Women's Health Exam 2 Flashcards
1
Q
PMDD
A
Premenstual dysphoric dysorder
2
Q
Premenopause
A
Erratic hormones, menses begin to be irregular
3
Q
Postmenopause
A
No menses for a year
4
Q
Dysmenorrhea
A
Painful menstrual bleeding
5
Q
Metorrhagia
A
Menstrual bleeding between periods
6
Q
Menometorrhagia
A
Irregular, unpredictable bleeding
7
Q
Oligomenorrhea
A
Periods more than 35 days apart
8
Q
BSO
A
Bilateral salpingo-oophorectomy
9
Q
TAH
A
Total abdominal hysterectomy - through abdomen
10
Q
TVH
A
Total vaginal hysterectomy - comes out through vagina
11
Q
Radical hysterectomy
A
Takes out uterus and additional tissue including the cervix
12
Q
Term pregnancy
A
37-42 weeks
13
Q
Preterm
A
20-36 weeks
14
Q
Abortion
A
Before 20 weeks
15
Q
Puerperium
A
Birth to 6 weeks postpartum
16
Q
3 trimesters
A
1 - 0-14
2 - 15-28
3 - 29-42
Each is 2 Weeks
17
Q
FHT
A
Fetal Heart Tones
18
Q
Grand multigravida
A
More than 5 times pregnant
19
Q
GTPAL
A
Gravida
Term
Preterm
Abortions
Lived 30 days
20
Q
Para
A
Pregnancies carried to term
21
Q
Recommended age for 1st reproductive health visit
A
Age 13-15
Only screen if STD suspected or symptomatic
22
Q
Age to begin pelvic exams and pap smear
A
21 years old
Frequency of pelvic depends on risk factors with pap every 3-5 years
23
Q
General breast exam screening
A
Every 1-3 years 20-39, yearly after 40 with mammograms done starting at 40
24
Q
Speculum lubrication for pap smear
A
Use warm water (officially)
25
Two ways to do pap smear
Use scraper and brush, or use the combo tool
26
General breast exam method
Palpate 4 quadrants and 4 positions
Palpate for regional lymphadenopathy
Palpate tail of spence
27
Bimanual exam
One hand in vagina and one on lower abdominal wall
Test for size shape, mobility, and consistency of organs
28
Skin exam recommendations
Q3 years 20-40 and then yearly 40+
Same as pap smears!!
29
Pap screening recommendations
21-29 every 3 years
30-65 every 3 years or HPV with pap every 5 years
Stop screening at 65
30
Reasons to stop pap smears after 65
No hx of dysplasia/cancer
3 negative smears or 2 negative Pap+HPV in a row
31
When do pap smear guidelines NOT apply
Hx of cervical cancer, HIV+, Immunedeficient, DES exposure
32
STD screenings for ALL pregnant women
Hep B, HIV, Syphillis
33
STD screenings in all women under 25
Gonorrhea and Chlamydia
34
STD to screen for in high risk sexual behavior women
Hep C
35
STD screening for all sexually active women
HIV - One time screen
Gonorrhea and Chlamydia - Yearly if under 25
36
STD screenings for High risk sexual behavior women
Annual for All:
HIV
Syphillis
Trichomoniasis
Hep B and C
G/C
HSV
37
Breast cancer screening
Depends on agency - start yearly 40-50 years old - definitely by 50
Clinical breast exam optional, Mammogram required
38
When to stop mammograms
When you wouldn't treat cancer if you found it
74 per official guidelines
39
Colon cancer screening recommendations
FOB, FITm CT Colonoscopy 45-75 - recommended against after 75
40
Bone density screening recommendations
65 years old
Or any woman who's risk is equal to a 65 year old woman
41
Bethesda system
Pap smear evaluation - grades pap cells for cancer
42
Atypical squamous cells
ASC - Lowest concern abnormal pap smear cells, can see in infection or atrophy
Undetermined significance = ASC-US
Cannot exclude High Grade = ASC-H
43
Low grade squamous intraepithelial lesion
LGSIL or LSIL
Corresponds to CIN-I
44
High grade squamous intraepithelial lesion
HGSIL or HSIL
Corresponds to CIN II or CIN III
45
Atypical glandular cells
Do not match normal cervical glandular cells but are also not cancer
Associated with adenocarcinoma of endocervix or of endometrium
46
CIN I
Disordered growth of lower 1/3 of epithelial lining - mild
47
CIN II
Disordered growth of lower 2/3 of epithelial lining - moderate
48
CIN III
Disordered growth of over 2/3 of epithelial lining of cervix - considered full thickness
49
CIN
Cervicle Intraepithelial Neoplasia
50
Treatment for CIN stages
Always treat CIN II or III
Except for in pregnant women (wait till after birth) or in adolescents with CIN II we can observe
51
Risk factors for cervicle dysplasia
Multiple sexual partners
High risk partner
HPV hx
Other STIs
Immune suppressed
Contraceptive use long term
Multiparous
52
Management for ASC-US
Repeat pap in 6 months and then again in 6 more months
Second abnormal smear - refer for colposcopy
Test for HPV - colposcopy if positive
Colposcopy
53
Colposcopy
Like a cervicle exam - use a magnifying light as well as acetic acid
Curette or brush endocervical canal
54
Indications for coloposcopy
Abnormal cervicle cytology
CLinically abnormal cervix
Unexplained intermenstrual or postcoital bleeding
Vulvar or vaginal neoplasia
In utero DES exposure
55
CIN I on colposcopy management
Expectant management
2 pap q6 months as with ASC-US
Repeat colpscopy if positive or +HPV
56
CIN II-III or cancer on colposcopy management
Surgery
57
Cervix surgery
Take out part of the cervix for cancer
58
3 estrogens in women
Estrone (E1) - Order when worried that thye have little estrogen
Estradiol (E2) - What we are usually talking about when talking about estrogen - ordered to monitor menopause, etc.
Estriol (E3) - Screen for fetal pathology and assess preterm labor risk
59
Where progesterone is produced
Corpus luteum
Placenta
Biotin - causes flase elevation
Should not be present post menopause
60
Percent of pregnancies that are unintended
50%
61
Percent of pregnancies that were unwanted but women not using birth control
40%
62
Coitus Interruptus
Pull out method
Very ineffective - very high failure rates
Semen can leak out before orgasm
Not recommended
63
Postcoital Douche
Fluch semen out of vagina
Not reliable - sperm are fast
Not recommended
64
Lactational amenorrhea
Suckling to reduce GnRH to suppress ovulation
Pregnancy rate of 7.4% after 12 months - less effective with time
Need to be amenorrheic
Start other birth control at 3 months postpartum
65
Periodic abstinence
Calendar methods - 11-25% failure rate
May be related to birth defects
66
Most effective determinant for ovulation
serum LH - not practical
67
Fertile period for periodic abstinence
2 days before and after ovulation - not very reliable
68
Temperature method of birth control
Check temp in the morning
first three days of elevated temperature after drop are the fertile period
69
Failure rate of combined temp/calendar method
5 per 100 couples per year - if consistent, need to be consistent
70
Cervical mucous method
Billings method
Check cervical mucus - when its thin, patient is fertile
71
Symptothermal method
Notice ovulation symptoms and be aware - most effect natural method
72
2 types of OCP
Combo or Progestin only pills
73
Combination OCPs
Include estrogen and a progestin -some kind of both
74
3rd or 4th generation progestins
Better to avoid male secondary sex characteristics
Worse for risk of clotting - DVT, etc.
75
Monophasic COC
Same hormones daily
76
Multiphasic COC
Different doses during the cycle
May give placebo at some points
77
Administration of COC
Ideally start on first day of cycle or just start the day you pick it up and your body will adjust
78
Single missed dose COC
Single high monophasic - makeup on the next day
79
Multiple missed doses for COC
Double dose and use added barrier contraceptive for 7 days
80
Tx for missed COC w/ coitus in past 5 days,
consider emergency contraception
81
MOA of COCs
Suppress LH and FSH
Alter cervical mucus
Make endometrium less receptive to implantation
82
Drug interactions with COCs
Antibiotics, Anticonvulsants, NSAIDs, SSRIs
83
Benefits of COC
Lower risk of ovarian and endometrial cancer
MSK benefits
Lower ectopic pregnancy
Less menstrual pain
84
Major side effects of COCs
Increased thromboembolic risk
MI risk increases
Stroke
Liver disease
Cervical and Breast cancer increase
85
Cautions for COCs
No use in migraine HAs with aura
May impair breast milk
86
Four Minor SEs for COCs
Nausea, dizziness, fatigue
Weight gain 2-5lbs
Abnormal menses
Melasma
87
8 Contrindications for COCs
Pregnancy
Undiagnosed vaginal bleeding
Migraine with Aura
Prior history of thromboembolic event
Uncontrolled HTM DM, or SLE
Smokers over 35
Breast cancer hx
Active liver disease
88
Progestin only contraceptives
Does not suppress ovulation
Thicken cervical mucous and make endometrium unsuitable
Need to be very compliant
89
Disadvantages of POCs
Must take at same time of day daily
Higher bleeding and pregnancy rates
Cancer is still a risk
90
CI to POCs
Unexplained uterine bleeding
Breast cancer
Hepatic neoplasms
Pregnancy
Active severe liver disease
91
Three ,method of emergency contraception
Yuzpee method
Levonorgestrel
Copper IUD
92
Yuzpee method of contraception
Emergent
COC with levonorgestrel
1st dose within 72 hours of intercourse - sooner is better
Causes nausea
93
Levonorgesterol alone
Plan B - OTC
Single dose of 1500mcg
Within 72 hours ideally, stops LH surge - not useful if already ovulated
94
Ulipristal
Ella - OTC
Single dose of 30mg
Within 72 hours recommended
Prevents LH surge - slightly better than plan B
95
Emergent Copper IUD
May inhibit implantation or interfere with sperm function
Insert up to 5-7 after
OTC
Emergency contraception
96
Levonorgestrel IUD for emergency contraception
52 mg for emergency contraception
Insert up to 5 days post intercourse
97
Vaginal ring
Combination contraception
3 weeks per month
No fitting, can remove for three hours and still work
98
Failure rate of vaginal ring
0.65 per 100 women per year
99
Transdermal patch contraception
New patch weekly for 3 weeks a month, not directly on breast - rotate sites
Less than 1% failure with less efficacy in obese patients
100
CI of transdermal patch and detachment
Have to restart if it has been off for 24 hours
101
Depot Medroxyprogesterone Acetate
SepoShot
Progesterone Q3 months
3% failure rate for typical (imperfect) use
0.3 - Ideally
102
Benefits of Depot Medro shot
Lower risk of ectopic pregnancy
Lower risk of endometrial cancer
Lower sickle cell crises
May help endometriosis
103
Side effects of Depot Medroxyprogesterone Acetate Shot
Decreased bone density
Irregular menses
Takes 10 months to return to baseline and get pregnant
104
Levonorgestrel implant
Implanted in arm
Contains a progesterone - etonogesterol
Almost 100%
Up to 3 years - some studies is 5
105
SE of implants (nexplanon)
Minor bruising, swelling, and itching at insertion site
Irregular menses
Weight gain
HA
106
Copper IUD non-emergent
FDA approved for 10 years
Uncertain MOA
0.6-0.8 per 100 woman-years
107
Risks/SEs of Copper IUD
Ectopic pregnancy
Spontaneous abortion
Uterine perforation
Menstrual irregularities, cramping, vaginitis
108
Contrindication to copper IUD
Pregnancy
Active infection
Wilson disease
Cancer or unknown bleeding
PID
109
Levonorgestrel IUD
Good for people having heavy periods and cramping
8 year lifespan
Very low failure
Bleeding as a SE, helps with cramping, breast pain
52 mg
110
Low dose levonorgestrel IUD
Kylea - 5
Skylea - 3
Not for cramps or menorrhagia
111
IUD expulsion
Check for strings
Happens in up to 5% in first year of use
Test for pregnancy if expelled
112
Spermicides
Most based on Nonoxynol-9
Phexxi - More natural
Most OTC
Placed in vagina and last around an hour
High pregnancy due to non-compliance
113
Contraceptive sponge
Nonoxyl-9 impregnated disk
Inserted up to 24 hours before and keep in 6hrs post coitus
Less effective than condom
114
Lamb skin condoms
Don't protect against STD's - latex DO
115
Female condom
May prevent STDs, not as effective as a male condom
116
DIaphragm and Spermicide
Rubber dome over cervix
Must use the spermicide
6 hours before and 24 hour max placement
6 per 100 with perfect use
15-20 per 100 with typical use
117
Cervical cap
Smaller than a diaphrage -can stay in up to 48 hours
Just on cervix
May be hard to place
118
Regret frequency for sterilization contraception
20% for women under 30 6% for women over 30
119
Legal limitations to sterilization
Federal won't pay for under 21 - some states may
None for incompetent patients
120
4 types of female tubal sterilization
Electrocoagulation
Mechanical occlusion
Ligation with suture material
Salpingectomy
121
Concerns with tubal sterilization
Tubal pregnancy
Chronic pelvic pain - tubal ligation syndrome
Irregular menses
Decreased ovarian cancer when removed
122
Tubal occlusions
No longer done, used a hysteroscopic precedure
123
Chemical tubal occlusion
Usually not done in US, never approved - seen in immigrants
124
Vasectomy
30x less failure, 20x less post-op complications
Need 1-2 consecutive sperm counts of zero to confirm it is working
Easier reversal
125
Suction curettage
Elective abortion performed 12 weeks for earlier
90% of US abortions
Cervical dilation and suction catheter insertion
126
Surgical curettage
Scrape out fetal parts - more bleeding less common than suction
127
Phamraceutical abortion
(Mifepristone OR methotrexate) and/or Misoprostol
Used in first trimester
SE of cramping/bleeding
CI in active liver/renal disease, anemia, bleed risk, IBF -may not expel everything
128
Intraamniotic instillation
Hypertonic solution put into uterus to kill the fetus - lots of side effects
129
Vaginal prostaglandins
For elective abortions - suppository containing misoprostal etc. to trigger preterm delivery
Can cause GI side effects, live abortion
130
MOA of misoprostol
Causes uterine contractions and cervicle ripening
Used for abortions and induction
131
Dilation and evacuation
Most common elective abortion for 2nd trimester
Cervical ripening agents used and forceps to break up tissue
Infection and blood loss - does not feel like a delivery
132
Post abortion follow up
Rho-Gam
Avoid anything intravaginal for 2 weeks
Birth control
2+ elective abortions lead to higher risk of miscarriage
133
Climacteric
Phase of aging from reproductive to non-reproductive age, before actual menopause occurs
134
Average langth of per menopausal transition
1-3 years
Part of climacteric period
135
Average age of final menstrual cycle
51
136
Premature menopause
Menopause at 40 or younger
137
Perimenopausal
Going through menopause but still having periods
138
Change in follicles over time
Ones most responsive to FSH are ovulated first
139
Estradiol of menopause
May see bursts of estradiol because follicles are not responding as well
140
Predisposing factors for menopause
Smoking advances by 2 years
Reproductive tract disease
GU infections
Chemo or radiation
Surgical impairment to ovarian blood supply
141
Artificial menopause
We do something that destroys the ovaries or take them out
May be due to endometriosis, cancer
142
Postmenopausal androgens
Decreased production, but still have androgenic symptoms because ovaries make some testosterone and binding protein is not produced
143
Gonadotropins in menopause
Increase because no estrogen - can be used for diagnosis
144
Common classic menopause symptoms
Irregular bleeding
Irritability and mood swings
Vaginal dryness
Decreased libido
Hot flashes
Hair loss
Hirsutism
Weight gain
145
Physical changes of menopause
Atrophy of cervix, uterus, tubes
Flattening of vaginal rugae
146
Urinary and mammary changes of menopause
Urgency, frequency, dysuria
Urethral prolapse
Regression and flattening of mammary glands
147
Atrophic vaginitis
Epithelium becomes thinner and rugae flatten out
Painful intercourse and friability
Smooth pale and shiny late
Diffuse patchy and red early
Increased pH
148
Diagnosis of atrophic vaginitis
Clinical dx - may see atrophic cells in cytology
149
Initial tx for atrophic vaginitis
Conservative first
Vaginal moisturizers AND lubricants - not the same thing
Moisturizers daily - not just for sex
150
Treatment for moderate/severe atrophic vaginitis
Vaginal estrogen, restores pH and microflora
Fewer UTIs and overactive bladder symptoms
Can go systemic
DOn't need a vaginal estrogen if systemic
151
Ospemifene
For atrophic vaginitis
Only targets vaginal estrogen receptors, MC MC SE is hot flashes
152
Prasterone
Vaginal DHEA that turns into estrogen for estrogen sensitive individuals
153
Presentation of hot flashes
Elevated HR - normal rhythm and BP
Night sweats, Insomnia
Cutaneous dilation - flushing
154
Risk factors for hot flashes
Obesity, Lower physical activity, Smoking, African american race
155
Normal hot flash length
seconds to 10 minutes
156
Tx for hot flashes
Estrogen = mainstay, give progestin if they cannot take it alone
157
Reasons to take eastrogen with progestin
Intact uterus due to endometrial cancer risk
158
First line for patients who don't want hormones for hot flashes
SNRI/SSRI
Citalopram or Venlafaxine, Paroxetine but it reacts with tamoxifen
Gapapentin, Clonidine can also be used
159
Protections of estrogen alone
CHD
Fractures
Diabetes
Not used to treat these conditions
160
Risks of MHT (Hormone therapy
Estrogen causes endometrial cancer - add progestin to prevent
Increased risk of breast cancer with combo therapy - d/t progesterone!!
161
Non-cancer risks of MHT
Thromboembolic diesease
Gallbradder disease
162
MHT contraindication
Hx of breast cancer
Unknown bleeding
Endometrial cancer
Thromboembolic disease
Liver dysfunction
Pregnancy
163
1st line MHT for vasomotor symptoms of menopause
Patch before pill - less risk of blood clots but insurance doesn't like to pay so oral is often used
164
Starting MHT
Increase at one month intervals if still symptomatic
Recommended not to use for more than 5 years - taper
165
Progesterone only therapy for menopause
Can be oral or IM if we don't want estrogen
166
Tissue selective estrogen complex
SERM and estrogen
Reduces some of the risk of using a progesterine
167
Oral estrogen and levonorgestrel IUD
May or may not help reduce risk of breast cancer - dubious
168
Alternative hot flash pharm and GU symptoms
Doesn't really help except oxybutynin
169
CAM for menopause
Isoflavone/Phytoestrogens - soy, lentils, etc.
Black Cohosh
Vitamin E
Weight loss
CBT
Supplements can still have problematic effects
170
Preparations for atrophic vaginitis
Ring, cream or tablet - every night for two weeks then two times per week
May use testosterone if estrogen is contraindicated
171
Lobes per breast
12-20 lobes
172
Apex of breast
Contains major excretory duct
173
Base of breast
Near ribs
174
Montgomery glands
Sebacecous glands of the areola - help the breast stay healthy while breastfeeding
175
Percent of the breast that is adipose tissue
80-85% adipose tissue
176
Coopers ligaments
Hold the breast to the chest wall - deeper
177
Beginning age for breast deveopment
Ages 10-13
178
Breast changes during menstrual cycles
Premenstrual - Epithelial cells proliferate - increased size by a little
Post menstrual - Epithelial cells die off, decreased turgor with some tenderness
179
When does the breast reach full development
End of a full term pregnancy only
180
Pregnancy changes of breast
Darkened areola - bulls eye for infant
Increased lubrication and milk ducts
Fatty tissue almost completely replaced by glands and ducts
181
Trigger and regulator of breast milk production
Progesterone drop triggers and prolactin maintains
182
Menopausal breast changes
Atrophy and loss of functional breast tissue
183
Fluids from breast commonality
40% of premenopausal women
55% of parous women
75% who have lactated in the past 3 years
184
Physiologic breast discharge
Expressed when pressure is applied and from multiple ducts/ both breasts
185
Causes of physiologic breast discharge
Normal lactation
Galactorrhea
Benign phys discharge
Can be an intraductal papilloma
186
Classical presentation of galactorrhea
Bilateral multiductal milky discharge, otherwise normal PE - may want to test for pregnancy
187
Classic pathologic discharge
Unilateral spontaneous bloody for serous discharge from a single duct
Bloody is more suggestive of cancer but also more likely due to benign papilloma
188
Cytology of breast discharge
Very los sensitivity - usually skip to imaging
189
Ductography
May show a filling defect in cancer - flush contrast into ducts
190
Ductoscopy
Use tiny endoscope for viewing
191
Definitive diagnostic for pathologic discharge
Microductectomy - excise ducts below areola and send to pathology
192
Gynecomastia
Glandular breast tissue in a biologic male
Normal in 60% of pubertal boys - usually resolves in a year
Anabolic steroids
193
Psudogynecomastia
Fat tissue that looks like gynecomastia - should not seem a firm tender area beneath the areola - firm
Glandular tissue not enlarged
194
Dx for gynecomastia
Elevated PRL or hCG
Can also chack testosterone, estradiol
Thyroid
195
Tx for gynecomastia
If painful and persistent for 9-12 months
SERM - raloxifine or tamoxifen
Anastrozole - not recommended long term in teens
196
When would we give testosterone to a male
Only for true hypogonadism
197
MCC of mastitis
Staph areus
198
Risk factors for mastitis
Seen in lactation and nursing in primiparous patients, rare before fifth day postpartum
199
Presentation of mastitis
Painful, erythematous lobule in the outer quadrant of the breast 2nd or 3rd week after birth
Systemic signs of infection - high fever not due to simple breast engorgement
Antibody coated bacteria in breast milk
200
Presentation of breast abcess
Pitting edema and fluctuation
201
Tx for mastitis
Keep draining breast - feed or pump
Local heat, warm compress
Well fitted bra
Instruct on techniques
Acetominophen/ibuprofen
202
Antibiotics for mastitis
Dicloxacillin of Keflex
Clinda or Bactrim (not for under 1 month old infants)
203
Abx for severe mastitis
Van and Ceftriaxone OR Zosyn
204
Tx for breast abcess
I&D with abx tx - oral abx usually not sufficient without draining
205
Non nursing breast abcess - peripheral
On side is often because of folliculitis or infected cyst
I&D and mastitis abx
206
Subareolar breast abcess
Due to keratin plugged milk ducts behind nipple
Simple I&D not enough
Requires duct excision with biopsy to rule out cancer
207
Breast fat necrosis presentation
Presents with nipple and skin retraction
May have signs or hx of trauma
Indistinguishible from breast cancer clinically
Biopsy if persistent
208
Fibrocystic breast changes
MCC of cyclic breast pain or mastalgia in women 30-50
Epithelial cells become cystic
May be increased in drinkers and estrogen users
Worsened by caffeine
209
Age of fibrocystic breast changes
30-50 - correlated with reproductive age, goes away with menopause
210
Presentation of fibrocystic breast changes
Pain or tenderness with lump
Present or worse during the premenstrual phase (later half of cycle)
Multiple lesions that change in size
211
Discharge of fibrocystic breast changes
Green or brown
212
Dx for fibrocystic breast changes
Mammogram for over 30
US and aspiration -US can be better than an ultrasound to see if lesions are cystic
Be on the lookout for odd one out
213
Tx for fibrocystic breast changes
Avoid trauma, well fitting bra
Avoid caffeine
Low fat diet may help
214
Tx for severe fibrocystic breast changes
Danazol and Tamoxifen
Surgery for most refractory cases
215
Prognosis for fibrocystic breast changes
Will subside with menopause
Usually not associated with breast cancer
216
Fibroadenoma
Enlarged lobule in young women - early and mid 30s
Larger with hormones and usually solitary
217
Presentation of fibroadenoma
Round, smooth, and nontender mass, discrete
Can dx clinically but usually get image to be sure
218
Fibroadenoma on imaging and def dx
Well defined solid mass with benign features
Def. dx is core biopsy or mass excision
219
Phyllodes tumor
Can become malignant - similar to a fibroadenoma
220
Tx for fibroadenoma or phyllodes tumor
Unclear or rapid growth -surgical excision with wide margins
Can monitor/follow-up fibroadenoma if asymptomatic with biopsy or US breast exam
221
Inheritance pattern of BRCA1 and 2
Autosomal dominant
Also causes risk in MEN!!
222
Risk factors for breast cancer
Nulliparity
First full term pregnancy after age 30
Early menarche or late menopause (reverse decreases risk)
Combo HRT
Hx of uterine or breast cancer
223
Usual presentation of breast cancer
Painless breast mass
Hard, fixed, irregular margins, nonmobile
May see metastatic symptoms first
May also see pain, discharge, erosion, retraction
224
MC site of breast cancer
Upper outer quadrant
225
4 positions for breast exam
Arms over head
Laying on back with arms up
Arms on hips
Leaning forward
226
Concerning PE findings for breast cancer
New unilateral side change in size, contour
Unilateral retraction of nipple
Edema or erythema
Firm, non mobile, matted lymph nodes
227
Main lymph nodes for breast drainage
85% goes to axillary but palpate everything
228
Paget's disease of the breast
Eczematoid eruption and ulceration - arises from nipple areola
Pain itching, burning discharge and superficial erosion or ulceration
Biopsy
Excision/Mastectomy to treat
229
Inflammatory carcinoma
Diffuse, brawny edema with erysipeloid border
Orange peel skin may be seen
No mass
Aggressive but rare - rule out in refractory or unexplained mastitis
230
BIRAD 1 and 2 on mammogram
Okay, anything higher is concerning
231
Definitive diagnosis for breast cancer
Biopsy
Fine needle - less invasive but less sensitive
Core needle - MOre invasive better
Can also excise
232
Hormone receptor sites for cancer
Can have estrogen, progesterone, and HER2 receptors - change how the cance will metastasize
Triple neg goes to lungs/liver
233
Indication for hormonal therapy
Positive for ER/PR/HER2 hormone receptors
234
Tamoxifen
Historically drug of choice for hormonal breast cancer - can cause clotting and endometrial cancer
235
Newer treatment for hormonal breast cancer
Anastrozole - aromatase inhibitor, more effective than tamoxifen
236
Therapy for non hormonal (triple neg) breast cancer
Consider an adjuvant -pembrolizumab (keytruda)
237
Selective estrogen receptor modulators
Bind to estrogen receptors and block estrogen SERMs -selective for tissues, tamoxifen is specific to breast tissue
Roloxifene blocks in breast and uterus
238
SEs of SERMs
Hot flashes, thin hair, thrombosis
Can stimulate OR inhibit estrogen
239
Aromatase inhibitors
Anastrozole, exemastane, letrozole
Inhibit aromatase which produces estrogen
Menopausal symptoms - hot flash, brain fog, thinning hair
Newer for breast cancer
240
Fulvestrant
Little brother elacestrant
Destroys estrogen receptors
Used for metastatic breast cancer
No blood clots or cancer
Need receptors to work
241
Breast cancer follow ups
Q4 months for 2 years
then Q6 for 3 years for PE
Mammogram in 6 months then yearly
242
Median time of breast cancer recurrence
At 4 months
243
Percent of those trafficked who are female and minors
55-70% female
About half minors
244
Warning signs of human trafficking
Social withdrawal
Physical abuse
Neglect
Practiced hx
Living in unsuitable conditions
245
What to do if you suspect human trafficking
Send tip to national hotline
Give resources to patient
DOCUMENT
246
Percent of domestic violence victims who are female
85%
247
Women killed by male partner or ex 2001-2012
11,766, more than died in the iraq war in the same period
248
DV
Domestic violence
Controlling with disregard for wellbeing
249
Risk factors for DV/IPV
Race - AA
Pregnancy is a huge risk factor - DV is the leading cause of death in pregnant women
Younger age (16-24)
Childhood exposure to violence
250
Presentation of domestic violence
Often vague
Chronic pelvic pain
Sexual dysfunction
Recurrent vaginitis
Anxiety and tearfulness during breast and pelvic exam
251
Body complaints of DV
HA
Fatigue
Sleep disturbance
Seems like a somatoform disorder
252
Percent of pregnancies with violence
4-9%
253
Cycle of abuse
Tension building
Incident
Reconciliation
Calm "Honeymoon" phase
254
Screening for domestic violens
Screen everybody at all checkups, especially in pregnancy screen at least once per trimester and postpartum
255
Bestway to screen for domestic violence
Do it in person
Say something universal first: Because so many people are abused.....I want to ask
Ask about specific behaviors - not general like "rape" or "abuse"
256
Mandatory report events in WV for abuse
Gunshot, Stab, Burn
257
After dx tx for DV
Acknowledge trauma
Document with photographs - flag to withold
Assess safety and lethality, substance abuse
Create safety plan
258
What to do if patient does not want to leave abusive situation
Don't place blame
Document
Support patient
Follow up with patient
259
Majority of teenage rapes
Acquaintance rape - by someone they know
260
Presentation of sexual assault
May say they were mugged, May be asking AIDS or STD screening
60-70% have no obvious physical injury
May have bleeding and vaginal irritation, few have major injuries
261
Rape trauma syndrome
Detached shock like state
Acute phase - hours to days, tired, HA, startled abates after about two weeks
Delayed phase - Months to years, chronic anxiety, mistrust, depression, sexual dysfunction
262
PE for sexual assault
Have a trained person do a sexual assault assessment kit
Sexual assault nurse examiner - take care not to tamper with evidence
263
Hx for sexual assault
Describe what happened
Any consensual sex
What happened between
Any infections
State "Use of Force"
264
Tx for sexual assault
Emergency contraception after pregnancy test - IUD
Ceftriaxone and potentially metronidazole or Doxycycline
Hep B and HIV prophylaxis
HPV vaccine
265
Psych tx for sexual assault
Refer to counseling even if they appear calm, admit if unstable
266
Follow up for sexual assault
2 weeks - for psych and other issues
