[Music] all right part two nine ecology so breast cancer screening starts at 40 years old and you want to do it every year osteoporosis screening starts at what age 65 when do you do the HPV vaccine ages nine to twenty six when do you give the herpes zoster vaccine age sixty when do you give a pneumococcal vaccine 65 years old when do you give the meningococcal vaccine college age when do you do a pap smear with patients who have HIV every year what about a normal population person when do you want to do the pap smears starting at age twenty one every three years and what age do stop at 65 whole dr. Noma hypothyroidism and pregnancy can all cause Galacta Riya how well prolactin will just stimulate the production of milk so that's self-explanatory but how does hypothyroidism do it well when you have hypothyroidism that increases TSH and TSH stimulates prolactin and then prolactin will increase breast milk pregnancy how does that work well beta HCG will stimulate prolactin which increases the production of rest milk but on top of that all of these can also lead to osteoporosis now how does that work so for prolactin oma it actually suppresses GnRH which suppresses LH and FSH which makes low estrogen and then low estrogen predisposes at osteoporosis for hypothyroidism I TSH will also stimulate prolactin which shuts down LH FSH and then that will cause low estrogen which leads to osteoporosis another key association with osteoporosis is called the female athlete triad which is a female athlete who has a very low BMI and exercises a lot and may have an eating disorder and then these can lead to osteoporosis also associated with EMI is something called hypo gonadotropic hypogonadism which means that because this person is has such a low BMI or exercises too much that hypothalamus shuts down which causes them to not have regular periods and then have low estrogen levels which causes osteoporosis also people who have low BM eyes tend to develop something called stress fractures which is quiet tenderness over the tibia which doesn't show up on an x-ray these are all kind of associated with each other like a female athlete who exercises a lot may not eat really well can have a man area through hypokinetic trophic hypogonadism osteoporosis as well and stress fractures so how do you prevent osteoporosis you want to do weight-bearing exercises supplement with calcium and vitamin D so anyone with secondary amenorrhea which means they used to have periods and now all of a sudden they're not getting periods what is the first thing you want to do is you want to rule out pregnancy with urine beta HCG after that then you want to work up prolactin and TSH so what is the most effective form of emergency contraception it's a copper IUD so there's two downsides to a copper IUD one is that IUDs can increase the risk of pelvic inflammatory disease through retrograde propulsion of bacteria and the second one is that upper IUDs tend to increase vaginal weaning which causes menorrhagia so it's a contraindicated in patients who have men or Raja other than that it's the most effective form of emergency contraception so post-op fever if you remember the five W's win water walking wound and wonder drugs and these will happen on want days 1 3 5 7 & 9 plus or minus a few days the first one wind stands for is pneumonia like the lungs and add electus water stands for UTI walking stands for much should remind you of your legs so DVT is self-explanatory wound infection and last is wonder drugs or abscess and after days nine drugs can cause fever and abscesses can cause fever next is stress incontinence stress incontinence is caused from ulta pole births and what this causes internal urethral sphincter to slip below the pelvic diaphragm muscles and so when when you cough or sneeze or valsalva on under physiologic situations this will compress the bladder and the internal urethral sphincter at the same time which will be above the pelvic floor and so nothing happens but in someone who has stress incontinence the internal urethral sphincter is now below the pelvic floor so now when they valsalva or increase external pressure on the bladder this increases the bladder pressure but the internal urethral sphincter won't contract so that causes leakage of urine so they'll usually complain a leakage of urine when they're working out or when they're coughing or sneezing how you diagnose that is with the q-tip test and the q-tip test will show you referral hypermobility due to the urethra are no longer being supported they'll usually ask you what the first-line treatment for this is and it's Kegel exercises to strengthen the pelvic floor and then if that doesn't work then the second line is a pessary as pessary is basically like a plastic device that you can insert into the vagina which acts as like artificial support and then the third mind treatment if that doesn't work which rarely gets asked would be like a maybe wreath role so swing then there's urge incontinence which is due to an overactive bladder and this is when the bladder spasms so they have uncontrollable urges to urinate and the first-line treatment for that is um bladder training exercises if that doesn't work then you want to use oxybutynin which is a muscarinic antagonist which prevents the ladder from contracting and then the last one is overflow incontinence which is usually caused by things like people who have severe and staged diabetes with diabetic neuropathy or people who were post-operative or post anesthesia where they have temporary stunning of their a system that's controlling their bladder and you get overflow incontinence this is treated by intermittent catheterization this can also be treated with the fana call which is a must rinic agonist and if you're unsure of what type of incontinence then you can do post-void residual volume studies and anything over 100 mils is considered overflow incontinence but mainly you can diagnose by looking at the clinical vignette and then there's four types of pelvic organ prolapse but we'll talk about the three main ones which is Sisto seal recto seal and Antero seal so Sisto seal is when the bladder herniates against the anterior wall of the vagina which causes the anterior wall of the vagina to prolapse that's called a sistah seal on recto seal is when the rectum her needs against the posterior wall of the vagina and this creates an out pouch which can cause constipation which due to like incomplete evacuation of stool that's piling up in that new pouch and it's usually relieved by digital rectal exam and then the last one is entero seal which is when the weight of the uterus prolapse is all the way out and down and this can also be associated with post hysterectomy so if you see all Jing mass at the introitus that's smooth and that's the most likely the uterus so in terms of defecation remember that a rectal seal will have constipation that's relieved with digital rectal exam versus uterine fibroids which are little 9 tumors of the uterus this can cause external compression against the rectum which can also cause constipation by decreasing the rectal lumen diameter and then the third one is endometriosis which doesn't cause constipation but it causes Ischia which is painful bowel movements remember in terms of post c-section applications you can have evisceration wound dehiscence which is also known as facial disruption or a wound infection so evisceration just means that all the organ contents the intestines the omentum have spilled out because the sutures were too weak and everything broke open how you want to treat that as cover with the sterile sponge soaked in saline and go straight to or the second one is facial disruption or what they call wound dehiscence and this is due to defect in the fascial repair and then that leaks salmon pink fluid and then what you want to do with this is an abdominal binder and then go to the or the last one is a wound infection will have red and tenderness around the wound site and they'll also be febrile what you want to do it this is actually open the wound to minimize infection clean it out and give antibiotics so then I want to talk about pelvic inflammatory disease which is most often caused by chlamydia and gonorrhea so the clip of chlamydia and gonorrhea will first infect the cervix it can then and start infecting the uterus it can ascend and then infect the fallopian tubes which was called salpingitis and then it can also be complicated by a tubo-ovarian abscess by forming an abscess in the fallopian tube or by spilling out and causing infection of the ovaries as well this can further progress and advance and then contaminate the peritoneum which produces adhesions ascend all the way up to the right upper quadrant by the ivory which can cause small bowel obstructions and this is called fitz hugh curtis syndrome and then pelvic inflammatory disease the signs are a red tender cervix uterine tenderness and nexon tenderness signs of infection such as fever leukocytosis and just prune yeah because vixx's enflamed you'll also see a pelvic mass on ultrasound which is a tubo-ovarian abscess then you have your your three most common vaginal infections which is trichomonas gardnerella and candidiasis so trichomonas is also known as bacterial vaginosis and this is the key things you want to look for is a strawberry cervix green frothy discharge and then on microscopy you'll see little flagellated protozoa it's also painful and it will have a positive Koh whiff test and you want to treat this with metronidazole and then gardnerella is also known as bacterial vaginosis and this has the thin white discharges that are very foul-smelling and then this is under microscopy you'll see clue cells which is where the bacteria are coding the epithelial cells and then you want to treat this with metronidazole as well remember trichomonas is sexually transmitted whereas ordinary Ella or vaginosis is not so with trichomonas you want to treat the partner too because this can cause ping-pong hang where if you treat the female and the guy has it and then they have sex and then he gives it back to her again and then so you want to treat both of them and then the last one is candidiasis which is characterized by a thick cheesy curd like discharge this is associated with diabetes it also causes extreme paratus as well which can cause excoriation around the vulva and then you want to treat this with a zoals and those are your three most common vaginal infections and then you have your painful uterine pathologies so you have adenomyosis and endometriosis and we can throw a fly on my oma in there as well which is also known as fibroids so I don't know meiosis is you have endometrial tissue in the myometrium and this will cause painful asmin area on physical exam you it'll be described as a painful uniformly enlarged blood you duress and you want to treat this with OCPs or NSAIDs and then for primary dysmenorrhea which is painful periods this is usually due to uterine contraction and uterine contraction is mediated by prostaglandin so you would treat it with NSAIDs which decrease prostaglandin that's treated with NSAIDs and then there is endometriosis which is characterized by the triad of dysmenorrhea discs easier and dyspareunia and then on physical like physical exam you'll feel little modularity x' around uterus and especially on digital rectal exam you can feel odd irregular nodules and this is due to ectopic endometrial tissue and then you want to treat endometriosis with OCPs as well or NSAIDs um in endometriosis remember that it's associated with infertility because it disrupts the ovulation cycle so then you have your more kind of rare genital ulcers which are lymphogranuloma venereum which is a type of chlamydia trachomatis l1 to l-3 and granuloma in Grinnell II which is caused by Klebsiella lymphogranuloma venereum and granuloma in Grinnell II are very similar because they both cause many painless ulcers on the genitals but the thing that makes them kind of unique is they also present with giant inguinal erythema does painful lymph nodes which are called buboes the difference here though is that in lymphogranuloma venereum the pupils are painful but they don't all straight whereas in granuloma in Benally these pupils will actually ulcerate and you want to treat these both the same which is doxycycline and ceftriaxone so we talked about UTI already increased frequency historia increased urge of your name sometimes on your urinalysis you might get something called sterile pi area which is you might see white blood cells but no bacteria and or you might have tried an antibiotic and it didn't work or you can't find a certain source and the patient says that usually their pain is relieved with urination once you've ruled out UTI and it's a mystery and the pain has relieved with urination your top differential should be interstitial cystitis also hematuria gross hematuria it can fall under the category of gross painful hematuria are gross painless hematuria gross pain full hematuria the top differential should be kidney stones Nefera with ISS but for painless hematuria you should look for a history of smoking because gross painless hematuria sets off the red flag for either bladder cancer or renal cell carcinoma and then leiomyoma which is known as fibroids is described as having these non-tender a midline irregular mass so all these lumps on the uterus and it moves with the cervix when the cervix is moved and leiomyoma or fibroids usually patient has the complaint of menorrhagia you want to treat it with NSAIDs or progestin if they have severe symptomatic anemia and definitive treatment would be hysterectomy if someone has fibroids but then in the history they've been stating that there's been wrap growth of the tumor and they might have had prior radiation for the pelvis then you should think of a malignant glioma oma which is known as leiomyosarcoma so threatened abortion is the cervix is closed but there's bleeding the baby is at risk but the cervix is closed and it can survive so you want to just follow up the beta HCG then you have something called inevitable abortion which is where the cervix is open and when the cervix is open the fetus is doomed to be expelled and that's called an inevitable abortion and then you have something called an incomplete portion which is the baby or the fetus is now on the way out but not completely out so there's some retained parts of conception and then the last is a complete abortion which says all the products of conception have been expelled and the cervix is now closed and there is no more cramping this is called a complete abortion and then the last one is called a missed abortion which means there was never any bleeding or cramping but the fetus inside is not viable another type of pregnancy you should be aware of is ectopic pregnancy and how you diagnose that is usually when the HCG is above 1,500 you should be able to see it through a chance vaginal ultrasound but if you don't see fetus in the uterus with HCG over 1500 then it's most likely an ectopic pregnancy and you treat ectopic pregnancy three ways if it's under 3 centimeters then you can use methotrexate if it's greater than 3 centimeters then you can do either a cell ping cost to me which is you cut into the fallopian tube and remove the product of conception or self injecting me which is you just completely remove the fallopian tube and this is more in cases where the patient is unstable so a lot of times ectopic pregnancy won't be diagnosed until it's symptomatic so the patient will have like right lower quadrant pain or left lower quadrant pain with an ad neck so mass possible symptoms of peritonitis due to irritation of the peritoneum and a gional bleeding so this is kind of a description of ectopic pregnancy and if they are hypotensive then this is an emergency you want to stabilize their vitals give them IV fluids and then get them to the or to do a what a cell pain yekta me all right and then molar pregnancies you can have a complete mall or an incomplete mall and they're also known as high data formals and this is basically characterized by super elevated beta HCG a really big uterus an ultrasound on snowstorm it's also associated with early preeclampsia and like hyperemesis gravidarum which means like a lot of vomiting early on the incomplete mole is one egg and two sperms which totals up to 69 chromosomes and the complete mole is empty eggshell with one sperm that splits into two so that has 46 chromosomes any type of high detta form wall you need to do a dilatation and curettage remove all the products of conception and you need to track the beta HCG to make sure that it's completely gone because why because the high data for mole has a likelihood of progressing to something called choriocarcinoma which is a cancer of since ushio trophoblast tissue and this can embolize and metastasize to the lungs so you need to track the beta HCG until that becomes zero and while you're tracking this you want to give the patient oral contraceptive pills so that they don't get pregnant because if they get pregnant their HCG will go up and that will mask that rise of the potential tumor so after DNC give the OCP tract the beta HCG sometimes in an incomplete abortion this can lead to retained products and these retained products are prone to getting infected which can lead to sepsis and this sepsis can be to septic abortion so septic abortion for example yet an incomplete abortion you did a DNC some parts are main the vaginal bacteria colonize the retained parts and then you can get contractions bleeding fever and so you want to treat this with antibiotics IV fluids to re punish their blood pressure and then do a DNC again remember that a septic portion has foul-smelling discharge you want to treat this with clean and gentamicin one of the scary complications of septic abortion is it can lead to necrotizing endometritis which has jazz pockets in the myometrium which then you treat that with the hysterectomy Listeria is one of the bacterias that can cause chorioamnionitis it's unique because it can cause corium amnion itis with an intact amniotic sac this is due to circulatory seeding into the placenta and you diagnosed it with amniocentesis doing a Gram stain and if it's Listeria then you treat with ampicillin and in chorioamnionitis which will present with you know uterine pain fever signs of infection and usually after prolonged rupture of membranes but in Listeria is far difficult to diagnose because the membrane is intact but in this case you don't deliver right away because the membranes intact so you can just treat with antibiotics but in chorioamnionitis which is caused by a rupture of the membrane then actually you want to deliver vaginally right away after giving antibiotics rest masses the two common benign ones are fibroadenoma and fibrocystic changes so fibroadenoma is a firm robbery mobile nodule that's like non-tender and it's very well circumscribed in a young female that's benign another one is called fibrocystic changes which has like a cord like mass which grows and fluctuates in size due to the menstrual cycles and it can be painful but anyways anytime you find a mass on a female patient on the breast you usually follow the same algorithm so if they're less than 30 years old you do an ultrasound on the mass and if they're older than 30 years old you do a mammography regardless of what happens on the ultrasound or mammography you also want to biopsy the mass and the most common type of breast cancer is invasive ductal carcinoma other common ones you might see are intraductal papillary lateral breast discharge which can be bloody or copper-colored that's intraductal papillary stood at the pedicle and it bleeds within the lumen of the ducts another common one is grass cyst that has fluid so if there's a stressed cyst with fluid the first thing you want to do is drain assist with that eye needle aspiration it's like straw colored or yellow colored and the cyst kind of flattens out and there's no longer a mask then you want to reassure the patient and follow-up in four weeks to make sure that it went away and come back but if it's bloody then you need to send it to cytology to analyze it and you also want to biopsy that mask then there's inflammatory breast cancer which is very like erythema to skin that can almost look like a cellulitis but the key thing here is you want to look for something called Poe Dhiraj which is where you have dimpling in the skin and this is actually caused by the cancer actually obstructs the lymph node rain edge which causes lymphedema and when the skin swells up then annex the pores more pronounced and then you have Paget's disease of the breast which is when you have kind of like a scab or rash looking type of thing over the nipple and when you see this this suggests that there's the underlying carcinoma of the breast patients with BRCA or breka you want to do testing if they have two first-degree relatives who had cancer someone in the family who had bilateral breast cancer or a male in the family with breast cancer and then um it's associated with Ashkenazi Jews and you want to do breast cancer screening if someone has BRCA it's autosomal dominant then you want to start doing breast MRI is starting at age 25 the breast cancer ambigram findings that are suspicious are described as having small clusters of calcifications or ill-defined border mass triple negative meaning no estrogen or progesterone and her2 negative have a poor prognosis because there's no drugs that can really target it like tamoxifen targets estrogen and like chest uzum heart gets her too so if you don't have any of those receptors then it's hard to treat if someone had eyelet ation and curettage and now they have amenorrhea what's the most likely diagnosis a sure man syndrome that's because with the DNC you've basically scraped out all of the endometrium and so there's no endometrial lining that can grow which makes it kind of try it you don't get endometrial flushing anymore because it's all just kind of scraped out down to the decidua basalis layer and it also can cause adhesions from the scar tissue so you want to diagnose this with the history so Pengo gram which is where you inject saline and do an ultrasound and you'll see that the uterus isn't completely filled up it's kind of patchy looking because the adhesions are getting in the way and then you can diagnose it also with the hysteroscopy where you go in with the camera and find all the adhesions and then to treat it you remove the adhesion so assessment of secondary amenorrhea the first thing you want to do is a beta HCG to rule out pregnancy then you can also rule out hypothyroidism with TSH and also prolactin levels hyperprolactinemia all three of those can cause you to not have periods if those are all negative then you wanna the next thing you want to do as a progestin challenge test so you give the patient progestin for a few days and then you cut it off and hopefully this causes something called withdrawal bleeding if there's bleeding then it's most likely PCOS or an ovulation if there's no bleeding then you gotta check the ovarian access either f it check the FSH levels the LH levels and the estrogen if all three are low and this is hypogonadism if estrogen is low like FSH and LH are high then this is most likely ovarian failure or like menopause or premature ovarian failure which is before age 40 if it's after age 40 then we just call it menopause if all three are normal then it's most likely a Sherman syndrome like I said a Sherman syndrome won't have any bleeding because you've basically destroyed the endometrium if someone has a prolactin oma what is the first-line treatment is a dopamine agonist agonist such as cabergoline or bromocriptine because dopamine prevents prolactin from being made so PCOS is something that they like to ask a lot - PCOS is usually a female who definitely has a high BMI and has been having irregular periods since she has been a teenager for a long time and she has her suit ism as well so that's kind of like the triad obesity hirsutism and an ovulation this is most likely PCOS on ultrasound you'll see multiple follicles in the ovaries the first-line treatment for PCOS is weight loss and then a second line would be to give oral contraceptive pills to regulate the menstrual cycles if they want to get pregnant and you can also give them clomiphene PCOS is associated with diabetes then there's Sheehan syndrome Sheehan syndrome is caused by during delivery if mom has a severe maternal hypotension through like hemorrhage and what will happen is it can cause ischemic necrosis of the pituitary gland and this will cause the patrick-man to no longer function so it will no longer make LH or FSH which leads to Lola or no longer make cortisol which can lead till it won't make TSH which can lead to hypothyroidism all the pituitary gland hormones and to treat it you just supplement with whatever is deficient sometimes it can be confusing knowing the difference between specie is versus a sertoli laid egg tumor which is found in the ovary because they can both cause like masculine features but the difference is that a certain laid egg tumor has a very sudden onset whereas PCOS is more gradual and sertoli laid egg will also cause something called virile ISM which should be distinguished from hirsutism virile ISM causes more like acne temporal balding deepening of the voice clitoral Magli those type of things whereas hirsutism is more just having male facial hair so piece us has more hirsutism and not virile ISM where sertoli laid egg which causes which is a tumor that produces a lot of androgens will have v realism and as well as ovarian mass that's very big also female ovarian tumors can also have granulosa thicker tumor which is the tumor that produces a lot of estrogens so this girl will have precocious puberty and that can be caused by a granulosa thicker tumor but the most common - ovarian tumor for young people is a teratoma which is a conglomeration of ectopic tissue like teeth hair and bones but the thing is to know about ovarian tumors is they're very prone to having ovarian torsion so an ovarian mass will twist around its pedicle and cut off blood supply to the ovary which is an emergency they'll usually complain of like abrupt onset of unbearable pain in the adnexal areas with possible hair tinnitus or nausea and vomiting and then the first thing you want to do is ultrasound to see if there's an ovarian mass and if there is and then you'll do a Doppler to check for blood flow to the ovary if that's decrease this is an emergency and you want to go into the or to untwist the ovary to try and keep it viable a congenital adrenal hyperplasia there's three that you need to know twenty-one hydroxylase deficiency eleven hydroxylase deficiency and seventeen hydroxylase deficiency so twenty-one hydroxylase deficiency remembering your adrenal gland will produce three hormones aldosterone cortisol and your antigens your sex hormones and so 21 we'll call it off aldosterone and cortisol but it'll allow for the formation of androgens so all of that will shunt towards the androgens so that's how you get the congenital adrenal hyperplasia if they have low aldosterone they'll be hypotensive hyponatremia hyperkalemia if they have low cortisol then they'll usually be hypoglycemic as well so that's the most common one and then the blood tests will show elevated 17 hydroxy progesterone and then there's eleven hydroxylase deficiency but this one is interesting it's kind of like the twenty one one but when you stop the eleven hydroxylase enzyme the thing that builds up before the block is called eleven deoxy corticosteroid which has aldosterone type of properties so this person will have v realism and signs of low cortisol but their blood pressure will be pretty much normal because the xi do c will make up for the deficiency that you would have normally seen in 21 hydroxylase deficiency so they'll be normal tensive hypoglycemic with sterile ism and then the last one a seventeen hydroxylase deficiency which basically cuts it off so that there's low cortisol and lo and but high aldosterone so this person will have good blood pressure but low cortisol and then no androgen features but the most important one you should remember is 21 hydroxylase deficiency and there's Turner syndrome the most common as 45 expo where they only have one X chromosome and this presents with the webbed neck the low hairline the shield chest this patient internally will have a bicuspid aortic valve coarctation of the aorta horseshoe kidney and streaked ovary but the street ovary won't be able to produce any estrogen because of this this patient will have delayed puberty and won't really reach puberty and so they'll look like a kid the whole time and then because the estrogen is low their FSH and LH are really high to help them you want to supplement them with estrogen to help them grow and once they reach new teenage age you want to get them growth hormone too so that they reach their full height remember too is there's a variant of Turner syndrome which is 46 X Y this Y chromosome actually makes the streak ovary potentially malignant so if they have the 46 X Y variant then you want to take out those streak ovaries mullerian a Genesis versus androgen insensitivity syndrome so mullerian a Genesis is a female who just doesn't have the mullerian system so they're missing the uterus the fallopian tubes and like the upper part of the vagina but everything else is okay but this causes them to have amenorrhea whereas androgen insensitivity syndrome is this person is actually 46 X Y so they're technically a male their body has defective testosterone receptors and during development testosterone helps convert the vulva the vagina labia minora and majora and the clitoris and helps transform it into a penis and scrotum and having male genitalia because they have defective testosterone receptors this person will have female external genitalia but internally it will have testicles and no uterus and because their testosterone receptors are defective testosterone helps increase sexual hair growth so this person will have no pubic hair or no axillary hair something to know is that these testicles because of the Y chromosome they can become malignant so you want to eventually remove these testicles so the key thing between mullerian a Genesis and androgen insensitivity syndrome is that their karyotypes are different mullerian a Genesis is 46 X X whereas androgen insensitivity syndrome is 46 X Y they both don't have uterus but in androgen insensitivity syndrome there's no pubic hair or armpit hair but mule Arian agenesis does androgen insensitivity syndrome will also have increased testosterone levels whereas valyrian a genesis has normal testosterone levels and then you might wonder why is it that people with androgen insensitivity syndrome also have normal-looking female breasts that's because the excess testosterone that's floating around in the system gets converted by aroma taste to estrogen and then the estrogen help stimulate breast growth and this is kind of the same mechanism white men who take anabolic steroids are prone to getting gynecomastia because that excess exogenous testosterone can convert to estrogen so people who take anabolic steroids that's why nowadays if they are on anabolic sterns like professional bodybuilders they also take a nostril as well to prevent romanization of testosterone there's also kalman syndrome which is loss of gnrh neurons this person will have the key thing as no sense of smell and they will also since they have no GM 8rh neurons they have no LH and FSH and then they can't stimulate their testicles and then so they have small testicles and delayed puberty and how do you define infertility so if in the question the patient is complaining that they've been trying with their partner to have a baby but they can and it's been eight months what should you do the answer is reassure why because infertility is defined as not being able to get pregnant after one year of trying if it's before that just reassure after one year then you start having you have to start analyzing why and what's the first thing you want to do the first thing is semen analysis check the guy first so the next thing we should talk about is endometrial cancer and endometrial cancer is caused by preceded most of the time by endometrial hyperplasia people who are postmenopausal or older than 45 years old if they have any abnormal uterine bleeding the first thing you should think about is that it's endometrial cancer I'm told proven otherwise so the next thing you want to do is a abdominal or transvaginal ultrasound to assess the endometrial stripe if it's greater than four millimeters that means there's endometrial hyperplasia and then the next step would be to do a endometrial biopsy to check for cancer if they're less than 45 years old and they have abnormal uterine bleeding and what you have to do to decide if you want to do an endometrial biopsy is if they are obese as well so if they're less than 45 they're obese they have a thickened endometrial stripe you want to also do an endometrial biopsy because they are at risk for endometrial cancer how does obesity lead to endometrial cancer well obesity causes excess estrogen which leads to endometrial hyperplasia and then the hyperplasia progresses to cancer what's the first-line treatment of endometrial cancer it's hysterectomy sometimes you can have a pap smear that shows up with atypical squamous cells or atypical glandular cells so like glandular cells remember that the uterus has glandular cells whereas the vagina and cervix are squamous cells so if on your pap smear you notice glandular cells that means that these cells have origin from the endometrium so not only do you do a colposcopy but you wanna do endometrial sampling as well on a pap smear remember if it's abnormal if it comes back as low-grade squamous cell and truth' epithelial lesion or high-grade then the next thing you want to do is a cold pasta pee if it's a schist such as atypical squamous cells of undetermined significance then you want to do HPV test if it's positive then you do colposcopy and with colposcopy that's where you do the biopsy remember that post coital bleeding is cervical cancer until proven otherwise HPV and HIV are risk factors for cervical cancer remember HPV can be strained 6 and 11 which is the genital wart variant or cervical work variant and then 16 to 18 are what's causes the cervical cancer ovarian cancer the main thing is if you have an ovarian mass with signs of cancer such as weight loss and ascites that should be ovarian cancer until proven otherwise you diagnose it by doing an ultrasound which will show thick zap tations cystic and solid components let me ask you would you do a biopsy to diagnose it no because a biopsy increases the risk of seating in the peritoneum so this is actually diagnosed through ultrasound and then do surgery to take out the mass then there's ovary cancer which is itchy and ulcer slash mass on the vulva you want to biopsy that and most likely it's squamous cell carcinoma licken sclerosis versus atrophic vaginitis so Lincoln sclerosis is actually it's like thin white cigarette paper looking skin and it's like a lot of scar tissue around the vulva and vagina and it can cause retraction of the clitoris and it's very itchy you want to do a punch biopsy because it can lead to squamous cell cancer and you treat it with topical steroids it's very itchy which is a good clue versus atrophic vaginitis is in postmenopausal women it's actually just dry vagina and it will have the characteristic itchiness and scar type of tissue and ah that one is treated by topical estrogen so if someone is pregnant and they start developing hirsutism and realization during pregnancy the most likely diagnosis is that it's a thicker ludian cyst which is something that is benign and resolves after pregnancy toxic shock syndrome is hypotension with the macular rash involving the palms and soles and look for a history of a girl who's had a tampon in for a few days or nosebleed with nasal packing this is caused by the staph aureus exotoxin which activates the t-cells which releases a lot of cytokines and you want to treat it with IV fluids and antibiotics if you don't hear fetal heart rate on Doppler sonography then you want to confirm with the trans abdominal ultrasound and look at the heart to see if it is indeed baby death or not what is the antidote for magnesium sulfate toxicity remember the first sign is decreased deep tendon reflexes the what you want to treat it with is calcium glucan remember a lego hi jameos because the baby isn't swallowing enough fluid this will lead to pulmonary hypoplasia Down syndrome screaming in the first trimester you do the beta HCG the nuchal translucency and the PAP a in the second trimester you do the quad stream which is AFP beta HCG estrogen and inhibin and it will go down up down up if these screens are positive then you have to confirm with either chorionic villus sampling or amniocentesis chorionic villus sampling happens in weeks 10 to 12 and amniocentesis happens in week 15 you'll end down syndrome which also helps us in the ultrasound you'll see the nuchal translucency or the nuchal thickening remember that child abuse is usually seen with spiral fractures or bruises of different ages or the classic burn where they have really red lower extremities which spares the creases or they do something that's ahead of their milestones like a six month year-old who was supposedly climbed on the couch and then fell down you know that they are not capable of that so you wanna look at their retinas to look for retinal hemorrhages but the first thing you want to do before contacting Child Protective Services or checking a bone scan for spiral fractures is you want to separate them from their parents so you want to admit the child to the hospital to separate them from their parents and then you contact Child Protective Services and do the full assessment and this is the same for elder abuse remember elder abuse the most likely person who's doing the abusing is the caretaker physicians are legally mandated reporters were legally required to report abuse in the elderly or children the last thing we're going to do is just review medications yeah used so pregnant endometritis you wanted to use clindamycin and gentamicin for pregnant chorioamnionitis you want to use ampicillin and gentamicin tubo-ovarian abscess you want to use clindamycin and metronidazole cover the anaerobes septic abortion you want to use clindamycin and gentamicin pulmonary edema is furiosa mind Listeria you want to treat with ampicillin PCOS OCPs licking sclerosis topical steroids vaginal atrophy use topical estrogen magnesium overdose antidote is calcium gluconate first-line for UTI and a pregnant woman is either amoxicillin cephalosporins or nitro fer an toen in a non-pregnant person you want to cover with TPMS MX nitro fer Antwon or fluoroquinolones and chlamydia is as if Tom Ison and gonorrhea as ceftriaxone with as if throw my son alright and that covers our super crown sesh I really hope that was 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