09/06/2015

increased risk of breast cancer if a first-degree relative has had

breast cancer. (A first-degree relative is a parent or a sibling.)
Waist circumference is also important to consider. In adults with a BMI
of 25 to 34.9 kg/m2, a waist circumference greater than 102 cm (40 in) for
men and 88cm (35 in) for women, is associated with a greater risk of
hypertension, type 2 diabetes, and dyslipidemia and CHD.
At 21 years of age -- cervical cancer screening should begin.
Between the ages of 21-29 years -- screening should be performed
every three years.
Between the ages of 30-65 years -- screening can be done every
three years with cytology alone, or every five years if co-tested for HPV.
Women older than 65 years who have had adequate screening
within the last ten years may choose to stop cervical cancer screening.
Adequate screening is three consecutive normal pap tests with cytology
alone or two normal pap tests if combined with HPV testing.
Women who have undergone a total hysterectomy for benign reasons
do not require cervical cancer screening.
Virtually all cervical cancers are caused by infection with certain highrisk types of human papilloma virus (HPV).
HPV is transmitted via vaginal (or oral) intercourse. Transmission by
nonpenetrative genital contact is rare. Therefore, squamous cell carcinoma
of the cervix is a disease of sexually active women. Factors such as age,
nutritional status, immune function, and possibly silent genetic
polymorphisms modulate the incorporation of viral DNA into host cells.
Sexual behaviors associated with an increased cervical cancer
risk include:
Early onset of intercourse
A greater number of lifetime sexual partners
Other risk factors include:
Diethylstilbestrol (DES) exposure in utero.
Cigarette smoking, which is strongly correlated with cervical dysplasia
and cancer, independently increasing the risk by up to fourfold.

Immunosuppression also significantly increases the risk of developing

cervical cancer
The USPSTF, the American College of Obstetricians and Gynecologists,
the American College of Physicians, and the Canadian Task Force on the
Periodic Health Examination all recommend against routine screening
for ovarian cancer in asymptomatic women.
insufficient evidence to recommend screening for endometrial cancer
in women with no identified risk factors.
For women with, or at high risk for, hereditary non-polyposis colon
cancer (HNPCC), annual screening should be offered for endometrial cancer,
with endometrial biopsy beginning at age 35.
USPSTF does recommend screening for lung cancer in patients 55-65
years old with 30-pack-history of smoking by low-dose CT scan.
American Cancer Society recommends the cancer related checkup
should include examination of the skin. USPSTF, however, concludes that the
current evidence is insufficient to assess the balance of benefits and harms
of using a whole-body skin examination by a primary care clinician
Mammography: Biennial screening mammography for women aged 5074 years
Breast exam: presence of a single, hard, immobile lesion of
approximately 2 cm or larger with irregular borders increases the likelihood
of malignancy.
Diagnostic tests:
If it feels cystic, aspiration can be attempted and the fluid sent for
cytology. Fine needle aspiration is a procedure family physicians can do in
the office.
If it feels solid, mammography is the next step.
Ultrasound can be helpful in distinguishing a solid mass from a cystic
lesion.
Reasons for nipple discharge may be physiologic or pathologic:

Physiologic

Pregnancy
Excessive
breast stimulation

Pathologic
Prolactinoma
Breast cancer
-Intraductal papilloma
-Mammary duct ectasia
-Paget's disease of the breast
-Ductal carcinoma in situ
Hormone imbalance
Injury or trauma to breast
Breast abscess
Use of medications use (e.g., antidepressants,
antipsychotics, some antihypertensives and opiates)

Interpretation of Pap Test Results

The Pap test generally shows one of the following:
normal results
low grade squamous epithelial cells (LSIL)
high grade squamous epithelial cells (HSIL)
atypical glandular cells of undetermined significance (AGUS), or
atypical squamous cells of undetermined significance (ASC-US).
ASC-US is considered an inconclusive pap test result that requires follow-up
testing to determine appropriate patient management. An ASC-US Pap test
result is often triaged by HPV testing when using liquid-based cytology.
"Reflex HPV testing" is easily performed as a follow-up test by utilizing
residual cells from the liquid-based Pap test vial to test for the presence or
absence of high-risk HPV.
Non-modifiable risk factors include:
Family history of breast cancer in a first-degree relative (i.e., mother
or sister)
Prolonged exposure to estrogen, including menarche before age 12 or
menopause after age 45
Genetic predisposition (BRCA 1 or 2 mutation)
Advanced age (The incidence of breast cancer is significantly greater in
postmenopausal women, and age is often the only known risk factor.)
Female sex
Increased breast density
Other hormonal risk factors include:

Advanced age at first pregnancy

Exposure to diethylstilbestrol
Hormone therapy
Environmental factors include:
Therapeutic radiation
Obesity
Smoking, drinking alcohol
Factors associated with decreased breast cancer rates include:
Pregnancy at an early age
Late menarche
Early menopause
High parity
Use of some medications, such as selective estrogen receptor
modulators and, possibly, nonsteroidal anti-inflammatory agents and aspirin.
Osteoporosis defined as a spinal or hip bone mineral density (BMD)
of 2.5 standard deviations or more below the mean for healthy, young
women (T-score of 2.5 or below) as measured by dual energy x-ray
absorptiometry (DEXA).
prevenation: USPSTF is currently recommending against calcium
and vitamin D supplementation in healthy pre or post menopausal women.
(b/c calcium supplements increase risk of atherosclerotic vascular diseases &
kidney stones)
*** USPSTF recommends: increase intake of dairy and try to include
weight bearing exercises such as walking into a daily routine.
Screening:
>65 screening w/ dual energy x-ray abdosptiometry (DEXA) scan
<65 use fracture risk assessment tool to risk stratify fracture risk
must be greater than or equal to that of a 65 y/o white woman

risk factors:
-low estrogen- early menopause, low BMI
-lack of physical activity
-inadequate calcium intake (think poor nutrition or alcoholism)
-fam hx of osteoporotic fx
-hx of previous fx as an adult
-dementia
-cigarette smoking
-white race
Osteopenia - defined as a spinal or hip BMD between 1 and 2.5
standard deviations below the mean (T-score between -1 and -2.5).
Menopause
avg age 51 must not menstruated for 12 months straight
- Perimenopause- still possible to get pregnant last 2-8years
Menopause symptoms:
-irregular period
- estrogen def hot flashes, vaginal dryness, mood swings
(depression common)
Treatment:
Hormone therapy [HT] relieves symptoms and protects against
osteoporosis
Estrogen and progestin supplements: if you take estrogen alone, it
causes hyperplasia of endometrial tissue risk of endometrial cancer.

-progestin balances estrogen, therefore taken together (esp women w/

intact uterus)
-progestin alone- prevents hot flashes
SE of HT: increase risk of breast cancer, heart disease, blood clots,
stroke.

Breast cancer risk:

-Obesity
-1st degree relative= mom, sister
-prolong estrogen espousre= menarche before age 12, menopause
after 45, advanced age of 1st pregnancy
-genetic = BRCA 1 or 2 mutation
-advanced age= older you are, higher the risk
-increased breast densisty
-exposures to diethylstibestrol, hormone, radiation therapy, heavy
smoking
Decrease risk of breast cancer:
-menopause before age 45 /early menopause = shortens expouse to
estrogen
-pregnancy at early age
-late menarche
-high parity
-meds eg: selective estrogen receptor modulators (SERM), NSAIDs,
Aspirin

Total hystercetomy = total removal of uterus & cervix w/ or w/o

oophorectomy:
USPSTF - recommend AGAINST continued cervical cancer screening if
UTERUS is removed
Cervical cancer screnning:
-begin at 21yo
-65-70 w/ 3 or more normal Pap tests in past 10 years may choose to
stop screnning
Mammography:
-decreases breast cancer mortality
-biennial/every 2 years testing 50-74yo female [if no family history]
Gardasil vaccine against HPV type 6, 11, 16, 18 --> females 9-26yo
Cervarix vaccine against HPV 16,18, 31, 45 --> 10-25 yo
Gardasil and Cervarix - series of 3 shots
Gardasil

Cervarix

quadravalent
bivalent vaccine
recombinant DNA vaccine
(HPV2)
(HPV4)
HPV serotypes
protected against

Licensed for
Number of doses
Timing
recommendation

6,11 (cause genital

warts)
16 and 18 (cause most
cervical cancers)
females & males
ages 9-26 yrs
3

16 and 18
(cause most cervical
cancers)
31 and 45
females 9-25
yrs
3

before sexual
before sexual debut
debut or shortly
or shortly thereafter
thereafter

Teen pregrenancy- infants at risks for:

-lower birth weight (secondary to pregnancy induced HTN)
-verticially acquired STI
-poorer developmental outcomes
-increased risk of fetal death
*teen mom at risk for premature death
Older age pregnancy- increased incidence of chromosomal
abnormalities- Tri 21
Tobacco use in prego- increase risk for low birth weight
Elements of Routine Newborn Care
-Use universal precautions.
-Stabilize the infant's temperature via:
Skin-to-skin contact with the mother
Radiant warmer, or
Incubator.
-Obtain Apgar scores at 1 and 5 minutes post delivery.
Appearance (skin color)
Pulse (heart rate)
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
A newborn receives a score of 0, 1, or 2 for each component, with the final
Apgar score ranging from 0 to 10.

Signs of respiratory distress in the newborn include:

-Apnea
-Poor respiratory effort
-Tachypnea (rapid respiratory rate): A normal newborn's respiratory
rate will be in the 30s to 50s.
-Nasal flaring
-Chest wall retractions: Retractions are observed when the skin over
the chest wall is "sucking in"; this is usually noted as intercostal (between
the ribs), suprasternal (above the sternum) or subcostal (below the ribcage)
retractions.
-Grunting; Grunting is a noise that is heard on expiration when an
infant in respiratory distress is working to keep his or her alveoli open to
increase oxygenation and/or ventilation.
The Ballard assessment tool uses signs of physical and neuromuscular
maturity to estimate gestational age.
This can be particularly helpful if there is no early prenatal ultrasound
to help confirm dates, or if the gestational age is in question because of
uncertain maternal dates.
Small for gestational age (SGA) = Weight below the 10th percentile
for gestational age
Microcephalic = Head circumference below the 10th percentile for
gestational age
Term = Born at > 37 weeks' gestation
Demonstration of Primitive Reflexes
Rooting
Newborn turns his head toward your finger when you touch his cheek.
Sucking
Newborn sucks on your finger when you touch the roof of his mouth.
Startle (Moro)
Support the newborn's head with one hand and buttocks with the
other. With the head in a midline position, the hand supporting it is quickly
dropped to a position approximately 10 cm below its original supporting
position, and the head is caught in its new position. In response, the
newborn will flex his thighs and knees, fan and then clench his fingers, with
arms first thrown outward and then brought together as though embracing
something.

Palmar and Plantar Grasps

Newborn grasps your finger when you stroke it against the palm of his
hand or plantar surface of his foot.
Asymmetrical Tonic Neck Response
Turning the newborn's head to one side causes gradual extension of
arm toward direction of infant's gaze with contralateral arm flexion--like a
fencer.
Stepping Response
Newborn's legs make a stepping motion when you hold him vertically
above the table and stroke the dorsum of his foot against the table edge.
TORCH:
T- toxoplasmosis
O- other eg: Hep B, Human parvovirus, Syphilis, HIV
R- Rubella
C- Cytomegalovirus
H- Herpes virus type 2
TORCH Infection
Hepatitis B
Rubella
Toxoplasma
CMV

Test
Maternal hepatitis B surface antigen (HBsAg)
Maternal and infant rubella titer
Infant toxoplasma titer
Infant urine culture

Routine Newborn Medications

Vitamin K: Newborns must get IM injection of vitamin K to prevent

hemorrhagic disease of the newborn / vitamin K deficiency bleeding
Hepatitis B vaccine: hepatitis B vaccine at birth as part of the routine
care of all medically stable newborns weighing > 2000 grams. This is true
for all of these babies, regardless of maternal testing results.
Hepatitis B immunoglobulin (HBIG) is given only to newborns at risk
for vertical transmission of hepatitis B virus.
Erythromycin (also tetracycline or silver nitrate): One of these
antibiotics is administered topically specifically to prevent gonococcal
conjunctivitis (within 2-7days) Chlamydia trachomatis conjunctivitis in
newborns is more common than gonococcal, but chlamydia typically
occurs at 714 days after birth, and neonatal prophylaxis does little to
prevent chlamydia conjunctivitis.
CMV
-leading cause of congenital infection in US
-more than 90% asymptomatic and symptomatic varies in severity
- systems affected:
skin: petechiae, purpura, ecchymosis, jaundice
heptatobiliary: >2mg/dl direct bilirubin, elevated ALT,
Hepatomegaly
Hematopoietic: thrombocytopenia, anemia, splenomegaly
CNS: Microcephaly, intracranial calcifications on CT, poor feeding,
lethargy, seizures, increased CSF
Auditory: sensorineural hearing loss
Visual: Chorioretinitis
- owls eyes =Enlarged cells with intranuclear inclusion bodies
CMV head CT shows:
- Intracranial calcifications (appear as bright areas)

- Diminished number of gyri & abnormally thick cortex aka

lissencephaly or agyria-pachygyria
- Enlarged ventricles

Antiviral meds: parenteral ganciclovir or oral valganciclovir

- drugs help to decrease progression of hearing impairment and
diminished developmental impairment in infants with congenital CMV
infection and CNS involvement
-Due to possible hematologic and other toxicities, use of these
antivirals is not routine, but is currently recommended in this cohort of
infants if they are able to start therapy within the first month of life.

Sequelae of Congenital CMV

Hearing loss

In many infected infants, the onset of

hearing loss may be after the newborn period.
The loss is often progressive.
Even if the newborn hearing screen is
normal, an infant infected with CMV may
develop hearing loss and progress to severe-toprofound bilateral hearing loss during the first
year of life.

These findings are associated with an

increased risk of CNS sequelae of congenital
CMV infection, such as developmental delay.
Microcephaly and
Infants with congenital CMV must have
intracranial calcifications
ongoing developmental assessments and may
ultimately demonstrate intellectual disabilities
and/or cerebral palsy.
Hepatosplenomegal
y
Rash

These nonneurological neonatal clinical

abnormalities can be expected to resolve
spontaneously within weeks.

Newborn Screening:
1) Metabolic disorders:
-PKU
-Hypothyroidism
-galactosemia
-biotinidase deficiency
-hemoglobinopathy
-maple syrup urine diseases (MSUD)
-homocystinuria
-congenital adrenal hyperplasia
-cystic fibrosis
-G6PD def
-Toxoplasmosis
2) Congenital deafness
3) Congenital heart defects by measuring transcutaneous oxygen
saturation
Mom w/ seizures using anticonvulsants during pregnancy baby at
risk for:
-cardiac defects
-dysmorphic craniofacial features
-hypoplastic nails and distal phalanges
-IUGR
-Microcephaly
-mental retardation
-methemoglobinuria
Red reflex: normal reddish-orange reflection of light from eyes retina
observed w/ ophthalmoscope
-absent red reflex indicats congenital cataracts or retinoblastoma

Chorioretinitis congenital toxoplasmosis and CMV infection

Ewings sarcoma, medulloblastoma, Neuroblastoma : Small round blue
cells with dense nuclei forming small rosettes.
--Neuroblastoma: baby version of pheochromcytoma, elevated urinary
HVA/VMA, large heterogeneous mass with scant calcifications on CT, bone
marrow biopsy will show small round blue cells w/ dense nuclei forming
small rosettes.
Fetal alcohol syndrome : smooth philtrum, thinning of the upper lip,
and small palpebral fissures + SGA
Congenital rubella presents with sensorineural deafness, eye
abnormalities (retinopathy, cataracts), and patent ductus arteriosus.
Symptomatic congenital CMV infection presents with microcephaly,
jaundice, hepatosplenomegaly, low birth weight, and petechiae at birth.
phenylketonuria (PKU), an autosomal recessive disorder of
amino acid metabolism caused by a deficiency in the enzyme
phenylalanine hydroxylase. Affected infants are normally detected
by newborn screening, but can present with vomiting, hypotonia,
musty odor, developmental delay, and decreased pigmentation of
the hair and eyes. The best developmental outcomes occur if a
phenylalanine-restricted diet is initiated in infancy.
defect in cystathionine synthase occurs in homocystinuria, a disorder
of amino acid metabolism. Homocystinuria is inherited in an autosomal
recessive pattern. Individuals display Marfanoid body habitus, a
hypercoaguable state, and possible developmental delay. The condition can
be diagnosed by testing for increased methionine in a patients urine or
blood.
defect in sphingomyelinase occurs in Niemann-Pick disease, a
lysosomal storage disease. Children present by six months of age with
hepatomegaly, ataxia, seizures, and progressive neurologic degeneration.
Fundoscopic exam reveals a cherry-red macula.

defect in alpha-L-iduronidase occurs in Hurler syndrome, a type of

autosomal recessive lysosomal storage disease. Children typically do not
display symptoms until one year of age. Symptoms include
hepatosplenomegaly, coarse facial features, frontal bossing, corneal
clouding, and developmental delay. Affected individuals typically do not live
past fifteen years old.
defect in glucose-6-phosphatase occurs in Von Gierkes disease, a
glycogen storage disease. Von Gierkes disease is inherited in an autosomal
recessive pattern. Individuals present with hypoglycemia, hepatomegaly, and
metabolic acidosis.
Opiate:
-use in pregnancy, baby will have:
CNS findings (irritability, hyperactivity, hypertonicity, incessant
high-pitched cry, tremors, seizures)
GI symptoms (vomiting, diarrhea, weight loss, poor feeding,
incessant hunger, excessive salivation)
respiratory findings (including nasal stuffiness, sneezing, and
yawning).
Cocaine:
- use in pregnancy, baby affected later in life : poor cognitive
performance, information processing, attention to tasks