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GYN > OSCE PREP > Flashcards

OSCE PREP Flashcards

1
Q

Hx needed for vaginal complaint (6)

A
  1. Personal hygiene – soaps, perfumes, douching
  2. Sexual activity – use of lubricants, condoms, etc.
  3. Medications that may alter vaginal pH or flora
    a. Oral contraceptive pills, antibiotics
  4. Underlying medical illness – diabetes, HIV
  5. History of STD
  6. Use of synthetic undergarments or tight clothing
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2
Q

what would you use if suspecting a yeast infection

A

KOH smear

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3
Q

non-sexually transmitted diseases

A

Candidiasis (Candida albicans)

Bacterial vaginosis (Gardnerella vaginalis)

Bartholin’s gland cyst/abscess

Mycoplasma hominis and Ureaplasma urealyticum

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4
Q

STDs

A

i. Trichomoniasis (Trichomonas vaginalis)

Gonorrhea (Neisseria gonorrhoeae)

Chlamydia (Chlamydia trachomatis)

Herpes simplex virus (HSV)

Syphilis

Human papillomavirus (HPV)

Human immunodeficiency virus (HIV)

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5
Q

Presentation of yeast infection

A
  1. Intense vulvar pruritis
  2. White “cottage cheese” vaginal discharge
  3. Vulvar, vaginal erythema
  4. Burning sensation of the vulva; dysuria
  5. May be vulvar excoriations
  6. Extensive erythema and edema may indicate underlying systemic illness
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6
Q

Vaginal Discharge dx tests for yeast infection

A
  1. Thick, white, curdlike, cheesy
  2. pH ≤ 4.5
  3. Buds and hyphae on wet mount and KOH prep
  4. Vaginal secretions may also be cultured for definitive diagnosis
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7
Q

manage

A
  1. Treat all patients with Candida infections
  2. Control underlying medical illness if present
  3. Discontinue offending medications
  4. Avoid douching, nonabsorbent undergarments, tight clothing such as pantyhose
  5. Not typically sexually transmitted
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8
Q

Topical (intravaginal) tx for yeast infect

A

a. OTC or Rx imidazoles
b. 85-95% cure rate
c. Combining with steroids for itching – a good idea?

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9
Q

systemic treatment for yeast infection

A

a. Oral fluconazole (Diflucan) 150mg po x 1

b. Oral itraconazole 200mg po bid x 1 day

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10
Q

yeast infection tx for pregnant pts

A

a. Avoid imidazoles in the first trimester

b. Nystatin vaginal tabs 100,000 units qhs x 2 weeks

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11
Q

MCC of bac vag

A

i. Caused by bacteria Gardnerella vaginalis

ii. Most common cause of symptomatic bacterial infections

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12
Q

BV sxs

A
  1. Malodorous, nonirritating vaginal discharge
  2. “Fishy” smell more noticeable after sexual intercourse
  3. May be found incidentally on well woman exam if asymptomatic
  4. Not considered sexually transmitted infection
    a. Women who are not sexually active rarely present with BV
  5. Watery vaginal DC and petechiae on cervix
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13
Q

pH of BV

A

vii. pH >4.5

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14
Q

what other tests would you want to confirm BV

A

Wet mount shows Clue cells

Numerous stippled or granulated epithelial cells

Adherence of bacteria to cell membrane

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15
Q

when would you treat BV

A

only sx or pregnant women

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16
Q

non pregnant tx of BV

A

Metronidazole 500mg po bid x 7 days

Metronidazole vag gel: 1 (5g) applicator qhs x 5 d

Clindamycin vaginal ovules 100mg qhs x 3 d

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17
Q

pregnant tx of BV

A

Metronidazole 500mg po bid x 7 days

Clindamycin 300mg po bid x 7 days

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18
Q

presentation of trichomons

A
  1. Persistent, copious vaginal discharge, usually without vulvar pruritis
  2. Worse after menstruation and during pregnancy
  3. Dysuria may be associated if vulvitis present
  4. Vaginal erythema with strawberry spots
    a. Multiple small petechiae on vaginal epithelium
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19
Q

Dx tests for trich

A
  1. Profuse, greenish, extremely frothy, thin
  2. May be foul smelling
  3. pH >5.0
  4. Wet mount increased PMN leukocytes and motile flagellates (trichomonads)
  5. Culture and DNA probes for definitive diagnosis
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20
Q

Tx for Trich

A
  1. Treat sexual partners simultaneously and avoid unprotected sex until treatment is finished
  2. Metronidazole 2g po x 1 or 500mg po bid x 7 days
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21
Q

sxs of gonorrhea

A
  1. Most women (85%) are asymptomatic
  2. Purulent vaginal discharge, urinary frequency and dysuria, perineal or rectal discomfort
  3. May cause conjunctivitis, arthritis, pharyngitis
  4. On PE: erythematous vulva, vagina, cervix, urethra with purulent discharge
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22
Q

Tx of gonorrhea

A
  1. Treat partner concurrently and abstain from sexual contact for 7 days after start of treatment
  2. Treat presumptively for Chlamydia infection
  3. Test patient for syphilis; consider HIV testing
  4. Ceftriaxone 125mg IM x 1 dose or Cefixime 400mg po x 1 dose
    a. PLUS Azithromycin 1g po x 1 or Doxycycline 100mg po bid x 7 days for Chlamydia coverage
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23
Q

smelly, strawberry cervix, green frothy dischar

A

Trichomoniasis

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24
Q

increased discharge, maybe purulent, maybe febrile,

A

foreign body

25
Q

what causes an increase in normal vaginal dc

A

– increase in vaginal discharge due to estrogen which makes everything plump and juicy

26
Q

mild itching and dyspareunia and a foul odor after intercourse

what labs do you want

A 
Urine dipstick (-), 
pregnancy test (-), 
KOH whiff test (positive if fishy stink -->trichomoniasis, bac vag)

if positive wiff send out afirm probe for BV or Trich

27
Q

DDX for pain without itching, dc or dysuria

A

PID, Bartholin’s cyst/abscess, Herpes

28
Q

vaginal itching x 1 week. Menses irregular, LMP about 8 weeks ago. She notes mild dysuria and vaginal discharg

a. Pregnancy test (+), UA (-)
b. Neg Whiff test

A

Send Affirm probe for BV, trich, candida

Treat presumptively for Candida

29
Q

possible exposure to STD testing

A

GC/Chlamydia, HIV, Syphilis, Hepatitis B and C

Vaginal swab for Affirm probe

Urine sample for GC/Chlamydia

30
Q

tx for chlamydia

A

Doxycycline 100mg PO BID x7 days or Azithromycin 1g PO x1 dose

31
Q

what type of f/u would you do for a pt who tested positive for chlamydia

A

Repeat GC/Chlamydia DNA on urine in 3 weeks

Abstain or use condoms for at least 1 week

32
Q

tx for primary HSV outbreak

A

c. Valacyclovir 1g PO BID x10 days for primary HSV infection

33
Q

Patients using HRT who require evaluation

A

On hormones for 6 months or more and bleeding

Bleeding is irregular, prolonged or heavy

Patients with intact uterus on unopposed estrogen

need endometrial biopsy

34
Q

evaluation of pts on hormones for 6 months or more and bleeding

A

Yearly endometrial biopsies (preferred)

Transvaginal ultrasound to check endometrial stripe

35
Q

two different stages for treating menopaus

A

menopause transition (Early)

post menopause (12 months after last mentsraul period)

36
Q

when is HRT not a viable option ?

why?

A

over the age of 60 or 10 years post menopause

huge risk for cardiovascular or stroke

37
Q

indications for hRT

A

vasomotor sxs

urogenital atrophy

sx after oophorectomy

AND
prevention of osteoperosis in pts that have failed estrogen tx

38
Q

definite benefits of estrogen (6)

A

Decreases hot flashes

Improves bone mineral density (BMD)

Decreases fracture risk

Improves sexual function

Improves symptoms of vaginal atrophy

Decreases risk of colon cancer

39
Q

possible benefits

A

Improves mood, libido

Decreases skin aging

Decreases incontinence

Reduced osteoarthritis

Prevents cataracts

Prevents macular degeneration

Prevents/slows dementia

40
Q

Advantages of using hormones (OCP or IUD):

A

Prevention of ovarian cancer and endometrial cancer

Reduction of benign breast disease

Decrease dysmenorrhea, menorrhagia and anemia

Improved bone density

Control of erratic vasomotor symptoms

Stabilization of irregular bleeding

41
Q

Reduction of benign breast disease seen with HRT as it relates to fibrocystic and fibroadenomas

A

30% reduction fibrocystic disease

60% reduction fibroadenomas

42
Q

what type of BC would you want for a pt with hot flashes

A

OCP

(IUD) is just progesterone good for irregular bleeding

43
Q

when would you switch from oCP to HRT

A

OCP until age 51 if no contraindications
Can switch without testing

may have some bleeding and some hot flasshes with switch

44
Q

when would you check and FSH in a pt taking OCP to HRT

A

Check FSH in day 5-7 of pill free week
FSH over 25, probably menopausal

probably just when the pt would want to

45
Q

world health initiative study found that for breast cancer

A

being overweight caused a greater risk

if on hormones those with breast cancer had more treatable cancer than those that didn’t

however if a women does have a estrogen response breast CA they should not be on this

46
Q

if pts have a family hx of breast cancer

A

want them on hRT for 5 years or less

47
Q

cardiovascular risk form women considering HRT

A

absolute risk is generally low in newly postmenopausal women, dependent on background rate and risk factors

Must consider other potential risks: DVT, PE, stroke

For many newly menopausal women with moderate to severe symptoms, benefits will outweigh risks

48
Q

biggest risk for CVD with this type of estrogen

A

oral estrogen

use transdermal

49
Q

Indicated to treat symptomatic patients

A

Vasomotor, depression/mood lability, genitourinary syndrome, sleep disturbances

Women in their 50’s who are otherwise healthy have very low risks from HRT

Women <60yo or within 10 yrs of menopause and without contraindications or other risk factors are appropriate candidates for HRT

50
Q

How to Prescribe HRT

A

Use lowest dose possible to achieve symptom relief
Use shortest duration of treatment
Suggest limiting to 5 years

51
Q

suggestion for women taking HRT

A

transdermal 17-beta estradiol for many women starting MHT

The transdermal route is particularly important in women with hypertriglyceridemia or risk factors for thromboembolism.

52
Q

when should you use topical estrogen?

A

if atrophy is the only sx

53
Q

what type of progesterone would be used

A

Recommend micronized progesterone

54
Q

what to say to the pt that is interested in identical hormones

A

not FDA regulated

no evidence

55
Q

mammography is indicated for women

A

age 50-75
every 2 years

family hx of breast cancer probably higher

56
Q

breast ROS (5)

A 
Lumps?
Pain or discomfort?
Nipple discharge?
Visible changes?
 SBE? 
Women: Do it? How often? When
in your cycle?; Men: Do you ever do self exam?
57
Q

genita ROS

A 
Vaginal discharge?
• Genital pain? Itching? Lesions?
• Dyspareunia?
o Pain during intercourse?
• Post-coital bleeding?
• Sexual satisfaction? Libido? Safe sex practices?
• Last PAP (result, abnormal PAPs)? o **Move to HM: Screening
• Contraception?
o **Move to OB/Gyn Hx
o **Oral Meds move to PMH: Medications
• History of STIs?
o **Move to PMH if yes &amp; Sexual Hx
58
Q

GYN ROS

A 
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 12) GYN – Female (Move to PMH: OB/GYN)
• LMP (last menstrual period date)?
o Flow/timing normal?
o Typical cycle (#days)?
o Changes in cycle: duration,
frequency?
• Abnormal vaginal bleeding?
• Dysmenorrhea (pain with period)? o Pain with period?
• Pre-menstrual symptoms?
• Peri or Post menopausal symptoms?
• Age at menarche (menses onset)?*
• Age menopause?
59
Q

OB ROS

A

– Female (Move to PMH: OB/GYN)
• # of pregnancies (gravida), number of live
births (para), number of spontaneous vs.
therapeutic abortions? (G3,P1,SAB1,TAB1) • Delivery type: Spontaneous vaginal (SVD)
or C-section (reason)
o **Repeat deliveries in PMH: Hospitalizations (NOT in the SOAP)
o **Repeat C-Sections in PMH: Surgeries (NOT in the SOAP)
• Complications during pregnancy or birth? • Contraception method?
o **If pills move to PMH: Meds (& write Drug name, dose, when started). In OB/GYN write: Oral Contraception.
o **Contraception devices go here! • Breastfeeding?
Omit nocturia, incontinence in infants.
Add **enuresis (diurnal or nocturnal) – issues
w/ urination or potty training
o **Move to Sexual Hx

GYN (13 decks)

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