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Glossary of USMLE step 2

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PAGET'S DISEASE PATHOPHYSIOLOGY
EXCESSIVE BONE TURNOVER BY OSTEOCLASTS +/- ASSOCIATED WITH PARAMYXOVIRUS INFECTION
PAGET'S S/S
DEEP BONE PAIN
FREQUENT #
INCREASED CRANIAL DIAMETER (=FRONTAL BOSSING)
DEAFNESS D/T CN VIII COMPRESSION
PAGET'S LAB & XRAY FINDINGS
INCREASED ALP, URNIARY HYDROXPROLINE
NORMAL Ca, PO4
XRAY - MARKEDLY EXPANDED BONY CORTEX - INCREASED DENSITY, THICKENED TRABECULAE, CHARACTERISTIC "JIGSAW" OR "MOSAIC" BONE PATTERN
PAGET'S - Rx
NSAIDS, CALCITONIN, ALENDRONATE
Paget's - complications
#'s, high output cardiac failure, deafness, secondary osteosarcoma
heliotrope rash
violacious periorbital rash in dermatomyositis
Grotton's papules
papules on dorsum of hand over bony prominences in dermatomyositis
polymyositis lab and EMG findings
elevated serum creatine, aldolase, CPK
EMG - fibrillations
complications of polymyositis
myocarditis, cardiac conduction defects, malignancy
Felty's triad
hepatosplenomeagly
TCP
RA
Lab, synovial fluid and Xray findings in RA
rh factor = anti-Fc IgG Ab - elevated in >75% (not specific)
+/- ESR elevated
synovial fluid - turbbid, decreased viscosity, WBC 3000-50000 cells/microL
Xray - juxta-articular dimineralization (early) joint space narrowing and erosions (late)
JRA - most common type?
pauciarticular - <30% develop iridocyclitis
ANA type - most common - asymmetric involvement of large joints with iridocyclitis
RF type - poor Px - concurrent with AS in HLA-B27+ males
Systemic acute febrile JRA
least common
characteristic arthritis with daily high spiking fevers
evanescent salmon coloured rash
+/- hepatosplenomegaly and serositis
Scleroderma S/S
thickening of skin of face +/or distal extremities
CREST
severe form - pulmonary fibrosis, cor pulmonales, ARF, malignant HTN
Anticentromere Ab
specific for CREST
anti-Scl-70 = anti-topoisomerase 1
specific for systemic scleroderma
treatment for scleroderma
glucocorticoids, penicillamine for skin changes, CCB for Raynaud's, ACEI for renal dz/HTN
SLE criteria
DOPAMINE RASH =
Discoid rash
Oral ulcers
Photosensitivity
Arthritis
Malar rash
Immunologic criteria
Neurologic symptoms (lupus cerebritis, seizures)
Elevated ESR
Renal disease
ANA +
Serositis
Hematologic abnormalities - anemia, leukopenia, TCP
Anti-dsDNA, Anti-Sm Ab's
highly specific, not sensitive for SLE
drug induced SLE antibodies
Antihistone Ab
Anti-Ro Ab's
neonatal SLE
Anti-phospholipid Ab's
hypercoagulability, thromboembolic disease, recurrent spontaneous abortions
Rx for SLE
NSAIDs (initial)
Steroids for acute exacerbations
hydroxychloroquine, cyclophosphamide, azithroprine for progressive/refractory cases
SLE pathogenesis, epidemiology
90% female (esp. African American)
Antibody-mediated cellular attack with deposits of antigen-antibody complexes
Drugs inducing SLE
hydralazine
pencillamine
procainamide
Temporal arteritis pathogenesis
subacute granulomatous inflammation of large vessels (includes aorta, ext. carotid - temp. br, vertebral a's)
temporal arteritis S/S
new h/a uni/bilateral with scalp pain
temporal tenderness
jaw claudication
fever
transient/perm monocular blindness
+/- wt loss, myalgia/arthralgia
bx findings in temporal arteritis
thrombosis, media necrosis, lymphocyes, plasma cells, giant cells
HSP path and epi
immune mediated small vessel vasculitis
children 2-11 y/o
HSP S/S
palpable purpura on buttocks, legs
asym. migartory periarticular swelling
abdominal pain
preceding URTI (75%)
Complications of HSP
GIB, intussusception, GN - degree of renal involvment determines Px
Barlow's maneuver
for DDH
pressure on inner aspect of abd thigh, hip add - causes post. dislocation
Ortolan's maneuver
for DDH
thighs abdocuted from midline with anterior pressure on greater trochanter - +ve = soft click (femoral head reduced into acetabulum)
Allis'/Galeazzi's sign
for DDH
knees at unequal heights when baby's hips and knees flexed (dislocated side lower)
Evaluation of DDH
clinical, U/S esp after 10 weeks old (not xray until >4m old)
Monteggia's #
diaphyseal # of prox ulna with subluxation of radial head
Galeazzi's #
diaphyseal # of radius with dislocation of distal r/u joint - d/t direct blow to radius
Rx - ORIF radius, cast in supination to reduce r/u jt
clavicular #
most common #'d long bone in kids
can be associated with brachial plexus injuries
greenstick #
incomplete # - cortex of only one side of bone
Rx - reduction with casting, repeat Xray 7-10days
nursemaid's elbow
radial head subluxation secondary to child being pulled or lifted by the the hand
Rx - gentle supination of elb at 90
Torus #
buckling of cortex of long bone secondary to trauma
- usually distal radius or ulna
Salter-Harris # type I
physis
Salter-Harris # type II
metaphysis and physis
Salter-Harris # type III
epiphysis and physis
Salter-Harris # type IV
epiphysis, metaphysis, physis
Salter-Harris # type V
crush injury of physis
Rx of Salter-harris #'s
Types I, II - conservative
III - V - Sx
Rx of DDH
Splint with Pavlik harness (maintains hip flexed, abd) if <6m old
6-15m old - spica cast
15-24m old - ORIF
DDx of limp in children
"STARTSS HOTT"
Septic joint
Tumor
AVN (LCPD)
RA/JRA
TB
SCA
SCFE
HSP
Osteomyelitis
Trauma
Toxic synovitis
osteosarcoma
2nd most common primary malignancy of bone (MM 1st)
metaphyseal region of distal femur, prox. tibia, prox. humerus - mets to lungs
males, 2nd-3rd decades
osteosarcoma vs Ewing's
Osteo
metaphyseal region distal femur, prox tibia/humerus
Xray - Codman's triangle, "sunburst" pattern
Ewing's
diaphyseal-metaphyseal regions of pelvis, femur, tibia
multilayered "onion-skinning"
Codman's triangle
Osteosarcoma Xray finding = periosteal new bone formation at diaphyseal end of bone
lesion of Broca's area
Broca's aphasia - motor (expressive) - broken speech, normal comprehension
lesion of Wernike's area
sensory (fluent/receptive)aphasia - poor comprehension
lesion to arcuate fasciculus
conduction aphasia - poor repitition with good comprehension, fluid speech
Lesion to amygdala bilaterally
Kluver-Bucy syndrome - hyperorality, hypersexuality, disinhibited behaviours
lesion to fronal lobe
frontal release signs - personality changes
deficits in concentration, orientation, judgement
right parietal lobe lesion
spatial neglect syndrome - agnosia of contralateral side of the world
Lesion to mamillary bodies bilaterally
Wernicke-Korsakoff's encephalopathy - confabulations, anterograde amnesia
CN XII lesion
tongue deviates towards lesion side
CN V lesion
jaw deviates towards
unilateral cerebellum lesion
patient falls towards side of lesion
CN X lesion
uvula deviates AWAY from lesion side
CN XI lesion
head turns towards side of lesion
R optic nerve defect
right hemianopsia
optic chiasm lesion
bitemporal hemianopsia
R optic tract lesion
L homonymous hemianopsia
R Meyer's loop lesion
L upper quadrant anopsia = right temporal lesion
R dorsal optic radiation lesion
L lower quadrant anopsia = R parietal lesion
R visual cortex lesion
L hemianopsia with macular sparing
anterior cerebral artery distribution
medial surface of brain, leg-foot area of motor and sensory cortices
middle cerebral artery distribution
lateral aspect of brain, Broca's and Wernicke's areas
Anterior communicating artery defects
most common circle of Willis aneurysm, +/- visual field defects
Posterior communicating artery defects
CN III palsy
common area of aneurysm
Lateral striae arteries distribution
internal capsule, caudate, putamen, globus pallidus = "arteries of stroke"
stroke of anterior Circle of Willis
general sensory and motor dysfunction, aphasia
Stroke of posterior Circle of Willis
vertigo, ataxia, visual defects, coma
Poliomyelitis/Werdnig-Hoffman disease spinal cord lesions
LMN lesions only = flaccid paralysis
MS spinal cord lesions
mostly white matter of cervical region - random and asym lesions
ALS
combined U/LMN deficits
NO sensory deficits
Anterior spinal artery lesion
spares dorsal columns
Tabes dorsalis
impaired propriocetion
locomotor ataxia
d/t tertiary syphilis
syringomyelia
affects ventral white commissure and ant. horns
Vit B12 neuropathy/Friedreich's ataxia
affects dorsal columns, lateral corticospinal and spinocerebellar tracts
Broca's aphasia
disorder of language production with intact comprehension - pts aware
impaired repitition
Associated with arm and face hemiparesis (right), hemisensory loss, apraxia of oral muscles
d/t L superior MCA stroke
Wernicke's aphasia
disorder of language comprehension
neologisms, paraphasic errors
pts unaware
no hemiparesis, dysarthria
L inf/post MCA embolic stoke
poor Px c/w Broca's
Locked in syndrome S/S, causes
awake and alert, unable to move except eyes and eyelids
central pontine myelinolysis
brain stem CVA
advanced ALS
Persistent vegetative state
normal sleep-wake cycles
most common - diffuse cortical injury
hypoxic-ischemic injury
5 A's of dementia
Aphasia
Amnesia
Agnosia
Apraxia
disturbances in Abstract thought
Causes of dementia
"DEMENTIAS"
neuroDegenerative diseases
Endocrine
Metabolic
Exogenous
Neoplasm
Trauma
Infection
Affective disorders
Stroke/Structural
Peripheral vs central vertigo
Peripheral - intermittent, severe, constant nystagmus, always horizonal, unidirectional, associated with hearing loss, no brain stem S/S
Central - constant, less severe, +/- nystagmus (absent, uni/bidirectional, +/- vertical)Rare hearing loss, often brain stem S/S (ataxia, dysarthria, CN abN, motor dysfunctions)
Most common causes dysequilibrium
BPPV (50%)
Ménière's
Others - hypothyroid, aminoglycoside/furosemide toxicity, stroke, trauma, labyrinthitis, acoustic neuroma
Nylen-Barany Maneuver
= Dix-Hallpike maneuver
pt sitting to supine quickly turning head to side - +ve if reproduces vertigo +/or nystagmus = BPPV
BPPV S/S
transient episodic vertigo <1min
nystagmus triggered by changes in head position (classic - turning in bed/getting up in am)
N/V
Symptoms decrease with repetitive testing
Meniere's disease S/S
(=endolymphatic hydrops)
intermittent peripheral vertigo d/t distention of endolymphatic compartment of inner ear
N/V
ear fullness
hearing loss
tinnitus
episodes resolve hrs-days
Causes of Meniere's
head trauma
syphilis
audiometry findings in Meniere's
low-frequency pure-tone hearing loss
Treatment of Meniere's
low salt diet
acetazolamide
actue attacks - antihistamines, antiemetics, benzo's
surgical decompression if refractory
acute h/a causes
SAH
hemorrhagic CVA
meningitis
seizure
acutely increased ICP
hypertensive encephalopathy
post-LP
ocular dz (glaucoma, iritis)
new migraine
subacute h/a causes
temporal arteritis
intracranial tumor
SDH
pseudotumor cerebri
trigeminal/glossopharyngeal neuralgia
post-herptic neuralgia
HTN
chronic/episodic h/a causes
migraine
cluster h/a
tension h/a
sinusitis
dental dz
neck pain
Migraine h/a S/S
throbbing h/a >2hrs, <24hrs
N/V
photophobia
noise sensitivity
"Classic" - u/l, visual aura (scintillating scotomas or field cuts)
"common" - b/l, periorbital without associated symp
Treatment of migraine h/a
ASA/NSAIDS, triptans
prophylaxis - BB, TCA, CCB, valproic acid
Cluster h/a description
brief, severe, usually u/l periorbital h/a 30min-3hrs
affects same part of head, same time of day (night), same time of year
triggers - EtOH, vasodilators
Cluster h/a S/S
ipsilateral tearing of eye
conjunctival injection
Horner's syndrome
nasal stuffiness
Treatment of cluster h/a
acutely - high flow O2 (100% non-rebreather)
ergots
sumatriptan
intranasal lidocaine
corticosteroids
Prophylaxis of cluster h/a
ergots
CCB
prednisone
lithium
valproic acid
topiramate
SAH causes
ruptured aneurysm (berry)
AVM
trauma (most common)
Berry aneurysms associated with?
PcKD
coarctation of aorta
CN involvment in SAH
CN III palsy with pupil involvement associated with Berry aneurysms
Treatment of SAH
prevent rebleeding - most likely in 1st 48hrs
prevent vasospasm - nimodipine and IV fluids, maintain elevated BP
antiseizure meds - phenytoin
NO NSAIDs
Complications of SAH
rebleeding aneurysm>AVM
extension into brain parenchyma (AVM)
vasospasm (in 1/3 of aneurysmal SAH)
obstructive hydrocephalus
EDH CT findings
lens-shaped CONVEX hyperdensity
SDH CT findings
cresent-shaped, CONCAVE hyperdensity
parenchymal hemorrhage causes
HTN - usually in basal ganglia
tumor
amyloid angiopathy (elderly)
vascular malformations (AVM, cavernous hemangiomas)
Cushing's triad
alterations in BP, HR, and respiratory patterns
Parkinson's tetrad
resting tremor
bradykinesia
rigidity
postural instability
treatment of parkinson's
dopamine agoinsts - brompcriptine, levo/carbadopa
MAO-B inhibitors - selegiline (neuroprotective, decreases levodopa need)
COMT inhibitors - entacapone (increase levodopa availability, may decrease motor fluctuations)
(amandatine, antiAch - limited efficacy)
astrocytomas
Adults
S/S h/a, increased ICP
+/- u/l paralysis CN V-VII, X
slow, protracted course
Rx - resection, XRT
GBM
most common primary
h/a, increased ICP
rapid progression, poor Px (<1yr)
meningiomas
women>men
from dura or arachnoid
increased incidence with age
acoustic neuroma
ipsilateral hearing loss
tinnitus
vertigo
signs of cerebellar dysfunction
Derived from Schwann cells
Medulloblastoma
children
from 4th vent - increased ICP
highly malignant - can seed subarachnoid space
Rx - Sx + chemo + XRT
ependymoma
children
from ependyma of ventricle (4th) or spinal cord
hydrocephalus
Rx - Sx + XRT
Neurocutaneous syndromes
NF 1,2
Tuberous sclerosis
NF 1 mutation
NFT-1 gene on 17q
NF 2 mutation
defective gene chrom. 22
NF1 diagnostic criteria
>=2 of:
1) 6 cafe au lait spots (>5mm kids, 15mm adults)
2) 2 neurofibromas (any type)
3)feckling-axillary/inguinal
4) optic glioma
5) 2 Lisch nodules = pigmented iris hamartomas
6)osseus abnormalities
7) 1st degree relative
NF2 diagnostic criteria
bilateral acoustic neuromas
1st degree relative
unilateral acoustic neuroma
any 2 of:
neurobfibroma
meningioma
glioma
schwannoma
Other features (not criteria)
seizures, skin nodules, cafe-au-lait spots
Tuberous Sclerosis - characterized by:
seizures (begin <1y/o)
mental retardation
skin and eye lesions
Tuberous sclerosis - presentation
infantile spasms
ash-leaf hypopigmented lesions
(trunk and extremities)
Skin lesions in tuberous sclerosis
sebaceous adenomas (small red nodules over nose and cheeks like acne)
shagreen patch (rough papule in L/S region with orange peel consistency)
Ash-leaf hypopigmented lesions (trunk and extremities)
Retinal lesions in tuberous sclerosis
mulberry tumors (arise from nerve head)
phakomas (round, flat, grey lesions near disc)
Tests and findings in Tuberous sclerosis
calcified tubers in periventricular area (rarely transform into malignant asyrocytomas)
Skin lesions with Wood's lamp
ECG for rhabdomyoma (apex of LV in 50% pts)
Renal U/S - renal hamartomas, PcKD
Pulmonary - angiomyolipomas (cause generalized cystic or fibrous changes)
Thiamine deficiency
Wernicke's encephalopathy
Korsakoff's dementia
Wernicke's encephalopathy
triad = encephalopathy, ophthalmoplegia (LR palsy,nystagmus, conjugate gaze palsy), ataxia (polyneuropathy, CB and ventricular dysfunction)
Korsakoff's dementia
Wernicke's (encephalopathy, ophthalmoplegia, ataxia) + amnesia, horizontal nystagmus
Way to elicit Wernicke's encephalopathy
Large dose glucose administration
Cyanocobalamin deficiency
= B12 deficiency
Combined system disease or subacute combined degeneration
Cyanocobalamin deficiency S/S
gradual, progressive onset
symm. P/N
leg stiffness
spasticity
paraplegia
bowel/bladder dysfunction
Dementia
Folate deficiency
irritability
memory loss
personality changes without CSD of B12
Seizure causes in infants
perinatal injury
infection
metabolic
congential
Childhood (2-10y/o) causes of seizures
idiopathic
infection
trauma
fever
Adolescent causes of seizures
idiopathic
trauma
drug withdrawl
AVM
Young adult (18-35y/o) causes of seizures
trauma
alcoholism
brain tumor
Adult (>35y/o) causes of seizures
trauma
stroke
metabolic disorder
alcoholism
brain tumor
Lab finding in epileptic seizure
elevated prolactin
Simple partial seizures
motor, sensory, autonomic, or psychic features without LOC
+/- post-ictal focal neuro
deficit resolves 1-2 days
Can evole into generalized
DDx from acute CVA with MRI
Complex partial seizures
temporal lobe (70-80%)
char by:
impaired LOC
auditory/visual hallucinations
deja vu
automatisms
post-ictal confusion/disorientation, amnesia
Symp can mimic schizophrenia/acute psychosis
Can evolve into generalized
Normal EEG in seizure
Does NOT r/o epileptic sz disorder
First line anti-convulsant in children
phenobarbital
1st line treatment of idiopathic generalized seizures
Valproic acid
Adjuncts - lamotrigine, topiramate
treatment of secondary tonic-clonic seizures
Same as partial seizures
Absence seizures EEG finding
3/sec spike-and-wave discharges (classic)
Absence seizures treatment
ethosuximide - 1st line
Valproic acid, zonisamide
West syndrome
Infantile spasms
Abnormal interictal EEG (v. high amplitude slow waves)
Arrest of psychomotor devt at age of sz onset
West syndrome S/S
begins 3-12m
sz - tonic, b/l, symm in clusters of 5-10 individual spasms - occur when drowsy or on awakening
MR in most pts
West syndrome Rx
ACTH
prednisone
anti-epileptics (clonazepam, valproic acid)
Status epilepticus definition
prolonged (>30min) or repetitive sz without a return to baseline
20% mortality
Status epilepticus causes
anticonvulsant withdrawl/non-comliance
anoxic brain injury
EtOH/sedative withdrawl
drug intoxication
metabolic - hyponatremia
trauma
infections
Treatment of Status epilepticus
ABC's
IV benzo + phenytoin loading dose
If sz continue - intubate + phenobarbital loading dose
glucose, thiamine, naloxone
Risk factors for CVA
non-modifiable - male, age, genetics, race (African-American, Hispanic, Asian)
Modifiable - HTN, DM, obesity, smoking, hypercholesterolemia, carotid stenosis, heavy EtOH, cocaine, IVDU, AFib
CVA most common etiology
athlerosclerosis of extracranial vessels (internal and common carotids, basilar, vertebral)
Underlying causes of lacunar infarcts
athlerosclerosis
HTN
DM
cardiac causes of CVA
Afib (risk increased 5-6x)
emboli - mural thrombi, diseased/prosthetic valves, paradoxic (venous) in R-to-L shunt (ASD, PFO)
MCA stroke S/S
aphasia (dominant hemisphere)
neglect (non-dominant)
contralat. hemiparesis, gaze preference, homonymous hemianopsia
ACA stroke S/S
leg paresis
amnesia
personality changes
foot drop
gait changes
cognitive changes
PCA stroke S/S
homonymous hemianopsia
memory deficits
dyslexia/alexia
Basilar stroke S/S
coma
CN palsies
apnea
visual symp
drop attacks
dysphagia
lacunar stroke S/S
pure motor or sensory
dysrthria-clumsy hand syndrome
ataxic hemiparesis
tPA contraindications
SBP >185 or DBP >110 despite aggressive antihypertensive Rx
prior ICH
CVA/head trauma in past 3m
recent MI
current anticoagulant Rx with INR >1.7
heparin in last 48hrs with increased PTT
platlets <100000
major Sx in last 14d
GI/GU bleed in past 21d
sz present at CVA onset
glucose <50/>400mg/dL
age <18
5 A's of Guillain-Barre
Acute inflammatory demyelinating polyradiculopathy
Ascending paralysis
Autonomic neuropathies
Arrhythmias
Albuminocytologic dissociation
Findings in Guillain-Barre
EMG/nerve conduction studies - diffuse demyelination
CSF - protein >55mg/dL with little/no pleocytosis
Myasthenia gravis antibodies
postsynaptic ACh receptor Ab (85-90%)
antistriational Ab (85% of pts with thymoma)
Labert-Eaton Syndrome antibodies
autoantibodies to presynaptic Ca channels
Myasthenia Gravis assoicated disorders
thymoma
thyrotoxicosis
autoimmune - SLE, RA
Myasthenia Gravis S/S
fatiguable ptosis/diplopia
dysphagia
proximal muscle weakness
symp worsen throughout day
"Myasthenic crisis"
respiratory compromise and aspiration (rare)
Drug induced myasthenic syndrome cause
aminoglycosides
Myasthenia Gravis findings
edrophonium - dramatic improvement (diagnostic)
Abnormal single fiber EMG +/or decremental response to repetitive nerve stim
ACh Ab (85-90%)
Antistriational Ab (85% of pts with thymoma)
Treatment of MG
anticholinesterases - neostigmine, pyridostigmine
immunosuppressants - prednisone
Resection of thymoma - can be curative
ALS pathogenesis
loss of motor neurons in spinal cord, brain stem, and motor cortex
ALS S/S
asymmetric, slowly progressive weakness of arms, legs, CNs
UMN and LMN signs
Diagnostic findings in ALSq
Combination of U and LMN signs in >= 3 extremities
Findings in ALS
EMG/NCS - widespread denervation and fibrillation potentials
treatment in ALS
supportive
aggressive pulmonary toilet
Riluzole - reduces presynaptic glutamate release, may slow progression
Risk factors for carpal tunnel syndrome
repetitive use injury
pregnancy
DM
hypothyroid
acromegaly
RA
obesity
MS possible pathogenesis
T cell mediated autoimmune progression
MS classic triad
scanning speech
intranuclear ophthalmoplegia
nystagmus
Most common presenting complaints in MS
limb weakness
optic neuritis
P/N
diplopia
urinary retention
vertigo
Exacerbating factors in MS
infection
heat
trauma
vigorous activity
(decreasing - pregnancy)
MRI findings in MS
multiple, asymmetric, often periventricular white matter lesions
Corpus callosum lesions ~pathognomonic
Active lesions enhance with gadolinium
CSF findings in MS
mononuclear pleocytosis (>5cells/microL) 25%
elevated IgG - 80%
oligoclonal bands (non-specific) albuminocytologic dissociation
Treatment for MS
Steroids - acute exacerbations
Immunomodulators - ABC
Avonex/Rebif (interferon-β-1a)
Betaseron (interferon-β-1b)
Copaxone (copolymer-1)
Symtomatic Rx for spasticity, pain, fatigue, depression
Closed angle glaucoma epidemiology
elderly
Asians
Causes of closed angle glaucoma
acute closure of narrow anterior chamber angle ==>
pupillary dilatation - prolonged time in dark, stress, meds
ant. uveitis
dislocation of lens
Closed angle glaucoma S/S
extreme pain and blurred vision, ~always u/l
eye hard and red
pupil dilated, non-reactive to light
N/V
increased IOP
Treatment of Closed angle glaucoma
lower intraocular pressure - acetazolamide
pilocarpine once pressure drops
laser iridotomy - curative
open angle glaucoma risk factors
>40 y/o
FHx
African-American
DM
myopia
Open angle glaucoma pathogenesis
intraocular pressure increase d/t diseased trabecular meshwork that obstructs proper drainage of eye ==> gradual pressure increase causing progressive visual loss
Open angle glaucoma S/S
frequent lens changes in pts >35y/o
mild h/a
visual disturbances
impaired adaption to darkness
visual loss begins peripherally
Fundoscopic findings in open angle glaucoma
cupping of optic disc
Treatment of open angle glaucoma
preventative - >40y/o see ophthalmologist q3-5yrs (annual if increased RFs)
topical α-blockers - timolol, betaxolol (decrease aqu. humor producation)
pilocarpine (increases aqu. outflow)
carbonic anhydrase inhibitors if eye drops insufficient control of IOP
laser trabeculoplasty
Macular degeneration risk factors
Caucasian
female
smokers
FHx
Macular degeneration types
atrophic - gradual visual loss
exudative - more rapid and severe visual loss
macular degeneration S/S
painless loss of central vision
macular degeneration fundoscopy findings
pigmentary or hemorrhagic disturbances of macular region
treatment of macular degeneration
limited
laser photocoagulation may delay loss of central vision in exudative type
CRAO S/S
sudden, painlesss, u/l blindness
pupil accomodates
sluggish pupil reaction to direct light
CRAO fundoscopy findings
cherry-red spot on fovea
arteries +/- bloodless appearance
+/- retinal swelling
CRVO S/S
rapid painless vision loss
elderly pts
fundoscopy findings of CRVO
retinal hemorrhages
cotton-wool spots
edema of fundus
sequelae of CRVO
macular degeneration
glaucoma
Treatment of CRAO
thrombolysis of ophthalmic artery within 8hrs of symp onset
IV acetazolamide -decrease IOP - increase drainage of aqu. humor
sequelae of CRAO
untreated - retinal infarction, permanent blindness
Treatment of CRVO
laser photocoagulation - variable results
Estrogen functions (8)
follicle growth
endometrial proliferation
myometrial excitability
hepatic synthesis of transport proteins
feedback inhibition of FSH
LH surge
smooth muscle relaxation
Progesterone functions (5)
endometrial gland secretions
spiral artery development
decreased myometrial excitability
increased body temperature
inhibition of LH, FSH
hCG functions (2)
maintians corpus luteum for T1 by acting like LH
detect pregnancy (in urine at 8 days)
physiologic changes in pregnancy - CVS (4)
increased CO (30-50%), HR (10-15bpm), SV
possible S3, syst. murmurs (Normal) (new diast. murmur never normal!)
decreased SVR
decreased BP T1, normalizes by 40 weeks
cardiomeagly on CXR d/t heart displacement upwards
physiologic changes in pregnancy - cervix (2)
softening and cyanosis ~4wks
bloody show = thick mucus clot
physiologic changes in pregnancy - endocrine (3)
high estrogen => ↑TBG, bound T3, T4, unchanged active unbound hormone
HPL - acts as insulin antagonist to maintain fetal glucose => prolonged post-prandial hyperglycemia, fasting hyperinsulinemia, triglyceridemia, exaggerated starvation ketone response
↑total and free cortisol
physiologic changes in pregnancy - GI (4)
N/V (<=70%) resolves by 14-16wks
↑acid reflux d/t ↓LES tone
constipation d/t ↓bowel motility,↑H2O absorption
↑biliary cholesterol
physiologic changes in pregnancy - hematologic
↑plasma V (50%), RBC mass (30%)=> ↓Hb, hct = 'physiologic anemia'
WBC count ↑s throughout X=10
pregnancy = hypercoagulable state
physiologic changes in pregnancy - pulmonary
↑tidal V (40%)
↓TLC, RV,ERV
RR same
↑minute vent. => ↑Pa/PAO2, ↓Pa/PACO2 = 'dyspnea of pregnancy'
physiologic changes in pregnancy - Renal
kidneys dilate
↑GFR (50%)
↑RPF (30%)
↑estrogen/progesterone => ↑RAAS = ↑aldosterone
physiologic changes in pregnancy - skin
↑estrogen - stigmata like liver disease
↑αMSH, steroids => hyperpigmentation - midline (linea nigra), face (chloasma), perineum
physiologic changes in pregnancy - vagina
thick acidic secretions
Chadwick's sign = violet colouration from ↑blood flow
Nagle's rule = EDD
add 9m + 7d to 1st day of LMP
Ways to determine GA
uterine size
quickening (17-18wks)
fetal heart tones (10wks)
U/S fetal crown-rump length (5-12wks) biparietal diameter (20-30wks)
Labs at initial visit for pregnancy
CBC, UA + culture, Pap, blood type, Rh + Ab screen, rubella Ab titer, HBsAg, syphilis screen, cervical gonoccocal & chlamydia
PPD
glucose teting
HIV
Labs at 15-19wks GA
MSAFP or triple screen (=MSAFP, estiol, β-hCG)
amnio if >35y/o
Labs at 26-28wks GA
glucose loading test
give Rhogam at 28 wks if mom Rh-ve
Labs at 32-36wks GA
cerval chlamydia + gonorrhea in high risk
GBS screen
causes of ↑MSAFP (MoM >2.5)
1. open NTD - anencephaly, SB
2. abdominal wall defects - gastroschisis, omphalocele
3. multiple gestation
4. incorrect dates
5. fetal death
6. placental abnormalities - abruption
causes of ↓MSAFP (MoM<0.5)
need amnio and karyotyping to r/o chromosomal abnormalities
- trisomy 18, 21
pattern of triple screen with Down's
↓AFP, estriol
↑hCG
pattern of triple screen with trisomy 18
↓AFP, estriol, hCG
Compare complications of amnio with CVS
amnio (15-17wks)
fetal maternal hemorrhage 1-2%
fetal loss 0.5%
CVS (10-12wks)
fetal loss 1%
inability to Dx NTD
limb defects if <9wks GA
Indications for percutaneous umbilical blood sampling
Ax/Rx Rh isoimmunization/erythroblastosis fetalis
karyotyping
fetal infection (CMV, toxo, rubella)
genetic dz
fetal acid-base status
Normal labour and deliver stages
first
latent - onset to 3-4cm
active - 4cm to 10cm (1.2cm/h primi, 1.5cm/h
multip)increased with CPD
2nd - complete dilatation to delivery
34d - delivery of infant to placenta
Factors affecting active phase of labour
3P's
power
passenger
pelvis
Normal NST
FHR monitored by doppler correlated with reported mvts by mom
- acceleration ≥15bpm above baseline for ≥15sec twice in 20min
positive contraction stress test
repetitive late decels during ≥3 contractions in 10min
Biophysical profile
"Test the Baby MAN" - give score of 0 or 2 for each
Tone
Breathing
Movement
Amniotic fluid volume
NST
"+ve test" = score 0-2
Early decelerations
begin and end with contraction
caused by cephalic compression (no fetal distress)
Variable decelerations
at any time during contraction
Caused by:
umbilical cord compression (change maternal position)
Late decelerations
begin at peak of contraction and end after contraction has finished
- uteroplacental insufficiency
- fetal hypoxemia
- potentially d/t abruption or hypotension
- if repetitive and severe deliver ASAP
Hyperemesis Gravidarum
intractable N/V after 14-16wks
poor wt gain/wt loss
more common in G1P0, molar pregnancies
labs - ketonemia, ketonuria, hyponatremia, hypokalemic-hypochloremic m.a.
Diagnosis of GDM
fasting serum glucose >126mg/dL
random >200mg/dL
abnormal GTT
1hr (50g) >140gm/dL
3hr (75g)with any 2 of -
fasting ≥95,
1h ≥180
2h ≥155
3h ≥140

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