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6011 Clinical Reasoning Test 3 COMPLETE ☑️ > Module 10: Female GU > Flashcards

Module 10: Female GU Flashcards

1
Q

Abnormal Uterine Bleeding

-Structural AUB (PALM)

A
  1. Polyps
  2. Adenomyosis
  3. Leiomyoma
  4. Malignancy & hyperplasia
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2
Q

Abnormal Uterine Bleeding

-NonStructural Causes of AUB (COEIN)

A
  1. Coagulopathy
  2. Ovulatory dysfunction
  3. Endometrial
  4. Iatrogenic
  5. Not otherwise classified
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3
Q

Abnormal Uterine Bleeding

-Amenorrhea - Primary Vs. Secondary

A

Primary — Early in adolescence or teenage years

Secondary — Caused by PCOS, thyroid issue, weight changes,

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4
Q

Abnormal Uterine Bleeding

-Definitions

A
  1. Menorrhagia — Excessive menstrual flow
  2. Metrorrhagia — Inter-menstrual bleeding
  3. Oligomenorrhea — Infrequent periods
  4. Polymenorrhea — Periods occurring less than a 20 day window of normal menses
  5. Post-coital bleeding — Bleeding after intercourse — may be indicative of CERVICAL Cancer or atrophic vaginitis
  6. Dysmenorrhea — Painful menses
    —Primary is d/t excessive PGA2 (Prostaglandin produced during luteal phase
    —Secondary d/t PCOS, endometriosis, PID
  7. Dyspareunia — Painful intercourse
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5
Q

Common Differentials in Women’s health

A
  1. Vulvovaginal infections/STIs
  2. UTI/Pyelonephritis
  3. Nephrolithiasis
  4. Pregnancy/ectopic
  5. Contraception
  6. Sexual dysfunction
  7. Pre/peri/post menopause
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6
Q

Well Women’s Exam

-Health Hx

A
  1. Menarche — Onset of first menses in a woman
  2. Menstruation — Regular? Excessive? Painful? Absence of menses
  3. Menopause — Later 40’s — Hot flashes? Periods? Vaginal dryness
  4. Grávida — Total number of pregnancies —Para — Outcome of those pregnancies
    —Full Term/Premature/Abortions/Living children
  5. Sx’s (Discharge, pain, itching, lesions)
  6. Sexual contacts and practices — Orientation and response — Sexual satisfaction
  7. STI’s — Testing? Protection?
  8. HPV vaccine?
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7
Q

Menopause Definition

A
  1. 12 consecutive months w/ NO bleeding or spotting
  2. If a patient has gone through menopause then has new onset of bleeding or spotting, that is considered Post-menopausal bleeding
    —Can be Malignancy**EST
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8
Q

Women Exam

-Taking a Comprehensive Hx

A
  1. Use Inclusive, gender-neutral language
  2. Avoid assumptions
  3. Avoid using identity or labeling terms
  4. Be welcoming and affirming
  5. Show respect and empathy

Example Questions

  1. Have you been involved w/ anyone during the past year including oral, vaginal, anal sex or other kinds of sexual practices?
  2. Have you every been sexually involved w/ men, women, or both?
  3. How many sexual partners have you had in the past year?
  4. Do you have any concerns about your sexual identify?
  5. Do you desire to be involved sexually with men, women, or both?
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9
Q

PAP

-Speculum Exam Info

A
  1. Arrange equipment
  2. Gloves
  3. Inspect and palpate lymph nodes and external genitalia
  4. Spread labia or create bridge w/ dirty hand
  5. Insert speculum at a downward 45 degree angle using gentle pressure — Fully insert before opening.
  6. Retract speculum and let blades collapse on their own
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10
Q

PAP - Bimanual Exam Info

A
  1. Lubricate pointer and middle finger
  2. Insert 2 fingers into vagina w/ finger pads facing down then rotate hand w/ finger pads facing up after insertion
  3. Locate cervix and assess for cervical motion tenderness
  4. Place other hand on lower abdomen and assess motility of the uterus
  5. Palpate ovaries — Pelvic hand into right lateral fórnix while palpating the RLQ w/ abdominal hand then repeat for the left
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11
Q

AAFT Recommendations

A
  1. Do NOT require pelvic exam or other PE to prescribe oral contraceptive meds
  2. Do NOT perform Pap smears on women younger than 21 or who had hysterectomy for non-cancerous disease
  3. No NOT screen for cervical cancer w/ HPV testing alone, or in combination w/ cytology in women <30 yrs
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12
Q

ACP and ACOG recommendations

A
  1. Screening pelvic exams should NOT be performed in asymptomatic non-pregnant women
  2. Pelvic exam should NOT be performed for STI screening; Urine or Vaginal swab testing is sufficient
  3. Screening pelvic exams are not needed before prescribing OCPs
  4. Shared decision-making — Some women may want a yearly pelvic exam
    —Some abnormal findings may not be worrisome.
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13
Q

Recto-Vaginal Exam Recommendations

A
  1. Sometimes indicated with retroverted uterus or retroflex

2. Rectal exams can be performed on pt’s >50 yrs for fecal occult blood test

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14
Q

Pelvic Exams

-Special Populations

A
  1. Atrophic Vaginitis/vaginal stenosis — Ex: Post-menopausal patients
    —Use good amount of lube and narrow speculum
  2. Vulvodynia/vestibulitis/Vaginismus — Pain disorders of vulva or vagina — spasms during exam
  3. Hx of sexual trauma or abuse
  4. Hx of female circumcision — Female genital mutilation
  5. LGBTQI & Gender minority Pt’s — Address negative experiences
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15
Q

Recommendations for Exam in Trauma

A
  1. Offer mental health counseling
  2. Acknowledge exam may be difficult
  3. Normalize anxiety
  4. Female examiner/accommodate requests
  5. Offer consult only at first visit
  6. Offer for patient to bring friend or comfort object
  7. Offer patient to keep part of clothing on
  8. Assure she can stop exam at any time
  9. Offer position alternatives
  10. Anxiolytic medication

MAKE SURE to obtain CONSENT**

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16
Q

Female Genital Mutilation

-Type 1

A
  1. Partial or total removal of the clitoris and/or the prepuce
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17
Q

Female Genital Mutilation

-Type 2

A
  1. Partial or total removal of the clitoris and the labia minora w/ or w/out excision of the labia
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18
Q

Female Genital Mutilation

-Type 3

A
  1. Narrowing of the vaginal orifice w/ creation of a covering seal by cutting and appositioning the labia minora, and/or Majora w/ or w/out excision of the clitoris
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19
Q

Female Genital Mutilation

-Type 4

A
  1. All other harmful procedures to the female genitalia for non-medical purposes
    —Ex: Pricking, piercing, incising, scraping, and cauterization
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20
Q

Pelvic Exam

-Visual Inspection External

A
  1. Bartholin gland infection Cyst — Glands that are posterior and to the side of the introitus
  2. Check Tanner stages, piercings and tattoos
  3. Lesions
    - Assess location, characteristics, cyst, chancre, wart, herpes, folliculitis, herniations
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21
Q

Pelvic Exam

-Internal Inspection

A
  1. Cervical polyps/irregularities
  2. Discharge, lesions
  3. Anatomical abnormalities — cystocele or prolapse
  4. Vaginal tissue integrity — Erythema, atrophy, collapsing walls
  5. Retained tampon/condom
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22
Q

Vaginal Lesions

A
  1. Herpetic Lesions — HSV — Vesicles that are closer together on vulva or in the vagina
  2. Bartholin cyst — located around 5 and 7 o’clock of the vulva — Needs IND
  3. Genital (Anal) Warts — Fleshy color — cauliflower appearance
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23
Q

Cervical Lesions

A
  1. Retention/Nabothian Cyst — cyst that retain mucous and appear on surface of the cervix - Benign
  2. Polyp — Blood filled — can contribute to spotting — Usually benign but should be removed
  3. Lacerations — Trauma, s/p delivery — Ectopy may occur — Beefy red appearance w/ ectopy no D/c
    —Long term OCP use can lead to ectopy as well
  4. Trichomoniasis — Strawberry cervix
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24
Q

Specimen Collection

-Microscopy TEST

A

Prepare 2 wet-mounts — One is Saline and second is KOH

  1. Saline Wet-mount — Identifies Trichomoniasis and Bacterial vaginosis
  2. Trichomoniasis microscopy - Round protozoan w/ a flagella moving quickly
  3. BV has CLUE CELLS - looks like pepper or sand on edges
  4. Yeast infection — KOH is best — hyphae look like branches
  5. Whiff test — Drop of KOH on saline mount — FISHY odor = Bacterial Vaginosis
25
Q

Pelvic Organ Prolapse

-Examples

A
  1. Uterine Prolapse — Herniation of uterus or cervix into vagina
  2. Cystocele — Herniation of bladder into vagina
  3. Rectocele — Herniation of rectum into vagina — Weak rectovaginal septum
26
Q

Pelvic Exam

-Ex of Normal Documentation

A
  1. No inguinal lymphadenopathy. External genitalia w/out erythema, lesions or masses. Cervix w/out lesions or D/C, no cervical motion tenderness. Uterus anterior, midline, non-enlarged. No adnexal tenderness

This is normal documentation

27
Q

Pelvic Exam

-Abnormal Findings

A
  1. Lesions
  2. Discharge
  3. Swelling
  4. Cervical lesions
  5. Myomas
  6. Prolapse/Herniation
  7. Cervical motion tenderness (CMT)
  8. Cysts
28
Q

CC: Discharge

-HPI & Episodic Hx

A
  1. When did Discharge start — After intercourse? Has it been 2 wks, 2 days? S/p period? New parters?
  2. Quantity color, consistency
  3. Any associated itching, irritation, burning, or swelling?
  4. Sexual hx — any new partners recent past? Trauma hx, toys?
  5. Any previous infections? STIs?
  6. Any previous antibiotics? — more prone to infection
    —vaginal hygiene? Any harsh soaps, stringent washes or douching
  7. Pelvic Exam on PE — Cervical motion tenderness? Urine exam for GC, chlamydia, Trich
29
Q

Vaginal Discharge TEST

-Characteristics

A
  1. BV —Grey, white, thin, homogenous discharge — malodorous “fishy odor” —Coats Vaginal walls
  2. Trich — Yellow to green and sometimes grey —FROTHY — Pools in fórnix — Malodorous
  3. Candida “Yeast”— White, “Curdy” sometimes yellow — “cottage cheese” Thick or thin d/c, No odor
  4. HSV — Vesicles in the vulva or vault — Vaginal Lesions in the vagina, see d/c, w/ streaks of blood
  5. Chlamydia & Gonorrhea —Increased Strong smelling discharge — Yellow — Often asymptomatic
30
Q

CC Abnormal Uterine Bleeding

-HPI & Episodic Hx

A
  1. AWLAYS get Urine HCG test
  2. R/O Endometrial Carcinoma in all high risk Including the following:
    —Morbid Obesity, DM or Chronic HTN, Age over 35 yrs w/ bleeding in between periods or post sex
  3. Also assess for:
    - Thyroid enlargement & manifestations of hyperthyroidism or hypothyroidism
    - Galactorrhea — May suggest hyperprolactinemia
    - Visual field deficits — Suspicion of intracranial/pituitary lesion
    - Ecchymosis, Purpura — signs of bleeding disorder
31
Q

Abnormal Uterine Bleeding

-Definition

A
  1. Having irregular uterine bleeding that occurs in the absence of recognizable pelvic pathology, general medical disease, or pregnancy.
  2. AUB Reflects a disruption in the normal cyclic pattern of Ovulatory hormonal stimulation to the endometrial lining
32
Q

CC: Secondary Amenorrhea

-Causes?

A
  1. Extreme weight loss or weight gain
  2. Low BMI, Anorexia, Athletes
  3. PCOS — Hallmark is amenorrhea
  4. Pregnancy
  5. Endocrine disorders —Thyroid disorders
33
Q

CC: PCOS

-How to Diagnose?

A
  1. Rotterdam Criteria is used for diagnosis**
    -Presence of 2 of 3 elements confirms PCOS
    —Hyperandrogenism —clinical (Hirsutism) biochemical signs (free/total testosterone, SHBG)
    —Oligo-ovulation and/or anovulation
    —Polycystic ovaries on US (“String of pearls”)
    —Exclusion of other androgen excess disorders —Ex. Adrenal hyperplasia
34
Q

CC: Pelvic Pain

-Info

A
  1. Acute Vs Chronic — Chronic is pain >6 months, NOT responsive to Tx
  2. Onset, timing (S/P eating?), features (Sharp/Dull?), associated Sx’s (N/V)
  3. GU/GI causes?
  4. Musculoskeletal
  5. Sx’s in partners?
  6. STIs and IUD? Unprotected sex?
35
Q

CC: Pelvic Pain

-Emergent Differentials

A
  1. Ectopic Pregnancy
  2. Appendicitis
  3. Ovarian Torsion
36
Q

Pelvic Pain

-Most Common Cuases

A
  1. PID
  2. Ruptured Ovarian Cyst
  3. Appendicitis
  4. Endometriosis (chronic)
  5. Sexual abuse (chronic)
  6. Groin injuries
37
Q

Ectopic Pregnancy

-Info

A
  1. Location is usually tubal
  2. Presents as Rigid abdomen, guarding and rebound tenderness on ONE SIDE
  3. 9% of all maternal deaths and 80% of 1st trimester deaths — Increased mortality in African American women and those >35 yrs
  4. 40% missed on 1st presentation to ED
  5. EARLY DETECTION & MGMT**
38
Q

Ectopic Pregnancy

-Risk??

A
  1. IUD —DO NOT increase absolute risk of ectopic pregnancy** A pregnancy that takes place with an IUD in place is more likely to be ectopicTEST
  2. Previous Ectopic Pregnancy
  3. Bilateral tubal ligation — Tubal procedures “Essure (Coils in the Fallopian tube)
  4. Smoking
  5. G/C or PID
  6. 50% have NO identifiable risk factors
39
Q

Ectopic Pregnancy

-Presentation

A
  1. 6-8 wks post LMP
  2. Sx’s include
    - Vaginal bleeding, spotting
    - Abdominal/pelvic pain/back pain
    - Amenorrhea
    - Breast tenderness
    - Fainting
    - GI Sx’s
  3. Pelvic exam — Adnexal tenderness or CMT
40
Q

Ectopic Pregnancy

-Work up, MGMT, Referral

A
  1. POC Urine HCG or Serum beta HCG
  2. Transvaginal US
  3. Serial hCGs
  4. Referral to ED
41
Q

CC: Dysuria/Urgency

A
  1. CVA Tenderness + = Pyelonephritis (COMPLICATED INFECTION)
  2. Nephrolithiasis — Groin or one sided pain
  3. Incontinence —Urge or stress
  4. Overactive bladder
  5. R/O Diabetes
  6. POC UA — + for nitrates, blood, and/or WBCs = UTI
42
Q

Health Promotion/Disease Prevention

-Women

A
  1. ASCCP — PAP/HPV
  2. CDC for STIs — Routine testing annually for women age 18 (21) to 25** Sexually active
  3. Vaccination — HPV, Flu
  4. Unplanned pregnancy prevention — healthy pregnancy, Family planning
  5. Menopause/HRT — Post menopause puts woman at risk for osteopenia or osteoporosis
    —Mamograms above 40-50 yrs especially when on HRT
43
Q

Promoting Safer Sex

A
  1. Delaying first sexual intercourse
  2. Reducing number of sex partners
  3. Decreasing the number of times students have unprotected sex
  4. Increasing condom use
44
Q

Family Planning

A
  1. Routine health promotion for all (men, women, teens)
  2. Include partners in planning
  3. Preconception counseling — Folic acid, healthy lifestyle, mgmt of chronic illness, mental health
45
Q

Disparities in Screening

A
  1. Adolescents — Assumed not sexually active
  2. Sexual, ethnic minorities
  3. Obese
  4. Trauma
  5. Disabilities

This can create emotional distress and fear of pain

46
Q

Cervical Cancer

-Risks

A
  1. Failure to screen
  2. Multiple sexual partners
  3. Smoking
  4. Immunosuppression
  5. Long term use of Oral contraceptives
  6. Chlamydia co-infection
  7. Parity
  8. Prior cervical CA
  9. Genetic polymorphism
47
Q

Cervical CA Prevention

-HPV Vaccine

A
  1. Girls and boys starting at age 9 or 11-12 (2 dose series)
  2. If older than 12, pt get 3 dose series
  3. Recent approval through age 45 for both men and women
  4. Consistent condom use does NOT eliminate risk
48
Q

Bethesda’s System & MGMT

A
  1. System used to describe the type of dysplasia that might be present when the PAP comes back abnormal
  2. Provides recommendations on how to manage
49
Q

Women who have sex with women

-Screening Guidelines

A
  1. Do NOT presume low or no risk based on sexual orientation or current behavior
  2. Up to 70% of WSW have had sex with men

Screening for CA in WSW

  • Increased rates of breast and ovarian CA
  • Increased rates of obesity, ETOH, smoking, decreased parity and breastfeeding
  • Less likely to have used OCPs
  • Decreased utilization of CA preventive services
  • Identical guidelines as heterosexual women — Mammograms q1-2 yrs starting age 40-50
  • Ovarian Screening NOT recommended
  • Cervical — PAP tests q3 yrs starting at age 21 — q5 yrs after age 30
  • HPV vaccine ages 9-26
50
Q

Women who have sex with women

-STIs and Considerations

A
  1. WSW can still get STIs
  2. HIGH Prevalence of BV among monogamous WSW

Consider

  • Genital condyloma
  • HSV-1 & HSV-2
  • Gonorrhea, Chlamydia
  • Syphilis
51
Q

Transgender Patients

-Screening

A
  1. Cervical CA screening per guidelines for ASSIGNED sex at birth
  2. Females — Inform pathologist of current or prior testosterone use
  3. Endometrial CA evaluation in spontaneous vaginal bleeding
52
Q

Transgender Patients

-RISKS?

A
  1. Depression
  2. Anxiety
  3. Bullying
  4. SUICIDE**TEST
  5. Teens, elderly
53
Q

Ovarian CA

-Sx’s

A
  1. Women >50 w/ 3 or more of the following Sx’s present >12 times/month in < 12 months
    - Increased abdominal size
    - Abdominal DISTENTION
    - Abdominal BLOATING
    - Urinary Frequency
    - Abdominal Pain
    - Early satiety or difficulty eating
    - Pelvic Pain
54
Q

Ovarian CA

-Risk Factors

A
  1. Family Hx — 1st degree relative w/ CRC, OV CA< Breast, or endometrial CA
  2. Ashkenazi, French Canadian, Dutch, Icelandic
  3. > 50 yrs old
  4. BRCA 1 and 2
  5. > 90% = random

DECREASED RISK in

  • OCP use
  • Breastfeeding
  • Pregnancy
  • **NO SCREENING TESTS (CA-125 is not specific)

Postmenopausal Pt’s should NOT have palpable ovaries — If ovaries are palpable think CANCER

55
Q

STI’s

-Screening

A
  1. Most cases are ASYMPTOMATIC
  2. Chlamydia is MOST COMMON — Can lead to PIC and infertility

Screening

  • C/G — Annual screening <25 yrs and sexually active OR >25 yrs w/ risk factors (ex multiple partners)
  • C/Syphilis,HepB, HIV in pregnancy —Gonorrhea for those at high risk
  • C/G, Syphilis — Yearly screening for sexually active gay, bisexual, and other MSM — increased frequency w/ multiple partners
  • HIV — Once for all 13-64 YO
  • HIV — Annually for all those at risk, increase frequency for MSM (3-6 months)

-Counseling: Grade B USPSTF

56
Q

KEY Preventative Med Points

A
  1. Safer Sex practices
  2. Contraception
  3. Vaccines
  4. Optimal MGMT of chronic diseases
  5. Screenings?
    - PAP smears and STD screenings
  6. Policy — Loca, National, International — Abuse is mandatory reporting
57
Q

Bacterial Vaginosis

-Case Study 1:44:32

A
  1. You don’t need a pelvic exam when screening for STIs
    - Appropriate to do Pelvic Exam
  2. Grey homogenous thin vaginal discharge w/ fishy odor
  3. Clue Cells on wet prep
  4. Tx — Metronidazle 500 mg BID x 7 days
    —Don’t consume ALCOHOL during treatment d/t it causing N/V
  5. Discuss OTC, HPV vaccine, and safe sex practices
58
Q

STI Case 1:47:28

A
  1. Rapid screen shows chlamydia
  2. Do not report even if patient is 15 years old
  3. Report to health department
    —Also test for HIV and syphilis
  4. HPV vaccine, Contraceptives, and safer sex practices
59
Q

Kidney Stone Case 1:49:20

A
  1. Watch video

6011 Clinical Reasoning Test 3 COMPLETE ☑️ (4 decks)

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