OBGYN

Which two cell types must be present on a Pap test for it to be considered adequate?

(Endocervical and sqaumous) exocervix (squamous cells) and the endocervical canal.

After fertilization of an ovum, when can β-hCG (human chorionic gonadotropin) first be detected in the maternal blood? A. 3 days B. 5 days C. 11 days D. 15 days

11 days

A 47-year-old G3P3 female status post-tubal ligation presents for an annual exam with complaints of menorrhagia. On exam there is a palpable abdominal mass, which is firm and nontender. Pelvic exam shows an enlarged uterus measuring 16 cm above the pubic symphysis. Urine human chorionic gonadotropin (hCG) is negative. What is the most likely diagnosis?

A leiomyoma or fibroid uterus is the most likely cause of the pelvic mass associated with menorrhagia.

A 56-year-old G3P3 female presents with a palpable breast lump, which she found on breast self-exam 3 days ago. Her mammogram last year was normal. Her family history is negative for breast cancer. On exam there is a 3 × 3-cm firm mobile mass under the left nipple. No nipple discharge is noted. What is the most appropriate next step?

Because her last mammogram was last year, the first step should be a mammogram. The patient's age places breast cancer high in the differential diagnosis.

A 27-year-old G2P1 woman presents at 14 weeks for routine prenatal care. Her examination shows an 8-week-sized uterus with no fetal heart tones. She denies any bleeding. Ultrasound shows an empty, irregularly shaped gestational sac. What is the most like diagnosis? A. Missed abortion B. Spontaneous abortion C. Blighted ovum D. Incomplete abortion E. Incorrect dates

Blighted ovum

A 42-year-old G2 P0 Ab1 woman presents at 12 weeks for prenatal care. Her past medical history is significant for spontaneous miscarriage at 8 weeks and polycystic ovary syndrome. Her current pregnancy is the result of in vitro fertilization. Her family history shows hypertension and type 2 diabetes in both parents; both sisters are healthy and her older sister (age 44) recently had a healthy baby. Along with advice for diet, exercise, and routine screening, what else should she be offered in the first trimester? A. Cardiology consultation B. Progesterone supplementation until 16 weeks C. Amniocentesis or chorionic villus sampling D. Ultrasounds every 2 weeks E. Consultation for a cesarean section

C. Amniocentesis or chorionic villus sampling

A 24-year-old G3P1 Ab1 has a pregnancy at 32 weeks and has had documented premature rupture of the membranes (PROM) since 30 weeks. Today, she notes a fever, vomiting, and stomach pain. Her blood pressure is 110/70, pulse is 102, and temperature is 102.1°F. On examination, she has hypoactive bowel sounds and a fundus, which is 27 centimeters, firm, and quite tender. The fetus is vertex with a heart rate of 180. Laboratory findings show a white blood cell count of 12,000/uL with a left shift. What is the most likely diagnosis? Normal values Pulse: 60 to 100 beats per minute Blood pressure: systolic 90 to 120, diastolic 60 to 80 Temperature: 98.6°F White blood cells: 4,500 to 11,000/uL Fetal heartrate: 120 to 160 beats per minute A. Gastroenteritis B. Small bowel obstruction C. Appendicitis D. Chorioamnionitis E. Abruption

Chorioamnionitis

A 16-year-old female presents with primary amenorrhea. Physical exam is unremarkable. The patient is Tanner stage 3, with height 5'8", and weight 140lbs. What is the most likely diagnosis?

Constitutional delay

A 28-year-old G4P1-1-1-2 female is brought into the emergency department by ambulance following a head-on collision in which she was the driver and the air bag deployed. She is 38 weeks pregnant and having contractions every 7 minutes. She also notes pain below the umbilicus that worsens with each contraction. Her blood pressure is 110/70 and pulse is 96. The fundus is 35 centimeters with palpable contractions and you note a 4 centimeter by 4 centimeter area in the suprapubic region that is very tender. There is no rebound tenderness. Vaginal examination reveals the cervix is 100% effaced and 1 centimeter dilated with intact membranes. A fetal heart tracing shows a fetal heart rate of 180 with no variability, and contractions every 7 minutes with late decelerations. What is the best course of action? Normal values Pulse: 60 to 100 beats per minute Blood pressure: systolic 90 to 120, diastolic 60 to 80 Fetal heart rate: 120 to 160 beats per minute A. IV hydration and magnesium sulfate B. Artificial rupture of membranes C. Oxytocin augmentation D. Cesarean section

D. Cesarean section

A 32-year-old G4P2-0-1-2 female is in the second stage of labor at term. Your recent examination shows a vertex presentation (left occipital posterior with a station of +1), which has not changed over the 2½ hours of her second stage. The fetal heart tracing is reactive. What is the most reasonable course of action at this point? A. Forceps delivery B. Reassess after 30 minutes C. Vacuum extraction D. Cesarean section E. Oxytocin augmentation

D. Cesarean section

How is macrosomia defined? A. Estimated fetal weight greater than 2,500 grams B. Estimated fetal weight greater than 3,500 grams C. Estimated fetal weight greater than 4,000 grams D. Estimated fetal weight greater than 4,500 grams E. Estimated fetal weight greater than 5,000 grams

D. Estimated fetal weight greater than 4,500 grams

An 18-year-old G1P0 presents with a request for a termination of pregnancy. By ultrasound she is 10 weeks pregnant. What is her best option for termination? A. Mifepristone B. Mifepristone and progesterone C. Prostaglandin induction D. Suction curettage E. Gestational age too advanced for termination

D. Suction curettage

A 24-year-old woman presents to the emergency department with an acute onset of right lower quadrant pain that began 3 hours ago. The pain is described as intermittent with radiation to the back and she rates it as a 6/10. She reports nausea but no vomiting. Her last menstrual period was 5 weeks ago. She is mildly tachycardic, but her vital signs are otherwise normal. Her abdomen has hypoactive bowel sounds, tenderness in the right lower quadrant, and no organomegaly. She has rebound tenderness and a positive Rovsing's sign. She has normal external genitalia, the uterus is normal size and nontender, the left adnexa is normal, and the right adnexa has a tender 5-centimeter mass. What is the most likely diagnosis? Laboratory findings Hemoglobin: 9.2 g/dL Hematocrit: 27.8% White blood cells: 12,000 Human chorionic gonadotropin (hCG): 4,000 mIU/mL Urinalysis: specific gravity 1.1020, 1+ white blood cells, 1+ protein, trace ketones Normal values Hematocrit: 35% to 49% Hemoglobin: 12 to 18 g/dL White blood cells: 4,500 to 11,000/uL HCG nonpregnant female: less than 3.0 mIU/mL Urinalysis ketones: negative Urinalysis protein: negative Urinalysis specific gravity: 1.003 to 1.030 Urinalysis leukocytes: less than 4 cells/high power field A. Ectopic pregnancy B. Corpus luteum cyst C. Appendicitis D. Ovarian torsion E. Tubo-ovarian abscess

A. Ectopic pregnancy

In a normal pregnancy, what causes hematocrit levels to fall? A. Increased blood volume B. Decreased production of red blood cells C. Increased breakdown of red blood cells D. Lack of available iron E. Sequestration of red blood cells in the placenta

A. Increased blood volume

A 25-year-old G3 P2 female is currently in labor at term. She has had two previous normal spontaneous vaginal deliveries at term with weights of 8 pounds 14 ounces and 9 pounds 3 ounces. The estimated fetal weight is 8 pounds, and the fetal heart tracing is reactive with good variability and contractions every 6 minutes. Three hours ago your examination showed her to be 8 cm and at 0 station. Your current examination shows a blood pressure of 120/78, and cervix at 8 centimeters and at 0 station with a left occipital anterior vertex presentation. What the best course at this point? Normal value blood pressure: systolic 90 to 120, diastolic 60 to 80 A. Oxytocin augmentation B. Cesarean section C. Magnesium sulfate D. Vacuum extraction

A. Oxytocin augmentation

What does the term metrorrhagia refer to?

Abnormally heavy bleeding

A 22-year-old woman at 39 weeks presents in early labor. Her pregnancy has been uncomplicated. Her past medical history is significant for a normal vaginal delivery at term and a spontaneous abortion. Her contractions began 3 hours ago and spontaneous rupture of membranes (SROM) occurred at home about 30 minutes ago with clear fluid. Vaginal examination shows the cervix is 2 centimeters, 100% effaced, with vertex at 0 station with a markedly tender area on the left labia. Examination of the area shows a 4-millimeter raised vesicle with clear fluid surrounded by several extremely tender ulcerated vesicles. What should be your next step? A. Culture of vesicles for herpes simplex B. Culture of vesicles for syphilis C. Prepare for vaginal delivery D. Start epidural anesthesia for pain control E. Consult with an obstetrician about performing an immediate cesarean section

E. Consult with an obstetrician about performing an immediate cesarean section

Which of the fetal tracing patterns listed is an indication for immediate delivery by cesarean section? A. Variable decelerations B. Early decelerations C. Acceleration after scalp stimulation D. Decreased variability E. Persistent late decelerations

E. Persistent late decelerations

A 23-year-old woman presents with left lower quadrant pain. On exam she is found to have a 4cm left ovarian cyst and an ultrasound shows a unilocular simple cyst. What is the best management for this patient? A. Start her on low-dose oral contraceptive pills B. Start her on high-dose oral contraceptive pills C. Follow up in 2 weeks D. Follow up in 2 months E. Refer for laparoscopy

Follow up in 2 months

A 19-year-old G0 female presents with a breast lump that she found yesterday. Her mother was recently diagnosed with breast cancer at age 53 and is undergoing chemotherapy. Her maternal aunt developed breast cancer at age 48. On exam there is a 2 × 2-cm nontender mobile mass in the upper outer quadrant of the left breast. What is the most appropriate next step?

Given this patient's age, the most likely diagnosis is a fibroadenoma, a benign lesion. Ultrasound is the test of choice because mammograms in this age group are difficult to interpret because of breast tissue density.

A 32-year-old G3P2 presents at 12 weeks with crampy lower abdominal pain and bleeding for the past 6 hours. The bleeding started off as spotting after intercourse but has continued and gotten heavier. Examination shows a soft, nontender abdomen with no rebound tenderness and negative Rovsing's sign. Pelvic examination shows bright red blood in the vagina and a 12-week-sized uterus that is firm and nontender. The cervix is soft, effaced, and open. Ultrasound shows a 12-week-sized fetus with absent fetal heart tones. What is the most likely diagnosis? A. Threatened abortion B. Inevitable abortion C. Incomplete abortion D. Missed abortion E. Septic abortione

Inevitable abortion

A 34-year-old G4P2 Ab1 woman presents at 34 weeks with abdominal pain and fever. The pain started 2 days ago, has been slowly intensifying, and is now ranked at 8/10. She is unable to localize it, saying that her whole abdomen hurts. She also notes that she has been leaking clear fluid for 4 days. Her blood pressure is 124/72, pulse is 102, and temperature is 102.1°F, and the fetal heart rate is 156. Her bowel sounds are hypoactive. The fundus is firm, is tender to light palpation, and has a height of 28 centimeters. A sterile speculum examination shows clear fluid positive for nitrazine and ferning. Her white blood cell count is 14,800/uL with 8% bands. Fetal tracing shows a baseline heart rate of 150 with good variability and no contractions. What is the best treatment for this patient? Normal values Pulse: 60 to 100 beats per minute Blood pressure: systolic 90 to 120, diastolic 60 to 80 Temperature: 98.6°F White blood cells: 4,500 to 11,000/uL Band neutrophils (Bands): 3% to 5% White blood cells: 4,500 to 11,000/uL Band neutrophils (Bands): 3% to 5% Fetal heart rate: 120 to 160 beats per minute A. Begin steroids to increase fetal lung maturity B. Begin tocolytic therapy to stop labor C. Begin antibiotics and oxytocin D. Immediate delivery by cesarean section E. Surgical consultation to rule out appendicitis

C. Begin antibiotics and oxytocin

Your patient is 12 weeks pregnant. Her obstetrical history is remarkable for a set of premature twins delivered at 30 weeks, and a miscarriage at 8 weeks. How would this be indicated on her chart? A. G2P1 B. G2P2 C. G3P1 D. G3P2 E. G3P3

C. G3P1

Ectopic pregnancies are most likely to occur in which section of the Fallopian tube?

Ampulla

A 23-year-old G2P1 woman presents at 18 weeks with right flank pain of 2 days' duration. The pain began in the right lower quadrant 3 days ago but then moved to the flank. She notes anorexia and nausea but no vomiting. She felt hot at work today but did not take her temperature. Her blood pressure is 104/70, pulse 92, respirations 14, and temperature 100.6°F; and the fetal heart rate is 140. She has hypoactive bowel sounds and a soft, nontender uterus with fundus two fingers below the umbilicus. There is mild tenderness at deep palpation in the right lower quadrant, with marked tenderness in the right flank and positive costovertebral angle (CVA) tenderness. Her white blood cell count is 14,600/uL with 8% bands. Urinalysis is normal except for two to five white blood cells and two red blood cells. What is the most likely diagnosis? Normal values Pulse: 60 to 100 beats per minute Respiration: 12 to 20 per minute Blood pressure: systolic 90 to 120, diastolic 60 to 80 Temperature: 98.6°F (37.0°C) White blood cells: 4,500 to 11,000/uL Band neutrophils (bands): 3 to 5% Urinalysis leukocytes: less than 4/high power field Urinalysis erythrocytes: less than 3/high power field Fetal heart rate: 120 to 160 beats per minute A. Appendicitis B. Pyelonephritis C. Uncomplicated urinary tract infection D. Chorioamnionitis E. Gastroenteritis

Appendicitis

According to Nagel's rule that would be the estimated date of delivery of a patient whose last menstrual period (LMP) was July 14th?

April 21

What is Chadwick's sign? A. Early effacement of cervix, seen in multiparous women B. Bluish discoloration of cervix, seen in early pregnancy C. Pain with movement of cervix, seen in pelvic inflammatory disease D. Change in shape of cervical os, seen after vaginal delivery E. Increased leukorrhea associated with pregnancy

B. Bluish discoloration of cervix, seen in early pregnancy

A 36-year-old G1P0 at 19 weeks presents with complaints of a facial rash that appeared after a trip to the beach. It is not pruritic or tender. You note smooth, dark patches over her forehead, nasal bridge, and cheekbones. What is the most likely diagnosis? A. Hegar's sign B. Chloasma C. Butterfly rash D. Rosacea E. Contact dermatitis

B. Chloasma

During the third stage of labor, your patient suddenly begins to hemorrhage. What is the best treatment for the patient? A. Administer oxytocin B. Manual extraction C. Vacuum extraction D. Cesarean section E. Forceps

B. Manual extraction

A 41-year-old G3P2 woman presents at 28 weeks complaining of wet underwear following an episode of sneezing several times. She is uncertain if she leaked urine or not. She reports normal fetal movement. What is the next best step in evaluating the patient? A. Sterile vaginal exam B. Sterile speculum exam C. Ultrasound D. Nonstress test E. Pap smear

B. Sterile speculum exam

A 22-year-old G0 female presents to the emergency department with abdominal pain that has been increasing for the past 3 days. She describes the pain as crampy with increased intensity with activity. She is sexually active and uses oral contraceptives for birth control. Her vital signs are temperature 101.3°F, blood pressure 134/78, pulse 84, and pain level 7/10. Her abdomen has normal bowel sounds with no masses or distention. She is tender in both lower quadrants with rebound tenderness and guarding. Pelvic exam shows normal external genitalia with a normal cervix. The uterus is normal sized with cervical motion tenderness and bilaterally tender adnexa. What is the best management of this patient? Normal values Pulse: 60-100 beats/minute Blood pressure: Systolic 90-120, diastolic 60-80 Temperature: 98.6°F

Inpatient, cefoxitin, clinda, gent. this patient has pelvic inflammatory disease (PID), which warrants inpatient therapy because her temperature is greater than 100.4°F and she has signs of peritonitis in the rebound and guarding. Given that she has not had children, preserving fertility with IV therapy is a goal. Treatment with IV cefoxitin alone does not provide the broad-spectrum coverage needed for PID.

A 37-year-old G5P2-0-2-2 woman presents for routine prenatal care at 12 weeks. She notes some nausea and breast tenderness but otherwise has no complaints. On examination, there are no fetal heart tones and the fundus is palpable 2 centimeters below the umbilicus. What would be your major concern for this patient? A. Fetal demise B. Molar pregnancy C. Missed abortion D. Blighted ovum

Molar pregnancy

What is the most common type of ovarian cancer in the United States?

Most ovarian cancers are of epithelial origin, and of those, serous carcinomas account for 40 percent to 50 percent of the ovarian epithelial carcinomas.

A 27-year-old female presents with complaints of oligomenorrhea and increased chin hair. Menarche occurred at age 12 with cycles of 30 to 42 days. Examination shows an obese woman with acne and hirsutism. What is the next step in treatment? A. Referral to a dermatologist B. Oral contraceptives C. Clomiphene D. Spironolactone

Oral contraceptives

A 78-year-old G5P5 woman presents for a routine annual pelvic exam. She has noted some weight gain recently but has no other complaints. On exam, her abdomen is soft, non tender, and slightly obese with no palpable masses. Her liver span is 12cm in the midclavicular line. She has a negative Murphy's sign. Her pelvic exam shows atrophic genitalia with a lack of rugation of the vaginal walls, and a small, nontender, mobile uterus. Her left ovary is palpable, mobile and nontender. The right ovary is not palpable. What physical finding is abnormal in this patient?

Palpation of an ovary

A 31-year-old G2P1 woman presents at 30 weeks with bright red bleeding. She reports awakening last night with a gush of blood after having intercourse earlier in the evening. The bleeding lasted about 2 hours then stopped with no recurrences during the past 8 hours. She denies cramps or pain at any time. She reports an active fetus. What is the most likely diagnosis? A. Placenta previa B. Postcoital bleeding C. Threatened abortion D. Cervical polyp E. Vasa previa

Placenta previa

A 16-year-old G1P0 woman presents for routine prenatal care at 39 weeks. She has no past medical history. Her blood pressure is 146/98, and a urine dipstick shows 2+ protein and negative glucose. What is the most likely diagnosis? Normal values Blood pressure: systolic 90 to 120, diastolic 60 to 80 Urinalysis protein: negative Urinalysis glucose: negative A. Renal disease B. Chronic hypertension C. Preeclampsia D. Severe preeclampsia E. Eclampsia

Preeclampsia

A 43-year-old obese G2P2 female presents with menorrhagia of 11 months' duration. She also notes oligomenorrhea for the past several years. Her last menstrual period was last week and her human chorionic gonadotropin (hCG) is negative. Her hemoglobin is 9.7 g/dL and ultrasound shows a thickened endometrial lining. What is the next best step in treating this patient? Normal value hemoglobin: 12 to 18 g/dL Computed tomography (CT) scan of the pelvis Magnetic resonance imaging (MRI) of the pelvis Refer for endometrial biopsy Refer for laparoscopy Repeat the ultrasound in 3 weeks

Refer for endometrial biopsy

A 37-year-old patient has a Pap smear report that reads, "Adequate specimen, high-grade squamous intraepithelial lesion (HSIL)." What is your next step in treating this patient? Continue with annual screening Have patient return for repeat Pap smear Have patient return for repeat Pap smear and human papillomavirus testing Have patient return for repeat Pap smear, and human papillomavirus and sexually transmitted infection testing Refer patient for a colposcopy

Refer patient for a colposcopy

A 75-year-old woman presents with postmenopausal bleeding. Her endometrial biopsy shows well-differentiated endometrial cancer. What is the best treatment for her?

Removal of the uterus and both ovaries is the first step in staging the endometrial cancer

A 22-year-old G1P0 woman with a history of gastroesophageal reflux disease presents at 32 weeks for routine prenatal care. She notes recent headaches with flashing lights, photophobia, and epigastric pain, which she attributes to stress. On examination, her blood pressure is 166/110, pulse is 64, and fundus height is 32 centimeters, and she has 2+ pedal edema bilaterally. The fetal heart rate is 120. A urine dipstick shows trace glucose and 3+ protein. What is the most likely diagnosis? Normal values Adult pulse: 60 to 100 beats per minute Blood pressure: systolic 90 to 120, diastolic 60 to 80 Urinalysis glucose: negative Urinalysis protein: negative Fetal heart rate: 120 to 160 beats per minute A. Migraine headache B. Esophagitis C. Chronic hypertension D. Preeclampsia E. Severe preeclampsia

Severe preeclampsia

What is the single most preventable cause of intrauterine growth restriction (IUGR) in the United States today? A. Alcohol use B. Recreational drugs C. Hypertension D. Smoking E. Gestational diabetes

Smoking

A 25-year-old G1P1 female presents to the emergency department with right lower quadrant pain of 4 hours duration. On pelvic computed tomography (CT) scan, a tooth-shaped object is noted in an enlarged right ovary. What is the most likely diagnosis?

Teratoma or dermoid cyst

After an episode of unprotected intercourse, when should emergency contraception be administered?

The first dose of emergency contraception should be administered within 72 hours.

A 58-year-old white woman presents to her primary care provider for a routine annual examination. Her last menstrual period was 3 years ago. She had a hysterectomy 10 years ago because of abnormal Pap smears and has not had another Pap smear since then. What do you recommend? A. There is no need for further gynecological screenings unless she develops new complaints B. Pap smear of the top of the vagina C. Ultrasound to assess the ovaries D. CT scan of the pelvis and abdomen E. Immediate referral to a gynecologist

The patient's history suggests that she had cervical intraepithelial neoplasia (CIN) and human papillomavirus (HPV). HPV can persist in the vagina following hysterectomy and may cause preinvasive lesions in the vagina. About 10% of women with CIN have concomitant preinvasive neoplasia of vulva, vagina, or anus.

For menopausal patients with symptomatic atrophic vaginitis, what is the treatment of choice?

treatment of choice is local application of estrogen to reduce the systemic risks of estrogen.

A 38-year-old G4P2-0-1-2 presents at 30 weeks with severe intermittent right flank pain that began 4 hours ago. In between the pain she has little discomfort; however, when the pain occurs she describes it as being excruciating and radiating to the right lower quadrant. She notes some nausea but no vomiting. She denies vaginal bleeding or discharge and states the baby is active. Her blood pressure is 112/70, pulse 76, respiration 14, and temperature 98.9°F. The fetal heart rate is 128. The fundus is soft and nontender, with a height of 29 centimeters. Bowel sounds are normal. There is slight tenderness in the right lower quadrant, but no rebound or Rovsing's sign. There is positive costovertebral angle (CVA) tenderness on the right. On sterile speculum exam, the cervix is closed and results are negative for nitrazine and ferning. Fetal monitoring shows a reactive fetal heart and no contractions. A complete blood cell count is normal, and urinalysis is normal except for the presence of 20 to 30 red blood cells. What is the most likely diagnosis? Normal values Pulse: 60 to 100 beats per minute Respiration: 12 to 20 per minute Blood pressure: systolic 90 to 120, diastolic 60 to 80 Temperature: 98.6°F (37.0°C) White blood cells: 4,500 to 11,000/uL Band neutrophils (Bands): 3 to 5% Urinalysis erythrocytes: less than 3/high power field Fetal heart rate: 120 to 160 beats per minute A. Abruption B. Preterm labor C. Pyelonephritis D. Nephrolithiasis E. Appendicitis

Nephrolithiasis