Office Flashcards
Define early pregnancy loss
EPL = nonviable IUP with either an empty gestational sac or a gestational sac with embryo or fetus without fetal cardiac activity within the first 12 + 6/7 days.
Common, 10% of all clinically recognized pregnancies
Prolog - Office Q23.
Mifepristone
Mechanism of Action
Mifepristone = 19-nor steroid
Acts as a competitive progesterone-receptor antagonist and a corticosteroid-receptor antagonist.
Primes myometrium and cervix for prostaglandin activity
Combined mifepristone, misoprostol is superior to either alone
Prolog - Office Q23.
Misoprostol Dosing for Early Pregnancy Loss
800 micrograms vaginally
with one repeat dose as needed - no earlier than 3 hours after first dose and typically within 7 days if not response to first dose
Prolog - Office Q23.
What are the 7 types of ethical conflicts with Industry (per ACOG)?
- Product promotion to individual physicians by advertising, personal communication, and provision samples
- Support of educational activities for individual physicians
- Industry-sponsored device training
- Industry sponsorship of research
- Speakers bureaus
- Physicians as consultants to industry
- Ghostwriting
Prolog - Office Q24.
Most common nongyn, non obstetric patient complaint encountered by OB/GYNs?
Low back pain.
Acute = 4- 6 weeks
Subacute = 6- 12 weeks
Chronic = > 12 weeks
MCC of disability world wide
Best initial/ first line treatment of non-specific back pain = NSAIDS and PT (physical therapy).
Prolog - Office Q25.
Risk factors for ectopic pregnancy?
-Hx ectopic
-Fallopian tube damage
-Prior pelvic surgery
50% of women with ectopic will have no risk factors
Prolog - Office Q26.
After uterine aspiration, what drop in bHCG would suggest failed early pregnancy versus ectopic pregnancy?
For a non diagnostic uterine aspiration (aka no chorionic vili)..
-First bHCG should be obtained 12- 24 hours following aspiration.
-bHCG drop >50% = likely failed IUP
-bHCG drop 15- <50% = low threshold for treatment for ectopic pregnancy
-bHCG drop 10- 15%, considered a plateau = should be treated for presumed ectopic
Regardless all patients should be given ectopic precautions and continue to monitor quant to zero.
Prolog - Office Q26.
Pyogenic Granuloma
-Occurs in 5% of pregnancies
-Spontaneously resolves
-Inflammatory hyperplasia develops because of hormonal factors, local injury or local irritation
-Symptom will be bleeding gums when brushing or specific lesion noted
-If does not resolve postpartum, then may require surgical excision
Prolog - Office Q27.
Most common cause of hypothyroidism?
Autoimmune thyroiditis
-90% will have anti-thyroglobulin and anti-thyroid peroxidase (TPO) antibodies
NOTE
-There is a natural increase in TSH with age, the upper limit rare increases > 8
-This puts women at risk for misinterpreted abnormals and over treatment with levothyroxine.
Prolog - Office Q28
What are symptoms of over treatment of hypothyroidism with levothyroxine?
-Weight loss
-Increased frailty
-Cardiac tachyarrhythmia
-Excessive bone loss
Prolog - Office Q28
What is a risk of untreated subclinical hypothyroidism in women?
What is the most common cause of subclinical hypothyroidism in elderly women?
- Increased risk of metabolic syndrome
-Hashimoto thyroiditis
FACT There tends to be a tentative link between incidence of heart failure and TSH concentration > 10.
Prolog - Office Q28
What is the most sensitive test to diagnose autoimmune thyroid disease?
Thyroid peroxidase antibody
Prolog - Office Q28
What is the prevalence of heavy menstrual bleeding in adolescents?
34- 37%
MCC of acquired or congenital = von Willebrand disease
Prolog - Office Q29
What is the role of von willebrand factor?
-Functions in both platelet binding and aggregation
-Transports and aids function of factor VIII (intrinsic pathway)
Prolog - Office Q29
Describe the three types of Von Willebrand Disease
Type 1 = mildest, most common
- inherited A.D.
- Quantitative deficiency in vWF
Type 2 =
- Qualitative or functional defect in vWF activity
- Multiple subtypes with different inheritance
Type 3 = Most severe
- Inherited A.R.
- Complete absence of vWF
Prolog - Office Q29
What is the preferred treatment of acute heavy vaginal bleeding in adolescents?
- Medical therapy with Estrogen (and Iron should be given concurrently)
- Monophonic COCP given in “blast” fashion (multiple pills at once) or in a taper
- MC risk/side effect of high dose estrogen = nausea
-Can also add TXA with COCPs. Theoretical increased risk of thrombosis but no established studies.
Inpatient admission recommended with hd compromise, dizziness or continuing to soak a pad an hour
Prolog - Office Q29
most common sexually transmitted infection?
HPV
HPV vaccine:
-Begin as early as 9yo, 2 dose regimen
-Age >15, receive 3 doses.
-Efficacy demonstrated up to age 45.
-Age 27- 45 may be less effective, but ACOG still supports giving it.
Prolog - Office Q30
What vaccinations are recommended for healthcare workers?
-Influenza
-Hep B
-MMR
-Tetanus toxoid
-Varicella
-Meningococcal
-Tdap
Prolog - Office Q30
What are the recommendations for pneumococcal vaccine?
- < 2 yo
- > 2 yo with immunocompromised, T2DM, asplenia.
- > 65yo without immunocompromised. Cannot have cochlear implant or CSF leak.
-Not a routine vaccine for healthy adults or health care workers
Prolog - Office Q30
When is the Zoster vaccination recommended?
- Adults > 50yo
- Shingles prevention
Prolog - Office Q30
What are the tumor markers and their tumors?
-bHCG
-LDH
-AFP
-Inhibin
-CEA
-Testosterone, Estradiol
-ca-125 = epithelial
-bHCG = choriocarcinoma, embryonal
-LDH = dysgerminoma
-AFP = endodermal sinus, embryonal
-Inhibin = Granulosa cell tumor
-CEA = mucinous carcinoma
-Testosterone, Estradiol
Prolog - Office Q31
Regardless of ethnic and familial factors, what two mutations are routinely recommended for carrier screening?
-Cystic Fibrosis
-Spinal Muscular Atrophy (SMA)
Carrier screening ideally is offered pre pregnancy but should be offered to all pregnant individuals.
Prolog - Office Q32
What is the gene mutation in cystic fibrosis?
CFTR (cystic fibrosis transmembrane regulator) gene
-MC life-threatening autosomal recessive (AR) condition in non-hispanic white population
Prolog - Office Q32
What is the gene mutation for spinal muscular atrophy that indicates non-carrier (normal), carrier, versus disease state?
SMA = degenerative disease of spinal cord motor neurons.
SMN1 Mutation = survival motor neuron 1
Carrier screening requires quantitative PCR assay giving the number and copy of the gene. >90% detection rate.
Normal = both normal copies
Carrier = single normal copy
Silent carrier = two copies on same chromosome –> copy number appears normal (and gives sometimes false negative result). This type is MC in african americans.
Prolog - Office Q32
what is the gene mutation for Gaucher disease?
GBA gene
= interferes with the enzyme B-glucocerebrosidase, leading to an accumulation of fatty substances in multiple organs.
-Carrier frequency = < 1 in 100.
-Higher in Ashkenazi jews
Prolog - Office Q32
what is the enzyme mutation for Tay Sachs disease?
Tay Sachs
-A.R. inherited lysosomal storage disease
-Severe and progressive neurodegenerative condition
-Higher in Ashkenazi jews
=functional deficiency in hexosaminidase A
Prolog - Office Q32
What is the most common form of inherited intellectual disability?
Fragile X
-General population carrier frequency 1 in 259
-X-linked inheritance
-FMR1 mutation, which encodes a protein that plays role in the development of neuronal synapses.
Prolog - Office Q32
Should a hemoglobinopathy panel be offered/ordered universally?
No!
This is only recommended as a targeted screen based on race and ethnicity.
Should only be offered for African, Middle eastern, mediterranean, southeast asian, or west Indian descent.
Prolog - Office Q32
What is the most common cause of vaginitis?
B.V.
Lactobacilli = facultative anaerobe
risk factors: sexual activity, obesity, vaginal douching, women who have sex with women.
Prolog - Office Q33
What is Amsel’s criteria?
- Presence of vaginal discharge
- Vaginal pH > 4.5
- > 20% epithelial cells = clue cells
- KOH whiff test
Sensitivity and specificity > 90%.
Prolog - Office Q33
Absolute contraindication to Estrogen:
-Acute VTE
-Known thrombophilia (including antiphospholipid syndrome)
-Active Cancer (excluding non-melanoma skin cancer)
-Hx of pregnancy-associated DVT or PE
Prolog - Office Q34
Most effective method of weight loss for obese patients
Bariatric surgery
-mechanism = decreasing gastric volume
Studies show that women who undergo barometric surgery and achieve pregnancy have a significant reduction in gDM, PIH and cesarean births.
Prolog - Office Q35
Which bariatric surgery has the highest success rate?
Those that combine restrictive and malabsorption = roux-en-y and sleeve gastrectomy
–> result in the most rapid weight loss
–>roux-en-y has a higher complication rate compared to sleeve gastrectomy
–>sleeve gastrectomy causes severe GERD
Prolog - Office Q35
What is the rate of ectopic pregnancy?
2%
Other key points:
-Okay to be conservative and follow a subsequent 48 hour quant for the first 48 hour quant is rises almost 50% –> as new studies show that not all pregnancies double as described previously.
-Discriminatory zone previously 1- 2k should now be 3500!
Prolog - Office Q36
What is the time frame of symptoms to diagnose interstitial cystitis (or bladder pain syndrome)?
6 weeks
-Described as unpleasant pain sensation (pain, pressure or discomfort as well as frequency) related to urinary bladder and associated with low urinary tract symptoms
-Underlying etiology unclear
-Treatment = conservative management (self care and behavioral modifications).
Prolog - Office Q37
What are behavioral modifications for bladder pain syndrome?
-Altering bladder habits
-Applying heart or cold to trigger points
-Taking OTC meds, such as Pyridium
-Avoid bladder irritants
-Trying elimination diet
-Perform pelvic floor muscle relaxation
-Wearing comfortable clothing
-Avoiding constipation
Prolog - Office Q37
What are medical treatments (second line treatment) for bladder pain syndrome?
—Physical therapy
—PO: amitriptyline, cimetidine, hydroxyzine, pentosane polysulfate sodium
—Intravesical: dimethyl sulfide, heparin, or lidocaine
3rd line treatment = cystoscopy with hydrodistention –> evidence of Hnner lesions. treatment = fulguration or injection triamcinolone.
4th line = botox
Prolog - Office Q37
Title VI of the Civil Rights Act of 1964 mandates that …
all patients with limited English proficiency who are receiving federal financial assistance, with the expectation of those receiving Medicare Part B, are provided interpreter services.
Prolog - Office Q38
Urinary incontinence affects ___ % of women.
25- 75%
Prolog - Office Q39
Define OAB (overactive bladder)
Urinary urgency, usually accompanied by frequency and nocturne, with or without urgency urinary incontinence, in the absence of UTI or other obvious pathology.
First line treatment = bladder training, possible PFPT and lifestyle modifications
2nd line tx = medications –> anti-muscarinic or B3 adrenergic agonists.
Prolog - Office Q39
What is the mechanism of action of anti-muscarinics
anti-muscarinics = anticholinergics
= antagonist acetylcholine at the M2 and M3 muscarinic receptors of the parasympathetic nervous system
M3 = responsible for normal detrusor contraction
Prolog - Office Q39
Should uric acid still be including in HELLP labs?
No! No longer part of the diagnostic criteria. Used to be used as an acute renal injury marker.
Prolog - Office Q40
Primary Amenorrhea:
-defintion
-Last of menarche by 15
-Evaluation is recommended if:
-no menarche age 15
-no thelarche by 13
-No menarche 3 years after thelarche
-Average age of menarche in the US = 12- 13.
-Nutritional, ethnic, socioeconomic and genetic factors all contribute
-Causes of primary amenorrhea: mullein anomalies/imperforate hymen (10%), Gonadol dysgenesis/P.O.I (40%),
Prolog - Office Q41
What is the normal cycle length for an adolescent female?
-21-45 days
-Cycles persistently outside this range or > 90 days should be evaluated.
Prolog - Office Q41
What is the definition of medical error?
“failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”
Timely disclosure of medical errors result in improved outcomes
Prolog - Office Q42
Patient c/o vaginal itching with noted multiple non-painful not friable lesions. Generalized LAD present. Patient reports fever week prior.
Lesions = Condyloma lata lesions, consistent with secondary syphilis.
-Syphilis = Treponema pallidum.
-Congenital Syphilis increased 71% since 2014.
-Primary Syph = painless ulceration known as chancre. Appears at site of infection (mouth, genitals, skin). Chancre develops 21 days post-exposure.
-Secondary syph = 4- 8 wks after primary infection or appearance of chancre, occurs in 30% untreated. Symptoms vary (rash, fever, fatigue, condyloma late, LAD).
-Tertiary syph = 30% untreated. symptoms develop 1 to 10 years later (gammas, Ao insufficient, aneurysm).
-Neurosyphilis = can affect any area of CNS/PNS.
Asymptomatic Syphilis = early versus late latent.
Prolog - Office Q43
What is the best and most effective method of contraception for a patient with personal history of breast cancer < 5 years ago.
Copper IUD.
Cannot have mirena or other hormonal methods
Prolog - Office Q44
Mumps orthorubulavirus
=Paramyxoviridae family
-Syndrome: generalized viral sx (fever, anorexia, malaise, HA), parotitis w/ face and jaw swelling.
-Peak incidence Jan- May
-INcubation = 2 -4 weeks.
-Treatment is supportive
Prolog - Office Q45
How many patient with HCV develop chronic infection?
What is the greatest risk for vertical transmission?
50%.
Vertical transmission rate = 2- 8 %.
-Higher rates in co-infected HIV
-Greatest risk = detectable viral load.
-Highest risk for infection occurs intrapartum to late pregnancy
-Breastfeeding is safe, no risk of transmission. However, HCV has been detectable in colostrum. Should only avoid breastfeeding if has cracked nipples due to blood borne nature.
Prolog - Office Q46
What percentage of women experience genitourinary syndrome of menopause?
50%.
Symptoms include bothersome vaginal dryness, irritation, or a burning sensation, decrease lubrication and pain with intercourse, urinary symptoms.
-Cause = hypo-estrogen
-Treatment: = lubricants or vaginal estrogen
-Estrogen = restore anatomy, reduce vaginal pH, increase superficial vaginal epithelial cells.
-Most note improvement at 2- 4 weeks.
Prolog - Office Q47
Filbanserin
FDA approved to treat female sexual interest and arousal disorder in premenopausal women without depression.
Prolog - Office Q47
Ospemifene
-Use in postmenopausal women
SERM, daily oral pill.
-FDA approved for postmenopausal moderate to severe dyspareunia and vaginal dryness.
-Agonist on endometrium
Contraindications: undiagnosed VB, DVT, PE., hx tumors.
-Adverse SE: hot flushes or sweating
Prolog - Office Q47
What is the testosterone dose to suppress menstruation in trans masculine patients?
Testosterone injections every 2 weeks (or can be transdermal)
-surpress menstruation
-results in secondary ex characteristics
-Typically amenorrhea in 3 - 6 months.
-Hormonal levels should be monitored.
-Can still get pregnant if not using other contraception.
-Risk factors to testosterone = polycythemia, HLD, HTN, mood changes, drug-induced hepatitis
Prolog - Office Q48
What is the preferred first line therapy for c. diffe?
C. Diffe, gram-positive, obligate anaerobic spore forming bacterium.
-Transmitted fecal oral
First line tx = oral Vanc
Prolog - Office Q50
What is the prevalence of vulvar pain in the united states?
What is the definition of vulvodynia versus vestibulodynia?
What is the first line treatment for all?
8- 15%.
Vulvodynia = vulvar pain, persistent for at least 3 months with no clearly identifiable cause. generalized = unprovoked, entire vulva.
Vestibulodynia = localized, provoked vulvodynia.
First line treatment = pelvic floor physical therapy.
Prolog - Office Q51
ABCDE of melanoma
What is the most predictive of survival?
ABCDE: asymmetry, border irregularity, color vegetation, diameter > 6mm, evolution.
Depth is the most predictive factor of metastasis and survival.
Prolog - Office Q52.
What is the recommended treatment for trichomonas?
Trich = symptomatic in 50% of patients.
NAAT = diagnostic standard.
Metronidazole 500mg PO BID x 7 days.
-resistance = 5- 10%
2nd line = tinidazole.
-resistance = 1%
Prolog - Office Q53
What is the rate of stillbirth in the U.S.?
1 in 160 deliveries.
Prolog - Office Q54
Patient presents with thunderclap, worst headache of her life during intercourse. Symptoms markedly improved after intercourse.
Coital Headache
-a/w sexual activity. RARE
-Preorgasmic and orgasmic types
-Symptoms are life limiting and resolve on their own
-Can give empiric treatment with B blockers or tapering calcium channel blockers
Prolog - Office Q55
What is the prevalence of depression in the US in adolescents (age 12- 17)?
13.3%
Depression:
-Earlier onset is a/w with longer lifetime depression
-MC in girls > boys
-A/w psychosocial impairment, increased risk suicide
-RF: hx parental psych illness, hx previous depressive episode, hx abuse, life loss, academic demands, hx bullying, fam hx alcoholism/substance abuse disorder, hx of ADHD/dyskexia/conduct disorder.
Prolog - Office Q56
Signs of depression in adolescents
-Depressed or irritable mood
-Diminished interest in all activities
-Significant weight change (or failure to achieve expected weight)
-Sleep disturbance
-Psychomotor agitation or retardation
-Fatigue
-Feelings worthlessness
-Inability to concentrate
-Recurrent thoughts of death
-Suicide ideation or attempt
Prolog - Office Q56
Treatment of depression in adolescents?
-Psychoeducation
-Psychotherapy
-Psychocotherapy therapy (SSRIs primarily)
-SSRIs studies show significant decrease in SI and attempts. Fluoxetine is most effective.
-Mood stabilizers (lithium, valproic acid) are reserved for bipolar only
-Psychostimulants for those with concurrent ADHD. No evidence to use for depression only.
-SNRIs: no signs of efficacy
Prolog - Office Q56
Steps in pre-pubertal girl evaluation of persistent or recurrent vaginal discharge?
Vaginal discharge can be common and normal in setting of hypo-estrogenic vaginal environment as well as poor hygiene.
Start with child directed exam, consider cultures, flush for possible foreign body and if all negative without improvement consider vaginoscopy/ EUA. Never do speculum exam.
Prolog - Office Q57
What is the gold standard treatment of septic abortion (even if there is an IUP with cardiac activity)?
Dilation and curettage - for removal of infected tissue.
Then also give IV antibiotics, fluid resuscitation, monitor for developing sepsis
Antibiotics
-Amp/gent + flagyl
-Gent/clinda +/- amp
-Levofloxacin + flatly
-Pip-tazo
Prolog - Office Q58
Hirsutism versus hypertrichosis
Hirsutism: excessive terminal hair in male androgen-dependent areas (face, neck, lower and, upper back, perineum, vulva, axilla, inner thighs)
Hypertrichosis: excessive hair growth with a nonsexual distribution
75% Hirsutism = PCOS
Prolog - Office Q60
How do you define Hirsutism clinically?
Ferriman-Gallwey Score
- A score above the 95%ile for population gets diagnosis.
-B/C women in US, score > 8.
-Med/Hisp/Middle eastern/south american: > 6
Hirsutism / hair growth occurs when testosterone is converted to more potent DHT by 5-a reductase
Prolog - Office Q60
What tests should be ordered when diagnosing PCOS?
-TSH, Prolactin (best tests)
Other tests:
-Morning 17-0HP (during early follicular– elevated in 21-OH Def, MCC CAH)
-DHEAS (adrenal tumors, etc)
-Testosterone (primary androgen produced by the ovary; total testosterone > 200 = suspicion for –> images ovaries)
Prolog - Office Q60
Where do androgens originate from in Women?
1) Adrenal Cortex
2) Ovarian Theca
3) Peripheral conversion in end organs
Prolog - Office Q60
When is admission indicated for PID?
-Surgical emergency (appendicitis)
-Tubo-ovarian abscess
-Pregnancy
-SEvere illness
-Nausea and vomiting
-High fever
-Unable to tolerate PO abx
-No clinical response to oral antimicrobial therapy
NOTE: 85% of TOAs < 7cm will resolve on their own
Prolog - Office Q61
What is the role of estrogen and increased risk of osteoporosis?
Estrogen increased bone mineralization - therefore decrease increased risk at menopause.
Tobacco causes imbalance in bone turnover, directly affecting BMD. Smoking cessation can improve BMD (esp in post menopausal).
Prolog - Office Q62
What is measured in DEXA?
-Hip and lumbar spine
-Reported as a T and Z score
-Initiate DEXA at 65
or initiate with risk factors such as:
-Med hx of fragility fracture
-Weight < 58 kilos
-Meds to cause bone loss
-History of parent with hip fracture
-Current smoking
-Alcoholism
-RA or HIV
Prolog - Office Q62
What FRAX score needs DEXA?
Major osteoporotic risk > 9.3%
Prolog - Office Q62
Asthma associations in pregnancy
-Preterm delivery
-Placental abruption
-Pre-E
-PPH
If given in 1st trimester, oral corticosteroid treatments for asthma are associated with cleft lip and palate.
-Use of systemic steroids has been a/w FGR, but this is not seen inhaled CCS.
Prolog - Office Q63
What percentage of postmenopausal bleeding will be endometrial cancer?
1- 14%.
VB = MC presenting sign of endometrial cancer (>90%).
Large study showed EML < 4mm had >99% Negative Predictive Value (NPV) of no cancer. Thus, does not require biopsy.
EndoCA = MC GYN cancer in the US
RF: age, obesity, exposure to unopposed estrogen, PCOS, T2DM, AGS on cytology, fam hx.
Prolog - Office Q64
In general, what is the leading cause of morbidity and mortality in women in the US?
-Cardiovascular disease or HTN
-1 in 3 deaths occur 2/2 CV disease.
0HTN = modifiable risk factor
-HTN complicates 5- 8% of pregnancies
-chronic HTN after PIH typically presents within 2- 7 years of pregnancy
-Early onset severe Pre-E confers greatest risk of developing cHTN
Prolog - Office Q65
What medications are including in BEERS criteria?
BEERS Criteria = potentially inappropriate medication use in elderly
Recommends avoiding..
-BZDs (inc RF delirium, falls, fractures, MVCs)
-anticholinergics
-desmopressin
-some anti-depressants
-systemic hormone therapy
-long term macrobid use
Prolog - Office Q66
What level of government establishes rights of a minor to healthcare including contraception, abortion, STD screening, etc. ?
-State law and policy
NOTE in 1977, US Supreme Court decision Carey v. Population Services International affirmed adolescent rights to access contraceptives.
Prolog - Office Q67
When should GBS on urine culture be treated in pregnancy (regardless of gestational age)?
Treat any woman who is..
-symptomatic
-CFU 10^5 (asymptomatic bacteruria).
Treatment has been shown to decrease risk of pyelonephritis, low birth weight, preterm birth.
Otherwise, if GBS on urine culture, then that woman should be treated as a carrier and be given ppx in labor.
Prolog - Office Q68
What are the cancers associated with, mutation and inheritance of: Cowden Syndrome?
COWDEN
-Breast (Prev 25-50%), Endometrial (Prev 5-10%), Colon (Prev 9%), + THYROID
-PTEN
-Autosomal Dominant
= benign and malignant neoplasms
-Typically have macrocephaly and pathognomonic skin lesions (papillomatous papules) on the face and mucous membranes by age 30.
-NCCN does recommend risk reducing surgery with hysterectomy, mastectomy.
Prolog - Office Q69O
What are the cancers associated with, mutation and inheritance of: BRCA or Hereditary Breast and ovarian cancer syndrome?
BRCA
-Breast, Ovarian (others = pancreatic, prostate, melanoma in BRCA2 mainly)
-BRCA1 & BRCA2
-Autosomal dominant
-Carrier freq = 1 in 500 general population and 1 in 40 in Aske Jews.
-ACOG and NCCN recommend risk reducing mastectomy and BSO
Prolog - Office Q69
What are the cancers associated with, mutation and inheritance of: Li-Fraumeni Syndrome
Li-Fraumeni = RARE
-Breast, Colon CA; also a/w osteosarcoma, adrenocortical carcinoma, leukemia, lymphoma, brain cancer.
-TP53 (tumor supressor)
-HIGH penetrant autosomal dominant
-NCCN recommends discussing options for risk reduction mastectomy on case-by-case basis.
Prolog - Office Q69
What are the cancers associated with, mutation and inheritance of: Lynch Syndrome ?
Lynch Syndrome (aka hereditary nonpolyposis colorectal cancer)
-Endo, Colon, +Ovarian, Gastric, ureteral, biliary, pancreatic, glioblastoma, renal, pelvis
-DNA mismatch repair genes: MLH1, MSH2, MSH6, PMS2.
-HIGH penetrant autosomal dominant
-Prevalence = 1 in 600 to 1 in 3k.
-Lynch = 2nd MCC of inherited ovarian
-Greater incidence in early onset
-NCCN recommended risk reducing surgery hysterectomy, BSO.
Prolog - Office Q69
What are the cancers associated with, mutation and inheritance of: Peutz-Jeghers
Peutz-Jeghers
-Breast (50% lifetime risk), ovarian sex cord stromal, lung, gastric, colon
-STK11 gene
-Autosomal dominant
-A/w hamartomatous polyps throughout GI tract, mucotaneous hyperpigmentation of mouth, lips, genitalia or fingers.
-No recommendations for risk reduction
Prolog - Office Q69
What are the cancers associated with, mutation and inheritance of: Hereditary diffuse gastric cancer?
Hereditary diffuse gastric cancer
-Diffuse gastric cancer, lobular breast cancer, colorectal cancer
-CDH1 gene
-NCCN recommends use same screening as BRCA.
Prolog - Office Q69
What are contraindications for hormone replacement therapy?
-Hx BCA
-Coronary heart disease
-Previous VTE
-Hx TIA or CVA
-Unexplained vaginal bleeding
-High-risk endometrial cancer
-Active liver disease
Other medication options that have shown benefit include clonidine, paroxetine, gabapentin, herbal remedies.
Prolog - Office Q70.
What is the definition of perimenopause?
= interval from the onset of menstrual bleeding changes and menopause-associated symptoms through 1 year after cessation of menses.
-Up to 25% of cycles lasting longer than 50- 60 days may be ovulatory. Therefore, women in perimenopause can still get pregnant.
-Hormone monitoring with labs is not recommended
-Best treatment option for symptoms and cycle control is COCP.
Prolog - Office Q71
What is the prevalence of intimate partner violence?
1 in 4 women (but the prevalence is likely higher given fear to disclose)
Prolog - Office Q72
ACOG recommends that drills/sims be conducted at least ___ each year.
Quarterly.
Prolog - Office Q73
What is the strongest predictor for malignancy with a pelvic mass?
When should you consult gyn onc?
-Age ( > 2/3 occur in women > 55yo; Median age diagnosis = 63).
GYO consult per ACOG when:
-Elevated Ca-125 based on pre/post menopausal ranges and TVUS findings suggest malignancy
-Ascites
-Nodular or fixed pelvic mass on exam
-Abdominal/distant mets
-TVUS findings: Cyst > 10cm, papillary or solid components, irregular shape, ascites, high doppler velocity.
Prolog - Office Q74
What does the NPDB (National Practitioner Data Bank) do?
NPDB =
-federally regulated, confidential, web-based archive of reports that contains information about health care practitioners, entities and suppliers.
-Mission is to improve health care quality, protect the public, and reduce health care fraud and abuse in the US.
Prolog - Office Q75.
What is the greatest RF for cervical cancer?
-HPV positive status
-Most carcinogenic = 16/18
-Type 16 = most virulent
-Persistent HPV is a RF for CIN3 development
Other RF for cervical ca =
smoking, immunocompromised (HIV, chronic steroid, solid transplant)
Prolog - Office Q76
When should you start pap screening for someone with HIV?
Start within 1 year of onset of sexual activity (and no later than age 21) regardless of viral load or CD4 count.
When pap smear screen initiated, and if normal results, then should continue q1 year x 3 years. Then can continue every 3 years if remain normal.
-Screening should also continue lifelong for those with HIV
Prolog - Office Q76
What is the most common cause (MCC) of overt hyperthyroidism?
Graves Disease
-Women = 3% lifetime risk
-Pathophys= activation of thyrotropin receptor in the thyroid gland by IgG ABs (anti-thyrotropin receptor antibodies)
—> increase production T3 and T4.
Prolog - Office Q77
What is the difference between Le Fort and Complete colpocleisis?
Le Fort = leaves uterus in situ and vaginal tissue closed anterior to posterior
Complete = removal of most of the vaginal tissue and closure of the vagina for women without a uterus who also undergo hysterectomy
Prolog - Office Q78
What vaccines are recommended in pregnancy?
-Influenza
-Tdap
-COVID-19
Vaccines with inactivated virus, bacterial vaccines and toxoids all appear to be safe in pregnant women.
Other vaccines that are safe and should be given if indicated based on other reasons include:
-Hep A
-Hep B
-Pneumococcal
-Meningococcal
Prolog - Office Q79
Which anti-hypertensive has a common side effect of chronic cough? and if occurs should it be continued or discontinued?
ACE inhibitor (i.e. lisinopril)
-Chronic cough: occurs in 10-30% of patients
-Discontinue the medications and should resolve within 1- 2 weeks
-Other adverse effects include hypotension, hyperkalemia, reduction in GFR, angioedema (rare)
Prolog - Office Q80
What percent of individuals in the US have serologic evidence of HSV 2?
What is the difference between primary, non-primary and recurrent.
21%.
-Most infections transmitted by asx partner
Primary: no prior antibodies to HSV 1 or HSV 2, typically most symptomatic with lesions more widespread, dysuria, urinary retention, inguinal LAD. Can also have systemic sx such as fever and meningitis.
Non-primary: outbreak, but have preexisting antibodies either HSV 1 or HSV 2 (i.e. antibodies to HSV1 only and now have HSV2 lesions/outbreak).
Recurrent: reactivation of the dorsal root ganglion HSV. Sx less severe and shorter duration. Varying presentation.
*Intermittent asx viral shedding can occur
*Consistent condom use decreases transmission by 96%.
Prolog - Office Q81
What is the definition of late term versus post term pregnancy?
What are the risks of posters pregnancy?
Late term: 41+0 - 41+6
Post term: 42+0 and beyond
Risks include: post maturity sun of newborn (Meconium, decreased subQ fat), cesarean, OASIS tears, PPH.
Prolog - Office Q82
How do you calculate the number needed to treat (NNT)?
NNT = 1/(ARR)
ARR = absolute risk reduction
ARR = difference between the two risks
Prolog - Office Q82
Cervical cytology has a (high/low) sensitivity and a (high/low) specificity.
Cervical cytology has a HIGH sensitivity and a LOW specificity.
Prolog - Office Q83
22yo health G0 with LSIL pap 1 year ago. What should be completed at todays visit?
Cytology alone
-HPV screening is not recommended or approved for women younger than 25 years.
-If <25yo and HSIL, ASC-H, AGC, AIS detected, then recommend colposcopy.
-If < 25yo and LSIL –> cytology in 1 year.
-If < 25yo and LSIL x 2, then colposcopy
Prolog - Office Q83
What are three ways to asses adequate breast milk supply?
If inadequate, what is the management?
1) BF freq 8- 12 x/day
2) Urination 6- 8 x /day and 3 or more stools/day
3) < 10% weight loss after birth and exceeding birth weight by 10- 14 days
Inadequate?
–> #1 assess / optimize BF technique; lactation consultant and physical exam of nipples, etc
–> #2 Assess Rx that could dec milk prodxn- decongestants, dopamine agonists, estrogens)
-If all above okay, then could be caused by inadequate tissue, hx augmentation or reduction. Also could be due to infant etiology (poor suck, neuro/motor conditions)
–> #3 Galactogogues =
- Dopamine Receptor antagonist (metoclopromide, domperidone)
-But these have poor evidence!
Prolog - Office Q84
Thinned vulvar skin in an hourglass shape encompassing labia, perineum and perianal skin. Diagnosis?
Given initial topical treatment without relief / persistent symptoms.
Next step?
Lichen Sclerosis
Tx: high-potency topical corticosteroids (clobetasol propionate). Daily x 1 month, then taper x 2 months
- Improves sx in 96% of patients.
No improvement, new ulcers / lesions –> BIOPSY.
Prolog - Office Q85
What is the rate of perineal laceration at time of vaginal delivery?
What 2 things can decrease risk of 3rd and 4th degrees?
50-80% of women will tear
1) Perineal massage
2) Warm perineal compresses during pushing
Classifications:
1st: perineal skin only
2nd: perineum involving perineal muscles but not the anal sphincter
3rd: perineum involing anal sphincter (AS) complex
-3a: <50% external AS
-3b: >50% external AS
-3c: both external and internal AS torn
4th: perineum, AS complex, and anal epithelium
Prolog - Office Q86
What are the classifications of OASIS tears?
Classifications:
1st: perineal skin only
2nd: perineum involving perineal muscles but not the anal sphincter
3rd: perineum involing anal sphincter (AS) complex
-3a: <50% external AS
-3b: >50% external AS
-3c: both external and internal AS torn
4th: perineum, AS complex, and anal epithelium
Prolog - Office Q86
What is the most common inherited thrombophilia?
What is the 2nd most common?
1 Factor V Leiden
-Autosomal dominant
-single point mutation
-MC heterzygous (99%) and only 5% will have VTE
-Autosomal dominant
-MC heterozygous
Classyfing Thrombophilias
1) Loss of function = Antithrombin 3 def, Protein C, Protein S
2) Gain of function =
Prothrombin mutation G20210A, Factor V Leiden
Prolog - Office Q87
What are the indications for testing for Antiphospholipid antibody syndrome?
-those with evidence of new or previously unexplained arterial or venous thrombosis
-one or more unexplained fetal losses after 10 weeks
-one or more episodes of Pre-E w/ SF before 34 weeks
-3 or more SABs before 10 weeks
APLS = autoimmune, acquired thrombophilia
ACOG does not recommend screening women for inheritable thrombophilias when they have a history of fetal loss or adverse pregnancy outcome.
Prolog - Office Q87
What is the only reliable testing for inherited thrombophilias in the setting of acute thrombosis and anticoagulation therapy?
What is the only test that is not reliable during pregnancy?
-DNA analyses –> specifically test for Factor 5 and Prothrombin gene mutations (the MC and 2nd MC disorders)
*acute VTE, AC, pregnancy or use of hormonal contraception does not alter testing.
Protein C, Protein S and antithrombin 3 deficiency are diagnosed using functional assays. Ideal timing is at least 6 weeks from diagnosis of VTE and when patient is off AC, at least 3 months prior to pregnancy or 3 month postpartum and absence of hormonal contraception.
However, all testing methods are reliable in pregnancy with the exception of Protein S deficiency.
Prolog - Office Q87
What is the prevalence of obesity in the united states?
35% (approx 1/3)
-Screening for obesity per USPSTF should start at age 6 and continue annually
When lifestyle modifications fail in a patient with Class II obesity (BMI > 35) with comorbidity (HTN, T2DM, etc), bariatric surgery is highly-effective and the most effective long-term sustained weight loss.
Roux-En-Y is better for patients w T2DM based on mechanism.
Sleeve gastrectomy is also great option and overall as effective (but not best for T2DM).
Prolog - Office Q88
Patient has persistent, symptomatic vaginal discharge, vulvar burning and irritation. Discharge yellow to green. Microscopy shows copious polymorphic neutrophils and parabasal cells. Vaginal pH > 4.5. Whiff negative.
What is the diagnosis?
Desquamative inflammatory vaginitis
-MC postmenopausal
-inflammatory, non-infectious
-Typically diagnosed after others are ruled out and made clinically
-pH > 4.5
-etiology unknown
-treatment options lacking but current recommend vaginal clindamycin 2% cream or compound hydrocortisone cream 10%.
Prolog - Office Q89
What is a normal vaginal pH?
< 4.7.
The only vaginitis that will have a lower pH is yeast. All others are > 4.7.
Prolog - Office Q89
Which Epithelial cells / microscopy and discharge are associated with each vaginitis (normal, VVC, BV, Trich, D.I.V, Atrophic).
1) Mature Squamous cells
2) Clue cells (> 20%)
3) Immature squamous cells or parabasal cells
4) Lactobacilli pre-dominant
5) Branch pseudo-hyphae or blastospores
6) coccobacillary flora
7) Some clue cells
A) White, creamy or clear
B) Thick, white, curd-like
C) Thin, white-gray homogenous
D) Yellow, frothy
E) Yellow or green or white and copious
7) Scant, dry
Normal = Mature Squamous cells, Lactobacilli pre-dominant
White/creamy/clear discharge
VVC = Mature Squamous cells, Branch pseudo-hyphae, Thick/white curd-like discharge
BV = Clue cells (> 20%),
only AMINE poss
coccobacillary flora
Thin, white-gray homogenous
Trich = Mature Squamous cells, some clue cells, trichomonads
Yellow frothy discharge
DIV = Immature squamous cells or parabasal cells, *ABUNDANT neutrophils
Yellow or green or white and copious
AV = Immature squamous cells or parabasal cells
deceased mixed flora
Scant, dry discharge
Prolog - Office Q89
What is the most common side effect of SSRIs and what are GYN side effects can occur?
-Sexual dysfunction = #1
-Fluoxetine is also a/w heavy menstrual bleeding
-SSRIs can cause affect on the HPA axis causing anovulatory cycles, menstrual disturbances, or galactorrhea
Prolog - Office Q90
Patient taking St. Johns Wort for depression, how should she be counseled in regards to contraception?
St. John’s Wort = hepatic metabolic enzyme inducer –> lowers efficacy of oral contraceptive pills.
Prolog - Office Q90
Patient has medication-induced sexual dysfunction with decreased libido. Her depression is well controlled on fluoxetine. What is the recommended treatment option?
-Continue Fluoxetine (because well controlled)
-Start psychotherapy
-Add Bupropion
–> Adjuvant therapy for sexual dysfunction is preferred over changing anti-depressant when depression is well controlled.
- Adjuvant tx with Bupropion has been shown to improve symptoms.
Prolog - Office Q91
6yo presents with dysuria, urinary hesitancy and constipation.
Exam porcelain-white papules and plaques with distinct borders, figure of 8 or butterfly distribution.
Diagnosis?
Lichen Sclerosis
-MC in age 6- 7yo
-May also present as behavioral changes
-Exam may also show excoriations or hyperkeratotic / hypertrophic appearance as well as ecchymosis
-DO NOT DO INTERNAL EXAM
-Tx: Clobetasol, daily x 1 month then taper x 2 -3 months
Prolog - Office Q92
> 60 yo with history of GERD now with new, worsening symptoms x 6 months including difficulty swallowing. What is the best next step?
EGD; best step due to alarm sx.
If no alarm sx, then can consider H. Pylori testing. H. Pylori also typically presents more dyspepsia only and no reflux.
Alarm Sx of GERD:
-Dysphagia (difficulty swallowing)
-Odynophagia
-Anemia
-GI Bleed
-Unexplained weight loss
-New onset sx > 60yo
-Anorexia
-Persistent emesis
-FamHx 1st degree GI cancer
Prolog - Office Q93
What are the 5 principles of trauma-informed care?
Choice: informing of options and letting pt choose
Collaboration: incorporating pt, family, staff into tx plan
Pt Empowerment: using pt strength to empower her in her own tx
Safety: create safe environment
Trustworthiness: communicate clear expectations about treatments, etc.
Prolog - Office Q94
30yo 12wks pregnant with HSIL and +HR-HPV pap. Colposcopy preformed showed 5mm lesion with vecsularity. What is the best next step?
-Biopsy the lesion!
Immediate excision with CKC is not recommended in pregnancy until early cervical cancer is confirmed on biopsy. A cerclage is also typically placed at the same time.
If CIN-2 or CIN-3 is found, then repeat colposcopy q12- 24 weeks (or each trimester).
It is not recommended to defer colposcopy until postpartum period in a patient with HSIL and a visible lesion.
Prolog - Office Q95
What is the mot effective form of emergency contraception (E.C.)?
What is the most used form of E.C. in the US?
Copper IUD = most effective
- Must be inserted within 5 days of unprotected intercourse
-However, this is not FDA approved!
Oral E.C. =
(1) Progestin-only pill; 1.5 mg levonorgestrel
-OTC and Rx
-up to 72 hours after unprotected sex
(2) Ulipristal acetate (30mg)
-RX only
-up to 72 - 120 hours after unprotected sex
-For both, pt should wait 5 days before resuming other OCPs. If at time of OCP EC and starting NEW contraception (IUD, implant, Depo) then patient should use back up contraception x 7 days.
-Both, have shown to be less effective in obese population.
Prolog - Office Q96
Postmenopausal F w/ PMHx T2DM, BMI 50, who is asymptomatic (no VB) and incidental finding of 18 mm EML. What is the best next step?
EMB
Any postmenopausal woman with EML > 4mm should be offered EMB.
However, in asx patients decision can be individualized.
Exception, patients with risk factors and EML > 15mm should have biopsy.
Prolog - Office Q97
At what upper range of BP should an elective surgery be postponed?
Systolic >180
Diastolic > 110
Prolog - Office Q98
What are the indications for CXR or ECG prior to surgery?
CXR
-COPD, current smoker, cardiac disease, recent URI for patients receiving general anesthesia.
ECG
-Low risk surgery: only if > 65yo and has not had Egg in 6- 12 months
-Moderate risk surgery: not indicated in healthy individuals, but consider ECG in pts ASA Class 2–> T2DM, renal or CV comorbidities.
-High risk surgery: obtain in all patients ASA Class 2 or greater. Unless ECG within 6 months that is normal.
Prolog - Office Q98
What is the mot appropriate diagnostic test for syphilis in an asymptomatic patient (non-pregnant) with a known partner exposure?
Treponemal enzyme immunoassay
If positive, then complete FTA-AB testing.
Prolog - Office Q100
What is the number of repeats (and what is the repeat) for premutation of Fragile X?
What is the primary association with premutation?
CGG repeats
55- 200 = Premutation
Increased risk of premature ovarian insufficiency/failure (POF)
Prolog - Office Q101
What are the four findings diagnostic for pregnancy failure?
(1) CRL 7mm or greater with no FCA
(2) MSD 25mm or greater with no embryo
(3) Absence of embryo with FCA 2 weeks after scan with gestational sac without a yolk sac
(4) Absence of embryo with FCA 11 days or more after a scan with a gestational sac and a yolk sac
Prolog - Office Q102
What is the recommended treatment of primary dysmenorrhea in adolescents?
NSAIDs or hormone-based methods - both are superior to tylenol
Primary Dysmenorrhea = absence of pelvic pathology, thought to be due to prostaglandin and leukotriene-mediated inflammation. Begins with ovulatory cycles and includes cramping, low back pain, +/- n/v/d, HA, sleep disturbance.
Prolog - Office Q103
Patient with IUD in place, has some cramping and 2D TVUS shows possible embedded in myometrium. What is the next best imaging modality to evaluate specific location?
-CT
-Fluoro
-MRI
-XR
-3D US
3D TVUS
-Can evaluated coronal view and enable detection of precise amount of embedment.
Both levonorgesteral and copper IUDs are radiopaque.
Prolog - Office Q104
At what age is the recombinant zoster vaccine recommended?
> 50yo
Two doses, 2- 6 months apart.
Prolog - Office Q105
What is the initial work-up for secondary amenorrhea, specific lab testing in POF?
-Start with UPT, TSH, Prolactin (must be negative/ normal to consider POF)
-If normal, then FSH, LH and Estradiol.
-Low EZ and High FSH, LH on two occasions > 1 month apart = diagnostic for P.O.F.
After diagnosis is made, then etiology should be determined.
Screening for Fragile X, Autoimmune thyroiditis and autoimmune adrenal insufficiency (Addison’s disease) are all recommended.
Prolog - Office Q106
What are the medical contraindications for medical abortion with misoprostal or mifepristone?
-Confirmed / suspected ectopic pregnancy
-Current IUD in place
-Current long term systemic corticosteroids
-Chronic adrenal failure
-Known coagulopathy
-Current AC therapy
-Patient intolerance / allergy
Of note, anemia has been excluded from all safety studies and there are no clear cut criteria or recommendations for patients with anemia alone.
Pts w contraindications should be recommended surgical tx.
Prolog - Office Q107
Acute onset pelvic pain and CT shows a “vascular whirl” near the ovary. Diagnosis?
Ovarian Torsion
Twisting first causes compression of thinner walled venous supply –> leads to edema.
Then, arterial compression leads to ischemia –> ovarian necrosis, infarction, hemorrhage.
RF for torsion: ovarian cyst, tubal sterilization, pregnancy.
S/s: Low grade fever, n/v, pelvic pain, mild leukocytosis, anemia.
TVUS = 1st line evaluation
Cyst (typically > 5cm), ovarian stroll edema, heterogenous ovary w peripheral follicles.
Normal doppler is seen in 45- 60% of individuals with torsion.
CT: rules out other etiology
-Ovary is edematous, enlarged w/ peripheral follicles + para ovarian mass = 84% PPV
-Whirl sign = twisted ovarian pedicle and PPV = 75-80%.
Prolog - Office Q108
5yo with spotting when wiping, resistance to urinating and new vulvar mass. Diagnosis and treatment?
(in the Q there is a pic of a bright red circumferential mass).
Urethral prolapse
Tx: Vaginal estrogen + conservative measures (sitz baths, behaviors modifications, barrier creams)
Benign condition, circumferential protrusion of distal urethral mucosa through external urethral meatus.
-Occurs in premenarchal and postmenopausal.
-Incidence 1 in 3k
-Exact etiology unknown
Prolog - Office Q109
What are the risks of untreated opioid use in pregnancy?
What is the gold standard of treatment, its mechanism of action and what changes are anticipated in pregnancy?
Inc RISK: PTD, FGR, Abruption, IUFD.
Standard treatment = Methadone or buprenorphine
Methadone
-Long-acting opioid agonist mu-receptor
-Decreased withdrawal sx, cravings and risk of relapse
-Pregnancy metabolism changes can result in need to increase dose throughout pregnancy
-Requires daily in-pt visits
Buprenorphine
-Partial agonist to mu-receptor
-Decreases risk of overdose or abuse
-Out-pt tx
-Fewer med reactions and decreased risk of NAS.
Other MOA related:
-Naloxone: short-acting opioid antagonist, used to reverse respiratory depression in overdose.
-Naloxone/Buprenorphne currently not recmd in pregnancy but no known adverse effects
-Naltrexone: full opioid antagonist that removes euphoria sensation that accompanies opioid use. no potential for abuse, good option for motivated indvls. Must dc x 7d prior to initiation.
Prolog - Office Q110
Spontaneous galactorrhea (bilaterally milky) and irregular cycles. What are the two best lab studies to order? and Most likely cause?
Labs: TSH and Prolactin
Dx: Elevated Prolactin –> Hyperprolactinemia.
Prolactin secreted by anterior pituitary by lactotrophs. Prolactin exerts action that affects reproduction, angiogenesis, osmoregulation and immune responses.
Elevated prolactin can suppress GnRH, decreasing LH and FSH. Decreasing estradiol and progesterone. –> irregular cycles, infertility.
High concentrations of TRH (thyroid releasing hormone) from the hypothalamus can result in elevated Prolactin. Thus, TSH and Hypothyroidism should be evaluated.
Prolog - Office Q111
What is the exception to the rule about REQUIRING a companion (aunt/parent/S.O./etc) to leave the room?
When clinical scenario suspects human trafficking.
1st goal = maintain patient safety.
-Never directly confront the other person
-Do not screen with person in the room
-Do not require the companion to leave
-Do not express concerns while companion in the room
Best option:
-Develop a protocol for your office –> small room for vitals (only fits one and give discrete screening)
-Create ways to allow patient to interact alone with staff
Prolog - Office Q112
What is the mainstay of therapy for diverticulitis?
-Antibiotics, dietary modification (bowel rest- but not NPO unless unable to tolerate PO), pain management
-Watchful waiting to avoid surgery as last resort
Simple, uncomplicated diverticulitis can be treated outpatient with CLD, slow advancing to low-fiber diet, with antibiotics case-by-case.
Complicated diverticulitis –> intraabdominal abscess or purulent or fecal peritonitis –> must be admitted in-patient.
if abscess >3cm, then percutaneous drain.
Prolog - Office Q113
How does the estrogen component of COCPs increase the risk of thrombosis?
Estrogen increases liver production of multiple coagulation factors including Factor VII, Factor X, and fibrinogen.
Estrogen containing contraception are category 3 in those with history of VTE.
DMPA is category 2 in those with history of VTE.
Prolog - Office Q114
List a specific contraindication of COCPs based on age.
> 35 years old and smoking at least 15 cigarettes per day.
= Category 4 (risk considered unacceptable)
Prolog - Office Q114.
What is the second most common cause of cancer death in the US in women?
Breast cancer
Per ACOG, start mammograms at age 40.
USPFTF states insufficient evidence to stop or continue screening after the age of 75.
ACS recommends continuing cancer screening as long as their health is good and life expectancy is 10 years.
Prolog - Office Q115
Patient 42yo with HSIL, positive HPV 16. What is the next step?
Excisional procedure
2019 Exec Summary:
“For non-pregnant patients 25 years or older, expedited tx, defined as tx without preceding colposcopes bx, demonstrating CIN2+, is preferred when the immediate risk of CIN3+ is >60%, and is acceptable for those with risks between 25-60%. This is preferred in patients with HSIL cytology and HPV positive 16.”
Prolog - Office Q116
What is the best first line medication for breastfeeding mother with perinatal depression?
SSRI = 1st line
-Pass minimally into breastmilk (sertraline is the least)
Perinatal depression occurs within 12 months
-Affects 20% of population
-Maternal suicide is more common cause of death than hemorrhage or HTN
-Major risk factor = hx depression or other mood disorder prior to pregnancy
Prolog - Office Q118
What STI testing should be done and what empiric treatment should be given for rape / sexual assault?
Testing-GC/CT/Trich, HBV, HCV, HIV, Syphilis.
Empiric Treatment:
-GC/CT/Trich
-Offer PrEP
-Offer Hep B vaccinations if needed
Prolog - Office Q119
What is the best contraception option for a patient with migraine (without aura) related to menses?
Continuous COCPs
(as long as no other risk factors for stroke including obesity, smoking)
1/2 of women with migraine headaches occur with their cycles.
Prolog - Office Q120
What are the three most common causes of chronic cough?
-Upper airway cough syndrome (post-nasal drip), Asthma, GERD
-Initial evaluation is empiric treatment for each based on clinical suspicion.
Page 210 of Prologs has algorithm chart to review!
This questions gets at Eosinophilic Bronchitis. An uncommon disorder that i didn’t think was worth going after. This disorder requires an induced sputum analysis preformed by a specialist.
Prolog - Office Q121
What are the four primary principles of medical ethics?
Autonomy:
-Right to an individual patient must choose or refuse medical treatment
-Patient gets to make their own decision
Justice:
-Most complex ethic principle
-deals w/ obligation to render to each indivdl pt what is owed, but this also must be weighed w the physicians role in allocating limited resources in a broader community setting
Beneficence:
-“doing or producing good”
-act in a way that benefits others
-opposite of non-maleficence
Non-maleficence:
-obligation to not do harm or cause injury
-present a balanced perspective of the risk and benefits of a proposed action so pt can proceed in way that is consistent with their views
Prolog - Office Q123- 125.
What is the typical pubertal progression?
TAGM
-T: Thelarche: onset of breast development
-A: Adrenarche: onset of maturation of the zona reticularis in the adrenal gland with subsequent secretion of androgens
-G: Growth Spurt: period of peak height velocity
-M: Menarche: onset of menstruation
What is the typical pubertal progression?
TAGM
-T: Thelarche: onset of breast development
-A: Adrenarche: onset of maturation of the zona reticularis in the adrenal gland with subsequent secretion of androgens
-G: Growth Spurt: period of peak height velocity
-M: Menarche: onset of menstruation
Breast and Pubic hair characterized as Tanner staging (I- V).
Prolog - Office Q126-129
Define Primary Amenorrhea.
Primary Amenorrhea: defined as the lack of menarche by age 15 years or within 3 years of thelarche.
Evaluation starts with birth, medical history, uses growth charts, Tanner stages.
Diagnosis can then be made with imaging as well as gonadotropin concentration measurement.
Prolog - Office Q126- 129.
Between FSH and LH, which is most sensitive at determining puberty and which is most sensitive at determining postpubertal hypothalamic or ovarian insufficiency?
LH = determining puberty
FSH = postpubertal hypothalamic or ovarian insufficiency
-High: gonadal dysgenesis or primary ovarian insufficiency
-Low: hypothalamic amenorrhea, CNS masses w effect, Kallman Syndrome, CAH, Prolactinoma, constitutional delay, anorexia, weight loss, stress or high anxiety.
Prolog - Office Q126-129
14yo amenorrhea, without cyclic sx or cramping. Breast, pubic hair = Tanner V. Thelarche at 10yo. Height 60th%ile. Pelvic US shows bilateral ovaries, absent uterus. FSH = 12. Diagnosis?
Mayer-Rokitansky-Kuster-Hauser syndrome
-Chr 46, XX.
-Ovaries normal but can be found in abnormal location.
-Assoc anomalies skeletal, hearing, renal.
Prolog - Office Q126
12yo 6 months of cyclic cramps without menarche. Thelarche occurred at 9yo. Height 54%ile. Tanner IV Breast and pubic hair. Nml external genitalia. US shows large hematometra and hematocolpos. Normal bilateral ovaries. FSH = 8. Diagnosis?
Transverse vaginal septum.
Etiologies of obstruction: imperforate hymen, distal vaginal atresia, or transverse vaginal septum.
-Chr 46, XX - nml female.
-Tx: surgery
Prolog - Office Q127
14yo amenorrhea, no cyclic sx. Thelarche at 10yo. Height 93%ile. Tanner III Breast, Tanner I pubic hair. Nml external female genitalia. 2cm palpable mass in inguinal cancal. US no uterus, cervix, ovaries. FSH = 10. Diagnosis?
Androgen Insensitivity Syndrome
-X-linked recessive
-1 in 20k, 1.1%
-Chr: 46, XY
-Y chr results in release of mullerian-inhibiting substance from the fetal gonads, which are testes.
-Leads to resorption of paramesonephric ducts –> absent fallopian tubes, uterus, cervix, upper vagina.
-Dysfunctional androgen receptor
-Testosterone = nml
-Scant pubic hair and nice boobs, tall.
Prolog - Office Q128
15yo amenorrhea, no cyclic sx. Thelarche at 10yo. Height 2%ile. Tanner II Breast/Pubic hair. Nml external genitalia. US nml uterus, cervix but no ovaries. FSH = 94. Diagnosis?
Primary ovarian insufficiency
-Depletion or dysfunction of ovarian follicles prior to age 40.
-5-10% will achieve pregnancy spontaneously
-Common in Turner Syndrome pts
Prolog - Office Q129
What is the embryological origin of the upper and lower vagina?
Upper vagina: (fallopian tubes, uterus, cervix) originate from two lateral mullerian ducts that fuse in the midline and then undergo canalization.
Lower vagina: (w/ urethra) originates from urigenital sinus.
Hymen = squamous structure that usually perforates, arises at junction of urogenital sinus and the sinovaginal bulb
Prolog - Office Q130- 133.
24yo 24 weeks gestation presents fever, rash, n/v. Ate deli meat at picnic. PTL and rapidly delivers. Amniotic fluid appears abnormal in coloration. Micro-abscesses are present in placental path.
Pathogen?
Listeria Monocytogenes
-Gram positive bacteria
-Sx: fever and diarrhea
-Inc risk: miscarriage, stillbirth, life-threatening neonatal infection.
-Pregnancy loss rate 20-30%
-A/w hot dogs and deli meats, unpasteurized dairy products, melons, spinach, mushrooms, celery.
-Obtain blood cultures
-Empiric tx: IV PCN
Prolog - Office Q139
36yo G1P0 at 5wks calls with watery diarrhea, abdominal pain, vomiting. Reports eating raw fish in sushi yesterday.
Pathogen?
Vibrio Cholerae
-Gram negative
-Undercooked shellfish
-Profuse watery diarrhea and vomiting –> dehydration, mylagias, emesis –> hypovolemic shock
-tx: fluid replacement w/ macrolides
Prolog - Office Q140
Pt just went to france 12 wks, she ate steak tartare every day in paris. A week later, generelized malaise, body aches and cervical LAD.
Pathogen?
Tocoplasmosis gondii
-Parasite
-Malaise, mylagias, HSM
-Leading cause of food borne illness in the US
-Congenital toxo: CNS dysfxn, retinitis
-Uncooked meats: lamp, pork, venison. or shellfish: oysters, clams and mussels.
-Soils and cat feces
-Tx: Spiramycin in pregnancy
-Dx with IgG and IgM
Prolog - Office Q141
What is part of the ASCVD risk calculator?
-Age, sex, BP, total cholesterol, HDL, LDL, Hx DM, smoking, anti-HTN therapy, statin therapy, ASA therapy
-Calculates 5 and 10 year risk of atherosclerotic CV disease
-Modifiable RF for CVD = HTN, smoking, DM, DLD, Obesity, physical inactivity, unhealthy diet.
-Non-modifiable: age, famHx
-Low-modifiable: CKD, OSA, low socioeconomic status, psychosocial stress
See Tables on page 226 for categories of BP and treatment recommendations.
Prolog - Office Q144- 146.
List each targeted fetal test indicated for each psychiatric medication:
-Lithium
-Olanzapine
-Topiramate
-Valproic acid
Lithium: Fetal ECHO
Olanzapine: early gDM
Topiramate: US for orofacial defects
Valproic acid: msAFP
Prolog - Office Q147- 150
What ovarian cancer risk assessment contains each of the following:
Ca-125
TVUS
Menopausal status
Risk Malignancy Index (RMI)
-Simple scoring system
-Ca-125 x US results (1- 3)
-Score > 200 = abnml
regardless of age
Prolog - Office Q157
What ovarian cancer risk assessment contains each of the following:
Ca-125
HE4 (human epididymis protein 4)
Menopausal status
Rock of Ovarian Malignancy Algorithm (ROMA)
-logistic regression model that categorizes women with adnexal mass into low and high risk of malignancy
-HE4 is not elevated in benign conditions like CA-125. –> together more sensitive.
Prolog - Office Q158
What ovarian cancer risk assessment contains each of the following:
Ca-125 II, Transferrin, transthyretin, apolipoprotein A-1, B 2-microglobulin, menopausal status
Multivariate index assay
-Abnormal scores
Premenopausal: >5
Postmenopausal: >4.4
Prolog - Office Q159
What are the recommendations for antiphospholipid antibody testing based on a clinical scenario?
What are the clinical and laboratory criteria?
-After > 2 pregnancy losses (see below)
-Between 5- 20% will test positive for APLA
-Diagnosis requires clinical and laboratory criteria (one of each)
Clinical criteria
1. Vascular thrombosis
2. Pregnancy morbidity
a. one or more unexplained deaths of a morphologically normal fetus > 10wks
b. One of more PTBs of morphologically normal neonate before 34 weeks due to eclampsia, severe Pre-E or recognized placental insufficiency.
c. three of more unexplained consecutive SABs < 10 wks
Laboratory criteria
`. Lupus anticogulant present in plasma on two or more occasions at least 12 weeks apart OR
2. Anticardiolopin AB of IgG or IgM isotype in serum or plasma present in medium or high titer, on two or more occasions at least 12 weeks apart , OR
3. Anti-B2 glycoprotein-1 AB of IgG isotype in serum or plasma present on two or more occasions at least 12 weeks apart
Prolog - Office Q160-162
19yo w 3 days of fever, chills, body aches, vulvar itching, dyspareunia and oral lesions. Lesion appeared sudden in onset, large, well-delineated formation with a fibrinous, necrotic or purulent center.
Lipschultz acute vulvar ulceration
-Typically women 20 and older
-Not an STI!
-Non sexually active
-Aphthous ulcer
-tend to occur concomitantly with flu like syndrome
-Enlarged LN or canker sores can occur
-Resolve spontaneously in 3 weeks
-Diagnosis of exclusion
Prolog - Office Q167- 171
