Office Complaints Flashcards
Fits-Hugh Curtis
when purulent tubal d/c from POD ascends to RUQ causing peri hepatitis and RUQ pain
Reasons to Admit for Inpatient Tx PID
- Severity of symptoms (ex- high fever)
- Peritoneal signs or poss TOA (see on US)
- If nausea and vomiting prevents oral medication use
- Pregnant
- If need to r/o appendicitis
3 Main Types Vaginitis
- BV = homogenous, white d/c, + whiff (amines w/ KOH);clue cells (shaggy)
- Candida = heterogeneous, white d/c (cottage cheese); normal pH (<4.5)
- Trich = frothy green d/c and strawberry cervix; flagellated trich
Syphilis (primary, secondary, tertiary)
- Primary - painLESS chancre + painLESS inguinl lymphadenopathy; appears w/in 3 wks exposure then gone in 2-6 wks
- Secondary - systemic including maculopapular rash on hands and feet; usually 9 wks after ulcer
- Tertiary - optic problems, tabes dorsalis (posterior columns - unsteady gait), aortic aneurysm, Argyll Robertson pupils
Syphilis Diagnostic Tests
- screen w/ non-treponemal test (RPR or VLDR) then confirm w/ dark field microscopy
- Initial RPR or VLDR is antibody / tiger measurement so decreases w/ treatment
- Test of cure at 6 and 12 mo; if no dec in titers than suspect neurosphyilis
Syphilis Tx
- If < 1 yr then 1 dose IM PCN
* If > 1 yr then 3 doses IM PCN (1 wk apart)
HSV
- Presentation
- Primary episode more likely systemic (fever and malaise)
- Prodrome of numbness and tingling –> vesicle on red base
- Dx - viral cx or PCR
- Tx - oral acyclovir
Chancroid
- Painful vulvar ulcer w/ ragged edges and necrotic base + painFUL lymphadenopathy
- H ducreyi (gram neg rod) - school of fish on gram stain
- Dx - biopsy / cx
- Tx - oral axithromycin or IM ceftriaxone
How do fibroids present?
- excess menstrual bleeding, compressive symptoms, uterus is irregular, midline, firm, mobile and moves w/ cervix
- Can also have anemia secondary to menstrual blood loss
Fibroid Tx
- 1- MEDS (NSAIDS, progesterone
- 2- If non-responsive to meds and want to shrink before surgery then give 3 mo GnRH agonist (leuprolide); will reverse as soon as you stop drug
- 3- Hysterectomy (indicated if still symptomatic despite medical treatment)
- Myomectomy if desire future pregnancy
Concerning Fibroid Features
Rapid growth and hx pelvic radiation makes you suspicious of leiomyosarcoma
Do ex lap w/ hysterectomy
Common Breast Complaints in Young Female (2)
Fibrocystic Change
- Mult irregular lumps and painful engorgement usually right before menstruation +/- serous or green d/c
- Tx - dec caffeine, use NSAIDs, tight fitting bra or OCPs
Fibroadenoma
- Benign smooth muscle tumor
- Firm, rubbery, mobile, solid w/o menstrual change
- Must do some sort of biopsy - FNA (cytology) or core needle
Differential for Amenorrhea
- Hypothalamus - Hypothyroid or hyper-prolactin both dec GnRH pulsating release –> dec FSH / LH OR due to stress, exercise, wt loss
- Pituitary
- Sheehan - anterior pituitary hemorrhagic necrosis (common in labor)
- Radiation or surgical damage to pituitary
- Ovaries
- Premature ovarian failure (if < 40 yo);
- PCOS (will shed when given progesterone challenge)
- R/o pregnancy
- Outflow Problems
- Cervical stenosis - leads to retrograde menstruation which can present as cramps abdominal pain 5-7 days / mo
- Asherman - adhesions after a uterine curettage - endometrium does not respond to hormones
Diagnosis and Treatment of Asherman
No response to progesterone therapy; no withdrawal bleeding
- Diagnose by hysterosalpingogram, saline infusion sonogram of uterine cavity or hysteroscopy
- Tx - operative hysteroscope and lysis of adhesions; may leave pediatric foley or IUD in place to prevent recurrence of adhesions
What is the #1 cause of unilateral serosanguinous nipple d/c?
Intraductal papilloma
Indication for BRCA testing
2 first degree relatives w/ breast cancer
Mgt of Breast Cyst
1- US
2- FNA
If straw colored then can just observe
If any other color then send for cytology
Differential for Galactorrhea
- Secondary to hypothyroidism
- Pathogenesis: hypothyroid –> inc TRH –> inc prolactin
- Inc prolactin –> inhibits GnRH pulsatile release –> amenorrhea
- Give thyroxine
- Pregnancy - test
- Pituitary prolactinoma - headaches or visual disturbances (bitemporal hemi)
- MRI
- Breast stimulation
- Meds - psychotropics (anything that dec dopamine will inc prolactin because less inhibition)
- Chest Wall Trauma
Tx of Prolactinoma
- Can treat w/ bromocriptine (used in pregnancy) or cabergoline (both dopamine agonists) or surgical resection
- Complications of surgery - transient DI, pan-hypopituitarism, CSF leakage, meningitis, hemorrhage
- Can also dec size w/ bromocriptine first ythen resect
Differential for Hirsuitism (5)
1- Cushing - hyperglycemia, HTN, buffalo hump/central obesity; treatment is surgical removal
2- Adrenal Tumor - RAPID hirsuitism and virilization w/ ab mass; see elevated DHEA
3- CAH - ambiguous genitalia + hypotension; inc 17-hydroxyprogesterone
* Must replace mineralocorticoid and cortisol
4- PCOS - insidious onset of hirsuitism rarely w/ virilization
5- Sertoli-Leydig tumor - RAPID onset hirsuitism and virilization w/ adenexal mass; inc testosterone
Differential for Hirsuitism (5)
1- Cushing - hyperglycemia, HTN, buffalo hump/central obesity; treatment is surgical removal
2- Adrenal Tumor - RAPID hirsuitism and virilization w/ ab mass; see elevated DHEA
3- CAH - ambiguous genitalia + hypotension; inc 17-hydroxyprogesterone
* Must replace mineralocorticoid and cortisol
4- PCOS - insidious onset of hirsuitism rarely w/ virilization
5- Sertoli-Leydig tumor - RAPID onset hirsuitism and virilization w/ adenexal mass; inc testosterone
Thought Process for Primary Amenorrhea
- Is there breast development?
- NO
- Hypergonadotropic Hypogonadism
- Most common is Turner (45, X); no estrogen because streak ovaries; high FSH
- Hypogonadotropic Hypogonadism (CNS problem)
- Causes - stress, exercise, pituitary adenoma, poor nutrition, chronic illness, Cushing, Kallman (lack of GnRH producing cells)
- Hypergonadotropic Hypogonadism
- YES
- Mullerian Dysgenesis
- Still have breast development (estrogen) and pubic/axillary hair development (androgens)
- 46, XX
- No uterus or Fallopian tubes, absent or short vagina + 1/3 have renal abnormalities too
- Androgen Insensitivity
- 46, XY but feminization; no internal or external male genitalia because not responsive to androgens; no female genitalia either because anti-mullerian in embryogenesis
- Have breast development because estrogen still present from peripheral conversion; no pubic hair because that requires androgens
- Phenotypically female
- Remove gonads after puberty
- Mullerian Dysgenesis
Normal Female Puberty
- Thelarche (avg 10.8) - breast development
- Adenarche (avg 11) adrenals - axillary and pubic hair
- Menarche (12.9) - mentstruation
Definition of Delayed Puberty
No secondary characteristics by age 14
Precocious Puberty (definition, causes, tx)
- Breast development b/f 7 (6 in blacks)
- Central (GnRH pulsation - have FSH and LH)
- Hydrocephalus, brain tumor, head trauma
- Peripheral - FSH and LH barely detectable
- Granulosa cell tumor (juvenile subtype) or adrenal tumor
- Can also be idiopathic
- Presenation - inc height earlier than peers but then overall shorter because epiphyseal plates close earlier
- Tx - GnRH agonist if idiopathic
5 Factors of Infertility + How to Eval Ea
- Ovulation
- Basal body temp recording - measure in bed under tongue each day and look for .5 degree spike
- Ask about menses regularity
- Can also do luteal phase biopsy and see secretory endometrium to confirm
- Tx - clomiphene citrate
- 2- Uterus - hysterosalpingogram; if not patent then do hysteroscope
- 3- Tubes - if suspected on hysterosalpingogram then do lap
- 4- Male Factor - Semen analysis
- 5- Peritoneal Factor (endometriosis) - do lap
- Esp if other signs - dysmenorrhea or dyspareunia
Semen Analysis
Volume (> 2mL), count (>20 million sperm / mL), 50% motile, 30% morphologically normal
Should be abstinent 2-3 days before test
If abnormal result repeat in 2-3 months
Lichen Sclerosis
- Peak in pre-pubertal and post-menopausal women
- Presentation
- Vulvar itching (worse at night) + constricted introitus which may cause pain w/ sex
- Figure 8 around vulva and around anus
- Paper thin skin +/- excoriations
- Do vulvar biopsy - will show thinned epidermis, hyperkeratosis, elongated rete pegs; will also r/o cancer
- If cancer - surgical staging, removal + ipsilateral inguinal nodes
- Diff - includes psoriasis (silver scale) and recurrent vulvar candidiasis (esp if DM)
- Tx - prevent itching, recommend hygiene, corticosteroid cream (clobetasol)
Bartholin Gland Abscess
- At 5 and 7 o clock; become enlarged and painful w/ inflammation
- Often polymicrobial
- Tx - Word catheter or marsupilization not just simple incision and drainage otherwise will recur
