Case List- Clinic

Question 1

CRC screening is now 45 for all.. why is that?

Answer 1

There was a notable rise in increase in CRC in younger adults, thus earlier screening would lead to earlier detection and improved outcomes

Question 2

What is age appropriate counseling?

Answer 2

Diet
Exercise
Calcium/Vitamin D (1,000/600) for <50 yo
Safety issues
Domestic Violence - do you feel safe at home?
Vaccination

Question 3

Loestrin components

Answer 3

1/20=
1 mg norethidnrone
20 mcg EE

Question 4

Non contraceptive benefits of OCP

Answer 4

Less dysmenorrhea, decreased endometrial and ovarian cancer, decreased ovarian cysts and benign breast disease, tx endometriosis, hyperandrogenism

Question 5

What is your breast cancer risk if first degree relative has breast cancer?

Answer 5

increased risk by 2-3X

Question 6

What is the baseline risk of breast cancer?
Is breast self exam recommended in average risk women?

Answer 6

1 in 8
No, bc it increases false positive rate and lack of evidence with benefit

Question 7

If you are Aschkenawzi jewish, what is your risk of being a carrier of BRCA 1/2… Compared to general population

Answer 7

Risk of BRCA 1/2 in A. Jewish: 1:40
Risk of BRCA 1/2 in general population: 1:300+

Question 8

3: what genetic testing would you do?

talk about referral to breast specialist if BRCA 1/2 positive..

Answer 8

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

Question 9

Who should be offered genetic counseling?
-long list that I reflect upon, however in general..

Answer 9

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

Question 10

Is BRCA the only hereditary cause of breast and ovarian cancer? If not, what % are due to other causes?

Answer 10

25% are due to other mutations
-use multigene panel to test for others

Question 11

What are the benefits of identifying a BRCA mutation?

Answer 11

-increased surveillance
-allows for risk reducing interventions (RRBSO and chemoprophylaxis)

Question 12

What are the A/E effects of tobacco abuse, especially regarding gyn organs?

Answer 12

cervical dysplasia, cervical cancer, endometrial cancer, colon cancer, early menopause, bladder cancer

Question 13

Tobacco Cessation
Meds and A/E

Smoking in pregnancy, when is the greatest benefit seen for cessation?

Answer 13

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

Question 14

Nicotine and pregnancy - vaping OK?

Answer 14

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.

Question 15

What vaccines do you check during preconception?

Answer 15

Covid, Flu (if during season), Hepatitis B, Varicella, MMR

Question 16

Nonclassical adrenal hyperplasia
-enzyme
-hormones

Answer 16

21 hydroxylase
-decreased cortisol and aldosterone

Question 17

Mirena amenorrhea rate (at 1 year)

Answer 17

20%

Question 18

SSRI CIN

Answer 18

concurrent use of MAOI (due to increased risk serotonin), QT prolongation

Question 19

Side effects of SSRI’s

Answer 19

GI upset such as nausea, vomiting, diarrhea, , insomnia, reduced sexual desire

Question 20

GAD -total
Moderate Anxiety
Severe anxiety

Answer 20

Out of 21
Moderate: >10
Severe > 15

Question 21

PHQ 9 - total
Moderate
Severe

Answer 21

out of 27
Moderate: >10
Moderete Severe> 15
Severe : 20

Question 22

EPDS - total out of
-positive for depression

Answer 22

out of 30
score 10+

Question 23

Breast Mass DDX

Answer 23

Benign: fibroadenoma, breast cyst, breast abscess, fibrocystic changes, fat necrosis

Malignant:
ductal carcinoma insitu
infiltrating ductal carcinoma
infiltrating lobular carcinoma
inflammatory breast cancer

Question 24

Breast Cancer in pregnancym- treatment

Answer 24

Breast surgery is feasible as well as chemotherapy during the 2 or 3rd trimester. Radiation would need to be deferred to post partum

Question 25

intraductal papilloma
-incidence
-why do we care?

Answer 25

10%
benign but some are malignant/can predispose to cancer (1% of cases, once excised can be upstaged to atypical ductal hyperplasia, DCIS, carcinoma)

Question 26

Breast abscess- I&D pump and dump?
what are complications of a breast abscess I&D?

Answer 26

1) no, can continue to feed
2) mammory duct fistula, milk fistula, recurrent infection, poor cosmoses

Question 27

What are the risks of a LEEP to future pregnancy?

Answer 27

PTD, cervical insufficiency– 2T loss, cervical stenosis

Question 28

What are HPV affects on path?

Answer 28

Koilocytes which are small raisinoid/small nuclei with a cytoplasmic halo

Question 29

15 Mgmt CIN 2 if concerns for pregnancy

Answer 29

Colposcopy + cotesting at 6 and 12 mo

Question 30

Pregnant and Cervical Cancer treatment:
Treatment depends on-
trimester

Answer 30

1T: treat as non pregnant
2T: terminate and treat
3T(and late 2T): weight risks/benefits delayed treatment with prematurity

Question 31

Pregnancy and Cervical cancer treatment:
weeks gestation and size

Answer 31

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

Question 32

After a LEEP, when should you wait to get pregnant?

Answer 32

want the cervix healed, ideally 3 months though there is no established guideline

Question 33

What is the definition of recurrent UTI?

Answer 33

3+ year or 2+ in 6 months

Question 34

how do you prescribe GNRH agonist?

Answer 34

Depo Lupron 11.25 mg IM x 3 months, daily Norehtinrone 5 mg. + Estrogen 0.625 mg if needed

Question 35

What is a Nuswab?

Answer 35

Nucleic Acid Amplification test
(NAAT)

Question 36

Nexplanon - when is back up not needed?

Answer 36

If Nexplanon inserted CD1-5, don’ need back up.

Question 37

Explain PCOS

Answer 37

Chronically elevated LH and insulin, leads to increased androgens made by ovaries. Hyperinsulimnemia suppressed liver production of SHBG, which results in increased free testosterone.

Question 38

Differential Diagnosis thyroid nodule

Answer 38

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

Question 39

Recurrent yeast infection: 4 + / year
Treatment

Answer 39

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)

Question 40

33 - what treatment would you offer her?

Answer 40

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