Ep.

127: Rapid Review, Series 8 Ob/Gyn

● Pt w/CD4 150 cc of vaginal itching. KOH show pseudohyphae → Candida
○ Risk factors for candida: DM, IC, chronic steroid use, abx use, smoking
○ Vaginal pH is <4.5
○ Tx: topical antifungal
● How often for paps:
○ Every 3 years after 21 yo
○ IC or HIV → once a year
● Old lady with vaginal itching → lichen sclerosus
○ Dx: punch biopsy to r/o vulvar carcinoma
○ Tx: clobetasol (high potency topical steroid)
● Bacterial vaginosis is a risk factor for preterm delivery in pregnant women
● 35 yo F w/multiple sexual partners, 6 mos of 30 lb wt loss, high creatinine → cervical cancer
○ MCC of death: lesion spreads to the ureters (obstructive uropathy)
● Mullerian duct gives rise to fallopian tubes, uterus, cervix, and upper ⅔ of vagina (NOT
OVARIES) → producing estrogen so they still have breasts in mullerian agenesis
○ Will also still have testosterone → axillary and pubic hair
○ Lack a uterus = mullerian duct agenesis
● Androgen insensitivity syndrome:
○ High testosterone but non responsive → no axillary or pubic hair
○ Lack a uterus, genotypic XY
○ Have breasts b/c fat converts aromatase to estrogen
● Pt virilizes over the course of a year in puberty → 5 alpha reductase deficiency
○ Genotypic XY, phenotypic XX until puberty
○ Testosterone is not converted to DHT → not virilization at birth
○ Normal testosterone, normal estrogen, - uterus, small beard, no male pattern baldness
● Old guy with suprapubic mass, anuria, high creatinine next step → BPH
○ Scarring of renal cortex, dribbling urine
○ Next step = cath
○ Tx: a1 antagonist to dilate the urinary neck, tamsulosin is specific for bladder (no ortho
hypotension), long term tx finasteride or dutasteride (shrink prostate)
● Wide QRS = TCA toxicity → tx w/sodium bicarb
● Myocarditis → dilated cardiomyopathy, systolic dysfunction, S3
○ Causes: Coxsackie B, T. cruzi, anthracyclines (doxorubicin → give dexrazoxane),
trastuzumab, clozapine
● Milrinone → phosphodiesterase inhibitor in cardiac and smooth muscle
○ Increases cAMP, increased cardiac contractility, BV dilation, decreased afterload, wide
pulse pressure
These are my personal notes that I took when originally listening to the podcast. I hope they
help!
Cross Checked: No

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Ep. 131: Rapid Review Series 11 (OB, Psych, IM, Neuro)

ep 131 notes were graciously provided by Divine Intervention from an anonymous contributor.
 ● 25F with multiple nose bleeds, Plt 10k, WBC nl, Hgb nl: ITP
o Pathophys: Ab-Gp2b3a
o RF: lupus
o Tx:
1. Mild: observation
2. Severe: steroids, splenectomy
● *prior to splenectomy, vaccinate against SHiN
● Newborn, has not pooped for a wk:
o DDx
● Hirschsprung's disease = aganglionic distal colon
● Meconium ileus 2/2 CF
● T. cruzi
● Big heart
● Big colon
● Big esophagus
o Supposed to poop within the first 48h!

Septic arthritis osteomyelitis

pathophys Infection within a joint Infection within a bone
sx Tenderness over joint Tenderness over bone
dx Arthrocentesis with high WBC MRI, Triple phase bone scan
tx Joint washout, abx Abx

● Postpartum, looking for means of contraception, what to avoid?

o Estrogen-based contraceptives!
● Other c/i:
● VTE
● Stroke
● MI
● Breast ca (ER/PR responsive)
● *also avoid progestin-containing OCP
● Hepatic adenoma
● >35 + smoker
● HTN
● Copper IUD best means of emergency contraception; c/I heavy menstrual bleeding
● Protect against STIs? Condoms or abstinence
o Spermicides do not offer protection!
o RF: IUD, diaphragm
● c/b toxic shock syndrome
● Injectable progestin analogs q3mo: c/I rapid return to fertility
● Progestin IUD Mirena --| adenomyosis
● Basal body temperature measurements
​LH surge
​Progestin makes temperature rise = the egg is around! Have intercourse!
 ● Kiddo w difficulty hearing, cataracts, deaf uncles, RBC casts in urine: Alport syndrome
​Sx: boy who "can't see, can't pee, can't hear a high C"
​Pathophys: COL4A5 mutation @ Type4 collagen; X-linked
● Genital warts
​Pathophys: HPV 6, 11
​NBS: screen for STIs, Pap smear if >21Y
● Pap smear
Cytology: q3y
HPV + cytology: q5y
*pap smear every year if immunodeficient
HPV vaccine 11-26Y
+ pap smear --> colposcopy
Atypical glandular cells? Endometrial biopsy!
MCC death d/t cervical cancer: invasion of ureters
● 75M with impaired IADL: Alzheimer's dementia
​Pathophys: low Ach (@basal nucleus of Meynert), decreased choline acetyltransferase
(ChAT)
● CHAT deficiency: no Ach! - edrophonium test, similar sx to MG
● Vs. MG: + edrophonium test
​RF: age, FMHx, Down syndrome
● Squamous bladder cancer
​RF:
1. Smoking
2. Anilin dyes
3. Cyclophosphamide
4. Schistosoma haematobium
o Vs glandular d/t failure of urachus involution
● 35F morning stiffness, pain in fingers: rheumatoid arthritis
o Dx: anti-RF (IgM-IgG), anti-CCP
o Tx: methotrexate, NSAIDs
● *PFTs before starting methotrexate dt ae: pulmonary fibrosis, hepatotoxicity
● Rescue bone marrow with leucovorin
Cerebrospinal fluid
Sx Dx CSF Tx
Dementia for 3 CJD elevated 14-3-3
weeks, myoclonus, protein
death
Bloody diarrhea Guillain-Barre Albumin-cytologic o plasmapheresis o RF: URI, GI
two weeks ago, syndrome/acute dissociation > IVIG illness
symmetric inflammatory o Plasmapheresis o NBS:
ascending paralysis, demyelinating also used in tx spirometry
shortness of breath polyneuropathy of TTP
MS oligoclonal bands Can also dx
with MRI
 Narcolepsy low hypocretin
SAH Xanthochromia
HSV RBC @temporal
lobes
Morning headache, Pseudotumor High opening
papilledema cerebri pressure (>250)
Bacterial High opening
meningitis pressure, lots of
neutrophils, low
glucose
Fungal meningitis High opening
pressure, lots of
lymphocytes, low
glucose

● Episodic palpitations, HA, hypertension: pheochromocytoma

o NBS: check metanephrine levels (HVA, VMA)
o Dx: MIBG scan, posterior mediastinum
o Pathophys: chromaffin cells of adrenal medulla (~ sympathetic neuron)
o RF: MEN2 (MCC sx is MTC), NF1
o Tx:
1. Alpha blockade i.e. phentolamine, phenoxybenzamine
2. Beta blockade
3. Surgery
● Profound hypertensive crisis during surgery d/t spilling catecholamines?
● NBS: phentolamine, nitroprusside
● Anti-vaxxer, coughing paroxysms: pertussis
o Tx: macrolide
● Ae: prolong QT interval, diarrhea
● "Weird cluster of sx": rock-hard thyroid gland, hypothyroid, recurrent epigastric pain radiating to
back, no biliary tract dz, no EtOH: IgG4 related disease
o =
● Reidel's thyroiditis
● Interstitial lung disease
● Autoimmune pancreatitis
● PSC
● Recurrent cholecystitis
● Prostatitis
● Urinary retention 2/2 retroperitoneal fibrosis

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Ep. 156: Rapid Review, Series 16, OB/GYN
● 52 yo woman with breast mass → mammogram
 ○ <30 yo → ultrasound
○ Risk factors: fam hx, personal hx, BRCA1/2, extra estrogen
○ Mets to bone and brain
● Acceptable contraceptives w/breast cancer hx:
○ NO ESTROGEN OR PROGESTIN
○ Copper IUD
● Eczematoid rash of breast → Paget’s Dz of Nipple
○ Next step = mammogram w/core needle biopsy
○ Sign of underlying DCIS (rarely LCIS)
● Most worrisome mammographic features → spiculated, irregular borders, microcalcifications
● How often for mammos → 40 yo or 50 yo q2 years or pt preference
● When to get a breast MRI in addition to mammo:
○ BRCA mutations, 1st deg. Relative
● Old lady was assaulted w/breast trauma and mass → fat necrosis
○ Next step = mammogram w/biopsy (just in case)
● FNA:
○ Serous fluid → cytology
○ Blood fluid → mammo
● Tamoxifen is not appropriate in women > 50 yo (give aromatase inhibitor ex. anastrozole)
○ If not in menopause aromatase inhibitor will start menopause
● Her2 positive and triple negative breast cancers have poor prognosis
○ Prior to starting trastuzumab get an echo!
● Suspect metastatic breast cancer to bone then next step = bone scan (sensitive but not specific)
● LCIS tx = lumpectomy with radiation (equivalent of mastectomy)
○ Increases risk of local recurrence of cancer
○ Cannot repeat lumpectomy if it recurs d/t fibrosis → mastectomy
● Pt had radiation for breast cancer, rapidly growing neck mass, cervical lymphadenopathy →
papillary thyroid cancer
● Positive sentinel lymph node biopsy → proceed to axillary node dissection
○ At increased risk for lymphangiosarcoma
Cross checked: No

-------------------------------------------------------------------------------------------------------------------------------

Ep. 177: Rapid Review Series 24 (OGBYN)

● 30 yo F with 15 months of infertility, BMI = 30, irregular periods → PCOS

○ Diagnostic criteria (must meet ⅔):
■ Hyperandrogenism (clinical or biochemical)
● E.g. hirsutism
■ Polycystic ovaries on US
■ Oligo-amenorrhea
○ Tx if trying to get pregnant? Clomiphene (SERM--partial agonist on estrogen
receptors in CNS, removes negative feedback → promote ovulation)
○ Tx for hirsutism?
■ OCPs
■ Spironolactone (aldosterone & androgen-receptor antagonist)
 ● Inhibits 5-alpha reductase in the skin
CERVICAL CANCER

● #1 RF? HPV exposure

○ Early coitarche
○ Multiple partners
● MC cause of death in pts with cervical cancer? Renal failure 2/2 obstructive nephropathy
● Screening
○ Start at age 21 (never before age 21!!)
○ If <30 yo: Pap q3years
○ If >=30 yo:
■ Pap q3years
■ Pap + cotesting q5years **preferred**
○ Stop at 65 if multiple negative Pap smears
■ If CIN2+, need to continue past 65
○ If s/p hysterectomy?
■ For benign reasons → not needed
■ For CIN2+ → do Pap of vaginal cuff
○ If hx of HIV? Pap q1year
● Pap f/u
○ Indeterminate/inadequate sample → repeat now
○ ASCUS → reflex HPV testing or repeat Pap in 1 year
■ If hrHPV present → colposcopy
○ Atypical glandular cells → colposcopy & endometrial bx
○ If CIN2+ → colposcopy
○ ASC-H (atypical squamous cells, cannot exclude high-grade) → colposcopy
● Prevention? HPV vaccine
○ Males & females age 9-26
● HPV 16, 18, 30s → cervical cancer
● HPV 6, 11 → genital warts
● HPV 1, 2, 4 → plantar warts

● M with lower abdominal pain + urinary incontinence + new parter 2 weeks ago → cystitis
○ Tx? TMP-SMX or cipro
■ Nitrofurantoin never used in men
● Fever + flank pain + urinary sxs → pyelo
○ Dx? CT abdomen with contrast
○ Tx?
■ Ceftriaxone
■ Cipro
■ TMP-SMX
○ What if pt is diabetic & not improving on abx?
■ NBS? Another CT scan to r/o complication (e.g. emphysematous pyelo,
perinephric abscess)
 ● UTI in pregnant woman
○ Tx for cystitis? Nitrofurantoin
○ Tx for pyelo? ceftriaxone
● UTIs associated with sexual activity?
○ Ppx abx prior to intercourse
○ Urinate after sex
● Weird diabetic infections
○ Gangrenous cholecystitis
○ Mucormycosis of face
■ Tx? Amphotericin B + aggressive debridement
○ Fournier’s gangrene = necrotizing fasciitis of perineum
■ Can start with lower reproductive tract infection

● Classic uses of an amnioinfusion

○ Cord compression → variable decels
○ Treat or prevent meconium aspiration syndrome (evidence mixed!)
■ RF? Post-term fetus

● Key tests during pregnancy

○ Kleihauer–Betke test
■ Purpose: detects degree of fetal–maternal hemorrhage, used to
determine dose of Rhogam after delivery to prevent Rh isoimmunization
■ Usually give Rhogam at 28 wks + after delivery
○ Fetal fibronectin
■ Purpose: used to determine probability of preterm delivery
○ Nitrazine paper test
■ Purpose: determine if the water has broken
■ Ferning pattern → fluid is amniotic fluid

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Ep. 239: Ob/Gyn Risk Factors

● #1 RF for postpartum depression → hx of depression

● Most reliable indicator of successful labor induction → Bishop score

● MCC of infertility → ovulatory dysfunction (PCOS)

● MC late-onset adverse effect of pelvic radiation → vaginal stenosis

● #1 RF for uterine sarcoma → pelvic radiation

● #1 RF for squamous cell carcinoma of vagina → HPV

● #1 RF for clear cell carcinoma → in-utero exposure to DES

○ DES results in t-shaped uteruses and 2nd trimester losses

● #1 RF for vulvar carcinoma → HPV

○ Note: If “HPV” is not listed, choose “lichen sclerosus”

○ NBSIM? Punch bx

● #1 RF for post-partum endometritis → recent C-section

● #1 RF for pelvic septic thrombophlebitis → hx of post-partum endometritis

● #1 Prognostic Factor for breast cancer→ involvement of axillary lymph nodes

● What 3 prognostic factors indicate worse outcomes for gestational trophoblastic

disease?

○ Mets to liver or brain

 ○ ↑↑↑ b-HCG

○ More time between pregnancy and gestational trophoblastic disease

● #1 Prognostic Factor for vulvar cancer → lymph nodes mets then lesion size

● #1 Prognostic Factor for endometrial cancer ­→ stage

● MC presenting complaint is vaginal bleeding

● #1 RF for endometriosis → family history of endometriosis

● MCC of DIC during pregnancy → placental abruption

● #1 RF for placenta previa → previous C-section

● #1 RF for placental abruption → hx of placental abruption or hypertension

● #1 RF for preterm labor → hx of preterm labor, Ureaplasma or Gardnerella vaginalis

● #1 RF for cervical incompetence → LEEP or conization

● #1 intervention prevent: NEC; intraventricular hemorrhage; and NRDS →

betamethasone
● Preventive measure in PPROM to prevent infection → decreasing cervical exam

numbers

● #1 RF for IUGR → hx of IUGR gestations

● #1 RF for fetal macrosomia → maternal diabetes

● #1 RF for fetal tachycardia → maternal fever

● #1 RF for post-partum hemorrhage → uterine atony

● PDA → premature

● #1 RF for ectopic pregnancy → hx of ectopic pregnancy

● #1 RF for uterine rupture → uterine scar d/t previous C-section

● #1 RF for breast cancer → increasing age

● #1 RF for pre-eclampsia → hx of pre-eclampsia

● #1 RF for uterine inversion → hx of uterine inversion

● #1 RF for chorioamnionitis → PROM

 ○ NBSIM? GBS PPx if > 18h

● What are 2 RF’s for gestational trophoblastic disease?

○ Nulliparity

○ Extremes of age (really young or really old)

● Indications to administer intrapartum penicillin as GBS PPx?

○ Child with GBS sepsis regardless of culture

○ +Urine culture at any point in pregnancy

○ If unknown status

○ Woman with ruptured membranes for ≥ 18h

○ Intrapartum fever

● Indications to give Rhogam?

○ At 28 wks

○ During any procedure

○ Within 3 days post-partum

○ During uterine cerclage

○ During ectopic pregnancy

○ Pregnant pt involved in MVA

○ Any other event that can cause maternal-fetal blood mixing

CROSS CHECKED? YES

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Ep. 240: Rapid Review Series 38 (Ortho and OBGYN)
PRENATAL TESTING BY DATES
● Things to do at first prenatal visit (usually 8-12 weeks)
○ CT/NG
○ Urine culture
■ To detect asymptomatic bacteriuria, which we treat in pregnancy
■ If you don’t treat → increase risk of PTL
■ After treating, do test of cure
○ HIV
○ Syphilis → RPR/VDRL
○ Hep B status → Hep BsAg
○ Rubella status
○ Varicella status
○ Parvovirus IgG/IgM (if teacher or daycare worker)
○ CBC
○ Blood group + Ab screen
■ Ab screen via indirect Coombs test (“are they Ab in the serum?”)
■ Contrast to direct Coombs test that detects Ab bound to RBCs
● 10 weeks → cell free DNA
○ Higher % inconclusive results in obese women
● 10-12 weeks → CVS
○ Give Rh- moms RhoGAM afterwards
○ 1% risk of fetal demise vs. <0.5% (1/300) amniocentesis
● 11-14 weeks → nuchal translucency
○ Nuchal translucency increased in Down syndrome & Edward syndrome
● >15 weeks → amniocentesis
○ Give Rh- mom RhoGAM afterwards
● 15-22 weeks → quad screen
○ beta-hCG high in Down Syndrome + low in Edward syndrome
■ “HIGH” for Down Syndrome → hCG & inhibit high in Down Syndrome
■ “HE” for Edward Syndrome → hCG & estriol low in Edward Syndrome
● 18-22 weeks → anatomy US
● 24-28 weeks → gestational diabetes testing
● 28 weeks → repeat CBC + RhoGAM for Rh- moms
● 35-37 weeks → GBS screen
● Postpartum
○ Avoid estrogen-containing contraceptives because they ruin milk supply

● Special considerations for Rh- moms

○ If Ab screen is negative
■ RhoGAM at 28 weeks
■ RhoGAM at delivery (within 72 hrs postpartum)
● Use Kleihauer–Betke test to determine dose
○ If Ab screen is positive
■ NBS? Check father’s Rh status
 ■ If dad Rh- → baby ok :)
■ If dad Rh+ → increased surveillance of baby
● Doppler US of MCA: increased flow → suspect anemia
○ Confirm with percutaneous umbilical blood sampling
(PUBS) + can give transfusion
○ Additional indications for RhoGAM
■ ANY invasive procedure
■ ANY trauma

ORTHO REVIEW
● Humerus
○ Surgical neck
■ Nerve damaged by fracture? Axillary nerve
○ Midshalf
■ Nerve damaged by fracture? Radial nerve
○ Supracondylar
■ Nerve damaged by fracture? Median nerve
○ Mnemonic: “ARM” → (proximal) axillary-radial-median (distal)
● Axillary nerve
○ Ways to injure axillary nerve?
■ Surgical neck fracture of the humerus
■ Anterior shoulder dislocation
● MC shoulder dislocation
● Posterior dislocation only with seizure or electric shock
■ Shoulder dystocia → C5-C6 brachial plexus injury
● “Waiter’s tip” position
○ Sensory innervation for axillary nerve? Lateral arm
○ Motor innervation for axillary nerve? Deltoid + teres minor
● Shoulder abduction
○ First 15 degrees → supraspinatus
■ Innervated by? Suprascapular
○ 15-90 degrees → deltoid
○ 90+ degrees → serratus anterior + trapezius
■ Serratus anterior innervated by? Long thoracic nerve
● Can by injured during mastectomy → winged scapula + can’t
abduct shoulder > 90 degrees
● Mnemonic: “SALT” = serratus anterior / long thoracic
■ Trapezius innervated by? CN11
● Other muscles innervated by CN11? Sternocleidomastoid (SCM)
○ Can’t turn head contralateral
● Baby with jaw angled to one side → congenital torticollis
○ Pathophys? Fibrosis of the SCM
○ Tx? Neck stretching exercises
----------------------------------------------------------------------------------------------------------------------------

Ep. 309 The "Clutch" Breast Cancer Podcast

Breast Cancer-Most frequently diagnosed cancer (Most common cancer is Skin Cancer)
2nd most common cause of death in women (1st is Lung Cancer)
Biggest RF for Breast Cancer
#1: AGE (Older a woman is --> higher likelihood of breast cancer)
Family History (1st degree relative)
Mammogram with Core Needle biopsy (lobular hyperplasia, atypical ductal hyperplasia,
premalignant disease)
Atypical ductal Hyperplasia BIGGER risk factor than Age
Early Menarche/Late Menopause (more follicular phases --> more lifetime estrogen)
Nulliparous (Lack of HIGH prolactin states & more follicular phases --> greater risk)
Obesity (Aromatase activity --> Increased Estrogen)
Genetic Factors
BRCA1 & BRCA 2 mutations (DNA repair abnormalities)
BRCA mutation associations
Family history of breast cancer BEFORE age 50
Family History of bilateral breast cancer
Family History of Breast AND ovarian cancer
Family history of MALE breast cancer
Klinefelter Syndrome (47, XXY)
Ashkanazi Jewish heritage

Risk Factors Present --> GET GENETIC TESTING for BRCA

Screening Guidelines for Breast Cancer

USPSTF: Start at 50, q2y, stop at 75
American Cancer Society: Start at 40

People with BRCA mutations screening guidelines

Annual mammogram and MRIs
Reduce risk of Developing breast cancer: Prophylactic Bilateral Mastectomy + TAHBSO
(Total Abdominal hysterectomy and bilateral sapligoophorectomy)

GAIL risk score (breast cancer risk assessment tool)

If Score ≥1.7%: increased risk --> ANTI-ESTROGEN therapy (SERM), Aromatase inhibitors
(depending on age and other risk factors)

SERMs: Tamoxifen/Raloxifen (for ER+/PR+ breast cancers)

Tamoxifen: Estrogen receptor Antagonist in Brest, Agonist in Bone & Uterus (5 year
course)
Lower risk of osteoporosis; Increases risk of Endometrial hyperplasia/Cancer
 Breast Cancer chemoprophylaxis
Raloxifen: Estrogen receptor Antagonist in Breast and Uterus, slight agonist in bone
Less effective in preventing osteoporosis
Side effects: Increase risk of VTE disease, Hot Flashes

Over 50 (postmenopausal) for Breast cancer Tx: Aromatase Inhibitors (Anastrazole, Letrozole,
Exemestane) (for ER+/PR+ breast cancers)
Reduced risk of Breast cancer (less conversion of testosterone to estrogen)
Side Effect: do NOT increase risk of VTE, do NOT increase risk of Endometrial Cancer

Breast Cancer signs/symptoms:

Lump in breast, weird nipple discharge, nipple retraction, skin dimpling, Orange-Peel
appearance (Peau d’orange)

Inflammatory Breast Cancer: Attempt to confuse you with mastitis/atopic eczema

DIFFERENTIATE: Inflammatory Breast cancer has symptoms present for weeks

Her-2 neu receptors (also can be present in breast cancers) 🡪Bad prognostic factor
Epidermal Growth Factor receptor; Tyrosine-Kinase activity
Her-2 neu positive cancers 🡪 TRASTUZUMAB (monoclonal antibody against Her-2 neu)
MOA: Works by ADCC (gamma receptor binds constant region of Her-2 neu
receptor)
Side Effect: Reversible Dilated Cardiomyopathy

Other drugs for treatment of Breast Cancer (adjuvant)

Doxorubicin/Daunorubicin (Side Effect: IRREVERSIBLE Dilated Cardiomyopathy; prior to
starting --> GET ECHO)
Mechanism: Upregulate Fenton reaction and destroy cardiac myocyte
Prevention of Cardiomyopathy via Dexrazoxane

Most common metastatic location of Breast Cancer: Axillary Lymph Nodes

Bone: Hypercalcemia of cancer due to Lytic/Blastic lesions (Blastic more common)
Reduce risk of pathologic fractures/bone pain --> Radiate the bone, Bisphosphonates
Side effect of Bisphosphonates (alendronate, zoledronic acid) --> Jaw
osteonecrosis

Diagnosis of Breast Mass:

Under 30: Ultrasound; or RETURN visit after 1-2 menstrual cycles
Solid Mass on U/S --> Mammogram + Core Needle Biopsy
Cystic Mass on U/S --> Fine needle aspiration
Blood in FNA --> cytology (look for possible malignancy)
If no breast mass found on U/S with symptoms --> get mammogram
Over 30: Mammogram
Unilateral Bloody Nipple Discharge: Intraductal Papilloma

Postmenopausal Woman with greenish breast discharge (biopsy, lymphoplasmocytic infiltrate)

--> Mammary duct ectasia

Most important prognostic factor in breast cancer

Axillary lymph node involvement, Metastasis
Biggest risk factor for breast abscess/mastitis is being a Lactating mother

Fibrocystic Breast disease: Nodularity in breast (lumpy-bumpy), lesions MORE painful with
menses

Mobile, well circumscribed breast mass --> Fibroadenoma

Trauma to breast with persistent pain, fluid collection --> Breast Hematoma

DCIS: No real difference between breast conservation therapy (lumpectomy + radiation) vs.
radical mastectomy
Some possibility of recurrence with conservation breast therapy

Lymph node dissection order: Sentinel Lymph Node biopsy FIRST --> if positive (+) --> THEN
Axillary lymph node dissection
Risk of Lymphangiosarcoma (due to obstruction of lymph drainage after lymph node
dissection)

Radiation to chest for breast cancer followed by Chest pain, shortness of breath:
Radiation-Associated Pericarditis

Radiation to chest for breast cancer followed by neck mass years later: Papillary Thyroid Cancer
Biggest risk factor for papillary thyroid cancer is prior head & neck radiation

NOTE: Greatest risk of Endometrial Cancer: Unopposed lifetime estrogen

-----------------------------------------------------------------------------------------------------------------------

Ep. 338 Fetal Heart Tracings Made

Easy
Fetal heart rate normally between 110-160 bpm
a. More than 160 --> fetal tachycardia
i. Causes? Maternal fever, Fetal anemia (as oxygen in
blood decreases, HR will increase to compensate), Maternal hypotension,
Fetal hypoxia
 b. Less than 110 --> fetal bradycardia
i. Mother on beta blocker like labetalol (possibly due to
maternal hypertension, preeclampsia), Maternal Lupus (3rd degree AV
block due to anti-Ro and anti-La antibodies
1. See a sine wave on fetal heart rate tracing--> think of severe fetal anemia

1. What is an acceleration? Deceleration?

a. Acceleration: Fetal heart rate goes up by over 15 bpm for at least 15 seconds
i. Non-reactive stress test: 2 accelerations in a 20-minute
time period
b. Deceleration: Fetal heart rate goes down by over 15 bpm for a sustained
period of time (exact timing is not clear, more than 30 seconds)
2. VEAL CHOP (all associated with uterine contractions)
a. V E A L (variable decelerations, early decelerations, accelerations, late
decelerations)
b. C H O P (cord compression, head compression, O (normal), uteroplacental
insufficiency
3. Variable Decelerations
a. Uterine contractions (M), fetal heart rate (V) measured over time.
b. Cord compression --> increased SVR --> fetal baroreceptors sense LOW BP (due
to decreased blood volume) --> vagal parasympathetic discharge --> lower fetal
HR
c. Peak to trough (time period LESS than 30 seconds) on the fetal heart tracing of
downsloping V (heart rate change over time)
d. 1st step of management? Mom lays in left lateral decubitus position (promote
perfusion to baby SHOULD improve),
i. if no improvement, 2nd step: Consider an amnioinfusion
(put fluid in)
ii. Another option: turn DOWN the oxytocin (less
contraction)
4. Early Deceleration
a. Due to head compression --> increased ICP --> Cushing’s reflex activated --> big
vagal tone --> bradycardia
b. Lowest point of Fetal heart rate tracing corresponds to Highest part of
maternal contraction
c. No treatment necessary
5. Accelerations
a. Completely normal
b. No treatment required
6. Late Deceleration
a. Gradual decrease and return to baseline of fetal heart rate
 i. How to differentiate from early deceleration?
(Lowest part of fetal heart rate comes AFTER highest point of maternal
contraction)
b. Peak to trough time (of heart rate change) should be greater than 30
seconds
c. Sign of uteroplacental insufficiency
i. 1st line management: Proceed to left lateral
decubitus position (increase cardiac output to placenta by diminishing the
placental compression of the IVC)
If this unsuccessful (recurrent decelerations): Rapid delivery of baby (Normal delivery OR
C-section may be necessary

------------------------------------------------------------------------------------------------------------------------------

Ep. 341 Lupus and USMLEs

Lupus affects lungs, skin, brain, hematologic system (affects MANY things)

Lupus on NBME: Generally in a FEMALE, generally NOT white/Caucasian (African American,

black heritage, Asian, etc..)

Classic HLA associations: HLA-1, HLA-DQ3

Lupus pathophysiology: 2 mechanisms that underlie the disease

Systemic effects due to TYPE III Hypersensitivity reaction, antigen-antibody immune
complexes deposit around the body --> excess inflammation
(ex. anti-double stranded DNA antibodies, body makes antibodies against double
stranded DNA)

Complex deposition occurs ALL over the body: Joints, serosal surfaces (pleural surfaces),
pericardial wall, Kidneys
Pleuritis/Serositis, Pericarditis, Lupus nephritis
Symptoms VERY disparate:
IgG/IgM can activate complement activation --> Complement LOW
Diffuse Proliferative Glomerulonephritis (DPGN): Lupus nephritis, LOW complement

Cytopenias that accompany lupus: Autoantibodies against components of hematologic system

Autoantibodies against RBCs --> autoimmune hemolytic anemia, coombs test (+)
Autoantibodies against Gp2b3a (platelets) --> thrombocytopenia
Autoantibodies against WBCs --> autoimmune leukopenia
TYPE II Hypersensitivity Reactions (due to Lupus)

Classic Findings of Lupus:

Fever, Malar Rash on Face (spare nasolabial folds), WORSENS with sun exposure,
photosensitivity, joint pain, serositis (pleuritis), pericarditis, autoimmune cytopenias

Joints: Specific KIND of arthropathy (lupus arthritis)

Symmetric damage of joints (unlike RA)
Joints “spic and span”, no erosion of joint (unlike RA)
Joint deformity NON deforming
Usually in the hands (MCPs and PIPs) (unlike RA)

Skin: Rash on face that worsens with Sun exposure (photosensitivity)

Develop rash AFTER going on vacation with lots of sun
Malar Rash does NOT equal lupus (can be present in sarcoidosis)

Kidneys: Hematuria, Creatinine Rising

Diffuse Proliferative Glomerulonephritis (Lupus Nephritis)
NBS in diagnosis? RENAL BIOPSY (5-6 types of lupus nephritis)
Once was Most common cause of death in lupus patients

Heart: Sterile vegetations on the mitral valve (Libman-Sacks endocarditis), Pericarditis (lupus
attacks serosal surfaces)
Mitral regurgitation common

Lungs: Pleurisy/Pleuritis
Pain that varies with respiration
Primary treatment: NSAIDs
Brain: Strokes (inflammation leads to thrombosis)

Pregnancy: Recurrent pregnancy loss (Antiphospholipid Antibody Syndrome)

Inflammation leads to thrombosis of utero-placental artery --> fetal demise due to lack
of proper perfusion
Antibodies: Anti-SSA (Ro) and Anti-SSB (La) antibodies
IgG antibodies that cross the placenta --> enter the fetus and cause damage to the
conducting system of heart --> 3rd Degree Heart Block (Complete)

Most common cause of death in Lupus patients today: Cardiovascular disease

Sarcoidosis: African American woman, Elevated ACE, Hilar Lymphadenopathy, hypercalcemia &
malar rash, painful circular erythematous rash in lower extremities (erythema nodosum)
Think Lupus Pernio (malar rash finding in Sarcoidosis)

Patient started on medication for AVNRT, starts having arthralgias, fevers, pleurisy:
DRUG-INDUCED LUPUS
Anti-histone Antibody association
Drugs: Hydralazine, Sulfonamides, Isoniazid, Procainamide, Etanercept
Tx: STOP the DRUG

Diagnosis of Lupus:
Screen by getting ANA (Highly sensitive, Low specificity)
Confirm with anti-dsDNA, anti-smith antibodies (Highly specific)
Anti-dsDNA antibodies track with disease

Treatment of Lupus:
1st line: Hydroxychloroquine
(screen with Eye exam EVERY YEAR due to possible retinopathy of retinal pigmented
epithelial)
2nd line: Steroids (useful for exacerbations of Lupus)
3rd line: TNF-inhibitor (adalimumab)
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---------------------
Ep. 350 Clutch Teratogen
Lady has been on acne medication for a few years, lost to follow up, and gets pregnant. What is
the most likely defect in the fetus?
Isotretinoin messes up HOX genes (where appendages are placed on the body as it
develops
Prior to using Isotretinoin (or other Vitamin A derivative oral medication), must be on 2
forms of contraception

Diabetic patient gets pregnant. Patient is taking oral hypoglycemic medications, statins, and
other medications for her diabetes. Which medications are most dangerous to the fetus?
STATINS should never be given to a pregnant woman
HMG-CoA reductase inhibitor if given to a pregnant women will also prevent
cholesterol synthesis in fetus

Woman is on medication for migraines

Contraindicated in pregnancy? Ergotamine (Ergot derivatives)
Severe vasoconstriction of placental arteries --> IUGR (intrauterine growth
restriction) and possible fetal demise
May cause uterine contractions (premature labor)

Other medication for migraines

Acute treatment: Sumatriptan
Chronic treatment (8 or more migraines a month): Beta blocker, TCA, topiramate

Pregnant Patient with a prosthetic valve. What drug CANNOT be given to the mother?
WARFARIN: can cause fetal hemorrhage, fetal bone damage, fetal brain bleeds
You can use heparin/LMWH in pregnancy safely

Benzodiazepines contraindicated in pregnancy

In Eclampsia/Preeclampsia, Magnesium Sulfate used (benzodiazepines a 2nd line therapy)

Patient who wants to get pregnant is currently on treatment for Endometriosis. What
medication(s) must be discontinued?
Danazol (Excellent for endometriosis), Pro-androgenic drug
Male fetus: precocious puberty
 Female fetus: virilization

Woman on therapy for Rheumatoid Arthritis (well controlled) and wants to become pregnant.
What therapy needs to be stopped in pregnancy?
Methotrexate (inhibits Dihydrofolate reductase)
can cause abortion of fetus, neural tube defects

IV drug user pregnant patient has delivered recently. Newborn is found to have a VSD
(holosystolic murmur heard in the left sternal border) and a hypoplastic/smooth/thin philtrum,
microcephaly, intellectual disability
Fetal Alcohol Syndrome (Mother has also been drinking during her pregnancy)
Most common cause of preventable intellectual disability
If VSD uncorrected --> may lead to Eisenmenger syndrome (reversal of the left to right shunt)

Down Syndrome: Thin upper lip, sharp Palpebral fissures

Woman is an IV drug user, comes into the clinic during her 3rd trimester complaining of sharp
abdominal pain, fresh bright blood from vagina
Abruptio Placentae (Placental abruption) due to cocaine usage
Cocaine: Powerful sympathomimetic; constricts all blood vessels --> ischemia to
placenta --> possible fetal demise
Asymmetric intrauterine growth restriction (Head/torso small, arms and legs normal)

Symmetric Intrauterine growth restriction (whole torso proportionally small)

Common in TORCHESZ infections, chromosomal abnormalities

Antihypertensives to AVOID in pregnancy:

ACE-Inhibitors/ARBs (Angiotensin converting enzyme inhibitors/Angiotensin II Receptor
Blockers)
Renal Agenesis --> Amniotic fluid depletion --> Limb development issues,
hypoplastic facies
Oligohydramnios (Woman is 33 weeks’ gestation, fluid index is less than 5 cm)

Patient who has a history of granulomatosis with polyangiitis (Wegner’s Granulomatosis). What
medication must be discontinued prior to pregnancy?
Cyclophosphamide (alkylating agent)
Renal Agenesis, Cleft Palate, no digits at birth
NO CHEMOTHERAPY for pregnant patients

Mother during her pregnancy took an older medication she once used for a UTI. Newborn does
not respond to sound, does not turn head towards stimulus. Drug? Aminoglycoside
Newborn is experiencing ototoxicity (cannot hear)
If you suspect a child has hearing loss --> perform audiometry
Classic clue: Language Delays (child most likely has hearing issue)

Aminoglycosides used to treat Meniere’s disease (can ablate CN VIII)

Antiepileptic drugs should NEVER be given during pregnancy (Phenytoin, Valproic Acid)
Valproic Acid: Neural Tube defects, Cardiac problems, Cleft lip/cleft palate, hepatotoxic

If a woman has been on an antiepileptic drug, and now becomes pregnant. Doctor is
considering lowering the dose/discontinuing medication. Patient begins to have seizures again.
Put the woman BACK on the antiepileptic (unless it’s Valproic Acid)
If on Valproic acid --> find a different antiepileptic
Antiepileptic safe in pregnancy: Lamotrigine

35-year-old lady, has had multiple 1st and 2nd trimester abortions. TVUS shows a T-shaped uterus
Woman was exposed to DES (Diethylstilbestrol) in her life/fetal period
DES side effects: Adenocarcinoma (Clear Cell) Carcinoma of the Vagina, Anatomical uterine
anatomy

Pregnant Woman had the Ixodes tick infection (borrelia burgdorferi; Lyme disease), and took
medication for the infection. Newborn having bone development issues, tooth discoloration
Tetracycline toxicity: Tetracyclines bind divalent ions well (antacids can chelate
tetracyclines, rendering them ineffective)

Less than 8-year-old patient, AMOXICILLIN/macrolide (NO tetracyclines) for Lyme disease
Exception: Rocky Mountain Spotted Fever Infection --> EVERYONE gets a tetracycline
(children and pregnant women included)

Immigrant mother who delivers a child, baby has circulatory collapse with ashen-gray skin
discoloration. Dx: Gray Baby syndrome
Mother has been treated with chloramphenicol (medication rarely used in the USA, used
in the developing world)
TMP-SMX (Trimethoprim-Sulfamethoxazole) Contraindicated in pregnancy
Folate synthesis inhibitor

Pyrimethamine-Sulfadiazine (Used for toxoplasmosis) Contraindicated in pregnancy

Folate synthesis inhibitor

Pregnant mother with toxoplasma infection --> Treat with Spiramycin

Child born with hypoplastic limbs, distal limbs connected to shoulder (feet connected to hip,
hands connected to shoulder). Dx: Phocomelia
Due to Thalidomide exposure

Pregnant Patient with history of Grave’s disease, newborn has an absence of hair in a localized
spot on the head. Dx: Aplasia Cutis
Due to PTU (propylthiouracil) and Methimazole (thyroid medications)

Which Antidepressant is contraindicated in pregnancy? Paroxetine

Can lead to pulmonary Hypertension in the newborn
Most other SSRIs safe in pregnancy

Person with a history of mania (bipolar disorder), treated with lithium

Teratogenic effect: Atrialization of the right ventricle (Ebstein’s anomaly)

If a woman is pregnant and has a mood disorder, can be put on antipsychotics (instead of
lithium)

Gestational Diabetes: BIG PROBLEM

Fetal problems associated: VSDs, Transposition of the Great Vessels, Caudal regression
syndrome (Sirenomelia)
Insulin inhibits synthesis of surfactant --> Neonatal Respiratory Distress Syndrome
Hyperinsulinemia in mother leads to inhibition of surfactant in baby (Beta pancreatic
islet cells undergo hyperplasia in the developing fetus) --> excess insulin production in
fetus --> surfactant production decreased)
Insulin excess can cause hypocalcemic seizures in a newborn
Insulin excess can cause hypoglycemic seizures in a newborn
Insulin excess can lead to underdevelopment of left colon growth --> failure to pass meconium
(in an infant of a diabetic mother)
Small left colon syndrome
Pathophysiology: (hypoglycemia-induced release of glucagon)

Newborn (less than 1 year old)/Pregnant woman: Do NOT give Live-attenuated vaccine
MMR vaccine, Varicella vaccine, Intranasal influenza vaccine
Single exception: Rotavirus vaccine (can be given to infants)

Child born to a mom with active Hepatitis B infection --> give newborn Hepatitis B surface
antigen and Hepatitis B vaccine
If a child develops Hepatitis B, 90% likely to develop chronic Hepatitis B
Give Hepatitis Immunoglobulin AND hepatitis B vaccine (to infant and mother)

Child born to a mom with HIV --> give newborn Zidovudine (AZT)
-------------------------------------------------------------------------------------------------------------------------------
--------------------

Ep. 356 Clutch UTI Podcast

UTIs come in 2 flavors
Cystitis (bladder infection) Pyelonephritis (kidney infection)

Cystitis --> URGE incontinence Pyelonephritis Symptoms:

Bladder infection leads to an urge to Flank pain, Fever, Costovertebral
pee (acute nature) angle tenderness
Goes away with treatment
UTI Symptoms:
Pain with urination, increased
Urinary frequency, increased Urinary
urgency

3 General things cause UTIs:

Stasis
Sweet Urine (Glucosuria)
Anatomical issues (BPH, female anatomy, etc..)

Person with a UTI MAY have delirium, Altered mental status (in the elderly)
Anticholinergics may cause problems
Anticholinergics decrease urinary output --> urinary stasis --> UTI possible

Elderly patient comes in with altered mental status, abdominal pain, taking OTC cold medicine
(i.e. diphenhydramine). Dx: Possible UTI
Due to strong anticholinergic effects

Causes of UTIs
MCC: E. Coli
2nd MCC: S. Saprophyticus
Most common nosocomial infection: Catheter-associated UTI

Patient with a UTI and urine pH is basic (>8.0), think Urease Positive Bug
Proteus Mirabilis, Klebsiella, Ureaplasma Urilitycum, Staph Saprophyticus

Proteus Mirabilis: Likes to form struvite stones/staghorn calculi (antler looking white buildup in
the renal calices on plain film x-ray)
Magnesium-Phosphate Renal stones

Risk Factors (ep. 37, 97, 184 on DI podcast)

Female Anatomy (Short urethra and close to the anus; bacteria can ascend easily)
Diabetes (urine is “very sweet” --> causing bacteria to grow easily)
SGLT-2 inhibitors (canagliflozin, dapagliflozin, empagliflozin), prevent glucose
reabsorption at the level of the PCT --> glucosuria (allow bacteria to grow more easily)
Pregnancy (placenta in uterus producing excess progesterone --> smooth muscle
relaxant --> bladder relaxes and fills --> urinary stasis possible)
Increasing Age (estrogen maintains vaginal flora which protects against UTI; hitting
menopause/hysterectomy --> decreased estrogen --> decreased natural vaginal flora -->
increased risk of UTI)
Sexual Activity (increased sexual activity --> increased risk of UTIs)
Stroke/Spinal Cord injury (bladder dysfunction --> urinary stasis --> UTI; regular catheter
usage in people with spinal cord injury to empty bladder --> UTI risk increased)
MC infection in person with Spinal Cord Injury: UTI
Males with BPH (prostate squeezes/squishes urethra --> bladder does not void properly
--> bladder stasis --> UTI)

SGLT-2 inhibitors can also cause life-threatening infections of the perineum Fournier’s Gangrene
(similar mechanism as UTIs; due to proximity of anus to urethra, especially in females)
3 General things cause UTIs:
Stasis
Sweet Urine (Glucosuria)
Anatomical issues (BPH, female anatomy, etc..)

How to diagnose UTIs

Usually clinical diagnosis (Cystitis OR pyelonephritis) --> proceed to treatment

Special populations for testing for UTIs (Urinalysis and Urine Culture)
Pyelonephritis, for certain populations, also may require CT scan of abdomen & pelvis
with IV contrast)

Treatment of Cystitis (oral antibiotics usually first)

1st line agents: TMP-SMX (trimethoprim-sulfamethoxazole) or Nitrofurantoin or
Amoxicillin-Clavulanic Acid, Cephalosporin if possible
2nd line agents: Fluoroquinolone

Fluoroquinolone side effects: Achilles tendon rupture, tendonitis, worsen Myasthenia Gravis
(effect on the NMJ; similar to aminoglycosides)

Treatment of Pyelonephritis (IV antibiotics usually)

1st line agents: Fluoroquinolone, Ceftriaxone, TMP-SMX

Special Populations (that may require further diagnostic testing, i.e. Urinalysis, CT):
People with complicated UTIs (Diabetics, Immunocompromised patients, HIV patients,
Pregnant patients, Males with UTIs)

If woman is not pregnant, has no symptoms, however urinalysis shows bacteria: do NOT treat
If woman is not pregnant, has symptoms: TREAT
If woman is pregnant symptoms/no symptoms: TREAT
Asymptomatic pregnant females are treated
Pregnant woman: special population that requires Urinalysis & Urine culture, avoid CT scan (no
radiation to fetus)
Treat with 7 days of therapy, Follow up with a Test of Cure
DOC for UTI in pregnancy: Cephalexin, Nitrofurantoin
NO TMP-SMX (folate synthesis inhibitor)
UTIs a RF for preterm labor

Patient has a UTI, gram stain of urine shows no bugs, culture shows no bugs, think Urethritis
Chlamydia, Mycoplasma Genitalium
Tx: Doxycycline, Azithromycin

Biggest RF in a sexually active female: Sexual Intercourse

Child less than 2 years old with a UTI: Do a Renal Ultrasound, followed up by a voiding
cystourethrogram
Confirm no anatomic problems causing UTI

Recurrent UTIs can cause permanent UTIs, especially in small children

Prevent this damage by putting child on Daily antibiotic therapy

Female who gets frequent UTIs especially associated with sexual intercourse: Put on daily
suppressive therapy, post-coital antibiotics

Children criteria for urine samples:

Clean catch, midstream sample
If hospitalized, easy to get sample from catheter bag

Patient has had dysuria, frequency, taking an OTC for the pain for 3 days. Patient has developed
perioral cyanosis, shortness of breath: Think methemoglobinemia from phenazopyridine
Methemoglobin (3+ state) CANNOT bind oxygen
Stop the phenazopyridine, start the patient on methylene blue and vitamin c

Vitamin C activates methemoglobin reductase (3+ to 2+)

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--------------------
Ep. 357 Clutch Disorders of Sexual
Differentiation

Normal differentiation of sexes

Default program: Female

Men have Y chromosome --> SRY region (sex determining region of Y chromosome)
Codes for Testes Determining Factor (TDF) makes undifferentiated gonad into a Testes

Sertoli Cells: Make Mullerian Inhibiting Factor (MIF); Anti-Mullerian Hormone (AMH)
Prevents fallopian tubes, uterus, upper portion of vagina (Muller Duct/Paramesonephric
Duct derivatives) from being formed
Mullerian duct becomes appendix testes (what remains of Mullerian duct)
Mullerian Duct does NOT give off ovaries

Young boy patient comes in to ED with acute onset testicular pain, bluish discoloration of the
testicle (blue dot sign)
Torsion of the Appendix testes (NOT Testicular Torsion)
Tx: Supportive care

Leydig Cells: Produce testosterone

Makes the Wolffian Duct (Mesonephric duct) form internal male genital structures
Epididymis, Seminal vesicles, Vas Deferens
External Genitalia to become male: comes from a derivative of testosterone
(DHT-Dihydrotestosterone)
Produced by 5-alpha reductase

Female Genitalia Male Genitalia (counterpart)

Labia Scrotum
Clitoris Penis

Cannot tell the sex of the fetus until a certain number of weeks
Penis develops from the clitoris (needs DHT for it to look male)

5 alpha reductase inhibitors (finasteride): Useful in Preventing growth of prostate

Extrinsic compression of prostatic urethra can lead to BPH
Urinary dribbling, abdominal pain in an elderly (70 year old male)

Acute treatment of BPH: Alpha-1 blocker, self-catheterization

Disorders of sexual differentiation (easy IF the understanding is there)

“Breasts and Pubic hair rule”

Person has right kinds of breasts --> ESTROGEN OK
Good axillary and pubic hair --> TESTOSTERONE OK
46 XX DSD (Genotypically female, BUT has phenotype of male)/ 46 XX Pseudohermaphrodite
Aromatase deficiency (convert androgen to estrogen)
Androgen Insensitivity disorder
21-hydroxylase deficiency
46 XY DSD (Genotypically male, BUT has phenotype of female)/ 46 XY Pseudohermaphrodite
Androgen Insensitivity disorder

Newborn has ambiguous genitalia with hyponatremia, hyperkalemia, and a normal anion gap
metabolic acidosis. Dx: 21-Hydroxylase deficiency (Congenital adrenal hyperplasia)
MCC of ambiguous genitalia
 Deficiency of 21-hydroxylase --> no aldosterone/cortisol, making excess DHEAs -->
ambiguous genitalia
Electrolyte abnormalities due to ALDOSTERONE deficiency (reabsorb sodium, urinate
potassium, urinate hydrogen ions)
Deficiency: Hyponatremia, hyperkalemia, Type IV RTA (low aldosterone state)

Sometimes Teenagers may have the same symptomology (CAH due to autoantibodies AGAINST
21-hydroxylase)
Almost a type II HSR

If MALE has 21-hydroxylase deficiency --> Precocious Puberty

Male child will develop PERIPHERAL precocious puberty (problem outside of brain)

21 year old female, never has had menses/period before. Vagina ends in a blind pouch, tanner
stage 1 pubic and axillary hair. Dx: Androgen Insensitivity Disorder
Male genotype, Female external genitalia (46 XY DSD)
Male that creates testosterone --> testosterone receptor does NOT work -->
many issues/problems --> no DHT --> no virilization
Wolffian develop will NOT develop (seminiferous tubules, vas deferens do NOT
develop)
Mullerian duct will NOT develop (fallopian tubes, uterus, upper vagina)
No DHT --> female external genitalia (lower vagina from urogenital sinus, labia,
clitoris)
Need to RESECT testes (can develop gonadoblastoma)

12 year old female with fused labia, nondescript clitoris, very femine features for first few years
of life. Over past 12 months, undergoing a “metamorphosis” of sorts. On ultrasound, see
normal male internal genital structures. Dx: 5-alpha reductase deficiency
Labia and clitoris in these females will be ABNORMAL (fused/ambiguous)
Pathophysiology: No testosterone converted to DHT
Internal male genital structures OK (require testosterone); seminiferous tubules,
vas deferens, testes
External genitalia FEMALE (ambiguous genitalia) at birth and until puberty
At puberty: EXCESS amount of testosterone produced --> will force virilization -->
begin to look like males
21 year old female, has never had menses. Vagina ends in a blind pouch. Axillary and pubic hair
are tanner stage IV/V. Dx: Mullerian Agenesis (MRKH syndrome
(Meyer-Rokitansky-Küster-Hauser syndrome)
Mullerian duct does NOT form (all derivatives do not form), oviducts/fallopian tubes,
uterus, upper vagina
Normal ovaries (not derived from Mullerian ducts) which will produce DHEAs --> will be
converted to estrogens (normal breast/pubic hair development)

46 XX DSD example: Aromatase deficiency (female genetically, look male on outside)

Aromatase converts androgens to estrogens
In females, will be female with LOTS of androgens (male features)
Deepening of voice, acne, male pattern hair growth
Person gets pregnant, but during pregnancy the signs of hyperandrogenism gets WORSE
Fetus creating excess androgens --> worsening the underlying condition
Do NOT confuse with PCOS

Aromatase: Breast cancer over the age of 50

Do NOT use tamoxifen (SERM; estrogen receptor agonist at uterus --> cancer)
Use Anastrozole/Letrozole/Exemestane (aromatase inhibitor)

Aromatase Inhibitor: Useful in PCOS patients who are trying to get pregnant
Letrozole (inhibit aromatase --> do NOT make estrogen --> no negative feedback at
hypothalamus --> excess GnRH --> excess FSH/LH)
Clomiphene (SERM; partial agonist estrogen receptor at Hypothalamus)

25 year old female, comes to the ER with very bad chest pain for 30 min, SOB, left sided pleural
effusion. The female is 4 feet 5 inches tall. Dx: Turner Syndrome (
Turner syndrome (45, XO): Chest pain due aortic issues
Aortic dissection
Bicuspid aortic valve --> aortic stenosis (40-50 years old, rapid breakdown)
Recurrent UTIs, Hydronephrosis, Renal failure
Due to Horseshoe kidneys (inferior poles of kidneys fused)
Cystic Hygroma/Webbed Neck (Congenital Lymphedema)
Abnormal development of lymphatic channels
Lower Extremity Claudication, Radio-femoral pulse delay
 Aortic Coarctation (CXR shows “3 sign”, “Rib notching”)
Tx: Surgery
Streak Ovaries (nonfunctioning ovaries)
Hypergonadotropic Hypogonadism leading to amenorrhea

Lady who has never had a period. Male with tanner stage 1 pubic/axillary hair. Kalman
Syndrome (Hypogonadotropic Hypogonadism)
Problems with cells migrating (neurons that make GnRH, CN I)
Gonadotropins LOW --> FSH/LH low --> sex steroids low (estrogen/testosterone)

Athletic Amenorrhea: Hypogonadotropic Hypogonadism

Excess exercise leads to shutdown of GnRH production

Male with low libido, poorly developed pubic hair/axillary hair. Tall gentleman with family
history of breast cancer. Gynecomastia and micropenis may be present. Kleinfelder syndrome
(47, XXY)
Male with a Barr Body
Risk factor for MALE breast cancer

BRCA-1 mutation: Risk Factor for Male breast cancer

-------------------------------------------------------------------------------------------------------------------------------
--------------------

Ep. 373 Progestin and Estrogen

Challenge Tests
Who do you do this test in?
Patient with AMENORRHEA

Progestin test FIRST, then Estrogen & progesterone challenge test SECOND

Giving patient Progesterone in progesterone test

What is the cause of amenorrhea?
1st phase: Buildup of endometrium by estrogen
2nd phase: Ovulation (LH surge) --> corpus luteum remains (creating
progesterone) --> converts follicular endometrium to secretory endometrium
Positive test (After giving progesterone for 5 days, remove progesterone and they have a
withdrawal bleed --> NO OVULATION)
PCOS highly possible
Negative test (after giving progesterone for 5-7 days, remove progesterone and they do
NOT bleed)
Not JUST a progesterone deficiency, some estrogen deficiency

After a FAILED progesterone test, do a progesterone & estrogen test

Estrogen 1st, then the progesterone, withdraw after 2-7 days
Withdrawal bleed --> hypoestrogenic state (low estrogen and progesterone)
Turner Syndrome (streak ovaries)
HPA axis problem (i.e. Kalman syndrome)
 NO withdrawal bleed
Uterine issue (Asherman syndrome)
Outflow tract issue
Imperforate Hymen

Asherman Syndrome: Due to multiple D&C procedures

Endometrial cavity CANNOT respond to estrogen, “strictures” in uterus
-------------------------------------------------------------------------------------------------------------------------------

Ep. 459 Clutch STIs

25 year old male who comes to the office has noticed that for the past 3 days he has had a
lesion on his penis. On physical exam the lesion is painless. Dx? SYPHILIS

Caused by treponema pallidum (spirochete shaped bacteria)

PAINLESS ulcer, usually WITH PAINLESS lymphadenopathy
Treatment: penicillin
Patients who have allergies to beta lactam antibiotics —> use doxycycline

Doxycycline: 30S inhibitor (part of tetracycline class of antibiotics)

30S inhibitors can be used in the treatment of acne
30S inhibitors are chelated by antacids (tetracycline will NOT work)
Tetracyclines associated with idiopathic intracranial hypertension (pseudotumor cerebri)

Patient on antibiotic therapy presents with headaches, blurry vision. Dx? Idiopathic intracranial
hypertension
ESPECIALLY in obese female (at high risk of pseudotumor cerebri)

Female patient with syphilis who is PREGNANT and has penicillin allergy: penicillin ONLY
 Must desensitize patient to penicillin

Stages of Syphilis infection

Primary: painless chancre/ulcer with painless lymphadenopathy
Secondary: rash on palms and soles with condyloma lata (wart like lesions)
Tertiary: Aortitis (leading to potential aortic dissection) Gummas, tabes dorsalis (degeneration of
the dorsal column)

Detection of primary syphilis: ONLY dark field microscopy will be able to identify presence of T.
Pallidum infection

Detection of secondary and tertiary syphilis: start with nontreponemal test (VDRL/RPR) to test,
confirm with FT-ABS/MHA-TP (microhemagglutination assay for Treponema Pallidum)

Once treated for syphilis with penicillin, do a RPR/VDRL to confirm efficacy of therapy/test of
cure (eradication of the treponema pallidum)

Tabes Dorsalis: destruction of dorsal columns (will present with a positive Romberg Test), not
necessary to have any issues with lateral corticospinal tracts
Vs.
Vitamin B12 deficiency: Subacute combined degeneration of spinal cord (positive Romberg test
due to degeneration of dorsal columns with issues of the lateral corticospinal tract)

Person with syphilis is treated with penicillin, and hours after treatment the patient exhibits
fevers, myalgias, chills. Dx? Jarisch Herxheimer reaction
Treatment? Fluids, NSAIDs
Pathophysiology: gave penicillin (cell wall inhibitor) that ruptured membranes of T.
pallidum bacteria —> release of components of bacteria into the body —> body mounts
strong immune response against the bacterial components

Borrelia burgdorferi ALSO a spirochete (causes Lyme disease)

Leptospira Interrogans (causes leptospirosis) is also a spirochete
Patient traveled to Hawaii recently and has conjunctival suffusion)
Lymphogranuloma Venereum (LGV)
SHALLOW ulcers –> progress to buboes
Painless ulcer + Painful lymphadenopathy
Caused by Chlamydia Trachomatis
Serovares L1-L3
On HISTOLOGY: INTRACELLULAR BODIES
Tx: DOXYCYCLINE (1st line drug); preferred over azithromycin (fewer treatment
failures)

Buboes + Painless ulcers

Histology of C. Trachomatis

Granuloma Inguinale (Donovanosis)

Painless ulcer + NO lymphadenopathy
Caused by Klebsiella Granulomatous
Base of Ulcer: GRANULATION TISSUE
Histology: Intracytoplasmic cysts
Tx: Doxycycline or Azyithromycin
 Ulcer of K. Granulomatosus
​

Histology of Granuloma Inguinale (intracytoplasmic cysts)

When forced to pick between 2 macrolides –> PICK AZITHROMYCIN

Well studied, effective, less side effects (compared to erythromycin)

Erythromycin: can be used for diabetic gastroparesis (acts on motilin receptors in the GI tract –>
speeds up gastric emptying)

25 year old male comes in with significant tenderness around the groin, with some ulcers
around penis/vesicles around the penis. Dx? HERPES
PAINFUL VESICLE ON ERYTHEMATOUS BASE
Not everyone who has herpes will have the painful vesicles (usually in the
immunocompromised/HIV patients)
 PAINFUL ulcers with PAINFUL lymphadenopathy
Histology: Multinucleated giant cells
Usually do a NAAT (nucleic acid amplification test) to test for herpes
Tx: Acyclovir (DOC); if resistant –> consider foscarnet
Acyclovir needs thymidine kinase for activation (if mutation in thymidine kinase,
will not work)
Foscarnet: Pyrophosphate analog (bypass thymidine kinase step)

Herpetic lesions on the penis Multinucleated Giant Cells on Histology

Chancroid
Painful ulcer with DEEP grayish base with Painful lymphadenopathy
Caused by Haemophilus Ducreyi
Lymphadenopathy USUALLY suppurative (pus-filled)
Gram (-) infection (stains on gram staining)
Histology: “school of fish” appearance
Tx: Ceftriaxone; macrolide; ciprofloxacin
Avoid ciprofloxacin due to side effects (ruptured tendons, prolong QT interval)
Avoid ciprofloxacin in pregnancy

Ulcers of H. Ducreyi (Chancroid) Gram Staining (“School of Fish”)

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Ep. 118: Confusing Breast Pathologies

SUMMARY

● Unilateral vs Bilateral?
o Bilateral process + breast-feeding = breast engorgement

● Unilateral: fever vs no fever?

o Unilateral + no fever + breast-feeding = galactocele

● Unilateral + fever: mass vs no mass?

o Unilateral + fever + no mass + breast-feeding = mastitis

● Unilateral + fever + mass: fluctuant mass vs mass in older pt?

o Unilateral + fever + fluctuant breast mass + breast-feeding = breast abscess
o Unilateral + fever + mass in older pt + progressive onset = inflammatory breast cancer
● Peau-d’orange appearance

● Unilateral erythema + tenderness + fever + recently gave birth = Mastitis

● Unilateral + painful + fluctuant mass + fever + recently gave birth = Breast Abscess

● Bilateral + fever + recently gave birth = Breast Engorgement

● Unilateral + tender + fluctuant mass + breast-feeding + NO FEVER = Galactocele

● Unilateral + older F (> 50 yo) + peau d’orange appearance = Inflammatory Breast

Cancer

CROSS CHECKED? Yes

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