GYN (part 1)-Exam 2 Flashcards

Question

Intrauterine Contraception * What medical conditions are indications? (5)

Answer 1

* DM * Thromboembolism * Menorrhagia/ dysmenorrhea * Breast CA * Liver Disease

Answer 2

* Pregnancy * PID (current or w/in past 3 months) * Current STDs * Undiagnosed abnormal vaginal bleeding * Malignancy of the genital tract * Purulent cervicitis

Answer 3

* Depo medroxyprogesterone acetate (Progestin only) * DMPA (150 mg) is given IM every three months * Efficacy is 99.7% * **DMPA use significantly reduces the risk of developing endometrial cancer**

Answer 4

* Menstrual irregularities (bleeding or amenorrhea), weight changes, headache, abdominal pain or discomfort, nervousness, dizziness, decreased bone mineral density * ACOG states that the advantages of DMPA generally outweigh the theoretical concerns about skeletal harm secondary to BMD loss due to decreased estrogen levels: use no longer than 2 years. * **Return of fertility may be delayed (need to educate them on this)**

Answer 5

* Nexplanon- A single rodprogestin implants * Contraception is provided for three years by slow release of progestin * Protection from pregnancy occurs within 24 hours of insertion

Answer 6

* Fertility returns rapidly after removal of the rod * Irregular bleeding is a common reason for discontinuation * Great option for a college student

Answer 7

* Early SE: Bloating, nausea, breast tenderness * Breakthrough bleeding is the MC SE (10-30% of women during the first 3 months) * Amenorrhea (should r/o pregnancy first)

Answer 8

more likely in high dose pills % with smoking * **Venous thrombosis** * PE * Gallbladder Dz * Stroke/ MI

Answer 9

* Estrogen has been shown to increase cholesterol production in the liver, with excess amounts precipitating in bile and leading to the formation of gallstones. * Progesterone has been shown to decrease gall-bladder motility, which impedes bile flow and leads to gallstone formation.

Answer 10

* Any previous thromboembolic event (clot) or stroke * Impaired liver function * Pregnancy * Undiagnosed abnormal vaginal bleeding (hormones can feed the carcinoma) * Cerebral vascular disease (past or current history) * Women over age 35 years who smoke * migraine with aura

Answer 11

* HTN * Anticonvulsants (may decrease effectiveness of OCP’s) * Migraine headaches (with focal neurologic symptoms) * Obese women over age 35 (due to glucose and hyperlipidemia) * DM

Answer 12

* The World Health Organization contraindicates the use of estrogen-based combined oral contraceptives in women with migraine with aura who are over 35. They are also contraindicated for women with migraine with aura who are under the age of 35 if they smoke due to their increased risk of cardiovascular disease. * Combined hormonal contraceptives are contraindicated in women who have migraine with aura, in whom these drugs can increase the risk of ischemic stroke. However, this contraindication is based on data from the 1960s and 1970s, when oral contraceptives contained much higher doses of estrogen

Answer 13

Emergency contraceptive pills * Levonorgestrel 0.75mg is given in 2 doses 12 hours apart; 1% failure rate; "plan B" * 4 pills taken 12 hours apart of LoOvral, Nordettee or Levlen; 3% failure rate

Answer 14

Copper IUD

Answer 15

Several anticonvulsants accelerate the metabolism of hormonal contraceptives; women on these medications should not use hormonal contraception (with the exception of depo provera) * Phenytoin * Carbamazepine * Topirimate

Answer 16

* Hormonal contraceptives may lower serum levels of lamotrigine * **Rifampin**

Answer 17

Multiple techniques (Laparoscopy or hysteroscopy) * Electrocautery of tube (poor reversibility) * Pomeroy Technique * Filshie Clip (lower failure rate) * Falope Ring (intermediate failure rates) * Hulka Clip (Reversible with great failure rate)

Answer 18

* Access to the fallopian tube is transcervical * A titanium-Dacron spring device is placed directly into the tubal ostia (Essure) or radiowaves scar surrounding tissue (Adiana) * A subsequent tissue reaction results in tubal occlusion

Answer 19

Often used for obese patients who may not be a candidate for laparoscopy

Answer 20

Realistic success rate 25% – 50% 25% of women under 30yo who undergo sterilization later regret the decision * Private insurance pays after age 18yo * Medicaid, in some states after age 25yo * Some OBGYNs will not do this until 30yo

Answer 21

* Permanent nature of the procedure * Alternate methods of contraception * Risks and benefits of the procedure (including risk of ectopic pregnancy)

Answer 22

Various techniques for vasectomy * Excision and ligation * Electrocautery * Mechanical or chemical occlusion of the vas deferens More easily reversed than sterilization procedures for women ## Footnote * Failure rate is 1% * 1/3 of surgical sterilization procedures are performed on men

Answer 23

Heterosexual and Lesbian females, Bisexual Men are at highest risk

Answer 24

Definition: When Sexual Violence (SV) involves a victim less than 18 years old. Involvement of a child in sexual activity that he/she: * Does not fully understand * Does not consent to or is unable to give informed consent or * Is not developmentally prepared for and cannot give consent to

Answer 25

* ACE may affect how a person thinks, acts and feels-over a lifetime * Short and long term physical and mental health consequences

Answer 26

* Type of human trafficking * Form of modern-day slavery * “use of force, fraud or coercion to make an adult engage in commercial sex acts” * 1 (888) 373-7888->National Human Trafficking Hotline

Answer 27

* Enacted in 2000 * Framework for the federal response to human trafficking * 3 pronged approach – Prevention, Prosecution and Protection

Answer 28

* Dept. of Homeland Security investigates bulk of sex and labor trafficking cases involving foreign nationals * FBI investigates domestic minor sex trafficking cases

Answer 29

* Attention to physical injury * Evaluate for STI * Emergency contraception * Pscyhological counseling-30/35% lifetime risk of posttraumatic stress response, depression and contemplation of suicide

Answer 30

* Landmark studies indicate ~ 52% * Serious injury requiring emergent intervention uncommon * Bruises and abrasions most common * Intracranial injury ~1% * Visceral injury ~3% * Fractures of face and skull ~2%

Answer 31

* Do you best to document the history in the patient’s own words * Document body cavities involved * Document number of assailants * Document last consensual intercourse * Document last LMP and if the patient is known to be pregnant

Answer 32

* Note time since assault, if the patient has changed clothes, bathed. * Assume your documentation will be used in court * Obtain consent from patient or next of kin to proceed to pelvic examination and take photographs and document that consent

Answer 33

* Have the patient disrobe while standing on a white sheet-collect any debris or pubic hair that fall * Use a wood light to identify semen (fluorsces), collect with swabs * Note any skin injury-entire body

Answer 34

* HEENT- Swab inside of cheeks and around molars in mouth * Pelvic exam-Swab vaginal walls-apply to slides, air dry * Look for motile or nonmotile sperm under microscopy and record

Answer 35

* When a stain is used on cervix, colposcopy raises the documentation of trauma to ~ 80% in adolescents, ~60% in women * Colposcopy with photographs has become the standard of care in the sexual assault forensic examination

Answer 36

* All may be applied to vagina, anus or mouth as history dictates * Neisseria gonorrhoeae, Chlamydia * Wet mount for Trichomonas * Pregnancy

Answer 37

* VDRL: Venereal Disease Research Laboratory (VDRL) test for syphilis * HIV viral load or antibody if indicated * Repeat pregnancy test if next LMP is missed, repeat VDRL in six weeks * Obtain blood and urine if forced drug or alcohol reported

Answer 38

* Analgesics or sedative if indicated * Tetanus toxoid * STD prophylaxis * HIV prophylaxis * Hep B vaccine * Counseling and psychologic support

Answer 39

* The CDC recommends the following testing schedule: Hepatitis B testing: 1–2 months after exposure. * Hepatitis C testing: 4–6 months after exposure (or earlier, if desired) * HIV testing: administered at 6 weeks, 3 months, and 6 months.

Answer 40

* Talk therapy with skilled clinician * Pharmaceuticals may be needed short and long-term * Supportive environment key * Insight key

Answer 41

Always refer to a facility that has providers qualified to perform an expert forensic examination, if available.

Answer 42

* Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision. * Document the informed consent conversation and the patient’s (or surrogate’s) decision in the medical record in some manner. When the patient/surrogate has provided specific written consent, the consent form should be included in the record.

Answer 43

Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about: * The diagnosis (when known) * The nature and purpose of recommended interventions * The burdens, risks, and expected benefits of all options, including forgoing treatment

Answer 44

* American Cancer Society (ACS) and the American Congress of Obstetricians and Gynecologists (ACOG): may begin every 1-3 years from age 25 to 39, and annually thereafter (Level C) * The US Preventive Services Task Force (USPSTF): concludes that evidence is insufficient to assess additional benefits of clinical breast examination beyond mammography (Level I)

Answer 45

* ACS recommends that women be educated about the benefits and limitations of BSE * ACOG recommends routine teaching of BSE * USPSTF recommends against teaching women the procedure stating there is moderate or high certainty that the service has no net benefit or that the harms outweigh the ben

Answer 46

* BSE alone has not been shown to reduce mortality rate, but evidence of its usefulness is mixed, and it is widely practiced. * Because a negative BSE may tempt some women to forego mammography or CBE, the need for these procedures should be reinforced when BSE is taught.

Answer 47

Patients should be instructed to do BSE on the same day each month. For menstruating women, 2 or 3 days after menses ends is recommended because breasts are less likely to be tender and swollen.

Answer 48

* Any inappropriate secretion of milky discharge from the breast. * Often results from abnormally elevated levels of prolactin, although it may occur with normal levels

Answer 49

* Med- MOIs, SSRIs, Many antihypertensives, drugs of abuse * Systemic disease-Chronic renal failure, hypothyroidism, Cushing's, acromegaly

Answer 50

* Any history of menstrual disorders, increased acne, hirsutism, infertility or libido * Review all medications, dietary supplements and drug use * Check thyroid function * Check for unknown pregnancy

Answer 51

* If possible, stop any medications that may be contributing * Correct any underlying disorder

Answer 52

* Severe pain, tenderness, swelling, redness * Fever, chills, myalgias * Typically occurs in second week postpartum * Due to milk stasis and infection * Ultrasound will reveal hypoechoic (dark) fluid surrounding subcutaneous fat lobules

Answer 53

* Staphylococcus aureus ~40% of cases * E. Coli * Streptococcus species * If abscess present, consider MRSA

Answer 54

Referral to breastfeeding support if desires breastfeeding * Correct latch * Drain plugged ducts ## Footnote You do not have to stop the patient from breastfeeding

Answer 55

* All Purpose Nipple Ointment: LANOLIN * Bactroban 2% ointment, betamethasone 0.1% ointment, miconazole powder 2% are not superior ## Footnote You do not have to stop the patient from breastfeeding

Answer 56

If significant, prophylax typical skin flora **You CANNOT give bactrim to lactating mothers with infants under 2 months old** Should respond rapidly, if not look for an abscess and broaden antibiotic coverage ## Footnote You do not have to stop the patient from breastfeeding

Answer 57

* Uncommon complication of Mastitis * Subcutaneous fluid collection on ultrasound * Management based no severity of infection-PO antibiotics, IV antibiotics, outpt/inpt * Surgical drainage last resort ## Footnote Occurs in about 3% of Mastitis cases

Answer 58

Erythematous, tender to palpation * May lead to mastitis Requires referral to a breast surgeon for imaging and possible biopsy

Answer 59

* Erythematous skin overlying a portion of, or the entire breast * Very tender to palpation * Possible enlarged axillary nodes, also tender * Infection can spread along lymphatic pathways (lymphangitis)

Answer 60

* Clinical diagnosis * No labs needed unless evidence of systemic infection or septic in appearance * Typically beta hemolytic streptococcus or staph-appropriate antibiotic coverage

Answer 61

* If no rapid response (48hours) to antibiotics- US of breat to look for abscess or malignancy * May also request mammography and MRI

Answer 62

Cyclic – begins with luteal phase and resolves with menses * Bilateral Noncyclic – not associated with menses * Common causes: tumors (adenoma), mastitis, cysts

Answer 63

Nonmammary * Common causes: chest wall trauma, rib fractures, fibromyalgia Treatment options: * OCPs, supportive undergarments, danazol, tamoxifen ## Footnote Under notes: * Danazol is in a class of medications called androgenic hormones. It works to treat endometriosis by shrinking the displaced tissue of the uterus. It works to treat fibrocystic breast disease by blocking the release of hormones that cause the breast pain and lumps. * tamoxifen blocks estrogen's action on breast cells,

Answer 64

* Bilateral nipple discharge is not as concerning as unilateral * Unilateral discharge carries a higher risk of cancer * Purulent likely indicates infection

Answer 65

Pink, bloody, or serosanguinous discharge carries a higher risk of cancer -> Requires further investigation with ductogram * Mammography and discharge fluid analysis warranted

Answer 66

Most common benign breast disease - ~50% of women of reproductive age * Most common ages 30-50 Thought to be due to hormonal imbalance * Estrogen

Answer 67

* Multiple, usually bilateral TENDER mobile masses in the breast * Cyclical bilateral breast tenderness, most prominent just before menstruation * Red flags: recurrent or severe symptoms, solid masses, nipple abnormalities, edema, skin changes, unilateral discharge

Answer 68

Although fibrocystic condition has generally been considered to increase the risk of subsequent breast cancer, only the variants with a component of epithelial proliferation (especially with atypia), papillomatosis, or increased breast density on mammogram represent true risk factors

Answer 69

Ultrasound: Especially in women under 30 * Too radiodense Mammogram Core needle biopsy Suspicious lesions

Answer 70

* GLA is known for its anti-inflammatory properties and its ability to support hormonal balance. * Once consumed, GLA is converted into beneficial compounds called prostaglandins, which regulate various bodily functions, including inflammation, blood clotting, and hormone synthesis

Answer 71

* African American>Caucasians * Benign mass * Usually occur ~20 years after puberty and regress after menopause

Answer 72

* Typically round, firm, discrete, relatively movable non-tender mass 1-5cm in diameter * Biopsy for definitive diagnosis * Excise

Answer 73

KNOW FIRST THREE

Answer 74

Milk ducts: Ductal Carcinoma * Can be both invasive and in situ Milk-producing lobules: Lobular Carcinoma * Usually invasive Connective tissues (rare) * Sarcoma (phyllodes tumor and angiosarcoma)

Answer 75

Fibroadenoma like tumor Grows rapidly Benign or malignant * Excise with margins of normal tissue Metastasis to the lungs

Answer 76

* Fibrocysitc changes * Lactational adenomas * Fibroadenomas

Answer 77

* Epithelial hyperplasia * Sclerosing adenosis * Papillomas

Answer 78

* Lobular carcinoma in situ (LCIS) * Ductal carcinoma in situ (DCIS)

Answer 79

* Three histological categories: Ductal, lobular and nipple * 70-80% are ductal which spread to regional LN * 5-50% are invasive lobular carcinomas

Answer 80

Graded after biopsy is performed Cancers are fueled by hormones * Estrogen receptor (ER) positive-> Treated with antiestrogens * Progesterone receptor (PR) positive->Treated with progesterone blockers * Hormone receptor (HR) negative->Endocrine treatment is not useful

Answer 81

* Specific genetic mutations: HER2 gene * **Different types with combo: Triple negative (KNOW THIS ONE) or ER/PR or HR-/HER2 negative. Here BRCA1 gene is common too** * HR + cancer grows slower, HR - faster, **triple negative are the fastest**

Answer 82

* Usually found via mammogram, less often from finding palpable mass * If palpable, mass is typically not painful * May have nipple discharge, erosion, retraction, enlargement or itching of the nipple

Answer 83

* Rare – bone pain, swelling of arm * Fewer than 10% of breast cancers are found on Physical Exam

Answer 84

* Inspect the. Breasts – asymmetry, retraction or dimpling of skin * Palpate breasts and axillary and supraclavicular areas thoroughly

Answer 85

* Non-tender, hard or firm with poorly defined margins * Lesions >1cm are generally palpable

Answer 86

* Edema * Redness * Peau d’orange * Fixated to chest wall * Retraction of breast * Marked axillary lymph nodes * Supraclavicular lymphadenopathy

Answer 87

* Diagnosis by H&P, mammography, needle aspiration, biopsy * Most common positive sentinel node is Axillary

Answer 88

Management depends on staging * Lumpectomy * Mastectomy * Axillary LN dissection * Radiation * Chemotherapy * Hormonal therapy

Answer 89

Eczematoid eruption and ulceration of the nipple Associated with underlying carcinoma * Adenocarcinoma cells There is a palpable mass in ~50% of patients with paget's disease

Answer 90

Of these masses-95% are found to be invasive cancer * Ductal carcioma in situ * 2 cm from nipple areolar complex If with no palpable mass-noninvasive breat cancer or cancer in situ is present in 75% of cases Uncommon (~1%) but important due to it's being frequently misdiagnosed

Answer 91

Paget’s Disease of the Breast (PDB)

Answer 92

Paget cells * These cells are found in the epidermis (surface layer) of the skin of the nipple and the areola. * Paget cells often have a large, round appearance under a microscope; they may be found as single cells or as small groups of cells within the epidermis.

Answer 93

* Aggressive * Clinical appearance – diffuse, brawny edema with erysipeloid boarder * Usually has an underlying palpable mass. * 35% of patients will have metastasis at presentation

Answer 94

block the lymph vessels in the skin of the breast. This causes the breast to look red and swollen. The skin may also appear dimpled or pitted, like the skin of an orange (peau d'orange), and the nipple may be inverted (facing inward).

Answer 95

* Pregnancy associated-breast cancer that occurs during pregnancy, in the first post-partum yeat or anytime during lactation * Tyically present at a later stage * Formerly, pregnancies were terminated within first two trimesters-this has been dtermined not to improve the outcome

Answer 96

* Women can receive some chemotherapeutic agents in second and third trimester, no radiation treatments. * There is a teratogenic risk and decision must be individualized

Answer 97

* <1% * However – breast cancer in one breast increases risk of future cancer in the other breast.

Answer 98

* Breast imaging modality of choice and the only screening method found to decrease mortality of breast cancer * Estimates that lesions can be detected 2 years earlier than on palpation * A skilled radiologist correctly interprets mammograms with a 90% rate

Answer 99

* Useful as a next step in evaluation of a breast mass detected on mammography * Recall negative predictive value from PAM670 * Useful in initial evaluation of suspected abscess, infection.

Answer 100

* Excellent visualization * Offered as initial test more frequently * Leads to biopsy more often

Answer 101

* Requires examination of tissue via biopsy * Safest course is to biopsy all suspicious masses * Also safest to biopsy all suspicious lesions demonstrated on mammography

Answer 102

hypercalcemia

Answer 103

* CT and bone scans used most frequently * Sentinel Node * Some cancer centers will use a combo of PET and CT scans – allows for evaluation of visceral and bony metastases

Answer 104

* American College of Radiology, American Cancer Society and American Medical Association recommend annual mammograms for women starting at age 40. * American College of Obstetricians and Gynecologists recommend mammography every 1-2 years for women age 40-49 and annually thereafter. * USPSTF recommends biennial screening at 50-74 | * TEST!!!

Answer 105

* Women with a genetic predisposition for breast cancer should be screened using MRI beginning at age 25 or the age of the youngest occurring breast cancer in family * Same women should undergo a combo of mammogram and MRI after age 30 | * TEST

Answer 106

* Breast cancer patients should have life-long follow-up * Physical exam every 3-6 months for first three years and then every 6-12 months until year 5, and annually thereafter * Mammogram within 6 months of treatment completion and annually thereafter * Routine labs-CBC, Chem panel with LFTs

Answer 107

* Due to lymphatic disruption * Significant Edema * May refer to a PT or OT who specializes in lymphedema * Wrapping * Therapeutic exercise

Answer 108

Bone is the most common site of metastatic disease both at initial diagnosis and recurrence * Thoracic spine 63.6% and Lumbar spine 53.8% Bisphosphonate therapy has been shown to decrease pain and slow rate of skeletal events and complications When given – monitor dental health, labs, renal function

Answer 109

* Stage at diagnosis single most reliable indicator. * Localized disease without evidence of regional lymph spread carries best prognosis. * 5-year survival rates are not indicative of any true value

Answer 110

* Women with breast cancer survive, on average, 20 years less than those at same as them at diagnosis * Clinical cure rate achieved in 75-80% of women with localized disease * Patients with metastatic breast cancer are unlikely to be cured and care shifts with time

Answer 111

* If you see cellulitis, treat it. Should the cellulitis not go away with ABX within 3-5 days, consider ultrasound. In this case ultrasound will be most effective and superior to r/o abscess (which could be the reason why cellulitis did not get better). * If there is no abscess, then mammogram is the next step to look for inflammatory mass/cancer. If mass is identified, refer to surgeon for biopsy.

Answer 112

* The above process is slightly different in a noncellulitic mass noted in a patient. If you find a noncellulitic mass in a 30yo female, US is best. If patient is 40yo, the mammogram is best. * Sometimes a negative predictive value is the goal. Lets say a 40yo patient has no risk factors for breast cancer and you find a tender (cyclical) mass on exam. Considering most likely diagnosis to be fibrocystic change, getting an ultrasound may prevent a biopsy (if the negative predictive value is achieved). If patient has risk factors, then biopsy should be the next step.