Random Flashcards
Basic principles of medical ethics?
Autonomy - right of choice
Beneficence: promote health/welfare
Nonmalficene: do no harm
Justice: equal service to everyone.
What are considerations for sterilization in women
respect for reproductive autonomy
- pre-sterilization counseling: include LARCs
- discuss male sterilization: safer and higher efficacy
What is transgender?
Someone’s gender identity aligns/differs from sex assigned to them at birth.
Gender dysphoria: distress/impairment associated w/ incongruence between internal sense of gender and primary/secondary sex characteristics.
preventative healthcare: cancer screening, contraception, family planning/fertility, routine screenings.
What are cancer screening recs in transgender patients?
TRANSMASCULINE:
- cervical, breast screening. NOT endometrium
TRANSFEMININE
- need breast after age 50 and 5+ yrs estrogen use. NEED prostate screen.
What is gender affirming hormone therapy?
Testosterone
- transmasculine. oral/IM/implant/transdermal
- contraindications: pregnancy, polycythemia, unstable CAD
- risks: incr triglycerides, low HDL
Estrogen: transfeminine
- oral/IM/transderma.
incr risk vTE, gallstones, incr triglycerides and lFTs.
Anti-androgen (spironolactone)
- transfeminine
-oral/IM/implant.
- avoid if: hyperkalemia, Addison’s disease.
How do you perform an oophoropexy?
Do it if you’ve had multiple torsions and lost ovary on other side.
Suture placed in utero-ovarian ligament and attach it to uterosacral ligament. It shortens the length of utero-ovarian ligament to decrease risk of torsion.
How would you manage a history of LE DVT in pregnancy?
If unprovoked -> treat.
If provoked, consider. If provoked was estrogen-related (OCP, pregnancy) -> prophylactic lovenox/UFH. If specific provoking factor (surgery, trauma immobility) -> don’t treat!
What is management of positive thrombophilia workup but no history of DVT in pregnancy?
High-risk thrombophilia: factor v leiden homozygote, protein G homozygote, antithrombin deficiency –> prophylaxis or intermediate dose LMWH/UFH
Low-risk thrombophilia; Factor 5 leiden heterozygote, prothrombin G heterozygote, protein CS or S deficiency, APL antibody: don’t treat!
Only prophylaxis if fam hx or prior DVT
What is management of hepatitis B in pregnancy?
Test for HCV, hepatitis A, hepatic function panel w/ LFTs. Inquire about immunization.
Could be chronic or acute.
Need core antibody. If positive, prior exposure. If neg, vaccination.
What would you see in chronic carrier state: +HBsAg and neg HBsAb. HBVcore is secondary to infection (NEVER IMMUNIZATION).
Prevalence of chronic HBV is 0.8% in pregnancy
What is workup of hep B in pregnancy?
HBV viral load in 3rd trimester. If >200K, need antiretroviral tx (Tenofovir 300mg/d until delivery. Lamivudine if used as single agent.
What precautions would you take during labor process? Avoid operative delivery and FSE.
Breastfeeding? Yes.
What is PMS/PMDD?
PMS occurs in 20-30%, PMDD in 2-5%
- pathophysiology unknown. 2/2 normal fluctuations in estrogen/progesteroen. ddx of exclusion.
PMS: physical/mood sx occur during gluteal phase and resolve shortly/yduring menstruation.
PMDD: type of depressive disorder.
ddx: pt report of symptoms most cycle of preceding year and 2 months of prospective symptom recording.
- sx present during luteal phase and 1st few days of menses. if sx present throughout cycle, consider mood disorder.
What is diagnosis of PMDD?
1+ of following:
- marked affective lability (mood swings)
- marked anger
- depressed mood
anxiety/tension
1+ or following to reach total of 5 sx:
- decreased interest in activities
concentration
nletheragy
changes in appetite
- hyeprsomnia/insomnia
- overwhelmed
- physical sx (breast tenderness)
What is treatment of PMDD?
- SSRI: during luteal phase or continuousy
- combined OCPs
- GnRH agonist w/ add-back for severe sx
- CBT
-exercise - calcium supplementation 100-1200mg /day
- Acupuncture
NSAIDs
-patient education
-surgery w/ bilateral oophorectomy with/without hyst ONLY when me management failed.
What is hormone replacement therapy?
What are the risks?
When to use it?
Used for treatment of mod-severe vasomotor sx
- Low dose E: 0.025mg/q estradiol patch or 0.5mg oral E2
- transdermal estrogen (little to no VTE risk)
- oral estrogen (prothrombotic effect, incr VTE risk)
- oral progesterone (no incr VTE, no decrease in HDL)
- VTE
- breast cancer
- no cardio protectiction (maybe if started close to menopause)
Use if :
- < 10 yrs from menopause
< age 60
- if symptomatic and no contraindications (Screen for CVD and breast cancer risk)
*don’t discontinue at age 65 IF pt still symptomatic).
What are contraindications to HRT?
Pregnancy
Breast cancer
estrogen sensitive tumor
undiagnosed vaginal bleeding
severe liver disease
hx DVT/thrombophilia
Coronary heart disease
- CVA/TIA
- HTN, smoking, migraine w/ aura are NOT contraindications but transdermal estrogen preferred.
What are the benefits of HRT?
- reduces osteoporosis progression/slows bone loss
- alleviates VMS
- improved memory and sleep
- can improve urinary incontinence
- less dyspareunia
- NOT cardioprotective
What was WHI design?
- enrolled 27K women into 3 arms: placebo, combination HT or continuous estrogen.
- primary outcome: CHD | adverse outcome: invasive breast Ca
- mean age 60
- women <50 excluded, severe VMS excluded, avg BMI 28
- 50% were smokers
What are takeaways from WHI?
-individualize therapy
- lowest dose for shortest duration possible
- DO NOT USE of prevention of heart disease, strokes or dementia
- use for tx menopausal VMS, vaginal dryness, prevent early osteoporosis bone loss.
- localized estrogen: Premarin vaginal vream. not same contraindications as systemic HRT.
- ## avoid in breast cancer pts on aromatase inhibitors
What were WHI results for combination HRT and estrogen-alone?
combination: + benefit for bone fracture reduction and colon cancer prevention
- no benefit for heart disease, breast cancer, stroke/PE prevention
ESTROGEN ALONE:
- CHD occurred less than in placebo
- more strokes
- less invasive breast cancer
- less fracture
What are non-hormonal alternatives for VMS?
SSRI and SNRI (paroxetine- FDA approved), fluoxetine, venlafaxine.
- avoid proxetine/fluoxetine if on tamoxifen
Gabapentin
Clonidine
Progestins (incr breast Ca risk, use for endometrial protection only)
Vitamin E
What is bioidentical hormone therapy?
plant-derived hormones.
- ONLY FDA approved ones should be used:
- micronized progesterone, estradiol, DHEA
What is headache classification?
- Migraines w/o auras: unilateral, pulsatile, aggravated by routine activity, mod/severe pain. AND N/V, photophobia.
- Migraines w/ aura: reversible aura sx, HA follows aura w/ sx-free interval of < 60 min.
- Tension HA (most common): mild-mod dull aching, pressure across forehead, sides and back. tenderness in neck and shoulder muscles.
- Cluster hA: rare. intense pain around 1 eye/side. can lasts weeks-months.
Aura: visual, sensory (pins/needles), speech, motor (Weakness). last less than 1 hr.
- POSITIVE: visual, auditory, somatosensory, motor
- NEGATIVE: loss of vision, hearing, ability to move part of body.
What is IBS?
functional disorder of GI tract assoc w/ chronic abdominal pain nd altered bowel habits. common cause of CPP.
Rome criteria: 2 or more at least 1/day week in last 3 months
- related to defecation
- associated w/ change in stool frequency
- associated with change in stool form.
What is workup of IBS?
- r/o other GI: diverticulosis/itis, H. Pylori, IBD, intestinal ameba
eval: H&P, CBC, fecal calprotectin or lactoferrin, stool test for giardia, serologic test for celiac, if constipation dependent Abdominal Xray
Management: dietary (fiber, low FODMAP diet, consider lactose intolerance, eat gluten-free foods).
What are causes of infectious diarrhea?
- Food poisoning: salmonella, norovirus, campylobacter, E. coli, listeria
- Traveler’s diarrhea: E. coli. abx if sx severe or >10d (azithro)
- Giardiasis: protozoa, watery diarrhea, malabsorption, bloating flatulence. ddx: fecal exam for trophozoites. tx=tinidazole
- Bloody diarrhea: campylobacter jejune. Enterohemorrhagic E. coli 2/2 undercooked meats. Shigella. C. Diff.
What are recommendations for obesity in pregnancy?
- cfDNA assoc w/ lower fetal fraction/test failure. offer US and diagnostic testing.
- incr Antenatal surveillance: weekly APT at 34w (BMI 40+), 37w for BMI 35-39.
Obesity class 1 30-35
class 2 35-40
class 3 >40
What is counseling for obese pregnant patients?
- Preconception - weight reduction, maternal/fetal risk discussion
- Prenatal care - scree for OSA and DM at IPV, refer to sleep medicine if suspect OSA. nutrition consult, weight gain
- 15-25lbs for BMI 25-29
- 11-20 lb BMI 30+
- nutrition deficiencies if bariatric surgery (B12, iron, folate, Ca)
- delivery (anesthesia consult - intubation difficulty, epidurall failure risk), longer labor, higher VBAC failure, incr PPH, incr risk CS (wound breakdown, DVT
If needle injury in OR, what is workup?
concern for HIV, Hepatitis B and C
Both the patient source and the surgeon need to be tested initially.
The affected surgeon should then be retested for HIV in 3 and 6 months.
He can be treated prophylactically with anti-retroviral agents.
What is the most common cause of cancer death in US women?
descending order
- Lung
- Breast
- Colon
- Pancreas
- Ovary
What are Schiller Duval bodies associated with?
Endodermal sinus tumor (yolk sac)
What are components of a time out during surgery?
correct patient
correct side
correct anatomical location/procedure
consent signed, correct pt position
all necessary images
Antibiotics required yes/no
review of allergies
What are absorbable sutures?
Vicryl, monocryl, PDS
What are non-absorbable sutures?
Nylon, prolene, silk
What are monofilament sutures?
PDS, monocryl, nylon, prolene
What are multi-filament sutures?
Vicryl, silk
What are considerations before going to OR for hyst?
- know indication for procedure, anatomy (i.e. mass, malignancy), consider approach (TVH, TAH)
- consider alternative options (medication) and discuss w/ pt
- know pt’s age, BMI, comorbidities, medical hx, allergies. Optimize medications, diabetic control, hTN.
- review pre-op labs and imaging
- consider pre-op consults: anesthesia, gyn onc
- review informed consent
- arrange pre-op abx, DVT ppl, bowel prep.
What is management after needle stick injury?
- clean w/ soap, water and alcohol-based agent.
- serologic test for HIV, HBV, HCV on both physician and patient
- if pt hIV pos, determine VL, tx hx.
- if pt HIV status unknown, start PEP while waiting results
- PEP: start within 1-2hrs exposure. risk of contracting HIV is 3/1000 without ppx.
PEP: 3-drug HAART (tenofovir + emtricitabine + dolutegravir) or tenofovir + emtricitabine + raltegravir of childbearing bc dolutegravir incr risk NTD.
- tx for minimum 4 weeks.
HIV screening of physician with rat testing at 6 weeks and 4 moths post exposure.
What is differential diagnosis for post-op profuse vaginal bleeding and hypotension after TVH/TAH?
Intra-peritoneal hemorrhage
Retro-peritoneal hemorrhage
Compression of IVC from expanding hematoma
- intra-op MI or PE
- asses airway/breathing, VS, level of consciousness, degree of pain.
Describe differential for post-op atelectasis vs pneumonia
Atelectasis: no sx or SOB. Can have fever, secretions. presents up to POD2
PNA: infix (F, WBC, purulent sputum, hypoxemia) and infiltrate on CXR
Differential:
- atelectasis
- peri-op intravascular fluid overload
- PNA
- exacerbation from existing URI
- unrecognized asthma/exacerbation
- peri-op MI
- CHF or fluid overload from renal dz
- PE or pneumothorax.
What is standard deviation?
1 SD=68% of population (confidence limits)
2 SD=96% of population
3 SD=99% o population.
What is sensitivity?
What is specificity?
ability to correctly diagnose disease: true pos/ (True pos + false neg)
ability to correctly exclude disease: true neg/ (true neg + false pos)
What is positive and negative predictive values?
PPV: probability that a positive result is correct
= true pos (true pos + false pos)
NPV: probability that a negative result is correct
= true neg/ (true neg + false neg)
What is incidence vs prevalence?
incidence=# new cases over specific period of time
prevalence=# cases at a given point in time
What is management of Bartholin abscess?
small abscess <3cm, I&D, sits bath
large abscess, I&D with word catheter.
- keep word catheter for 4-6wks to allow permanent opening to develop.
- if word falls out, can do marsupialization.
- if >40, can consider excision or biopsy to r/o adenocarcinoma.
how to counsel trans masculine patient taking gender-affirming testosterone therapy for 6 mo who still has bleeding?
- common concern
- majority of pts have elimination of bleeding by 18 months
- history: sexual activity
- workup: transABDOMINAL US (anatomic causes), B-HCG
- counseling: bleeding profiles can differ, confirm need for contraception (amenorrhea 2/2 testosterone is NOT reliable contraception), discuss fertility, family planning.
