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Rotation 2: IM Outpatient > GU Portion > Flashcards

GU Portion Flashcards

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1
Q

stress urinary incontinence

who is this common in?

why does it occur?

explain the pressure differences?

what actions might bring this on?

what are 3 things that could cause this in a person?

A

common problem in women of all ages and results from weakness or disruption in the pelvic floor muscles leading to poor support of the vesicourethral sphincters

usually: the i_ntraurethral pressure is greater than the intravesicular pressure_ which is called the urethral closure pressure

if i_ntra-abdominal pressure increases_ from things like coughing, laughing, or sneezing and the pressure isn’t equally distributed to the urethra then incontinence occurs

causes of decreased muscle tone: aging, child birth, surgical procedures

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2
Q

urge urinary incontinence

what does the pt feel?

what is this associated with?

what is the definition of this?

what are 2 contributing factors?

3 symptoms?

A

overactive, nocturia, urinary frequency, detrusor overactivity

loss of urine associated with strong desire to void URGENCY, often associated with overactive bladder

definition: urgency, frequency with or without incontinence in the absence of UTI or obvious pathology

Two contributing factors to overactive bladder:

  1. CNS and neural control of bladder sensation and emptying, ex: stroke, Parkinsons, MS
  2. smooth muscle of the bladder itself (myogenic)
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3
Q

incomplete emptying “overflow” urinary incontinence

what are 7 signs of this?

what are two causes?

what are 2 causes in women?

what are 2 causes in men?

A

intravesical pressure exceeds the maximal urethral pressure because of bladder distension

dribbling, weak urinary stream, frequency, and nocturia, hesitancy, frequency, nocturia, nocturnal enuresis (bedwetting), detrusor underactivity or bladder outlet obstruction

women causes: uterine prolapse, previous incontinence surgery

men: most common is enlarged prostate gland

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4
Q

what are the 3 PE tests you want to do with someone with urinary incontinence?

what are the 4 workup tests you would do?

A

PE:

  1. pelvic exam
  2. digital rectal exam (masses, prostate)
  3. neuro exam if sudden loss (think cauda equina)

Workup:

  1. urinalysis
  2. prostate specific antigen
  3. post void bladder scan
  4. urology consult
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5
Q

although urinary incontince tx is dependent on the type, what are 5 tx options you could consider?

A
  1. fluid management
  2. timed voiding
  3. bladder retraining
  4. keagle/pelvic floor exercises
  5. surgical intervention
  6. pessaries to hold uterus up
  7. decrease caffine/alchohol
  8. (urge) anticholinergics

(oxybutynin, possibly tricyclic antidepressant)

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6
Q

nephrolithiasis

calcium oxalate stones

can you see it on a xray?

what is it usually associated with?

what are 4 associated factors?

3 tx options in general?

A

MOST COMMON TYPE OF STONE

  1. RADIOOPAQUE
  2. usually associated with high calcium levels in the blood and urine
  3. contributing factors: excessive bone reabsorption, bone disease, hyperparathyroidism and renal tubular acidosis predispose for these stones

TX:

treat underlying conditions

increased fluid intake

thiazide diuretics

(70-80%)

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7
Q

nephrolithiasis

uric acid stone

what is this caused by?

can you see on xray?

what are 2 RF?

2 tx options?

A

caused by low Ph (acidic) urine

  1. radiolucent cant be seen on xray
  2. caused by high levels of uric acid in the urine or gout
  3. RF: obesity/diabetic or both

Tx:

  1. decrease uring PH below 6 (more alkaline) using potassium citrate
  2. allopurinol with decrease purine diet (fish, shellfish, and meats)
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8
Q

nephrolithiasis

cystine stones

what type of disorder is this and who is it common in?

what is the appearance of the stones?

what are the two treatement options?

A

autosomally recessive inherited abnormalities CYSTINURIA

“childhood caliculi”

1.smooth-edged ground glass appearence

TX:

  1. increase urine volumes to 3 L a day and increase urine pH to greater than 7
  2. occasionally chelating agents
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9
Q

what are 6 RF for nephrolithiasis in general?

A

high humidity

high temp

sedentary

high animal protein and high salt

FH for calcium stones

hyperthyroidism/hypothyroidism

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10
Q

what are the 4 most common symptoms with nephrolithiasis? and less common symtpoms? (4)

A

Most common:

  1. unilateral flank pain
  2. sudden onset
  3. renal colic
  4. hematuria

Less common:

  1. vague abdominal pain
  2. acute abdominal/flank pain
  3. difficulty urinating
  4. penile or testicular pain
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11
Q

what is the most common cause of recurrent calcium stones?

A

most common abnormality elevated Ca excretion, decreased serum Ca

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12
Q

stone passage

  1. explain how size and location effect the ability to pass the stone?
  2. what are two meds you can give to help during the passage?
A

size

5-10 mm less likely to pass on their own

>10 mm won’t pass on their own

location

stones in proximal ureter less likely to pass

ureterovesicular junction more likely to pass

Meds to help pass:

alpha blocker (tramsulosin)

CCB (nifedipine)

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13
Q

if you txing a pt with nephrolithiasis what are 3 things you want to do to help manage the pt?

when do you consider hospitalization (2)?

A
  1. most managed conservatively with pain management Nsaids and Opoids (BETTER USED TOGETHER!!)
  2. hydration
  3. strain urine

consider hospitalization:

uncontrolled pain/fever

can’t tolerate oral intake

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14
Q

why is it important to educate your patient on recurrence for nephrolithiasis?

A

⅓ will experience stone recurrence within 5 years

½ experience stone reccurence within 10 years

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15
Q

Nephrolithiasis

what are the two things you need for the formation of crystals?

what are four risk factors that allows this to happen?

what are the four types of stones?

A

formation is dependent on supersaturation and an environment that allows the stone to grow!

supersaturation risk:

heredity- cystinuria SLC3A1/SLC7A9

environmental

diet

obesity

four types of stones:

  1. calcium oxalate
  2. struvite
  3. uric acid
  4. cystine
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16
Q

nephrolathiasis

struvite stone

what 2 things is this associated with?

4 bacteria?

can you pass them?

when do they get bigger?

3 tx options?

A

“staghorn” stones that always associated with UTI and alkaline urine

  1. produced by UTI with urease producing bacteria
  2. proteus, klebsiella, pseudomonas, enterobacter
  3. made of magnesium ammonium
  4. usually too large to pass and require lithotripsy or surgical removal
  5. they enlarge as the bacterial count increases

Tx:

  1. prevent UTIs
  2. lithrotripsy
  3. surgical removal
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17
Q

what is the most important test when suspecting nephrolithiasis? what do you expect to see for each of the stones? 4 types of labs you should consider ordering?

A
  1. non-contrast CT (gold standard)
    used to identify the size, location and type of stone

  • low density (aka can’t see): uric acid, cystine
  • high density: calcium oxalate, struvite
  • struvite: laminar, rugged apperance, full of casts with “stag horn apperance”

*****do renal US for pregnant people who can’t have the CT****

  1. labs
  2. urinalysis (stone type/blood)
  3. BMP (calcium and creatinine if worried about kidney function)
  4. 24 hour urine for the amount excreted
  5. thyroid function test
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18
Q

what are the 5 tx options for nephrolithiasis?

A

1. NSAIDS and opoids!!

1.5. increased fluid intake key!

2. shock wave lithotripsy (small renal caliculi)

3. precutaneous nephrolithotomy

4. rigid and flexible ureterscopy +/- stent placement

(tx of choice for maority of middle and distal urethral stones or those who failed shock wave lithrotripsy)

5. diet changes for Ca oxalate stones (decrease spinach, animal protein, Na intake)

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19
Q

Complicated UTI

Pregnancy

what are 3 things its assocaited with?

do you screen?

if positive what must you do (2)?

what is one really key thing to remember about UTI and pregnant women?

A

associated with preterm birth, low birth weight, prenatal mortality

screen in 1st trimester with UC

admit them since dangerous with baby

always check urine culture if asymptomatic because the bacteria in the urine can cause the things under A, if + treat with abx

if they get 2+ positive tests with greater than 100,000 positive tests they they will be on suppressive abx for the remainder of the pregnancy

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20
Q

Complicated UTI

eldery

what are two groups of peopel that are esp susceptible?

what are three things that contribute to the first?

A

postmenopausal women

  1. bladder/uterine prolapse
  2. loss of lactobacilli in vaginal flor allos for E. coli to take over
  3. diabetes (sugar)

benign prostatic hypertrophy

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21
Q

complicated UTI

children

who is this more common in?

3 symptoms?

what is the DOC?

how long do you treat for, two options?

A

white children more common than black children

fever, hematuria, abdominal pain

DOC: 2nd-3rd line cephalosporin

7-14 days if febrile

5 days if immune competent and afebrile

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22
Q

complicated UTI

males

what are two risk factors?

urethra length?

A

unusual for men 15-50

RF: uncircumcised, anal intercourse

antibacterial material in prostatic fluid

18-20 cm urethra

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23
Q

who are UTIs most common in?

what is the most common route of infection?

what are most from?

what isthe pathogenisis of this and what does it RARELY come from?

A

30:1 ratio women to men because women have a significantly short urethra

route of infection: ascending from the urethra

UTI most commonly from uncomplifcated acute cystitis

pathogenisis:

  1. colonization of vaginal introitus by uropathogens from fecal flora ascend from urethra into bladder CYSTITIS
  2. uropathogens ascend from bladder to kidney via ureters

RARELY CAUSED BY SEEDING OF BACTERIA

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24
Q

what are 5 RF for UTI?

A

female sex

frequent sexual intercourse

diaphragm/spermicide use

delayed post-coital micturition (not urinating after intercourse)

hx of UTI

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25
what are four bacteria that cause UTI and which is by far the most common? what percent?
**e.coli most common 75-95%** proteus mirabilis klebsiella pneumoniae enterococcus
26
what are the difference in symptoms for cystitis (6) vs pyelonephritis? (5)
cystitis: ## Footnote 1. dysuria or burning while urination 2. increased frequency/urgency 3. suprapubic pain/discomfort 4. hematuria 5. voiding small amounts 6. AFEBRILE pyelonephritis 1. FEBRILE 2. chils 3. flank pain 4. costovertebral tenderness 5. CBC with left shift
27
what 3 lab tests are important to do when diagnosiing a UTI? what do you find on each?
**1. UDIP** _+ leukocyte esterase (product of baceteria)_ _+ nitrites (conversion of nitrates to nitrites via bacteria)_ _+WBC_ _+WBC casts (**INDICATES KIDNEY ORIGIN!\*\*\***)_ **2. hematuria** **3. culture greater than 100,000**
28
what are the DOC fo acute cystitis (4) vs pyelonephritits (2)? what do you need to note?
**_acute cystitis_** _DOC1: TMP-SMX_ DOC2: CIPRO DOC3 if pregnant/allergic: Nitrofurantoin \*\*\*add _pyridium_\*\*\* **_acute pyelonephritis_** _DOC1: ciprofloxacin_ DOC2: TMP-SMX \*\*\*\*\*NOTE THE DOC FOR FOR THESE TWO ARE DIFFERENT!!!\*\*\*\*\*
29
what is the DOC for an inpatient with UTI/pyelonphritis?
CIPROFLOXACIN!! others: fluoroquinolone, amp+gentamycin, ceftriaxone
30
what is the most common nosocomial infection in the US? what is the tx protocol with this?
cathertized associated UTI ## Footnote _if asymptomatic don’t need to treat with abx_ screen urine 48 hours after removing catheter
31
recurrent UTIs ## Footnote what are the two definitions of this? what should you consider? what about in women with decrease in lactobacillis?
_3 or more episodes per year confirmed UC_ OR _2 UTIs in last 6 months_ ## Footnote consider self treatment at first sign (urine cup for UC) vaginal estrogen in women since they have a decrease in lactobacillus
32
in _asymptomatic bacteremia_ who do you treat (3) and who do you not treat (3)? \*key!\*
**_treat:_** 1. pregnant 2. before urologic procedures 3. after renal transplant **_DONT TREAT_** 1. diabetics 2. elderly 3. patients with spinal cord injury or indwelling urethral catheter
33
do you tx UTI empirically while waiting for culture?
YES! then adjust abx as appropriate! :)
34
benign prostatic hyperplasia ## Footnote who does this happen in? where does it start in response to what? what does it cause? 7 sxs!!!
increased incidence in nearly ALL MEN!! 80 and up 90% incidence!!! begins around the **_urethra in response to increase dihydrotestosterone production and estrogen causing_** **_urinary obstruction leading to SXS_** SXS: **1. decrease in stream quality** **_a. hesitancy_** **_b. dribbling_** **_c. takes longer to pee, don't pee as far_** **2. incomplete emptying/frequency** **3. retention** **4. nocturia**
35
how are symptoms for BPH scored? 2
international prostate symptom score (IPSS) American system (AUA)
36
what are the 3 general tx options for BPH?
1. watchful waiting 2. medications 3. surgery \*\*depends on severtiy of sxs!!\*\*\*
37
what are 3 tx options for BPH? how do they work? any cautions? 3
1. alpha 1 adrenergic blockers "flow" ## Footnote **"TAMULOSIN"** **relax bladder to improve sxs** \*\*\*watch for decreased libido, dizziness, floppy iris syndrome\*\*\* 2. 5 alpha reductase inhibitors "shrink" **"FINASTERIDE"** inhibit enzyme that convert testosterone to 5 alpha dihydrotestosterone (DHT) which decreases testosterone stimulation of the gland 3. combination-increase flow and shrink 1. dutasteride/tamulosin 2. tadalafil
38
what are the 4 surigcal options for BPH?
1. transurethral resection of prostate (TURP) 2. transurethral microwave therapy (TUMT) 3. transurethral needle ablation (TUNA) 4. transurethral US guided laser induced prostaectomy (TULIP)
39
do you always tx BPH?
no! only if pt is symptomatic
40
prostate cancer ## Footnote where does this occur? invasive? sizes of prostate? screening?
occurs in the secretory gland below the bladder that contributes to seminal fluid **_common, slow growing cancer that leads to urinary obstruction_**"you die with it not from it!! Prostate usually 20 ml (chesetnut or walnut) prostate cancer: 40 ml enlarged golf ball Need to make sure to screeen since hereditary!!!!
41
prostate cancer staging!\*\* ## Footnote what do you use to stage? explain the rating system
gleason scoring ## Footnote 1= well differentiated (favorable) 5=poorly differentiated (unfavorable) THEN add the two bx together for a score between 2-10, 10 is the worst oucome
42
what are the sxs with prostate cancer? 2 ## Footnote how do you dx? 3
sxs: _usually asymptomatic_ untill metastsizes to _bone_ causing _bone_ pain might cause urinary sxs if gotten into uretha and cause dx 1. DRE: hard irregularity/nodule, usually posterior 2. transrectal bx or US guided bx 3. if positive _get erdionucleotide bone scane to look for metastasis_
43
where are the 4 places prostate cancer likes to metastasize?
1. _bone_ 2. blood 3. lymph 4. local
44
how can you screen for prostate cancer? 3
controversial 1. DRE 2. PSA 3. prostate cancer antigen 3
45
who has the highest incidence for prostate cancer? general lifetime risk?
african americans general lifetime risk: 16%
46
what are the 4 tx options for prostate cancer? what is the gold standard?
1. surgery-radical prostatectomy or robotically ## Footnote a. can cure b. high incidence of impotence and incontinence 2. radiation with external beam or implantable seeds a. not curative b. palliation of bone mets c. less impotence and incontinence than surgery 3. hormone-androgen deprevation a. suppressive, not curative 4. chemo? not effective as much
47
what are you options when using hormone therapy for prostate cancer and androgen deprivation? what drugs can you use for each method?
1. remove testosterone production via orchiectomy (remove teste) ## Footnote 2. inhibit ACTH and estrogen (leuprolide) 3. inhibit testicular synthesis of testosterone (aminoglutethimide) 4. inhibit binding of androgen (flutamide)
48
prostate specific antigen ## Footnote what is this? 1 pro 2 cons controversial?
serine protease that is involved in liquefaction ## Footnote **pros:** **elevated in 65% of cases** **Cons:** **35% false negative rate** **non specific since also raised in prostate enlargement and prostatis** leads to more dx but doesn't decrease mortality so controversial...why look for a problem?
49
prostatitis ## Footnote what is the difference between acute and chronic? SXS? 5 2 dx? 2 tx?
**ACUTE:** ## Footnote often in _young_, with _sudden onset_ often **_e.coli, klebsiella (poop bugs)_** **CHRONIC:** prostate normal on exam can be from reccurent infection or inflammation SXS: 1. **FEVER CHILLS** **2. PROSTATE TENDERNESS** **3. DYSURIA (SINCE INFECTION!)** **4. URINARY FREQUENCY** **5. LOW BACK PAIN!** DX: 1. consider prostate massage if first culture negative 2. clinical and UA Tx: 1. ciprofloxacin 2. alpha blockers
51
psychogenic causes of erectile dysfunction ## Footnote what percent of cases? what is this? 2 common causes? 3 problems seen
20% of cases ## Footnote common cause and occurs because the _mood must br right_, commonly effected by _depression and anxiety_ Problems seen: **1. can't initiate** **2. can't fill (encgorge) usually arterial proble** **-diabetes** **-HTN** **-ASHD** **3. can't store veno occlusive** **dysfunction**
52
organic causes of erectile dysfunction ## Footnote what perecent of cases is this? 4 causes 3 2 1 1
80% of cases ## Footnote causes: **1. hormonal** **-loss of testosterone in testicular failure** **-pituitary tumor producing prolactin** **-pituitary failue** **2. drugs** **-antihypertensives** **-psychological** **3. vascular disease** **4. peyronies disease**
53
priaspism ## Footnote what is it what do you do?
persistent painful erection ## Footnote emergent urology consult
54
what is the difference between primary and secondary hypogonadism?
_primary_ low testosterone, high LH or FSH (north works, south doesn't _secondary_ low testosterone, low to normal LH/FSH, so therefor north not working well too
55
what testing sequence should you do to evaluate for hypogonadism?
1. AM total testosterone level 2. if low, repeat morning testosterone x2 Interpreation: A. if low testosterone, with LH and FSH not elevated then it is **secondary hypogonadism** B. if low testosterone, with increased LH and FSH than **primary hypogonadism**
56
what are 5 test you want to do for erectile dysfunction?
**1. testosterone level** **2. prolactin levels** \*\*if this is high, it causes low levels of testosterone\*\* **3. LH** **4. US** **5. nocturnal penile tumescence testing "tape testing"**
57
if prolactin levels are high what do you want to do?
get MRI because it likely has CNS origin, possibly tumor
58
what are 5 tx options for erectile dysfunction? ## Footnote what does the medication do? what can it cause? effected by? 2 names?
1. replace testosterone if low 2. phosphodiesterase 5 inhibitor - relaxes SM allowing for filling - can cause headaches and flushing and when combined with nitrates can cause massive dip in BP - effected by high fat meanls SILDENAFIL/TADALAFIL 3. prostaglandin E1 - alprostadil - intra-penile injection or intraurethral 4. vaccum device 5. surgery-penile prosthesis
59
what is hypogonadism caused by? how to you give testosterone?
1. testicular failure 2. problems from hypothalamic/pituary axis \*\*give depo-testosterone _IM_ 1-2x a month!!\*\*
60
Cervical Cancer ## Footnote what is it? what 4 things most commonly cause it?
**_IT IS A STI!!!!_** ## Footnote HPV in 99.7% of cases HPV: **_16, 18_**, 31, and 33
61
Cervical cancer ## Footnote what are two important stats on this? where does this likely occur? what are the two most common histological types?
3rd most common GYN cancer in US and #2 of ALL CANCERS in women worldwide ## Footnote usually occurs at the **_transformation zone_** (at SJC junction between squamous epithelium and glandular epitelium) squamous cell 69% adenocarcinoma 25%
62
explain the progesson of cervical cancer and why this is considered a cancer that effects 40-50s and why we screen in younger women?
cervical dysplasia is a precursor for cervical cancer ## Footnote **Cervical intraepithelial neoplasia _CIN_ is the _preinvasive phases of cervical cancer_** (it isn't cancer yet!) **carcinoma in situ _CIS is the first cell change to cancer_** Ages: 20s: common occurance of CIN 25-35: CIS becomes more common in addition to continuation of CIN 40-50: Cervical cancer
63
explain the ranking of cervical intraepithelial neoplasia (CIN)?
CIN1: mild dysplasia CIN2: modterate dysplasia CIN3: severe dysplasia \*\*1/3 of patients will progress to carcinoma\*\* CIS: carcinoma in situ
65
how do you prevent cervical cancer?
gardisil vaccine protects: 6, 11, _16, 18_ reccomended ages for bots and girls 11-26 years old
66
why was the pap smear considered a epidemology succes?
decreased the insicidence and mortality from cervical cancer 75% in the last 50 years in developed countries, 95% according to hoffmans lecture?
67
explain the process of performing a colposcopy? what is it used for? what are 2 management tecnniques?
used to follow up abnormal pap results ## Footnote magnifies cervix cervix stainged with **_acetic acid (vinegar) or iodine_** to identify the areas that need to be bxed tx/management options 1. loop-electrosurgical excision procedure (LEEP) 2. ablation of T-zone with cryrotherapy or laser
68
what are you intervention options based on the possible cervical bx results?
1. mild lesions may resolve spontaneously 2. preinvasive neoplasia can be txed with electrocautery, cryocautery, laser surgery, conization, large loop excesion of transitional zone, or LEEP procedure (Green book)
69
what symptom and PE findings are found with cervical cancer? what do you use to dx? what are the tx options? 3
SXS: early cervical CA is **_asymptomatic_** irregular or heavy vaginal bleeding **_post coital bleeding and spotting MC sxs_** PE: **_possible lesions that are raised and friable_** DX: colpscopy with bx Tx: if early stage 1. radical hysterectomy 2. fertility-sparing surgery 3. radiation and chemo **_if metastic of reccurent, media survival is less than 2 years_**
72
explain HPV 16 and 18 and what they are likely to cause?
responsible for 70% of cervical cancers **_16_:** higher rates of **_squamous cell cancers_** CIN3 **_18:**_ higher rates of _**adenocarcinomas_**
73
what percent of woman who get cervical cancer never got a pap?!
50%
74
what are the screening guidelines for a pap smear?
1. start at age 21 until 65 (don't check if under 21 and sexually active) ## Footnote 2. screen every _3 years_ from _21-29_ 3. _pap + HPV "co-test" every 5 years_ if between _30-65_ \*\*notice you don't screen for the actualy HPV virus if you are under 30
75
testicular cancer ## Footnote who is this most common in? what are the two types? 3 1 2 main presentations?
**typically in younger men 20-40 years old** 1. seminoma tumors a. less aggressive b. radiosensitive (get radiation tx) c. normal levels \*\*\*\*\*\*seminoma are Simple and Sensitive\*\*\*\*\* 2 ​non-seminomatous tumors a. screte AFP but not HCG (green book says both sxs: _painless testicular nodule_, solid mass, or enlargement "_heavy testicle_"
77
what puts a person at higher risk for testicular cancer?
cryptochidism (undescended testicle)
78
what is the cure rate for testicular cancer?
90%
79
testicular cancer ## Footnote 3 dx 3 tx
dx: ## Footnote **1. US** **2. Self exam/physical exam** **3. tumor markers** **_beta human gonadotrophic hormone_** (beta HCG) **_alpha feto protein (AFP)_** tx: 1. orchioplexy-CUT IT OUT 2. chemotherapy etoposide +cisplatin+/-bleomycin 3. fix cryptochidism before puberty
80
if someone is dx with testicular cancer, what MUST you do?!
you must get a chest xray because testicular cancer metastasizes here!
81
what must you do for ANY breast lump?
exclude cancer!!!!!!!!! ## Footnote this is 2nd most common breast complain in primary care, 90% are benign but still need to rule out cancer!!!
82
what is the triple test used when a breast lump is identified?
1. breast exam 2. mammorgram (often with US) 3. needle BX **A. fine need aspiration (FNA)** **B. core needle Bx (CNB)**
83
how do you make a definitive dx of breast cancer? (3)
bx via... 1. fine needle aspiration 2. core needle bx 3. open bx
84
what is the most common cancer in women?
breast cancer!
85
where are the 7 MC mestastasis placed for breast cancer?
1. lymph node 2. liver 3. lung 4. brain 5. bone
86
what are 7 potenital sxs of breast cancer?
1. lumps 2. bumps 3. skin changes 4. dimpling 5. red, hot 6. pain/no pain 7. regional node enlargement
87
what predominates in premenopausal women with bumps/lumps
benign conditions predominate
88
what predominates in post menopausal women with lumps and bumps? what do you need to remeber?
malignant lesions ## Footnote in postmenopausal women, any dominant mass or assymetry should be presumed cancerous until proven otherwise
89
how do you determine between a mass and a cyst?
US!!! sometimes simplest is to aspirate the mass
90
what should any solid mass, wheter or not it is imageable, warrants...
a definitive dx...bx it!!!
91
what is the GOLD STANDARD for dx breast cancer?
Biopsy!!! superior to even the most advanced imaging
92
when in doubt when it comes to a mass...
assume nothing! aspirate or refer to surgeon
93
Malignant neoplasm: Pagets disease what is this? common? what are two other things to look for? 5 sxs?
cells collect around the nipple causing eczematous appearance Rare-5% 97% also have **_ductal carcinoma in situ OR invasiver cancer elsewhere in the breast_** sxs: **_ITCHING_** **_TINGLING_** **_BURNING_** **_scaling and thickening of the skin_** **_yellow or bloody discharge from the nipple_**
95
non-invasive breast cancer: ## Footnote _ductal carinoma in situ_ what is this? common? life-threatening? how are they found? 2 tx options?
_MOST COMMON TYPE OF NON-INSIVE BREAST CANCER_ _1 in 5, 25% of all BC is this_ non-lifethreatening, typically without signs and symptoms **increases risk of developing invasive BC** **80% found on mammorgram** tx: 1. lumpectomy alone 25-30% recurrence 2. lumpectomy and radiation 15% recurreny
96
non-invasive breast cancer: _lobular carcinoma in situ_ what is this? what does it increase risk of? when/how is it dxed? receptor positive?
collection of abnormal cells, not true cancer ## Footnote **_increases risk of invasive cancer later in life_** dxed before menopause, usually dxed becuase bx performed for some other reason **hormonal receptor positive**
97
Breast Cancer: _invasive ductal carcinoma_ what is this? what percent? 6 sxs? 5 tx options?
most common invasive breast cancer!!! 70-80% of BC SXS: **_1. swelling of all or part of the breast_** **_2. skin irritation or dippling_** **_3. breast pain_** **_4. nipple pain/nipple turing inwards_** **_5. nipple discharge other than milk_** **_6. enlarged lymph nodes in the axilla_** TX: 1. lumpectomy less than 2 cm 2. mastectomy (partial, total, radical) 3. sentinel lymph node bx 4. axillary lymph node bx 5. post surgical radiation
98
what is involved in pt follow up for invasive ductal carinoma breast cancer? 4
1. provider visit with exam every 3-6 months for first 3 years 2. every 6-12 months for 4-5 years 3. every year post 5 years 4. yearly mammogram
99
breast cancer: _invasive lobular carcinoma_ common? where does it occur? age?
**2ND MOST COMMON TYPE 10% OF CA** **BEGINS IN THE MILK PRODUCING LOBULES** occurs later in life around 60s
100
what are 5 additional tx options for a patient with with invasive ductal carcinoma post lumpectomy?
**1. chemotherapy** **2. hormonal therapy** **3. estrogen receptor down regulatiors-tamoxifen** **4. oviaran shut down or removal** **5. HER2 therapies-block HER2 that allows for rapid cancer growth**
102
invasive breast cancer: ## Footnote _inflammatory breast cancer_ what does this look like? how to dx? 4 staging options? 2 tx options?
rare, average age in 55s **_looks like eczema on the breast (not confined to nipple), breast enlarged_** DX: 1. **_skin punch bx_** Staging: **_1. CXR_** **_2. CT of chest/abdomen_** **3. bone scan** **4.LFT** TX: _1. chemotherapy prior to surgery_ _2. targeted therapy: if HER2 receptor postivie **also treat prior to surgery HECEPTIN**_
103
invasive breast cancer: _inflammatory breast cancer_ how does your response to pre-surgical chemo effect the next step in tx?
if cancer response to first dose chemo before surgery: _modified radical mastectomy_ ## Footnote if no response to first dose chemo before surgery: _another round chemo + radiation and likely radiation AFTER surgery_
104
what are 7 RF in developing breast cancer?
1. female 2. greater to 55 3. no children, no breastfeeding 4. exogenous exposure to estroen 5. family hx postive for BC 1st degree relative 6. BRCA1 and 2 7. obesity
105
BRCA1 and BRCA2 ## Footnote risk? age? where?
60% increase in risk of BC 1. develope breast cancer earlier 2. have bilaterally breast more often
106
do malignant breast conditions tend to have more or less discharge?
less
107
how do you dx breast cancer? 4
1. yearly breast exam by provider 2. US 3. _aspiration/bx=gold standard_ 4. mammogram-controversial time frame
108
mammogram guidelines: ## Footnote (2 main guidelines)
very controversial ## Footnote 2 main: - start at 40, Q 1 or 2 years - start at 50, Q1 or 2 years
109
how is Breast cancer staged? 3
1. size 2. spread to lymph node 3. metastasis
110
when are 6 instances it is appropriate to test a patient for BRCA1 and BRCA2?
1. eastern european 2. AA before dx before 35 3. in all family of man dx 4. women with BC in both breasts 5. multiple family with breast or ovarian cancer 6. blood relative before 50
111
what is the most LETHAL GYN cancer? what the nickname?
Ovarian cancer! "silent killer" by the time we dx it it is already really progressed and metastisizes!
112
if you find an enlarging ovarian mass with a solid component or change in character _esp in post menopausal woman_, what should you do?
REMOVE IT!! ASAP!!!
113
is it reccomended to screen for ovarian cancer?
no because it does not appeare to reduce mortality
114
what are the genetic markers associated with ovarian cancer?
CA-125 BRCA1 and 2
115
what is the most common type of ovarian cancer?
_epithelial carcinomas_ 85-90% of all ovarian cancers
116
what are the 3 types of ovariance cancer classifications? ## Footnote include caracteristics of each 5 4 4
**1. _epithelial_** ## Footnote **MC TYPE** **most are benign** - epithelial carcinomas 85-90% of all ovarian cancers - clear cell-rarely benign - transitional **_2.**_ _**germ cell_** occurs in cells that produce eggs young women teenage-20s 5-10% _teratomes or dermoid cysts are in 40-50% and can contian hair and teeth_ _3. stomal carcinoma_ in connective tissues of the ovaries that produce estrogen and progesterone rare low grade _produce hormones_
117
what are 4 protective factors of ovarian cancer?
OCP more than 1 full term pregnancy before age 35 breast feeding tubal ligation
118
how much does have the BRCA1 and BRCA2 genes increase womens chance of ovarian cancer? what should they consider?
increase lifetime risk by 25-50% ## Footnote \*\*\*consider **_prophylactic billateral salpino-oophorectomy (BSO) by age 35 or as SOON as childbearing is complete for familial ovariance cancer syndrome!!!!!\*\*\*\*_**
119
ovarian cancer ## Footnote what are the 3 sxs that are likely to present in late dxs? what do you need to keep in mind? 2 dx?
**usually asymptomatic until late disease** **_late stage sxs usually when person presents_** **1. abdominal pain/bloating** **2. early satiety (feeling full)** **3. urinary urgency/frequency** palpable ovary needs evaluation!!! dx: 1. transvaginal US 2. laparoscopic evaluation
120
what is the 4 tx options for ovarian cancer?
1. surgery-removal of tumor (may be total hysterectomy) ## Footnote 2. oophorectomy 3. chemotherapy 4. sometimes radiation

Rotation 2: IM Outpatient (12 decks)

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