contractions and irritation to trigone), dysuria (inflammation of the urethra), flank pain (stretching and irritation of renal capsule), pain on defecation (compression of inflamed prostate), N/V (increased vagal activity
What is asymptomatic bacteriuria?
PT has sufficient number of bacteria to be consistent with infection (> 10^5 colony forming units/mL) but no symptoms
When is fever encountered with a UTI?
when infection is related to invasive tissue infection => pyelonephritis
What are the signs and symptoms of an uncomplicated cystitis?
dysuria, lower abdominal cramping, frequency, and urgency => diagnosis based on dipstick urinalysis (no culture or labs needed)
What is a biomarker?
anything that can be measured to extract information about a biological state or process
What are the characteristics of an ideal biomarker?
(1) non-invasive, easily measured inexpensive, and produce rapid results; (2) readily available source (blood or urine); (3) high sensitivity; (4) high specificity; (5) levels should vary rapidly in response to Tx; (6) aids in risk stratification; (7) biologically plausible and provides insight into disease mechanism
What should be suspected in a patient with symptoms consistent with cystitis but a negative urine culture?
urethritis - Chlamydia trachomatis and Neisseria gonorrhoeae most common organisms
What is the gold standard for diagnosing UTI?
What are the diagnostic criteria for UTI in a symptomatic patient?
culture of 10^2 colony forming units/mL
What are the diagnostic criteria for UTI in an asymptomatic patient?
culture of 10^5 colony forming units/mL
What should you suspect in a woman with signs and symptoms of a UTI with vaginal discharge?
vaginal disorder - absence of vaginal discharge increases probability of UTI
What is the treatment for urethritis?
ceftriaxone (250 mg IM as a 1-time dose); doxycycline (100 mg PO BID for 7 days); azithromycin (1 g single oral dose)
What makes serum creatinine a poor biomarker of kidney disease?
(1) is cleared through both glomerular filtration and tubular secretion; (2) certain drugs compete with tubular secretion; (3) dependent on laboratory technique; (4) gender and muscle mass of PT can influence concentration