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Table of Contents
1. Cardiology
a. Coronary Artery Disease 1
b. Congestive Heart Failure 2
c. Valve Disease 3
d. Cardiomyopathy 4
e. Pericardial Disease 4
f. Hypertension 5
g. Cholesterol 5
h. ACLS 6
i. Syncope 7
2. Pulmonary
a. Asthma 8
b. Lung Cancer 8
c. Pleural Effusion 9
d. DVT PE 9
e. COPD 10
f. ARDS 10
g. Interstitial Lung Disease 11
3. Gastroenterology
a. Gallbladder Disease 12
b. Esophagitis 12
c. Esophageal Disorders 13
d. Peptic Ulcer Disease 14
e. Misc. Gastric Disorders 14
f. Acute Diarrhea 15
g. Chronic Diarrhea 15
h. Malabsorption 16
i. Diverticular Disease 16
j. Colon Cancer 17
k. GI Bleed 18
l. Cirrhosis Etiologies 19
m. Cirrhosis Complications 20
n. Acute Pancreatitis 21
o. Inflammatory Bowel Disease 21
p. Jaundice 22
q. Viral Hepatitis 22
4. Nephrology
a. Acute Kidney Injury 24
b. Sodium 25
c. Calcium 25
d. Potassium 27
e. Kidney Stones 27
f. Cysts and Cancer 28
g. Acid Base 28
5. Hematology Oncology
a. Macrocytic Anemia 30
b. Microcytic Anemia 30
c. Normocytic Anemia 31
d. Leukemia 32
e. Lymphoma 32
f. Plasma Cell Dyscrasia 33
g. Thrombophilia 33
h. Bleeding, Thrombocytopenia 34
6. Infectious Disease
a. Antibiotics 36
b. HIV 36

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 c. TB 37
d. Sepsis 37
e. Brain Inflammation 38
f. Lung Infection 38
g. UTI 39
h. Genital Ulcers 39
i. Skin Infections 40
j. Endocarditis 41
k. Antibiotics 41
l. Surgery 41
7. Endocrinology
a. Anterior Pituitary 42
b. Posterior Pituitary 43
c. Thyroid Nodules 43
d. Men Syndromes 43
e. Thyroid Disorders 44
f. Adrenals 45
g. Diabetes 46
h. Diabetic Emergencies 47
8. Neurology
a. Stroke 48
b. Dizziness 48
c. Seizure 49
d. Tremor 50
e. Headache 50
f. Back Pain 51
g. Dementia 52
h. Coma 52
i. Weakness 53
9. Rheumatology
a. Approach To Joint Pain 54
b. Lupus 55
c. Rheumatoid Arthritis 55
d. Other Connective Tissue Dz 56
e. Monoarticular Athropathies 56
f. Seronegative Arthropathies 57
10. Dermatology
a. Blistering Disease 58
b. Papulosquamous Dermatoses 58
c. Eczematous Dermatoses 59
d. Hypersensitivity Reactions 59
e. Hyperpigmentation 60
f. Hypopigmentation 61
g. Skin Infections 61
h. Alopecia 62
11. Pediatrics
a. Newborn Management 64
b. Neonatal ICU 64
c. FTPM and Constipation 65
d. Neonatal Jaundice 65
e. Baby Emesis 66
f. Congenital Defects 67
g. Well Child Visit 68
h. Vaccinations 69
i. Preventable Trauma 70
j. Abuse 71
k. ALTE / BRUE and SIDS 71
l. Infectious Rashes 72
m. Acute Allergic Reactions 73

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 n. Chronic Allergic Reactions 73
o. ENT 74
p. Peds Psych 75
q. Upper Airway 76
r. Lower Airway 77
s. GI Bleed 78
t. CT Surgery 79
u. Orthopedics 80
v. Ophthalmology 81
w. Urology 82
x. Seizures 83
y. Sickle Cell 83
z. Immunodeficiencies 84
12. Psychiatry
a. Defense Mechanisms 86
b. Anxiety & Related Disorders 87
c. Impulse Control Disorders 88
d. Eating Disorders 88
e. Mood Disorders I And II 89
f. Delusional Disorders 90
g. Personality Disorders 91
h. Peds Psych 92
i. Dissociative Disorders 93
j. Addiction 93
k. Drugs of Addiction: Intoxication and Withdrawal 94
l. Sleep I And II 95
m. Psych Pharm 96
n. Psych Cognition 98
o. Somatic Symptom Disorders 98
13. Gynecology
a. Gynecologic Cancers 100
b. Gestational Trophoblastic Disease 101
c. Incontinence 101
d. Adnexal Mass 102
e. Pelvic Anatomy 103
f. Gyn Infections 104
g. Vaginal Bleeding: Premenarche 105
h. Vaginal Bleeding: Reproductive Years 105
i. Vaginal Bleeding: Anatomy 106
j. Vaginal Bleeding: Puberty 106
k. Primary Amenorrhea 107
l. Secondary Amenorrhea 108
m. Infertility 109
n. Menopause 109
o. Virilization 110
14. Obstetrics
a. Physiology Of Pregnancy 112
b. Normal Prenatal Care 112
c. Genetic Diseases 113
d. Third Trimester Labs 113
e. Advanced Prenatal Evaluation 114
f. Medical Disease 115
g. Normal Labor 116
h. Abnormal Labor 117
i. L & D Pathology 118
j. Eclampsia 119
k. Multiple Gestations 120
l. Post-Partum Hemorrhage 120
m. Antenatal Testing 121

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 n. Third Trimester Bleeding 121
o. Alloimmunization 122
p. Prenatal Infections 122
q. OB Operations 123
r. Contraception 124
15. Surgery: General
a. Pre-op Evaluation 126
b. Post-op Fever 126
c. Chest Pain 127
d. Abdominal Distention 128
e. Fistula 129
f. Decreased Urinary Output 129
g. Obstructive Jaundice 130
h. Esophagus 131
i. Small Bowel 131
j. Pancreas 132
k. Leg Ulcers 132
l. Colorectal 133
m. Breast Cancer 134
15. Surgery: Specialty
a. Pediatrics First Day 135
b. Pediatrics Weeks To Months 136
c. Surgical Hypertension 136
d. Endocrine 137
e. CT Surgery 138
f. Pediatrics CT 139
g. Vascular 140
h. Adult Ophtho 141
i. Skin Cancer 142
j. Pediatric Ophtho 143
k. Neurosurgery Bleeds 144
l. Neurosurgery Tumors 144
m. Urologic Cancer 145
n. Urology Peds 146
o. Urologic Miscellaneous 147
p. Ortho Injury 148
q. Ortho Hand 150
r. Ortho Peds 151
15. Surgery: Trauma
a. Shock 152
b. Head Trauma 153
c. Neck Trauma 153
d. Chest Trauma 154
e. Abdominal Trauma 155
f. Burns 156
g. Bites 156
h. Toxic Ingestion 157
16. Epidemiology and Stats
a. Prevention 158
b. Screening 158
c. Vaccinations 159
d. Diagnostic Tests 159
e. Study Design 160
f. Bias 160
g. Hypothesis Testing 161
h. Confidence Interval 161
i. Risk 161

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 Cardio
Cardiology

Coronary Artery Disease

Myocardial Infarction ACUTE Treatment Options
Path: Occlusion of a coronary vessel ASA FIRST drug to give
Pt: Chest pain that is worse with exertion, Nitrates Second
better with rest, relieved with Angioplasty No Clopidogrel needed, only in
nitrates in a hypertensive, diabetic, single-vessel disease
dyslipidemic smoker, who is old
Bare-Metal Clopidogrel x 1 month, only in
Dx: ST segment changes = STEMI Stent single-vessel disease
Biomarker Elevation = NSTEMI
Drug-Eluting Clopidogrel x 1 year, only in
Stress Test = CAD
Stent single-vessel disease
Coronary Angiogram = best test
CABG Left Mainstem equivalent or
Tx: Morphine, Oxygen, Nitrates, Aspirin
multi-vessel disease
(MONA)
Beta-Blocker, Ace-inhibitor, Statin, tPA No PCI is available within 60
Heparin (BASH) minutes transport time
Coronary Angiography with Door-to- 90 minutes
Stent (single vessel disease) balloon
CABG (multi-vessel disease) Prasugrel = Clopidogrel
tPA if no transport available (60
minutes)
CHRONIC Treatment Options
R isk F actors and G oals Beta-Blocker BP < 140 / < 90, HR < 70
Hypertension < 140 / < 90 Ace-inhibitor BP < 140 / < 90
Diabetes A1c < 7.0 Aspirin Anti-Platelet
Smoking Cessation Clopidogrel Anti-Platelet
Dyslipidemia LDL < 100, better < 70 Statins LDL < 100 (prefer < 70)
HDL > 40, better > 60
Age Woman > 55 Stress Testing
Man > 45 Imaging
EKG Test of choice, no baseline
Story Physical abnormality
Left sided / Substernal Nonpositional Echo EKG abnormalities, no CABG
Worse with exertion Nonpleuritic Nuclear CABG, Baseline wall defects,
Better with rest Nontender LBBB
Testing
Stable Unstable Exercise Test of choice, no
nstemi stemi contraindication to exercise
Angina Angina
with feet
Pain Exercise @ rest @ rest @ rest
Pharm Any reason why they can’t get
Relief Rest + Ø Ø Ø on a treadmill, of any kind.
Nitrates Dobutamine and Adenosine
essentially identical
Trops Ø Ø ↑ ↑
ST ∆s Ø Ø Ø ↑ Complications of MI
RV Failure Right Sided ECG
No Nitrates
Aneurysm Diagnosed by Echo
Arrhythmia Vtach / Vfib – ventricular ectopy
from dying cells
Brady / Blocks – AV nodal
dysfunction

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chapter 1: Cardiology

ACLS
Rhythms to Treatment Vfib
Rhythm Drug Electricity
Vfib Amio Shock
Vtach Amio Shock Vtach
Torsades Mag Shock
SVT Adenosine Shock
1° Block Atropine Pace
Torsades
2° Type 1 Atropine Pace
2° Type 2 Pace
3° Block Pace
SVT
Codes
No pulse CPR
Shock delivered CPR
Anything CPR Sbrady
All codes Epi
VT/VF Codes Epi, Amio
PEA, Asystole Epi
Stach
Afib with RVR
Path: Underlying stressor
Ischemia, Infection, Structural heart 1 ° Block
Pt: Palpitations, Asymptomatic
Dx: ECG
Tx: NO HEART FAILURE: BB or CCB 2 ° Type 1
HEART FAILURE: Dig, Amio
Shock: Shock
2 ° Type 2
Afib
Path: PIRATES mnemonic
Ischemia, Infection, Structural heart
Pt: Palpitations, Asymptomatic 3 ° Block
Dx: ECG
Tx: Rate control = Rhythm Control
(AFFIRM) Afib
Rhythm: Cardioversion after TTE, TEE,
one month of anticoagulation
Rate: BB, CCB
Rate: Anticoagulate with CHADS2
C CHF Aflutter
H HTN
A Age > 75
D Diabetes
S Stroke Idioventricular
S Stroke
Score 0 – Aspirin
Score 1 – Rivaroxaban, Apixaban
Score 2 + Warfarin or -axabans
Asystole

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chapter 3: Gastroenterology

Cirrhosis Complications
Cirrhosis Spontaneous Bacterial Peritonitis
Path: Bridging fibrosis in islands of Path: Spontaneous = Strep, GNR
regenerating islands of good liver Pt: Asx
Pt: Asx until advanced then… Fever and Abd Pain
↑ Bilirubin = Jaundice Dx: Paracentesis > 250 Polys
↑ Bile Salts = Pruritis Culture is done, but not needed
↓ Factor 2,7,9,10 = Bleeding, ↑ INR
Tx: Ceftriaxone
↓ Albumin = 3rd spacing fluid
Portal HTN = Ascites f/u: TP < 1.0 = FQ
Estrogen = Palmar Erythema, Spider
Angiomata, Gynecomastia Secondary Bacterial Peritonitis
Splenomegaly = ↓ Plts
Path: Perforation of hollow viscous
Dx: Multiple Testing
Pt: Abdominal pain, fever, cirrhosis
1st: U/S = fatty liver, small
Monitor = LFTs, Cr, INR Dx: Paracentesis > 250 polys
Then = Triple Phase CT (HCC) ≥ 2 organisms seen
Best = Transjugular Biopsy Tx: Stop EtOH
Tx: Irreversible once cirrhotic Transplant
Stop Drinking EtOH
Vaccinate Hep A + Hep B Hepatocellular Carcinoma
Transplant
Path: Cirhosis
f/u: Screen AFP + RUQ U/S q6mo (HCC) Hep B, HIV
Pt: Asx screen
Hepatic Encephalopathy
Dx: Screen = RUQ U/S + AFP
Path: Ammonium Triple Phase CT
Pt: Altered with Asterixis Tx: Resect
Dx: Clx NH3 Transplant
RFA, TACE
Tx: Lactulose, Rifaximin, Zinc
Primary Biliary Cirrhosis
Varices
Path: Intrahepatic NO association with UC,
Path: Porto-Caval Shunt in Esophagus IBD
Portal HTN
Pt: Women with pruritis and jaundice, 30-50
Pt: Asx screen vs Vigorous GI Bleed years old
Dx: EGD Dx: AMA
Tx: Bleeding = Banding Imaging = Normal
(Ceftriaxone, Octreotide) Best = Biopsy
Not bleeding = Nadolol, Propranolol Tx: Transplant
Refractory = TIPS
EtOH
Ascites
Path: EtOH
Path: Fluid in Belly
SAAG = Serum Alb – Fluid Alb Pt: EtOH
Pt: ≥ 1.1 Portal HTN Non < 1.1 Dx: EtOH
Cirrhosis TB Tx: Stop EtOH
Right CHF Ca Transplant
Dx: Paracentesis = Bx = SAAG
Tx: Furosemide < 2gNaCl
Spironolactone < 2LH2O
Therapeutic Tap

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chapter 7: Endocrinology

Anterior Pituitary
3 Levels of Feedback and Endocrine Reg of the Ant Pituitary
Hypothalamus GnRH TRH CRH GHRH
Portal Circulation
↓ ↓ ↓ ↓
Pituitary FSH/LH TSH ACTH GH
Systemic Circulation
↓ ↓ ↓ ↓
Target Organ Ovaries Thyroid Adrenals Liver
Metabolic Effect Estrogen T3 Cortisol ILGF
Progesterone T4
Ovulation Metabolism Stress Growth

Prolactinoma Cushing’s Syndrome

Path: Autonomously secreting prolactin See Adrenal
Most common pituitary lesion
Pt: Women: Galactorrhea, Amenorrhea, ACUTE Pan Hypopituitarism
Microadenomas, No Vision Change
Path: Infection, Infarction, Surgery, Rads
Men: Decreased libido, Gynecomastia,
Macroadenomas, Vision Changes Pt: TSH: Lethargy, Coma
Dx: 1st: TSH/fT4 ACTH: Hypotension, Tachycardia
Then: Prolactin levels GH/LH/FSH: Irrelevant
Best: MRI Dx: Clinical
Tx: Bromocriptine or Cabergoline Hormone (Cortisol and T4)
Surgery Tx: Replace end hormones
f/u: Surgery is NOT first line therapy for f/u: Sheehan’s: Pregnancy, bloody delivery
prolactinomas; it is for all other Apoplexy: Tumor outgrows blood
secreting pituitary tumors and supply and dies, necrosis
macroadenomas
CHRONIC Pan Hypopituitarism
Acromegaly
Path: Autoimmune, Deposition, Cancer
Path: Growth hormone = things that can grow
GH / FSH / LH sacrificed so that TSH
Child = Long bones (Gigantism)
and ACTH can persist
Adult = visceral organs
Pt: Cardiomegaly → DIA heart failure Pt: ↓ Libido, changes in menstruation
Diabetes ↓ Growth
Wide-spaced teeth Dx: Insulin Stimulation Test
Hat/ring/shoe size increases ˗˗ Growth Hormone fails to rise
Coarse features, CARPAL TUNNEL MRI
Big hands
Tx: Reverse underlying cause
Dx: Growth Hormone Replace hormones as needed
ILGF-1
Glucose Suppression Test
MRI Empty Sella Syndrome
Tx: Surgery first Path: Normal variant
Octreotide or Cabergoline (adjunct) Pt: Asymptomatic
f/u: Glucose Suppression Test = give Dx: MRI
glucose, test is positive (abnormal) if
the GH does not change Tx: Reassurance
Wait Carpal tunnel is more associated with RA
than Acromegaly… don’t be tricked

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chapter 9: Rheumatology

Approach To Joint Pain

Single Joint vs Multiple Joints
Septic Osteoarthritis, Lupus, Rheumatoid
Crystals Scleroderma, Myositis, Seronegatives
Acute vs Chronic
Septic, Osteo, Lupus, Rheumatoid, Scleroderma, Myositis,
Trauma, Seronegatives
Crystal,
Reactive
Isolated vs Systemic Manifestations
Septic Seronegative (IBD)
Crystal Lupus (Face, CNS, Renal, Heart, Lung)
Rheumatoid (Nodules, Serositis)
Reactive (Oral + Genital Ulcer)
Degenerative vs Inflammatory
Osteoarthritis Everything Else

Non-
Normal Inflammatory Sepsis
Inflammatory
Appearance Clear Clear Yellow, White Opaque
WBC <2 <2 > 2, < 50 > 50
Polys < 25% < 25% ≥ 50% ≥ 75%
Gram/Cx - - - +
Dz None Osteoarthritis Everything Else Infection

Antibody Interpretation
Antinuclear Antibodies Sensitive Lupus
Anti-Histone Antibodies Specific Drug-Induced Lupus
Anti-ds-DNA Antibodies Specific Lupus + Renal Involvement
Anti-Smooth Muscle Ab Autoimmune Hepatitis
Anti-Mitochondrial Antibodies Primary Biliary Cirrhosis
Anti-Centromere Antibodies Scleroderma (CREST)
Anti-Ro+La Antibodies Sjogren’s
Anti-CCP Antibodies Rheumatoid Arthritis
Anti-RF Antibodies Rheumatoid Arthritis
Anti-Jo Antibodies Polymyositis
Anti-Topoisomerase Antibodies Systemic Scleroderma

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chapter 11: Pediatrics

Preventable Trauma
Burns
1 Degree = epidermis only, + pain + erythema
st

2nd Degree = epi + dermis, + pain + blisters + erythema

3rd Degree = through dermis, white and painless with surrounding 2nd degree burns
Parkland %BSA x Kg x 4 50% in 8 hrs
Formula 2o and 3o only 50% in 16 hrs
Rule of 9s
Head 9 + 9 = 18
Front Thorax 9 + 9 = 18
Back Thorax 9 + 9 = 18
Arms L = 9 + R = 9 = 18
Legs 9 + 9 + 9 = 27
Genitals 1
Front Back

Head Trauma Severity of Concussion to Treatment

Disease Trauma Symptoms CT Mild Severe
Epidural Temple + LOC Biconvex None FND Positive
Hematoma Trauma with Lucid “lens”
Interval < 60 seconds LOC > 60 seconds
None, Headache Present or
Subdural Major + LOC Concave
Improving worsening
Hematoma trauma or Ø “crescent”
abuse Lucidity None Amnesia Retrograde or
Anterograde
Cerebral Major + LOC Punctate No CT CT scan
Contusion Trauma Hemorrhage Discharge Observe in
Home house
Head Trauma Prevention Treatment regardless of severity
Helmets Helmets in sports and on bikes Step-Wise Return to play
Car Safety Rear-facing car seats day 0 - 2 Sleep → go to school → homework
years → practice → play
Booster seat until 4’9” and 8-12
years old Drowning Prevention
Seat belts in cars for everyone Limit Locked Gates Surrounding all
in every seat Access pools
Trampolines Eliminate trampolines Supervision Supervision near tubs, pools,
˗˗ Nets, Soft ground, water, etc. and tanks
DON’T COUNT
Flotation Use life jackets, NOT arm floaties
Up Risk Too young to know
Too drunk to remember
(adolescents)

Gun and Chemical Safety

Best Eliminate them from the home
OK Keep them out of reach – store up high
Keep them locked in a safe or locked
cabinet
do NOT depend on “child-proof” lids
Guns Ammo stored separately from Weapon
Store guns unloaded

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 Psychiatry

Personality Disorders
How to
PD Description Defense Examples
Handle Them
Distrustful, Suspicious,
Gene Hackman in Clear, Honest,
Paranoid Interpret others are Projection
“Enemy of the state” Nonthreatening
malicious
Loners, have no Night-Shift Toll
relationships Booth
A Schizoid - You won’t see them
and are happy being IBM clandestine
alone Analyst
Magical Thinking,
Clear, Honest,
Schizotypal Bizarre Thoughts, - Lady Gaga
Nonthreatening
Behavior, and Dress
Unstable, Impulsive,
Promiscuous,
unable to control
“Girl Interrupted”
Borderline rapid changes in Splitting
“Fatal Attraction”
mood, emotional
emptiness, suicidal Patients will try to
gestures change the rules
being manipulative
Theatrical, Attention-
and demanding.
Seeking, Superficial “Marilyn Monroe”
Histrionic - Follow the rules, do
Emotions, “Gone with the Wind”
B not deviate, be firm,
Hypersexual
but non-accusatory
Self-centered, Inflate
sense of worth or
Narcissistic talent, Exploitive, - “Zoolander”
demands the best,
entitled
Criminal. No regard
for rights of others.
Anti-Social - “Tony Soprano” Jail
Impulsive, lacks
remorse
Fears Rejection and
Criticism, wants Really shy, hot Avoid power struggles
Avoidant relationships but - librarian make patients
does not pursue “Napoleon Dynamite” choose
them
Submissive, Clingy,
Stay at home mom
C need to be taken
Dependent - in the abusive
Psych

care of, unrealistic Give clear advice

relationship
fear of rejection patient may try to
Order, Control, and sabotage their own
Obsessive- perfection treatment
- “Monk”
Compulsive at the expense of
efficacy

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 Obstetrics

Genetic Diseases Third Trimester Labs

Aneuploidy Gestational Diabetes (not chronic diabetes)
Disease Memory Tool Chromosome Path: Insulin insensitivity
Down’s Drinking Age 21 Preconception Obesity
1lb / week gain
Edwards Election Age 18 Advanced maternal age
Patau The other one 13 Pt: Asx Screen
(also PG-13 movies)
Dx: 1 hr glucose tolerance test 50g: + > 140
3 hr glucose tolerance test 100g:
Screening and Diagnostic testing ˗˗ Fasting ≥ 95
Screening Identifies Risk, not diagnosis ˗˗ 1 hr ≥ 180
If High Risk Invasive Procedure ˗˗ 2 hr ≥ 155
˗˗ 3 hr ≥ 140
If Low Risk Reassurance ˗˗ Positive if 2 of 4
Hgb A1c
Risk of Aneuploidy Fasting Glucose
↑ maternal age RISK is high Tx: Insulin → qHs qAc
˗˗ Fewer pregnancies Oral
˗˗ Higher risk f/u: Oral agents (Metformin and Glyburide
Normal maternal age PREVALENCE is high are ok if a patient won’t take insulin.
˗˗ Many pregnancies Insulin is still the right answer)
˗˗ Lower risk
Anemia
First Trimester Markers Path: Hemoglobin Nadir 28-36 weeks
PAPP-A hCG NT Iron deficiency
Down’s ↓ ↑ ↑ Pt: Asx Screen
18 ↓↓ ↓↓ ↑ Dx: CBC – Anemia only if < 10 / < 30
↓ MCV
13 ↓↓ ↓ ↑ ↓ Ferritin
Bone Marrow Biopsy
Second Trimester Markers Tx: Iron
Tri Screen Quad f/u: Prophylaxis with Folate is not for
hCG AFP tEstriol InhibinA anemia, but for baby’s development.
Down’s ↑ ↓ ↓ ↑
18 ↓↓ ↓ ↓↓ - Isoimmunization (full lecture later)
13 - - - - Path: Rh- Mom and Rh+ Dad = Rh+ Baby
Rh- Mom and Rh+ Baby =
Rh-IgM → Rh-IgG
Rh- Mom and Rh+ Baby and Rh-IgG
= Anemia
Isoimmunization during delivery/
procedure
Pt: Asx screen
˗˗ Rh status at first visit
˗˗ Rh antibody status at 24 weeks
Dx: Mom’s Rh status (must be Rh- to matter)
Dad Rh+ or Unknown
OB

Get Rh antibody for mom

Tx: Rh- Mom and Rh-Ab-Neg = Rhogam at
28 weeks and 72 hours from delivery
Rh- mom and Rh-Ab-Pos = Too Late

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 Obstetrics

OB Operations
Method Indication Modifiers Side Effects
C-Section Fetal Distress Os not @ 10cm ↑ Risk of rupture with attempted
˗˗ Nonreassuring CST VBAC
˗˗ Breech Birth
˗˗ Fetal Bradycardia

Maternal Distress Station ≤ 0 Repeat pregnancy after C-section

˗˗ PreE, Eclampsia < 2 C-sections and Low transverse cut
˗˗ Hemorrhage ˗˗ Try Vaginal Deliver
˗˗ If it works = VBAC =
Best outcome
˗˗ If it doesn’t = TOLAC =
worst outcome
Elective Contractions > 2 C-sections or classical cut
˗˗ Pfannenstiel = Bikini Irrelevant ˗˗ Planned C-section
˗˗ Low transverse ˗˗ TOLAC worse, VBAC Better
Forceps Fetal Distress Os @ 10 cm Facial Palsy
Prolonged Labor Station ≥ +1 Cephalohematoma
Vacuum Fetal Distress Os @ 10 cm Vaginal Bleeding
Prolonged Labor Station ≥ +1 Denuding of Vagina
Episiotomy Macrosomic babies in Medial Ø heals, Ø Hurts, Grade IV
nulliparous moms Mediolateral Heals, Hurts, no grade IV
Prolonged labor
Prevent uncontrolled
lacerations
Cerclage Recurrent second trimester Place week 12-14 ppROM (you nick baby 12-16 wks)
losses Remove week 36-38 Cervical Rupture (fail to
Incompetent Cervix remove 34-38 wks)
Anesthesia Narcotics Naloxone for baby

Paracervical block Pain of cervical Fetal bradycardia rarely, NOT an

dilation indication for section
Local Lidocaine

Pudendal Block Ischial tuberosity You can miss

Sacrospinous
Ligament

Epidural Preferred method for Into CSF = shock

delivery and C/S
OB

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chapter 15: Surgery: General

Breast Cancer
Breast Cancer Pick the Treatment
Path: Estrogen - Obesity, Nulliparity, Early Local Surgical Therapy
Menarche, Late Menopause, HRT Disease:
Genes – BRCA ½, Radiation Lumpectomy + Radiation OR
Pt: Asymptomatic Screen Mastectomy
Breast Lump, Breast Mass Sentinel Lymph Node Biopsy
and then Axillary Lymph Node
Dx: Mammogram Dissection if +
Core Needle Biopsy
Spread Systemic Therapy
Tx: Lumpectomy + radiation = Mastectomy Disease:
Sentinel Lymph Node Biopsy Chemo: Doxorubicin, Paclitaxel
Axillary Lymph Node Dissection if Her2neu: Trastuzumab
positive ER/PR: SERMS (Pre-Menopausal)
Chemo ER/PR: Aromatase-I (Post-
˗˗ Her 2 Neu + Menopausal)
˗˗ Trastuzumab
˗˗ ER/PR +
Know Your Treatments
˗˗ Tamoxifen (pre-menopausal)
˗˗ Anastrozole (post-menopausal) Tamoxifen: Better, ↑ DVT, ↑ Endo Ca
˗˗ All Raloxifene: Worse, ↓ DVT, ↓ Endo Ca
˗˗ Doxorubicin or Daunorubicin Trastuzumab: Heart Failure, Reversible,
(anthracycline) based regimen EARLY
Doxorubicin: Heart Failure, Irreversible,
Breast Cancer Screen LATE
USPTF: 50q2, start at 50, every 2 years Daunorubicin: The other Doxorubicin
ACS: 40q1, start at 40, every 1 year ALND: Sentinel Lymph Node First
All: Mammogram → Core Needle Biopsy
BRCA: MRI

Diagnostic Dilemma: The Young Woman

< 30 gets a different set of rules
< 30 = Reassurance x 2-3 cycles
Then < 30 + persists = Ultrasound
Then < 30 + cyst on ultrasound = FNA
Then < 30 + cyst resolves = reassurance
Mammogram and Core Needle Biopsy
if…
OR > 30
OR Ultrasound shows mass
OR Aspirate is bloody
Cyst recurs after aspiration

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chapter 16: Epidemiology and Stats

Study Design Bias

Experimental Study Bias in Studies/Screens
Randomized Gold standard, uses intervention Lead Time Pt of diagnosis changes, but no
Controlled vs control groups & tracks dz effect on outcome, artificially
Trial outcomes, uses odds ratio ↑ survival time
Intervention = The treatment Length Time Deadly dz is found less often,
Control = Placebo bias that assumes finding dz
Standard of Care means it’s less dangerous,
Nothing artificially makes screening ↑
Overdiagnosis Diagnosis is ↑ but has Ø effect
Observational Studies on mortality, is meaningless.
Artificially ↑ survival stats
Case Series Qualitative, narrative
Selection Pt group isn’t chosen at
Cross Retrospective, snapshot of dz random, can’t get meaningful
Sectional and exposure in a given time, comparisons, skews outcome
uses prevalence
Measurement Using different tools to
Cohort Prospective, starts with exposed measure same thing, can’t
vs unexposed and tracks dz get meaningful comparisons,
outcomes over time, uses skews outcome
relative risk
Recall Sick patients remember more,
Case Control Retrospective, starts with dz vs skews risk outcomes
no dz and looks at exposures,
uses odds ratio Information Pts know something that affects
their actions, skews outcome
Observational studies can’t establish causation
(only correlation) Observer Knowing being observed leads
to change in pt behaviors,
skews reliability
Methods to Eliminate Bias
Publication Null/negative results less likely
Randomization Blinding to be published, skews
Standardization Statistical Controlling available data
**Bias is addressed in study design.** Confounding 3rd variable that has a
noncasual relationship with
exposure AND outcome,
why correlation doesn’t =
causation

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