padmaanjali1972

Vaginal Bleeding - Differential Diagnosis - Pregnant - Early | Late (> 20 weeks) - Non-Pregnant - Structural - Non-Structural - Katie Selman, MD #Vaginal #Bleeding #Differential #Diagnosis #Algorithm #OBGyn #Gynecology

Ovarian Cycle - Ovulation By @rev.med #Ovarian #Cycle #gynecology #obgyn #Ovulation

Causes of Abnormal Uterine Bleeding Non-pregnant bleeding that is inegular in timing, frequency, or flow Mnemonic: PALM-COEIN STRUCTURAL CAUSES Polyps - Endometrial - Cervical Adenomyosis - Painful heavy periods in women 30s-40s Leiomyoma - Increase in size in pregnancy or with OCPs Malignancy / hyperplasia - Consider in all peri- and postmenopausal women NON-STRUCTURAL CAUSES Coagulopathy - Undiagnosed coagulopathy in adolescents - Acquired (anticoagulants, cirrhosis) Ovulatory dysfunction - Adolescents - Perimenopause - PCOS - Hypothyroidism - Anorexia - Athletes Endometrial causes - Diagnosis of exclusion Iatrogenic - Hormonal contraceptive use - Hormone replacement therapy - Post-GYN surgery Not otherwise classified - Endometritis - Cervical erosions, cervicitis - Vaginal trauma - Foreign bodies #AUB #Abnormal #Uterine #Bleeding #Mnemonic #PALMCOEIN #Diagnosis #Obstetrics #Gynecology #Differential #Causes

Chronic Abdominal Pain Causes - Differential Diagnosis Framework Many patients with chronic abdominal pain have had prior evaluations that did not yield a diagnosis after history, physical and testing. • Could potentially be an acute exacerbation of a chronic problem. • Process: Accelerating vs plateaued? Long-standing vs intermittent Chronic Abdominal Pain Red Flags: • Fever • Anorexia, weight loss • Pain that awakens the patient • Blood in stool • Jaundice • Edema • Abdominal mass/organomegaly • Vomiting, diarrhea • Back pain • Skin changes • Urinary symptoms • Family history of IBD Chronic abdominal pain > 3 months • Recurrent: Consider tumor • Upper quadrant/Epigastric: Consider cardiac causes • Lower quadrant: Consider genitourinary causes RUQ: • Biliary colic/Chronic cholecystitis • Functional biliary pain • Sphincter of Oddi dysfunction • PSC • Budd-Chiari syndrome • Chronic portal vein thrombosis • Hepatocellular carcinoma Epigastric/LUQ Pain: • Cardiopulmonary disease/AMI • PUD • Gastric malignancy • Esophageal malignancy • GERD/Dyspepsia • Gastritis: H. pylori/NSAIDs • Chronic pancreatitis • Splenomegaly/Abscess • Splenic vein thrombus • Splenic infarction • Lymphoma/Leukemia Lower Abdominal Pain: • Pregnancy • Diverticulitis • IBD • Intestinal obstruction • Colorectal CA • Urinary retention • Pyelonephritis • Nephrolithiasis • Femoral/Inguinal hernia • Epididymitis • Endometriosis • Fibroids • Ovulatory pain • Ectopic pregnancy • Ovarian CA Diffuse Pain: • Constipation • Irritable bowel syndrome • Celiac disease • Inflammatory bowel disease • Chronic mesenteric ischemia • GI malignancy • Lactase malabsorption/intolerance • SIBO Focal Pain: • Abdominal wall pain • Abdominal cutaneous nerve entrapment • Abdominal hernia • Rib fracture • Shingles Poorly Localized Pain: • Abdominal aortic aneurysms • Acute intermittent porphyria • Hypercalcemia • Hypothyroidism • Lead poisoning • Celiac artery compression syndrome • Mesenteric ischemia • Chronic intestinal pseudoobstruction • Eosinophilic gastroenteritis • Epiploic appendages • FMF • Adult Still's disease • Necrotic bowel disease • Somatization #Abdominal #Pain #Chronic #Causes #Differential #Diagnosis #gastroenterology

Hepatopulmonary Syndrome - Diagnosis and Management Summary A defect in arterial oxygenation due to a gas exchange disorder occurring in the setting of liver disease and in the absence of intrinsic lung disease Caused by intrapulmonary vascular dilation (IVPD) either due to a diffusion-perfusion defect (Type 1) or anatomic shunt (Type 2) Clinical Presentation: • Dyspnea - Common but not specific to HPS alone • Platypnea - Dyspnea worse when sitting upright compared to lying supine • Orthopnea - PaO2 ↓ by ≥ 5% or ≥ 4mmHg from supine to upright position • Hypoxemia - V/Q mismatch and restricted diffusion from IPVDs Diagnostic Testing: • Pulse oximetry - Non-invasive initial screening tool using cutoff SpO2 < 96% detects severe HPS with 100% sens, 88% spec • Contrast-enhanced echocardiography - Assess for IPVD using peripherally injected agitated saline during echocardiography - Microbubbles appear in left heart 3-6 cardiac cycles after right atrial passage • Arterial blood gas (ABC) analysis - Quantifies degree of hypoxemia. Should be performed on room air in seated position after 10 minutes of rest HPS Diagnostic Criteria: • Underlying liver disease - Portal hypertension with or without cirrhosis • Intra-pulmonary vascular dilation - Positive findings on contrast-enhanced TTE. Can also be seen on radioactive lung perfusion scanning or pulmonary angiography (in select patients) • Oxygenation defect - PaO2 < 80mmHg or A-a gradient ≥ 15mmHg (≥ 20mmHg in patients aged 65 and older) on room air Treatment: • There is no established medical therapy for HPS. Supportive care with supplemental oxygen if PaO2 < 60mmHg, goal SpO2 > 88% • Management of underlying portal hypertension • Liver transplantation: results in almost uniform resolution of HPS features - Complete resolution of symptoms may take months after transplant - Lizzie Aby, MD @LizzieAbyMD #hepatopulmonary #syndrome #diagnosis #management #treatment #hepatology

Peripartum Cardiomyopathy - Summary 1. Definition • Towards the end of pregnancy to 5 months postpartum • Usually LVEF <45% with or without LV dilation • Idiopathic LV dysfunction → exclude other causes* 2. Differential Diagnosis • Pre-existing cardiomyopathy (e.g., familial or dilated) • Valvular heart disease • Congenital heart disease • Hypertensive heart disease • Myocardial infarction • Stress cardiomyopathy • Pulmonary embolus 3. Etiology • Actual etiology remains unknown • Final pathway likely an imbalance of angiogenic factors + oxidative stress - Proposed Mechanism: Dysregulation of VEGF (Pro-Angiogenic) through ↑ sFLT1 levels (levels ↑ in pre-eclampsia) - Proposed Mechanism: Altered prolactin processing with ↑ cleavage into a pro-angiogenic fragment • Other: Myocarditis? Genetic predisposition (TTN gene) ? Hemodynamic stressors of pregnancy 4. Risk Factors and Worse Prognostic Markers • Risk Factors: African ancestry, pre-eclampsia, hypertension, multiple pregnancy, maternal age > 30 years, cocaine use • Worse Prognosis: LVEF < 30%, LVEDd > 6.0 cm, LV thrombus, RV systolic dysfunction, Obesity, African ancestry, LGE on MRI 5. Clinical • Under-recognized: sx overlap with normal pregnancy • May have typical HF sx: dyspnea on exertion, orthopnea, PND, LE edema • Minority of Pts: cardiogenic shock and severe arrhythmias 6. Management during Pregnancy • Avoid ARB/ACE-I/ARNI/MRA • Avoid Warfarin and DOAC • Planning for delivery mode and timing with Cardio-OB team 7. Management during Delivery • Stable patients typically deliver vaginally • Account for changes in hemodynamics (e.g., placental auto-transfusion and relief of IVC compression ↑ preload) • A multi-disciplinary team is critical! 8. Management during Postpartum Period • Breast-feeding: no consensus on risk vs. benefit. - Some studies show no ↓ LV function. Avoid ARBs • ICD: Many patients will recover LVEF. Consider waiting ~6 months before 1° prevention. Possible role for wearable defibrillator as a "bridge to recovery" • Contraception counseling should be done on diagnosis or discharge. Avoid estrogen products early post-partum 9. Other Considerations • Thromboembolic complications are relatively common. In patients with LVEF (ESC), suggest prophylactic anticoagulation up to 8 weeks postpartum • Consider early mechanical support for patients clinically deteriorating on medical therapy, including inotropes • Bromocriptine, a dopamine agonist, prevents the release of prolactin. It is an investigative therapy in PPCM. If started, patients should be on a/c. • If no LVEF recovery (e.g., <50%), ESC guidelines recommend against future pregnancy. Risk of recurrence remains even if recovery. • During a future pregnancy, teratogenic GDMT meds (e.g., ACE/ARB) need to be stopped. Serial TTE and close follow-up with Cardio-OB team needed! - Cardionerds - Karan Desai MD, MPH @karanpdesai #Peripartum #Cardiomyopathy #diagnosis #management #cardiology #treatment

An Approach to Chronic Dyspnea - Diagnostic Framework Pulmonary, Cardiovascular and Miscellaneous Cause Dr. Eric Strong https://twitter.com/DrEricStrong #Dyspnea #Chronic #Differential #Diagnosis

Dyspnea - Differential Diagnosis and Presentation #Diagnosis #Differential #Table #Dyspnea #SOB #Causes

Algorithmic Approach to Hypothyroidism - Differential Diagnosis and Management Framework Central Hypothyroidism (Secondary or tertiary) ↓TSH, ↓FT4 • Post-GH therapy, drug-induced • Pituitary adenoma • Craniopharyngioma • Meningioma • Glioma • Germinoma • Immunologic lesions Overt Hypothyroidism ↑TSH, ↓FT4 • Initiate LT4 ≤ 65 yo; no CVD: 1.6 μg/kg daily > 65 yo or CVD: 12.5-25 μg daily • Measure TSH in 4-6 weeks, Titrate LT4 based on TSH Subclinical Hypothyroidism ↑TSH, ↔FT4 • Recheck TSH after 2-3 months and obtain TPOAb Euthyroid sick syndrome ↔TSH, ↓FT3/↓FT4 • Treat acute illness Matthew Ho, MD PhD @MatthewHoMD #Hypothyroidism #Differential #Diagnosis #algorithm #endocrinology #hypothyroid #Management

Hypothyroidism - symptoms and signs #Hypothyroidism #symptoms #signs #diagnosis #endocrinology