1. Appearance

2. Speech

3. Mood/affect

4. Thought - form & content

5. Perception

6. Cognition

7. Judgement

8. Insight

grooming, level of hygiene,

unusual physical characteristics/movements,

attitude to interviewer,

psychomotor activity - retardation or agigitation,

degree of eye contact

rate

volume

articulation

tone 

Pressured speech  - rapid, uninterruptible - ex. mania

Poverty of speech - yes/no responses

Blocking - cessation of speech before idea is completed

Echolalia

Neologisms

Clanging

Perseveration - repetition of words or phrases

Mood - patient's subjective emotional state

Affect - external range of expression described in terms of quality, range, and appropriateness. Ex. flat (no affect), blunted/restricted, labile, full or wide-range (appropriate)

Hallucinations and illusions

Derealization and depersonalization

*may be categorized as part of thought content

Circumstantial - lots of extra details, but eventually gets to the point

Tangential

Loosening of Associations --> Word salad

Flight of ideas  (mania)

Goal-directed (normal)

Suicide/homicide ideation (always ask about plan & intent)

Delusions (persecutory, erotomanic, grandiose, somatic, guilt)

Obsessions

Ideas of reference

May include hallucinations/illusions

1. Level of consciousness

2. Orientation - person, place, time

3. Attention/concentration - serial 7's, world backwards

4. Memory - registration (immediate), short term, long term

5. Fund of knowledge - presidents

6. Abstract thought - interpret proverbs (ex. Don't cry over spiled milk), similarities between 2 objects.

Insight - awaresness of problems/illness (can be a spectrum ex. insight into fact that something is wrong but doesn't know/understand exactly what/why)

Judgement - ability to make decisions regarding problems, everyday activities.

Schizophrenia: bizarre (or non-bizarre) delusions, daily functioning is significantly impaired. Must have 2 or more of the following: delusions, hallucinations, disorganized speech, disorganzied behavior, negative sx

Delusional disorder: only non-bizarre delusions, daily functioning is not significantly impaired, does not meet criteria for schizophrenia

A peruid if abnormally elevated, expansive, or irritable mood, lasting at least 1 week and including 3 of the following (4 if irritable): DIG FAST

• Distractibilty
• Irritable mood/insomnia - decreased need for sleep
• Grandiosity
• Flight of ideas
• Acitivity increased, agitation
• Speech is pressured
• Thoughtlessness - impulsivity/impaired judgement

• lasts 4 days (vs 7)
• no marked impaired in daily functioning
• Does not require hospitalization
• Does not have psychotic features

Manic episodes cause severe impairment in functioning, may require hospitalization, and may have psychotic features.

Irritability

Carbohydrate craving

Hypersomnia

1. phobias
2. substance induced disorders
3. major depression
4. OCD

• schizoid, schizotypal, and paranoid
• patients are eccentric, withdrawn, or peculiar
• familial association with psychtoic disorders

• antisocial, borderline, histrionic, narcissistic 
• patients seems emotional, dramatic, or inconsistent
• familial association with mood disorders

• avoidant, dependent, and obsessive-compulsive
• patients seem anxious or fearful
• familial association with anxiety disorders

substance use leadss to impairment or distress for at least 1 year with one or more of the following:

1. failure to fulfill obligations at work, school, or home
2. use in dangerous situation (ex. while driving)
3. recurrent substance related legal problems
4. continued use depsite social or interpersonal problems to the substance use

substance use leading to impairment or distress with at least 3 of the following during a 12 month period:

1. tolerance
2. withdrawal
3. use substance more than originally intended
4. desire or unsuccessful effots to cut down
5. significant time spent in getting, using, or recovering 
6. decreased social, occupational, or recreational activities b/c of use
7. continued use despite physical or psychological problems caused by use

Activates GABA and 5HT receptors in CNS.

Inhibits glutamate receptors.

1. Have you ever wanted to cut down?

2. Have you ever felt annoyed by criticism of your drinking?

3. Have you ever felt guilty about drinking?

4. Have you ever taken a drink as an "eye opener"?

2 or more "yes" = positive screen

1. respiratory depression
2. altered mental status
3. miosis*

"Rebels Admire Morphine"
*exception = meperidine - Demerol Dilates pupils. 

1. Alzheimer's disesae (50 - 60%)

2. Vascular dementia (10 - 20%)

3. Major depression ("pseudodementia")

Memory impairment plus at least one of the following:

1. aphasia - problems with language affecting speech and understanding
2. apraxia - inability to perform purposeful movements (ex. tying shoes, copying a picture)
3. agnosia - inability to interepret sensations correctly/recognize things that were once known
4. diminished executive functioning - problems with planning, organizing, abstracting

- Same general manifestations and DSM criteria

- vascular dementia may have focal neurological sx

- onset is usually more abrupt in vascular dementia 

- greater personality preservation in vascular dementia

- can reduce risk of vascular dementia by modifying risk factors (smoking, HTN, DM). 

Cortical dementias - marked by decline in intellectual functioning. Ex: Alzheimer's, Pick's, CJD.

Subcortical dementias - more prominent affective and movement sx. Ex: Huntington's, Parkinson's, multi-infarct dementia. 

Amnestic disorders are caused by underlying medical condition, whereas dissociative disorder are not.

Onset of dissociative disorders is related to a stressful life event or personal problem and many have history of trauma/abuse in childhood.

Dyssomnias = disturbance in amount, quality, or timing of sleep (insomnia, hypersomnia, narcolepsy, etc)

Parasomnias = abornal event in behavior or physiology during sleep (nightmare d/o, night terror d/o, sleep walking)

Stage 1 (lightest sleep) - alpha waves

Stage 2 (light sleep) - sleep spindles and k-complexes

Stages 3/4 (deep sleep) - Delta waves (lowest frequency)

REM - sawtooth waves and REM

Dopamine enhances libido.

Serotonin inhibits libido.

SSRIs and antipsychotics can contribute to sexual dysfunction.

Classical conditioning - stimulus can eventually evoke a conditioned response (Dog salivates when he hears bell because he associates it with food).

Operant conditioning - behaviors can be learned when followed by positive or negative reinforcement (Ex. Skinner's box: rat happended upon a lever and received food - eventually learns to press lever to get food).

*incorporated into behavioral therapy

1. Systemic desensitization - tx of phobias
2. Flooding and implosion - tx of phobias
3. Aversion therapy - tx of addictions or paraphilias - couples a negative stimulus to a specific unwanted behavior
4. Token economy - reward given for specific behavior
5. Biofeedback - ex. of use: migraines

OCD

Eating d/o

Social phobia

Panic d/o

PTSD

IBS

Migraines

Autsim

PMDD

Dysthymia

Depressive phase of manic depression

OCD (clomipramine)

Eating d/o

Panic d/o

PTSD

IBS

Enuresis 

Neuropathic pain

Migraines

Insomnia 

Panic d/o

Eating d/o

Social phobia

Bupropion:

Migraines 

Smoking cessation 

Depressive phase of manic depression

Mirtazapine:

Insomnia

Sympathomimetics (amphetamine-based drugs).

Used rarely due to addiction potention. Use should be short-term and carefully monitored.

Nortriptyline - least likely to cause orthostatic hypotension

Desipramine - least sedating, least anticholinergic SE

Clomipramine - most serotnin-specific, useful in tx of OCD.

1. anti-histaminic: sedation
2. anti-adrenergic: orthostatic hypotension (most life threatening), tachycardia, arrhythmias. 
3. anti-muscarinic: dry mouth, constipation, urinary retention, tachycardia, blurred vision
4. Weight gain
5. Lethal in OD - must assess suicide risk!
6. Major complications = 3 C's: Convulsions, Comas, Cardiotoxicity

Refractory depression & Refractory panic d/o

Examples of MAOIs: phenelzine, tranylcypromine, isocarboxazid

1. Fluoxetine - SSRI with longest half life. Has active metabolites. Do not need to taper.
2. Sertraline - highest risk for GI SE
3. Paroxetine - most serotonin-specific, most activating (stimulant)
4. Fluvoxamine - approved only for OCD
5. Escitalopram - levo enantiomer of citalopram. Similar efficacy, fewer SE, much more $$$$

Sexual dysfunction (MC)

GI disturbance

Insomnia

Anorexia/weight loss

Headache

Serotonin sydrome when used w/ MAOIs

Mechanism: NE/DA reuptake inhibitor.

Uses: smoking cessation, SAD, adult ADHD. SE: Lacks sexual SE compared to SSRIs. High doses can exacerbate psychosis. SE similar to SSRIs with increased sweating and increased risk of seizures (lowers threshold) and psychosis at high doses. Not optimal for patients with significant anxiety. CI in patients with seizure, active eating d/o, or currently taking an MAOI. 

Nefazodone and Trazodone -

mechanisms, uses, side effects

Mechanism: serotonin antagonists and reuptake inhibitor.

Useful for tx of refractory depression, major depression with anxiety, and insomnia (secondary to its sedative effects).

SE: nausea, dizziness, orthostatic hypotension, arrhythmias, sedation, and priapism (last 2 esp with trazadone).

Mechanism – NE and 5HT antagonist.

Useful in tx of refractory depression, esp in patients who need to gain weight.

SE: sedations, weight gain, dizziness, somnolence, tremor, and agranulocytosis.  Maximal sedative effect occurs at dose of 15 mg and less. At higher doses, it increases NE uptake and is less sedating.

Low potency: low affinity for DA receptor. Equal efficacy, but uses higher dose.   

Chlorpromaize (thorazine) and thioridazine (Mellaril) – higher incidence of anticholinergic effects & antihistaminic effects. Lower incidence of EPS and NMS. 

High potency: have greater affinity for DA receptor – smaller dose required to achieve effect.

Includes haloperiodol, fluphenazine, trifluoperazine, perphenazine, pimozide. Higher incidence of EPS and NMS,

lower incidence of anticholinergic and antihistaminic effects. 

Haloperidol and fluphenazine decanoate.

Administer IM - every 2-3 weeks for fluphenazie, 4-5 weeks for haloperidol. 

- EPS (antidopaminergic effect) – parkinsonism, akathisia, dystonia.

- hyperprolactinemia à decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea, osteoporosis.

- Anti-HAM effects

        Antihistaminic – sedation

Anti-alpha-adrenergic – orthostatic hypotension, cardiac abnormalities, and sexual dysfunction

Antimuscarinic – dry mouth, tachycardia, urinary retention, blurry vision,constipation.

- weight gain

- elevated LFTs, jaundice

- ophthalmologic problems: high dose thioridazine à irreversible retinal pigmentation. Clorpromazine – deposits in lens and cornea

- dermatologic – rashes, photosensitivity, blue/gray discoloration with chlorpromazine

- seizures – lower thresholds. Low potency antipsychotics lower threshold more than high potency

- TD – may occur in pts that have used neuroleptic for > 6 months. Most often occurs in older women. 50% spontaneously remit, but can be permanent.

- NMS

•     Some HAM effects
•    1% incidece of agranulocytosis and 2-5% incidence of seizures with clozapine
•  Olanzapine and clozapine – metabolic syndrome/weight gain
• Olanzapine – liver toxicity – monitor LFTs
•  Quetiapine – less weight gain, but may cause cataracts – do slit lamp exam every 6 months. 

- potentiation of antidepressants in pts with MDD refractory to monotherapy

- potentiation of antipsychotics in pts with schizophrenia

- enhancement of abstinence in tx of alcoholism.

- Tx of aggression and impulsivity (dementia, intoxication, MR, PDs, and general medical conditions).

Lithium

Carbamezapine

Valproic acid

1. NSAIDS (increase)

2. Aspirin

3. Dehydration (increase)

4. Salt deprivation (increase)

5. Impaired renal fxn (increase)

6. Diuretics 

7. Caffeine/theophylline (decrease)

anticonvulsant.

Esp. good for treating mixed episodes and rapid cycling bipolar d/o. Also used for trigeminal neuralgia.

Mechanism: blocks sodium channels and inhibits APs.

Onset of action 5-7 days.

skin rash, drowsiness, ataxia, slurred speech, leukopenia, hyponatremia , aplastic anemia, and agranulocytosis. Elevates liver enzymes and teratogenic effects (NT defects). CBC and LFTs must be obtained pre-tx and monitored regularly.

anticonvulsant – also esp good for treating mixed manic episodes and rapid-cycling bipolar d/o. Unknown mechanism of action, but has been shown to increase CNS levels of GABA. 

sedation, weight gain, alopecia, hemorrhagic pancreatitis, hepatotoxicity, and thrombocytopenia, teratogenic (NT defects). Monitor LFTs and CBCs regularly.

Chlordiazepoxide – alcohol dependence, presurgery anxiety

Diazepam (valium) – rapid onset, used in tx of anxiety and seizures

Flurazepam – rapid onset, tx of insomnia

almost all used for panic attacks (plus other indications):

Alprazolam, 

Clonazepam – also for anxiety,

Lorazepam – also for alcohol withdrawal,

Temazepam – for insomnia only

Oxazepam & 

Triazolam – rapid onset, for insomnia

alternative to BDZ or venlafaxine for treating GAD. Slower onset of action than BDZs (1-2 weeks for effect).

Anxiolytic action 5HT-1A receptor (partial agonist). Does not potentiate CNS depression of alcohol, so safe to use in alcoholics.

Low potential for abuse/addiction.

Panic attacks

Performance anxiety

Akathisia

Sustained contraction of muscles of neck, tongue, eyes. Occurs with high-potentcy typical antipsychotics.

Reversible - occurs within days.

Can be life threatening.

Tx - benztropine

NARCC

Name and purpose of tx

Alternatives to tx

Risks/benefits

Consequences of refusing

Capacity (ability to make informed decision)

1. can communicate a choice/preference

2. understand relevant info regarding tx – purpose, risk, benefits, and alternatives. Patient must be able to explain this info to you.

3. appreciates the situation and its potential impact or consequences according his or her own value system and understand the ramifications of refusing tx.

4. can logically manipulate information regarding the situation and reach rational conclusions

 *criteria may be more stringent if the consequences of the patient’s decision are very serious.

#1 (Most important) – history of violence

2. specific threat w/ a plan

3. hx of impulsivity

4. psychiatric dx

5. substance abuse. 

• hyperreligious thinking/preoccupation with moral behavior
• altered sexual behaviors
• hypergraphia/overelaborative communication styles ("viscosity"
• heightened experience of emotions

Range is from 3 (deep coma) to 14 (fully alert). Looks at:

1. eye opening: 1  (not opening) to 4 (open spontaneously). 2=open in response to pain
2. best motor response: 1 (no response), 2 (extension), 3 (flexion), 4 (localizes pain), 5 (obeys commands)
3. best verbal response: 1 (no response) to 5 (fully oriented). 

Haloperidol/typical antipsychotics can be continued without signficant SE during ECT. They even lower the seizure threshold which facilitates ECT. 

[Lithium is assoc with prolong delirium post-ECT. BDZs hinder ECT via anticonvulsant effects. Clozapine can cause tardive seizures (no good) when given with ECT.]

- sensory aura before seizures

- automatic behaviors during seizure (lip smacking, eye blinking)

- pt may look dazed during seizure

- has impaired consciousness

*complex partial seizures are usually assoc with temporal lobe epilepsy

Must have the following sx, with onset before 30 yo:

• 4 pain complaints
• 2 GI
• 1 sexual
• 1 neuro

What are antipsychotics used for other than psychosis? (3)

Partial agonist of D2 receptor and 5HT-1A receptor.

Anagonist of 5HT-2A (like other atypicals).

Age of onset: 20

Prevalence: 2-3%, M=F

MDD ad social phobia

*lifetime prevalence of MDD in patients with OCD is 67%

What do the following tests assess:

1) Brown Peterson Task

2) Geriatric Rating Scale

3) Blessed Rating Scale 

1. Brown Peterson Task evaluates short term memory.
2. Geriatric Rating Scale assesses patient's ability to perform activities of daily living.
3. Blessed Rating Scale asks patient's friends & family to assess patient's ability to function in his/her own environment.

What is assessed by the following tests:

1. Wisconsin Card Sorting Test (WCST)
2. Draw-a-person Test
3. Luria-Nebraska Neuropsychiatric battery

1. WCST - tests executive functions
2. Draw-a-person - screening test for brain damage
3. Luria-Nebraska neuropsych battery - assesses specific cortical areas and helps in assessment of hemispheric dominance.

What is assessed in the following tests:

1. Stroop test
2. Fargo Map test
3. WMT

1. Stroop Test - tests ability to concentrate (identification of words and colors)
2. Fargo Map test - evaluates recent and remote spatial memory and visuospatial orientation
3. WMT - tests memory in adults

What is assessed in the following tests:

1. Rey-Osterrieth Test
2. Bender-Gestalt Test
3. Random Letter Test

1. Rey-Osterrieth Test - assesses visual/nonverbal memory (copying a picture from memory) and also can detect R. parietal lesion (left hemineglect)
2. Bender-Gestalt Test - can help to localizes brain lesion/determine if organic lesion is present. Involves copying figures.
3. Random Letter Test - concentration test; good alternative to serial 7s in patient w/ low education level.

What is deja entendu?

What is jamais vu?

Deja entendu - feeling that one is hearing something one has heard before (seeing --> deja vu)

Jamais vu - when somethiing should be familiar seems unfamiliar

Most common method by which adolescents complete suicide?

Most common method by which children attempt suicide?

Complete - firearms

Attempts - substance ingestion

When an infant repeatedly regurgitates and re-chews food. Must be for at least 1 month and follow a period of normal functioning.

Sx: may appear that baby's drooling (actually regurgitated food), baby fails to gain weight appropriately.

Often seen in infants who have a variety of caretakers in an unstable environment.

MDD - 50% comorbid with childhood anxiety d/o

ADHD - 30% comorbid with childhood anxiety d/o

Substance related disorders

ADHD

Most common initial sx of Tourette's d/o?

Average age of onset?

#1 - eye tics - blinking, eye rolling

#2 - facial and vocal tics

Average age of onset - 7 yo (sx must occur for majority of 1 year for dx).

Early alterations in embryonic development (ex. chromosomal changes - Down's, toxin-induced damage- alcohol). 

This category accounts of 30% of cases of MR.

Common: sedation

Less common: dry mouth, hypotension

What are the PANDAS (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)?

Cotard Syndrome

Capgras Syndrome

Cotard Syndrome - nihilistic delusions, including delusion that one is dead or is rotting away. 

Capgras Syndrome - delusion that people have been replace by imposters

Cortisol level is increased

Catecholamines and sex hormones are decreased.

Manic/psychotic sx and abdominal pain. 

Dx can be made with UA (elevated ALA and porphrobilinogen).

How many ECT sessions are needed for

1) catatonia, 2) MDD, 3) psychosis/mania?

1. Catatonia: 2-4 sessions
2. MDD: 6 - 12 sessions
3. Psychosis/mania: 20+ sessions

Strokes of the left frontal area (L. MCA) are often followed by depression.  (Rule: L>R, Anterior>Posterior).

Infarcts of the right frontal area often present with euphoria, inappropriate indifference, and mania.

1. Localized - memory loss surrounding a discrete period of time (usually a traumatic event)
2. Selective - inability to recalll certain aspects of an event.
3. Generalized - forget entire preceding life
4. Continuous - forget all events following trauma except the immediate past
5. Retrograde - forget all events from before trauma

1. Increased sleep latency (i.e. trouble falling asleep)
2. Early morning wakening (overall increased wakefulness)
3. REM sleep is redistributed so most occurs earlier in the night
4. Decreased REM latency

What is cacodemonomania?

In what mental illnesses is cotard syndrome typically seen?

Cacodemonomania = delusion of being poisoned by an evil spirit

Cotard syndrome (delusion of nihilism/dead/rotting away) can be seen in schizophrenia, bipolar d/o, and Alzheimer's.

What is Fregoli syndrome?

What are haptic hallucinations?

Fregoli syndrome - delusion that a person is taking the form of a number of people or creatures

Haptic hallucinations - tactile hallucination in which one feels as if hes being touched

Synesthesia is when a secondary sensation follows an actual perception. Ex: a color associated with a taste.

It is seen in neurologic disease and hallucinogen use, esp. LSD.

Hippocampus, parahippocampus, and amygdala

*Hippocampus size is decreased in patients with depression and/or Alzheimer's (Alzheimer's can present with depressive sx)

Oxazepam and lorazepam are okay to use.

Don't use chlordiazepoxide or diazepam (these undergo extensive liver metabolism).

Aripiprazole and ziprasidone

(most likely = olanzapine and clozapine0

1. 6 - 8 hours: tremulousness/jittery
2. 8 - 12 hours: psychosis and perceptual sx
3. 12 - 24 hours: seizures
4. 24 -  72 hours, up to 1 week: DTs

Attention = ability to focus one's perception on an outside or inside stimulus. Test = digit recall (backwards/forwards).

Concentration = sustained attention to an internal thought process. Test = serial 7s, WORLD backwards.

1. Flank tenderness
2. Leg swelling
3. Ureter obstruction and hydronephrosis

Most common cause of death due to cervical CA is bilateral ureter obstruction leading to uremia.

• Early cervical CA (contained within the cervix) may be treated equally well with surgery (radical hysterectomy) or radiation tx.
• Advanced cervical CA is bested treat with radiotherapy, consisting of brachytherapy (implants) with teletherapy (whole pelvis radiation) along with chemotherapy (usually cis-platinum) to sensitize the tissue to radiation.

• Abnormal vaginal bleeding. Postcoital spotting is common in women who are sexually active.
• Another symptom is water and/or malodorous vaginal discharge.
• The mean age of presentation is 51 yo.

• early age of first intercourse
• STI's
• early childbearing
• Low SES
• HPV (= #1 risk factor)
• HIV
• cigarette smoking
• multiple sexual partners

Dysplastic lesions often have vascular changes (reflecting rapid growth) that correlate with the severity of the disease: mild vascular pattern = punctations vs. "atypical vessels" = corkscrews & hairpins.

The biopsy should be taken of the worst-appearing area.

• Cervical cancer is the only gynecologic cancer that is still staged clinically (as opposed to surgically). 
• Staging may involve examination under anesthesia, IVP, chest XR, cystoscopy, and protoscopy or barium enema.
• Findings from MRI, CT, or surgery do NOT impact or change the staging of the disease.

1. Stage I - confined to cervix
2. Stage II - extends beyond cervix but not to pelvic sidewalls or lower 1/3 of vagina
3. Stage III - extends to pelvic sidewalls or lower 1/3 of vagina; any renal involvement
4. Stage IV - extends beyond pelvis, invades local structures including bladder or rectum, or has distant mets. 

• Pap smears usually begin 3 years after onset of sexual activity, or by age 21.  
• HPV typing can be useful for triaging atypical squamous cells of undetermined signficance (ASCUS). (

Characteristics of PCOS (5)

What lab finding is common?

• obesity
• anovulation/oligomenorrhea
• hirsutism
• glucose intolerance
• estrogen excess
• Often there is an elevated LH:FSH ratio.
• PCOS is the MC cause of ovulatory dysfxn in reproductive-age women.

• Sheehan syndrome: anterior pituitary hemorrhagic necrosis is caused by hypertrophy of the prolactin-secreting cells in conjunction with a hypotensive episode (postpartum hemorrhage).
• Asherman syndrome/intrauterine adhesions: caused by uterine curretage (may be part of tx of postpartum hemorrhage); the decidua basalis layer becomes damaged, rendering the endometrium unresponsive.

1. Amenorrhea = no menses for 6 months
2. Postpartum hemorrhage = bleeading > 500 mL for a vaginal delivery and > 1000 mL for c-section. (The amount of bleeding that may result in hemodynamic instability if left unabated.)

• Sheehan syndrome: low anterior pituitary hormones and their counterparts (TSH and T4, FSH and ER, ACTH and cortisol, prolactin, etc.) No LH surge = no biphasic basal body temp. There will be bleeding in response to progestin.
• Asherman's syndrome: normal levels of anterior pituitary hormones and their counterpart. Normal LH surge = normal bisphasic body temp. No bleeding in response to progestin.

• Hypothalamic/pituitary pathology vs. ovarian failure.
• If the cause is ovarian failure, FSH will be elevated.

• The biphasic basal temperature is caused by progesterone (elevates body temp).
• Thus, when present, it indicates the presence of progesterone as well as normal pituitary fxn and normal ovulation. 

• Distinguish fetal HR from the maternal pulse - this can be done with an internal fetal scalp electrode or an US.
• Examine the vagina to assess for cord prolapse.

• Vertex & frank breech presentations have a low risk of cord prolapse.
• Footling breech and transverse lie have a much higher risk of cord prolapse.
• The risk is also increased if the presenting fetal part is unengaged (not at the bony pelvis inlet, ex. -3 station). AROM should be avoided in these pts, as it can cause a cord prolapse.

• The MC finding in uterine rupture is fetal HR abnormality, such as fetal bradycardia, deep variable decels, or late decels.
• The best tx for suspected uterine rupture is immediate c-section. 

• The initial steps are improving maternal oxygenation and delivery of CO to the fetus:
• place patient on her left side to improve VR to heart
• IV fluid bolus if pt may be volume depleted
• administer 100% oxygen
• stop oxytocin if it is being given.

1. Hyperstimulation d/t oxytocin. Tx: IV beta agonist (terbutaline) helps relax the uterus.
2. Hypotension d/t an epidural Tx: IV hydration; if unsuccessful, use a pressor agent (ephedrine).
3. Cord prolapse (identified with vaginal exam); Tx: elevation of presenting part and emergent c/s.

1. drugs (meds)
2. hypothyroidism
3. pituitary adenoma
4. hypothalamic causes (ex. craniopharyngioma)
5. hyperplasia of lactotrophs (pregnancy)
6. empty sella syndrome
7. acromegaly
8. renal disease
9. chest surgery or trauma (implants, T2 herpes zoster).

• galactorrhea (will see fat droplets under microscope) - prolactin stimulates milk production
• amenorrhea or oligomenorrhea occur because high prolactin levels inhibit GnRH pulsations from the hypothalamus
• Hypoestrogenemia (lack of GnRH pulsations) - may lead to osteoporosis.

• Sx of a secreting pituitary adenoma include galactorrhea, headache, and bitemporal hemianopsia.
• MRI is the most sensitive test to detect pituitary adenomas.

• These patients can be observed - following serum prolactin levels annually.
• Normal menses and serum prolactin put the patient at low risk for having a prolactinoma. (Regular menses indicate normal HT fxn).

• This patient should be worked up to determine if there's a prolactinoma:
• MRI scan of the sella turcica/pituitary gland
• Secondary amenorrhea and hypoestrogenism significantly increase the risk of a pituitary adenoma as well as early onset osteoporosis.

1. Cholestasis in pregnancy = MC; pruritus with or w/o jaundice; no skin rash.
2. Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) = skin condition of unknown etiology, unique to pregnancy; Intense pruritus and erythematous papules that begin on the abdomen and spread to thighs and sometimes butt and arms.
3. Herpes gestationis - rare skin condition; unique to pregnancy. Intense itching and vesicles on abdomen and extremities.

• cholestasis of pregnancy usually begins in the 3rd trimester
• the diagnosis is confirmed by increased levels of circulating bile acids
• the tx includes: antihistamines and cornstarch baths; ursodiol (reduces cholesterol absorption) and cholestyramine (bile acid-binding resin; assoc with Vit K deficiency).
• Should also check LFTs

• Cholestasis of pregnancy, esp. when accompanied by jaundice, is assoc with increased incidence of:
• prematurity
• fetal distress
• fetal loss

• Usually begins in 2nd trimester
• Autoimmune-related etiology: IgG auto-Ab against the basement membrane leads to activation of complement cascade
• Definitive dx is made by immunofluorescent exam of biopsy specimens.

• Adverse outcomes include increased incidence of fetal growth retardation and stillbirth, as well as a transient (self-limiting) neonatal herpes gestationis
• Tx = oral corticosteroids.

• No studies suggest adverse effects of PUPPP on mom or fetus.
• Tx includes topical steroids and antihistamines.

• Usually occurs at 35 - 36 weeks.
• Usually occurs with first pregnancy only (does not recur). 

• Usually a polymicrobial infection (ascending infxn) - organisms may include gonorrhea, chlamydia, anerobes, & gram - rods. 
• Classic triad: lower abdominal tenderness, cervical motion tenderness, and adnexal tenderness.

• In practice, dx of PID is made clinically (based on sx and PE: class triad +/- vaginal discharge, fever, pelvic mass indicating TOA). 
• Gold standard for dx = laparoscopy - visualize purulent drainage from fallopian tubes
• Long term sequelae: chronic pelvic pain, ectopic pregnancy, infertility

• mostly anerobes
• adnexal mass on PE or US may reveal a complex ovarian mass
• Tx - Can often be treated with abx without surgical drainage: clindamycin or metronidazole (target anerobes). Radiological percutaneous drainage may be used to hasten resolution.
• Major complication = rupture - surgical emergency

• dyspnea (MC presenting sx)
• pleuritic chest pain
• clear chest radiograph
• hypoxemia (PO2 < 80 in pregnant woman is abnormal)
• some may have palpitations or feel like they are having an anxiety attack 
• few pts have hemoptysis
• tachycardia

1. Spiral (or helical) CT scan - uses IV contrast to detect vascular filling defects
2. MR angiography - also uses IV contrast
3. Ventilation-perfusion scan - uses IV radioactively-tagged albumin (technetium) in conjunction with ventilation imaging (inhaled xenon or technetium)

• Venous stasis occurs d/t the mechanical effect of the uterus on the vena cava
• High ER level induces a hypercoaguable state d/t increase in clotting factors, esp. fibrinogen. 

• A pulse oximetry reading < 90% corresponds to an oxygen tension < 60 mmHg. 

• Full IV anticoagulation (heparin) for 5-7 days. 
• Later, switch to subcutaneous therapy to maintain aPTT at 1.5 - 2.5x control for at least 3 months.
• After 3 months, heparin may be continued prophylacticly for the remainder of the pregnancy and for 6 weeks postpartum. 
• Consider looking for other causes of thrombosis (besides pregnancy alone) - i.e. factor V leiden, antiphospholipid syndrome, etc.

Embolism

(thromboembolism and amniotic fluid embolism)

• Most neonatal herpes infections occur from HSV from genital tract secretions and fluids.
• 5-10% of neonatal infections are acquired in utero (transplacentally). These are usually d/t primary episodes. 

• Tx  of the primary epsidoecan decrease the duration of viral shedding, pain sx, and the duration of lesions. Treating the primary episode does not affect the likelihood of future recurrence. 
• Suppressive acyclovir tx may help decrease risk of recurrence at the time of labor and decrease the need for c/s. Therefore, some praciticioners use suppressive tx when a woman has her first episode during pregnancy. Suppressive therapy is also used in pts with recurrent outbreaks. 

• C-section should be offered in patients with a h/o HSV who have (1) prodromal sx or (2) suspicious lesions of the genital tract.

• These are sx that occur prior to the outbreak of vesicles.
• They can include burning, itching, or tingling. 

• Menorrhagia is MC presenting sx.
• Physical exam demonstrates an irregular pelvic mass that is mobile, midline, and moves contiguously with the cervix.
• Note: fibroids can be submucosal (endometrial side), intramural (within the uterine muscle), or subserosal. They may or may not be pedunculated.

• AKA "red degeneration"
• changes of the leiomyomata d/t rapid growth
• center becomes red and causes pain

1. increased endometrial surface area
2. fibroids may cause disruption of the hemostatic mechanisms during menses
3. possible ulceration of submucosal fibroid surfaces

• GnRH agonists are used to shrink fibroids.
• Achieve maximal effect in 3 months.
• After the agonist is removed, fibroids will return to pre-tx size.
• Therefore, GnRH agonists are only give for tumor shrinkage or correction of anemia prior to operative tx.

• Patients who do not respond to medical tx may consider surgical tx, which includes:
• Hysterectomy - for women who do not desire future pregnancy.
• Uterine artery embolization to cause fibroid infarction and subsequent hyalinizations/fibrosis
• Myomectomy - for women who desire future pregnancy

• rapid growth
• history of prior pelvic irradiation
• significant growth of suspected uterine fibroids in a postmenopausal woman.
• Suspicion of leiomyosarcoma requires surgical evaluation.

• Most cases can be observed.
• Asymptomatic fibroids require surgical intervention if there is: 1) unexplained rapid growth, 2) ureteral obstruction, or 3) inability to differentiate the fibroid from other types of pelvic masses.

• Preterm - observation until severe criteria are noted or term gestation is reached. [Severe preeclampsia requires delivery regardless of GA.]
• Term - give magnesium sulfate (prevent seizures) and deliver.

• 1st sign of Mg toxicity = decreased DTRs
• Respiratory depression
• Dyspnea (pulmonary edema)
• Should monitor DTRs and urine output (Mg is excreted renally).

• CHTN = HTN prior to 20 weeks, or if HTN persists beyond 12 weeks postpartum.
• Gestational HTN = HTN without proteinuria beginning after 20 weeks.
• Preeclampsia = HTN w/ proteinuria (>300/24 hr; dipstick > 1+ to 2+) at GA > 20 weeks; caused by vasospasm.

• Epigastric pain is d/t ischemia of the liver.
• Rarely hepatic hematomas may form and may rupture, resulting in massive hemorrhage (requires immediate laparotomy)

• BP of at least 160 systolic or 110 diastolic (or)
• 24 hr protein >5 g or urine dipstick with 3+ / 4+ (or)
• Sx that indicate end-organ damage are present: HA, RUQ pain, vision changes, etc.

• placental abruption
• eclampsia (with possible intracerebral hemorrhage)
• coagulopathies
• renal failure
• hepatic subcapsular hematoma/rupture
• uteroplacental insufficiency

• nulliparity
• CHTN
• age extremes
• African American race
• Antiphospholipid syndrome
• DM
• multifetal gestation
• chronic renal dz
• personal h/o severe preeclampsia
• Family h/o preeclampsia

• just prior to delivery
• during labor (intrapartum)
• first 24 hours postpartum (Mg is continued until 24 hrs postpartum).

• Mild - no treatment (unless pt was being treated for CHTN before pregnancy)
• Severe - labetalol, hydralazine

• firm, rubbery, mobile mass that is solid in consistency in adolescent - 20s
• most common cause of a "dominant breast mass"
• does not change with menstrual cycle (as opposed to fibrocystic changes)

• multiple, irregular "lumpiness of the breast"
• MC benign breast condition
• Much more common premenopause (hormone-dependent).
• Sx: cyclic, painful, engorged breast

• decrease caffiene intake
• NSAIDs
• wear tight-fitting bra
• combined OCPs or oral progestin
• danazol (weak anti-estrogen, androgenic compound) for severe cases

• ALL 3D dominant masses require biopsy for histologic evaluation.
• Women < 35: often do FNA or core biopsy
• Women >35 or with increased risk (FHx) of breast cancer: excisional biopsy
• Triple assessment: clinical exam, imaging (US or mammography), and histology should all agree. (Nonconcordance --> obtain more tissue).

• small, benign tumor of the milk duct
• bloody nipple discharge
• highest incidence beween ages 35 - 55.
• Since malignancy is the 2nd MC cause of bloody nipple discharge, ductal exploration is required to r/o cancer.

• Ultrasound
• This is b/c the dense fibrocystic changes in younger women that interfere with mammogram interpretation.
• US can differentiate solid vs. cystic, but should stil obtain tissue to confirm dx of fibroadenoma.

1. Ovulatory 
2. Uterine
3. Tubal
4. Male
5. Peritoneal

[6th, less common etiology = cervical]

• H/o of irregular menses, +/- obesity
• Dx: basal body temperature chart does not show biphasic pattern, midluteal (day 21) serum progesterone level (indicates ovulation),  LH surge detectable with self-administered urine test, endometrial biospy, US.
• Tx: generally amenable to tx with clomiphene

• H/o uterine fibroids (esp. submucosal myomata interfere with implantation)
• Dx: hysterosalpingogram showing abnromal uterine cavity
• Work-up/tx: hysteroscopy

• h/o hernia, varicocele, mumps
• dx: semen analysis
• tx: repair of hernia or varicocele; IVF

• H/o chlamydial or gonococcal infxn
• dx: hysterosalpingogram may be helpful, but gold standard = laparoscopy
• Tx: often surgery; IVF

• Hx - Endometriosis. 3 D's: dysmenorrhea, dyspareunia, dyschezia. (May be asymptomatic or presenting sx = infertility.)
• Dx - laparoscopy = gold standard
• Tx - surgical ablation of lesions; medical tx

• infrequent etiology!
• hx: prior cryotherapy of the cervix; pt has thick mucus before ovulation
• tx: intrauterine inseminsation (catheter injects sperm directly into uterus).

• High dose combination hormones (Yuzpe regimen), high dose progestin (Plan B), insertion of IUD.
• Hormones must be taken within 72 hours of intercourse. IUD up to 5 days.
• Main SE of combination hormonal contraception = nausea and vomiting (caused by high dose ER). May be given with an antiemetic. 
• Progestin-only method has better efficacy (85% vs 75%) and less nausea compared to combination hormones.

• PR - inhibits ovulation; thickens cervical mucus
• ER - maintains endometrium, prevents unscheduled bleeding, inhibits follicular development. 

1. nausea
2. fluid retention
3. weight gain
4. breast tenderness

1. Septic shock - pyelonephritis = MC cause of sepsis/septic shock in pregnancy
2. ARDS.

• sx: dyspnea, tachypnea
• mechanism: bacterial endotoxins (esp. gm neg) damage the endothelium, creating leaky pulmonary capillaries. Typically occurs after abx have been started (d/t lysis of bacteria).
• findings: may have CXR with patchy inflitrates. CXR may be normal early in dz process.
• Tx: oxygen supplementation, monitor fluids (not to overload), supportive measures. Intubation if necessary.
• In pregnancy endotoxemia may cause uterine ctx and put a pt into preterm labor.

• Aerobic bacteria:
• E. Coli (80% cases)
• Klebsiella pneumoniae
• Staph aureus
•  Proteus mirabilis

• IV antibiotics: cephalosporins or combination of gentamicin and ampicillin.
• Continue suppressive oral therapy for remainder of pregnancy.
• Obtain repeat urine culture to ensure clearance of infxn.
• If there's no clinical improvement in 48-72 hours, urinary tract obstruction or perinephric abscess should be suspected.

• It is a 3-dimensional mass that, on palpation, is felt to be separate from the remainder of the breat tissue. 
• All dominant masses (even those with normal imaging) must be biopsied.
• Depending on risk factors, may choose an excisional biospy (remove entire mass) or FNA. 

• BRCA1 is on chr 17; BRCA2 is on chr 13.
• Both are tumor supressor genes (AD).
• Mutations confer increased risk for breast (50-70%) and ovarian (30%) cancers. (%s for BRCA1).
• Pts with 2 first degree relatives with breast CA are candidates for genetic testing.
• Ashkenzai Jews are at increased risk

• Women > 40: annual mammograms and annual clinical breast exam
• 20 - 39: annual clinical breast exam q1-3 years.

• Breast cysts that have a straw-colored or clear aspirate and breast mass disappears upon aspiration may be observed.
• If fluid is another color, the fluid should be sent for cytology.
• If the mass persists after aspiration it should be biopsied.

• < 30 years: benign cystic teratoma (aka dermoid cyst, a germ cell tumor). Tx in a young woman = ovarian cystectomy.
• Dermoid cyst with thyroid tissue = struma ovarii
• > 30 years: serous cystadenoma (epithelial origin)

• They usually present as a pelvic mass that causes pain d/t rapidly enlarging size.
• Most are unilateral. 10-15% are bilateral. 
• 60-70% present in stage 1. 
• Dx with ultrasound is very accurate.
• Most frequent complication = torsion - severe, acute abdominal pain. Occurs more frequently in pregnancy and puerperium.
• Another less common complication = rupture [leading to] hemorrhage. 

• less common than mature teratomas; in general, uncommon
• contain all 3 germ layers AND embryonic-like tissue/structures.
• most occur in 1st and 2nd decades
• almost always unilateral
• tx - unilateral salpingooophorectomy with wide sampling of perioteal implants

1. serous = most common; often bilateral.
2. mucinous = very large; can cause pseudomyxoma peritonei if ruptured - leads to repeated bouts of bowel obstruction. Generally unilateral.
3. Endometrioid - can coexist with primary endometrial CA of the uterus
4. Brenner
5. Clear cell

• Tx is first surgical.
• If malignancy is confirmed, cancer staging is indicated.
• After surgical staging, combination chemotherapy.

• Masses > 8 cm - likely to be neoplastic.
• Masses < 5 cm - likely a functional cyst (follicular, corpus luteal, etc).
• Masses between 5 - 8 cm - Do sonogram - septations, solid components, or excrescences suggest neoplasm - must operate. May also observe for 1 month and operate if mass persists.

• these tumors are completely solid
• they secrete hormones.

• Wound dehiscence - separation of part of the surgical  incision, but with intact peritoneum. 
• Superficial separation is usually assoc. with infxn or hematoma.
•  Presents 4-10 d post-op with red, tender incision. 
• Tx = open wound and drain purulence. Give broad-spectrum abx with wet-to-dry dressings. 

• Fascial disruption - separation of facial layer, usually leadng to a communication of the peritoneal cavity with the skin.
• Increased risk with vertical incisions, obesity, intra-abdominal distension, diabetes, expsoure to radiation, corticosteroid use, infxn, coughing, and malnutrition.
• Presents as profuse serosanguinous drainage from the incision 5-7 days post-op.
• Requires repair ASAP (surgical emergency) and initiation of broad-spectrum abx. 

• Evisceration - disruption of all layers of the incision with omentum or bowel protruding through. Significant mortality d/t sepsis. 
• Surgical emergency
• When encountered - place sterile sponge wet with saline over bowel and take pt to OR. Start abx immediately.

• Most common = ectopic pregnancy
• ruptured corpus luteum (note: corpus luteum cysts tend to rupture more often during pregnancy)

• Used to diagnose intrauterine pregnancy (95% accurate).
• Tissue passed by a pt floats in a "frond pattern" when placed in saline d/t presence of chorionic villi.
• Helps to r/o ectopic pregnancy

• suddent onset of severe lower abdominal pain
• some women have unilateral cramping and lower abdominal pain for 1-2 weeks before overt rupture
• commonly ruptures between days 20-26 of menstrual cycle. 
• Dx is confirmed by laparoscopy.
• Tx - first secure hemostasis. once bleeding stops no further tx is needed. If bleeding persists, cystectomy should be performed.

• It is the main source of progesterone until about 10 weeks GA. 
• hCG maintains luteal fxn until placenta is making its own progesterone sufficiently.
• If corpus luteum is removed surgically before 10-12 weeks GA, exogenous progesterone is needed to sustain the pregnancy.