Case Files 49-54 (C) Flashcards
Which factors increase a woman’s risk of breast cancer?
FHx in a first-degree relative (especially if the cancer occurred in a premenopausal woman and was bilateral)
BRCA-1/BRCA-2
Early menarche, late menopause, and nulliparity or first live birth after the age of 30
Obesity and alcohol use (> 3 drinks per day)
Approximately ___% of breast cancers occur in women older than age 50 years
70%
Acromegaly
A condition that results from the excessive production of growth hormone by a pituitary adenoma
Physical Exam:
Benign vs Malignant
Benign: soft, smooth/regular, mobile, tender, < 30
Malignant: firm, irregular, fixed/tethered, painless, > 50
Triple Assessment
- Clinical breast exam
- Imaging
- Pathology assessment (core biopsy or surgical excision)
True/False: Breast pain is not a common presentation of breast cancer, particularly when it is bilateral breast pain
True
Types of breast pain
- Cyclic mastalgia: diffuse, bilateral, radiating, and related to the woman’s menstrual cycle
- Noncyclic mastalgia: continuous/intermittent, but not associated with the menstrual cycle
- Extra-mammary pain: breast pain secondary to another etiology (ie, chest pain)
For women with unrelenting pain in spite of the above modifications, _______, an antigonodotropin, is FDS approved for the treatment of breast pain
danazol
side effects: hair loss, acne, weight gain, and irregular menses
other options include: tamoxifen, toremiphene, and bromocriptine
Discharge that is spontaneous, persistent, bloody, from a single duct, associated with a mass, and occurs in women over 40 years of age is more likely to represent a ________
pathologic process
most common causes are: intraductal papillomas, duct ectasia, cancers, and infections
The treatment of most unilateral, spontaneous, or bloody nipple discharges is:
surgical excision of the terminal duct
Define galactorrhea
Discharge of milk or a milk-like secretion from the breast in the absence of parturition or beyond 6 months postpartum in a non-breast-feeding woman
SSRIs
TCAs
Atenolol
Verapamil
Antipsychotics
Cimetidine
Opiates
Common medications associated with galactorrhea
Treatment for:
- Hyperprolactinemic disorders
- Hyperprolactinemic-induced anovulatory infertility
- Prolactinomas
- Dopamine
- Bromocriptine
- Surgical resection
Diagnosis of PCOS
Made by having 2 of the 3 factors:
hyperandrogenism
chronic anovulation
polycystic ovaries on ultrasound
What is the menstrual cycle irregularity associated with PCOS?
Anovulation
Treatment of insulin resistance and infertility in patients with PCOS
Metformin and thiazolidinediones
Weight loss, clomiphene citrate, aromatase inhibitors, and gonadotropins
Leiomyomata (fibroids)
Endometrial polyps
von Willebrand disease
Warfarin
Common causes of abnormal bleeding associated with regular menstrual cycles
Common causes of abnormal bleeding and irregular menstrual cycles
aka dysfunctional uterine bleeding (DUB)
generally implies an abnormality within the HPO axis
History of anovulatory menstrual cycles
Obesity
Nulliparity
> 35 years
Tamoxifen use
Risk factors for endometrial carcinoma
The evaluation of a woman with DUB is dependent on:
age and risk factors
in the period after menarche, watchful waiting is usually indicated
in women < 35 who are not at increased risk of endometrial cancer, treatment may be offered without workup beyond the history and PE
Evaluation of DUB
Transvaginal pelvic ultrasound
Endometrial biospy
Hysteroscopy
D&C
Treatment of anovulatory bleeding after a workup has ruled out malignancy
*OCPs or progestin alone
Hysterectomy
Ablation
*Reduce the risk of developing endometrial hyperplasia and carcinoma
Which of the following increases risk of endometrial cancer:
smoking, having kids, being obese, or taking OCPs
being obese
Initial tests for the evaluation of menstrual irregularities
Pregnancy test
TSH
Prolactin level
Commonly isolated organisms found in cases of endometritis
Gonorrhea, Chlamydia, Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, and GBS
Diagnosis of endometritis can be confirmed with endometrial biopsy showing inflammatory cells (plasma cells)
The leading cause of blindness in working-age adults in the US
Diabetes
Goals for diabetic control
- Glycemic
- LDL
- BP
- Life style
- Hemoglobin A1C of 7% or less
- LDL 70-100
- BP < 130/80
- At least 150 min/wk of moderate-intesnity aerobic physical activity and resistance training 3x per wk
Diabetic ketoacidosis
Commonly seen in uncontrolled Type I DM
Type I diabetics are prone to metabolize fats, with the resultant production of ketones
A syndrome characterized by hyperglycemia, high levels of serum acetone, and an anion gap metabolic acidosis
True/False: Type II DM has a stronger familial predisposition than type I
True
Nonketotic hyperosmolar syndrome
Often seen with uncontrolled Type II DM
Occurs when blood sugar levels become highly elevated, often approaching 1000 mg/dL
Serum osmolarity is elevated (> 320 mOsm/kg) and the patient has a large fluid deficit (up to 9 L)
Maternal complications of gestational DM
hyperglycemia
DKA
UTIs
HTN/pre-E
retinopathy
Fetal effects of gestational DM
Congenital malformations
Macrosomia
RDS
Hypoglycemia
Hyperbilirubinemia
Hypocalcemia
Polycythemia
Hydramnios
True/False: Women with gestational diabetes are more prone to develop non-pregnancy-related type 2 diabetes and should be screened with a glucose tolerance test postpartum
True
ACOG screening guidelines for gestational diabetes
50g 1 hr glucose challenge test (GCT) at initial visit for high risk and between 24-28 for all pregnant women
> 130 mg/dL = 100g 3 hr glucose challenge
Diagnosis is made based on greater than two abnormal results (fasting - 95, 1 hr - 180, 2 hr - 155, 3 hr - 140)
Diagnostic criteria for diabetes are:
- Random glucose > 200 with classic symptoms
- Fasting glucose > 126
- A 2 hr plasma glucose 200 or more after a 75g glucose load
- HbA1C > 6.5
Instead of A1C, what can you measure in patients with haemoglobinopathies, recent blood loss, or recent changes in diet to screen for diabetes?
Fructosamine
Indicates average glucose levels over a 2 to 3 week period
Other tests recommended for diabetic screening
Fasting lipid profiles
Serum creatinine
Urinalysis
creatinine ratios
eye exam
foot exam
ECG
TSH
Lispro or Aspart Insulin
Rapid acting
15 min onset of action
3-5 hour duration
Regular insulin
Short acting
30-60 min onset of action
5-8 hour duration
NPH insulin
Immediate acting
13 hour onset of action
18-24 hours duration
Glargine insulin
insulin detemir
Long acting
1 hour onset of action
24 hour duration
Biguanides mechanism of action
Metformin
Act on the liver to decrease glucose output during gluconeogenesis
Secondary actions include improved insulin sensitivity in the liver and muscle and a hypothesized decrease in intestinal absorption of glucose
Most dangerous side effect of metformin
Lactic acidosis
Risk is increased by renal insufficiency and metformin in contraindicated in those with a creatinine > 1.5 in men and 1.4 in women, hepatic insufficiency, or congestive heart failure
Sulfonylureas mechanism of action
First oral agents for type 2 diabetes
Function as insulin secretagogues that stimulate beta cells in the pancrease to secrete insulin
Unlike metformin, sulfonylureas carry a risk of causing hypoglycemia
What are considered the best validated second-line add-on therapies if metformin does not control diabetes well enough?
Sulfonylureas and insulin
The principal action thiazolidinediones (TZDs) is:
glitazone
improving insulin sensitivy in muscle and adipose tissue
Secondary actions are decreased hepatic gluconeogenesis and increased peripheral glucose utilization
Because they are metabolized in the liver, they can be used in patients with renal impairment
What are meglitinides?
Short-acting secretagogues (taken no more than 1 hour before meals)
Increase insulin secretion from the pancreas
Risk of hypoglycemia (especially if meal is skipped after taken medication)
How do α-Glucosidase inhibitors work?
Delay carbohydrate absorption by inhibiting α-glucosidase in the small intestine, which decreases postprandial hyperglycemia
What is pramlintide?
An amylinomimetic agent that has physiologic actions equivalent to those of human amylin (glucoregulatory hormone synthesized by pancreatic β cells and released with insulin in response to a meal)
It works to inhibit inappropriately high glucagon secretion secretion during episodes of hyperglycemia
GLP-1 Agonist (eg, exenatide)
Glucagon-like peptide-1 mimetic
Synthetic peptide that stimulates insulin release
DDP-4 inhibitor
Examples: sitagliptin, saxagliptin
Inhibit DDP-4 which is an enzyme that inactives incretin hormones GLP-1 and GIP (both stimulate insulin release, and GLP-1 also decreases glucagon secretion from the pancreas leading to reduced hepatic glucose production)
Compared to gestational diabetes, patients with type 2 diabetes who become pregnant are at increased risk of what happening to the fetus?
Fetal malformations
Where else is cytochrome P450 found apart from the liver?
Small intestine, lungs, and kidneys
What protocol is used to avoid miuse of medications in the elderly?
Beers criteria
STOPP (Screening Tool of Older Person’s Prescriptions)
Although more than 50 CYP isoenzymes have been identified, __ of these isoenzymes metabolize 90% of drugs
6
Which medication can be given to increase the therapeutic effect of penicillin?
probenecid (decreases renal excretion of pencillin)
Why do elderly often have falsely elevated calculated creatinine clearance rates?
Because they have decreased muscle mass
Creatinine clearance = (140 - age)x(ideal body wt)x(0.85 for women) / 72x(serum creatinine)
A 62-year-old man presents with increasing muscle aches in his thighs/shoulders and complains of dark, tea-colored urine. His only medications are lisinopril, simvastatin, and a baby aspirin. Which food should you ask him about eating and what is most likely going on?
Grapefruit (inhibits C P450)
The patient probably has rhabdomyolysis from increased circulating simvastatin
A 36-year-old woman presents very distressed after having a positive pregnancy test. She says she has taken her OCPs religiously and the only other medication she takes is an herbal supplement for depression. What supplement is she taking?
St. John’s wort
A common herbal antidepressant, can induce CYP3A4 and CYP3A5 causing increased metabolism of estradiol
What is the classic sign of a herniated disc?
Sciatica
What are the most common acquired causes of lumbar spinal stenosis?
Degenerative arthritis
Spondylolisthesis
Congenital causes = dwarfism, spina bifida, and myelomeningocele
The vast majority of patients visiting a doctor for back pain will be diagnosed with…
lumbar strain
What imaging should you order for a 45-year-old man presenting with a 2 day history of severe back pain that radiates to his great toe (+ straight leg on exam)?
None
There is no evidence that imaging within the first month after a herniated disc has any morbidity benefit (if symptoms persists after 1 month, then MRI is appropriate)
X-rays do not show disks or nerve roots and CT has poorer visualization of soft tissue than a MRI
What is the preferred treatment for spinal stenosis (pain relieved by sitting or stooping)?
NSAIDS, physical therapy, and epidural steroid injection
How to treat cauda equina
Decompression
Treatment for verterbral fractures
kyphoplasty
No single words by __ months is a red flag for the presence of autism spectrum disorder (ASD)
16 months
Which 3 developmental disorders does ASD encompass?
Autistic disorder (AD)
Asperger syndrome (AS)
Pervasive developmnetal disorder not otherwise specified (PDD-NOS)
Prevalence of ASDs is….
1 per 110
Common features shared by all ASDs include severe deficits in social skills and limited, repetitive, and stereotyped behavior patterns. Only ___ and ___ are characterized by significant language delays.
AD and PDD-NOS
What age must a child demonstrate abnormal behavior before in order to be diagnosed with autistic disorder?
before age 3
The key to successful treatment of ASDs is…
early diagnosis leading to early intervention
Most common genetic cause of AD and retardation in males
Fragile X Syndrome
Characteristics: mental retardation, macrocephaly, large pinnae, large testicles, hypotonia, and hyperextensible joints
All children should be screen with the _____ at the 18- and 24-month visits
Modified Checklist for Autism in Toddlers (M-CHAT)
Red flags indicating the need for immediate evaluation:
no babbling or pointing by 12 months
no single words by 16 months
no 2-word phrases by 24 months
loss of language or social skills at any age
Monotone, restricted speech limited to only one topic
Lack of eye contact
Lack of peer relationships
Repetitive, nonfunctional, atypical behavior of rocking and twirling
Asperger syndrome
True/False: Parents who have a child with autism have an increased risk for having another child with an ASD
True. Recurrence risk of 5-6% when there is an older sibling with an ASD.
