Docstoc

A year old woman comes to the physician for follow up of

Document Sample
A year old woman comes to the physician for follow up of Powered By Docstoc
					A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed
the
     lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred
about 1
     month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump
has
     recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound
     demonstrates a cystic lesion. Which of the following is the most appropriate next step in
management?


           A. Mammography in 1 year

           B. Ultrasound in 1 year

           C. Tamoxifen therapy

           D. Open biopsy

           E. Mastectomy


     Explanation:

      The correct answer is D. Breast lumps are a common complaint in women. Many of these masses are
      benign processes. Benign conditions of the breast include fibrocystic disease, fibroadenomas,
galactoceles,
      abscesses, and necrosis. It is appropriate to aspirate a palpable macrocyst in the breast; the fluid
should be
      placed on a slide and sent for cytologic evaluation. If the cytology is negative, no further treatment is
needed.
      Some would argue that if the cyst recurs, it may be aspirated again. However, when a lesion recurs
twice, as
      has occurred in this patient, open biopsy is warranted.

      To wait to perform mammography in 1 year (choice A) or ultrasound in 1 year (choice B) would be
incorrect
      management. First, if a malignancy is present, waiting another year will allow progression of the
cancer.
      Second, the mammogram is not definitive. Imaging can contribute information to the workup of a
breast mass,
      but the definitive diagnosis rests on histologic evaluation.

     Tamoxifen therapy (choice C) is used to both prevent and treat breast cancer. However, this patient
does not
     yet have a diagnosis. She has a cystic mass that has been aspirated twice and has recurred twice. She
     therefore requires a biopsy to establish a diagnosis prior to the institution of any treatment.

     Mastectomy (choice E) would not be indicated for this patient. Again, this patient does not have a
diagnosis,
     and to perform a mastectomy for a recurrent cyst would be inappropriate.

An 18-year-old woman comes to the physician for advice regarding birth control. She has been sexually
active
      since the age of 15 and has had numerous sexual partners since that time. She has tried the oral
contraceptive
      pill twice, for approximately two cycles each time, but stopped because of irregular bleeding. She has
had
    gonorrhea once and Chlamydia twice. She does not smoke. Physical examination is unremarkable.
Which of the
    following forms of birth control should be recommended for this patient?


           A. Condoms

           B. Diaphragm

           C. Intrauterine device

           D. Oral contraceptive pill

           E. Tubal ligation


      Explanation:

      The correct answer is A. All of the above options will provide birth control for this patient. However,
another
      major factor for this patient is the prevention of sexually transmitted disease. Other than abstinence,
condoms
      provide the best protection against the acquisition of sexually transmitted diseases. This patient, with
her early
      onset of intercourse at the age of 15 and her numerous sexual partners, is at high risk for HIV,
hepatitis,
      herpes, chlamydia, gonorrhea, syphilis, human papillomavirus, and the eventual development of
cervical
      cancer. It is absolutely essential that she be counseled regarding condom use and the importance of
her
      protecting herself from sexually transmitted diseases as well as pregnancy.

      The diaphragm (choice B) is an effective method of birth control for motivated women who are able
to use
      this method with each episode of intercourse. Because it covers the cervix, it provides some
protection against
      disease. However, it does not provide as much protection against sexually transmitted diseases as
condoms
      do.

     The intrauterine device (choice C) is absolutely contraindicated in a woman with numerous sexual
partners
     and a recent history of sexually transmitted disease. Furthermore, it is highly suboptimal for young
women, in
     whom a pelvic infection could lead to reduced or absent future fertility.

     The oral contraceptive pill (OCP) (choice D) would provide this patient with protection against
pregnancy;
     however, it would not protect her from sexually transmitted diseases. An ideal approach may be to
have her
     use both the OCP and condoms. However, consistent use of both can be difficult.

      Tubal ligation (choice E) would provide this patient with no protection against sexually transmitted
disease.
      Furthermore, except in very rare circumstances, it is contraindicated for an 18-year-old.



A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has
    hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past
gynecologic
    history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent
    mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable.
Which of
    the following procedures or tests should most likely be performed on this patient?


          A. Chest x-ray

          B. Pap test

          C. Pelvic ultrasound

          D. Prostate-specific antigen (PSA)

          E. Rectal examination


      Explanation:

      The correct answer is E. Cancer screening should be an essential part of an annual examination.
Colorectal
      cancer is a major cause of serious morbidity and mortality for women in the U.S.: greater than 50,000
new
      cases are diagnosed each year, and there are more than 25,000 deaths from colorectal cancer.
Screening
      should begin at age 50 in asymptomatic women with no significant family history. Screening consists
of a digital
      rectal examination with fecal occult blood testing. This can be performed at the same time that pelvic
      examination is performed. Sigmoidoscopy should be performed every 3-5 years.

      This patient has no indication for a chest x-ray (choice A). Lung cancer has surpassed breast cancer as
the
     major cause of cancer death in women. However, chest x-ray films are not used for lung cancer
screening.
     There is currently no technique available for routine screening for lung cancer.

     The Pap test (choice B) is an important method of screening for cervical cancer and should be
performed
     annually. However, this patient had a normal Pap test 2 months ago.

      Pelvic ultrasound (choice C) is not indicated in this patient. She has nothing abnormal in her history
or
      physical that would warrant pelvic ultrasound. Pelvic ultrasound is not used for cancer screening.

      Prostate-specific antigen (PSA) (choice D) is an appropriate test in men. PSA testing would not be
indicated in
      this (female) patient.
A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been
menopausal
      for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds
intolerable. She
      has a complicated past medical history including hypertension, diabetes, and severe chronic
obstructive
      pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that
demonstrates an
      endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most
appropriate next
      step in management?


          A. Hormone replacement therapy

          B. Oral contraceptive pill

          C. Hysteroscopy

          D. Laparoscopy

          E. Hysterectomy


     Explanation:

      The correct answer is C. This patient is likely having irregular spotting secondary to the polyp.
Endometrial
      polyps are projections of endometrial tissue that protrude into the endometrial cavity. They can be
seen in
      women of any age, but are most commonly seen in perimenopausal women. This problem should be
      addressed for 2 reasons: 1. The bleeding per vagina is distressing to the patient. 2. There are some
atypical
      cells from the biopsy that may represent cancer and polyps can contain malignant cells within them.
Therefore,
      the polyp should be removed. The question then becomes how best to remove it. A hysteroscopy can
be
      performed under monitored anesthesia care (MAC), an approach that provides adequate anesthesia
without
      requiring the patient to have general anesthesia. It would be preferable to avoid general anesthesia in
a
      patient with so many medical conditions. Hysteroscopy would allow visualization of the entire uterine
cavity and
      removal of the polyp. A curettage should be performed afterward to fully sample the cavity.

     Hormone replacement therapy (choice A) would not be the most appropriate next step. First, the
polyp must
     be removed and histologic evaluation of the polyp and endometrial tissues performed to rule out
malignancy
     prior to instituting hormone replacement therapy.

    The oral contraceptive pill (choice B) would not be appropriate management for a 75-year-old
woman, as the
    dose of hormones is higher than necessary.
      Laparoscopy (choice D) would not be indicated. This patient is having spotting, which is an
intrauterine
      process. Laparoscopy allows visualization of only the external, serosal uterine surface.

      Hysterectomy (choice E) would not be the most appropriate management. Hysterectomy would take
care of
      the patient's spotting and would provide tissue for pathologic diagnosis. However, in this patient with
multiple
      medical problems, the same goals can be achieved with the less invasive procedure of hysteroscopy.

A 21-year-old woman comes to the physician because of "bumps" on her vulva that she has just recently
      noticed. These bumps do not cause her symptoms, but she wants to know what they are and wants
them
      removed. She has no medical problems, takes no medications, and has no allergies to medications.
She
      smokes one-half pack of cigarettes per day. She is sexually active with 3 partners. Examination shows
3
      cauliflower-like lesions on the right labia majora. Which of the following is the most appropriate next
step in
      management?


          A. Acyclovir

          B. Penicillin

          C. Cone biopsy

          D. Cryotherapy

          E. Vulvectomy


     Explanation:

     The correct answer is D. This patient has findings that are most consistent with condyloma acuminata,
or
      genital warts. Condyloma acuminata is caused by the human papillomavirus. This virus, of which
there are
      many different subtypes, infects epidermal cells and can cause warty growths. When the virus affects
skin cells
      on the hands, the result is the common warts that are often seen in children. When the virus affects
cells on
      the perineum, the result is condyloma acuminata. Diagnosis is made on the basis of the classic,
verrucous
      (cauliflower-like) appearance of the lesions. Treatment is with local destruction. This local
destruction can be
      achieved in a variety of ways including with cryotherapy (i.e. freezing of the skin), laser therapy,
trichloroacetic
      acid (i.e. chemical destruction of the skin), or imiquimod. However, while the lesions themselves are
often
      successfully treated with these locally destructive agents, the virus is not usually completely
eradicated and
      recurrences of the lesions may occur.

     Acyclovir (choice A) is used to treat herpes viruses. Condyloma acuminata is caused by the human
     papillomavirus and, therefore, acyclovir is not used.

     Penicillin (choice B) is an antibiotic effective against bacteria, and not the human papillomavirus.

     Cone biopsy (choice C) is performed on the cervix when a patient has high-grade dysplasia or cancer.
While
     there is an association between human papillomavirus infection and cervical dysplasia, cone biopsy
would not
     be indicated for a patient on the basis of the presence of condyloma.

      Vulvectomy (choice E) is performed on patients for vulvar dysplasia or cancer. It is not indicated for
patients
      with condyloma.




A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28
weeks,
     she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral
glucose
     tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past
several
     weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by
adhering to
     the diet recommendations of her physician. She asks the physician what effect her type of diabetes
can have on
     her or her fetus. Which of the following is the most appropriate response?


          A. Gestational diabetes is associated with fetal anomalies

          B. Gestational diabetes is associated with intrauterine growth restriction

          C. Gestational diabetes is associated with macrosomia

          D. Gestational diabetes is not associated with future diabetes

          E. Gestational diabetes with normal fasting glucose is associated with stillbirth


     Explanation:

     The correct answer is C. Gestational diabetes is defined as glucose intolerance that either has its onset
or
       its first recognition during pregnancy. Gestational diabetes is usually diagnosed by means of oral
glucose
       tolerance testing. Patients with gestational diabetes and normal fasting glucose levels have two major
risks.
       The first is fetal macrosomia. Women with gestational diabetes are known to have larger babies, and
this
       creates an increased risk of complications of delivery including shoulder dystocia and cesarean
delivery. The
       second risk is of the eventual development of overt diabetes. Fifty percent of women with gestational
diabetes
     will go on to develop overt diabetes within the next 20 years. Patients with gestational diabetes and
abnormal
     fasting glucose levels do have an increased risk of stillbirth.

      To state that gestational diabetes is associated with fetal anomalies (choice A) is incorrect. However,
patients
      with overt diabetes do have an increased risk of fetal anomalies.

     To state that gestational diabetes is associated with intrauterine growth restriction (choice B) is not
correct.
     Gestational diabetes is associated with macrosomia.

     To state that gestational diabetes is not associated with future diabetes is incorrect (choice D), as
explained
     above.

      To state that gestational diabetes with normal fasting glucose is associated with stillbirth (choice E) is
      incorrect. However, overt diabetes and gestational diabetes with abnormal fasting glucose levels
(class A2)
      are associated with stillbirth.




A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward with a gush of blood,
     abdominal pain, and irregular, painful contractions. Her prenatal course was significant for her being
Rh
     negative and antibody negative. Her temperature is 37 C (98.6 F), pulse is 110/minute, blood pressure
is 110/70
     mm Hg, and respirations are 12/minute. Abdominal examination shows a tender abdomen and cervical
     examination shows the cervix to be closed and long with a significant amount of blood in the vagina.
The fetal
     heart rate is in the 170s with moderate to severe variable decelerations with contractions. The
diagnosis of
     placental abruption is made and an emergent cesarean delivery is performed. To determine the correct
amount
     of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most
appropriate
     laboratory test to send?


          A. Apt test

          B. Complete blood count

          C. Kleihauer-Betke

          D. Partial thromboplastin time

          E. Serum potassium


     Explanation:

     The correct answer is C. Women that are Rh negative are at risk for developing Rh isoimmunization.
Rh
      isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red
blood
      cells of an Rh-positive fetus. This exposure may lead the mother's immune system to become
sensitized to the
      Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother's immune system
may "attack"
      the Rh antigen on the fetal red blood cells. This immune response may lead to the development of
fetal
      anemia, hydrops, and death. To prevent Rh isoimmunization from occurring, Rh-negative women
who are not
      Rh alloimmunized should receive RhoGAM (anti-D immune globulin) at 28 weeks of gestation,
within 72 hours
      after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such
as
      amniocentesis. RhoGAM should also be strongly considered in cases of threatened abortion, antenatal
      bleeding, external cephalic version, or abdominal trauma. The amount that is usually given after the
delivery of
      an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30
mL (or
      15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in
excess of this 30
      mL—especially in cases such as manual removal of the placenta or placental abruption (as this
patient
      had). To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to
perform a
      Kleihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells to be
identified and
      counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct
amount of
      RhoGAM to be given.

     An apt test (choice A) is used to differentiate fetal from maternal blood. It can be used in the
diagnosis of vasa
     previa or with neonatal melena.

    A complete blood count (choice B) will demonstrate the amount of maternal hemorrhage, but not the
amount
    of fetal to maternal hemorrhage.

     Partial thromboplastin time (choice D), and serum potassium (choice E) do not allow for the
determination of
     the amount of fetal to maternal hemorrhage.




A 28-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. A
home
     pregnancy test was positive. She has no complaints. She is concerned, however, because she is a
carrier of the
     fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She
wants to
     know whether there is a way to determine whether the fetus is affected. Which of the following is the
most
     appropriate next step in management?
          A. There is nothing to offer this couple

          B. Offer testing of the parents

          C. Offer MRI of the fetus

          D. Offer 2nd trimester amniocentesis

          E. Offer termination of the pregnancy


     Explanation:

      The correct answer is D. Fragile X syndrome is the most common inherited form of mental
retardation. Down
      syndrome may cause more absolute cases of mental retardation, but it results from a spontaneously
occurring
      trisomy and most cases are not considered inherited. The gene for fragile X syndrome is located on
the long
      arm of the X-chromosome. It has a complex inheritance pattern that is related to the number of
repeating
      cytosine-guanine-guanine triplets. When greater than 200 repeats are present, a person will have the
full
      mutation and have phenotypic fragile X syndrome. A patient with 50-200 repeats is phenotypically
normal and
      is said to have a premutation. Along with mental retardation, related features of the fragile X
syndrome include
      autistic behaviors, speech and language problems, facial anomalies, and macroorchidism in adult
males.
      DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed
on cultured
      amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliable for
the
      diagnosis of fragile X syndrome because of different methylation patterns in the trophoblast
compared with the
      fetus.

     To state that there is nothing to offer this couple (choice A) is incorrect. As detailed above,
amniocentesis can
     be used to allow for prenatal diagnosis of fragile X syndrome.

     To offer testing of the parents (choice B) would not be correct. Based on the history provided, the
parents
     have already been tested and are known to be carriers. Their concern at this point is whether the fetus
will
     have fragile X syndrome, and that can only be determined by genetic analysis of the fetus.

     To offer MRI of the fetus (choice C) would be incorrect. The diagnosis is made based on DNA-based
     molecular analysis and not an imaging study.

     To offer termination of the pregnancy (choice E) would be incorrect. This is a desired pregnancy.
This patient
     is seeking prenatal diagnosis at this point, not termination.
A 23-year-old female comes to the physician because of a swelling in her vagina. She states that the
swelling
     started about 3 days ago and has been growing larger since. The swelling is not painful, but it is
uncomfortable
     when she jogs. She has asthma for which she uses an albuterol inhaler, but no other medical problems.
     Examination shows a cystic mass 4 cm in diameter near the hymen by the patient's left labia minora.
The mass is
     nontender and there is no associated erythema. The mass is freely mobile. The rest of the pelvic
examination is
     unremarkable. Which of the following is the most likely diagnosis?


            A. Bartholin's cyst

            B. Condyloma lata

            C. Granuloma inguinale

            D. Hematocolpos

            E. Vulvar cancer


        Explanation:

      The correct answer is A. This patient has a presentation and findings that are most consistent with a
      Bartholin's cyst. Bartholin's cysts develop when a Bartholin's gland becomes obstructed. The
Bartholin's
      glands are bilateral structures that are present near the posterior fourchette of the vagina at the 5 and 7
      o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the
posterior
      vagina.They undergo rapid growth during the process of puberty and they shrink after the menopause.
When
      the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst results. If the cyst becomes
infected,
      the result is a Bartholin's abscess. These abscesses are usually polymicrobial in nature, although the
      gonococcus is implicated in about 25% of cases. Treatment of a symptomatic Bartholin's cyst is with
placement
      of a Word catheter. This is a small balloon-tipped catheter device that is placed into a small hole that
is
      punched into the cyst itself. This catheter allows drainage of the cyst and the formation of an
epithelialized
      tract that will allow continued drainage once the catheter is removed. This tract should prevent the
cyst from
      reforming. If Bartholin's cysts continue to form in spite of the use of the Word catheter, a
marsupialization
      procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding skin to
prevent
      re-closure and re-formation of the cyst.

        Condyloma lata (choice B) is a manifestation of secondary syphilis. They appear as coalesced, large,
pale,
        flat-topped papules and not as a cystic mass.

        Granuloma inguinale (choice C) is also known as Donovanosis and is a sexually transmitted disease
     associated with the gram-negative bacillus Calymmatobacterium granulomatis. The disease is
characterized by
     papules progressing to ulcers and not by a vulvar cyst.

      Hematocolpos (choice D) describes the condition in which there is blood filling the vagina. This is
often seen
      with an imperforate hymen.

     Vulvar cancer (choice E) does not usually present as a single cystic mass at the introitus and, in young
     women, is far less common than Bartholin's cysts




A 47-year-old woman comes to the physician for an annual examination. One year ago, she was diagnosed
with
     endometrial carcinoma and underwent a total abdominal hysterectomy and bilateral salpingo-
oophorectomy. She
     was found to have grade I, stage I, disease at that time. Over the past year, she has developed severe
hot
     flashes that occur throughout the day and night and are worsening. She is also concerned because her
mother
     and several of her aunts have severe osteoporosis. She wonders whether she can take estrogen
replacement
     therapy. Which of the following is the most appropriate response?


          A. Estrogen replacement therapy is absolutely contraindicated

          B. Estrogen replacement therapy may be used, and there are no risks

          C. Estrogen replacement therapy may be used, but there are risks

          D. Estrogen replacement therapy will lead to breast cancer

          E. Estrogen replacement therapy will lead to cancer recurrence


     Explanation:

     The correct answer is C. The issue of whether a patient who had endometrial carcinoma can be placed
on
     estrogen replacement therapy (ERT) is somewhat controversial. If the patient is completely free of
tumor,
     estrogen replacement therapy should not result in recurrence. And, in this patient's case, it would be
helpful for
     her hot flashes and osteoporosis. However, if an estrogen-dependent neoplasm is still present
somewhere in
     her body, ERT may result in an earlier recurrence. Stage I, grade I, endometrial cancer is the lowest
grade and
     lowest stage endometrial cancer. The risk of persistent disease is less than 5%. Many gynecologic
oncologists
     would feel comfortable giving ERT to this patient. However, the patient must be fully informed
regarding the
     benefits and risks of ERT. These risks include not only earlier recurrence, but also the standard risks
such as
     venous thrombosis.

     To state that estrogen replacement therapy is absolutely contraindicated (choice A) is incorrect. As
explained
     above, ERT may be given to certain patients with a history of grade I, stage I, endometrial carcinoma.

     To state that estrogen replacement therapy may be used and there are no risks (choice B) is not
appropriate.
     Even in women with no history of endometrial carcinoma, there are risks to ERT. The history of
endometrial
     carcinoma adds a further risk for this patient.

     To state that estrogen replacement therapy will lead to breast cancer (choice D) is incorrect. There are
a
      number of studies that show that ERT leads to increased rates of breast cancer. There are also a
number of
      studies that show no increased risk. Therefore, to make the definitive statement that ERT will lead to
breast
      cancer is incorrect.

     As explained above, to state that ERT will lead to cancer recurrence (choice E) is not correct.



A 52-year-old woman comes to the physician because of hot flashes. Her last menstrual period was 1 year
ago.
     Over the past year, she has noted a persistence of her hot flashes, which come several times each day
and are
     associated with a feeling of heat and flushing. They also awaken her at night and interfere with her
sleep. She
     has no medical problems, takes no medications, and has no known drug allergies. She has a family
history of
     cardiovascular disease and she does not smoke. Physical examination is unremarkable. She is started
on
     estrogen and medroxyprogesterone acetate (Provera). The addition of a progestin is most likely to
decrease her
     risk of which of the following?


          A. Breast cancer

          B. Breast pain

          C. Endometrial cancer

          D. Mood changes

          E. Weight gain


     Explanation:

      The correct answer is C. Unopposed estrogen is known to cause endometrial hyperplasia and cancer.
      Estrogen has direct effects on the growth and development of the endometrium. Studies have shown
that the
      addition of a progestin can protect a woman from the development of endometrial hyperplasia and
that the
      addition of a progestin to women with endometrial hyperplasia can lead the endometrium to revert to
normal.
      Thus, any woman with a uterus who is on estrogen therapy should also be on a progestin to protect
her
      endometrium. This is usually done by placing the patient on daily estrogen and progesterone or on
cyclic
      progesterone.

     Progestins do not protect against the development of breast cancer (choice A). In fact, there is
evidence that
     progestins may stimulate the growth of breast tumors.

       Breast pain (choice B) is often a result of progestin therapy.

       Mood changes (choice D) and weight gain (choice E) are well-known side effects of progestins.


A 27-year-old woman, gravida 2, para 2, comes to the physician to have her staples removed after an
elective
      repeat cesarean delivery. Her pregnancy course was uncomplicated. She states that she is doing well
except
      that since the delivery she has noticed some episodes of sadness and tearfulness. She is eating and
sleeping
      normally and has no strange thoughts or thoughts of hurting herself or others. Physical examination is
within
      normal limits for a patient who is status post cesarean delivery. Which of the following is the most
likely
      diagnosis?


            A. Maternity blues

            B. Postpartum depression

            C. Postpartum mania

            D. Postpartum psychosis

            E. Poststerilization depression


       Explanation:

       The correct answer is A. Maternity blues is the term used to describe a common postpartum reaction
that
      occurs in 50 to 70% of postpartum patients. It is characterized by tearfulness, restlessness, and
anxiety.
      Symptoms typically start in the first few days postpartum and resolve within 2 weeks. However,
certain patients
      continue to have the symptoms for several weeks. Many symptoms may be seen in association with
this
      disorder including headache, backache, fatigue, forgetfulness, insomnia, weeping, depression,
anxiety, and
        negative feelings toward the newborn infant. Interestingly, another component of the syndrome may
be
      episodes of elation, and such mood lability can be especially distressing for the new mother. It is
unclear what
      the etiology of these symptoms is. Certainly, the postpartum period with a newborn can be stressful
and life
      changing, which can certainly lead to mood changes and a number of emotional responses. Some
researchers
      have argued that changes in hormone levels are at the root of the maternity blues, but this has never
been
      definitively proven. This patient does not have evidence of a true postpartum depression (e.g.,
insomnia, lack
      of appetite, or anhedonia) or postpartum psychosis (e.g., bizarre thoughts) and she does not have any
      thoughts of hurting herself or her baby. Therefore, the most likely diagnosis is maternity blues and
she should
      be given support and reassurance. The patient must also be cautioned, however, that if her symptoms
do not
      resolve, or if they worsen, then she must call or return.

        Postpartum depression (choice B) is a depression that occurs in about 10% of postpartum women and
it is
     more serious than the maternity blues. Symptoms may include sleep disturbances and changes in
appetite.

        Postpartum mania (choice C) or postpartum psychosis (choice D) is a psychiatric disorder that occurs
in
        about 1 per 1,000 deliveries. It is characterized by severe anxiety, agitation, disordered thoughts, and
        confusion. Hospitalization is required.

      Poststerilization depression (choice E) is a depression that is seen in women following a tubal ligation
or other
      form of permanent sterilization. This patient did not have a sterilization procedure.




A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician for a
prenatal
      visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies
are moving
      well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-
presenting
      fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to
know if she
      should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this
patient?


             A. Both vaginal delivery and cesarean delivery are acceptable.

             B. Cesarean delivery is mandated because the fetuses are > 2000g.

             C. Cesarean delivery is mandated because the second twin is breech.

             D. Vaginal delivery is mandated because the fetuses are > 2000g.
            E. Vaginal delivery is mandated because the first twin is vertex.


       Explanation:

      The correct answer is A. Mode of delivery with twin gestations is an area that has generated
controversy
      over time. Patients with vertex-vertex twins are generally allowed to have a vaginal delivery. Patients
with a
      presenting twin that is non-vertex are generally advised to have a cesarean delivery. Patients with the
      presenting twin vertex and the non-presenting twin non-vertex may decide which mode of delivery
they would
      prefer. Once the presenting (vertex) twin has delivered, there are essentially 2 options for delivery of
the
      second (non-vertex) twin. The first option is an external cephalic version, in which the head of the
second twin
      is guided into the pelvis so that it becomes a vertex presentation. The second option is a breech
extraction of
      the second twin. Breech extraction may be performed so long as there is an adequate pelvis, a fetal
weight
      greater than 2,000g, an experienced physician, a flexed fetal head, and available general anesthesia.

       To state that cesarean delivery is mandated because the fetuses are > 2000g (choice B) is incorrect.
The
       fact that the fetuses are > 2000g makes a vaginal delivery with a non-vertex second twin possible.

       To state that cesarean delivery is mandated because the second twin is breech (choice C) is incorrect.
As
       explained above, vertex-nonvertex twins may be delivered vaginally so long as certain criteria are
met.

     To state that vaginal delivery is mandated because the fetuses are > 2000g (choice D) is incorrect.
Vaginal
     delivery is possible because the fetuses are > 2000g, but the mother may still choose to have a
cesarean
     delivery.

       To state that vaginal delivery is mandated because the first twin is vertex (choice E) is incorrect. With
the first
       twin vertex, vaginal delivery is possible, but with a non-vertex second twin, cesarean delivery would
also be
       entirely appropriate.



A 22-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit.
She has
     had some nausea but no other complaints. She has had no bleeding per vagina or abdominal pain. She
had an
     ovarian cystectomy at age 18 but no other medical or surgical problems. She takes no medications and
has no
     known drug allergies. Examination is unremarkable except for an 8-week-sized non-tender uterus. The
patient
     wants information on vitamin supplementation during pregnancy. Which of the following represents
the correct
     amount of vitamin A supplementation this patient should take daily?
          A. 10,000 IU

          B. 25,000 IU

          C. 50,000 IU

          D. 100,000 IU

          E. Vitamin A supplementation during pregnancy is not recommended


     Explanation:

      The correct answer is E. Vitamin A is an important vitamin for human reproduction and normal
bodily
      functioning, and vitamin A deficiency is a problem throughout much of the world. In the U.S. and
other
      developed nations, however, the overwhelming majority of women have sufficient stores of vitamin
A in the
      liver. Thus, vitamin A supplementation during pregnancy is not needed or recommended for most
women. In
      fact, vitamin A supplementation has been associated with birth defects, including cranial neural crest
      malformations. Most commonly used prenatal vitamins contain 5000 IU or less, and this is considered
      acceptable. Women should be instructed not to take any further supplementation than this. The only
exception
      to this rule is for women who may be vitamin A deficient because of strict vegetarianism or because
they are
      recent emigrants from countries in which vitamin A deficiency is endemic.

      Recent studies have suggested that vitamin A supplementation with as little as 10,000 IU (choice A)
per day
      may cause birth defects. Therefore, this amount of supplementation should be avoided.

     The probable teratogenic dose of vitamin A, notwithstanding the abovementioned study, is 25,000 IU
(choice
     B) to 50,000 IU (choice C). Patients should therefore be instructed to avoid these levels.

     100,000 IU (choice D) would certainly not be recommended.



A 25-year-old woman comes to the physician because of pain and burning with urination. She states that
the
     symptoms started two days ago and have worsened since. She has no fever or chills and has never had
these
     symptoms before. She has hypothyroidism for which she takes thyroid hormone replacement.
Otherwise she has
     no medical problems. Her temperature is 37 C (98.6 F). Examination is unremarkable including a
normal pelvic
     examination. A KOH and normal saline "wet prep" is performed on her vaginal discharge and is
negative.
     Urinalysis reveals numerous white blood cells. Which of the following is the most likely pathogen?
           A. Escherichia coli

           B. Neisseria gonorrhoeae

           C. Pseudomonas species

           D. Staphylococcus saprophyticus

           E. Trichomonas vaginalis


       Explanation:

      The correct answer is A. This patient has findings that are most consistent with a lower urinary tract
      infection. A lower urinary tract infection refers to infection of the bladder (cystitis) or urethra
(urethritis). The
      principal complaints for women with lower urinary tract infections are dysuria, urgency, and
frequency. Most
      often examination will be unremarkable. Occasionally, suprapubic tenderness may be present. A
urinalysis will
      often reveal a positive leukocyte esterase or nitrite test. The microscopic analysis will show white
blood cells.
      The most significant risk factors are related to sexual activity and hypoestrogenism. These factors
lead to
      invasion by pathogenic organisms. E. coli is by far the most common causative organism in cases of
acute
      uncomplicated cystitis. It is responsible for approximately 80% of these cases.

      N. gonorrhoeae(choice B) is often associated with cervicitis and pelvic inflammatory disease. Yet, it
can also
      cause urethritis. However, N. gonorrhoeae is a far less frequent cause of acute uncomplicated cystitis
than E.
      coli.

     Pseudomonas species (choice C) can cause urinary tract infections. It is often seen in patients with
metabolic
     or anatomic abnormalities. In a routine case of UTI, however, it is not the most common pathogen.

       Staphylococcus saprophyticus(choice D) is a somewhat common cause of acute, uncomplicated UTIs.
It
       accounts for approximately 10% of cases.

       Trichomonas vaginalis(choice E) is an organism that is most often associated with vaginitis, but can
also
      cause a urethritis. This patient, however, has a negative normal saline "wet prep." Patients with
trichomoniasis
      usually have visible organisms on the "wet prep." Also, while Trichomonas vaginalis can cause
urethritis, it is
      not nearly as common a cause as is E. coli.



A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days
ago
     she had burning with urination. Over the next few days she developed fevers and chills and a pain on
the right
    side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C
(102 F),
    blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination
shows a
    patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count
is
    18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most
appropriate
    next step in management?


         A. Observation only

         B. Spinal magnetic resonance imaging (MRI) scan

         C. Outpatient management with oral trimethoprim-sulfamethoxazole

         D. Hospital admission and initiation of IV trimethoprim-sulfamethoxazole

         E. Hospital admission and administration of a 2-week course of IV tetracycline


     Explanation:

     The correct answer is D. This patient has a presentation that is most consistent with pyelonephritis.
Patients
     with pyelonephritis typically complain of some combination of back pain, fevers, chills, dysuria,
nausea, and
     vomiting. Examination will often show an elevated temperature, costovertebral angle tenderness, and
an
     elevated leukocyte count. Urinalysis may demonstrate positive nitrite and leukocyte esterase testing.
Urine
     sediment often reveals white blood cells, red blood cells, and white cell casts. Pyelonephritis can be
managed on
     an outpatient basis if the patient is otherwise healthy, has no complicating factors, and is reliable to
return if her
     condition worsens. A patient cannot be managed as an outpatient if there is any evidence of sepsis.
This
     patient, with her high fevers, shaking chills, and elevated leukocyte count may have sepsis and should
therefore
     be admitted to the hospital for intravenous antibiotics. Treatment is with IV trimethoprim-
sulfamethoxazole, IV
     ceftriaxone, IV gentamicin with or without ampicillin, or an IV fluoroquinolone. Once the patient is
afebrile, her
     condition is improving, and she is able to tolerate oral intake, she may be converted to an oral
antibiotic regimen
     to complete a 14-day course.

    Observation only (choice A) would not be correct for this patient. This patient has pyelonephritis,
which is
    unlikely to resolve without antibiotic therapy.

     Spinal MRI (choice B) is often used to evaluate patients with back pain. This patient, however, has
back pain
     that is almost certainly related to a renal infection, therefore spinal MRI would not be necessary.
     Outpatient management with oral trimethoprim-sulfamethoxazole (choice C) is appropriate in some
cases of
     uncomplicated pyelonephritis, as explained above. This patient, however, is quite ill and possibly
septic. She,
     therefore, requires hospital admission.

     Hospital admission and administration of a 2-week course of IV tetracycline (choice E) would not be
     appropriate. Tetracycline is not a drug-of-choice in the treatment of pyelonephritis.



A 32-year-old woman, gravida 3, para 0, at 29 weeks' gestation comes to the physician for a prenatal visit.
She
      has no complaints. She had a prophylactic cerclage placed at 12 weeks' gestation because of her
history of two
      consecutive 20-week losses. These spontaneous abortions were both characterized by painless
cervical
      dilation, with the membranes found bulging into the vagina on examination . Ultrasound now
demonstrates her
      cervix to be long and closed with no evidence of funneling. Which of the following is the most
appropriate time to
      remove the cerclage from this patient?


          A. 30-32 weeks

          B. 32-34 weeks

          C. 34-36 weeks

          D. 36-38 weeks

          E. 38-40 weeks


     Explanation:

      The correct answer is D. This patient has a history that is classic for cervical incompetence. Cervical
      incompetence is characterized by painless cervical dilation, typically in the second or early third
trimester.
      Patients will often have membranes bulging into the vagina. In reality, many patients will present
with cervical
      dilation, but they will also have some cramping or contractions. This can make distinguishing preterm
labor
      from cervical incompetence difficult. Also, cervical incompetence often leads to bulging membranes
that then
      rupture. This rupture of the membranes can also cause contractions and labor such that when the
patient
      presents, the diagnosis of cervical incompetence versus preterm labor is clouded. However, when the
      diagnosis of cervical incompetence is clear, as it is in this patient, many practitioners favor placing a
cerclage
      (a stitch around the cervix intended to support the pregnancy). This cerclage should be left in place
      throughout the pregnancy. Only when the patient is at term (36-38 weeks) should the cerclage be
removed.
     To remove the cerclage at 30-32 weeks (choice A), 32-34 weeks (choice B), or 34-36 weeks (choice
C)
     places the patient at risk of iatrogenic prematurity. Say, for example, that the cerclage is removed at
33 weeks,
     and the patient goes into labor immediately thereafter and delivers. This would result in a 33-week
newborn,
     with risks of intraventricular hemorrhage, respiratory distress syndrome, and necrotizing enterocolitis.
This
     outcome would have been avoided by leaving the stitch in until 36-38 weeks.

      To remove the cerclage at 38-40 weeks (choice E) runs the risk that the patient may go into labor
prior to
      removal of the stitch. The concern here is that with labor, the stitch will cause a cervical laceration.
Therefore,
      the stitch should be removed prior to the likely onset of labor, but not so early so as to result in a
premature
      newborn if the patient goes into labor with removal of the stitch. Thus, 36-38 weeks is an ideal time
for removal
      of a cerclage.



A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit.
She
      has no current complaints. Her past medical history is significant for hepatitis C infection, which she
acquired
      through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no
medications
      and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know
whether
      she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following
is the
      correct response?


          A. There is no evidence that breast-feeding increases HCV transmission

          B. There is strong evidence that breast-feeding increases HCV transmission

          C. Complete isolation is not needed but breast-feeding is prohibited

          D. The patient should be completely isolated from the baby

          E. Casual contact with the baby is prohibited


     Explanation:

      The correct answer is A. In the U.S., hepatitis C virus (HCV) is the most common blood-borne
infection. HCV
      is a single-stranded RNA virus that is transmitted by blood-borne transmission or through sexual
contact. With
      the disease being so prevalent—it affects 3.9 million Americans—it is not rare to find a
pregnant
      patient with hepatitis C. In fact, it appears to infect as much as 0.6% of the pregnant population.
Studies that
      have been performed so far show that the rate of infection of infants born to hepatitis
C—positive,
      HIV-negative mothers is about 5%. Hepatitis C transmission through breast milk has not been clearly
proven.
      Breast-fed and bottle-fed infants have a rate of infection that is approximately 4%. Therefore, the
patient
      should be told that casual contact is permitted and that currently there is no evidence that breast-
feeding
      increases HCV transmission to the baby.

      To state that there is strong evidence that breast-feeding increases HCV transmission to the baby
(choice B)
      is incorrect. As explained above, the available studies do not demonstrate that breast-feeding
increases HCV
      transmission.

      To state that complete isolation is not needed but breast-feeding is prohibited (choice C) is incorrect
for the
      reasons detailed above.

       To state that the patient should be completely isolated from the baby (choice D), or that casual contact
with
     the baby is prohibited (choice E) are both incorrect for the reasons detailed above. If patients with
hepatitis C
     were not allowed contact with their infants, they would have to give them up, because hepatitis C is a
chronic
     disease. Fifty percent of patients with HCV develop biochemical evidence of chronic liver disease.
Hepatitis C
     is not like varicella-zoster (chickenpox), where a neonate can be isolated from the mother until she is
no longer
     infectious.


A 39-year-old woman, gravida 3, para 2, at term comes to the labor and delivery ward complaining of a
gush of
     fluid. Examination shows her to be grossly ruptured, and ultrasound reveals that the fetus is in vertex
     presentation. The fetal heart rate is in the 120s and reactive. After a few hours, with no contractions
present,
     oxytocin is started. Three hours later, the tocodynamometer shows the patient to be having
contractions every
     minute and lasting for approximately 1 minute with almost no rest in between contractions. The fetal
heart rate
     changes from 120s and reactive to a bradycardia to the 80s. Sterile vaginal examination shows that the
cervix is
     6 cm dilated. Which of the following is the most appropriate next step in management?


           A. Discontinue oxytocin

           B. Start magnesium sulfate

           C. Perform forceps assisted vaginal delivery

           D. Perform vacuum assisted vaginal delivery

           E. Perform cesarean delivery
        Explanation:

      The correct answer is A. This patient has the findings most consistent with uterine
      hyperstimulation—more than 5 contractions in 10 minutes, contractions lasting 2 minutes or
more, or
      contractions of normal duration occurring within 1 minute of each other and a non-reassuring fetal
heart rate
      tracing. Oxytocin is one of the most frequently used medications in the U.S. It is very effective at
producing
      contractions and used very often for induction of labor. The most common adverse effect with
oxytocin is a
      non-reassuring fetal heart rate pattern brought about by uterine hyperstimulation. Because it has a very
short
      half-life (3-5 minutes), discontinuing the oxytocin often resolves the hyperstimulation quickly. In this
patient, with
      a bradycardia to the 80s, this step is most appropriate. In situations where the fetal heart rate tracing is
not as
      non-reassuring, the oxytocin dosage may be reduced rather than discontinued completely.

        If uterine hyperstimulation induced by oxytocin does not respond to shutting the oxytocin off, one can
start
     magnesium sulfate (choice B) or give terbutaline. Both of these may be given intravenously to treat
uterine
     hyperstimulation that does not respond to other measures.

     To perform forceps-assisted (choice C) or vacuum-assisted (choice D) vaginal delivery would be
     contraindicated. This patient's cervix is only 6 cm dilated. Forceps and vacuum are not used unless the
cervix is
     fully dilated.

     To perform a cesarean delivery (choice E) would not be appropriate prior to trying other steps. This
fetus most
     likely is not suffering a metabolic acidemia, based on the fact that its reassuring heart rate tracing is in
the 120s
     and reactive. Its bradycardia is directly related to the hyperstimulation, which is caused by the
oxytocin. Thus,
     efforts should be made to manage the fetal distress with conservative measures prior to resorting to
cesarean
     delivery.



A 29-year-old female comes to the physician because of fevers and back pain. She is otherwise healthy
with no
      significant past medical history. Examination is significant for a temperature of 38.3 C (101 F),
moderate
      costovertebral angle tenderness, leukocytosis, and white blood cells and red blood cells in the urine.
The
      patients is diagnosed with pyelonephritis and started on intravenous antibiotics. Over the next two
days, she
      rapidly improves, and by hospital day 3, she is tolerating oral intake, voiding without difficulty,
feeling no pain,
      and she has not had a fever for 48 hours. Which of the following is the most appropriate next step in
      management?
            A. Continue intravenous antibiotics for 2 weeks

            B. Discharge home and recommend post-coital prophylaxis

            C. Discharge home off all antibiotics

            D. Discharge home to complete a 2-week course of oral antibiotics

            E. Obtain surgical evaluation


       Explanation:

      The correct answer is D. This patient has had an uncomplicated course of pyelonephritis thus far.
      Pyelonephritis is an infection of the kidney. Patients with pyelonephritis typically present with some
      combination of back pain, dysuria, hematuria, frequency, urgency, fevers, chills, nausea, and
vomiting.
      Examination often shows an elevated temperature, costovertebral angle tenderness, leukocytosis, and
white
      cells and red cells in the urine. Completely uncomplicated cases of pyelonephritis can be treated on an
      outpatient basis. When there are any complicating factors (e.g., concern for sepsis, pregnancy, old
age, or
      other medical illnesses), the patient should be admitted to the hospital for intravenous antibiotics.
However,
      once the patient's condition has improved and she is tolerating oral intake, she may be discharged
home to
      complete a 2-week course of antibiotics. When discharged, however, she should be given strict
instructions
      and precautions regarding the need to return for recurrence of the symptoms or worsening condition.

       To continue intravenous antibiotics for 2 weeks (choice A) would not be necessary. Once a patient
with
       pyelonephritis is afebrile, doing better, and able to tolerate oral intake, she may be converted to oral
       antibiotics and be discharged to home. To keep the patient hospitalized for a full 2 weeks would not
be
       necessary.

      To discharge home and recommend post-coital prophylaxis (choice B) or to discharge home off all
antibiotics
      (choice C) would not be correct. Even though the patient is feeling better, she must still complete a 2-
week
      course of oral antibiotics and not just use antibiotics for post-coital prophylaxis.

       To obtain surgical evaluation (choice E) would not be necessary. If a patient with pyelonephritis is
not
       improving, then surgical evaluation may be required to determine if another etiology is responsible or
to
     determine if surgical intervention is required. This patient, however, is improving and surgical
evaluation would
     not be necessary.


A 27-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with a gush
of
      fluid and regular contractions. Examination shows that she is grossly ruptured, contracting every 2
minutes, and
      that her cervix is dilated to 4 cm. The fetal heart rate tracing is in the 140s and reactive. She is
admitted to labor
      and delivery, and over the following 4 hours she progresses to 9 cm dilation. Over the past hour, the
fetal heart
      rate has increased from a baseline of 140 to a baseline of 160. Furthermore, moderate to severe
variable
      decelerations are seen with each contraction. The fetal heart rate does not respond to scalp stimulation.
The
      decision is made to proceed with cesarean delivery. Which of the following is the reason for the
cesarean
      delivery and the preoperative diagnosis?


          A. Fetal acidemia

          B. Fetal distress

          C. Fetal hypoxic encephalopathy

          D. Low neonatal APGAR scores

          E. Non-reassuring fetal heart rate tracing


     Explanation:

      The correct answer is E. Labor and delivery represents a process of stress for the fetus. With each
uterine
      contraction, blood flow to the placenta decreases, and the fetus is exposed to transient hypoxia. As the
labor
      progresses and more and more contractions occur, this hypoxia can eventually lead to a change from
aerobic
      to anaerobic metabolism. This change can lead to a buildup of acid in the fetus, or fetal acidemia.
However,
      most fetuses tolerate the stress of labor and delivery just fine. The fetus has a variety of protective
      mechanisms, including a blood buffering system and the diving reflex (a lowering of the heart rate in
times of
      hypoxic stress), to protect it from becoming dangerously acidemic. Electronic fetal monitoring is used
to
      determine whether the fetus is becoming dangerously acidemic or "stressed" during labor so that
delivery can
      occur prior to hypoxic damage to organs. Unfortunately, electronic fetal monitoring is not a very
specific tool for
      identifying fetal acidemia. Many fetuses with a non-reassuring fetal heart rate tracing do not have
acidemia
      and are not in distress. However, it can be very difficult to distinguish non-acidemic fetuses with non-
reassuring
      fetal heart rate tracings from acidemic fetuses with non-reassuring fetal heart rate tracings. Thus, the
delivery
      of many fetuses is expedited because of the concern for fetal acidemia when, in fact, the fetus is not
acidemic
      at all. Thus, it is most accurate to state, as is in this case, that the fetus was delivered because of the
      non-reassuring fetal heart rate tracing.
      Fetal acidemia (choice A) is not the reason for delivery. In fact, there is a strong likelihood that this
fetus is not
      acidemic at all.

     Fetal distress (choice B) is not the reason for delivery. There is a strong likelihood that this fetus is
perfectly
     healthy and will have high neonatal APGAR scores and no distress at all.

    Fetal hypoxic encephalopathy (choice C) is not the reason for delivery. The desire to prevent
    hypoxic/acidemic damage to organs, including the brain, is the reason for expediting delivery.
However, the
    non-reassuring fetal tracing does not indicate that hypoxic encephalopathy is necessarily occurring.

       Low neonatal APGAR scores (choice D) can be a marker of fetal acidemia. However, many fetuses
with
       non-reassuring fetal heart rate tracings do not have low neonatal APGAR scores.




A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has
not
      yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago,
and her
      weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her
breasts
      and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past
the
      medial border of the labia. Which of the following is the most likely diagnosis?


           A. Constitutional delay

           B. Dysfunctional uterine bleeding

           C. Dysmenorrhea

           D. Primary amenorrhea

           E. Secondary amenorrhea


       Explanation:

      The correct answer is A. Constitutional delay is normal pubertal progression at a delayed rate or
onset. The
      average age at menarche is 12 1/2 years, but it may be delayed until 16 or may begin as early as age
10.

      Dysfunctional uterine bleeding (choice B) results when the endometrium has proliferated under
estrogen
      stimulation, and then begins to slough and causes irregular painless bleeding. This is common in
younger
      adolescents who have not been menstruating long.
     Dysmenorrhea (choice C) is pain associated with menstrual cycles, and this adolescent is not
menstruating
     yet.

       Primary amenorrhea (choice D) is a delay in menarche with no menstrual cycles or secondary sex
       characteristics by 14 years of age or no menses with secondary sex characteristics by 16 years of age.
This
       adolescent has secondary characteristics but is not yet 16 years of age.

     Secondary amenorrhea (choice E) is the absence of menses for at least three cycles after regular
cycles
     have been present.



A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a
      gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the
      membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a
reassuring
      fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that
she feels
      hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8
      centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most
appropriate
      management of this patient?


            A. Administer antibiotics to the mother after vaginal delivery

            B. Administer antibiotics to the mother now and allow vaginal delivery

            C. Perform cesarean delivery

            D. Perform cesarean delivery and then administer antibiotics to the mother

            E. Perform intra-amniotic injection of antibiotics


       Explanation:

      The correct answer is B. Chorioamnionitis is an infection that can develop at any time before and
during
      delivery. The most common findings in patients with chorioamnionitis are a fever and uterine
tenderness. An
      elevated fetal heart rate is also often seen. This patient has a temperature elevation and uterine
tenderness,
      which make the diagnosis of chorioamnionitis. It is essential that antibiotics be started immediately
because
      prompt initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better
maternal and
      neonatal outcomes than if therapy is delayed. It is also essential that broad-spectrum antibiotic
therapy be
      chosen because a mixture of organisms is usually involved including aerobes and anaerobes. The
most
      frequently used regimen is ampicillin or penicillin with gentamicin. In terms of the mode of delivery,
vaginal
      delivery is acceptable in patients with chorioamnionitis. While it is desirable to have an expeditious
delivery,
      chorioamnionitis is not an indication for cesarean delivery.

      To wait to administer antibiotics to the mother after vaginal delivery (choice A) would not be correct,
as the
      delay would deprive both the mother and the fetus of the beneficial effects of the antibiotics.

      To perform cesarean delivery (choice C) or to perform cesarean delivery and then administer
antibiotics to
      the mother (choice D) would not be indicated. As explained above, when a woman has
chorioamnionitis, it is
      desirable to expedite delivery, but cesarean delivery should be performed only for obstetric
indications.

      To perform intra-amniotic injection of antibiotics (choice E) would not be indicated. Intra-amniotic
injection of
      antibiotics during labor is not a therapy used to treat chorioamnionitis during labor.




A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual
period was
     7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical
and
     surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected
aunt. Her
     husband has an affected cousin. Physical examination is unremarkable. Given her family history, she
is
     concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis
screening.
     Which of the following is the appropriate response?


          A. Screening is available

          B. Screening is inappropriate in her case

          C. Screening is mandatory

          D. Screening is not available

          E. Screening is unnecessary: she has a 1 in 4 chance of having an affected child


     Explanation:

     The correct answer is A. Cystic fibrosis (CF) is an autosomal-recessive disease that is common in
North
     American Caucasians of European ancestry. In this population, the frequency of the disease is 1 in
2500 live
     births. The carrier rate is approximately 1 in 25 individuals. The outcome of patients with CF is
highly variable.
     Some will die in infancy from complications of meconium ileus, whereas others will live beyond the
age of 50.
      The usual clinic manifestations include pulmonary disease with bronchiectasis, pancreatic
insufficiency, and
      failure to thrive. The gene for the disease is known. However, there are more than 500 mutations that
can
      cause CF. The most common mutation, which causes 75% of cases in Caucasians, is referred to as
      delta-F508. The CF gene has been cloned, and it is possible to perform screening on couples. Genetic
      techniques can also be used to determine whether the fetus has the relevant mutations. In this patient,
with her
      and her husband's family histories, screening would be available and appropriate.

     To state that screening is inappropriate in her case (choice B) is incorrect. This patient has relatives
with CF
     and so does her husband. She is concerned about the possibility of having a child with this disease.
Screening
     is available and appropriate in her case.

      To state that screening is mandatory (choice C) is inappropriate. Whether to undergo screening for a
genetic
      disease is a very personal choice. This patient may not want to know whether she is a carrier or
whether her
      fetus is affected. Many patients with genetic diseases or with family histories of genetic disease feel
this way,
      and screening is certainly not mandatory.

      To state that screening is not available (choice D) is incorrect. As stated above, CF screening is
available.

      To state that screening is unnecessary because she has a 1 in 4 chance of having an affected child
(choice
      E) is incorrect. If she and her husband were both carriers with the same mutation, the risk would be 1
in 4.
      However, we do not know this. Although they both have positive family histories, neither may be a
carrier.



A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child
has
      delayed physical development. In particular, the mother is concerned because her daughter has not yet
had a
      menstrual period. The daughter began developing breasts at age 10, but has not had her first period.
The
      daughter has no medical problems and takes no medications. Examination shows developing breasts
and
      normal external female genitalia. Which of the following is the most appropriate response to the
mother?


           A. Breast development at age 10 is abnormally early.

           B. Breast development at age 10 is abnormally late.

           C. Evaluation for late menses should be started immediately.

           D. Evaluation for late menses should be started at age 15.
          E. Her child's sexual development is none of her business.


     Explanation:

      The correct answer is D. Sexual development is variable from woman to woman, although there are
certain
      ranges of normal. Thelarche, also known as breast-budding, is usually the first sign of secondary
sexual
      development and this occurs on average between the ages of 8 and 10 years of age. The growth spurt
usually
      follows after breast budding and menarche is one of the last stages, occurring, on average, between
the ages
      of 12 and 13. This young woman began developing breasts at age 10, which is entirely appropriate.
That she
      has not had her first menstrual period yet is not abnormal. The general rule is that evaluation for
delayed
      sexual development should be started if there is no breast development by the age of 13 or menses by
the
      age of 15. This general rule can be adapted to fit the circumstances if there are tempo or sequence
      abnormalities. In this case, with breast development occurring normally and development appearing
to
      proceed in a standard fashion, the mother can be reassured and evaluation for late menses delayed
until age
      15, if it has not come before that time.

      To state that breast development at age 10 is abnormally early (choice A) or that breast development
at age
      10 is abnormally late (choice B) is incorrect. In North America, thelarche occurs, on average, between
ages 8
      to 10. Therefore, this young woman, who began breast development at age 10, falls into the normal
range.

     To state that evaluation for late menses should be started immediately (choice C) is incorrect. The
general
     rule for evaluation of delayed puberty is that evaluation should take place if thelarche has not
occurred by age
     13 or menarche by age 15. These ages represent roughly a 2.5 standard deviation from the mean and
     therefore warrant evaluation.

     To tell this mother that her child's sexual development is none of her business (choice E) would not be
     appropriate. While there are certain sexual issues where confidential discussion with an adolescent is
     appropriate, concerns regarding delayed sexual development are appropriate issues for a parent to be
     concerned with.



A 75-year-old woman comes to the physician because of abdominal distension. She states that she always
feels
      bloated and that she gets full quickly when eating. She has hypertension, for which she takes an
angiotensin
      converting enzyme (ACE) inhibitor, and no other medical problems. Examination shows abdominal
distension
      and a positive fluid wave. Pelvic examination reveals a large, nontender right adnexal mass.
Abdominal CT scan
     demonstrates masses on both ovaries, ascites, and omental caking. CA-125 level is significantly
elevated.
     Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) are negative. Which of the
following is
     the most likely diagnosis?


           A. Choriocarcinoma

           B. Cystic teratoma (dermoid)

           C. Embryonal carcinoma

           D. Epithelial ovarian cancer

           E. Sertoli stromal cell tumor


       Explanation:

      The correct answer is D. The lifetime incidence of ovarian cancer is 1.4% (1 in 70 women).
Unfortunately,
      there are no early symptoms of ovarian cancer: presenting symptoms have to do with increasing
tumor mass.
      This patient has abdominal discomfort and early satiety, which are often associated with ovarian
cancer. Other
      symptoms that may be seen are fatigue, urinary frequency, and shortness of breath. The most common
finding
      on examination is a pelvic mass, as this patient has. Masses, ascites, and evidence of tumor spread
may be
      seen on CT scan. Roughly 80% of all ovarian cancers are derived from ovarian epithelium. The other
major
      categories of ovarian tumors are germ cell tumors, sex cord stromal tumors, and metastatic tumors.
The fact
      that this patient is 75 years old, has what appears to be ovarian cancer, and has an elevated serum CA-
125
      level (seen in approximately 80% of women with epithelial cancers), makes epithelial ovarian cancer
most
      likely.

       Nongestational choriocarcinoma (choice A) of the ovary is extremely rare. Furthermore, in a patient
with
       choriocarcinoma, the serum hCG should be elevated.

       Cystic teratoma (dermoid) (choice B) accounts for 25 to 40% of all ovarian neoplasms. However,
most
       teratomas are diagnosed in premenopausal women and they do not usually present as bilateral masses,
       ascites, and evidence of tumor spread with an elevated serum CA-125 level.

      Embryonal carcinoma (choice C) is a rare germ cell tumor. Serum AFP and hCG are often elevated
with this
      tumor.

      Sertoli stromal cell tumor (choice E) is a rare sex cord stromal tumor that exhibits a male or testicular
direction
      of differentiation.
A 22-year-old woman comes to the physician for an annual examination. She has normal periods every
month
     and has no complaints. She has no medical problems but does smoke one pack of cigarettes per day.
She has
     intercourse with more than one partner. Examination is unremarkable, including a normal pelvic
examination. A
     Papanicolaou smear shows a high-grade squamous intraepithelial lesion. Which of the following is
the most
     appropriate next step in management?


           A. Repeat Pap smear in 1 year

           B. Repeat Pap smear in 6 months

           C. Perform colposcopy

           D. Perform a cone biopsy

           E. Perform a hysterectomy


     Explanation:

      The correct answer is C. The Papanicolaou smear is an excellent screening technique for cervical
cancer
      because it is easy to perform, has a relatively low-cost, and is noninvasive. All women who are either
sexually
      active or older than 18 should have annual Pap smears. The downside of the Pap smear is that it has a
low
      sensitivity and high false-negative rate. That is, many women with abnormal cervical cells will have a
negative
      Pap smear. However, if a woman receives an annual Pap smear, it is likely that the lesion will be
discovered.
      Because the progression of cervical dysplasia to cancer takes time, it is believed that these lesions will
be
      discovered early enough to cure them so long as annual screening occurs. This patient has what is
called a
      high-grade squamous intraepithelial lesion (HGSIL). These lesions have a significant risk of
eventually
      progressing to invasive cervical cancer if they are not treated. Therefore, any patient with HGSIL on a
Pap
      smear must undergo colposcopy with directed biopsies so that the lesion can be removed.

      To repeat the Pap smear in 1 year (choice A) is incorrect. A 1-year follow-up is appropriate for a
patient with
      normal Pap smears. This patient has HGSIL and therefore needs much closer follow-up.

      To repeat the Pap smear in 6 months (choice B) is incorrect. A 6-month follow-up is appropriate for
patients
      with a Pap smear showing atypical squamous cells of undetermined significance (ASCUS), or in
some patients
      with a low-grade squamous intraepithelial lesion (LGSIL).
     To perform a cone biopsy (choice D) would be incorrect. Prior to surgical management of an
abnormal Pap
     smear result, a tissue diagnosis should be made (Pap smear provides only a cytologic diagnosis). This
     requires colposcopy with directed biopsies.

      To perform a hysterectomy (choice E) would not be proper management. Hysterectomy as treatment
for
      HGSIL is generally not indicated. Some patients with recurrent HGSIL, or those with lesions that
cannot be
      properly treated with local therapy, may be candidates for hysterectomy. However, this patient is 22
years old
      and likely desires future fertility. Also, this is her first HGSIL Pap smear. Therefore, the proper
management is
      to perform a colposcopy.


A 55-year-old woman comes to the physician because of hot flashes. She first noted them about 9 months
ago,
      and since then they have been worsening. She states that the flashes come on at various times
throughout the
      day, but that they are especially intense at night. She had her last menstrual period approximately 5
months
      ago. Her medical history is significant for a pulmonary embolus at the age of 36 and severe
depression. She
      takes fluoxetine for depression and has no allergies to medications but smokes one pack of cigarettes
per day.
      Physical examination is unremarkable, including a normal pelvic examination. Which of the
following is the most
      appropriate pharmacotherapy for this patient?


           A. Clonidine

           B. Estrogen and progesterone

           C. Estrogen only

           D. Glucophage

           E. Tamoxifen


      Explanation:

      The correct answer is A. This patient has a presentation that is most consistent with perimenopausal
hot
      flashes (or hot flushes as they are sometimes called). The exact pathophysiology that underlies the hot
flash is
      not known. However, it is known that women at the menopause and men that undergo orchiectomies
      experience these symptoms. Therefore, it is assumed that it is the removal of normal levels of sex
steroids
      from the circulation that results in the hot flash. These hot feelings are experienced as a flushing that
can last
      from several seconds to many minutes. The first-line treatment for most women is with hormone
replacement
     therapy. However, estrogen is contraindicated in this patient given her history of pulmonary embolus.
The fact
     that she is a current smoker also places her at greater risk of developing a thrombus if she were to take
     hormones. Progestins alone have also been shown to relieve hot flashes; however, they may worsen
     depression and cause other mood changes in patients. Therefore an alternative treatment is needed for
her.
     Clonidine has been used with some success by many women for relief from hot flashes. It is a blood
pressure
     medication, but it has been shown to be effective against hot flashes when used in low doses.

       Estrogen and progesterone (choice B) should not be used in this patient because of her history of a
       pulmonary embolus. Combined hormone replacement therapy has been shown to increase the risk of
clot
      formation in patients. With her history and current smoking, this patient would be at a particularly
increased
      risk.

       Estrogen only (choice C) would be contraindicated in this patient for two reasons. First, her uterus is
still in
       place, and unopposed estrogen would place her at greater risk for endometrial hyperplasia and cancer.
       Second, estrogen would increase this patient's risk of thrombus formation.

    Glucophage (choice D) is an oral hypoglycemic medication used in patients with diabetes. It is not
known to
    be effective for the treatment of hot flashes.

       Tamoxifen (choice E) actually causes hot flashes in many patients and is not used to treat them.




A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this
      symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses
condoms
      intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A
urine culture is
      sent which comes back negative. Sexually transmitted disease testing is performed and the patient is
found to
      have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for
which of the
      following?


            A. Bacterial vaginosis

            B. Chlamydia

            C. Herpes

            D. Syphilis

            E. Trichomoniasis


       Explanation:
      The correct answer is B. This patient has a gonorrhea infection. Gonorrhea is one of the most
prevalent
      sexually transmitted diseases (STDs) in the United States. It is more common in patients of lower
      socioeconomic status, patients with multiple sexual partners, and in urban settings. The causative
organism is
      N. gonorrhoeae, a gram-negative aerobic diplococcus. Up to 80% of women that are infected with the
      organism will have no symptoms at all or only vague symptoms. Symptoms that are frequently noted
are
      vaginal discharge, postcoital spotting, and urinary symptoms if the urethra is involved. Examination
may reveal
      a cervicitis, although this is not always present. A patient found to have gonorrhea should be treated
with
      intramuscular ceftriaxone or oral cefixime, ofloxacin, or ciprofloxacin. These medications will
effectively
      eradicate the gonococcus. However, because Chlamydia trachomatis can be isolated in up to 50% of
women
      with gonorrhea and because women treated for gonorrhea only may soon go on to develop Chlamydia
or
      pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhea should also be
treated for
      Chlamydia. Treatment of Chlamydia is with azithromycin or doxycycline. It is also essential that this
patient's
      partner be treated as well.

        When treating a patient for gonorrhea, there is no need to treat the patient with metronidazole to treat
        bacterial vaginosis (choice A) as well, unless there is evidence of a bacterial vaginosis .

        Herpes (choice C) often presents as painful vesicles and ulcers. Patients with gonorrhea do not need
to be
        treated for herpes as well, unless there is evidence for herpes infection.

     Patients with gonorrhea are at increased risk of having other sexually transmitted diseases, including
syphilis
     (choice D). It would be prudent to check this patient for syphilis with a blood test. However, in the
absence of
     a positive syphilis test, patients with gonorrhea do not need to be treated for syphilis.

        Trichomoniasis (choice E) is treated with metronidazole. Again, as with bacterial vaginosis, herpes,
and
        syphilis, unless there is evidence of Trichomonas infection, the patient does not needed to be treated
for
        trichomoniasis.



A 36-year-old woman, gravida 5, para 4, at 30 weeks' gestation comes to the physician for a prenatal visit.
She
      feels the baby moving and has not had bleeding per vagina, contractions, or loss of fluid. The prenatal
course
      has been uncomplicated thus far. The patient is interested in having a postpartum tubal ligation. She
has many
      questions regarding the procedure, including whether there is a risk of failure. Which of the following
represents
      the closest estimate for the likelihood of failure of a postpartum tubal ligation?
           A. 1 in 10

           B. 1 in 100

           C. 1 in 1000

           D. 1 in 1,000,000

           E. There are no reported failures of postpartum tubal ligation.


      Explanation:

      The correct answer is B. Postpartum tubal ligation is a highly effective method for giving a woman
      permanent sterilization. Many methods have been developed, but the most common methods involve
doubly
      ligating a portion of each tube and excising an intervening segment. A postpartum tubal ligation can
be
      performed at the time of cesarean delivery or after a vaginal delivery. If the procedure is performed
after a
      vaginal delivery, a relatively small skin incision is usually made in or near the umbilicus. Patients
undergoing
      postpartum tubal ligation should be warned, however, that the procedure could fail. Failure may result
from
      many factors including recannalization of the tube and poor surgical technique. The most commonly
quoted
      failure rate is about 1 in 100, although a more accurate figure may be closer to 1 in 300. However, it
is
      impossible to give one exact rate, because the risk of failure depends on the patient's age. A 25-year-
old
      woman undergoing tubal ligation is more likely to experience failure than a 40-year-old woman,
because the
      25-year-old has so many more years of fertility ahead of her.

      If the failure rate were 1 in 10 (choice A) few doctors would recommend the procedure. For a birth
control
      method to be useful, it must have a low overall failure rate. A failure rate of 10% would be too great
to justify
      the risk of the procedure.

      1 in 1000 (choice C) or 1 in 1,000,000 (choice D) are the failure rates that obstetricians would like to
see
       from tubal ligation. Perhaps with time and changes in methodology, the failure rates will continue to
fall. At
       present, however, the most commonly quoted failure rate is 1 in 100.

      To state that there are no reported failures of postpartum tubal ligation (choice E) is absolutely
incorrect.
      Patients need to be cautioned that the procedure can fail and that if pregnancy is suspected, they
should
      notify their doctor immediately, as the risk of ectopic pregnancy after tubal ligation is significant.



A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of
      painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear
fluid in the
      vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern
is seen.
      Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal
fingers can be
      felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes.
External fetal
      monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the
most
      appropriate next step in management?


           A. Expectant management

           B. Oxytocin augmentation

           C. Forceps delivery

           D. Vacuum delivery

           E. Cesarean section


      Explanation:

      The correct answer is A. This patient has a compound presentation, which happens when an extremity
      prolapses alongside the fetal presenting part. In this case, the compound presentation is the fetal
vertex along
      with a fetal arm. Compound presentation occurs in approximately 1 in 1000 deliveries and is brought
about
      when the pelvic inlet is not completely occluded by the fetal head. Most often this occurs with
premature
      fetuses. A compound presentation can be allowed to undergo a normal labor and delivery. The
prolapsed arm
      should be left alone, as it will not interfere with the labor and delivery in most cases. Often the arm
will rise out
      the way as the vertex descends further.

      Oxytocin augmentation (choice B) would not be appropriate management. This patient is in active
labor, with
      painful contractions every 2 minutes and 4 cm of cervical dilation. Oxytocin is used in cases in which
there is a
      need to augment labor (e.g., when contractions are not adequate) or to induce labor (e.g., when there
are no
      contractions present.) This patient has adequate contractions.

      Forceps delivery (choice C) is not indicated at this point. The patient's cervix is not fully dilated, and
the
      presence of the fetal arm, if it persists, would prevent proper application of the forceps.

      Vacuum delivery (choice D) would not be appropriate. As with forceps, vacuum is not used unless the
cervix is
      fully dilated and the vertex is at +2 to +3 station. This patient is only 4 cm dilated, and the vertex is at
0 station.
      There is no fetal or maternal indication at this point for vacuum delivery.
     Cesarean delivery (choice E) is not indicated. As noted above, most women with a compound
presentation,
     with a hand presenting by the fetal head, can undergo a normal labor and delivery.



A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states
that
      she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes
in bowel
      or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is
intermittent
      and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that
is mildly
      tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with
features
      consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate
next step in
      management?


          A. Repeat pelvic examination in 1 year

          B. Repeat pelvic ultrasound in 6 weeks

          C. Prescribe the oral contraceptive pill

          D. Perform hysteroscopy

          E. Perform laparotomy


     Explanation:

       The correct answer is E. This patient has a presentation and findings that are most consistent with a
benign
       cystic teratoma (dermoid). Dermoids are a type of ovarian germ cell tumor. Germ cell tumors are the
most
       common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common
benign
       ovarian neoplasm. Dermoids can range in size from small masses that are noted incidentally on
ultrasound
       and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is
the
       most appropriate next step in the management of this patient because, as adnexal masses enlarge--
especially
       when they become greater than 5 cm--the risk of ovarian torsion increases. Thus, laparotomy with
removal of
       the dermoid is indicated to prevent torsion. Also, this patient's mass is causing her symptoms of pain
and
       pressure and, on that basis, should be removed. Finally, while the mass most likely is a dermoid, this
is not
       certain without pathologic diagnosis and, therefore, the cyst should be removed and evaluated by a
       pathologist. At the time of surgery, close examination should be made of the other ovary because
dermoids
      may be found bilaterally in more than 10% of cases.

      To repeat pelvic examination in 1 year (choice A) would not be correct management. This patient is
      symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed
surgically.

      To repeat pelvic ultrasound in 6 weeks choice B) is appropriate for some adnexal masses. For
example, in a
      young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most
prudent
      to recheck an ultrasound in 6 weeks to see if the cyst has resolved. This patient, however, is
symptomatic with
      a 6 cm cyst that appears to be a dermoid, which will not resolve spontaneously. She, therefore,
requires
      surgery.

      To prescribe the oral contraceptive pill (choice C) may help to prevent future ovarian cysts but it will
not
      resolve this cyst, which requires surgical management.

      To perform hysteroscopy (choice D) would not be indicated. Hysteroscopy is used to evaluate the
uterine
      cavity and would not be used for management of an adnexal mass.



A 34-year-old woman comes the physician because of lower abdominal cramping. The cramping started 2
days
      ago. Examination is unremarkable except for a pelvic examination that reveals a 10-week sized
uterus. Urine
      hCG is positive, and pelvic ultrasound reveals a 10-week intrauterine pregnancy with a fetal heart rate
of 160.
      The patient states that she is not sure whether to keep the pregnancy. Which of the following is the
most
      appropriate next step in management?


           A. Counsel the patient or refer to an appropriate counselor

           B. Notify the patient's parents

           C. Notify the patient's partner

           D. Schedule a termination of pregnancy

           E. Tell the patient that she is likely to have a miscarriage


      Explanation:

     The correct answer is A. The decision of whether to have a termination of pregnancy is a deeply
personal
     one. This patient has just been notified that she is pregnant with a 10-week fetus. She is unsure
whether she
     wants to keep her pregnancy or terminate it. In this setting, the most appropriate next step is to
counsel the
      patient regarding her options or refer the patient for counseling. In a balanced way, the patient should
be fully
      informed of all of her options including raising the child herself, placing the child up for adoption,
and abortion.

     To notify the patient's parents (choice B) is not appropriate. Such an act would violate the patient's
     confidentiality. A 34-year-old woman is an adult and issues of parental notification do not apply.

     To notify the patient's partner (choice C) is not appropriate. This notification would also violate
confidentiality.

     To schedule a termination of pregnancy (choice D) would not be appropriate. This patient has just
informed
     the physician that she is unsure what she wants to do. To just go ahead and schedule the termination
without
     proper counseling of the patient would not be a balanced or proper approach for the patient.

     To tell the patient that she is likely to have a miscarriage (choice E) is inappropriate. This patient may
have a
     miscarriage, as might any patient with a first-trimester pregnancy. However, once an intrauterine
pregnancy
     with fetal cardiac activity is identified, the risk of miscarriage is approximately 10%. Therefore, she is
most
     likely not to have a miscarriage.


A 20-year-old female comes to the physician because she has never had a period. She has no medical
      problems, has never had surgery, and takes no medications. Examination shows that she is a tall
female with
      long extremities. She has normal size breasts, although the areolas are pale. She has little axillary hair.
Pelvic
      examination is significant for scant pubic hair and a short, blind-ended vaginal pouch. Which of the
following is
      the most appropriate next step in the management of this patient?


           A. No intervention is necessary

           B. Bilateral gonadectomy

           C. Unilateral gonadectomy

           D. Bilateral mastectomy

           E. Unilateral mastectomy


     Explanation:

     The correct answer is B. This patient has the findings that are most consistent with androgen
insensitivity
     syndrome (formerly called testicular feminization syndrome). This syndrome results from genetic
defects
     leading to abnormal androgen receptor function. Patients with androgen insensitivity syndrome are
     genotypically males (46, XY) but phenotypically females-with breasts and no external male genitalia.
The
       reason that breasts develop is that estrogens, which are expressed at puberty and which also result
from
       peripheral conversion of androgens, act upon the breast tissues unopposed by androgens because of
the
      androgen receptor defect. This unopposed estrogen leads to breast growth and the resultant breasts are
      normal sized, although they have undeveloped nipples and pale areolae. There are no internal female
organs,
      because mullerian-inhibiting substance is present during development. There are no external male
organs
      because of the androgen receptor defect. Testicles do exist, but they are intra-abdominal. The gonads
have a
      high rate of malignant degeneration in patients with androgen insensitivity syndrome and therefore,
after
      puberty, they should be removed via bilateral gonadectomy. It is important to wait until after puberty
so that full
      development can take place.

     To state that no intervention is necessary (choice A) is incorrect. If the gonads are not removed from a
     patient with androgen insensitivity syndrome there is a significant risk that the patient will develop a
gonadal
     malignancy.

      To perform a unilateral gonadectomy (choice C) is incorrect. To leave one of the gonads in would still
run the
      risk of malignant degeneration in that gonad. Once puberty has taken place, therefore, both gonads
should be
      removed.

       To perform a bilateral mastectomy (choice D) or a unilateral mastectomy (choice E) would be
incorrect. In
       patients with androgen insensitivity syndrome (testicular feminization syndrome) the primary concern
is for
       gonadal malignancy and not breast malignancy.




A 33-year-old primigravid woman at 18 weeks' gestation comes to the physician for a prenatal visit. Her
prenatal
      course has been uncomplicated thus far. She has no complaints. She has had no loss of fluid,
bleeding, or
      contractions. She has hypothyroidism, for which she takes thyroid hormone replacement. The patient
states that
      a friend of hers recently had a preterm delivery. The patient is quite concerned about preterm delivery
and
      wants to know whether home uterine activity monitoring (HUAM) is recommended. Which of the
following is the
      most appropriate response?


            A. HUAM has been proven to cause preterm birth

            B. HUAM has been proven to prevent preterm birth

            C. HUAM has not been proven to prevent preterm birth
           D. HUAM should be started immediately

           E. HUAM should be started at 35 weeks


     Explanation:

      The correct answer is C. Home uterine activity monitoring (HUAM) became a controversial area of
obstetrics
      during the 1990s. Of all liveborn neonates, approximately 7% will be less than 2500 g (low birth
weight).
      Approximately 1% will be less than 1500 g (very low birth weight). Most of the infant mortality rate
comes from
      these low birth weight and very low birth weight neonates. Preterm labor and delivery is the cause of
many of
      these cases. Thus, strategies to prevent preterm delivery are very much sought after. One such
strategy is
      HUAM. With this technique, women are monitored at home with a tocodynamometer (a way to
measure uterine
      contractions). The theory is that this home monitoring will allow for preterm labor to be recognized
and treated
      in its earliest stages, which may help to prevent preterm births. In practice, however, this has not been
proven
      to be the case. Numerous studies have been performed, and HUAM has not been proven to prevent
preterm
      birth. A possible benefit of HUAM may be the early recognition of preterm labor, which would allow
for the
      administration of corticosteroids to bring about fetal pulmonary maturity, even if a preterm delivery
could not
      be prevented. This question has not been fully answered. At present, therefore, HUAM has not been
proven to
      prevent preterm birth, and its use is not recommended.

     To state that HUAM has been proven to cause preterm birth (choice A) is not correct. HUAM is a
noninvasive
     technique for monitoring uterine activity, and it is used to try to prevent preterm birth. Side effects
and
     complications are rare.

      To state that HUAM has been proven to prevent preterm birth (choice B) is incorrect. This is the
central area
      of controversy for this technique, namely that it has not been proven to prevent preterm birth.

    To state that HUAM should be started immediately (choice D), or that HUAM should be started at 35
weeks
    (choice E) is incorrect. As explained above, HUAM has not been proven to prevent preterm delivery;
    therefore, its use is not currently recommended.



A 26-year-old primigravid woman at 12 weeks' gestation comes to the physician because of pain and
swelling in
     her right thigh. She first noted the onset of the pain 2 days ago, and since then it has grown worse. An
     ultrasound study performed on her lower-extremity venous system reveals evidence of a proximal
thrombus in
    the right leg. She is started on low-molecular-weight heparin injections. Which of the following is an
advantage of
    low-molecular-weight heparin compared with unfractionated heparin?


          A. Low-molecular-weight heparin has a shorter half-life

          B. Low-molecular-weight heparin is cheaper

          C. Low-molecular-weight heparin is less likely to cause birth defects

          D. Low-molecular-weight heparin is less likely to cause thrombocytopenia

          E. Low-molecular-weight heparin is less likely to cross the placenta


     Explanation:

      The correct answer is D. This patient has a deep venous thrombosis (DVT) in her right lower
extremity.
      Pregnancy is a risk factor for the development of DVTs because of alterations in coagulation factors,
venous
      stasis, and, often, decreased physical activity. It is essential that DVT during pregnancy be treated so
that the
      thrombus does not proliferate or embolize and so that new thrombi do not form. Coumadin is
contraindicated
      during the first trimester because of the risk of birth defects in fetuses exposed to this drug. Coumadin
      embryopathy is a syndrome consisting of nasal hypoplasia and stippled vertebral and femoral
epiphyses.
      Second- and third-trimester exposure to Coumadin can lead to hydrocephaly, microcephaly,
ophthalmologic
      abnormalities, fetal growth retardation, and developmental delay. Low-molecular-weight heparin has
been
      shown to be an excellent anticoagulant because it has a longer half-life and a more predictable dose-
response
      relationship compared with unfractionated heparin, which allows once- or twice-daily dosing without
the need for
      frequent laboratory monitoring of the prothrombin time and activated partial thromboplastin time.
      Low-molecular-weight heparin is also less likely to cause thrombocytopenia and hemorrhagic
complications
      than unfractionated heparin.

     Low-molecular-weight heparin does not have a shorter half-life (choice A) than unfractionated
heparin. In fact,
     low-molecular-weight heparin has a longer half-life, and it is this quality that allows for once- or
twice-daily
     dosing.

     Low-molecular-weight heparin is not cheaper (choice B) than unfractionated heparin. Low-
molecular-weight
     heparin itself is more expensive, but there is a cost advantage in that less frequent laboratory
monitoring is
     needed.

     Neither low-molecular-weight heparin nor unfractionated heparin is likely to cause birth defects
(choice C).
      Neither crosses the placenta (choice E) and neither is associated with teratogenesis.



A 31-year-old, HIV-positive woman, gravida 3, para 2, at 32-weeks' gestation comes to the physician for a
      prenatal visit. Her prenatal course is significant for the fact that she has taken zidovudine throughout
the
      pregnancy. Otherwise, her prenatal course has been unremarkable. She has no history of mental
illness. She
      states that she has been weighing the benefits and risks of cesarean delivery in preventing
transmission of the
      virus to her baby. After much deliberation, she has decided that she does not want a cesarean delivery
and
      would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in
      management?


           A. Contact psychiatry to evaluate the patient

           B. Contact the hospital lawyers to get a court order for cesarean delivery

           C. Perform cesarean delivery at 38 weeks

           D. Perform cesarean delivery once the patient is in labor

           E. Respect the patient's decision and perform the vaginal delivery


      Explanation:

      The correct answer is E. Cesarean delivery has been shown to decrease the rate of transmission of
HIV
      from an infected mother to her fetus. Some reports have shown that the transmission rate can be
decreased
      to as low as 2% with the combination of antiretroviral medication and elective cesarean delivery prior
to labor
      or rupture of membranes. However, although cesarean delivery benefits the infant by decreasing the
risk of
      transmission, the risks of the surgery accrue to the mother. Risks of cesarean delivery include
bleeding,
      infection, and injury to internal organs. HIV-infected women with low CD4 cell counts are known to
have higher
      rates of postoperative complications. Thus, the decision of whether to have a cesarean ultimately
belongs to
      the mother. This patient's autonomy must be respected and she should have a vaginal delivery if she
so
      chooses.

       To contact either psychiatry to evaluate the patient (choice A) or the hospital lawyers to get a court
order for
       cesarean delivery (choice B) would be incorrect. Patient autonomy must be respected when it comes
to the
       decision of whether to have a cesarean delivery. This patient has weighed the benefits and risks and
has put
       a great deal of deliberation into her decision. There is no need to involve the psychiatry department or
the
     hospital lawyers in this decision.

      To perform cesarean delivery at 38 weeks (choice C) or once the patient is in labor (choice D) would
not be
      correct. In HIV-positive women who do want an elective cesarean delivery, the delivery should be
performed at
      38 weeks to avoid the risk of labor or rupture of membranes. Once labor starts or the membranes are
      ruptured, the risk of HIV transmission increases. However, this patient does not want a cesarean
delivery, so
      that operation should not be performed.



A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for
induction of
     labor. The prenatal course was significant for a positive group B Streptococcus culture performed at
35 weeks.
     Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated
Ringer's IV
     solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed.
Prostaglandin
     (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In
approximately 60
     minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting
every 1
     minute with essentially no rest in between contractions. Which of the following was most likely the
cause of the
     uterine hyperstimulation?


          A. Infection

          B. IV fluids

          C. Postdates pregnancy

          D. Prostaglandin (PGE2) gel

          E. Vaginal examination


     Explanation:

      The correct answer is D. Prostaglandin (PGE2) gel is widely used for labor induction. In simple
terms, it is
      used "to soften" an unfavorable cervix, to make the cervix more favorable for induction. It has been
shown to
      lead to an improvement in the Bishop's score, a shorter duration of labor, a need for lower maximal
doses of
      oxytocin, and a reduced incidence of cesarean deliveries. PGE2 gel can also cause uterine
contractions. One
      of the major side effects with PGE2 gel is uterine hyperstimulation. This occurs when uterine
contractions come
      one right after the other, or when there is a tetanic contraction (a prolonged uterine contraction with
no rest
      period). In this setting, the fetus can become hypoxic with a resultant bradycardia. This patient had
the gel
      placed and 60 minutes later had uterine hyperstimulation.

     Infection (choice A) has not been shown to cause uterine hyperstimulation. This patient's group B
     Streptococcus colonization is likely noncontributory.

     IV fluids (choice B), unless oxytocin is present, do not cause uterine hyperstimulation.

      Postdates pregnancy (choice C) is the reason for this patient's induction and not likely the direct cause
of her
      uterine hyperstimulation.

      Vaginal examination (choice E) does not usually cause uterine hyperstimulation. Vaginal examination
with a
      cervical examination can be used for fetal scalp stimulation—rubbing the baby's head to
provoke an
      acceleration of the fetal heart rate. However, this does not usually provoke uterine hyperstimulation.



A 29-year-old woman comes to the emergency department because of abdominal distension and shortness
of
     breath. Approximately 1 week ago, she underwent fertility treatment with ovulation induction and
oocyte retrieval.
     She has a history of polycystic ovarian syndrome but no other medical problems. She had laparoscopy
1 year
     ago as part of a fertility evaluation. She has no known drug allergies. Her temperature is 37 C (98.6 F),
blood
     pressure is 80/40 mm Hg, pulse is 130/min, and respirations are 28/min. Physical examination is
remarkable for
     crackles at the lung bases bilaterally and a distended, nontender abdomen with a fluid wave.
Ultrasound
     demonstrates bilaterally enlarged ovaries (each >10 cm) and free fluid in the abdomen. Urine hCG is
negative.
     Which of the following is the most likely diagnosis?


          A. Ectopic pregnancy

          B. Hemorrhagic ovarian cyst

          C. Ovarian hyperstimulation syndrome

          D. Ovarian torsion

          E. Tubo-ovarian abscess


     Explanation:

     The correct answer is C. This patient has a presentation that is most consistent with ovarian
     hyperstimulation syndrome (OHSS). OHSS most often occurs in patients undergoing ovulation
induction with
     gonadotropins, although it can also occur with use of clomiphene citrate. The signs and symptoms of
OHSS
      run a spectrum depending on whether the disease is mild, moderate, or severe. In mild OHSS, the
ovaries are
      less than 5 cm, and the patient has mild weight gain and pelvic discomfort. In moderate OHSS, the
ovaries can
      be up to 10 cm in diameter, and the patient has at least a 10-pound weight gain, nausea, and vomiting.
In
      severe OHSS, the ovaries are greater than 10 cm, with ascites, hydrothorax, hemoconcentration, and
oliguria.
      Management depends on the severity of the syndrome, with mild cases being managed conservatively
and
      more severe cases being managed more aggressively with the possible need for paracentesis,
thoracentesis,
      or surgery. Pelvic or abdominal examinations should not be performed if OHSS is on the differential
diagnosis
      because examination can lead to rupture of the ovarian capsule. Evaluation should be done with a
careful
      ultrasound examination.

       Ectopic pregnancy (choice A) can cause abdominal distension. However, this patient has a negative
hCG,
       which effectively rules out pregnancy.

     A hemorrhagic ovarian cyst (choice B) can also cause abdominal distension. However, with a
hemorrhagic
     cyst, pain is most often the presenting complaint. The distension is usually caused by intraperitoneal
bleeding,
     which causes significant pain and tenderness on examination. This patient has no tenderness on
examination.

     Ovarian torsion (choice D) causes significant pain. Abdominal pain and tenderness are not the
predominant
     features of this patient's presentation.

     Tubo-ovarian abscess (choice E) causes significant pain and often a fever. This patient is afebrile,
with no
     abdominal tenderness.

A 22-year-old woman, gravida 3, para 2, at 22 weeks' gestation comes to the physician because of an ulcer
      near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The
patient has
      no history of medical problems and takes no medications. She is allergic to penicillin. Examination is
significant
      for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A
rapid
      plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema
pallidum
      (MHA-TP) is also read as positive. Which of the following is the most appropriate management for
this patient?


           A. Administer erythromycin

           B. Administer levofloxacin

           C. Administer metronidazole
          D. Administer tetracycline

          E. Desensitize the patient and then administer penicillin


     Explanation:

       The correct answer is E. This patient has a presentation that is consistent with primary syphilis.
Syphilis is
       caused by the organism Treponema pallidum, which is a highly contagious spirochete. The incubation
period
       for the organism is anywhere from 10 to 90 days, after which a chancre, which is a raised, painless
ulcer, will
       appear. T. pallidum cannot be cultured, but it can be identified with darkfield microscopy or
fluorescent
       antibody staining from obvious lesions. Serologic tests can also be used, such as the RPR and VDRL
tests,
       which are not specific for T. pallidum infection and may be positive in patients with collagen vascular
disease,
       intravenous drug abuse, bacterial and viral infections, a history of blood transfusions, and even
pregnancy.
       Because the RPR and VDRL are not specific, a treponemal specific assay such as the FTA-ABS or
MHA-TP
       should also be used for confirmation. When these are positive and the patient has no history of
treatment, it is
       absolutely essential that treatment be given because syphilis in pregnancy is associated with a number
of
       complications including fetal demise, IUGR, preterm delivery, and congenital infection. Treatment
during
       pregnancy must be with penicillin as no other drug permits safe and effective treatment of the fetus as
well as
       the mother. In a patient who is allergic to penicillin, oral desensitization must be performed first in a
hospital
       setting with appropriate facilities.

      To administer erythromycin (choice A), levofloxacin (choice B), or metronidazole (choice C) would
not be
      proper management. These are not drugs that will effectively treat syphilis in pregnancy.
Furthermore,
      levofloxacin is contraindicated during pregnancy, as are all fluoroquinolones, because of the possible
      relationship between maternal use and arthropathies in the offspring.

     To administer tetracycline (choice D) would be appropriate in the non-pregnant patient with syphilis
who is
     allergic to penicillin. Tetracycline is considered a reasonable alternative in that situation. However, in
the
     pregnant patient, tetracycline cannot be used because of effects on the fetal teeth and bones. Only
penicillin is
     considered adequate for the treatment of syphilis in pregnancy.


A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks.
Her
    prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load
has
     remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other
medical
     problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes
to do
     everything possible to prevent the transmission of HIV to her baby. Which of the following is the most
     appropriate next step in management?


           A. Offer elective cesarean section after amniocentesis to determine lung maturity

           B. Offer elective cesarean section at 38 weeks

           C. Offer elective cesarean section at 34 weeks

           D. Recommend forceps-assisted vaginal delivery

           E. Recommend vaginal delivery


       Explanation:

       The correct answer is B. A significant body of evidence has developed that transmission rates of HIV
from
      mother to infant can be decreased through the use of medications and cesarean delivery. The Pediatric
AIDS
      Clinical Trials Group (PACTG) 076 Zidovudine Regimen was shown to decrease the rate of
transmission from
      25% to 8%. This regimen consisted of ZDV being given antepartum and intrapartum to the mother
and
      postpartum to the infant. More recent evidence is accumulating that the mode of delivery also affects
      transmission rates. The combination of ZDV therapy and cesarean delivery decreases the risk of
transmission
      to approximately 2%. But, the decrease in transmission with cesarean delivery occurs regardless of
whether
      the patient is receiving antiretroviral therapy. Thus, cesarean delivery should be offered to HIV-
positive women
      to prevent transmission. Delivery at 38 weeks is recommended to reduce the chances that the patient
will go
      into labor or rupture her membranes. Once these occur, the benefit of cesarean delivery is reduced.

       To offer elective c-section after amniocentesis to determine lung maturity (choice A) is incorrect.
       Amniocentesis should be avoided, if possible, in the HIV-positive woman.

      To offer elective c-section at 34 weeks (choice C) is incorrect. To perform a cesarean delivery at 34
weeks
      risks iatrogenic prematurity in the neonate. Cesarean delivery prior to the onset of labor or rupture of
      membranes is the preference, and this can be accomplished at 38 weeks with a lower risk of
iatrogenic
      prematurity.

      To recommend forceps-assisted vaginal delivery (choice D) or vaginal delivery (choice E) is
incorrect. The
      decision of which mode of delivery to choose ultimately belongs to the patient. But, vaginal delivery
would not
      be recommended, as cesarean delivery has been shown to decrease transmission rates.
A 12-year-old female comes to the physician because of a vaginal discharge. The discharge started about 2
     months ago and is whitish in color. There is no odor. The patient has no complaints of itching,
burning, or pain.
     The patient started breast development at 9 years of age and her pubertal development has proceeded
     normally to this point. She has not had her first menses and she is not sexually active. She has no
medical
     problems. Examination is normal for a 12-year-old female. Microscopic examination of the discharge
shows no
     evidence of pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely
diagnosis?


          A. Bacterial vaginosis

          B. Candida vulvovaginitis

          C. Physiologic leukorrhea

          D. Syphilis

          E. Trichomoniasis


      Explanation:

       The correct answer is C. Physiologic leukorrhea can be seen during 2 different periods of childhood.
Some
       female neonates develop a physiologic leukorrhea shortly after birth as maternal circulating estrogens
       stimulate the newborn's endocervical glands and vaginal epithelium. The discharge in these neonates
is often
       gray and gelatinous. Physiologic leukorrhea can also be seen during the months preceding menarche.
During
       this time, rising estrogen levels lead to a whitish discharge not associated with any symptoms of
irritation. This
       patient has a whitish discharge, no other symptoms, and she has had normal pubertal development up
to this
       point. The discharge itself has no characteristics of infection. Therefore, physiologic leukorrhea is the
most
       likely diagnosis.

      Bacterial vaginosis (choice A) is not the most likely diagnosis in this patient because the discharge is
not
      malodorous and there are no clue cells seen on microscopic examination of the discharge.

     Candida vulvovaginitis (choice B) is not the most likely diagnosis because the discharge is not thick
and white
     (or "cottage-cheese"-like) and the patient has no irritative symptomatology.

      Syphilis (choice D) most often presents with a painless ulcer (called a chancre) or is found with
serologic
      testing. A nonmalodorous, whitish vaginal discharge in a 12-year-old female who is not sexually
active is almost
      certainly not evidence of syphilis.
     Trichomoniasis (choice E) is also highly unlikely in this patient and the lack of trichomonads on the
     microscopic examination effectively rules out this diagnosis.




A 33-year-old woman comes to the physician because she has not had a menstrual period for 8 months. She
     had menarche at the age of 12 and, after a few years of irregular menses, has since had normal
monthly
     menses. She has no medical problems and takes no medications. Examination reveals a normal-
appearing
     female with no abnormalities noted. Urine human chorionic gonadotropin (hCG) is negative. Serum
thyroid
     stimulating hormone (TSH) and prolactin are also normal. The patient is given a 10-day course of
     medroxyprogesterone acetate. Upon completing the 10 days, she has a heavy menstrual period. This
patient's
     withdrawal bleeding in response to the progesterone provides good evidence for which of the
following?


          A. Asherman syndrome

          B. Endogenous estrogen production

          C. Endometrial carcinoma

          D. Menopause

          E. Pregnancy


     Explanation:

       The correct answer is B. Primary amenorrhea is defined as the lack of spontaneous uterine bleeding
by the
       age of 16. Secondary amenorrhea is defined as the absence of a menstrual period for 6 months or
more in a
       woman who previously had normal periods or the absence of menses for 12 months or more in
women with
       previously irregular menstrual periods. This patient, given that she previously had normal menstrual
periods,
       has secondary amenorrhea. The most common cause of missed menses in previously cycling women
is
       pregnancy. Therefore, it is absolutely essential that a pregnancy test be performed on any woman with
this
       complaint. Hyperprolactinemia is the cause of amenorrhea in 10 to 20% of cases, so it is also
important that a
       prolactin level be checked. And, because thyroid dysfunction can also cause a loss of menses, a TSH
should
       also be checked. This patient, however, is not pregnant and has normal TSH and prolactin levels. At
this point,
       some physicians would perform a progesterone withdrawal test. This consists of giving a woman an
       intramuscular injection of progesterone or oral progesterone for 5 to 10 days and then checking to see
if the
       patient has withdrawal menstrual bleeding. If withdrawal bleeding occurs within 7 days, then patients
are
     assumed to have adequate levels of endogenous estrogen production. Most patients with amenorrhea,
     adequate endogenous estrogen production, and withdrawal bleeding after the administration of
progestins will
     have some form of polycystic ovarian syndrome (PCOS).

      Asherman syndrome (choice A) describes the condition in which menstrual periods do not occur
because the
      uterine cavity has become obliterated with adhesions. These adhesions result from trauma to the basal
level of
      the endometrium, most often occurring at the time of dilation and curettage. Patients with this
syndrome would
      not be expected to have menses in response to progesterone.

     Endometrial carcinoma (choice C) typically presents with heavy, irregular bleeding or as
postmenopausal
     bleeding.

     Menopause (choice D) represents the loss of menstrual periods as ovarian function decreases.
     Postmenopausal patients would not be expected to have withdrawal menses after progesterone
exposure.

    This patient's bleeding does not provide good evidence of pregnancy (choice E). Her negative urine
hCG and
    withdrawal bleeding after progesterone make it extremely unlikely that she is pregnant.


A 25-year-old woman, gravida 2, para 2, comes to the physician to discuss birth control options. She and
her
     partner have tried to use condoms; however, they find it difficult to use them consistently and she
would like to
     try another form of contraception. She has no medical problems, takes no medications, and has no
family
     history of cancer. Her examination is within normal limits. After a discussion with the physician, she
chooses to
     take the oral contraceptive pill (OCP). She stays on the pill for the next three years. She now has most
     significantly decreased her risk of developing which of the following malignancies?


           A. Bone cancer

           B. Breast cancer

           C. Cervical cancer

           D. Endometrial cancer

           E. Liver cancer


       Explanation:

       The correct answer is D. Numerous studies have demonstrated that use of the oral contraceptive pill
       significantly decreases a woman's likelihood of developing endometrial cancer. Overall, use of the
oral
      contraceptive pill appears to decrease the risk by approximately 50%, with greatest effects in those
using the
      pill for more than 3 years. One theory to explain the decreased endometrial cancer risk in oral
contraceptive
      users is that the oral contraceptive pill provides almost continuous exposure of the endometrium to
progestins.
      The major factor in the development of endometrial cancer is estrogen exposure, whether
endogenously (e.g.,
      due to obesity or chronic anovulation) or exogenously (e.g., from unopposed estrogen replacement
therapy).
      By providing almost daily exposure to progestins, the oral contraceptive pill works to counteract the
effects of
      estrogens. Over time, women on the OCP develop thinner endometrial linings and have a lower risk
of
      developing endometrial cancer.

        There is no clear relationship between bone cancer (choice A) and OCP use.

        The relationship between breast cancer (choice B) and oral contraceptives remains unclear at this
time.
      There is some evidence that current users and those who have recently stopped may be at some
increased
      risk of breast cancer. However, there is also evidence that when breast cancer is diagnosed in an oral
      contraceptive user, it tends to be more localized than in a nonuser.

      The relationship between cervical cancer (choice C) and the OCP also remains unclear at this time.
Overall
      the results have been inconclusive. All sexually active patients should have regular screening for
cervical
      dysplasia with a Pap smear starting at age 18 or with the onset of sexual intercourse.

      The OCP does not protect against liver cancer (choice E). The OCP is believed to increase the risk of
certain
      benign liver tumors.


A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no
complaints.
      She has a regular period every month. She is sexually active with her husband. She has migraine
headaches
      and is status post a tubal ligation. She states that she uses numerous alternative medications for mood,
sleep,
      and disease prevention. Examination, including pelvic and breast examination, is unremarkable.
Which of the
      following is an appropriate question to ask this patient?


             A. Does your husband know you are using these alternative medications?

             B. Do you realize how dangerous alternative medicines are?

             C. Which alternative medications do you use?

             D. Why don't you stick with traditional medicines?

             E. Why haven't you revealed your use of alternative medications before?
     Explanation:

      The correct answer is C. Some estimates indicate that roughly 50% of Americans use some forms of
      complementary and alternative medicine (CAM). The categories of these include mind-body
interventions,
      such as yoga, alternative systems of medical practice such as Chinese medicine, pharmacologic
treatments
      such as medicinal plants, herbal medicine such as St. John's wort, diet therapies such as
vegetarianism,
      manual healing methods such as massage, and bioelectromagnetic applications such as magnets for
      musculoskeletal pain. It is essential for the physician to work with the patient regarding the use of
CAM. The
      first step is to find out which methods the patient uses. This patient has told the physician that she
uses
      alternative medications. Many patients do not offer this information, assuming that the usual
physician will not
      support CAM. It is therefore important to ask the patient whether she is using, or considering using,
CAM.
      Because the field of CAM is so broad, it is essential to ask which types of CAM the patient uses. One
cannot
      assume that all alternative therapies are equivalent. Thus, the most appropriate question to ask this
patient is
      "Which alternative medications do you use?" This is a non-threatening question that will allow her to
further
      detail her use.

     To ask, "Does your husband know you are using these alternative medications?" (choice A) is
inappropriate.
     The physician's role is to care for the patient. Whether the patient reveals her use of alternative
medicines to
     her husband is not the prime concern to the physician. This question is more likely to create conflict
than
     reveal needed information for the physician.

      To ask, "Do you realize how dangerous alternative medicines are?" (choice B) is incorrect. This
question is
      confrontational and judgmental. Many alternative therapies are safe and effective.

     To ask, "Why don't you stick with traditional medicines?" (choice D) is inappropriate. If a patient has
a
      condition and there is a remedy from the conventional medical system (known as allopathy in North
America)
      available, then it is reasonable to offer this remedy as a possibility for the patient. However, inquiring
as to why
      the patient doesn't "stick" with traditional medicine is likely to cause confrontation and a worsening
of the
      patient-doctor relationship.

     To ask, "Why haven't you revealed your use of alternative medications before?" (choice E) is also
somewhat
     challenging and confrontational. Perhaps the patient did not think a conventional physician would be
accepting
     of CAM. The important step at this point is to identify the medications and discuss their risks,
benefits, and side
     effects with the patient, as one would with traditional medications.



A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with
      contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at
term.
      Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting
every 4
      minutes. Over the next 2 hours the patient progresses to 5 centimeters dilation. An epidural is placed.
Artificial
      rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still
at 5
      centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following
is the
      most appropriate next step in management?


          A. Expectant management

          B. Intravenous oxytocin

          C. Cesarean delivery

          D. Forceps-assisted vaginal delivery

          E. Vacuum-assisted vaginal delivery


     Explanation:

      The correct answer is B. This patient is demonstrating an abnormal labor pattern with arrest of
dilation. The
      normal pattern of labor is one of continued progression. Whether a patient is in the latent phase or the
active
      phase, there should be a gradual progression with an increase in the amount of cervical dilation. This
patient,
      however, has stopped dilating and has had her contractions space out considerably. An arrest of labor
like this
      can be caused by several reasons: contractions may not be adequate; the fetus may have a
malpresentation;
      or the maternal pelvis may not be able to accommodate the fetus. In this case it appears that the
contractions
      are not adequate, so at this point, it would be reasonable to give intravenous oxytocin in an effort to
      re-establish a contraction pattern that can effect a vaginal delivery.

      Expectant management (choice A) would not be the most appropriate next step. The patient is clearly
      demonstrating a dysfunctional labor pattern at this point. To "watch and wait" in the face of
insufficient uterine
      contractions is to place the patient at risk of an even longer labor and the correspondingly higher risk
of
      infection.

      Cesarean delivery (choice C) would not be the most appropriate next step in management. This
patient may
     very well need a cesarean delivery if she is truly unable to progress in labor. However, it is worth
attempting a
     vaginal delivery in this multiparous patient who has already had two vaginal deliveries.

     To attempt a forceps-assisted vaginal delivery (choice D) or a vacuum-assisted vaginal delivery
(choice E)
     would be contraindicated. This patient's cervix is only 5 centimeters dilated. Forceps and vacuum
cannot be
     attempted in patients unless they are fully dilated and at +2 station or lower.




A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since
the
     age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with
multiple
     partners and intermittently uses condoms. She has no medical problems and takes no medications.
Her
     examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of
     endocervical cells. It is otherwise within normal limits. Which of the following is the most
appropriate next step in
     management?


           A. Repeat the Pap smear in 1 year

           B. Repeat the endocervical portion of the Pap test as soon as possible

           C. Perform colposcopy with colposcopically directed biopsies

           D. Perform laparoscopy with laparoscopically directed biopsies

           E. Perform exploratory laparotomy


     Explanation:

      The correct answer is B. A Papanicolaou smear should ideally be a sampling of the transformation
zone. An
      adequate sample should show endocervical cells. When endocervical cells are not present, there is
some
      question as to whether the transformation zone was fully sampled. If a woman has no risk factors for
cervical
      dysplasia, has had three normal annual Pap smears in a row, and has a current Pap that shows no
      abnormality other than the absence of endocervical cells, then the Pap smear can be repeated in 1
year. This
      patient, however, has significant risk factors for cervical dysplasia, including early initiation of sexual
activity,
      multiple partners, and unprotected intercourse. Therefore, this patient needs the endocervical portion
of the
      Pap test to be repeated as soon as possible.

     To repeat the Pap smear in 1 year (choice A) would be incorrect management. As noted above,
repeating the
    Pap smear in 1 year is correct only in patients who have no risk factors for cervical dysplasia, three
normal
    annual Pap smears, and a present Pap that is normal except for the lack of endocervical cells.

      To perform a colposcopy with colposcopically directed biopsies (choice C) would not be correct. This
patient
      has a normal Pap smear overall. The lack of endocervical cells makes the smear incomplete but not
abnormal.

     To perform laparoscopy with laparoscopically directed biopsies (choice D) would not be correct.
Laparoscopy
     does not allow evaluation of the cervix and is not indicated for abnormal or incomplete Pap smears.

     To perform an exploratory laparotomy (choice E) is not indicated. Again, this patient has a normal but
     incomplete Pap smear, and major surgery would not be correct management.



A 23-year-old primigravid woman at 29-weeks' gestation comes to the physician because of contractions.
She
      states that they have been occurring every 3-5 minutes for the past few hours and that they are
worsening in
      intensity. Examination reveals that the patient is afebrile and her abdomen is nontender. Her cervix is
3 cm
      dilated, and the fetus is in vertex position. The patient is started on IV magnesium sulfate and
penicillin and
      given an intramuscular injection of betamethasone. Which of the following represents the most
significant
      consequence of this patient's preterm labor?


          A. Cesarean delivery

          B. Forceps assisted vaginal delivery

          C. Maternal infection

          D. Neonatal prematurity

          E. Shoulder dystocia


     Explanation:

      The correct answer is D. Preterm labor is a major problem in the U.S. Estimates are that it affects
      somewhere between 5% and 10% of all pregnancies. The exact etiology of the preterm labor is
usually difficult
      to determine. Theories abound as to why some women develop contractions and cervical dilation
prior to term
      whereas others do not. Possible etiologies include infection, dehydration, cervical weakness, multiple
      gestation, and uterine anomalies. The most significant consequence of preterm labor is that it often
results in
      premature delivery of a premature neonate. Premature neonates are at high risk for pulmonary
immaturity,
      intraventricular hemorrhage, necrotizing enterocolitis, apnea, bradycardia, and other complications.
      Cesarean delivery (choice A) is not necessarily a consequence of preterm labor. This fetus is in the
vertex
      position, and this patient, should she have unstoppable preterm labor, could have a vaginal delivery.

      Forceps assisted vaginal delivery (choice B) is not necessarily a consequence of preterm labor. If this
patient
      is in unstoppable preterm labor, she may have a vaginal delivery without the need of forceps.

     Maternal infection (choice C) may be the cause of this patient's preterm labor, but it is unlikely to be
the most
     significant consequence of the preterm labor.

        Shoulder dystocia (choice E) has been reported to occur even in a preterm delivery, although this is
rare.
        The most significant consequence of preterm labor is neonatal prematurity, not shoulder dystocia.




A 65-year-old woman comes to the physician because of bleeding from the vagina. She states that her last
      menstrual period was at age 50 and that she has had no bleeding since. She has no medical problems
and
      takes no medications. She is not sexually active. Examination is unremarkable, including a normal
pelvic
      examination. After informed consent is obtained, an endometrial biopsy is performed. The patient
complains of
      discomfort during and after the procedure but feels well enough to go home. Later that night, with her
abdominal
      pain worsening, the patient comes to the emergency department. An ultrasound is performed that
shows a
      normal uterus and adnexae but a complex fluid collection posterior to the uterus. Which of the
following is the
      most likely diagnosis?


             A. Bowel perforation

             B. Endometritis

             C. Endometrial cancer

             D. Tuboovarian abscess

             E. Uterine perforation


        Explanation:

        The correct answer is E. This patient presents with postmenopausal bleeding. The majority of patients
who
      have postmenopausal bleeding will not have endometrial hyperplasia or cancer. However, because
      postmenopausal bleeding is the most common presenting complaint of women with endometrial
cancer, it is
      important to rule this out. A common way to evaluate the endometrium is with an endometrial biopsy.
This can
       be performed with a small suction cannula that is introduced through the cervical os and into the
uterine cavity
       to get a sample of the endometrium. The procedure is standard in the practice of gynecology but is not
without
       risks. One of the risks of endometrial biopsy is uterine perforation (i.e. advancing the cannula too far
such that
       it penetrates and perforates through the wall of the uterus). This patient has evidence of uterine
perforation.
       First, she experienced significant pain during the procedure and continuing afterwards. While
endometrial
       biopsy can cause considerable discomfort, it is usually of a crampy nature that should resolve shortly
after the
       procedure. Second, her pelvic ultrasound now shows a complex fluid collection posterior to the
uterus, which
       likely represents a collection of blood in the posterior cul-de-sac. If the patient has stable vital signs
and an
       acceptable hematocrit, uterine perforation can be managed expectantly. If, however, the patient has
evidence
       of hemodynamically significant bleeding, then she will require operative intervention.

      Bowel perforation (choice A) is a very unlikely complication with an endometrial biopsy. It's rare for
the
    cannula to be advanced far enough to damage the uterus (uterine perforation), let alone damage the
bowel.

      Endometritis (choice B) can be a complication of an endometrial biopsy. Patients undergoing
endometrial
      biopsy should be counseled that infection is one of the risks of the procedure. However, this patient is
afebrile
      and the pelvic fluid collection is more suggestive of a perforation than an endometritis.

     While it is possible that this patient has endometrial cancer (choice C), it is not likely that endometrial
cancer
     is causing her acute problem. Again, most women with postmenopausal bleeding do not have
endometrial
     cancer. And, this patient's sudden onset of pain and pelvic fluid collection after endometrial biopsy is
most
     suggestive of endometrial cancer.

     A patient with a tuboovarian abscess (choice D) usually presents with abdominal pain and fevers, and
     ultrasound will reveal a pelvic mass. In a non-sexually active patient with no adnexal mass,
tuboovarian
     abscess can be effectively ruled out.



A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit.
She
      has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician
with
      bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the
patient today
      is unremarkable. She declines to have a cerclage placed. When should this patient begin having
regular
      cervical examinations?
             A. 10 weeks

             B. 16 weeks

             C. 22 weeks

             D. 28 weeks

             E. 37 weeks


        Explanation:

       The correct answer is B. This patient has an obstetrical history that is consistent with abnormal
cervical
       competence. This diagnosis may be made when the patient has a history of painless cervical dilation
in the
       second trimester. Cervical incompetence is a cause of second-trimester pregnancy loss and preterm
delivery.
       Cervical incompetence may be congenital and/or acquired. Women who have had previous trauma to
the
       cervix (e.g. dilation of the cervix, cervical conization, or obstetric trauma) and women with mullerian
anomalies,
       or a history of in-utero exposure to diethylstilbestrol may be at increased risk. This patient, given her
history,
       was offered a cerclage. Cerclage is a procedure in which a suture is placed at the level of the internal
os after
       bladder dissection (Shirodkar) or as high up on the cervix as possible (McDonald). A prophylactic
cerclage is
       placed between 12 and 16 weeks' gestation. Once the cerclage is placed, the patient should not engage
in
       sexual intercourse, prolonged standing, or heavy lifting. This patient, however, refused to have a
cerclage
       placed. Given her history, however, she needs to be followed closely to ensure that any signs of
cervical
       incompetence are detected as soon as possible. Regular examinations of the cervix, either digitally or
with
       ultrasound, should begin at 16 weeks because cervical incompetence becomes a concern during the
second
       trimester.

        Starting regular examinations at 10 weeks (choice A) is unlikely to be helpful. Cervical incompetence
most
        often manifests itself in the second or third trimester.

        Starting regular examinations at 22 weeks (choice C) or 28 weeks (choice D) would not be correct, as
these
     gestational ages may be too late to detect cervical changes. This patient lost her last pregnancy at 22
weeks,
     which means that her cervix may have started changing several weeks earlier. To wait until 22 or 28
weeks
     would risk missing cervical changes and the possibility of instituting changes (e.g., bed rest,
hospitalization, or
     cerclage placement) to help prevent pregnancy loss.
    37 weeks (choice E) is the time at which a cerclage should be removed. In a woman with a history of
a
    22-week loss, waiting until 37 weeks to start checking the cervix regularly would not be appropriate.

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:146
posted:3/30/2011
language:English
pages:60