Another 10 "silly things" that can screw y - triplehelix

[ArchivalUser]

1. COPD pt survival can be increased by two most important things: a. stop smoking, b. start home oxygen therapy.

2. Cyanosis just after birth (within 24 hrs): think straight, it is transposition of great vessels (not TOF !!), usually in diabetic mom and male infant !

3. Decision making criteria for chest tube placement: if pleural fluid a. pH is<7.2 and/or b. pleural fluid glucose is <60 mg%

4. Young women with HTN and fibromyalgia, think of renal artery stenosis (fibromyalgia and renal artery stenosis association).

5. Dysmenorrhea, dysperunia, and infertility = Endometriosis, you can do USG, but laparoscopy is GOLD-STANDARD (Is there any thing platinum-standard, isn't platinum more expensive than gold ?)

6. Pregnant woman with PPD (=): next step ? CXR. CXR is not contraindicated. By the way, two drugs absolutely contraindicated in pregnancy: 1. ACEi 2. Oral hypoglycemics (sulfonylurea).

7. Normal person has fasting glucose >126% during regular visit, next step ? Repeat fasting blood glucose (YOu need two fasting glucose >126 mg% to make dx of DM), if in 2 occasions it is >126 mg5, you go for intervention.

8. Turner syndrome karyotope is 45 XO, most of the time PATERNAL X is missing., but REMEMBER that Turner can be also 46XY (Yes !!), and if so, the pt has increased risk of gonadoblastoma (do prophylactic bilateral gonadectomy).

9. If you find buzz word "Koilocyes" is histology report, think of Condylomata acuminata (HPV 6, 11...........)

10. Rx of 1' biliary cirrhosis (did you think of anti-mitochondrial antibody now ?) is Ursodeoxycholic acid (if severe: liver transplant).

Thats the "silly 10" for today..............................

Good luck

[ArchivalUser]

Nice refresher.

Thanks again triplehelix!

Ari Vederci

[ArchivalUser]

great! especially No.9

[ArchivalUser]

yes presence of Y chromsomes in turners increases the risk of gonadoblastomas...
but i have a question in regular turners 45 X0 do we still do a b/l oophorectomy as there is still a risk of gonadoblastomas or do we only do b/l oophorectomy of there is an asso Y chromosome?

[ArchivalUser]

Ok, i think then i need to mention a bit detail, cd45

There are two types of Turner: Typical and Atypical

1. Typical Turner's Syndrome (45,XO Gonadal Dysgenesis)
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Less than 3% of these zygotes survive to term Table 26“17. Manifestations of Turner's syndrome. May be you know that this is most common monosomy causing abortion !

Rx of typical turner
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a. for short stature: daily injections of growth hormone plus an androgen (eg, oxandrolone) for at least 4 years before epiphysial fusion increases final height by a mean of about 10.3 cm over the mean predicted height of 144.2 cm (such growth hormone treatment rarely causes pseudotumor cerebri)
b. After age 12 years, estrogen therapy is begun with low doses of conjugated estrogens or ethinyl estradiol given on days 1“21 per month. When growth stops, HRT is begun with estrogen and progestin; transdermal estrogen may be used to initiate pubertal development.

SO NO NEED OF GONADECTOMT !!

Associated complication of Turner:
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Women with Turner's syndrome have a reduced life expectancy due in part to their increased risk for diabetes mellitus (types 1 and 2), hypertension, dyslipidemia, and osteoporosis (See, no gonadoblatoma !!).
Diagnostic vigilance and aggressive treatment of these conditions reduce the risk of aortic aneurysm dissection, ischemic heart disease, stroke, and fracture. Patients are prone to keloid formation after surgery or ear piercing.
Yearly ocular examinations and periodic thyroid evaluations are recommended. It is advisable to evaluate all patients with Turner's syndrome with an ultrasound, CT, or MRI examination of the chest and abdomen, looking for cardiac, aortic, and renal abnormalities.

Patients with a prominent webbed neck also tend to have a bicuspid aortic valve and aortic coarctation. Aortic aneurysms are common, as are cases of unilateral renal agenesis.

2. Variant Turner Syndrome:
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a. 46,X (Abnormal X) Karyotype
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An abnormality or deletion of certain genes on the short arm of the X chromosome causes short stature and other signs of Turner's syndrome; some gonadal function and even fertility are possible. Transmission of Turner's syndrome from mother to daughter can occur. There may be an increased risk of trisomy 21 in the conceptuses of women with Turner's syndrome. Abnormalities or deletions of other genes located on both the long and short arms of the X chromosome can produce gonadal dysgenesis with few other somatic features.

b. 45,XO/46,XX Mosaicism
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This karyotype results in a modified form of Turner's syndrome. Such girls tend to be taller and may have more gonadal function and fewer other manifestations of Turner's syndrome.

c. Other Variants
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45,XO/46,XY mosaicism can produce some manifestations of Turner's syndrome. Patients may have ambiguous genitalia or male infertility with an otherwise normal phenotype. Germ cell tumors, such as gonadoblastomas and seminomas, develop in about 10% of patients with 45,XO/46,XY mosaicism
So, ONLY they need gonadectomy prophylactically

[ArchivalUser]

wowwww thanks triplehelix this summary was really coool and very helpful

[ArchivalUser]

One of the HIGHEST yield topic is ENDOMETRIOSIS:

Essentials of Diagnosis
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Pelvic pain related to menstrual cycle.
Dysmenorrhea.
Dyspareunia.
Increased frequency among infertile women.
General Considerations

Endometriosis is an aberrant growth of endometrium outside the uterus, particularly in the dependent parts of the pelvis and in the ovaries and is the most common cause of secondary dysmenorrhea (see illustration). While retrograde menstruation is the most widely accepted cause, its pathogenesis and natural course are not fully understood. The overall prevalence in the United States is 6“10% and is fourfold to fivefold greater among infertile women.



Clinical Findings
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Women with endometriosis will complain of pelvic pain, which may be associated with infertility, dyspareunia, or rectal pain with bleeding. Initially, pain tends to start 2“7 days before the onset of menses and becomes increasingly severe until flow slackens. With increasing duration of disease, pain may become continuous. Pelvic examination may disclose tender nodules in the cul-de-sac or rectovaginal septum, uterine retroversion with decreased uterine mobility, cervical motion tenderness, or an adnexal mass or tenderness. However, most women with endometriosis have a normal pelvic examination.

Endometriosis must be distinguished from PID, ovarian neoplasms, and uterine myomas. Bowel invasion by endometrial tissue may produce blood in the stool that must be distinguished from bowel neoplasm. Paradoxically, the severity of pain associated with endometriosis may be inversely related to the anatomic extent of the disease.

Imaging is of little value. Ultrasound examination will often reveal complex fluid-filled masses that cannot be distinguished from neoplasms. MRI is more sensitive and specific than ultrasound, particularly in the diagnosis of adnexal masses (see ultrasound); (see ultrasound). However, the clinical diagnosis of endometriosis is presumptive and usually confirmed by laparoscopy.

Treatment
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Medical Treatment
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Medical treatment, using a variety of hormonal therapies, is effective in the amelioration of pain associated with endometriosis. However, there is no evidence that any of these agents increase the likelihood of pregnancy. Their preoperative use is of questionable value in reducing the difficulty of surgery. Most of these regimens are designed to inhibit ovulation over 4“9 months and lower hormone levels, thus preventing cyclic stimulation of endometriotic implants and decreasing their size. The optimum duration of therapy is not clear, and the relative merits in terms of side effects and long-term risks and benefits show insignificant differences when compared with each other and, in mild cases, with placebo.

1. The GnRH analogs such as nafarelin nasal spray, 0.2“0.4 mg twice daily, or long-acting injectable leuprolide acetate, 3.75 mg intramuscularly monthly, used for 6 months, suppress ovulation. Side effects of vasomotor symptoms and bone demineralization may be relieved by "add-back" therapy with norethindrone, 5“10 mg daily.

2.Danazol is used for 4“6 months in the lowest dose necessary to suppress menstruation, usually 200“400 mg twice daily. Danazol has a high incidence of androgenic side effects, including decreased breast size, weight gain, acne, and hirsutism.

3. Any of the combination oral contraceptives, the contraceptive patch, or vaginal ring may be used continuously for 6“12 months. Breakthrough bleeding can be treated with conjugated estrogens, 1.25 mg daily for 1 week, or estradiol, 2 mg daily for 1 week.

4.Medroxyprogesterone acetate, 100 mg intramuscularly every 2 weeks for four doses and then 100 mg every 4 weeks; add oral estrogen or estradiol valerate, 30 mg intramuscularly, for breakthrough bleeding. Use for 6“9 months.

5. Low-dose oral contraceptives can also be given cyclically; prolonged suppression of ovulation will often inhibit further stimulation of residual endometriosis, especially if taken after one of the therapies mentioned above.

6. Analgesics, with or without codeine, may be needed during menses. NSAIDs may be helpful.

Surgical Measures
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Surgical treatment of endometriosis”particularly extensive disease”is effective both in reducing pain and in promoting fertility. Laparoscopic ablation of endometrial implants along with uterine nerve ablation significantly reduces pain. Ablation of implants and, if necessary, removal of ovarian endometriomas enhance fertility, although subsequent pregnancy rates are related to the severity of disease. Women with disabling pain who no longer desire childbearing can be treated definitively with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO).

Prognosis
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The prognosis for reproductive function in early or moderately advanced endometriosis is good with conservative therapy. TAH-BSO is curative for patients with severe and extensive endometriosis with pain.

[ArchivalUser]

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[ArchivalUser]

1. Benzodiazepine can cause paradoxical insomnia in elderly. Be careful to use BDZ in elderly !

2. Metabolic acidosis in renal failure patient is due to impaired NH4 excretion (not impaired HCO3- handling).

3. Presence of S4 gallop (indicates atrial click): think ventricular diastolic dysfunction (e.g. hypertrophic cardiomyopathy).

4. Lyme disease: Normally treated with Doxycycline except pregnant woman and children <9 yr old, who get amoxycillin.

5. Henoch-Schonlein purpura: thesept has increased risk to develop intusseception and GIT bleeding, keep your eyes open !

6. Any adult comes for routine visit, and question asks you about possible vaccine: always first look for Td vaccine !

7. Mixed essential cyoglobulinemia: look for Hepatitis C virus association.

8. Polycythemia patient can present with HTN and peptic ulcer (beside plethora).

9. Legionella pneumonia: look for mental confusion, non-productive cough, hyponatermia in elderly pt. Do not respond to beta-lactam antibiotic. Do urine antigen ELISA, Rx with azithromycin.

10. RSV infection in childhood increases the risk of asthma in adult life.

[ArchivalUser]

Thanks-Good One!