Primary Health Exam 3 Review - Men's Health PDF

### **Primary Health Exam 3 Review** ### **Men's Health** **Prostate Screening Guidelines**: USPSTF recommends against routine screening. ACS and AUA guidelines recommend individualized approach with shared decision making on whether ADRE and PSA screening together are in the patient\'s best int...

### **Primary Health Exam 3 Review** ### **Men's Health** **Prostate Screening Guidelines**: USPSTF recommends against routine screening. ACS and AUA guidelines recommend individualized approach with shared decision making on whether ADRE and PSA screening together are in the patient\'s best interest. For most men, screening with PSA and DRE starting at the age of 50. Consider screening at 45 for those at high risk (1stdegree relative with prostate cancer before the age of 65 black ethnicity). For men with more than one first- degree relative with history of prostate cancer, begin screening at the age of 40. Asymptomatic men with 10-year life expectancy should not be offer a PSA testing. Routine screening for prostate cancer involves PSA testing and digital rectal examination. PSA levels above 4 ng/mL may warrant further investigation (e.g., biopsy or imaging). Screening frequency depends on risk factors, including age, family history, and ethnicity. **Risk Factors**: Age: Risk increases after age 50. Family history of prostate cancer. African American ethnicity. Diet high in red meat and low in fruits and vegetables. **Diagnostics**: Digital Rectal Exam (DRE): Palpable abnormalities suggest malignancy. Prostate-Specific Antigen (PSA) Testing: Elevated levels require follow-up. Prostate specific antigen (PSA) usually \< 4 ng/mL. However, PSA can be normal. Evaluate velocity of change in PSA and use in conjunction with digital rectal exam (DRE). A PSA value \> 10ng/mL generally necessitates biopsy. A PSA value \> 4 -- 9.9ng/mL usually is biopsied, but only 20% of these patients have prostate cancer. Prostate cancer antigen 3, TMPRSS2 -- ERG gene fusion, and prostate health index are infrequently used by clinicians, but are adjunct tests to use with PSA. Alkaline phosphate: elevated with metastasis. Testosterone and liver function test if provided suspect androgen deprivation. Transrectal biopsy with transrectal ultrasound TRUS) guidance prostate biopsy. CT, primarily to evaluate the size of the prostate and assess for pelvic lymph node involvement in the preoperative. For staging purposes or evaluation of metastasis. MRI and bone scan if evidence of no involvement, PSA \> 20ng/mL or Gleason Score \> 8; Gleason score \> 8 indicates cancer more likely to spread rapidly. Bones can: positive if metastasis (always indicated if PSA \> 20). **Referral and Follow-Up**: Clinical examination with PSA every 6 months for 5 years, then annually; DRE annually. If patient is under active surveillance, follow up should include repeat prostate biopsies 1 year after original diagnosis coma then every 2 to 4 years to monitor progression. Men treated with antiandrogen deprivation therapy(ADT) require evaluation for CVD and prevention. Screening for urinary tract dysfunction and sexual dysfunction; treat symptomatically. Screening for depression, anxiety, suicidality, and caregiver distress. Urologist consultation for elevated PSA or abnormal DRE. Biopsy for confirmed diagnosis. **Testicular Cancer** Malignant tumor of the testicle. Two types of testicular cancer have been identified: Germ cell (90-95% of the cases: seminoma, teratoma, teratocarcinoma, and embryonal carcinoma). Nongerm cell - (5 -- 10% of cases: Leydig cell, gonadoblastoma, adenocarcinoma). **Screening**: With early detection, testicular cancer is one of the most curable solid cancers in the United States. Controversy surrounds the initiation of monthly self-testicular examinations in adolescence. Boys with cryptorchidism are encouraged to undergo orchiopexy before age 13. **Risk Factors**: history of cryptorchidism (even if repaired), family history of testicular cancer, and previous history of testicular cancer, testicular atrophy. White race; rare in Black people, gonadal dysgenesis. **Assessment Findings**: Symptoms may include painless testicular mass, swelling, or discomfort. The affected testicle may feel harder than normal. Solid, firm, non-tender, unilateral testicular mass. Sensation of fullness, heaviness, or dull ache in scrotum, lower abdomen, or perennial area. Previous mole testicle and largest to size of normal testicle. Hydrocele. Gynecomastia in 5% of patients with germ cell tumors. Mass does not transilluminate. Erectile dysfunction and or loss of libido. **Treatment**: typically involves surgical removal of the affected testicle (orchiectomy), followed by chemotherapy or radiation if the cancer has spread. Non-pharmacologic management: Active surveillance, surgical intervention: radical orchiectomy in all testicular cancers, regardless of staging. Radiation therapy. Pharmacological management: chemotherapy: cryopreservation of sperm should be discussed prior to initiation of treatment; type of chemotherapy treatment depends on type of cancer: seminoma or non-seminoma. Who is at most risk for testicular cancer: prior cryptorchidism, white race, and family history Treatment for stage 1 testicular cancer: surgery radical orchiectomy and radiation. **Referral and Follow-up**: Referral to a urologist or oncologist for evaluation and treatment. Close monitoring of hCG, LDH an alpha-fetoprotein for indication of therapy response and recurrence. Periodic chest and abdominal CT for detection of metastasis. Follow up is largely dictated by the type of cancer and treatment. Typically, initial office visits are everyone 1-2 months after orchiectomy with adjuvant therapy. For patients with orchiectomy, and adjuvant therapy initial follow up is every 3-4 months. Frequency tapered, if no evidence of relapse. Regular follow-up with a urologist is necessary for surveillance of potential recurrence. Routine self-exams can be encouraged to catch early signs of recurrence (Dunphy et Al. 2022). **Cryptorchidism --** Undescended testicle. incomplete migration of the testes to the scrotum during embryogenesis. Passage to the inguinal canal begins at 28 weeks gestation. Testicular descent typically occur during the seventh or eighth month in utero. **Risk Factors**: Idiopathic , May involve hormonal, environmental, prenatal health, genetic, mechanical, and or neural factors. Premature birth (30% in preterm infants, 5% full term). Genetic disorders or hormonal imbalances. **Assessment**: Absence of one testis or both testes palpation of scrotum. One or both testicles in location other than the scrotum. This exam is best performed by an examiner who has warm hands. Infant examination: supine, frog leg position or seating on parents\' lap. Older child examination: supine, or sitting a right cross legged position. GU examination to locate testes; attempt to \"milk\" testes into scrotum. Ultrasound if testes are non-palpable. **Referral**: Urology/surgery referral if undescended by 4--6 months. Refer for urology for evaluation if testicle(s) not descended by age 6 months or for boys, \>6 months (corrected for gestational age) with possible newly diagnose (acquire) cryptorchidism. Multiple specialist consultation for evaluation of possible disorders of sex development for all phenotypic newborn boys with bilateral nonpalpable testes. Orchiopexy surgery recommended by 12 months. **Inguinal Hernia** The protrusion of viscera or adipose tissue through the inguinal or femoral canal. Three types have been identified.: Indirect: abdominal tissue passes through an abdominal wall defect into the internal inguinal ring and inguinal canal. Direct: abdominal tissue through the posterior wall of the inguinal canal. Femoral: hernia located inferior to the inguinal ligament and protruding through the femoral ring. 40% are incarcerated or strangulated. Incarcerated: content cannot be replaced into the abdomen. Strangulated: blood supply to the entire bowel is diminished; a surgical emergency. Pain it\'s out of proportion to exam. Erythema, hyper T-shirt, or wound drainage might be present. Reducible: hernia easily replaced into the abdomen, using gentle pressure or may occur spontaneously. **Risk Factors**: Premature birth. 8 -- 10 times more common in men. Age \> 60 years Cigarette smoking: can damage connective tissue. Inheritance: first-degree relative, especially in woman. Family history of hernia. Connective tissue disorder history previous contralateral hernia low body mass index. **Assessment**: A heavy or dragging sensation in the groin or hernia. Painful or painless, swelling, or lump in the groin or into scrotum; may increase with standing or sitting. Bulge might be intermittent and palpable during episodes of increased abdominal pressure (coughing, defecation, micturition, exercise, sexual intercourse). Symptoms worse at the end of the day and relief by laying down or manually reducing the hernia. In woman, bulge might be seeing in the labia majora. Strangulated hernia: colicky abdominal pain, nausea and vomiting, and abdominal distention. Bulge in groin or scrotum, more noticeable during crying or straining. Reducible or irreducible on physical examination. **Treatment:** Surgical repair is typically indicated, particularly if the hernia is painful, enlarging, or causing complications (Dunphy et al., 2022). Educate about signs and symptoms of strangulation and advised to seek immediate medical help if these occur. Do not attempt to reduce a strangulated hernia. Surgical correction (herniorrhaphy) is required if hernia does not resolve spontaneously. **Referral:** Watchful waiting is an acceptable treatment in patients with minimal to no symptoms and with low risk of strangulation. Follow these patients every six months. Refer to surgeon for evaluation. Refer immediately if strangulated. **Follow-up:** Resume preoperative diet. Ambulation as tolerated with no restriction; do not lift more than 5 pounds until clear by surgeon. Avoid straining and other Valsalva maneuvers. Postoperative follow-up is crucial to monitor for complications such as recurrence or infection (Dunphy et al., 2022). **Testicular Torsion** **Findings**: Sudden, severe, unilateral scrotal pain. Scrotal edema, and erythema Firm tender mass that might appear retracted upward No relief of pain with testicular, scrotal elevation Lower abdominal pain Reactive hydrocele High-riding testicle with \"bell-clapper\" deformity. Horizontal lie within the scrotum Nausea and vomiting Testes tenderness is significant Absent cremasteric reflex. Negative Prehn's sign. In children may present a sudden awakening, which scrotal pain Twist score (ranges 0 to 7 points) Testicular swelling -2 points Hard testicle - 2 points Absent cremasteric reflex - 1 point Nausea and vomiting - 1 point High riding testicle - 1 point Testicular pain associated with testicular torsion is usually abrupt on onset. A twist score of \> 4 is a medical emergency. **Treatment**: Non-pharmacological management: Immediate surgical intervention (orchiopexy) within 6 hours. Manual detortion if surgery is not performed within six hours. Bilateral orchiopexy. Surgical exploration and detorsion with orchiopexy or orchiectomy for non-viable testis. Pharmacological management: pain medication antiemetic. **Erectile Dysfunction -** inability to achieve or maintain an erection of sufficient rigidity for sexual performance and or ejaculation. **Screening**: Always consider concurrent medical disorders when a man reports erectile dysfunction. Aging is not a cause. Detailed sexual and medical history, including psychogenic and organic causes. Physical examination (DRE, vascular testing, nocturnal penile tumescence). **Risk Factors**: Vascular - Cardiovascular disease, hypertension, diabetes, smoking, hyperlipidemia, radiation of the pelvis, or retroperitoneum. Respiratory- COPD sleep apnea Neurologic - injuries to spinal cord/brain, Parkinson\'s disease, Alzheimer\'s disease, multiple sclerosis, and stroke. Penile conditions- Peyrone's disease, cavernous fibrosis, penile fracture, epispadias and priapism. Hormonal- hypogonadism hyper or hypothyroidism, hyper or hypercortisolism, hyperprolactinemia. Drug induce: antihypertensive, antidepressant, antipsychotic, antiandrogens, recreational drugs, pain medication, (specially opioids and anticholinergics) 5- alpha reductase inhibitors, antiulcer drugs and alcohol use. Psychogenic- performance related anxiety, PTSD relationship problems, lack of arousal -- attraction in a specific relationship, anxiety, depression, stress. Surgical procedure- radical prostatectomy, retroperitoneal or pelvic lymph node dissection, transurethral resection of the prostate, postoperative disruption in neurologic function. Atherosclerosis, smoking, hypertension, diabetes. Psychological factors (stress, depression). Hormonal imbalances (low testosterone). Age, obesity, diabetes, cardiovascular disease and depression (Dunphy et al., 2022). **Treatment**: Address underlying causes (e.g., lifestyle modification). Phosphodiesterase inhibitors (e.g., sildenafil, tadalafil). Psychotherapy for psychogenic causes. Non-for psychological management - treatment of the underlined condition, psychological support/psychosexual therapy, education about cause, medication dosage adjustment or medication change, penile prosthesis for patient with refractory erectile dysfunction. Vacuum constriction device (27-74% success) vascular surgery when vascular insufficiency is present. Pharmacology management : Sildenafil/Viagra (25mg, 50mg, and 100 mg) Initial dose 50 mg PO 30 minutes to 4 hours before sexual activity. Maximum dose 100 mg PO per dose one time a day. Advise patients to take on an empty stomach if possible. 4 to 8 hours duration. Side effects: avoid concomitant use of nitrates or alpha-blockers. Use with caution impatient with recent MI, CVA. Contraindicated impatience with heart failure. May use a lower starting dose in older adults or patients with diminished renal, or hepatic function. Tadalafil/Cialis (2.5 mg, 5 mg, 10 mg, and 20 mg) Initial dose PRN use: 10 mg PO before sexual activity. Max dose 20 mg PO daily one dose per day; one dose per 72 hours if strong CYP384 use. Daily use initial 2.5 mg PO daily, max 5 mg PO daily; 2.5 mg daily if strong, CYP384 use. Maybe taken without regard of meals. Up to 36 hours duration. Side effects monitoring avoid concomitant use of nitrates. Use caution with alpha-blocker. Use with caution in patients with recent MI or CVA. May use lower starting dose in older adults or patients with diminished renal or hepatic function. Intracavernous injection therapy is a second line treatment. Intracavernosal injection of vasodilators: alprostadil (31-72% success rate). Alprostadil intraurethral suppository (66% success). Hormone replacement, my benefit men with severe hypogonadism or type two diabetes. ### **Sexually Transmitted and Genital Infections** **Gonorrhea --** *Neisseria Gonorrhoeae.* Sexually transmitted disease that produces purulent inflammation of mucous membranes. Can be asymptomatic in early infection, especially among women. Untreated gonorrhea infection can cause significant complications. **Testing**: nucleic acid amplification test (NAT) is most sensitive and specific. Appropriate and sensitive for screening Urogenital, rectal or pharyngeal infection. Samples can be self-collected by the patient with similar sensitivity and accuracy. Should not be used to diagnose infections in sexual assault, neonatal infection, other body fluids (CSF, blood, joint aspirate), or anti-microbial acceptability testing AST. Diagnosis of infection at specific site must occur by testing secretions from specific sites ( rectum, pharynx, cervix, or urethra, eye, scalp wound). Testing must be done with separate sampling and is indicated based on sexual practices and clinical symptoms. Due to similarities in etiology and presentation testing for C. Trachomatis at the same time, from all relevant sites, is recommended. Gonococcal culture and NAAT test. First urine of the day. Female: endocervical swab Male: urethral swab All sex partners in the past 60 days should be tested for infection. If no sex partners in the last 60 days, most recent partner should be tested for infection. NAAT and AST exam should be done concurrently. Test of cure is not necessary except: with potential treatment failure, in pregnancy, after treatment of antibiotic resistant organism, always retest with NAAT culture and AST 7-14 days after treatment. **Treatment**: antibiotics Ceftriaxone 250mg IM for one dose PLUS Azithromycin 1g PO x 1 dose. Alternative therapy (less effective): Cefixime 400 mg orally for one dose PLUS Azithromycin 1g PO x 1 dose. If cephalosporin allergy: gemifloxacin 320 mg orally in a single dose PLUS Azithromycin 2 g PO x 1 dose. Follow CDC guidelines for complicated or refractory gonorrhea. Consider EPT (Expedited Partner Treatment). **Retesting:** Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated; scheduling the follow-up visit at the time of treatment is encouraged. If retesting at 3 months is not possible, clinicians should retest whenever persons next seek medical care \ 20 WBC per high powered field. Culture: not typically use secondary to cost; technical expertise required. **Treatment**: Non-pharmacological management: Education about serious sequelae of C. trachomatis. Abstinence for seven days after partner completion of treatment. Evaluate and treat sexual partners. All sexual contact within the past 60 days should undergo testing. Expedite partner treatment. Sexual abuse should be considered in any child with confirmed chlamydia after the neonatal period. Report to local health department. In woman at risk, screening during third trimester (\< 25 years old, recent new sexual partner, more than one sexual partner). **Pharmacologic management:** Treatment is started after results are known, but if clinical suspicion is high, treatment can commence before test results are known. For adult: first line is a Azythromycin 1 g PO single dose. OR Doxycycline 100 mg orally 2 times/day for 7 days OR doxycycline for 10 to 14 days if epididymis involve or for pelvic inflammatory disease. Second line Levofloxacin 500 mg PO daily for seven days OR ofloxacin 300 mg PO BID for seven days. Erythromycin base 500 mg PO QID for seven days or erythromycin ethylsuccinate 800 mg QID for seven days if patient unable to take doxycycline. Pregnancy: amoxicillin 500 mg PO TID for seven days. Treat with Azythromycin , erythromycin base or amoxicillin. Tetracycline and quinolones are contraindicated during pregnancy. **Signs and Symptoms**: Chlamydia is the most common STI, highest rates under age 25, often asymptomatic, screen under age 25 annually, new sex partner, more than 1 partner, recent partner with STI. If symptomatic: Burning upon urination, pain during sex, lower belly pain, abnormal, smelly discharge, bleeding between periods. **Woman:** often asymptomatic 85%, mucopurulent cervicitis, edema, congested, friable cervix, vaginal discharge and or vaginal bleeding, breakthrough bleeding or spotting, discharged from Barltholin glands when milked, cervical motion tenderness. Dysuria/pyuria, urethritis, pelvic pain/ salpengitis. Higher risk of premature rupture of membranes and preterm delivery during pregnancy, proctitis. **Male:** Dysuria, proctitis, epididymitis, prostatitis, penile discharge. **Herpes -** common sexually transmitted viral infection, characterized by incurable cutaneous, or mucous membrane alterations that are often recurring. Even when no signs of infection are present and genital herpes is easily spread to sexual partners. **Testing**: PCR assays for HSV DNA or IGG testing which is often included in an STI panel. Many point of care test available. Viral culture by on roofing vesicle for fluid culture (ask lab about specific testing tube -- swap); lower sensitivity and specificity HSV PCR higher sensitivity than viral culture. Type-specific cytologic essays (usually +4 to 6 weeks after onset of symptoms.) seroconversion can take up to six months; my repeat testing in six months if initially IgG negative. False positive may occur; repeat testing in three months if low positive. Tzanck smear. ELISA, Syphilis Serology. **Treatment**: Non-pharmacological management: counseling, natural course of disease, asymptomatic viral, shedding, potential for recurring episodes, sexual transmission, implications for pregnancy, counseling for discordant couple, cool conferences with Burow's solution. sitz bath, ice packs to lesion area, NSAIDs or acetaminophen for pain, good hygiene, a boy sexual contact during symptomatic periods, for 48 hours after symptom resolve, and during prodromal symptoms. Use condoms during all sexual exposure to decrease risk of transmission when asymptomatic. Avoidance of triggers for recurrence infections when possible. Pharmacological management: treatment regimen, determined by infection type or purpose: primary infection, recurrent episode or deceased suppression. Per CDC guidelines, treatment is with nucleotide analogs that selectively inhibit replication of HSV one, HSV2 and Varicella Zoster virus. PRIMARY treatment: Acyclovir 400mg TID 7-10 days OR Acyclovir 200mg po x 5 days for 7/10 days OR Famciclovir 250 mg TID for 7- 10 days OR Recurrence: acyclovir 800 mg PO BID for five days OR acyclovir 400 mg PO TID for 5 to 10 days OR acyclovir 800 mg PO TID for two days or famciclovir 125 mg POBID for five days SUPPRESSIVE -- azyclovir 400 mg PO BID or famciclovir 250 mg PO BID up to one year. **Signs and Symptoms**: Many people have no symptoms while shedding the virus. Primary infection might be proceeded by non-primary first episode infection (few lesions and less systemic symptoms and primary infection.) initial infection may be asymptomatic, painful ulceration, hyperesthesia, headache, malaise, myalgia, dysuria, lymphadenopathy, localized pruritus. Recurrent infections: prodrome of pain, burning, and or paresthesia over area of eruption. Burning genital, pain, lesion (vesicular or ulcerative) that resolved within 7 to 10 days. **Bacterial Vaginosis -** Gardnerella Vaginalis **Testing**: To be diagnosed, need at least three clinical criteria: Thin white discharge, Clue cells (seen on Wet Mount Test when Potassium hydroxide (KOH) is added), Ph\>4.5, Fishy odor with the "whiff test" **Treatment**: Metronidazole 500mg orally BID for 7 days, OR metronidazole gel 0.75% one full applicator (5g) intravaginally QD 5 days OR Clindamycin cream 2% one fill applicator (5g) intravaginally at bedtime for 5 days **Signs and Symptoms** Thin, grayish-white discharge with a fishy odor, especially after intercourse. **Trichomonas** **Testing**: **Gold standard -- Affirm (checks for BV, yeast, trich), w**et mount -\> low sensitivity, **Gold standard -- Affirm (checks for BV, yeast, trich)** **Treatment**: Metronidazole 2g single dose OR tinidazole 2g single dose OR Metronidazole 500mg BID x 7 days **Signs and Symptoms**: Vaginal discharge that is thin, frothy, and has a foul or fishy smell , itching or burning of the genitals or inner thighs, pain or discomfort when urinating or during sex , redness or swelling of the vulva or labia , symptoms can appear within 5 to 28 days of exposure, but some people don\'t develop symptoms until much later. Most people with trich don\'t have any symptoms. **HIV** **Testing** HIV antibodies and/or RNA test (ELISA and confirmatory Western blot, or rapid tests). Antiretroviral therapy (ART), consisting of a combination of at least three antiretroviral drugs, typically from different classes (e.g., NRTIs, NNRTIs, protease inhibitors). **Signs and Symptoms** Acute retroviral syndrome (ARS) includes fever, sore throat, rash, swollen lymph nodes, and myalgia 2-4 weeks after exposure. Asymptomatic in the early stages but can progress to AIDS without treatment. **PID** **Testing** Clinical diagnosis based on pelvic tenderness, cervical motion tenderness, and/or positive tests for gonorrhea or chlamydia. **Treatment** Empiric, antibiotic therapy for broad coverage, including ceftriaxone (for gonorrhea) and doxycycline (for chlamydia). Hospitalization may be required for severe cases. **Signs and symptoms** lower abdominal/pelvic pain, fever, abnormal vaginal discharge and dyspareunia. Severe cases may result in turbo-ovarian abscesses or infertility. **PCOS:** a complex endocrine condition characterized by hyperandrogenism, adulatory dysfunction, and or polycystic ovaries. **Testing**: Hyperandrogenism: Exclusion of other causes: TSH: normal prolactin: normal 7 hydroxy progesterone FSH or LH age to evaluate for premature ovarian failure Evaluate for catching syndrome 24hour urine for cortisol excretion test Ultrasound Quantify hirsutism using the Ferriman -- Gallwey score Labs to monitor for cardiometabolic risk Glucose tolerance test Lipid profile **Treatment**: Nonpharmacological treatment Lifestyle modification Weight loss is first line intervention, if overweight Education Screening for management of behavioral health conditions Acupuncture Hair removal therapy Bariatric surgery Monitor for cardio metabolic risk at least annually Blood pressure, consider ambulatory BP monitoring Waist circumference BMI Lab monitoring at diagnosis and every two years in patients who are overweight, patient at high risk for insulin resistance Lipid Glucose tolerance test Pharmacological management: Pharmacological treatment is generally aimed at the management of menstrual disorder and hyperandrogenism associated with PCOS. Combined oral contraceptive for management of oligomenorrhea. First line treatment for PCOS. Mechanism of action: Inhibit ovulation through negative feedback on pituitary tropic release. FDA indication: contraception, select formulations also indicated for acne bulgaris, premenstrual dysphoric disorder. Progesterone with higher antiadrenergic properties might be more beneficial to woman with PCOS (desogestrel, norgestimate, and progestin). Estrogen (ethinyl estradiol) and progesterone: Norethindrone, drospirenone, levonorgestrel, desogestrel, norgestrel, ethynediol diacetate (pills, patch, ring). Progesterone-only method for management of oligomenorrhea. Mechanism of action: transform a proliferative endometrium into a secretory endometrium, inhibit secretion of pituitary gonadotropins. Medroxyprogesterone (Depo-Provera) Estonogestrel (Nexplanon), Levonogestrel (Kyleena, Liletta, Mirena, Skyla). Biguanide for management of insulin sensitivity. Mechanism of action decreases hepatic glucose production, intestinal absorption of glucose; improves insulin sensitivity; in PCOS, reduces hyperinsulinemia, reduces serum testosterone, increases pregnancy rates, improve metabolic syndrome symptoms. Metformin or Glucophage 500 mg twice a day may increase weekly. Monitor hemoglobin A1c at least every six months, CBC, renal function, at least annually, B12 every three years. **Signs and Symptoms:** Common feature is hypersecretion of androgens. In adult women 2 of 3 must be present for diagnosis: Hyperandrogenism Acne Hair statism (male pattern terminal hair growth) Thinning, scalp hair, alopecia Clitoral hypertrophy Deeping off voice Ovulatory dysfunction Oligoovulation or anovulation Amenorrhea or oligomenorrhea Ovarian cyst Weight gain Acanthosis nigricans Polycystic ovaries on ultrasound **Infertility** ### **Women's Health** **Menstrual Health** **Amenorrhea and Irregular Vaginal Bleeding**: Primary or secondary amenorrhea; bleeding irregularities often point to underlying hormonal imbalances or structural issues. **Primary Amenorrhea:** Complete absence of a menstrual period by the age of 16 in a person with normal sexual development.  **Secondary Amenorrhea:** The sudden cessation of menstrual periods for several months in a person who previously had regular cycles PCOS is most common cause of Secondary Amenorrhea **Menstrual Cycle**: Phases of the cycle---menstrual, follicular, ovulatory, and luteal phases---each with its hormonal shifts. The rise and fall of your hormones trigger the steps in your menstrual cycle. Your hormones cause the organs of your reproductive tract to respond in certain ways. The specific events that occur during your menstrual cycle are: **The menses phase: **This phase begins on the first day of your period. It\'s when the lining of your uterus sheds through your vagina if pregnancy hasn't occurred. Most people bleed for three to five days, but a period lasting only three days to as many as seven days is usually not a cause for worry. **[The follicular phase](https://my.clevelandclinic.org/health/body/23953-follicular-phase):** Less consistent phase of the cycle. This phase begins on the day you get your period and ends at ovulation (it overlaps with the menses phase and ends when you ovulate). During this time, the level of the hormone estrogen rises, which causes the lining of your uterus (the endometrium) to grow and thicken. In addition, another hormone --- [follicle-stimulating hormone (FSH)](https://my.clevelandclinic.org/health/articles/24638-follicle-stimulating-hormone-fsh) --- causes follicles in your ovaries to grow. During days 10 to 14, one of the developing follicles will form a fully mature egg (ovum). The follicular phase of the menstrual cycle is considered less consistent compared to the luteal phase, which tends to be relatively stable in length for most women; meaning the length of the follicular phase can vary more from cycle to cycle while the luteal phase usually stays around 14 days. **[Ovulation](https://my.clevelandclinic.org/health/articles/23439-ovulation):** This phase occurs roughly at about day 14 in a 28-day menstrual cycle. A sudden increase in another hormone --- [luteinizing hormone (LH)](https://my.clevelandclinic.org/health/body/22255-luteinizing-hormone) --- causes your ovary to release its egg. This event is ovulation. **The luteal (secretory) phase:** This phase lasts from about day 15 to day 28. Your egg leaves your ovary and begins to travel through your fallopian tubes to your uterus. The level of the hormone progesterone rises to help prepare your uterine lining for pregnancy. If the egg becomes fertilized by sperm and attaches itself to your uterine wall (implantation), you become pregnant. If pregnancy doesn't occur, estrogen and progesterone levels drop and the thick lining of your uterus sheds during your period. **PCOS** **Diagnosis**: Based on symptoms like irregular periods, hyperandrogenism, and polycystic ovaries on ultrasound. Common feature is hypersecretion of androgens. In adult women 2 of 3 must be present for diagnosis: Hyperandrogenism, Oligoovulation or anovulation, Polycystic ovaries on ultrasound **Management**: Lifestyle adjustments, hormonal contraceptives, and insulin-sensitizing medications. **Contraception**: Discussion of options from hormonal (pills, IUDs) to barrier methods, benefits, and risks. **Breast Cancer Screening**: Mammograms and breast self-exams; follow current guidelines for age and risk factors. Manual exam in every visit. 40 and over every two years for mammograms, but also encourage self exam and perform manual exam at every wellness visit **Lactation and Postpartum Care** **Mastitis**: Recognize symptoms like breast pain, redness, and fever; treat with antibiotics. **Breastfeeding Support**: Guidelines on feeding frequency, latch techniques, and troubleshooting. **Preeclampsia: Early sign of preeclampsia what gestational week you see preeclamsia** Management of blood pressure, regular monitoring for proteinuria, and signs of worsening condition. **Labor**: Stages and physiological changes; recognizing signs of labor onset. **RhoGAM**: Administration to Rh-negative mothers to prevent alloimmunization. **UTI**: Prevention, common symptoms like dysuria, frequency, and urgency, and appropriate antibiotic treatment. **Care of the Pregnant Patient** **Gestational Diabetes**: Screening at 24-28 weeks, management with diet, exercise, and insulin if needed. **Pregnancy Complications**: 10 - 20% of pregnant patients. **Early Pregnancy loss:** Within the first 13 weeks of pregnancy, miscarriage spontaneous abortion (SAB). If suspected loss referral to OBGYN or midwife. After 13 weeks GYN surgeon for possible intervention. Beta HCG after SAB follow levels until 0. Advice patient not to try to conceive until results are 0. 80% loss happens in first semester 1/5 women will miscarriage at some point. Complete AB - at some point that may actually be much higher as many women may have a late period and even a positive home pregnancy test, but we\'ll go onto abortion shortly after and assume they were just having a late period and a false positive pregnancy test completed. Gestational trophoblastic disease (GTD). Molar pregnancy, intermitting spotting, grossly enlarged uterus, extreme N/V, requires D&C referred to GYN, pt not to become pregnant withing 6 months, suspect of reoccurrence with next pregnancy. Placenta previa. provided consult is recommended. 1 in 4 women may experience bleeding during pregnancy. Common during intercourse in the first half of pregnancy. Light bleeding with no pain least risk of SAB. R/O any immediate or life-threatening concerns more than 2 pads per hour for more than 2 hours evaluate if pt is hemodynamically stable and referred as needed. Beta HCG -- a test that uses a number to associate gestational age. May repeat every 2-3 days, an increase in HCG levels indicates a viable pregnancy. Helpful tool in evaluating early bleeding specially before 6 weeks. Ultrasound Gestational sac can be seen as early as 4-5 weeks, yolk sac been seen at 5 weeks. Fetal heartbeat and cardiac activity after 6-7 weeks. **Second & Third Trimester Bleeding**: Emphasizes no vaginal exams and includes necessary lab tests like CBC and Type and Screen for Rh-negative cases. **Preterm Labor and Birth** : Identified as a leading cause of neonatal mortality with social and racial disparities impacting risk. Prevention includes nutrition, substance cessation, and adequate spacing between pregnancies. **Hypertensive Disorders** : Covers chronic hypertension, gestational hypertension, preeclampsia, and eclampsia, stressing accurate blood pressure measurement and early screening. Key symptoms include visual disturbances, RUQ pain, and edema. **Hyperemesis Gravidarum**: Defined by symptoms like excessive nausea, likely due to high hCG, estrogen, and thyroid levels. Management strategies are outlined, including IV fluids as needed. **Hematologic & Thromboembolic Disorders**: Focuses on anemia, blood type issues, and specific conditions like Sickle Cell Disease and Thalassemia. Thrombocytopenia and folate deficiency are also noted. **Dermatologic Disorders**: Common conditions include PUPP, PG, and ICP, with reference to pre-existing conditions that may flare during pregnancy. **Group B Strep (GBS)**: Screening recommendations and treatment during labor to prevent neonatal mortality are discussed. **STIs in Pregnancy**: Regular screening and management, emphasizing treatment protocols and prevention strategies. **Medications During Pregnancy** **Depression:** Selective serotonin reuptake inhibitors (SSRIs). These are often the first-line treatment for depression during pregnancy because they have minimal side effects and have been studied extensively. Some examples include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). However, SSRIs can cause adaptation syndrome in newborns, which is similar to withdrawal symptoms **Diabetes: From the ADA:** Insulin is the traditional first-choice drug for blood glucose control during pregnancy because it is the most effective for fine-tuning blood glucose and it doesn't cross the placenta. Therefore, it is safe for the baby. Insulin can be injected with a syringe, an insulin pen, or through an insulin pump. All three methods are safe for pregnant women. **High blood pressure: Studies show that three blood pressure medications are generally safe for treating high blood pressure in most pregnancies:** [Methyldopa](https://www.goodrx.com/methyldopa/what-is) has the longest and most reassuring track record of safety in pregnancy. This medication relaxes the blood vessels, which lowers blood pressure. [Labetalol](https://www.goodrx.com/labetalol/what-is) slows your heart rate, which lets your heart relax. [Nifedipine](https://www.goodrx.com/nifedipine-er-procardia-xl/what-is) only needs to be taken once a day in the extended-release form. **Pre- and Post-Pregnancy Follow-up**: Importance of regular check-ups to monitor both maternal and fetal health. **Ectopic Pregnancy**: **Symptoms:** Abdominal pain, vaginal bleeding, amenorrhea; may also include dizziness, fever, and syncope. Sever abdominal pain and bleeding between week 5- 8. Emergency referral. 50% of patients that have an ectopic pregnancy will have: Abdominal pain, vaginal bleeding, amenorrhea. May also present with symptoms common to early pregnancy (nausea, breast fullness) Dizziness, fever, weakness, flu like symptoms, vomiting, syncope, cardiac arrest. Any of the following signs and symptoms are an EMERGENCY Abdominal rigidity, involuntary guarding, severe tenderness, evidence of hypovolemic shock (examples -- orthostatic blood pressure changes, tachycardia) **Diagnostics:** Ultrasound imaging to visually determine location and serial quantitative beta-hCG. **Treatment:** Methotrexate intramuscular for non-ruptured hemodynamically stable cases. THIS IS NOT FDA APPROVED but has been endorsed by the ACOG, it avoids surgery, hcg values must be less than 1500. Surgical intervention if unstable. **Group B Strep Screening and Treatment**: Screening at 35-37 weeks gestation; antibiotics during labor for positive cases. **Naegele's Rule**: Method to estimate the due date---add one year, subtract three months to the LMP and add seven days and a year. **Genetic Screening**: Understanding indications and types, such as noninvasive prenatal testing (NIPT). **Family Planning**: Counseling on options for future pregnancies and spacing. **Management of Pregnant Patients in Primary Care**: Addressing primary care concerns while balancing pregnancy-related health needs. No live vaccines MMR, Varicella, Shingles, live flu. **Screening Tests:** Various tests are conducted based on gestational age, including first-trimester screening, cell-free DNA testing, and Group B strep testing. **Gestational Diabetes:** a complex metabolic disorder in which pregnancy related insulin resistance results in a higher blood glucose levels. Current screening guidelines typically lead to diagnosis between 24- and 28-weeks\' gestation. Woman whose diabetes is identified in the first trimester should be diagnosed with overt or T2DM not his stational diabetes. Nonpharmacological management: major component of managing his stational diabetes is patient education about diet, exercise and blood glucose self-monitoring. Caloric requirements: normal BMI 30 to 35 kcal per kilogram per day. Greater than 90% of normal BMI 30 to 40 kcal per kilo kilogram per day. Greater than 120% of normal BMI 24 kcal per kilogram per day. Low carbohydrate, diet, complex, high fiber, carbohydrate, decrease refined carbohydrate. Exercise 30 to 60 minutes of moderate intensity exercise at least three times per week or 30 minutes of moderate intensity, exercise daily. Glucose monitoring after beginning dietary recommendations to confirm glycemic control and determine medication choice. Insulin therapy is standard for pharmacological therapy for gestational diabetes. Screening protocols at 24-28 weeks and includes a glucose tolerance test. Management in primary care highlights the adverse outcomes and weight gain recommendations for obese patients. **Puerperium:** Postpartum period where the body adjusts and returns to its non-pregnant state, which includes uterine involution and gradual muscle tone recovery. Exam review from Dr. Hammond **Must review!** **Herina inguinal, ventral, umbilical: indirect hernia How they precent** **Phrengs lifting testicules if pain goes awai is epididymitis if pain exacerbates is testicular torion** **Cremasteric reflex** a superficial reflex when the inner thigh is stroked, causing the cremaster muscle to contract and pull the testicle up. Absent in testicular torsion. **STDs focus in male Tx is the same make Chlamydia, gonorrhea, trich herpes, syphilis.** **Scrotal mass and hydrocele when will you have the patient re assess if a baby we watch but how long will you re assess.** **Cryptorchidism and when to do an orchiopexy when is SX recommended** **Tx for ED and when is med contraindicated, possible side effect to watch , common cause.** **BPH s/s how it present and what is the tx plan** **Scrotal pain and swelling Dx test** **Squamous cell ca of the penis which patient is at risk** **Testicular torsion DX test and how to treat** **Pyrones disease presentation and pathological content how it will present** **Symptoms of bladder ca** **Tx of chronic bacterial prostatitis** **Symptoms of bladder ca** **Placenta abruptae presentation** **Placenta previa previa presentation** **Symptoms of pre-eclamcia** **Stage for amniocentesis -- Between 15 and 20 weeks gestation** **Weight gain in pregnancy how much underweight normal overweight:** Underweight: BMI \< 18.5 28-40 lb Normal BMI: 18.5 - 24.9 25-35 lb Overweight: BMI 25- 29.9 15- 25 lb Obese: BMI ≥30 11- lb **Naegels rule:** -3 months + 7 days + 1 year **When to give Rhogam** -- is given to pregnant people with Rh D- blood at 28 weeks of gestation and protect for 12 weeks. Repeat dose at 72 hours post-partum. If a dose is needed before 28 weeks give a second dose within 12 weeks of the first dose. Early sign of preeclampsia what gestational week you see preeclampsia Hegar signs - the isthmus of the uterus softens and becomes compressible Chadwick's sign -- increase vascularity and swelling of the cervix during early pregnancy cause blush coloring. Goodell's sign - a probable sign of pregnancy that occurs when the cervix softens during the first 4 to 8 weeks of pregnancy **Important gestational developmental stages feel fundal at the umbilicus** **Prenatal vitamins to prevent neural tube defect: 400 mcg** Folic Acid **Dx test to perform for pt who are infertile w/ varicocele, what Dx text you do** **Varicocele:** Normal degree of venous dilation of the pampiniform plexus in the spermatic cord above the testes, which usually results in pain and endorsement of the testes. Diagnostics: A system of grading has been established to better define varicocele. Grade 1: varicocele is palpable only when the patient performs the Valsalva maneuver. Grade 2: Palpable when the patient is standing. Grade 3 varicocele may be assessed with the light palpation and visual inspection. Sperm count, and motility are significant decrease in patients with a varicocele approximately 65 to 75% of the time there is evidence of a progressive decline in fertility. Scrotal ultrasound venography (showing testicular Venus reflux from a varicocele) and thermographic (showing an increase in temperature at the varicocele) help to confirm the diagnosis. For a patient with a varicocele and suspected infertility, the primary diagnostic test is a semen analysis to assess sperm quality, including count, motility, and morphology, as this is the most direct way to evaluate if the varicocele is impacting fertility