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AMCB Memorization concepts 2023
Diaphragm of Stethoscope ✔Used to listed to high pitch sounds-S1, S2, heart sounds Big and flat Bell of Stethoscope ✔Used to listen to low pitch sounds Bruits, murmurs concave Underweight BMI ✔<18. Wt gain in preg: 28-40lbs Normal Weight BMI ✔18.5-24. Wt gain in preg: 25-35lbs Overweight BMI ✔25-29. Wt gain in preg: 15-25lbs Obese BMI ✔30-39. Weight Gain in preg: 11-20lbs Extreme Obesity BMI ✔> RBCs ✔4.2-5. Hematocrit ✔33% in 1st and 3rd trimester 32% in 2nd trimester -2% for Black women Hemogobin
✔11 in 1st and 3rd trimester 10.5 in 2nd -0.8 for Black Women MCV ✔Average volume or size of a single RBC 80- WBC ✔3,900-12, Up to 16,900 is normal in 3rd trimester HbA1c ✔<5.
6.5%=DM ADA Criteria for DX of DM (primary care) ✔Random glucose > 200 + s/s of Hyperglycemia Fasting of 126 or greater Two hr PP of 200 or greater Total cholesterol ✔<200 mg/dL May be elevated in pregnancy Triglycerides ✔35- May be elevated in pregnancy HDL ✔"Happy" Removes cholesterol from peripheral tissues and transports to liver 40 or greater LDL ✔"Lowsy" < BUN ✔10- Indirect measure of kidney and liver function
Murmur Referral ✔For all diastolic above grade 3 IDA ✔microcytic, hypochromic MCV <80, low MCH, Low HCHV low RBCs, Ferratin <10, high TIBC TX: Ferrous sulfate for 4-6mos Thalessemia ✔microcytic, hypochromic Usu asymptomatic if mild MCV <80, RBC> 5.5, normal ferratin Hbg electrophoresis- Alpha all normal, beta abnormal Refer for all MAJOR B12 Anemia ✔Macrocytic, normochromic MCV >100, B12 < could be d/t deficiency or intrinsic factor--> pernicious anemia s/s sore swollen tongue, fatigue, weakness, dyspnea, paresthesias TX: Vit B12 IM daily for one week, then weekly Folate Anemia ✔Macrocytic, normochromic, MCV >100, B12 normal, Folate <3, elevated homocysteine, normal methylmalonic acid d/t malabsorption, pregnancy, ETOH, PPIs, elderly, metformin S/S similar to B12, but not neural involvement TX: dietary first, then folic acid supplement RA ✔chronic, possible autoimmune, multi system disease, SYMMETRICAL JOINT involvement, joint inflammation and loss of synovial fluid and joint anatomy (pannus) +RF TX: PT and rest, NSAIDs REFER for Meds-DMARDs, hydroxychloroquine Basal Cell Carcinoma ✔Rolled "B"oarders, waxy nodule, pearly, blood vessels Squamous Cell Carcinoma ✔Most common Atinicic keratoses at first
reddish brown, papule, surface is crusted, scaly Psoriasis ✔Clear defined boarders, red-plaques, silvery scales, chronic immune mediated, associated with RA Refer for severe disease or mild relief GDM Diagnosis ✔Non fasting 50g, 1hr GTT >130- 100g, fasting with two of the four values elevated Fasting > 1hr > 2hr > 3hr> 140 PP DM Screening ✔Done with 75g OGTT at 4-12 weeks PP
126 fasting =DM 200 at 2 hrs=DM Hyperthyroid ✔Low TSH, elevated Free T4, high serum T3, +anti-TPO(graves) REFER for meds Bacterial Conjunctivitis ✔Acute start, mucupurulent discharge, eyes stick together TX: topical Erythromycin Otitis Externa ✔Inner ear canal inflammation Pain with palpation of tragus or pinna may be d/t hearing aids, q-tip use, cerumen Tx: removal, ETOH/Vinegar drops or antifungals/antibiptocs for Otitis Media ✔Infection of middle ear May precede URI, HA, fever, N/V, dizziness, BULDGING TM, pain with palpation of tragus Tx: With different antibiotic if one had already been taken for URI Treat for mod/severe pain, temp>39 OR no improvement for 48-72hrs Amoxicillin or Augmentin, Azithromycin Sinusitis
Sputum culture is diagnostic for active TB Refer latent and active TB for treatment GERD and PPI treatment ✔If antacids are not giving relief can start on a PPI (omeprazole (prilosec), esemeprazole (Nexium) or lansoprazole (Prevacid) for 8 weeks and if treatment is not successful REFER Acute Abdomen ✔Sudden, severe, abdominal pain- rigidity, distention, guarding, rebound pain, tachycardia, decreased bowel sounds, fever may or may not be present, vomiting, urinary, or vaginal symptoms may or may not be present- REFER Cholecystitis ✔Inflammation of gallbladder causes by back up of cholesterol (gallstones) Sharp RUQ pain after fatty, large meal, N/V May radiate to right shoulder blade or central back Murphy's sign positive Elevated WBCs, elevated LFTs, elevated bili REFER for removal Appendicitis ✔Pain that starts at periumbilicus and accompanied by N/V or anorexia, RLQ pain Tenderness at McBurney's point +Rovsing's Sign, +Psoas sign, +obturator sign elevated WBCs, shift to the left REFER Peptic Ulcer Disease ✔Burning relieved by food RF: H. Pylori, ETOH, SMOKING, NSAIDs, stress TX: Avoid ETOH and NSAIDs Meds Histamine 2 receptor antagonists: Cimetidine, ranitidine, famitotdine(most commonly used in Preg) Refer for 2nd failed tx of H. Pylori Osteoarthritis (OA) ✔Non-inflammatory, degenerative joint disease from wear and tear- can be ASYMMETRICAL, pain subsides with rest Most commonly distal joints, hands, hips, knees,cervical, lumbar spine TX: Exercise, tylenol, rest, NSAIDs, PT, glucocortiocsteroirds Osteoporosis
✔a marked loss of bone density and an increase in bone porosity that is frequently associated with aging more BMD scan for all women starting at age 65 Normal T-score is above -1. Osteopenia -1.0- -2.5 (start meds with additional 10 year prob to hip fracture of 3% or greater or 10 yr prop of major fracture of 20% or greater) Osteoporosis below -2.5- should start bisphosphonate TX: Weight bearing exercise, Vit D, Calcium, Biphosphonates (take w/ full glass of water and sit up for 30 min), SERMs Repeat test in 2 years Abortive therapy for migraines ✔Triptans: Sumatriptan (Immitrex) contraindicated in CAD, HTN and there are concerns for Pre-E when taken in late pregnancy as well as PPH and PTL Ergotamines: (Ergomar) and Dihydroergotamine (Migranal) Dihydroergotamine (DHE): contraindicated in pregnancy, CAD, HTN Preventative therapy for migraines ✔Propranolol (beta blocker), CCB (verapamil), antileptics Referral for these medications usually ACE Inhibitors ✔"prils" ex: Lisinopril -Pricks that block conversion, decreasing BP -Inhibit angiotensin converting enzyme, precents conversion of angio 1--2 enhancing vasodilation SE: COUGH, hypotension, rash angioedema Contraindications: PREGNANCY, HYPERkalemia, renal arterial stenosis Beta Blockers ✔"LOLs" Ex: Labetalol- 1st line cardiac med in preg BLOCK the beats- decrease HR and BP -Inhibit sympathetic stimulation of heart, blocks renin release from kidneys SE: bronchospasm, may mask hypoglycemia Contraindications: Asthma, AV block, caution with DM Ca Channel Blockers ✔"PINES", diltiazem (zen), verapamil CALM the heart Decrease HR and BP SE: dizziness, HA, gastro, peripheral edema Nifedipine 1st line tx for CHTN in preg Thiazide Diuretics
TOC in 3 weeks if pregnant Gonorrhea ✔s/s post-coital bleeding, dysuria, vulvar pain, Bartholins or Skenes gland infections, sore throat, joint pain, PID SX: NAAT culture Tx Ceftriaxone 250mg IM and Azithromycin 1 gm single dose (also in preg) Syphylis ✔s/s Chancre---> lesions, swelling, fever, flu like symptoms, condyloma lata, macupapular rash on palms and soles---> gummas cardiac symptoms DX: +VDLR/RPR confirm with FTA-ABS or TP-PA Tx: PCN G or Doxy Repeat test at 6, 12, 24mo PID ✔s/s severe abd pain, discharge, fever, dysuira, dyspareunia, N/V spotting DX: One or more:
- CMT
- Uterine tenderness
- Adnexal tenderness Enhanced specificity: fever, mucopurulent d/c WBCs on wet mount, recent GC/CT infection TX: Ceftriaxone and Doxycycline and metrondiazole REFER: Pregnant, abcess, to rule out ectopic, appenticitis Follow-up in 72hrs for improvement Angiotensin II Receptor Blockers (ARBs) ✔"SARTANs" Block binding of angiotension II to receptor, thereby enhancing vasodilation SE: similar to ACE, less likely to cause cough, or angioedema Combined Genetic Tests ✔Sequential and Integrated(most accurate after NIPT) 1st blood draw 11-13.6 weeks 2nd blood draw: 15-21.6 weeks Aneuploidy Tests ✔NIPT from 10.0 weeks and on NT US and blood test 11-13.6 weeks Quad screen: includes down syndrome and NTDs (15-22 weeks) CVS
✔Diagnostic done at 10-13 weeks Does not screen for NTDs Amniocentesis ✔Diagnostic Done at 15-20 weeks Screens for aneuploidy, CF, Tay Sachs, Sickel Cell, muscular dystrophy Oligohydraminos ✔AFI < 5cm DVP <2cm Polyhydramnios ✔AFI>24cm DVP>8cm Metronidazole (Flagyl) ✔ANTIBIOTIC TX: BV, Trich, PID, H. Pylori, C-Diff Given PO of vaginally Crosses the placenta, but safe in ALL trimesters Adverse Rxns: GI, HAs Interactions: ETOH (avoid for 48hrs), warfarin, Cimitidine, phenobarbital/phenytoin Contraindications: Preexisting SEIZUREs, hematologic disease, severe hepatic disease, renal impairment EDU: Take with food, report nervous symptoms, avoid BF for 12-24hrs after dose Fluconazole (Diflucan) ✔ANTIFUNGAL Tx: Candida PO or Topical (for preg) SEs: HA, GI Contraindications: cardia arrhythmia, heapatic diease, renal impairment Preg: Topical for 7 days, or one single dose of 150mg PO Safe with BF Symptoms should start to go away in 24hrs Meds to AVOID in Pregnancy ✔ACEs, ARBs Accutane Floroqunioloines Macrobid (in 3rd trimeser) Sulfonadmides (Bactrim) (1st and 3rd trimester)
Gestational Hypertension ✔BP >140/90 x 2, 4hrs apart without proteinuria Occurring for the first time after 20 weeks gestation and disappearing by 12 weeks postpartum Pre-eclampsia ✔>140/90 x 2, 4hrs apart 24 hr urine >300mg of protien PRO/CRE Ratio > 0.3mg NORMAL: Plts, LFTs, serum creatinine Severe Pre-E ✔160/110 x2, 4hrs apart 24 hr urine >300mg of protien PRO/CRE Ratio > 0.3mg PLTS <100, LFTs 2x normal Serum Cre >1. Pulmonary edema, visual changes, RUQ pain HELLP ✔Plts <100, Serum AST > 70 LDH >600, increased indirect bili**Diagnostic ASB ✔+Nitrites, +WBCs----> send C&S and wait with no symptoms
100,000 of single organism- treat Amoxicillin or Augmentin Cystitis ✔Lower UTI +Nitrites, +WBCs and SYMPTOMS Order C&S, DONT WAIT to treat C&S >1,000 if single organism and s/s TX in pregnancy: Amoxicillin, augmentin or Keflex NON pregnant tx: Bactrim, Macrobid TOC 10 days after tx completed Pyelonephritis ✔FEVER, Chills, CVA tenderness, urinary symptoms REFER for treatment while pregnant--IV antibiptocs C&S shows >10,000 of single organism and s/s
Recurrent UTI ✔2nd occurance after TOC showing cure Consider suppressive for pre-preg h/o UTIs, Pyelo in this preg Tx: Keflex, Macrobid (contra in 3rd tri for G6PD) GDM ✔Screened high risk at 1st PNV and everyone at 24-28 weeks Tx for A1- diet and exercise, BS monitoring: fasting <95 and PP <120- no additional testing until 40 weeks with good control--EM up to 40. A2- Insulin is 1st line Metformin crosses placenta and Glyburide causes worse neonatal outcomes NST 2x weekly at 32 weeks, IOL at 39-39. Seizures in Pregnancy ✔threshold may be lowered, best predictoin is last 9-12mo of seizure history Meds: Lamotrigine (lamictal) and levetiracetam (keppra) best in pregnancy AVOID: Valproic acid, phenobarbital, topramate Should be taking 4mg of Folic Acif Consult/co-manage with OB Chorioamnionitis ✔Suspected Infection: fever >39m and/or maternal leukocytosis >15,000, purulent discharge from cervical os, and FETAL tachycardia Tx: Ampicillin 2g q 6hrs and Gentamycin 1.5mg/kg q 8hrs OR Clindamycin and Vancomycin for anaphylactic PCN allergy GBS ✔Screened between 35-37 weeks Antibiotics should be started at ROM or active labor for <37.0 weeks antibiotics should be started at 18hrs of ROM or temp >100. PCN is gold standard, or Amp Gent and Vanco for anaphylactic PCN allergy Candida of the Breast ✔burning, sharp, knifelike pain that radiates towards the chest wall shiny, red, may be cracking nipple Tx: Diflucan, APNO, Montistat-Derm, Nystatin for baby consider antibiotics Mastitis ✔Fever, hot, red, inflamed area of the breast, malaise Move milk, continue breastfeeding Tx: Dicloxacillin, Cephalexin (Keflex) or clinda for PCN allergy
- Ductus Arteriosis- From pulmonary arteries to aorta, allows blood to bypass lungs, closes over hours after birth d/t O2m decrease in prostaglandins Newborn Labs ✔Hgb 14- RBC 4.2-5. Hct- 43-63% WBCs 10,000-30,000 -assess neutrophils for a shift to the left for signs of infection PLTs 100,000-350, Abnormal bilirubin levels ✔TSB < 5mg with Direct Bili >1mg OR TSB >5mg with direct bili equal to 20% or greater of the TSB SGA ✔< 10%tile LGA ✔>90th percentile Macrosomnia ✔EFW of 4500g with non DM or 5000g with DM-consider C/S Birth weight greater than 4000 or 4500g Cervical Cancer Screening ✔<21 do not screen 21-25 if Pap comes back ASCUS or LSIL--> repeat in 1 year 25-30 if Pap comes back ASCUS do refelx testing for HPV and if it is + for 16 and 18 do colpo now -If Pap is LSIL do colpo regardless of type of HPV
30 y/o- Do pap +co-testing q 5 years or pap alone q 3years -Negative Pap +HPV types 16 and 18-->colpo now -Negative Pap +low risk HPV repeat both tests in 12 mo 65 years old with adequate prior screening=no more screening h/o Hysterectomy- w/o high grade precancer/cancer=no more screening Fibrocystic Breast Changes ✔B/L Breast pain, usually cyclical (1-2 weeks before menses), white d/c -Well defined, mobile TENDER mass Dx Mammo for >40 y/o TX: NSAIDs, decrease caffeine, cola, chocolate intake Fibroadenoma
✔Common right after menarche 15-25y.o NONTENDER, single, round, mobile, rubbery mass, NO nipple d/c TX: Observation if <25 y/o, annual breast exam by clinician Intraductal Papilloma ✔Benign lesion of lactiferous duct 35-50y/o Bloody, serous, nipple d/c, may or may not have mass, UNIlateral, UNIductal TX: Biopsy, mammo/US REFER for excision Mammory Duct Ectasia ✔Dilation of ducts, surrounding inflammation and fibrosis
50 y.o Sticky, GREEN/BROWN/BLACK d/c, may have mass BIlateral, MULTIductal TX: Smoking cessation, Refer for Biopsy with mass Breast Cancer ✔75% older than 40 y/o FIXED, NONTENDER, gritty, clear/serous/bloody nipple d/d, skin retraction, dimpling, enlarged lymph nodes DX: Mammo, US, biopsy, MRI to r/o mets REFER for TX Vaginismus ✔involuntary muscle spasms in the outer part of the vagina that make intercourse impossible Vulvodynia ✔a syndrome of unknown cause that is characterized by chronic burning, pain during sexual intercourse, itching, or stinging irritation of the vulva Menopause ✔Absence of menses for 12 months due to decrease in responsive follicles, INCREASE in FSH and decrease in estrogen Common by age 52 s/s hot flashes, moody, vaginal pH more alkaline, vaginal walls more smooth, pale Systemic HT ✔Oral, transDERMAL, FemRing -All require uterine protection with Progesterone if has uterus
40-50 y/o Boggy, tender urterus Hysterectomy is only cure What is the basis for persistent asthma? ✔inhaled corticosteroids What characteristics define metabolic syndrome? ✔Waist >35 in Trig > HDL < BP 135/ Fasting gluc > What does CURB-65 stand for? ✔Confusion blood Urea nitrogen (>19 mg/dL) Respiratory rate (>30 breaths per min) Blood pressure (sBP <90 or dBP <60) age (65 or older) What time frame is the HPV vaccine given? ✔2 months and 6 months after initial dose Signs of SLE ✔derm symptoms serositis renal neurologic hematologic +ANA test
- immunologic tests Describe innate immunity ✔● It is pre-formed ● Does not have immunological memory ● Innate immunity does not improve over time ● Innate immunity is non-specific (can kill wide range of organisms) Common community acquired pneumonia ✔Streptococcus PNA What is adaptive immunity?
✔Your immune responses to a specific invader, in which both B and T lymphocytes respond to. Attacks antigens IgG antibodies ✔can cross placenta smallest IgM ✔first antibody produced largest IgA ✔breastmilk IgE ✔allergic reactions What will the straight leg raise determine? ✔Herniated disc L5-S1 nerve irritation pneumonic for heart valves ✔All Aortic People Pulmonic Enjoy Erbs Time Tricuspid Magazine Mitral Maternal obesity risk factors ✔GDM, PreE, Eclampsia, stroke, thromboembolism, c/s, intrapartum and PP complications Obesity r/t fetal complications ✔miscarriage, stillbirth, preterm birth, low birth wt, IUGR, macrosomia, fetal and congenital anomalies and neonatal mortality chronic hypertension ✔A blood pressure that is equal to or greater than 140/90 mm Hg, which exists prior to pregnancy, occurs
