General Surgery Rotation

General Surgery: Obstetrics and Gynecology (PEARLS)

The General Surgery End of Rotation Blueprint obstetrics and gynecology section covers six topics and represents 3% of your General Surgery EOR Exam

Adenopathy Adenopathy: enlargement of lymph nodes due to gynecologic infections, malignancy or inflammation.

  • The most commonly seen adenopathy in breast disease is axillary adenopathy (85%).
  • Other adenopathies seen are internal mammary, parasternal, and supraclavicular.
Benign breast disease: fibroadenomas and fibrocystic breast disease A 28-year-old woman with unilateral green-brown nipple discharge increasing immediately before menses

Fibroadenoma: Solid, mobile, well-circumscribed round breast mass. Most common breast tumor in women < 30 years.

Fibrocystic breast disease: common benign breast condition consisting of fibrous and cystic changes in breast. Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous (“nodular”) fullness.

  • Aspirated cysts - usually straw-colored or green fluid
Breast carcinoma Most common malignancy in women: breast mass- immobile, irregular, nipple retraction, bloody nipple discharge, spiculated mass on mammogram

Risk factors (increased exposure to estrogen): NAACP

  • Nulliparity
  • Age at menarche (<13 yrs)
  • Age at menopause (>55 yrs)
  • Breast cancer (self, family)
  • Pregnancy of 1st child >30yrs

USPSTF guidelines for breast cancer screening:

  • Baseline mammogram every 2 years from age 50-74
  • Every 2 years beginning at age 40 if increased risk factors – 10 years prior to the age the 1'st degree relative was diagnosed. 
  • Clinical breast exam: every 3 years in women age 20-39 years then annually after age 40
  • Breast self-exam – monthly beginning at age 20 – immediately after menstruation on days 5-7 of the menstrual cycle

Most common type - Infiltrating Intraductal Carcinoma

  • Infiltrating ductal carcinoma (~75%)
  • Medullary carcinoma (~15%)
  • Infiltrating lobular carcinoma (~5%)
  • Tubular carcinoma (~2%)
  • Mucinous colloid carcinoma (~1%)
  • Inflammatory breast cancer (~1%)

Sites of metastases: 

  • Lymph nodes (most common)
  • Lung/Pleura
  • Liver
  • Bones
  • Brain
Nipple discharge Intraductal papilloma - the most common cause of bloody nipple discharge
Pain 32-year-old lactating female with breast painswelling, fever, chills and a fluctuant mass of her left breast. The area directly above the lesion is warm, erythematous and tender to touch

Mastitis: superficial infection of the breast - usually occurs during breastfeeding.

Breast abscess: often a progression of mastitis

  • Nursing: Staphylococcus aureus
  • Nonlactating: mixed infection
Skin changes
Paget’s disease of the breast: Scaling rash/dermatitis of the nipple caused by an invasion of skin by cells from a ductal carcinoma

Skin changes during pregnancy

Melasma (ie, chloasma or mask of pregnancy) is the most cosmetically disturbing pigmentary change and occurs in up to 75 percent of pregnant women

  • The characteristic hyperpigmentation of the face may also occur in nonpregnant women and women taking oral contraceptive pills

Vascular changes — Estrogen, and other factors, cause vascular distention and instability, and proliferation of blood vessels during pregnancy

  • Spider angiomas - They appear in the second to fifth month of pregnancy as red lesions with branches extending out from a central puncta
  • Varicosities — Saphenous, vulvar, and hemorrhoidal varicosities all occur at an increased rate during pregnancy and cannot be prevented

Striae gravidarum — Connective tissue changes, such as stretch marks (ie, striae distensae, striae gravidarum), are a common source of cosmetic concerns among pregnant women

Pruritus in pregnant women may be physiologic, related to a flare of disorder present prior to conception, or related to pregnancy-specific dermatoses

  • Chlorpheniramine has been recommended as the first generation antihistamine of choice for use during pregnancy

Hirsutism is noted most frequently on the face, but may also be seen on the arms, legs, back, and suprapubic region

Nails grow faster during gestation. Changes that may occur include development of transverse grooves, subungual keratosis, and distal onycholysis, and melanonychia

Androgenic alopecia — Rarely, late in pregnancy, hair in the frontoparietal area recedes in a mild form of androgenic alopecia

Vaginal – Bluish/purplish coloration of the vagina (Chadwick sign) and cervix (Goodell sign) are early anatomic changes historically important in the diagnosis of pregnancy

  • The blue appearance is related to increased blood flow
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