Family Medicine PAEA- OBGYN

Which of the following laboratory markers are helpful in establishing the diagnosis of ovarian cancer in a 55 year-old post-menopausal women? Ca-125 CEA LDH AFP

(Ca-125 is one of the best tumor markers in epithelial ovarian cancer)

A woman who is late in her last trimester presents in the emergency department with bright, red vaginal bleeding with no abdominal pain. Her blood pressure is 120/80 mm Hg. The most likely diagnosis is spontaneous abortion placenta previa hydatidiform mole abruptio placentae

(Placenta previa presents sudden painless, profuse bleeding in the third trimester)

Which of the following is a contraindication to prescribing oral hormonal contraceptives? history of iron deficiency anemia history of dysmenorrhea since age 15 positive family history of ovarian cancer history of smoking in a patient older than age 35

A history of smoking in a patient older than age 35 is considered one of the absolute contraindications to prescribing oral hormonal contraceptives due to the increased risk of thromboembolic events)

A 24 year-old sexually active woman presents to the clinic complaining of dysmenorrhea, dyspareunia and backache that occurs premenstrually. Pelvic examination shows pain upon uterine motion and uterosacral nodularity in the posterior vaginal fornix. The definitive diagnosis for this patient requires which of the following? Pelvic ultrasound CT of the abdomen Laparoscopy with biopsy CA-125 test

Diagnosis of endometriosis must be made by direct visualization. Laparoscopy with biopsy is the most appropriate diagnostic study in this patient)

Colposcopic examination of the cervix of a 38 year-old woman with a high-grade lesion on Papanicolaou (Pap) smear yields a positive endocervical canal curettage (ECC) as its only abnormality. Which of the following is the most appropriate next step in this patient? Repeat the Pap smear in 3 months Perform a conization of the cervix Repeat the colposcopic examination in 3 months No follow-up is required

( A conization of the cervix is recommended in this case because there is a substantial discrepancy between the screening Pap test and the histologic data from biopsy and ECC. Additionally the ECC is positive for disease in this case)

A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis? Ectopic pregnancy Appendicitis Crohn's disease Pelvic inflammatory disease

( High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain.)

Human papilloma virus has been strongly associated with the development of which of the following? Cervical carcinoma Ovarian carcinoma Pelvic inflammatory disease Vaginitis

( Human papilloma virus (types 16, 18, and 31) has been linked to the development of cervical carcinoma)

A 32 year-old female complains of severe irritability and emotional lability accompanied by weight gain, breast tenderness, and headache starting mid-cycle each month and abating with the onset of menses. She has tried relaxation therapy, exercise, dietary changes and over the counter pharmacologic interventions with minimal relief of her symptoms. Which of the following prescription medications is the best choice to relieve her symptoms? Alprazolam (Xanax) Fluoxetine (Prozac) Oral contraceptive pill (Ortho-novum 1/35) Spironolactone (Aldactone)

( SSRI's provide symptom improvement for patients with premenstrual syndrome (PMS))

A 56 year-old female patient comes to the office for evaluation. She complains of dyspareunia and a thin vaginal discharge. On physical examination atrophic vulvar changes are noted associated with vaginal petechiae and a thin clear discharge. What medication is recommended to treat this patient's symptoms? Topical estrogen (Estrace) cream Topical hydrocortisone (Gynecort) Metronidazole (MetroGel) vaginal gel Terconazole (Terazol) vaginal suppository

( This patient has atrophic vaginitis which is very common in postmenopausal patients. The vagina will appear atrophied, will look pale, and thin and dry in appearance. Best to treat with topical or oral estrogen preparations.)

A 24 year-old female presents with complaints of dysuria associated with fever, malaise, myalgias and headache for the past 3 days. Today she noticed some lesions on her genitalia. Physical examination reveals the presence of multiple clear vesicles and erythematous ulcers with tender bilateral inguinal adenopathy. Which of the following is the most appropriate treatment for this patient? valacyclovir (Valtrex) metronidazole (Flagyl) ceftriaxone (Rocephin) benzathine penicillin G (Bicillin)

( This patient most likely has herpes genitalis which may be treated with oral antivirals, such as valacyclovir, that will reduce the duration of viral shedding and shorten the duration of symptoms)

Which of the following is the most common presenting clinical manifestation of breast cancer? breast tenderness nipple discharge nipple retraction breast mass

(A breast mass is the most common presenting clinical manifestation of breast cancer found by the patient or health care provider.)

Which of the following is the most significant factor in the production of menopausal symptoms? decrease in estrogen decrease in testosterone increase in progesterone increase in androstenedione

(A decrease in estrogen is responsible for the majority of menopausal symptoms including, but not limited to, hot flashes, sleep disturbances, genital tract atrophy and mood changes)

A 52 year-old female complains of bouts of anxiety and depression, the latter very deep but short lived (<24 hours). She states "I often feel like I am going to jump out of my skin". Her periods have become less frequent over the past 6 months. She denies suicidal ideations. She is not sleeping through the night. Which of the following the most appropriate next step in this patient? Check a follicle-stimulating hormone level Start a tricyclic antidepressant Refer her to a psychiatrist Endometrial biopsy

(An FSH level should be assessed in this patient to evaluate for menopause as a cause for her psychiatric symptoms)

A 54 year-old female comes to your office with the complaint of vaginal itching. Her last menstrual period was three years ago. On examination the patient's vulva is smooth and somewhat shiny; her vaginal mucosa is pale and thin with a mild yellowish discharge with a pH of 6.0. The most likely cause of these symptoms is which of the following? Lichen sclerosis Atrophic vaginitis Contact Dermatitis Candidiasis

(Atrophic vaginitis is typically caused by reduced estrogen levels producing intense itching and thin vaginal mucosa with a resultant yellowish discharge that has a pH > 5.5)

A 28 year-old female presents with lower abdominal pain and vaginal discharge. On examination the patient is toxic appearing and her temperature is 39°C. Pelvic examination reveals cervical motion tenderness. What is the next best step in the evaluation of this patient? Abdominal x-ray Endocervical culture Laparoscopy Hysterosalpingogram

(Endocervical culture would be helpful in the diagnosis of pelvic infection)

A 25 year-old female presents with constant premenstrual pelvic pain. She also notes dysmenorrhea and dyspareunia. Which of the following is the most likely diagnosis? Uterine leiomyoma Endometrial polyps Ovarian cysts Endometriosis

(Endometriosis presents with premenstrual pelvic pain, dysmenorrhea, and dyspareunia)

A 35 year-old female presents with a solitary breast mass. Fine needle aspiration reveals bloody fluid with no malignant cells. What is the next best step in the care of this patient? Monthly follow-up Excisional biopsy Hormone therapy Repeat fine needle aspiration

(Excisional biopsy is the next step in cases of bloody fluid, residual mass or thickening)

A 22 year-old G0P0 asymptomatic female is seen for her yearly gynecologic examination. She denies performing self-breast exams and any family history of breast or gynecologic cancers. On palpation of her left breast, a solitary 1 cm rubbery, firm, well-circumscribed, non-tender breast mass is noted. In review of her records, similar findings were noted on last year's examination. Which of the following is the most likely diagnosis? fibroadenoma breast fat necrosis fibrocystic changes intraductal carcinoma

(Fibroadenoma of the breast most commonly is seen in young females. Typical characteristics include a solitary 1-3 cm firm, painless, freely movable mass that does not change with the menstrual cycle and are slow growing. Most are found as an incidental finding on physical examination or during self-breast examination)

A 40 year-old female presents with a 1.5 cm well-circumscribed mass noted on mammography in the right upper, outer quadrant. Which of the following procedures is most appropriate and should be done next? Fine needle aspiration BRCA 1 and BRCA 2 genetic testing Serum CA-125 Radiation therapy

(Fine needle aspiration is fairly accurate, easily performed, and has minimal morbidity)

Progesterone influence on the breast tissue prior to menstruation causes proliferation of the mammary ducts growth of the lobules and alveol proliferation of Cooper's ligaments increase in the number of glands of Montgomery

(Growth of the lobules and alveoli is under the influence of progesterone. Prior to menses, the breast swelling that women notice is a result of the progesterone which is secreted from the corpus luteum. During menses, the swelling subsides)

A 25 year-old female presents for a routine gynecological examination. You palpate a 2 cm breast mass in her right breast. Her menstrual period was last week. She has no family history of breast cancer. What is the modality of choice to further evaluate her breast mass? Magnetic resonance imaging (MRI) Excisional biopsy Ultrasound Mammography

(In a 25 year-old an ultrasound is the best choice because of the density of the breast tissue in young women)

A 25 year-old female, G2 P1001, presents to your office at 11-weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, blood is noted at the dilated cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8-9 weeks gestation. No other abnormalities are found. Which of the following is the most likely diagnosis? Threatened abortion Inevitable abortion Incomplete abortion Complete abortion

(Inevitable abortion is the gross rupture of membranes in the presence of cervical dilation)

Post-menopausal atrophic vaginitis is best treated with vaginal podophyllin solution estrogen cream corticosteroid cream boric acid solution

(Intravaginal estrogen cream is the treatment of choice for post menopausal atrophic vaginitis)

An increased incidence of breast cancer is associated with nulliparity late menarche trauma to the breast early natural menopause

(Nulliparous women have a 1.5 times higher incidence of breast cancer than multiparous women)

You are performing a routine gynecological examination on a 49 year-old female. She states that for the last six months her periods have been getting heavier and lasting for seven days duration. She also tells you that she has been experiencing urinary frequency and constipation. Her abdominal exam is unremarkable. On pelvic examination you feel a slightly enlarged uterus and a left adnexal mass that moves with the uterine fundus. Which of the following is the most likely diagnosis? Adenomyosis Uterine fibroids Ovarian neoplasm D. Diverticular disease in the colon

(Patients with uterine fibroids often have menorrhagia and/ or metrorrhagia. On examination, the uterus will be larger, and irregularly-shaped. If a mass is present and it moves with the uterus, it is suggestive of a fibroid)

A postmenopausal patient is diagnosed with grade I breast cancer. The tumor is 0.7 cm in size, estrogen-receptor positive, and axillary nodes are negative. After undergoing a lumpectomy, which of the following adjuvant therapy is indicated for this patient? chemotherapy tamoxifen ovarian ablation bisphosphonate therapy

(Tamoxifen is the adjuvant therapy of choice in post menopausal estrogen receptor positive axillary node negative breast cancer)

Mastitis associated with breastfeeding is most commonly caused by what bacteria? Listeria monocytogenes Escherichia coli Staphylococcus aureus Streptococcus pyogenes

(The most common pathogen associated with postpartum mastitis is Staphylococcus aureus which arises from the nursing infant's throat and nose)

A 56 year-old female presents to the clinic wanting testing for ovarian cancer. Her best friend was just diagnosed with Stage 4 primary cancer of the ovary. She denies family history of breast or ovarian cancer. According to screening guidelines, which of the following do you recommend? BRCA 1-2 gene testing A pelvic ultrasound yearly Continue her yearly women's health examinations CA-125testing

(The patient is advised to have regular pelvic exams. The limited prevalence of ovarian cancer and the lack of sensitivity and specificity of current available tests have so far prevented the implementation of routine ovarian cancer screening of the general population)

A 25 year-old presents with pelvic pain and uterine bleeding. Her Beta-HCG was 1200 mIU/L six days ago. Her current Beta-HCG is 1600 mIU/L. What is the next best test in the evaluation of this patient? Laparoscopy Culdocentesis Dilation and curettage Transvaginal ultrasound

(Transvaginal ultrasound is the best test to separate ectopic from intrauterine pregnancy)

A 30 year-old presents with persistent vaginal discharge and vulvar pruritus. The discharge is profuse, frothy, greenish, and foul smelling. pH of the vagina is 6.0. Which of the following is the most likely diagnosis? Vulvovaginal candidiasis Bacterial vaginosis Trichomoniasis Atrophic vaginitis

(Trichomoniasis presents with vulvar pruritus and a profuse, frothy, greenish, foul-smelling vaginal discharge with a pH usually exceeding 5.0)

A 72 year-old female presents with vulvular pruritus for the last nine months, which has progressively worsened over the last two months. She states that she went through menopause at age 54 and has been on estrogen and progesterone therapy since that time. Physical examination reveals red lesions with white plaques on the vulva. What should the next course of management include? Refer to a gynecologist for biopsy Refer to a dermatologist for antifungal therapy. Treat with a topical steroid. Treat with estrogen cream.

(Vulvular squamous cell hyperplasia causes thickening and hyperkeratosis of the vulva. The lesions are red and moist and cause intense pruritus over time the area becomes thickened and a white plaque may develop. Biopsy must be done to evaluate for intraepithelial neoplasm or invasive tumor.)

A 26 year-old monogamous female presents with cyclic pelvic pain that has been increasing over the last 6 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis? Ovarian cancer Endometriosis Functional ovarian cyst Pelvic inflammatory disease

(With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or "chocolate cyst". The patient with endometriosis also often has dysmenorrhea, dyspareunia, and dyschezia)

Dysmenorrhea would most likely occur in which of the following patients? A young teenager who just started having her menses A woman on birth control pills A marathon runner with one menses per year A 35 year-old woman with regular cycles

(Women with regular menstrual cycles are most likely to have dysmenorrhea. Dysmenorrhea is caused by a excess of prostaglandin F 2 alpha. Prostaglandin production increases under the influence of progesterone, reaching a peak at, or soon after, the start of menstruation)

When starting a patient on oral contraceptives, she should be advised to use an additional form of contraception for how long in order to prevent inadvertent pregnancy? 1 week 2 weeks 3 weeks 4 weeks

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Which of the following signs and symptoms is common in candidal vulvovaginitis? extreme vulvar irritation firm, painless ulcer tender lymphadenopathy purulent discharge

A (Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that is malodorous)

In which of the following maternal-fetal blood type pairings should the mother receive Rho-GAM? A positive mother, O negative infant A negative mother, O negative infant AB positive mother, spontaneous abortion AB negative mother, spontaneous abortion

D (Rho-GAM is indicated for an unsensitized Rh-negative patient who has had a spontaneous or induced abortion, ectopic pregnancy, or at the time of amniocentesis. It is also indicated at 28 weeks gestation and within 72 hours of delivery of an Rh-positive infant)

A 26 year-old monogamous female presents with cyclic pelvic pain that has been increasing over the last 6 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis? Ovarian cancer Endometriosis Functional ovarian cyst Pelvic inflammatory disease

Endometriosis (With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or "chocolate cyst". The patient with endometriosis also often has dysmenorrhea, dyspareunia, and dyschezia)

A 16 year-old nulliparous acutely ill female presents with bilateral lower abdominal pain. She has a temperature of 100.4 degrees F and on examination has a tender, enlarged left adnexa. Cervical culture is positive for Chlamydia. Ultrasound reveals a complex tubular structure in the left adnexal area. What is the recommended treatment? Outpatient treatment with IM ceftriaxone and oral doxycycline Oral doxycycline IM procaine penicillin Hospitalization with parenteral doxycycline and cefoxitin

Hospitalize (this patient has PID and most likely a tubo-ovarian abscess. It is recommended that the patient be hospitalized and treated with high-dose IV antibiotic therapy. For patients with tubo-ovarian abscesses, surgical drainage is often necessary)

A 24 year-old sexually active female patient is seen for the first time in the office for a complete history and physical examination. During the history, you find that the patient smokes 2 packs per day and has been sexually active since age 14 with multiple partners without the use of barrier protection. Given this information, what is the patient most at risk for developing? Cervical carcinoma Ovarian carcinoma Uterine carcinoma Vulvar carcinoma

Human papilloma virus (HPV) is a prime etiologic factor of developing cervical intraepithelial neoplasia (CIN) and cervical cancer. Cigarette smoking and HPV is associated with a two-to-four fold increase in the relative risk for developing cervical cancer)

A 47 year-old female presents to the clinic with complaints of prolonged, heavy menses that have been getting progressively worse for 3 years. She denies any pain. On physical examination, enlargement of the uterus with multiple smooth, spherical, firm masses is noted. A CBC is consistent with a mild anemia. Which of the following is the most likely diagnosis? Leiomyoma Adenomyosis Endometriosis Endometrial polyps

Leiyoma (Abnormal uterine bleeding and irregular enlargement of the uterus are most consistent with leiomyoma. Pain is rarely present unless vascular compromise occurs)

A 16 year-old G0P0 patient presents complaining of lower pelvic pain that alternates from right to left side of her pelvis. She states that it is related to her cycle and occurs most commonly midcycle. She denies sexual activity. She reports that she has taken ibuprofen at the time of the discomfort with some relief. Her pelvic examination is unremarkable. Which of the following is the most likely diagnosis? Endometriosis Mittelschmerz Functional ovarian cyst Pelvic inflammatory disease

Mittleschmerz (Women may experience pain at the time of ovulation, may alternate side to side)

A 17-year-old female presents with significant dysmenorrhea. Which of the following medications will provide relief by directly targeting prostaglandin synthesis? narcotic analgesics anabolic hormones oral contraceptive pills nonsteroidal anti-inflammatory agents

NSAIDs NSAIDs Inhibit the enzymatic production of prostaglandins

What is the most common cause of secondary amenorrhea? Pregnancy Ovarian failure Imperforate hymen Hypothalamic amenorrhea

Pregnancy is the most common cause of amenorrhea and is essential to exclude by a serum or urine pregnancy test)

A 47 year-old perimenopausal female with vasomotor symptoms complains of vulvar itching and copious vaginal discharge with a rancid odor. Physical examination reveals erythema of the vulva and petechiae on the cervix. The pH of the vaginal discharge is five. Which of the following is the recommended treatment for this patient? Topical metronidazole (Metrogel) Oral fluconazole (Diflucan) Topical estradiol (Estrace) cream Oral metronidazole (Flagyl)

This is a classic description of trichomonas vulvovaginitis. This condition must be treated with oral metronidazole or tinidazole)

A 13 year-old female presents with a six month history of lower mid-abdominal pain that is spasmodic in nature and radiates to the inner thighs. The pain usually starts within a few hours of the onset of menses and lasts about 2 days. The patient's menarche began 2 years ago. She denies any sexual activity. Physical examination, including pelvic, is unremarkable. Which of the following is the most likely diagnosis? ovarian cyst endometriosis primary dysmenorrhea premenstrual syndrome

This patient most likely has primary dysmenorrhea supported by onset of pain within 1-2 years after onset of menarche and characteristic symptoms of low, mid-abdominal, spasmodic cramping pain that radiates to the back or inner thighs beginning on the first or second day of menstruation. Pelvic examination fails to reveal any pathological findings

An 18 year-old female comes to the clinic with the complaint of increased vaginal discharge and vaginal odor. She also complains of urinary frequency. On physical examination there is evidence of thin, gray, frothy discharge in the vagina. The cervix appears erythematous and the vaginal pH is 6. Which of the following is the most likely diagnosis? Candida vaginitis Bacterial vaginosis Trichomonas vaginitis Chlamydia trachomatis

Trich

A 48 year old G3P3003 female presents to the office complaining of severe secondary dysmenorrhea and menorrhagia over the last 6 months. On physical examination her uterus feels enlarged and irregular. Which of the following is the most likely diagnosis? Endometritis Endometriosis Uterine leiomyoma Endometrial hyperplasia

Uterine leiomymoata (fibroid) typically presents with severe dysmenorrhea and menorrhagia. An enlarged, irregular uterus is noted on examination)

A 30 year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The most likely diagnosis is placenta abruption ectopic pregnancy pelvic inflammatory disease ruptured ovarian cyst

ectopic ( Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis)

Which of the following is the best test to confirm the presence of gonorrhea in a female? culture of the endocervix culture of vaginal discharge Gram stain of cervical discharge Presence of yellow discharge

the standard for diagnosis of gonorrhea is the isolation of the organsm by culture from the endocervix in women) `