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NR602 Final
Which one best describes lesions associated with condyloma acuminatum? a. Verruciform b. Plaque-like c. Vesicular d. Bullous - a 39yo female has completed course of amox for strep throat. LMP was 2wks ago, says it was normal. On exam, there's erythema of extern. genitalia w/small amount of white discharge. Micro wet prep reveals few clue cells, but many budding hyphae. No WBCs. Which one would be the most appropriate treatment? a. Metronidazole 500mg BID x7 days b. OTC hydrocortisone 1% cream TID c. Fluconazole tabs 150mg x1 dose d. Erythromycin 500mg TID x10 days - c Woman c/o vaginal itching, white discharge. She is in good health except for recent abx for strep throat. Pelvic reveals tender vulvovaginal area w/edema and nonmalodorous white patches. Which is the most likely cause? a. Bacterial vaginosis b. Trichomonas c. Lactobacillus overgrowth d. Candidiasis - d 18yo female c/o secondary amenorrhea. On exam, there is normal secondary sex characteristics and normal genitalia. Pregnancy is ruled out. What would necessitate further eval? a. Elevated blood cholesterol levels b. Androgen deficiency c. Galactorrhea d. Hirsutism - c 24yo female is dx'd w/primary dysmenorrhea. Which med would be used as first-line to help control symptoms? a. Antianxiety meds
b. Progesterone-only contraception c. Oral steroids d. NSAIDs - d Primary amenorrhea is best described as: a. Cessation of menstruation x6mo b. Failure of menstruation to occur by 17ho c. Failure of menstruation to occur by 13yo d. Cessation of menstruation x6mo after menarche - c 25yo female c/o vaginal irritation and discharge. On exam, cervix is easily friable and erythematous. No adnexal tenderness. Wet prep reveals mobile protozoa on NS slide. This most likely represents: a. Trichomonas b. Mucopurulent cervicitis c. Bacterial vaginosis d. Gonorrhea - a 16yo female has h/o secondary amenorrhea. Menarche at 10yo, regular cycles x2yrs, has not menstruated x4yrs. What is most frequent etiology of this problem? a. Eating disorder b. Pregnancy c. Anovulatory cycles d. Stress - a Woman is experiencing vaginal discharge. Wet mount with KOH would be used to confirm: a. Herpes simplex b. Gonorrhea c. Candidiasis d. Chlamydia - c Treatment options for condyloma acuminatum include: a. Imiquimod (Aldera) b. Azithromycin c. Acyclovir d. Metronidazole - a
a. Temp <100F b. Absence of WBCs in vag fluid c. Mucopurulent vag discharge d. Lab documentation of cervical infection w/E. coli - c When educating pt about rationale for getting mammo, which statement is false? a. Mammo is cost-effective method to screen for breast cancer b. Mammo detects all breast cancers c. Mammo should be accompanied by breast exam d. Negative mammo should not delay biopsy of clinically suspicious mass - b When educating women about breast cancer risk factors, which statement is incorrect? a. Pregnancy after 35yo b. Late menopause after 57yo c. Fibrocystic breast dz d. H/o maternal breast cancer - c Which of the following statements is accurate regarding the usefulness of mammo in screening and detection of breast cancer? a. Mammo shouldn't be done if there is any breast pain or nipple retraction b. All women >40yo should have mammo on annual basis c. Mammo should be done annually for all women of child-bearing age d. Mammos should be performed annually after initial pregnancy, especially if women doesn't breastfeed - b Which would be considered normal surface characteristic of the cervix during a speculum exam? a. Small, yellow, raised around area on cervix b. Friable, bleeding tissue opening of the cervical os c. Red patch areas w/occasional white spots d. Irregular, granular surface w/red patches - a What is the most common cause of dysfunctional uterine bleeding? a. Endocrine disorders b. Stress c. Anovulation d. Anatomical abnormality - c
PMS occurs with greatest frequency and severity in the: a. Late luteal phase b. Midfollicular phase c. Proliferative phase d. Early luteal phase - a Which is not a common cause of irregular menstrual bleeding? a. Endocrine disorders b. Stress c. Anovulation d. Anatomical abnormality - c What is considered the primary etiology of primary dysmenorrhea? a. Ovarian cysts b. Prostaglandin production c. Endometriosis d. Adenomyosis - b 28yo female c/o breast tenderness, fatigue, abd bloating, fluid retention, irritability 1wk before her menses onset. What is most important info to obtain from this pt to determine if the pt has PMS? a. Severity of symptoms b. Occurrence of symptoms in menstrual cycle c. Frequency and number of symptoms over past 4mo - b 35yo woman c/o 6mo h/o hypermenorrhea, backache, pelvic pressure. On exam, you discover 12wk size uterus w/irregular contour. What does this represent? a. Uterine cancer b. Dysfunctional uterine bleeding c. Uterine fibroid d. Fecal impaction - c Female c/o vaginal itching and white discharge. Denies sexual activity or douching. In good health except for recurrent strep throat. Pelvic reveals tender vulvovag area w/edema and white patches. No odor. What is the most likely cause? a. Bacterial vaginosis
What is acute DUB? - Episode of sufficient quantity to require immediate intervention to prevent further blood loss What is chronic DUB? - Present for the majority of the last 6mo What is the most common benign tumor of the genital tract? - Leiomyomas? (Hollier CPG p. 772) Name some risk factors for DUB. - Anovulation Hormone replacement anovulation Obesity Nulliparity
35yo DM Personal/fam h/o coagulation disorder Liver disorder Anticoagulant therapy/chemo What are some subjective findings for DUB? - Heavy bleeding Bleeding >7 days Cycles closer than 21 days Pain Post-coital bleeding Passing clots/tissue Dizziness Hot flashes Temp intolerance Uterine/cervical tenderness What are some objective findings for DUB? - Excessive bleeding on exam Hypotension Tachycardia Diaphoresis Vag atrophy Mass Trauma Enlarged uterus/adnexa Hirsutism Thyromegaly Bruising Galactorrhea
What are some diff dx's for DUB? - PALM-COEIN Traumatic injury Pregnancy-related bleeding (ectopic, SAB, placenta previa/abruptio) What are some diagnostic lab studies for DUB? - -*Serum hCG: always do first before examining pt of menstruating age w/vag bleeding -CBC -ABO/Rh if preg. suspected/severe bleeding -STD tests/wet prep -Cervical cytology -CMP (w/renal & liver panel) -Coags -If hx indicates: screen for bleeding disorders for DUB at menarche. -If hx indicates: thyroid panel -Endometrial bx What are some diagnostic imaging studies for DUB? - -TVUS: first-line if imaging needed -Saline infusion sonohysterography (helpful for leiomyoma) -Hysteroscopy (can be used for guided endometrial bx) -MRI What are some diagnostic studies for polyps in DUB? - -TVUS -Saline infusion sonography -Hysteroscopy What are some diagnostic studies for adenomyosis in DUB? - TVUS or MRI What are some diagnostic studies for leiomyomas in DUB? - TVUS What are some diagnostic studies for malignancy in DUB? - Bx/pathology What are some diagnostic studies for coagulopathies in DUB? - Labs What are some surgical options for DUB? - -Varies depending on dx, age, fertility status/desire -If bleeding severe/pregn. related: D&C or hysterectomy in extreme cases -Hysteroscopic removal of polyps -Endometrial ablation -Hysterectomy
-Anemia -Break through bleeding -VTE -Uterine artery embolization/polypectomy: maybe issues w/infertility -Premature ovarian failure secondary to hysterectomy What is the average age of menarche for Caucasians? - 12.6y What is average age of menarche for African-Americans? - 12.1y What is average age of menarche for Latinas? - 12.2y What does higher BMI in childhood result in regarding puberty? - Earlier onset Timing and progression of puberty are related to... - Environmental factors, including: -Socioeconomic conditions -Nutrition -Access to preventive healthcare At what average age do secondary sexual development occur? - 9y Menarche usually occurs w/in ______________ after thelarche (breast buds). - 2-3y When should dx/referral be made for primary amenorrhea? - -Any adolescent w/out menarche by 15yo -Any adolescent w/out menarche 3y after thelarche What are some things that can cause menstrual irregularities? - -Disturbances in normal hormone release -Significant wt loss -Strenuous exercise -Substantial changes in sleep/eating habits -Severe stressors Most cycles range from ___________. - 21-34 days When is woman's normal cycle length usually established? - Around 6th gynecological yr, ~19-20yo
What are the 2 cycles that occur simultaneously in the menstrual cycle? - Ovarian and endometrial What cycle are follicular, ovulation, & luteal phases? - Ovarian What phase is menstrual days 1-14 in ovarian cycle? - Follicular Prominent hormones: FSH, estrogen Description: maturation of ovarian follicle What phase is menstrual day 14 in ovarian cycle? - Ovulation Prominent hormones: LH Description: ovulation 36h after LH surge; increased basal body temp What phase is menstrual days 15-28 in ovarian cycle? - Luteal Prominent hormones: Progesterone, estrogen Description: follicle becomes corpus luteum What cycle are menses, proliferative, & secretory phases? - Endometrial/ovarian What phase is menstrual days 1-5 (variable) in endometrial phase? - Menses (part of proliferative phase) Prominent hormones: prostaglandin Description: endometrium sloughs if fertilization of ovum doesn't occur What phase is menstrual days 1-14 in endometrial phase? - Proliferative Prominent hormones: estrogen Description: endometrium proliferates What phase is menstrual days 14-28 in endometrial phase? - Secretory
What are some diagnostic studies for Bartholin's gland cyst/abscess? - -Usually none unless other infection suspected -C/S of cyst contents -Cx for STD, esp. gonorrhea & chlamydia What is the most common causative organism of Bartholin's gland cyst/abscess? - Aerobic bacteria E. coli What are some preventive measures for Bartholin's gland cyst/abscess? - -Loose breathable garments -Good perineal hygiene -Early treatment What are some nonpharm treatment options for Bartholin's gland cyst/abscess? - -None needed if only 1-2mm & asymptomatic -Exclude possible carcinoma if >40yo -Local moist heat -Warm sitz baths/tepid water soak 3-4 times/day -I&D w/Word cath of fluctuant abscess if refractory to initial treatment (no sex until cath removed) -Possible marsupialization (permanent surgical opening allowing drainage) What is the goal of treatment for Bartholin's gland cyst/abscess? - To facilitate drainage of cyst contents What are some pharm options for Bartholin's gland cyst/abscess? - -If high risk/recurrent: Augmentin for E. coli/Strep, clinda for Staph (incl. MRSA) -Treat for any STD -NSAIDs When is consultation/referral recommended for Bartholin's gland cyst/abscess? - Surgical or gyn consult if large cyst or unresponsive to treatment What are follow up recommendations for Bartholin's gland cyst/abscess? - Re-eval in 7-10days What is expected course of Bartholin's gland cyst/abscess? - -Complete resolution w/appropriate treatment -1 of 10 will recur What are possible complications of Bartholin's gland cyst/abscess? - Cellulitis What is description of breast cancer? - -Malignant breast tumors -Primarily female, but can be in males
-Stratified into 1 of 5 subtypes based on histopathological characteristics (Luminal A/B/B-like, HER positive, Triple Negative) Presence of _________________ and _____________________ gene mutations are associated with lifetime risk of breast ca from 45-60%. - BRCA 1, BRCA 2 What cancer is the most frequently diagnosed in females? - Breast Which ethnic group is more likely to develop breast ca? - Caucasians What are some risk factors for breast ca? - -Increasing age -Dense breast tissue -Prolonged estrogen exposure (menarche <12yo, 1st term pregn >35yo, nulliparity, never breastfeeding, contraceptives w/exogenous hormones, menopause >55yo, postmenopausal hormone therapy) -Fam h/o breast ca (esp. 1st degree relative) -Personal h/o breast ca -H/o benign breast dz (nonproliferative = slight risk, proliferative = high risk) -Obesity in postmenopause -Inherited gene mutations -High dose radiation exposure to chest area at <20yo ->3 ETOH drinks/day -Emerging/unclear risk factors (tobacco, phys. inactivity, high fat diet, night shift) What are some assessment findings in breast ca? - -Painless, firm, fixed mass (most common symptom; no changes in mass w/menstruation) -Nipple discharge that's not breast milk -Skin/nipple changes (dimpling, skin ulceration, lymphedema, nipple retraction, scaly nipple lesion or eczematous rash i.e. Paget's) -Increased vascular pattern of breast -Significant asymmetry of breasts -Axillary, supraclavicular, infraclavicular lymph node enlargement -Late findings: wt loss, anorexia, bone pain, anemia What are some diff dx for breast ca? - -Breast cysts -Fibroadenoma -Sclerosing adenosis -Intraductal papilloma -Hyperplasia -Radial scars -Mastitis What are some diagnostic studies for breast ca? -
-Reg gyn follow-up (tamoxifen increases risk for endometrial ca; any vag bleeding should be eval'd) -Mammo q6-12mo for surveillance, yearly once stability of mammo findings achieved -MRI yearly if meets certain risk criteria What is expected 5-year survival rate for noninvasive and Stage I breast ca? - Non (tumor <1cm w/no ax node involvement) & Stage I (tumor >1cm w/no ax node involvement) = 100% What is expected 5-yr survival rate for Stage II breast ca? - 93% (tumor <5cm w/ax node involvement) What is expected 5-yr survival rate for Stage III breast ca? - 72% (tumor >5cm w/chest wall or skin extension, inflammatory changes, or supraclavicular involvement) What is expected 5-yr survival rate for Stage IV breast ca? - 22% (metastatic) What are some possible surgical complications of breast ca? - -Postop lymphedema -Limited upper extrem. movement What are some possible chemo complications of breast ca? - -N/v -Alopecia -Leukopenia -Stomatitis -Fatigue What are some possible radiation complications of breast ca? - -Skin changes (burning, peeling, discoloration) -Fatigue -Axillary hair loss -Rib fx, heart damage, radiation pneumonitis, brachial plexopathy, slight increased risk for secondary cancer (all rare) What are some general possible complications of breast ca? - -Infertility -Osteoporosis -Musculoskeletal complaints -Sexual dysf. -Cog. changes -Fatigue -Depression -Insomnia -Neuropathy -Cardiac toxicity
-CVD
What is fibroadenoma? - Benign breast lesion of fibrotic stroma (connective tissue) & glandular tissue; heterogenous lesion AKA benign breast dz (BBD) What is etiology of fibroadenoma? - Unknown, thought to be exaggerated response to normal hormonal stimuli What is the most common benign tumor in female breast? - Fibroadenoma (most common 15-40yo, but can be any age) What are some risk factors for fibroadenoma? - -Multiple FA's associated w/rare ca syndromes (Maffuci syndrome, Cowden syndrome, Carney complex) -Increased risk of BBD with h/o adolescent ETOH consumption, esp. >/=10g per day What are some assessment findings of BBD? - -Discrete, painless, firm/rubbery mass w/well-defined borders -Freely mobile -Fluctuations in size w/pregn. or menst. cycle ->5cm considered giant FA -No nipple discharge What are some diff dx for BBD? - -Fibrocystic breast dz -Intraductal papilloma -Breast ca -Phyllodes tumor -Cyst -Other benign breast dz What are some diagnostic studies for BBD? - -Mammo -US -Fine needle bx -Open bx What are some nonpharm options for BBD? - -Conservative observation, pt reassurance -Surgical excision if >3cm, symptomatic, or if dx questionable due to imaging findings such as irreg. borders or abnormal vascularity. -Cryoablation What are some pharm options for BBD? - There are none
-Breast pain/discomfort/tenderness, diminishes after menses -Breasts feeling full, swollen, heavy, engorged -Worsening of symptoms premenstr. -Nipple discharge (varying color/consistency) What are diff. dx for FBD? - -Breast ca -Intraductal papillomas -FA -Mastitis -Chest wall syndrome -Neuralgia What are diagnostic studies for FBD? - -Prolactin level -TSH -Mammo -US -Needle/open bx -Maybe galactography (ductography) when nipple discharge present What are some nonpharm options for FBD? - -Eval to rule out malign. -Therapeutic aspiration of cysts -Reassurance -Cold compress -Supportive bra worn 24h -Na restriction 10d before menstr. onset -Decreased/eliminated caffeine -Reduce dietary fat -Fine, core, excisional bx often needed to differentiate from malign. What are some pharm options for FBD? - Spironolactone (Aldactone): -For swelling/pain premenstr. -Usually 100mg x5d, then retitrate (25-200mg/day) Vit B6, E Evening primrose oil: -For mastalgia OCPs Danazol (Danocrine) Bromocriptine (Parlodel):
-For more severe dz Is there any affect on lactation with FBD? - No When is consultation/referral recomm. for FBD? - Surgeon for eval of masses that are very painful/cause continuous pain, or any abnorm. on mammo/US What is recomm. follow up for FBD? - Mammo as indicated by age/risk factors What is expected course for FBD? - Benign but chronic condition What are possible complications of FBD? - Maybe increased risk of malign. if atypical hyperplasia on bx, though >80% w/atyp. hyperplasia don't develop invasive ca in their life. What is intraductal papilloma? - -Benign tumor in ductal system of breast -Part of BBD group What is cause of IP? - Unknown, but maybe proliferation of ductal epithelium What is usual age for IP? - 30-50yo What are risk factors for IP? - -Mult. papillomas increase lifetime risk of breast ca -Increased risk of BBD in adolescent ETOH >/=10g/day What are assessment findings for IP? - -Smooth, small mass (may/may not be palp) -Typically retroareolar -Bloody/serous nipple discharge -Usually unilat unless mult. ducts involved What are some diff dx for IP? - -Breast ca -Galactorrhea -In situ carcinoma -Ductal ectasia -Epithelial hyperplasia -Physiological or gestational nipple discharge
