Ob/Gyn Flashcards
1
Q
Most common cause of unilateral nonbloody nipple discharge?
A
Inraductal papilloma
2
Q
Diagnostic testing for nipple discharge?
A
Mammogram and definitive diagnosis is surgical duct excision. Cytology not helpful.
3
Q
Bilateral nipple discharge, most likely diagnosis? What test to order?
A
Most likely prolactinoma. Order prolactin and tsh levels.
4
Q
20-50 year old woman with cyclical bilateral breast lumps with pain that varies with menstrual cycle. Diagnosis?
A
Fibrocystic breast disease
5
Q
Treatment for fibrocystic breast disease?
A
OCPs, Danazol if severe pain.
6
Q
Firm, discrete, nontender, highly-mobile breast nodule. FNA shows epithelial and stromal elements. Diagnosis?
A
Fibroadenoma
7
Q
Steps for diagnosis of breast mass?
A
- Clinical breast exam
- U/S or mammography (if patient over 40)
- FNA biopsy
8
Q
When do you use ultrasound to evaluate breast mass?
A
If mass feels cystic on palpation, or mass is on younger women with denser breast
9
Q
Patient with ductal carcinoma in situ (DCIS), what is the treatment?
A
Lumpectomy (with clear margins) along with radiation therapy and tamoxifen for 5 years
10
Q
Lobular carcinoma in situ (LCIS), what is the treatment?
A
Tamoxifen alone for 5 years, don’t have to perform surgery.
11
Q
Risks associated with tamoxifen use?
A
Endometrial carcinoma and thromboembolism
12
Q
Most common form of breast cancer?
A
Invasive ductal carcinoma (85%), mets to bone, liver, and brain
13
Q
Second most common form of breast cancer?
A
Invasive lobular carcinoma (10%), will be bilateral 20% of cases
14
Q
Red, swollen, warm breast with pitted, edematous skin. Have to rule out?
A
Inflammatory breast cancer. It metastasizes early
15
Q
USPSTF breast cancer screening recommendation?
A
Biennial mammography for women age 50-74
16
Q
Indications for BRCA1 and BRCA2 gene testing?
A
- Family history of early-onset (before age 50) breast or ovarian cancer
- Breast and/or ovarian cancer in the same patient
- Family history of male breast cancer
- Ashkenazi Jew
17
Q
Which hormone receptor confers a greater benefit for adjuvant therapy for breast cancer?
A
Estrogen. Both estrogen and progesterone positive tumors are the most responsive, however estrogen alone is nearly as good.
18
Q
MOA of tamoxifen?
A
SERM. 5 year treatment -> 25% decrease in mortality
19
Q
MOA of anastrozole, exemestane, letrozole?
A
Aromatase inhibitors. Blocks peripheral production of estrogen. Standard of care for HR+ postmenopausal women.
20
Q
Indication for chemotherapy in breast cancer?
A
Tumor size >1 cm or positive lymph node
21
Q
Adverse effects of tamoxifen?
A
- Worsens menopausal symptoms
- Increases risk of endometrial cancer
- Increases risk of thromboembolism
22
Q
Women with history of of tamoxifen use presents with vaginal bleeding. Next diagnostic step?
A
Endometrial biopsy, need to rule out endometrial cancer.
23
Q
Pre or postmenopausal women presents with HR-negative invasive breast cancer. Treatment?
A
Chemotherapy w/wo Radiation therapy
24
Q
Premenopausal women presents with HR-positive invasive breast cancer. Treatment?
A
Chemotherapy w/wo Radiation therapy plus tamoxifen
25
Postmenopausal women presents with HR-positive invasive breast cancer. Treatment?
Chemo w/wo Radiation plus aromatase inhibitor
26
African american woman presents with enlarged, firm, asymmetric, nontender uterus. Beta-hCG negative. Diagnosis?
Leiomyoma
27
What is adenomyosis and how does it present?
Abnormal location of endometrial glands and stroma within myometrium of uterine wall. Uterus feels soft, symmetric, and is tender.
28
Ultrasound findings of adenomyosis?
Diffusely enlarged uterus with cystic areas within myometrial wall
29
Options for leiomoma management?
Observation, myomectomy, embolization, or hysterectomy (reserved for once fertility is completed)
30
Risk factors for endometrial carcinoma?
Unopposed estrogen states (obesity, nulliparity, late menopause/early menarche, chronic anovulation)
31
Endometrial biopsy shows adenocarcinoma, next step?
TAH w/ BSO, pelvic and para-aortic lymphadenectomy, and peritoneal washings, may need RT or chemo if mets
32
Indications for surgical removal of an asymptomatic simple cyst?
- Cyst >7 cm
| - Previous steroid contraception without resolution of cyst.
33
31 y/o F w/ sudden severe abdominal pain for 3 hours, 8 cm adnexal mass present, must rule out?
Ovarian torsion
34
9 y/o F w/ R adnexal pain and complex cystic mass on u/s. Most likely diagnosis? What tumor markers should order?
Germ cell tumor.
| Tumor markers: LDH, b-hCG, aFP
35
Postmenopausal F with weight loss, distended abdomen and L adnexal mass. Most likely diagnoses? Tumor markers?
Epithelial tumor
| Tumor markers: CA-125, CEA
36
Postmenopausal F w/ bleeding. Endometrial bx shows endometrial hyperplasia. Pelvic U/S shows R ovarian mass. Most likely diagnosis? Tumor markers?
Granulosa-theca (stromal tumor), these tumors secrete estrogen which cause endometrial hyperplasia
Tumor markers: Estrogen
37
48 y/o F w/ increased facial hair and deepening of voice. Adnexal mass noted on exam. Most likely diagnoses? Tumor markers?
Sertoli-Leydic cell (stromal tumor), these tumors secrete testosterone which causes masculinization syndromes.
Tumor markers: testosterone
38
64 y/o F w/ hx of gastric ulcer, worsening dyspepsia, weight loss, adnexal mass found on exam. Most likely diagnosis? Tumor markers?
Metastatic gastric cancer (Krukenberg tumor), these are mucin producing adenocarcinomas from stomach that metastasize to the ovaries, often times both ovaries.
Tumor markers: CEA
39
Benign HPV is which numbers, and what do they cause?
6 and 11, causes condyloma acuminata
40
Age range for Pap smear screening?
21-65
41
Below 30 yr screening frequency for average risk pt?
every 3 years, cytology only
42
After 30 y/o screening frequency for average risk pt?
Every 3 years w/ cytology alone. Or, every 5 years w/ HPV testing
43
Most common type of cervical cancer?
Squamous cell carcinoma
44
Age for gardasil vaccine?
8-26
45
Antibiotics for chlamydia?
Azithromycin PO or Doxycycline PO
46
Abx for Gonorrhea?
Ceftriaxone IM or Cefixime PO
47
Ultrasound shows bilateral cystic pelvic masses, most likely diagnosis?
Chronic PID
48
30 y/o female with dysmenorrhea, dyspareunia, painful bowel movements, and infertility. Most likely diagnosis?
Endometriosis
49
First and second most common sites of endometriosis?
1. Ovaries (chocolate cysts)
| 2. Cul-de-sac
50
Work up for endometriosis?
Start with ultrasound, definitive diagnosis with laparoscopic visualization
51
First/Second line treatment and general management of endometriosis?
1. Continuous oral progesterone
2. Testosterone derivatives (danazol) or GnRH analogs (Lupron)
Additionally laparoscopic lysis adhesions, laser vaporization of lesions - can help w/ infertility
Or TAH/BSO for severe symptoms
52
Premenarchal bleeding, must rule out?
```
Sarcoma botryoides (cancer of vagina or cervix, will see grapelike mass arising form vaginal lining)
Also rule out tumors pituitary gland, adrenal gland, ovaries, and sexual abuse
```
53
Evaluation of premenarchal bleeding?
Pelvic exam, followed by CT or MRI of brain, abdomen, pelvis to look for estrogen-producing tumor. If work-up negative -> Idiopathic Precocious Puberty
54
Primary amenorrhea diagnosis criteria?
- Absence of menses at age 14 w/o secondary sexual development or,
- Absence of menses at age 16 w secondary sexual development
55
16 y/o f w/ primary amenorrhea, breasts present but uterus absent on ultrasound. Differential diagnosis? What tests do you order next?
- Mullerian agenesis versus Complete androgen insensitivity
- Order testosterone levels and karyotype. Mullerian agenesis XX karyotype, and normal testosterone for female. Complete androgen insensitivity, XY karyotype, and normal testosterone for male.
56
16 y/o f w/ primary amenorrhea, breast absent and ultrasound shows uterus present. Differential? What tests do you order next?
- Differential: Gonadal dysgenesis (Turner's syndrome) versus Hypothalamic-pituitary failure
- Order FSH and karyotype. Turner syndrome will see XO karyotype and elevated FSH. Hypothalamic-pituitary failure will have XX karyotype, low FSH.
57
Androgen insensitivity management?
Removal of testes before age 20 (risk of testicular cancer). Followed by estrogen replacement.
58
Turner syndrome management?
Estrogen and progesterone replacement for development of secondary sex characteristics
59
Evaluation of secondary amenorrhea?
1. beta-hCG
2. TSH
3. Prolactin level
4. Progesterone challenge test
5. Estrogen-Progesterone Challenge test
60
Treatment for premenstrual dysphoric disorder?
SSRIs, may add Vitamin B6 (pyridoxine)
61
Presence of gestional sac visible at approximately what b-HCG level?
1500
62
Fetal heart sounds first heard at approximately what age?
8-10 weeks
63
Fetal movements first felt by approximately what week?
20 weeks
64
What caution is there for nitrofurantoin for UTI's in pregnancy?
Avoid after 30-38 weeks, may cause neonatal anemia
65
Rubella antibody negative pregnant mother, next step?
Immunize after pregnancy, do not give immunization during pregnancy
66
Trisomy 21 early testing in pregnancy consists of?
b-hCG, PAPP-A, Fetal nuchal translucency
67
Increased MS-AFP for triple marker testing, differential diagnosis?
Neural tube defect, ventral wall defect, twin pregnancy, placental bleeding, renal disease, sacrococcygeal teratoma, gestational dating error
68
Decreased MS-AFP in triple marker screening, differential diagnosis?
Trisomy 21, Trisomy 18, gestational dating error
69
What are the 3 types of placenta accreta?
Placenta accreta - Placenta does not penetrate entire thickness of myometrium
Placenta increta - extends further into myometrium
Placenta percreta - penetrates entire myometrium to uterine serosa
70
Pregnant women in first trimester. Gets mononucleosis type symptoms. Says she handled cat feces, drank raw goats milk, and ate some undercooked meat. Diagnosis? Confirmation? Treatment?
- Toxoplasmosis gondii infection
- Diagnose by testing serum toxoplasma IgG and Igm levels
- Treat with pyrimethamine and sulfadiazine
71
Can you give live attenuated varicella vaccine to pregnant women?
No
72
Congenital varicella infection presentation?
Zigzag skin lesions, limb hypoplasia, microcephaly, microphthalmia, chorioretinitis, cataracts
73
Congenital rubella presentation?
Congenital deafness, congenital heart defects, "blueberry muffin" rash
74
Late-acquired congenital syphyllis presents as?
Diagnosed after 2 years of age:
- Hutchinson teeth
- "Saddle" nose
- "Saber" shins
- Deafness
- "mulberry" molars
75
Pregnant women with hx of DVT in previous pregnancy, what do you do in this pregnancy?
Prophylactic LMWH throughout pregnancy. Unfractionated heparin during L&D. Warfarin for 6 weeks post-partum
76
First and Second line agents for Graves' disease in pregnancy?
First line - Propylthiouracil
| Second line - Methimazole
77
Surveillance of fetus in diabetic mothers?
- Monthly ultrasounds to look for macrosomia or IUGR
- Monthly BPPs
- Weekly NSTs and AFIs starting at 32 weeks, start at 26 weeks if poor glycemic control
78
Gestational diabetic mother, what weight fetus do you proceed with cesarean section?
>4500 grams, because of risk of shoulder dystocia
79
31 y/o multigravida having twins, itching of palms and soles, no physical exam findings, dark-colored urine. Diagnosis? Labs? Treatment?
Diagnosis - Intrahepatic cholestasis of pregnancy
Labs - will see 10-100x increase in serum bile acids
Tx - Ursodeoxycholic acid, can also give choleysteramin and antihistamines.
80
Management of septic abortion?
D&C and IV levaquin and flagyl
81
Prolonged fetal demise (>2 weeks), most serious complication?
DIC, from release of tissue thromboplastin from deteriorating fetal organs. Always order CBC, D-dimer, Fibrinogen, PT, PTT
82
Beta-hCG level at which intrauterine pregnancy should be seen?
1500 mIU using transvaginal ultrasound
83
Pregnant patient at 19 weeks presents with cervical insufficiency. Must first rule out?
chorioamnionitis
84
When do you place and remove elective cerclages, and for whom?
Place at 13-16 weeks for pts with 3 unexplained midtrimester losses, remove at 36-37 weeks
85
Definition of IUGR?
Less than 5-10% weight for gestation age, or
| <2500 g
86
How do you differentiate symmetric from asymmetric IUGR?
Asymmetric has decreased abdominal size but normal head size
87
Causes of symmetric IUGR?
anything that causes decreased growth potential:
- Aneupoloidy
- TORCH infxs
- Structural anomalies
88
Causes of asymmetric IUGR?
Anything that causes decreased placental perfusion:
- Maternal causes - HTN, malnutrition, smoking, alcohol, drugs
- Placental causes - Infarction, abruption, twin-twin transfusion, velamentous cord insertion
89
Definition of macrosomia?
Estimated fetal weight > 90-95% for gestational age, or >4500 g
90
Size cut-off values to proceed with elective c-section in fetal macrosomia?
Estimated fetal weight >4500 g in diabetic mothers, >5000g in normal mothers
91
Most common risk factor for PROM?
ascending infection from lower genital tract
92
Chorioamnionitis diagnosed clinically as?
- Maternal fever w/ uterine tenderness
| - Confirmed rupture of membranes w/ absence of UTI or URI
