OBGYN Block 3 Flashcards

1
Q

What is the MC form of contraception in the world?

What is the MC form used in the US?

A

IUD

PO CHCs

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2
Q

What two forms of contraception are not recommended for PTs w/ HTN?

What form is not recommended for PTs w/ migraine and aura?

A

Depo, CHC

CHCs

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3
Q

What are the 5 tiers of contraception?

What tier would PTs w/ HIV want to avoid?

A

1: implant, IUD, Sterilization
2: Ring Injection Pill Patch
3: Barrier Behavior
4: Spermicide Sponge Cream/Jelly/Foam
No: Plan-B Abortion

4: spermicide

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4
Q

What are the criteria for being reasonably certain PT is not pregnant?

A

<7d after start of normal menses

No intercourse since start of last normal menses

Correct/consistent contraception use

<7 days post-abortion

<4wks post-partum

Breastfeeding >85%, amenorrheic and <6mon post-partum

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5
Q

What form of contraception can HIV PTs use?

Breast feeding PTs should not be given COCs if they are post-partum for how long?

A

All forms, caution w/ spermicide

<1mon PP, no COCs
Use POPs

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6
Q

Tier 1 contraceptives are AKA ?

What are the indications for a PT to receive an IUD?

A

Long Acting Reversible Contraception (LARCs)

Hormone avoidance
Adolescent
Nulliparous
Dysfunctional bleeds- Levon
Stable relationship
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7
Q

What are the 4 brands w/ length of use?

What is their MOA?

? term encompasses the brand names?

A

Mirena- 5yrs
Liletta- 3yrs
Kyleena- 5yrs
Skyla- 3yrs

Prevention of fertilization

Levonorgestrel

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8
Q

Cu IUD

A

Endometrial inflammation
No impact on ovulation

Dec sperm/egg viability, motility
Anti-blastocyst action

Good for:
Breast Ca
Anti-phospholipid Ab syndrome
Thromboembolic dz

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9
Q

What are the s/e of Cu IUD?

How long does it take for fertility to return upon d/c of this form?

A

Menstrual changes- first 3mon
Possible dysmenorrhea or heavier cycles, Tx w/ NSAIDs

Immediately

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10
Q

Levonorgestrel IUDs are used for how long?

The long term progestin release of this form leads to what 3 results?

A

Used up to 5yrs

Dec sperm motility
Inconsistent ovulation inhibition
Endometrial atrophy prevents implantation

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11
Q

What are the s/e of using Levonorgestrel IUDs?

What is a benefit of using these?

A

Spot/irregular bleeds x 6mon
1mon post-insertion- device related infections

Improves dysmenorrhea

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12
Q

What do PTs have to do if Levonorgestrel device is placed >7d after menses started?

When do they need to f/u w/ PCM?

What is done if strings can’t be visualized?

A

Use back up x 7d

6wks

Verify non-pregnancy
Cytology brush to entangle strings and pull into vaginal vault
No strings= US

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13
Q

What are the S/Sxs of PT that has an IUD that has moved into lower uterine segment?

When are IUD expulsions more common?

A

Continued/new pelvic pain or cramps

First month
Placement <6wks post partum
<25y/o

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14
Q

If PT becomes pregnant w/ IUD in place, there is a higher change of ?

If PT has 2nd trimester miscarriage w/ IUD in place there is a higher likelihood for ?

A

Ectopic pregnancy

Infection

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15
Q

MOA of Etonogestrel rod implant

How long is this good for?

This form can’t be seen on ? imaging and is not affected by ? PT Hx

A

Inhibits LH, endometrial atrophy, thickens mucus=
Inhibits ovulation*, implantation and sperm motility

3yrs

Radiopaque
Obesity

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16
Q

What is the MC adverse effect of all progestin-only contraceptives?

What are the two absolute c/is for use?

A

Irregular/heavy uterine bleeds

Current breast Ca
Pregnancy

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17
Q

Nexplanons are placed w/in ? days of menses onset

What if this time limit is not met and device is still inserted?

A

5days

Back up x 7d

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18
Q

How long does it take for fertility to return after removal of Nexplanon?

When is Nexplanon use more preferred?

A

6wks, up to 1yr

Post-partum/abortion
Lactating

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19
Q

How often are Depo shots given?

What is the MOA

A

150mg q3mon IM- delt/glut

Same as progestin only:
Inhibits LH, endometrial atrophy, thickens mucus=
Inhibits ovulation, implantation and sperm motility

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20
Q

What is the non-contraceptive benefit of Depo?

What are the c/is?

What is the absolute c/i?

A

Improves dys/menorrhea, endometriosis pain
Dec risk hyperplasia/cancer
Inc risk functional cysts

Recent breast Ca
Progesterone + Ca
Prior ectopic pregnancy
Pregnant

Current breast Ca

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21
Q

What are the adverse effects of Depo use?

How does this effect post-partum status?

A
Bone loss, reversible (supp E secretion)
Irregular bleeding
Weight gain
Amenorrhea
Severe HTN
Prolong anovulation/amenses after d/c

No impairment on milk production

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22
Q

What are POPs AKA and what is the only formula?

A

Norethindrone 0.35mg

Mini-pill

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23
Q

What is the MOA of POPs?

What is a non-contraceptive MOA?

A

Inhibits LH, endometrial atrophy, thickens mucus=
Inhibits ovulation, implantation and sperm motility

Unreliable ovulation inhibition

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24
Q

POPs are mostly used in ? PT population?

What PT education piece has to go with this Rx?

A

Breast feeding
Estrogen c/i PTs

Same 4hr window every day of use back up x 48hrs

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25
What are the absolute c/is for Rx POPs? What are the three forms of CHCs?
Breast Ca Pregnancy Ring Patch Pill (CoC)
26
What is the MOA of CHCs?
Suppress LH/FSH release to inhibit ovulation P: inhibits LH= suppresses ovulation, dec sperm motility, inhibits implantation E: inhibits FSH release to suppress ovulation, cycle control to prevent bleeding
27
CHCs contain ? max amount of estrogen? Why is this? Progestin component of CHCs have been modified to provide ? benefits
<35mcg Dec risk for thromboembolus Dec androgenic effect (weight acne hair lipids)
28
When would a 4th Generation progestin like Yaz be preferred? What is the adverse effect of Yaz?
PTs w/ PMS- breast tenderness, Inc Na/Water excretion to dec bloat HyperK+
29
What are the two types of CHC hormone levels How does the generation of CHC and amount of progestin differ? How many days are spent hormone free on this regime?
Monophasic- same amount/pill Multiphasic- estrogen varies 10-50mcg Later generation= less androgenic effect, inc PE/VT/MI risk 4-7days
30
What are the benefits of PO CHCs? What are the risks?
No risk Ca Efficacy not impacted by obesity Dec bleeding, acne, hair Inc clot risk
31
What are the non-contraceptive benefits of PO CHCs? How long does it take for fertility to return?
Dec heavy bleeding/androgen Improves PMDD Sxs Improves cycle irregularities 1-2wks for return 6-12mon to regular
32
What are the PO CHC initiation methods?
1st day: day 1 of menses, no back up needed Sunday: first Sunday after menses starts, back up x 7d No weekend withdrawal/bleed Quick: start day Rx, back up x 7d
33
What chemical in PO CHCs helps improve PMDD Sxs?
Drospirenone
34
What are the absolute c/is to CHCs?
``` CLIMBED UP PAD TV CVA Liver tumor Ischemic heart dz Migraine w/ aura Breast Ca Estrogen dependent tumore Decompensated cirrhosis ``` UnDx genital bleeding Pregnancy Peripartum cardiomyopathy >35y/o and >15 smokes/day DM x 20yrs Thrombogenic states: <21d post partum, DVT/PE, SLE Vascular dz/uncontrolled HTN
35
What are the complications that can arise from CHC use?
``` Benign hepatic tumor Cholelithiasis Post-pill amenorrhea HTN Mood swings Thromboembolism Stroke ```
36
What are the s/es in order of prevalence PT experience upon d/c of PO contraceptives?
``` Irregular bleeds Nausea Weight gain Mood swing Breast tenderness HA ```
37
What are the 3 forms of continuous PO OCP
EE 30mcg + Levon .15mg= 84/7, 4 menses/year EE 10mcg Levon 90mcg/EE 20mcg
38
Where is the patch placed on the body? What is the down side of patch CHC use?
Weekly on butt arm abdomen or torso x 3wks Not on breast >90kg dec efficacy
39
What is done if patch placement is delayed in 1st wk? What is done if patch placement is delays in 2nd or 3rd week? What if the patch becomes detached?
Reapply, back up x7d <2d, no back up >2d, back up x 7d <24hrs- replace same patch, no back up >24hrs- new patch, back up x 7d
40
What are the advantages of transdermal CHCs? What are the disadvantages?
Avoidance of first pass Constant plasma hormone Inc compliance Immediate fertility return Inc DCT Skin rash
41
How long are these used for? Why are these poor choices for deployments?
3wks in, 1wk out Refrigeration requirement Annovera doesn't require this
42
When is back up birth control needed w/ CHC rings? What is done if the ring falls out?
Day 1 start- none Day 2-5: 7d back up Reinsert <3hrs, none Out for >3hrs, back up x 7d
43
What is a non-contraceptive benefit to CHC rings? How long does it take for fertility to return?
Lighter/shorter cycles after 6mon Rapidly
44
What are the steps if PT misses one pill but is <48hrs total?
Take late/missed pill ASAP Continue taking remaining pills on schedule No back up needed
45
What are the steps taken if PT misses one pill but is >48hrs total?
Take most recent missed, toss remaining missed Continue taking remaining pills on schedule Use back up If pills were missed on days 15-21: finish hormone pack, start new pack next day
46
PO COCs decrease the chances/prevalence of ? two cancers? What is the only physical assessment required prior to starting CHCs?
Ovarian Endometrial BP
47
What are the facts about diaphragms? How long do cervical caps need to remain in place and what is it AKA?
``` Require fitting 6hrs prior/post intercourse Inc UTI risk Inc efficacy w/ spermicide Dec risk of STDs ``` 48hrs, higher failure rate Sailor cap
48
What are the 4 fertility awareness methods?
Standard days- avoid sex day 8-19; must have cycles q 26-32d Temp rhythm- every morning, 0.4-0.8* inc x 2d Cervical mucus- high E= prep for ovulation/implant, inc mucus High P= white/thick mucus to prevent sperm entrance Symptothermal methods- combo mucus and body temp; reqs 12-17d of abstinence/mon
49
What are the two cervical mucus methods?
Two day- safe if no mucus on/day prior to intercourse Billings- abstain from menses to 4d after identification of watery/slippery mucus
50
What are the 3 forms of emergency contraception?
PO hormones <72hrs P only: Levon 1.5mg COC: EE + Levon 100mcg (Yuzpe regime) Progesterone antagonist <120hrs (most efficient PO regimen) Ulipristal 30mg Cu IUD <120hrs (most effective)
51
Facts of Lactational Amenorrhea What form of contraception can be used while breast feeding?
Unlikely ovulation 10wks post-delivery Switch to back up after 6mon Must feed >85% of time POP/mini
52
When is post-partum contraception recommended to begin? Do not give E/P contraceptives w/in ? after delivery
Prior to first menses 4wks d/t inc venous thrombus risk
53
How long after vasectomy is male considered 'safe'? Why is this form of sterilization preferred?
3mon/20 ejaculations Requires confirmation Safer/more efficacious than tube ligation
54
What meds are used for elective pregnancy termination and they're taken on ? day What are the 3 surgical procedures?
Mifepristone/Methotrexate- 1 Misoprostol- 3 Vacuum: 5-6wks DnC: 6-13wks Induction: >16wks
55
Ovulation can return as quickly as ? wks after pregnancy terminations? Define Fecundity Define Fecundability
2wks Probability of achieving live birth in single menstrual cycle Ability to conceive; probability of achieving pregnancy per month of exposure (20%/cycle, 50% in 3mon, 85%/year)
56
Female fertility if reduced by half during what ages? What is the 'conception window'? What can be done to maximize this window?
37-45y/o 5 days prior to day of ovulation Daily intercourse Qod 10 days around ovulation
57
What is the criteria to begin infertility work ups? How does this change if female is of advanced age?
Failure to conceive w/in 12mon w/ regular coitus and w/out contraception >35y/o= 6mon
58
COCs can prevent ovulation from returning x ?mon Dep can prevent ovulation from returning x ?mon
12mon 24mon
59
What are the 5 etiologies of infertility in order of prevalence? What has more impact on inability to conceive, under/over weight?
``` Ovulatory Male factors Tubal/uterine Unexplained Other ``` Under, <19
60
How does smoking induce infertility? How does alcohol induce infertility?
Vascular/endothelial dysfunction do to reduced nitric oxide availability Dec female fertility/sperm count Inc male sex dysfunction
61
How does marijuana/coke induce infertility? Infertility eval consists of ? and encompasses ? triad
M: suppresses HPG axis C: impairs speratogenesis Hx/PE both partners Ovulation Norm F reproductive tract Norm semen characteristics
62
Semen analysis reqs ? days of abstinence? How many samples are needed?
2 days 2 samples 3wks apart
63
What presenting female PE indicated ovulation is occurring? Define Mittelschmerz How does this present
Menses q25-35d w/ 3-7d duration Ovulation pain: unilateral mid-cycle pelvic pain w/ ovulation Breast tenderness Acne Mood swings Food cravings
64
What are the luteal phase/PMS Sxs? At home ovulation kits are made to detect ?
Breast heaviness Dec vaginal secretion Abdominal bloating Mild peripheral edema LH surge prior to fertility window
65
? test is a more direct and earlier detection of ovulation? PTs w/ irregular menstrual cycles have ? labs drawn for anovulation work ups?
Serum progesterone >4-6ng during mid-luteal phase TSH/FSH Testosterone Prolactin DHEA-5
66
Female PT w/ STI Hx may indicate ? anatomic reason for infertility? What imaging studies are used for assessing tubal patency?
Tubal for STI/PID issues HSG SIS Laparoscopy
67
What imaging studies are used for assessing uterine cavity? What imaging studies are used for assessing ovaries?
All but laparoscopy All but HSG and Hysteroscopy
68
What imaging studies are used for assessing for endometriosis/PAD? What imaging studies are used for assessing for developmental defects?
HSG Laparoscopy All
69
What tests are done for suspected ovulatory dysfunction? What tests are done for suspected uterine factors?
Ovulation kit Antral follicle count FSH AMH TSH PRL Androgen HSG Hystero/Laparoscopy MRI TVUS/saline sonography
70
What tests are done for suspected tubal/pelvic dz? Overall miscarriage risks double by 50% by ? age
HSG Laparoscopy + chromotubation >40y/o
71
What is the most cost-effective fertility test ordered? What other test has become standard practice? An US antral follicle count below ? indicates poor ovarian response? If any of the above three ovarian reserve tests are abnormal, what is the next step?
Day 3 labs: FSH + Estradiol on cycle day 3 Serum anti-mullerian hormone levels done at anytime, potential earlier predictor <5-7 Refer
72
What are the ideal/bad levels of he ovarian reserve tests? What hormone must be below 100pg for FSH to be valid?
AMH: 2.0 or higher/<0.5 FSH/E2: <10miu/20 or higher AFC: 20 or higher/below 5 Estradiol
73
What is the initial Tx for most anovulatory infertile women?? What other medication could be used? What are two other classes that could be used?
Clomiphene on day 3-5 Metformin- inc spontaneous ovulation Gonadotropin Aromatase inhibitors
74
Hx Test and Therapy for PTs presenting w/ ovulatory infertility
Irregular menses BBT, LH Progesterone Clomiphene/metformin
75
Hx Test and Therapy for PTs presenting w/ | Uterine infertility
Fibroids HSG Procedure
76
Hx Test and Therapy for PTs presenting w/ | Male infertility
Hernia/varicocele/mumps SA Procedure/IVF
77
Hx Test and Therapy for PTs presenting w/ Tubal infertility
GC/PID HSG Laparoscopy/IVF
78
Hx Test Hx Test and Therapy for PTs presenting w/ Peritoneal infertility
Dyschezia, -pareunia, =menorrhea Laparoscopy Ablation Excision
79
Pthirus is AKA ? How is is transmitted and present? How is it Dx How is it Tx
Crabs Contact- pruritis excoriation adenopathy Microscopy/exam Permethrin Pyrethrins Lindane- not if pregnant/infant
80
Sarcoptes is AKA ? How is this transmitted and present? How is it Dx How is it Tx
Scabies Contact- pruritus, dermatitis Oil scrape/exam Lindane- not if pregnant/infant Ivermectin- PO x 2wks Permethrin
81
What are the S/Sxs of an initial HSV outbreak? How is it transmitted? How is it Dx?
HA Adenopathy Malaise Saliva/Contact Culture/PCR/Serum Abs
82
What causes genital warts? How is it transmitted? What is the clinical Dx term
HPV 6, 11 Contact Objects Birth canal to larynx Condylomata acuminatum
83
How are genital warts Dx How are they Tx by provider How are they Tx by PT
Acetic acid Biopsy to test Tx response Podophyllin T/BCA Cryo Podofilox Imiquimod- not if pregnant
84
What bacterial spirochete causes Syphilis? How is it transmitted? How is it detected and confirmed?
Treponema pallidum Contact Transplacental RPR/VDRL FTA-ABS
85
How does Secondary Syphilis present? What part of the PT is contagious w/ this Dx? What other PE finding may be seen?
Bacteremia 6wks-6mon Maculopapular rash on palm/sole Exanthem- sheds spirochetes Condylomata lata- broad pink plaques in moist body areas
86
What is the criteria for Early and Late Latent Syphilis What are the 3 areas of the body that untreated syphilis may reappear in? What two forms are less likely to occur in females compared to males?
Early: <1yr after secondary Late: >yrs after infection Cardiovascular CNS MSK CV/Neuro
87
What syphilis PTs are more likely to present w/ Jarish-Herxheimer reactions? What causes this reaction and how does it present? When do these PTs need to f/u w/ PCM?
Secondary Endotoxin release Fever Malaise HA 6mon intervals Re-treat w/ weekly PCN x 3wks
88
? is intracellular bacteria that is ASx in 70% female/50% males? How does this present? How is it Dx? How is it Tx
Chlamydia Ureth/Cervicitis Culture, Ag, PCR Azithromycin 1g PO x 1 Doxy 100mg BID x 7d
89
How long do PTs being Tx for G/C need to avoid sex? What is the only time test for cure is required? What f/u is needed?
7d during ABX Pregnant post chlamydia Re-screen in 3-4mon
90
What STD are most females ASx but only 5% of males are ASx How is it Dx How is it Tx
Gonorrhea Gram stain Culture w/ Thayer martin media PCR ``` Primary: Ceftriax 250mg IM Azith 1g PO Secondary: IM/PO Cephalosporin Azith 1g PO Teriatry: IM/PO cephalosporin + Doxy 100mg bid x 1wk ```
91
Upper PID/genital tract infections are a result of ? What are the MC microbes
Ascending lower tract infections Chlamydia Gonorrhea BV Mycoplasmas- M hominis U urealyticum M genitallium
92
What are the common/unwanted sequels of female STDs? What is the triad for PID?
Infertility Chronic pelvic pain Ectopic CMT Dysparunia Fever that develop at/soon after menstruation
93
How are inpatient PIDs Tx?
Parentaral IV Tx* Cefotetan or Cefoxitin w/ Doxy Clinda w/ Gentamicin Alt: Ampicillin/Sulbactam and Doxy
94
# Define Tuboovarian abscess How does it Present If left untreated, ? occurs How is it Dx and Tx
Infection/inflammation of tube or ovary PID Sxs + Fever Leukocytosis Abd pain Mass Rupture and peritonitis US Broad IV ABX
95
What causes TSSyndrome When does it present? What are the classic Sxs
Staph A Exotoxin 2days post surgery or menstruation Fever Malaise Diarrhea Non-painful/itchy macular rash
96
What causes TSSyndrome When does it present? What are the classic Sxs
Exotoxin from Staph A 2days after surgery/menstruation Fever Malaise Diarrhea Non-painful/itchy macular rash
97
What are the major criteria needed to Dx TSS What are the minor criteria that only require 3 for Dx
``` HOTN Orthostatic syncope BP <90 Macular erythroderma Temp >38.8 Late skin desquamation ``` ``` Myalgia/Cr 2x inc AMS D/V Elevated bili Platelets <100K Mucous membrane erythema ```
98
What are the major criteria needed to Dx TSS What are the minors that need 3 for Dx
``` HOTN Orthostatic syncope BP <90 Macular erythroderma Temp >38.8 Late skin desquamation ``` ``` D/V Mucous membrane erythema Platelets <100K AMS Myalgia/Cr 2x inc Elevated bili ```
99
What is a normal life cycle for breast epithelial cells? Young premenopausal women w/ breast growths are usually ? What is the sequence of working up a suspected breast growth
Proliferate in LUTEAL phase Inc water retention/fullness week preceding menses Benign Exam Image Cytology
100
How do fibroadenomas present? How are these managed? How are breast cysts Dx?
Mobile, well circumcised, non-tender rubbery growth in adolescent/pre-menopause Biopsy to Dx, if stable/ASx, leave in place Unstable/growing- excise Sonography
101
What are the 3 categories of breast cysts and how do they appear?
Simple: Sonolucent/smooth No special management Recurrent= Excision ``` Complicated: Aspirate Culture Cytology Core needle ``` Complex: Co Ex Core needle Excise
102
Fibrocycstic breast changes
Nodular tissue from dilated ducts/acini w/ dense collagen Ropy/tender from exaggerated stromal response to hormone/Gfs No breast Ca risk if alone Hyperplasia from low progesterone
103
Fibrocycstic breast changes
Nodular tissue from dilated ducts/acini w/ dense collagen Ropy/tender from exagerated stromal response to hormone/Gfs No breast Ca risk if alone Hyperplasia from low Progesterone
104
What is the MC benign breast tumor What is the MC benign breast d/o
Fibroadenoma Fibrocystic changes
105
PTs w/ green nipple d/c indicates ? issue? What does multi duct d/c after manual expression indicate? What does serous/spontaneous bloody discharge indicate?
Cholesterol, not infection/Ca Physiologic Pathological, concerning if only one duct invovled
106
What is the MC cause of mastitis On top of warm compresses and continuing to feed, what meds can be added for Tx?
Staph ``` Dicloxacillin Cephalexen Augmentin PCN Allergy- erythromycin MRSA: TMP/SMX, Clinda, Vanc ```
107
How is cyclic mastalgia Tx How is noncyclic mastalgia Tx
No eval, Sx Tx w/ NSAID Exam Image Biopsy
108
How are breast tumors annotated/recorded in records? What imaging modality is used for focal mass in in PTs <30 or pregnant? What image is preferred if PTs are older?
Left breast, 2.5cm mass, 10:00, 6cm FN US, differentiates cyst from solid Mammograms
109
How are neoplasms Dx
Biopsy- minimally invasive Open biopsy: excision FNA- small masses for cytology Core needle- Dx w/out excision
110
What eval technique is used for the following: Palpable cyst Recurrent cyst/blood fluid Non-Dx FNA Solid mass Non-Dx CNB
Needle drainage Excision Core/excision biopsy Core biopsy Excision biopsy
111
Nulliparous PTs w/ tender, red, hot breast and adenopathy not responding to ABX, what is the next best step? What are the 4 muscles of the Levator Ani
US/Biopsy Pubococcygeus Puborectalis Iliococcygeus Coccygeus
112
Dx criteria for chronic pelvic pain
Non-cyclic pain persisting x 6mon Pain localized to pelvis, anterior abdominal wall, lumbrosacral back/butt Pain severe enough to cause functional disability
113
Chronic pelvic pain can be that cause for ? mental dx? CPP can be comorbid w/ ? 4 somatic syndromes?
Depression Fibromyalgia Chronic fatigue Temporomandibular d/o Migraine
114
# Define Allodynia Define Hyperalgesia
Painful response to normally innocuous stimuli Extreme response to painful stimulus
115
What MSK issues can cause CPP? How does Pelvic Congestion Syndrome present
Kyphodosis Lorodosis Worse Sxs pre-menstrual Ache, pressure, heaviness Hormone suppression Ovarian vein embolization Hyst w/ BSO
116
How is CPP managed? Define Vulvodynia How does it present
Acetaminophen/NSAIDs Neuro Pain= SSRI/SNRI Gabapentin 3-6mon vulvular discomfort w/ot visbile/neuro findings Burning Stinging Itching Pain
117
How is Vulvodynia Tx Rates of dyspareunia have been linked w/ ?
10% spontaneously resolve TCAs w/ topical lidocaine/gabapentin CPPs
118
What are the different types of dyspareunia
Primary: onset at coitarche Secondary: after pain free sex Generalized: all intercourse Situations: partners/positions
119
# Define Myofascial Pain Syndrome How is Levator Ani Syndrome Tx
Hyperirritable area of muscle due to trigger point of taught/ropy bands Primary- MSK Secondary- visceral Local anesthetic injections Botulinum A injection
120
# Define Pudendal Neuralgia Where does it present? What makes it better/worse?
Sharp severe pain in pudendal nerve distribution area: Perineal- vulva Inferior rectal Dorsal clitoris Unilateral pain worse sitting Better standing/sitting on toilet
121
How is Pudendal Neuralgia Dx How is it Tx
``` Nantes Criteria: Pain follow innervation Worse w/ sitting No sensory loss No awakening from sleep Relieved w/ nerve block ``` TCA, Gabapentin
122
What are the 4 types of pelvic organ prolapse? This issue is the 3rd MC cause for ?
Cystocele Rectocele Enterocele Procidentia- uterus Hysterectomy
123
# Define prolapse splinting Define prolapse digitization
Manual bolstering of prolapse to improve Sxs Manual pressure to aid stool evacuation
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What are the RFs for developing prolapses? How are prolapses Tx/Managed?
Vaginal births, 1.2x/delivery Forcep delivery Episiotomy Post-meno/atrophy- estrogen ASx/Mild Sxs- kegels Non-surgical candidate or prolapse w/ urine incontinence- pessary Surgery
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Interstitial cystitis and painful bladder syndrome both present w/ ? 3 Sxs How are they different
Frequency Urgency Pain IC: mucosal changes, dec bladder capacity PBS: no bladder pathology
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What PT presentation indicates interstitial cystitis/painful bladder syndrome? What do these PTs need to avoid?
Unexplained chronic pain/voiding Sxs Dyspareunia/postcoital ache Cranberry juice
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How is interstitial cystitis/painful bladder syndrome Tx What is the only FDA approved med for Tx?
Education/behavior mods Pelvic PT Amitriptyline Cimetidine Hydroxyzine Elmiron but takes months to take effect
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What medication can sometimes help with incontinence? What are the two main types of incontinence?
Topical estrogens Stress: involuntary leakage w/ inc intraabdoinal pressures Urge: involuntary leakage followed by urge to void
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What are the DDxs for transient causes of incontinence?
``` DIAPPERS Delerium Infection Atrophic vagin/urethritis Pharmaceuticals Psych Excess urine output Restricted mobility Stool impaction ```
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What is the MC cause of transient incontinence in hospitalized PTs? What meds can cause transient incontinence by gender
Derlirum A-blockers: women A-agonists: men
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What part of the NS controls the inferior/superior parts of the bladder? What muscle helps counteract increased pressure from the abdomen?
Inferior: SNS, A adrenergic Superior: PNS, B/Muscarinic Levator ani Vaginal CT
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What are the characteristics of stress urinary incontinence? What causes this? What are the 3 degrees of this issue
Cough laugh sneeze causing dribbles, no bladder contraction Pelvic/urethral weakness- change in urethral angles HypoEstrogen 1: only w/ severe stress 2: rapid movement, stairs 3: mild stress, standing
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What are the characteristics of urge urinary incontinence? What causes this issue?
Urgency w/ dec volume Detrusor instability but not impaired or weak
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What are the characteristics of incomplete bladder emptying? What can cause this?
Frequency w/ hesitation Over distension of detrusor Restricted outlet CCBs/A-agonists need to be avoided, cause retention
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What PE test is done to Dx stress incontinence? How are most cases Tx
Q-tip test- change of >30*= hypermobility Kegels for both Ca glycerosphate to dec urge/frequency by buffering urine pH
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What meds are used for managing incontinence
Anticholinergics- inhibits muscarinic receptors to dec detrusor contractions Imipramine- TCA w/ A-adrenergic and anticholinergic effects for Mixed Incontinence Mirbegron- anti-spasmotic; relaxes smooth muscles and inc bladder capacity for Urge Incontinence Botulism Injection- Idiopathic detrusor over activity/urge incontinence
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Sexual expression is determined by ? What is the sexual response cycle
``` Psych Social Environment Spiritual Learned factors ``` Excite Plateau Orgasm Resolution
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What part of the sexual response cycle holds the most weight? What hormones modulate, excite or suppress libido What are the two forms of d/os?
Motivation/emotional willingness to engage Mod: testosterone Ex: dopamine Sup: serotonin Hypoactivity Aversion
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Arousal signals come from what part of the spine? What part of the NS controls excitement/arousal? This part is modulated by ? hormone and is the cause of ?
T11-L2, S2-S4 PNS Estrogen Sex flush
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What is the MC cause of excitement/arousal dysfunction? What is the most treatable sexual phase d/o? What part of the NS controls this phase?
Estrogen deficit Orgasmic phase SNS
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What optimizes orgasmic phase dysfunction What are the RFs for dyspareunia?
Afferent concentration <50y/o Hx of abuse Hx of PID Depression/Anxiety
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What age groups are more likely to experience sexual violence? What ages are least likely?
16-24y/o >65
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What is the leading cause of death during pregnancy? What area of the female genitalia is MC injured during assault? How long after attack can evidence be collected from PT?
Homicide Posterior fourchete 5days
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VEAL CHOPS Which ones require intervention?
Variable - Cord compression (MC) Early - Head compression Accelerate - OK Late - Placental insufficiency Late/Variable
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Normal fetal heart rate Reassuring patterns for moderate variability and weeks of gestation
110-160 Moderate: 6-25 Two acceleration/20min of: >32wks: 15bpm x 15sec <32wks: 10bpm x 10sex
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Non reassuring patterns
Brady <100bpm Recurrent late/variable Absent/Minimal variability w/ late/variable Dcells Sinusoidal
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How do early Dcells appear on a strip? What is the most frequent abnormal pattern? What is the criteria for severe?
Mirror image of contraction Variable Declls 60 FHR decel x 60sec
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How do variable Dcells appear on a strip? How are non-assuring FHR patterns managed?
Shoulder/deep drop off D/c oxy/pitocin Put PT on L side/all 4s Cervical exam, r/o entrapment O2/Fluids
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6 cardinal movements of labor
``` Descent Flexion Internal rotation Extension External rotation/restitution Expulsion ```
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# Define Caput Succedaneum Define Cephalohematoma Define Subgaleal hemorrhage
Boggy head, crosses suture lines Does not cross sutures, associated w/ jaundice Crosses sutures, jaundice and blood loss
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Indications to do vaginal operative delivery As soon as baby is delivered, what is given to mother and when/why?
Breech- forcep only Compromise Prolonged 2nd stage Shorten 2nd stage for maternal benefit Placental delivery= Oxytocin/Pitocin- PPH ABX x 24-48hrs
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# Define Chorioamnionitis This is not an indication for ?
Infection of membrane/fluids around fetus C-section
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# Define Turtle Sign Define HELPERR acronym
Retraction/recoiling of fetal head toward perineum despite pushing ``` Help Eval for episiotomy Legs hyperflexed: McRoberts Pressure Enter: rotation/remove Roll onto all 4s- Gaskin maneuver ```
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What part of HELPERR acronym has the highest success rate? 4 severity of episiotomy
Step 5: removal of posterior arm 1: skin 2: skin, subcutaneous 3: skin, sub-cutaneous, anal sphincter 4: All and rectal mucosa
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How long are post-MVA PTs monitored to r/o abruption? They can only be d/c if ? criteria is met?
4hrs Contracting <1 q10min No bleeding/abdominal pain FHR reassuring No visible bruising
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4 causes of PPH Why is this so scary
Tone Tissue Trauma Thrombin P/BP don't change until large amounts have been lost
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What PE finding indicates lack of uterine atony/possible PPH MC cause of mortality from PPH
Boggy/soft uterus on bimanual exam Atony
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What two drugs will be pushed during PPH Tx
Oxy/Pitocin 10U IM Methergine 0.2mg IM- not if pre-clamptic/HTN Hemabate- not if asthma, cardiac/renal/liver dz, seizure Failure/c/i- mesoprostol
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What happens to the brain if too much blood is loss? What are the different types of PID
Sheehan Syndrome- pituitary failure/infarct causing hypothyroid issues Silent- ASx woman Dx PT w/ tubal infertility w/out Hx of UTIs Acute: Sxs develop after menstruation CMT/Dysparunia/Fever
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What happens to the brain if too much blood is loss? What is the 'classic' hemorrhage disaster?
Sheehan Syndrome- pituitary failure/infarct causing hypothyroid issues Uterine inversion
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Mastitis may be AKA What are 3 DDx for mastitis in non-pregnant/feeding woman
Puerperal breast infection Inflammatory Ca- image and biopsy Peripheral abscess- drain, ABX Subareolar abscess- duct/tract excision and biopsy
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What are the names of the lesions seen on cystoscopy of IC/PBS? These findings are indicative of ? Dx
Hunner ulcers Interstitial cystitis
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Urgency incontinence Tx Stress incontinence Tx and medication avoidance
Schedule Anticholinergics Detro/Ditro Kegels Collagen injection Topical estrogen Imipramine/Duloxetin Pessary/Kegels Avoid: AAntagonists
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What meds are avoided in overflow incontinence What is a normal sexual response during pregnancy and menopause?
AAgonists Anticholinergics CCBs Preg: dec desire Meno: inc dysfunction
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What are the 3 phases of sexual response? What is the most intense reaction experienced during sexual assault?
Desire- libido Excitement- arousal Orgasm- climax Fear of dying
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What are the two phases of Sexual Trauma Syndrome
Acute disorganization: shock disbelief shame blame anger Reoganization: vulnerable, despair guilt shame Somatic Sxs Anxiety Depression
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How long do narcotics affect fetal respiration? What sedatives are used during false labor?
Fentanyl 20-60min Morphine 1-2hrs Meperidine 4-6hrs Promethazine Hydroxyzine Zolpidem
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What is the regional analgesia procedure of choice? Microbes associated w/ chorioamnionitis
Lumbar epidural ``` Bacteroides E Coli Anaerobes Mycoplasma Strep ```
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RFs for shoulder dystocia Risks to mother and baby
Hx Macrosomia DM Obesity Mother: PPH Atony 4th* lacs Fetus: Hypoxic Erbs Fx
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Criteria for high risk atony Criteria for mod risk atony
Prolonged labor Over distended uterus Grand multiparity Multiple gestations Polyhydrammnios Fetal macrosomia
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PPH management
``` Help/examine Uterine massage Meds IV fluids Bimanual compression ```