Obstetrics/Gynecology

Question 1

breast fibroadenoma

Answer 1

• more common in AA and young (15-35)
• presentation: round, firm (soft, rubbery), painless, freely movable, discrete, mobile
  
  • hormonal relationship: cyclical size
• signs: nontender, unilateral, mobile density, smooth firm mass
• dx: if <30 - US +/- FNA
  
  • if >30 - mammogram
  • Excisional bx (if <25), if BRCA + mom
• tx: decrease caffeine

Question 2

fibrocystic breast dz

Answer 2

• MC benign breast condition (MC 30-50yo)
• Presentation: asx or painful, bilateral, size fluctuation during menstrual cycle
  
  • MULTIPLE LESIONS distinguishes fibrocystic changes from carcinoma
  • breast pain, dipple discharge, lumpy and bumpy prior to menses
• signs: tender, bilateral, mobile density, thick gray-green nipple d/c, worse with caffeine intake
• dx: US +/- bx, FNA (diagnostic and tx)
• tx: support bra, decrease caffeine, danazol
• increased risk breast CA when atypia is present

Question 3

Breast cancer RF

Answer 3

• age, sex, first degree relative, BRCA1 or 2
• associated factors: nulliparity, ealry menarche, late menopause, post men ERT or radiation exposure, advanced maternal age at first term birth
• ALL invasive lobular and 2/3 ductal carcinomas are HER2 pos (estrogen-receptor)

Question 4

Breast CA presentation

Answer 4

• single, nontender, firm, immobile mass
• 45% upper outer quadrant, 25% under nipple and areola
• signs: early, no palpable masses
  
  • rare: nipple d/c, retraction, dimpling, breast enlargement, shrinkage, skin thickening or peau d’orange, eczematous changes, breast pain, fixed mass, axillary node enlargement, ulcerations, arm edema, palpable supraclavicular nodes

Question 5

Breast CA dx

Answer 5

• any solid dominant breast mass on exam evaluated with FNA or excisional bx
• genetic testing for pts with strong family hx
• axillary lymph node staging with sentinel lymph node bx

Question 6

breast CA tx

Answer 6

• tamoxifen: for estrogen receptor pos dz and postmen women
• adjuvant chemo and hormonal manipulaiton
• lumpectomy with sentinel node bx preferred for early stage
• breast cancer associated with higher risk of endometrial cancer and vice-versa
• axillary lymph node status is the most important prognostic factor for invasive carcinoma in the absence of distant metastasis

Question 7

Paget dz of the breast

Answer 7

• uncommon, ductal carcinoma, presents as eczematous lesions of the nipple
• presentation: eczematoid eruption and ulceration of nipple and areola, pain, itching, burning
  
  • bloody d/c or nipple retraction
• signs: scale, crust, itching, palpable mass (50%)
• dx: full-thickness bx
• tx: local excision, breast conservation with whole breast radiation (if negative margins)
  
  • most are high grade and show HER2 overexpression

Question 8

breast abscess

Answer 8

• occurs especially during nursing (MC s. aureus)
• presentation: redness, tenderness, induration
• dx: incision and bx if severe or indurated - r/o inflammatory carcinoma
• tx: bactrim, clinda, doxy

Question 9

mastitis

Answer 9

• MC in postpartum (2-4th week, S. aureus)
• Presentation: lactating women, FEVER, chills, flu-like, acute, responds to abx
• signs: decreased milk, redness, tenderness, firm mass, breast pain, unlilateral, heat
• dx: culture of purulent material or milk (not routine)
• tx: dicloxacillin (PCN allergy - erythromycin)
  
  • cold compress, NSAIDs and tylenol, continue to breast feed and express milk