4.5 Flashcards
is estrogen high or low in someone with atrophic vaginitis
low
why is cervix friable in atrophic vaginitis
hypoestrogenic state
why is someone with atrophic vaginitis at increased risk of infections
decreased lactobacilli –> increased pH
therapy for atrophic vaginitis
intravaginal estrogen products
can lichen sclerosis be spread through sexual contact
yes
what is a precursor to osteoporosis
osteopenia
what pathologic fractures are most common in osteoporosis
vertebral fractures
best diagnostic test for osteoporosis
DEXA scan
osteoporosis T score
T score -2.5 or less
Initial lifestyle modifications for osteoporosis
Vitamin D + calcium supplementation
how much vitamin D is advised
800 mg
how much calcium is advised
1500 mg
first line MEDICAL management and prevention of osteoporosis
bisphosphonates
Osteopenia T score
-1 to -2.5
USPSTF advice for screening men for osteoporosis
insufficient evidence to screen men
best tool for diagnosis of osteoporosis
DEXA
USPSTF recommendations for DEXA scan
women 65 and older
younger women at risk
-a personal history of fractures
-low body weight
-smoking
-glucocorticoids
-and early menopause
classification used based on vertebral height lost
Genant classification
fractures above what level are suggestive of a malignancy
T4
types of compression fractures
wedge
crush
burst
what is the most common type of compression fracture
wedge
menorrhagia
heavy menstrual bleeding that lasts longer than 7 days
women who take estrogen alone and risk of breast cancer
lower risk of breast cancer
women who take estrogen + progesterone and risk of breast cancer
higher risk of breast cancer
two types of breast implants
saline
silicone
which breast implant is safer
silicone
when do patients with breast implants need an MRI
5 years later
and then every 2-3 years
do breast implants affect a woman’s ability to breastfeed
no
ALP tends to be higher in
bone disease
if ALP + GGT are high this indicates
hepatobiliary issue
BAP
bone alkaline phosphatase
measures metabolic status of osteoblasts
should BAP be used for screening of osteoporosis
NO – can be used to monitor meds
what is necessary for activation of vitamin D
magnesium
functional cells in parathyroid
chief cells
blood supply to parathyroid
same as for thyroid
inferior thyroid arteries
congenital parathyroid aplasia
DiGeorge syndrome - a type of hypoparathyroidism
vitamin D levels at what level indicate risk for osteomalacia
< 12
preferred vitamin D supplementation
D3 (cholecalciferol)
after starting vitamin D supplementation, when should you recheck serum levels
3 months
cancer associated with proliferation of a single clone of immunoglobulin-producing plasma cells leading to increased production of ineffective monoclonal antibodies
multiple myeloma
what are the main ineffective monoclonal antibodies in multiple myeloma
IgG (60%) and IgA (20%)
most common primary bone malignancy in adults
multiple myeloma
risk factors for multiple myeloma
older adults (median age 65)
african americans
men
bones BREAK in multiple myeloma
Bone pain
Recurrent infections
Elevated calcium
Anemia
Kidney injury
most common symptom of multiple myeloma
bone pain; vertebral involvement most common
bone pain in multiple myeloma is due to what type of lesions
osteolytic lesions
what will you see on CBC for multiple myeloma
Rouleaux formation “stack of coins”
calcium levels in multiple myeloma
hypercalcemia!!!!
serum protein electrophoresis for multiple myeloma
monoclonal spike protein - IgG most common
urine protein electrophoresis in multiple myeloma
Bence-Jones proteins composed of kappa or lambda light chains
what causes kidney injury in multiple myeloma
light chain antibody deposition in kidneys
radiographs for multiple myeloma
“punched out” lytic lesions
definitive diagnosis of multiple myeloma
bone marrow aspiration –> plasmacytosis (clonal plasma cells) >/= 10%
most effective therapy in multiple myeloma
autologous stem cell transplant
low bone turnover + decreased bone mineralization and/or cartilage at the epiphyseal plates
vitamin D deficiency
decreased bone (osteoid) mineralization)
osteomalacia
decreased cartilage at the epiphyseal plates
Rickets
if we have demineralization of the bone osteoid, what do we see in our bones
soft bones
malabsorption from what diseases can cause vitamin D deficiency
chronic liver or kidney disease
gastric bypass
celiac
most common form of vitamin D deficiency in kids
Rickets
most common form of vitamin D deficiency in adults
osteomalacia
clinical manifestations of vitamin D deficiency
diffuse bone pain and tenderness
proximal muscular weakness
hip pain
bowing of long bones –> antalgic/waddling gait
hypocalcemia
what clinical symptoms are associated with hypocalcemia
muscle spasms
cramps
positive Chvostek’s sign
tingling, numbness
Diagnosis of vitamin D deficiency
decreased calcium, phosphate, and 25-hydroxyvitamin D levels
Increased alkaline phosphatase
increased parathyroid hormones
what will you see on radiographs for vitamin D deficiency
looser lines (zones) – transverse pseudo-fracture lines
often bilateral and symmetrical
management for vitamin D deficiency
vitamin D supplementation
when do we commonly see vitamin D deficiency in Rickets in kids
between 3 most - 3 years when growth needs are high and decreased sun exposure
common causes of rickets
calcipenic - calcium or vitamin D deficiency
phosphopenic - due to renal phosphate wasting
initial clinical manifestations of rickets
bowing of forearm bone, knee, costochondral junction
other clinical manifestations in rickets
delayed fontanel closure
craniotabes (soft skull bones)
genu varum (bowing of the femur and tibia)
growth delays
delayed dentition
parietal and frontal bossing
Diagnosis for rickets
decreased calcium
decreased phosphate
decreased 25-hydroxyvitamin D
what will you see on radiographs for rickets
costochondral junction enlargement
long bones have a “fuzzy” cortex
widening of epiphyseal plate
management for rickets
vitamin D supplementation
screening with mammogram
biennial screening (every other year) for women 50-74
category 1 mammogram
negative
category 2 mammogram
benign findings noted
category 3 mammogram
probably benign findings, short term follow up suggested
category 4 mammogram
suspicious findings; further evaluation noted
category 5 mammogram
cancer is highly suspected
category 6 mammogram
known breast cancer
category 0 mammogram
abnormality noted for which more imaging is recommended
fine needle breast aspiration
collects sample of cells
core needle breast biopsy
collects core of tissue
US or MRI guides process
open (surgical) breast biopsy
removes all or part of abnormality
what is the preferred breast biopsy
core needle biopsy
abnormal bone remodeling in aging bone due to increased osteoclastic and osteoblastic activity
Paget’s disease of the bone
increased osteoclastic and osteoblastic activity leads to
larger and weaker bones
clinical manifestations of Paget’s disease of the bone
most are asymptomatic
bone pain (MC)
skull enlargement
deafness
labs for Paget’s disease of the bone
markedly elevated alkaline phosphatase
initial test for Paget’s disease of the bone
radiograph
what will radiographs show for Paget disease of the bone
lytic phase: blade of grass or flame shaped
sclerotic phase: increased trabecular markings
what will skull radiographs for Paget disease of the bone show
cotton wool appearance
first line for treating Paget’s disease of the bone
bisphosphonates - Zoledronate has greater efficacy
calcium and vitamin D supplementation recommended
is Paget disease of the breast a type of breast cancer
yes
what will you see on PE for Paget disease of the breast
chronic eczematous itchy scaly rash on the nipples and areola (may ooze)
most accurate biopsy for breast cancer
open biopsy
most common carcinoma for vaginal cancer
squamous cell carcinoma
risk factor for vaginal cancer
HPV types 16 and 18
most common symptom of vaginal cancer
abnormal vaginal bleeding
most common site for vaginal cancer
posterior wall of the upper 1/3 of the vagina
definitive diagnosis of vaginal cancer
biopsy
most common type of cancer of the vulva
squamous cell carcinoma
risk factor for cancer of the vulva
HPV types 16 and 18
most common site for cancer of the vulva
labia majora
what will you see on PE for cancer of the vulva
red or white ulcerative or raised crusted lesion
most common skin cancer
basal cell carcinoma
squamous cell carcinoma in situ (has not invaded the dermis)
Bowen’s disease
major risk factor for squamous cell carcinoma
sun exposure
squamous cell carcinoma is often preceded by
actinic keratosis
clinical manifestations of squamous cell carcinoma
erythematous, elevated thickened nodule with white scaly or crusted, bloody margins
may present as a non healing ulceration
most common cause of skin cancer related death
melanoma
major risk factor for melanoma
UV radiation
most common type of melanoma
superficial spreading
where is superficial spreading melanoma most commonly found
trunk in men
legs in women
melanoma that most commonly arises in chronically sun-damaged or sun-exposed areas the skin in older individuals such as the face
lentigo maligna
most common melanoma found in darker-pigmented individuals
acral lentiginous
clinical manifestations of basal cell carcinoma
small raised (dome shaped) papule that are pink, white or flesh colored
Translucent, waxy, or pearly quality with raised “rolled” borders
central depression
with overlying telangiectatic present on head and face
describe inheritance of osteogenesis imperfecta
autosomal dominant
what is abnormal in osteogenesis imperfecta
type 1 collagen
clinical manifestations of osteogenesis imperfecta
severe premature osteoporosis –> multiple recurrent spontaneous fractures
Presenile deafness
what might you see on PE in osteogenesis imperfecta
blue tinted sclera
brown teeth
management for osteogenesis imperfecta
bisphosphonates
PT
surgery
most common primary bone malignancy in children and young adults
osteosarcoma
what bone is most commonly affected on osteosarcoma
distal femur
where does osteosarcoma most commonly metastasize
lungs
clinical manifestations of osteosarcoma
bone pain that is worse at night
radiographs for osteosarcoma
hair on end or sunburst appearance
definitive diagnosis for osteosarcoma
biopsy
labs for osteosarcoma
increased alkaline phosphatase
second most common primary bone malignancy in adolescents and young adults (after osteosarcoma)
Ewing sarcoma
peak incidence of Ewing sarcoma
10-15 years
Ewing sarcoma is due to translocation between what chromosomes
11 & 22
Ewing sarcoma originates from what cells
mesenchymal progenitor cells
most common location for Ewing sarcoma
diaphysis of long bones – femur most common then pelvis
common sites for metastasis for Ewing sarcoma
bone
bone marrow
lung
common cause of death for Ewing sarcoma
METs to lungs
clinical manifestations of Ewing sarcoma
localized bone pain and swelling
PE for Ewing sarcoma
palpable soft tissue mass
local tenderness
joint swelling
what will radiographs show for Ewing sarcoma
multilayered periosteal reaction with an “onion skin/peel” appearance
destructive lytic lesions have a “moth-eaten” appearance
Codman’s triangle (can also be seen in osteosarcoma)
lab values in Ewing sarcoma
increased ESR, leukocytosis
LDH carries prognostic significance
when should kyphoplasty be performed (time period)
within 8 weeks of fracture
when should A1C be drawn in diabetic patients
twice per year for screening
goal of A1C levels in diabetic patients
<7%; 53 mmol/mol
what A1C level is diagnostic for diabetes
> 6.5%; 48 mmol/mol
screening A1C for nondiabetics
adults 35-70 who are overweight or obese every 3 years
what is A1C
glycated hemoglobin; average blood glucose concentration over the course of RBC lifespan (120 days)
ovaries stop functioning before 40 years old
primary ovarian insufficiency
young women with primary ovarian insufficiency are at an increased risk of developing
hypothyroidism; they should have TSH screen yearly
common causes of primary ovarian insufficiency
chemotherapy
radiation
Turner’s syndrome
what testing should women with primary ovarian syndrome undergo
karyotype testing; to see if underlying genetic abnormality
excess parathyroid hormone
hyerparathyroidism
what is the most common cause of hypercalcemia
hyperparathyroidism
most common cause of hyperparathyroidism
parathyroid adenoma
What medication can cause hyperparathyroidism
lithium
clinical manifestations of hyperparathyroidism
usually asymptomatic
may have sign of hypercalcemia
clinical manifestations of hypercalcemia
bones - bone pain
stones - kidney stones
moans - abdominal pain
psychic undertones - psychosis, decreased DTR
triad for diagnosis of hyperparathyroidism
hypercalcemia + increased intact PTH + decreased phosphate
what else will you see for diagnosis for hyperparathyroidism
increased vitamin D; increased 24-hour urine calcium excretion
what may you see on bone scan for hyperparathyroidism
osteopenia
management for hyperparathyroidism
parathyroidectomy is definitive
calcium and vitamin D post parathyroidectomy to prevent hyperparathyroidism supplementation
Bisphosphonates
2 most common causes of hypoparathyroidism
post neck surgery (thyroidectomy, parathyroidectomy)
autoimmune destruction of parathyroid gland
clinical manifestations of hypoparathyroidism
most are aysmptomatic
may have signs of hypocalcemia
clinical manifestations of hypocalcemia
increased muscle contraction (Trousseau sign - carpopedal spasms when blood pressure cuff is inflated & Chvostek sign - tapping the cheek causes facial spasm)
triad for diagnosing hypoparathyoidism
decreased calcium + decreased PTH + increased phosphate
what may you see on EKG for hypoparathyroidism
prolonged QT interval (increased risk of arrhythmia)
management for hypoparathyroidism
calcium supplementation + activated vitamin D
if acute symptomatic – IV calcium gluconate
gold standard testing for calcium levels
ionized calcium
when do you use corrected calcium to measure calcium levels
in patients with hypoalbuminemia
uterine herniation into the vagina
uterine prolapse
what causes uterine prolapse
weakness of pelvic support structures
when does uterine prolapse most commonly occur
after childbirth
posterior bladder herniating into the anterior vagina
cystocele
small bowel herniating into upper vagina
enterocele
distal sigmoid colon or rectum herniating into the posterior distal vagina
rectocele
what is removed in a total hysterectomy
cervix and uterus
what is removed in a partial hysterectomy
upper part of the uterus is removed but the cervix is left in place
what is ligated in hysterectomy due to blood supply
suspensory ligament (contains ovarian vessels)
procedure to remove tissue from the endometrium
endometrial ablasion
chronic, non-infectious inflammation of the bladder
interstitial cystitis
clinical manifestations of interstitial cystitis
suprapubic pain
urinary frequency
dysuria
hematuria
possible weight loss
treatment for interstitial cystitis
PT
bladder re-training
meds for pain or antidepressants
