Clinical Medicine - TW: intimate partner violence, sexual violence

Question 1

What is the differential if the fundal height is lower than expected?

Height (cm)

Answer 1

• Wrong dates
• Intrauterine growth restriction
• Oligohydraminos (decreased amniotic fluid)

Question 2

Which patients should be screened for intimate partner violence?

Answer 2

ALL patients

• Every new patient
• Any patient with signs of trauma
• Any patient with conditions associated with IPV
  
  • Extensive, can affect many organ systems: GI, Repro, Psych, behavioral signs

Question 3

G_P_ _ _ _

What does each blank stand for?

Answer 3

G_aP_{b c d e}

• a = Number of pregnancies
• b = Number of term births
• c = Number of preterm births
• d = Number of abortions (spontaneous or otherwise)
• e = Number of living children

Question 4

When should intimate partner violence be documented in a patient’s chart?

Answer 4

ONLY if the patient says it’s okay

Question 5

What is the differential if the fundal height is higher than expected?

Height (cm) > (#weeks gestation = 3)

Answer 5

• Wrong dates
• Multiples (twins, triplets)
• Fibroids
• Macrosomia
• Hydraminos

Question 6

List and describe the 3 components of the cycle of abuse

Answer 6

• Intimidation
  
  • Threats, abuse (physical, emotional, sexual)
• Violence escalation
  
  • This is often when pts will present to the ER or engage with healthcare providers
• Honeymoon phase
  
  • Abuser shows remorse
  • Victim may blame themselves

Question 7

After 20 weeks gestation, blood pressures above ____ would raise concern for pre-eclampsia or gestational HTN?

Answer 7

140/90

Question 8

How do you calculate the estimated date of delivery (EDD) for a pregnant patient?

Answer 8

From the first day of the last menstrual period (LMP)

EDD = LMP + one year - 3 months + 7 days

Question 9

When is it mandatory to report intimate partner violence?

Answer 9

When a patient presents with injuries from a firearm

If children are involved

Otherwise, not necessary to document/report - ALWAYS ask pt before documenting in their chart

Question 10

When during gestation does fetal movement begin?

When should there be a expected pattern?

Answer 10

Begins at 20 weeks

At 26 weeks, there is an expected pattern; deviations need to be evaluated for fetal well-being

Question 11

What is considered normal for fundal height?

At 20 weeks:

Beyond:

Answer 11

• At 20 weeks:
  
  • At umbilicus
• > 20 weeks:
  
  • #cm above pubic symphysis should be equal to weeks of gestation +/-3
  • Ex: 26 weeks => fundal height should be 23-29 cm above the pubic symphysis

Question 12

What tissue does Non-invasive prenatal screening (NIPS) look at to analyze the fetal genome?

Answer 12

Cell free DNA

Based on the assumption that the total number of fragments of any one chromosome is proportional to the size of the chromosome

Question 13

List 4 factors that will affect the fetal fraction of cell free DNA in maternal blood

Answer 13

• Gestational age
  
  • Slightly increases 10-21 weeks
  • Significant increase >21 weeks
• Maternal BMI
  
  • Higher BMI = lower Fetal fraction
• Small placenta
• Aneuploidy
  
  • Increased in Trisomy 21, decreased in Trisomy 18 and 13
  • This is what we’re actually looking for

Normally, fetal cell-free DNA is 10% of the total circulating cell-free DNA

Question 14

What is the earliest gestational age at which NIPS can be performed?

Answer 14

Any time after 10 weeks

Question 15

List 4 limitations of NIPS

Answer 15

• False positives
• Failed results
• Re-draw also has potential to fail
  
  • Delayed results delay time-sensitive decision making
• Results take 1-2 weeks
  
  • Especially important if close to 24 weeks

Question 16

What is the appropriate next test if NIPS is positive for a fetal aneuploidy?

Answer 16

Diagnostic testing

(Invasive method, ex: amniocentesis)

Question 17

Who should be offered prenatal genetic screening?

Answer 17

All pregnant patients

Offer either standard screening of cell free DNA

Question 18

A 62 year old man is seeing you in the office and complains that he wakes up 4 times per night to void (nocturia). He also communicates to you that the caliber of his urinary stream is narrow and he feels that his bladder is not emptying after voiding. Digitial rectal examination is most likely to reveal.

1. Absent Prostate
2. A prostate with multiple hard nodules
3. An enlarged, smooth contoured prostate
4. A soft (boggy), tender prostate

Answer 18

3. An enlarged, smooth contoured prostate

This is BPH

Question 19

A femoral hernia

1. Is the most common type of genital hernia
2. Is more common in women
3. Always presents with bulge into the scrotum
4. Occurs above the inguinal ligament

Answer 19

2. More common in women

Not sure why?

Question 20

All of the following STI screenings are used except

1. Gonorrhea at the cervix using cervival swab
2. Chlamydia at the urethra via urine testing
3. Gonorrhea at the rectum via rectal swab
4. Chlamydia at the pharynx via oral swab

Answer 20

4. Chlamydia at the pharynx via oral swab

Can test for gonorrhea at the pharynx

Take a detailed sexual history to know what kind of screening is recommended!

Question 21

What are NOT key cervical cancer considerations in FTM (female to male) patients?

1. screening according to USPSTF guidelines for all AFAB patients
2. required cervical cancer screening to be completed prior to starting gender affirming hormones
3. swabbing a greater circumference of the cervix to ensure an adequate sample
4. discussing the use of estradiol cream prior to office vist

Answer 21

2. required cervical cancer screening to be completed prior to starting gender affirming hormones

PAP Smears are NOT required

Everything else is best practice to make the screening more comfortable and accurate (testosterone can atrophy the vagina)

FTM patients are 10x more likely to have cervical cancer

Question 22

What are components of the Sexual Orientation and Gender Identity smartform in Epic?

Answer 22

• gender identity
• sex assigned at birth
• pronouns
• organ inventory
  
  • VERY IMPORTANT FOR CANCER SCREENINGS!

Question 23

What are the 5Ps of a comprehensive sexual history?

Answer 23

• Partners
• Practices (types of sexual activities)
• Prevention of pregnancy
• Protection from STIs
• Past history of STIs

Question 24

What kind of breast cancer screening is recommended for transgender patients?

Answer 24

Transfemale: high risk patients >50 yo (estrogen therapy for >5 years, family history, BMI >35) need screening

Transmale:

if intact breasts→ routine screening as AFAB

if post-mastectomy→ yearly chest wall and axillary exam

Question 25

What are puberty blockers?

Answer 25

GnRH agonists/analogs

Reversible intervention, but cannot regress puberty that has already taken place

Purberty occurs with pulsatile GnRH secretions, continuous GnRH secretions are inhibitory

Question 26

For patients taking gender affirming hormones, what are the reproductive considerations?

Answer 26

Discuss effects on future reproduction and possible fertility preservation (save eggs or sperm?)

Discuss prior to initiation and on an ongoing basis.

For transfemales: Estrogen is spermatotoxic.

For transmales: Eggs will never fully mature/develop without estrogen.

Question 27

What is the differential diagnosis for a pregnant patient who presents at 24 wks of gestation with a fundal height of 30 cm?

Answer 27

This is too big! (should be 21-27 inches)

Wrong dates, multiple gestation (twins), macrosomic fetus (big), uterine fibroids, polyhydramnios (excess amniotic fluid)

Question 28

A currently pregnant patient has a history of spontaneous miscarriage at 8 wks, an ectopic pregnancy, a vaginal delivery of a stillborn infant at 30 wks that was growth-restricted, a cesarean delivery of live-born twins at 32 wks who both weighed 2.5 lbs and another vaginal delivery at 38 wks of a live-born 10 lb infant. What is her gravidity and parity?

Answer 28

G6 P1223

6- pregnancies

1- term delivery

2- preterm deliveries

2 -abortions/miscarriages

3 living children

Question 29

A currently pregnant patient has a history of spontaneous miscarriage at 8 wks, an ectopic pregnancy, a vaginal delivery of a stillborn infant at 30 wks that was growth-restricted, a cesarean delivery of live-born twins at 32 wks who both weighed 2.5 lbs and another vaginal delivery at 38 wks of a live-born 10 lb infant.

What are the greatest health risks to her current pregnancy?

Answer 29

Gestational diabetes given the prior macrosomic infant.

Small risk of recurrent stillbirth

Question 30

Whar are the OB Review of Systems?

Answer 30

• Gestational movement (starts at 20 weeks)
• Uterine contractions
• Vaginal bleeding
• Leakage of fluid
• Pre-eclampsia signs/symptoms (headache, visual disturbances, RUQ/epigastric pain, shortness of breath, swelling)

Question 31

How do pregnancy complications impact future health?

Answer 31

Hypertensive disorders of pregnancy significantly increase risk of futre heart disease.

Women with gestational diabetes have a 35-60% chance of developing T2DM 10-20 years after the pregnancy.