Buzzwords + Dx + Tx Flashcards
Unilateral breast erythema, tenderness, and warmth in lactating woman
DDx and Tx?
Ddx:
*Mastitis
Inflammatory breast Cx
Paget’s
*Suspect mastitis in a lactating woman. Caused by S. aureus MC.
Tx = Dicloxacillin + NSAIDs + CLOSE FOLLOW UP in 48 hours to monitor for abscess formation (US if fluctuance is present). Monitor for sepsis.
*If no improvement after 1 week of antibiotics, be suspicious of inflammatory breast Cx or Paget’s.
Continue breast feeding (can pump and dump if uncomfortable feeding, but NOT as effective as feeding). No tight-fitting bras/pressure on breasts.
Dx and management of breast abscess?
Complication of mastitis:
- Suspect in mastitis with fluctuance
- US = imaging
- FNA or incision & drainage + Dicloxacillin
Continue breast feeding
Cyclical, bilateral breast pain and masses.
Dx and Tx?
Fibrocystic breast changes - MC benign breast disorder in women of reproductive age.
Hormone sensitive - change with cycle (vs fibroadenomas). BILATERAL.
Not ass’d with increased risk of Cx but can make detection more difficult.
Dx: Mammogram + biopsy. (Consider US if <40)
Tx:
Non-med: Properly fitted bra, analgesics, compresses
Med: C-OCP
FNA can be therapeutic and Dx in complex cases.
Non-tender, mobile, ovid breast mass in reproductive-age woman.
Dx and Tx?
Most likely is fibroadenoma. In average woman, this does NOT raise risk of future breast Cx. Usually relatively large (1-5 cm).
Differences from fibrocystic breasts: unilateral, does NOT change with cycle.
Dx: Seen on US or mammogram; definitive Dx is via US-guided needle biopsy. FNA will show “swirl” of fibrous tissue and collagen.
Also consider breast cyst: FNA will show fluid if cystic.
Tx: Excision or monitoring – if in a juvenile patient, excise because they can cause deformity/have higher risk of future malignancy
Swirl of fibrous tissue and collagen found on FNA of breast tissue?
Fibroadenoma
Iatrogenic causes and Tx of gynecomastia?
*Antipsychotics
*Antidepressants
Spironolactone
5-a-reductase inhibitors
Leuprolide (GnRH agonist)
Cimetidine
Ranitidine
Tx: Discontinue offending med; can use tamoxifen if medical Tx desired/needed
MC type and location of breast Cx
Type: Infiltrative ductal carcinoma
Location: upper outer quadrant
Risk factors for breast Cx
- FHx/BRCA status
- Estrogen exposure
- Increasing age
- Nulliparity
- Early menarche/late menopause
- Unopposed estrogen HRT
- Obesity
- Smoking
- EtOH
- Endometrial Cx
Painless, immobile breast mass
Suspect breast Cx
Breast skin retraction - anatomical correlate
Cooper’s ligament
Erythematous, scaling, pruritic changes to nipple and areola
Dx, other ass’d symptoms, and Tx
Must r/o Paget’s Dz
- Lump may be present
- Nipple d/c may be present
- MC in women 50-60
Dx: Full thickness wedge/punch biopsy of nipple.
Maintain high degree of suspicion because 1.) no mass may be present and 2.) mammogram may not show changes. Occult DCIS may still be present.
Tx: lumpectomy + radiation (if possible: conservative excision)
MC cause of bloody nipple discharge
DDx, Dx, and Tx?
Intraductal papilloma - non-cancerous mass. Solitary papilloma does NOT increase risk of breast Cx. Multiple DOES.
Must r/o Paget’s Dz/other Breast Cx: bloody nipple d/c is Cx until proven otherwise.
Dx: Ductography + US/mammogram (US<40YO). Biopsy required!
Tx: Excision
Buzzword: Calcifications seen on mammogram
Suspect breast Cx
Buzzword: spiculations seen on mammogram
Suspect breast Cx
A patient presents with a mobile, firm breast mass and is referred to a specialist for aspiration. The aspirate is clear and the mass disappears. How should this patient be handled?
What if the aspirate was bloody? Or if the mass did not disappear?
This was likely a simple cyst.
Since the fluid was clear, no further evaluation of the fluid is needed, but she should receive a follow-up breast exam in 3-6 months.
If bloody or persists after aspiration: send aspirate to cytology and get diagnostic mammogram/US
What are appropriate treatment options for a suspected breast cyst?
- Observation: see if it resolves with cycle but MUST follow-up in 4-8 weeks
- Referral –> aspiration
MC cause(s) of non-spontaneous, non-bloody, bilateral nipple discharge
MC = Pregnancy/lactation!
Fibrocystic changes
Ductal ectasia
Treatments for mastalgia
1st line: properly fitted bra, weight reduction, exercise, decrease caffeine, vitamin E + NSAIDs
2: Danazol (only FDA approved tx)
3: OCPs, IUD
4: SERMs (tamoxifen, off-label)
General recommendations for mammography for the average woman
Offer at 40, don’t start later than 50
Every 1-2 years
Stop at 75
All shared decision making
For any palpable breast mass, we should consider what three evaluation steps?
- Physical exam
- Diagnostic mammography
- Biopsy
What differentiates DCIS from the MC form of breast Cx?
MC = infiltrative ductal carcinoma, which invades basement membrane and spreads to surrounding tissue (can metastasize via lymph nodes).
DCIS: has not yet invased basement membrane – but is a precursor to infiltrative Cx so get it out of there!
Acute onset of breast tenderness, pruritis, and erythema.
If in a non-lactating woman, be suspicious of inflammatory breast cancer: do diagnostic mammogram + US + needle biopsy
Dx via biopsy
Can look like mastitis. Be suspicious if mastitis patient does not respond to one week of antibiotics.
Buzzword: peau d’orange
Inflammatory breast cancer
What are the MC sites of breast Cx metastasis?
Bone
Liver
Lungs
Brain
What two classes of drugs are used as hormonal therapy in patients with breast cancer?
SERMs (tamoxifen)
Aromatase inhibitors
Define infertility
Inability to conceive despite frequent, unprotected intercourse for:
12+ months (<35 YO)
6+ months (>35 YO)
Differentiate fecundity vs fecundability
Fecundity = probability of achieving live offspring
Fecundability = probability of achieving pregnancy in 1 menstrual cycle (avg = 20-25%)
What is involved in a sperm analysis for male infertility?
Repeat after several weeks if anything is abnormal If volume is low, perform post-ejaculatory UA to identify retrograde ejaculation - Volume - pH - Concentration - Count - Motility - Morphology - Debris/agglutination - Leukocytes - Immature germ cell
Most common female factor of infertility?
Ovulation disorders
Ex: PCOS, excessive exercise, hyperprolactinemia, ovarian tumors/injury, EDs
What’s the second MC female factor contributing to infertility?
Tubual factors - specifically occlusion due to fimbrial dysfunction
How is tubal-factor female infertility diagnosed?
Hysterosalpingography (first line - the gold std requires anesthesia, etc)
What is the first line treatment for infertility?
IVF via intracytoplasmic sperm injection
What is clomiphene citrate used to treat?
Luteal insufficiency
Oligomenorrhea
PCOS
Stimulates ovulation
What is HMG (human menopausal gonadotropin) used to treat?
Pituitary insufficiency
Hypothalamic amenorrhea
Lack of follicular development
In the setting of infertility, what are dopamine agonists used to treat?
Hyperprolactinemia
Why is hCG administered in the setting of infertility?
It is timed to help support LH surge and/or to support implantation
You have a couple who is experiencing infertility. Sperm analysis is normal. What is the MC cause and tx?
MC cause = ovarian dysfunction
Tx = clomiphene to initiate ovulation
In a woman with Hx of PID, what is the MC cause of infertility?
Tubal factors such as fimbrae dysfunction
How is endometriosis diagnosed and what are some buzzwords associated with it?
Dx = laparoscopy + histology
(do NOT get tumor markers, Greenspan emphasized this)
Buzzwords:
- Chocolate cysts
- Triad of dyspareunia, dysmenorrhea, and AUB
- Uterine retroversion
- Dyschezia
What is an ideal treatment for a woman with PCOS trying to conceive?
Letrozole + metformin
If that answer isn’t an option, select clomiphene
For the love of god what guidelines for cervical cancer screening are we using for this test???
Start at 25
Continue until 65
Every 5 years
(Pap looks for dysplasia and reflexes to HPV test)
Give a general algorithm for working up an abnormal pap smear
Abnormal pap –> Colpo
Colpo will show endo/ecto:
If + ecto and (-) endo –> LEEP
If + endo (+/- ecto) –> Cone biopsy
If ASCUS = HPV DNA screen and/or q6mo pap
(Assuming in-situ)
What is the MC type of cervical cancer?
Squamous cell carcinoma
What strains of HPV are ass’d with cervical Cx?
11, 18 (+ 30’s)
What are the MC types of vaginal Cx and how do they present?
Squamous Cell: Black, pruritic lesion
Clear Cell Adenoma: grape-like mass in vagina
There are two malignancies in which “grape-like masses” can be seen. Differentiate the two and associate their conditions.
Grape-like mass in the vagina –> vaginal clear cell adenocarcinoma
Grape-like mass coming out of cervix –> choriocarcinoma
What are the MC types of vulvar Cx?
- Squamous cell carcinoma is MC!!!
- Melanoma
(^ both present as black lesions or asymptomatic) - Paget’s
(^ presents as superficial red lesions)
What is the MC endometrial Cx and risk factor? What is the MC presentation and how is it Dx? What is the Tx?
MC = adenocarcinoma
RF = estrogen exposure
Pt = post-menopausal bleeding
Dx = Endometrial sampling or D&C
Tx = TAH + BSO
(if mets are present, add radiation + chemo)What is the MC ovarian Cx and risk factor? What is the MC presentation and how is it Dx? What is the Tx?
MC = Epithelial RF = Ovulation Pt = Asymptomatic until late, then renal failure, small bowel obstruction, or ascites Dx = Transvaginal US Tx = TAH + BSO + chemo
A teenage girl presenting with large adnexal mass is suspicious for …?
Ovarian germ cell tumor – non-malignant tumor that does not invade the basement membrane. Dx via transvaginal US and treat with USO to preserve fertility.
A 18 YO woman presenting with positive BhCG of 100,100 and complaining of severe nausea and vomiting is suspicious for what? How is this Dx and Tx?
Suspicious for gestational trophoblastic disease (molar pregnancy)
Dx via transvaginal US showing snowstorm or cluster of grapes and markedly elevated BhCG (as well as size/date discrepancies)
Tx:
- Blood type and match
- Must surgically evacuate uterus via suction curettage, be prepared to transfuse.
- Follow with serial BhCG and keep patient on OCPs for 12 months
Buzzword: Snowstorm seen on US
Gestational trophoblastic disease
Buzzword: precocious puberty
Consider granulosa cell tumor
Buzzword: coffee bean nuclei
Consider Brenner ovarian tumor
Buzzword: signet ring cells
Consider Krukenburg ovarian tumor
What kind of cells are in the vagina?
Epithelial cells, not mucosal cells
Differentiate complete vs partial molar pregnancy
Complete = no fetal tissue is present. Usually 46XX. Egg with no DNA is fertilized by 1 or 2 sperm.
Incomplete = fetal tissue is present; usually 69XXX or XXY. One egg fertilized by 2 sperm (or 1 sperm that duplicates its chromosomes).
Sudden-onset of severe unilateral pelvic pain, usually preceded by activity
Consider ovarian torsion – surgical emergency
Buzzword: Chocolate cyst
Endometriosis
Buzzword + Dx + Tx: Thin, malodorous vaginal discharge
BV
Amsel criteria for Dx:
- KOH whiff test
- pH > 4.5
- Clue cells on wet mount
- Milky-white or grey d/c
Tx: Metronidazole 500 mg BID x 7 days
Buzzword + Dx + Tx: Cottage cheese vaginal discharge
Vulvovaginal candidiasis
Dx: PMNs and yeast (hyphae) on KOH prep
Tx: Single dose fluconazole
Buzzword + Dx + Tx: Punctate cervix
Trichomoniasis
Dx: Pirouette/tumbling motility on wet mount
Tx: Metronidazole 500 mg x 7 days OR single 2 gr dose
Buzzword + Dx + Tx: Frothy vaginal discharge
Trichomoniasis
Dx: Pirouette/tumbling motility on wet mount
Tx: Metronidazole 500 mg x 7 days OR single 2 gr dose
Buzzword: Pirouette motility
Trichomoniasis
Dx and Tx for peri/postmenopausal woman with thin, dry, shiny epithelium
Atrophic vaginitis – r/o STIs and Cx if bleeding is present
Tx: Vaginal moisturizers and lubricants; topical estrogen (if given PO, MUST not be unopposed estrogen)
Dx and Tx: Pruritis of vulva and anus
Lichen sclerosis
Tx: Pt education; high-potency topical steroids and monitor for atrophy
Dx and Tx of genital warts
For Dx: clinical and/or acetic acid application during colposcopy + PCR
Tx: cryo, cautery, excision, laser
Topical imiquimod
Vax: Gardasil
Buzzword + Dx + Tx: Boggy uterus on bimanual exam
Adenomyosis
First line Dx = US or MRI, but definitive Dx via histology post TAH
Tx: Conservative = COC, IUD, or aromatase inhibitors
TAH is definitive treatment
Your patient is a 25 YO woman presenting with small amounts of inter-menstrual bleeding. What is the most likely Dx and Tx?
Endometrial polyp = MC cause of AUB
Dx via histology post polypectomy; Tx
What is the MC cause of AUB? How is it diagnosed and treated?
Ovulatory dysfunction: ovaries produce estrogen but no ovulation takes place, so corpus luteus is not formed and unopposed estrogen causes endometrial growth/unpredictable shedding.
Clinical diagnosis: >7 day variability in cycle schedule for previous 12 months. Run FSH, LH, E2. Any woman with RF should have full workup to r/o endometrial Cx.
Tx: COC is first line; NSAIDs for pain
Definitive Tx = TAH
What are four meds/drug classes associated with abnormal uterine bleeding?
- Psych drugs
- Opioids
- Metolopramide
- Methyldopa
What are three RF for uterine polyps?
Age
Tamoxifen use
Obesity
What are treatment options for a patient presenting with a leiomyoma?
Asymptomatic: observation +/- NSAIDs, COC/IUD
Symptomatic women who desire fertility: Above or myomectomy
Definitive Tx: TAH
Describe the presentation of a woman who is infertile with the most common etiology
Ovulatory dysfunction is the MC etiology:
- Cycle length variability >7 days for previous 12 months
- Abnormal uterine bleeding and/or heavy menstrual bleeding
Describe the difference between the “G” and “P” given when describing a woman’s childbearing status
G = total number of pregnancies P = number times the uterus emptied
Three numbers are given after G#P#. What do they represent?
Preterm
Abortions
Living children
(“Power And Light”)
You just confirmed that your patient is pregnant. How often do you advise her to return for antepartum care?
During first and second trimester: every 4 weeks
During third trimester: every 2 weeks
During the last month: weekly
If extends post-due date, twice weekly
What is Goodell’s sign?
Softening of cervix and lower uterus
What is Chadwick’s sign?
Bluish discoloration of cervix/vagina
In addition to taking recent history, answering questions, and running any necessary labs, what are 4 things that are done during any routine antepartum visit?
UA
BP monitoring
Fundal height (after 20 weeks)
Fetal heart tones/movements
Describe changes to vascular resistance, CO, HR, and BP in pregnancy
Resistance decreases
CO increases
HR increases
BP decreases early, then rises back up to baseline level
What are 5 hematologic changes that occur in pregnancy?
- Increased volume of both plasma and RBCs (plasma > RBCs; dilutional effect)
- Anemia (Hgb down to 9-11)
- Platelets drop
- WBCs increase
- Hypercoaguability
What is the recommended amount of weight gain for an average patient during pregnancy?
25-35 lbs
Less (even 0) if overweight before pregnancy
More if underweight before pregnancy
When is first trimester genetic screening done and what does it include?
11-13 weeks
Nuchal thickness, protein-A, and B-hCG
What is the MC performed second trimester genetic screening?
Quad screen:
- Inhibin A
- BhCG
- Estradiol
- MS alpha-fetoprotein
If these are positive, consider amnio
Your patient is being treated for HTN and you note that she is not on birth control. What is an important consideration for this patient?
If she is not on contraceptives, make sure that she is not on any potentially teratogenic medications. Lisinopril (ACEi) is NOT appropriate for such a patient.
What is the MC cause of painless vaginal bleeding in pregnancy after 20 weeks?
How is it managed?
Placenta previa - requires C-section delivery when viable (36-37 weeks ideally, 34 if necessary)
- Do US
- Pelvic rest and no digital vaginal exams
- Transfuse as necessary
- Toclysis, mag sulfate, and steroids for lung maturity as needed
- If there are two episodes = admit + bed rest
When do we start treating gestational HTN? How is it treated?
150/100
- Nifedipine (ONLY XR!!!) or labetalol
What is the treatment for preeclampsia?
Deliver the baby
Bed rest not associated with better outcomes
Treat HTN; monitor labs; aim for delivery at 37 weeks or sooner if severe features are present
What is the treatment for eclampsia?
Deliver the baby: C-section vs vaginal
- Immediate management of hypoxia/trauma necessary
- Manage HTN with hydralazine/labetalol
- Benzos for seizure
- Mag sulfate to prevent more seizures
What is the suspected diagnosis in a pregnant woman presenting with painful uterine bleeding?
Placental abruption:
Deliver if possible, monitor for DIC, hemorrhage, and renal failure
What are the MC RF of placental abruption?
Smoking, trauma, and prior abruption
What is the definition of preterm premature rupture of membranes?
ROM < 37 weeks
Your pregnant patient presents with fluid discharge and you suspect rupture of membranes. How can this be confirmed?
- pH: >6.5 on nitrazine paper
- Ferning of fluid when dried
When do we typically test for GBS?
36 weeks
If labor begins before this, treat prophylactically with PCN
Generally, how is preterm labor managed?
> 34 weeks: admit for delivery, but if the contractions stop she can go home
<34 weeks: admit, give tocolytics, bethamethasone, mag sulfate, and GBS prophylaxis (PCN)
Describe the diagnosis of gestational DM
~24-28 weeks: screen via 1 hr glucose test:
- If >200 = GDM Dx
- If <135 = no GDM
- If 135-140, come back on another day and do another test (preferably 3 hr)
On second test, if any are elevated = Dx (2 abnormal tests): fasting: >95 1 hr: >180 2 hr: >155 3 hr: >140
What is the treatment for GDM?
- Lifestyle/nutritional changes
- Insulin
(Metformin is acceptable, but greater risk for preterm birth)
What is the postpartum prognosis for women with GDM?
95% will return to non-DM state (screen at 2-4 months), but great risk for future GDM
(The infant has greater risk for DM later in life)
Describe some differences between true labor and term contractions.
True labor = cervical dilation & effacement; regular contractions with shortening intervals and increasing intensity. Discomfort is not helped by sedation.
Term contractions: CERVIX DOES NOT DILATE OR EFFACE and sedation helps with discomfort
To what structures might the vagina be surgically attached during a procedure to correct a cystocele?
- Uterosacral ligament
- Sacrospinous ligament
- Anterior longitudinal ligament
Anatomy: “Water under the bridge” is used to remember what in female anatomy? What is the relevance?
The ureters pass under the uterine artery – important during hysterectomy (don’t accidentally damage the ureter when cutting the uterine artery)
What structure receives most of the lymphatic drainage from the breast?
The axillary lymph nodes; the anterior pectoral specifically
Clinical correlate: this would be biopsied during sentinel node biopsy to assess spread of breast cancer
When delivering, a woman can choose between an epidural block, a spinal block, or a pudendal block. What is the difference between these?
Epidural and spinal blocks anesthetize the intra- and subperitoneal viscera as well as the somatic structures from the waste down. The uterovaginal plexus (intra), the pelvic splanchnic nerves (sub), and the pudendal nerves (somatic) are affected.
Pudendal blocks ONLY anesthetize the somatic structures of the perineum. Only the pudendal nerve is affected.
