Office Flashcards
screening tests at WWE
GC and clamydia: yearly between 13-24; >25 if high risk
glucos: annually if high risk, every 3 years at 45
lipid profile: q5 years starting at 21
DEXA: age 65; sooner with risk factorsHIV: at least once during a woman’s lifetime
Hep C: once in a lifetime >18
counseling for WWE
exercise
breast self awarenesss
diet: decrease caffeine cholesterol calories
Increase: calcium 1300mg/day, vitamin D 600-800IU/day (800 if over 70), fiber, folate
STD, contraception, HRT, driving habits/seat belt use, bone health, sexual health, vulvar/vaginal symptoms/smoking /alcohol/drugs, pregnancy
TACE for alcohol use
Tolerance; how many drinks you require to get a high
annoyed: has anyone annoyed you by questioning your drinking
cut down: has anyone told you to cut down on drinking
eye opener: do you have one shortly after awakening
The 5 A’s of tobacco cessation
Ask about presence and degree of smoking
Advise to stop smoking
Assess patient willingness to stop
Assist with counseling support groups, materials
Arrange follow up
cervical cancer screening pearls
Age 21-29: cytology only q 3 years
Age 30 and more: co-testing q5 years; cytology alone q3 years; primary HR HPV testing alone every 5 years
stop following hysterectomy for benign reasons; continue Pap alone q3 yrs until 25yrs post treatment
LSIL CIN1 not a precursor to cancer except in an older woman over an extended period of time
CIN2 is the threshold for treatment over 24yrs old
ECC indicated if colposcopy is unsatisfactory, if contemplating ablative therapy; ASC-H, HSIL or AGC or AIS
Under age 25: LSIL, ASCUS_HPV or ASCUS without HPV, repeat cytology alone at 1-2 yrs
colpo if high grade ctyology or if low grade persists at 2 year follow up
if histologic CIN3 found, treatment is recommended
CIN23, observation is preferred–cytology and colpo at 6 month intervals; treatment if persistent x2 years
Post treatment HPV statusis MOST accurate predictor of treatment outcome; HPV testing in 6 months is preferred
give statin’s if:
clinical CVD
LDL>190
DM age 40-75 with LDL 70-189 and w/o clinical CVD
LDL 70-189 and 10yr CVD risk >7.5%
CVD is the leading cause of death for women
Osteoporosis
DEXA
normal: >-1 SD below young adult peak bone mass mean
Low bone mass: -1 to 12.5 SD below young adult peak bone mass mean
Osteoporosis <-2.5 SD below young adult peak mass
T score: SD from mean peak bone density of a normal young adult
Z score: SD from reference population of the same age, sex, and race
begin age 65; of PMW <65 and FRAX>8.4%
repeat no sooner than 2 years; if on treatment q1-3 years until stable; do not repat once DEXA stable or improed unless risk factgors change
RF: personal history of fracture, 1st degree relative with fracture, caucasian race, current cigarette smoker, low calcium intake, poor eyesight, drugs, frail, inadequate physical activity, estrogen deficiency, EtOHism, RA, gastric bypass
normal bone loss: pre menopause 0.5% per year, in post menopause 5% per year
Work up: CBC, chem profile–Ca, Mg, P, LFTs, 25 OH Vit D, 24hr urine Ca, TSH
FRAX
fracture risk screening tool, valid for women >40
predicts risk for fracture in next 10yrs
considers: age, sex, BMI, previous fragility fracture, parental hx of hip fracture, smoking status, corticosteroid use, EtOH, RA, other secondary causes of ostoporosis
when to treat low bone mass
T score <2.5
T score <1 and FRAX 3% for hip fx or 20% for major fx
history of fragility fracture including asymptomatic vert fx regardless of T score
treatment of low bone mass
bisphosphonates: 1st line for postmenopausal; inhibits bone reorption by osteoclasts
Contraindication: esophageal abnormalities including reflux and renal failure
take on an empty stomach with a lot of water but no food; remain upright for 30 minutes
HRT: indicated for prevention but can use for treatment iF all other options fail/not tolerated
SERM: raloxifene; pro-estrogenic to bone, anti-estrogenic to endometrium
Calcitonin: 200IU/day nasal spray or subq injection; increased risk for malignancy
Prolia; contraindications are hypocalcemia
above are anti-resorptive; decrease bone breakdown
anabolic: parathyroid hormone; sclerostin inhibitor; for very high risk only T score <-3.0 or <-2.5 with fracture in past 12 months
counseling on spousal abuse
screen and counsel at each annual exam, New OB and each trimester
ppx for STI: 500mg ceftriaxone IM x1; 100mg doxycycline BID x7days; 500mg metronidazole BID x7days; Hep B and HPV vaccines; if assailant HIV+ start HAART within 72hrs
treatment of chlamydia
non pregnant: doxycycline 100mg BID x7days
pregnant: azithromycin 1gm PO or amoxicillin 500mg TID x7days
gonorrhea and chlamydia: add ceftriaxone 500mg IM x1 (1gm if >150kg)
treatment of endometritis/PID
outpatient: ceftriaxone 500mg IM x1; doxycycline 100mg PO BID x14 days and flagyl 500mg BID x14 days
inpatient: ceftriaxone 1g IV q24hrs plus docycline 100mg PO/IV BID plus flagyl 500mg PO/IV BID
OR cefoxitin 2g IV q6hrs
OR cefotetan 2g IV q12hrs plus doxycycling 100mg PO/IV BID
treatment of BV
clinda 2% cream 5gm x7 dyas intravaginally
OR flagyl 0.75% gel/5gm QD intravaginally x5 days
OR flagyl 500mg PO BID x7 days (also good for trich)
treatment of UTI/pyelo
lower tract: bactrim 100/800mg BID x3 days
OR macrobid 100mg BID x7 days
give quinolones if no alternatives
upper tract: ceftriaxone 1gm IV daily then PO meds for 7 days
outpatient: ciprofloxacin 500mg PO BID x7days
treatment of syphilis
primary, secondary, early latent <1 year: benzathinge penicillin 2.4mil u IM x1
unknown, late: benzathine penicillin 2.4 mil uIM q week x3 if prior negative status not confirmed
transmissible during primary, secondary and first year of latent phase
fetal transmission can occur during primary, secondary and latent
Criteria to diagnose PID
empiric therapy based on lwoer abdominal/pelvic pain in sexually active female and other obvious causes have been ruled out
OR
one of the followign: adnexal tenderness, uterine tenderness or cervical motion tenderness
supportive evidence: fever, mucopurulent vaginal discharge, WBC on saline wet prep, positive GC/CT, gram + diplococci on gram stain, WBC >10, elevated CRP, elevated ESR
criteria for inpatient therapy for PID
cannot exclude surgical emergencies
pregnant
no response clinically to oral antibx therapy
unable to follow or tolerate outpatient regimen
severe illness,n/v, high fever
TOA
syphilis
primary: incubation period 9-90 days; lesion = primary chancre (painless ulcer with clear margins and punched out crater like appearance, usually 1-2cm diameter); heals spontaneously even without treatment
secondary: 6w-6mo after primary chancre, systemic symptoms possible; lesion=condylomata lata, maculo-papular rash (torso, palms, soles, mucous membranes), LAD
latent: no evidence of disease
tertiary: many years later; lesion=gymma, cardiac lesion, tabes dorsalis, argyll-robinson pupil
serology of syphilis
nonspecific: VDRL, STS, RPR; screening; false positives can be present
specific: FTA-Abs, TPHA, TPI; confirmatory, no false positives; permanent
sero conversion takes 4-6weeks
causes of false positive RPR: auto immune disease (SLE)–anti-cardiolipin Ab effect; smallpox vaccination or history of smallpox, history of malaria, mycoplasma pneumonia, HIV, pregnancy, IV drug use
Jarisch-Herxheimer reaction
acute febrile illness (fever, HA, myalgias, possibly increased rash)
within 6-8hrs of treatment with PCN
often mistaken for PCN allergy
can cause PTL/fetal distress
due to release of toxins from dying spirochetes
if pcn sensitive: erythromycin; if pregnant, desensitize and give pcn–tetracycline contraindicated in pregnancy (yellow teeth), erythromycin doesn’t adequately treat fetus
differences between syphilis and chancroid
syphilis: single, painless lesion, clear margin (crater like), rubbery painless nodes, treponema pallidum, cold
chancroid: multiple, painful, vague margin, painful nodes, hemophilus ducreyi, hot
if unsure, treatment of an ulcer with erythromycin (assuming patient not pregnant) will cover for syphilis, chancroid, granuloma inguinale and lymph granuloma venereum
ddx of a vulvar ulcer
HSV
syphilis
chancroid
LGV
granuloma inguinale
Bechet’s
vulvar carcinoma
Bartholin gland abscess
biopsy or excise gland to r/o adenocarcinoma in patients >40
abscess: I&D, word catheter 4-6 weeks
culture abscess to r/o MRSA
if absces recurrs: repeat I&D, word catheter or marsupialization and add abx
abx should be given if recurrent abscess, estensive surroundign cellulitis, pregnant, immunocompromised, risk fo MRSA or cx + MRSA, signs of systemic infection
Abx: bactrim 5-7d; consider adding augmentin or flagyl
vaginitis
normal pH <4.5
dx by: history and symptoms; pH, 10% KOH (yeast), normal saline wet prep slide,
types: BV 40%, yeast 30%, tich 20%
uncomplicated yeast infection: infrequent/sporadic episodes, mild-moderate symptoms, c. albicans, not immunocmpromised
TREAT: intravaginal azoles or oral fluconazole
complicated: >4 infections per year, severe symptoms, non-albicans, DM, iummunocompromised
TREAT: do yeast culture with speciation; non-albicans are less responsive to azoles; 600mg boric acid capsules x14d minimmum
severe disease: vulvar sx, erythema, fissures, edema–treat with topical intravaginal zoles x14d or 150mg fluconazole q3d x3 doses
recurrent disease: fluconazole 150mg q3d x3 doses then weekly x6 months OR topical clotrimazole 500mg intravaginally q week x6 months
BV
Amsels criteria (3 of 4)
pH >4.5, +amine test, >20% clue cells, white-pray homogenous discharge
OR with commercial test
can be associated with PTL/PROM/post hysterectomy cuff cellulitis/PID/increased aquisition of STDs
recurrent BV: 3 infections in 1 year; treat after initial therapy for 7-14d twice weekly gel x6 months
Trich
increased pH
can see trichomonads on wet prep
NAAT recommended for diagnosis
50% asymptommatic
asymptomatic carriage state can occur for prolonged periods of time
flagyl 500mg BID x7 days
TB
dx of infection: PPD, IGRA blood test, CXR–apical cavitation, hilar adenopathy
emb: langhans cells on bx; TB on cx
tx: 6-9 months
INH, rifampin (interes with OCP), ethambutol (if INH resistance)
supplement with Vit B6 to reduce risk fo neurotoxicity
tx consists of 2 phases: intensive phase is 4 drugs and lasts 2 months; second phase lasts 2-7 months and includes 2-3 drugs
test: clinical suspicion-cough >2-3 weeks, fever, night sweats, weight loss
if suspicious get CXR and 3 sputum samples for culture, AFB stain or NAATS for TB
AUB ddx by age
13-18: anovulation due to immature HPO axis, hypothalamic dysfxn, coagulopathies, hormonal contraceptives, infections, pregnancy, tumors
19-39: pregnancy, PCOS, anatomic lesions, hormonal contraceptives, hyperplasia/malignancy
40 and older: anovulation with declining ovarian fucntion, fibroids, hyperplasia/malignancy, atrophy
PMS v PMDD
presence of both physical and behavioral symptosm that occur repetitively in the 2nd half of a woman’s menstrual cycle and interfere with some aspect of her life
behavior: depression, irritability, anxiety
physical: breast pain, bloating, swelling, extreme fatigue and headache
PMDD is a severe form of PMS; symptoms of anger irritability and ternal tension are prominent 2% of population
women have normal levels of hormones but an abnormal neurotransmitter response
galactorrhea work up
milky nipple discharge
prolactin inhibited by dopamine and stimulated by TRH and nipple stim
work up: medciation history, breast exam, look at discharge under microscope (fat droplets), prolactin level, TSH, renal function and hCG, visual field test, MRI of pituitary fossa
hypoT and CKD can increase prolactin
blood testing for prolactin: early AM, prior to breakfast, prior to exercise, no intercourse or nipple stimulation
indications for treatment: existing/impending neurologic sx due to macroadenoma; hypogonadism or bothersome galactorrhea
tx with dopamine agonists: cabergoline; bromocriptine
