Case List- Clinic Flashcards
CRC screening is now 45 for all.. why is that?
There was a notable rise in increase in CRC in younger adults, thus earlier screening would lead to earlier detection and improved outcomes
What is age appropriate counseling?
Diet
Exercise
Calcium/Vitamin D (1,000/600) for <50 yo
Safety issues
Domestic Violence - do you feel safe at home?
Vaccination
Loestrin components
1/20=
1 mg norethidnrone
20 mcg EE
Non contraceptive benefits of OCP
Less dysmenorrhea, decreased endometrial and ovarian cancer, decreased ovarian cysts and benign breast disease, tx endometriosis, hyperandrogenism
What is your breast cancer risk if first degree relative has breast cancer?
increased risk by 2-3X
What is the baseline risk of breast cancer?
Is breast self exam recommended in average risk women?
1 in 8
No, bc it increases false positive rate and lack of evidence with benefit
If you are Aschkenawzi jewish, what is your risk of being a carrier of BRCA 1/2… Compared to general population
Risk of BRCA 1/2 in A. Jewish: 1:40
Risk of BRCA 1/2 in general population: 1:300+
3: what genetic testing would you do?
talk about referral to breast specialist if BRCA 1/2 positive..
It is my practice and my colleagues practice to refer to genetic counseling for further testing. Though. I am aware of a hereditary breast cancer panel that may be ordered.
-I would refer her to a breast specialist to talk about prophylactic modalities for breast cancer reduction therapy or chemoprophylaxis
Who should be offered genetic counseling?
-long list that I reflect upon, however in general..
1) family hx BRCA
2) hx suggestive of dominant cancer syndorme
3)Breast cancer dx < 50
4)male breast cancer
5)multiple primary breast cancers
6) breast cancer Aschkenawzi jewish
7)tripe negative breast cancer
… others
Is BRCA the only hereditary cause of breast and ovarian cancer? If not, what % are due to other causes?
25% are due to other mutations
-use multigene panel to test for others
What are the benefits of identifying a BRCA mutation?
-increased surveillance
-allows for risk reducing interventions (RRBSO and chemoprophylaxis)
What are the A/E effects of tobacco abuse, especially regarding gyn organs?
cervical dysplasia, cervical cancer, endometrial cancer, colon cancer, early menopause, bladder cancer
Tobacco Cessation
Meds and A/E
Smoking in pregnancy, when is the greatest benefit seen for cessation?
Recommend behavioral and rx treatment
1800 Quit Now
Varenicycline: blocks nicotine from binding to receptor, thus reducing the rewards of cigarette smoking and reduced withdrawal
-quit smoking 1 week after starting rx
Wellbutrin: enhances CNS noradrenergin and dopaminergic release
contraindicated if seizure disorder
Rx available in pregnancy:
15 weeks
Nicotine and pregnancy - vaping OK?
No, vaping is not a safer alternative. They often contain nicotine salts.
Nicotine crossest placenta, and intake in any form adversely affects fetal brain and lung tissue.
What vaccines do you check during preconception?
Covid, Flu (if during season), Hepatitis B, Varicella, MMR
Nonclassical adrenal hyperplasia
-enzyme
-hormones
21 hydroxylase
-decreased cortisol and aldosterone
Mirena amenorrhea rate (at 1 year)
20%
SSRI CIN
concurrent use of MAOI (due to increased risk serotonin), QT prolongation
Side effects of SSRI’s
GI upset such as nausea, vomiting, diarrhea, , insomnia, reduced sexual desire
GAD -total
Moderate Anxiety
Severe anxiety
Out of 21
Moderate: >10
Severe > 15
PHQ 9 - total
Moderate
Severe
out of 27
Moderate: >10
Moderete Severe> 15
Severe : 20
EPDS - total out of
-positive for depression
out of 30
score 10+
Breast Mass DDX
Benign: fibroadenoma, breast cyst, breast abscess, fibrocystic changes, fat necrosis
Malignant:
ductal carcinoma insitu
infiltrating ductal carcinoma
infiltrating lobular carcinoma
inflammatory breast cancer
Breast Cancer in pregnancym- treatment
Breast surgery is feasible as well as chemotherapy during the 2 or 3rd trimester. Radiation would need to be deferred to post partum
intraductal papilloma
-incidence
-why do we care?
10%
benign but some are malignant/can predispose to cancer (1% of cases, once excised can be upstaged to atypical ductal hyperplasia, DCIS, carcinoma)
Breast abscess- I&D pump and dump?
what are complications of a breast abscess I&D?
1) no, can continue to feed
2) mammory duct fistula, milk fistula, recurrent infection, poor cosmoses
What are the risks of a LEEP to future pregnancy?
PTD, cervical insufficiency– 2T loss, cervical stenosis
What are HPV affects on path?
Koilocytes which are small raisinoid/small nuclei with a cytoplasmic halo
15 Mgmt CIN 2 if concerns for pregnancy
Colposcopy + cotesting at 6 and 12 mo
Pregnant and Cervical Cancer treatment:
Treatment depends on-
trimester
1T: treat as non pregnant
2T: terminate and treat
3T(and late 2T): weight risks/benefits delayed treatment with prematurity
Pregnancy and Cervical cancer treatment:
weeks gestation and size
Stage 1A1 (microscopic lesion- <3 mm depth) –> CKC
If <22 weeks and lesions 2 cm –> +/- chemo depending on PLND status
If> 22 weeks and lesion >2cm chemo
After a LEEP, when should you wait to get pregnant?
want the cervix healed, ideally 3 months though there is no established guideline
What is the definition of recurrent UTI?
3+ year or 2+ in 6 months
how do you prescribe GNRH agonist?
Depo Lupron 11.25 mg IM x 3 months, daily Norehtinrone 5 mg. + Estrogen 0.625 mg if needed
What is a Nuswab?
Nucleic Acid Amplification test
(NAAT)
Nexplanon - when is back up not needed?
If Nexplanon inserted CD1-5, don’ need back up.
Explain PCOS
Chronically elevated LH and insulin, leads to increased androgens made by ovaries. Hyperinsulimnemia suppressed liver production of SHBG, which results in increased free testosterone.
Differential Diagnosis thyroid nodule
o Benign vs. malignant forms. Benign conditions include: hashimoto’s, graves disease, thyroid cyst, multinodular goiter, follicular adenoma.
o Malignant conditions: papillary or follicular carcinoma, mets from breast
Recurrent yeast infection: 4 + / year
Treatment
Fluconazole 150 mg q 3 d x 3 doses
Fluconazole weekly therapy x 6 months (Diflucan 150 mg weekly x 6 months OR clotrimazole topical 500 mg q week)
33 - what treatment would you offer her?
o This patient was undecided regarding her fertility. If she were certain about preserving fertility, I would recommend Hysteroscopy D&C with IUD replacement and serial biopsies q 3 months, anticipate regression at 9 months
