OB/GYN

Total daily calcium in postmenopausal women (diet + supplementation)

1200 mg Calcium absorption decreases with age because of decrease in biologically active vitamin D. Calcium supplementation reduces bone loss and decreases fractures in individuals with low dietary intakes.

A 38 y/o G3P3 woman has experienced chronic pelvic pain for the last 6 years. She has experienced minor improvement with NSAIDs and depot medroxyprogesterone acetate to suppress her periods. However, her pain has continued and is affecting her ability to work and socialize. She is experiencing depressed moods most days, with difficulty enjoying activities that usually appeal to her and poor energy and concentration. She is otherwise healthy and uses no other medications. Which of the following treatments is most likely to improve her mood symptoms in conjunction with medical and physical therapy? A. Cognitive behavioral therapy B. Marijuana C. Gabapentin D. Alprazolam E. Oxycodone

A. CBT Pain and depression are mutually enhancing, with chronic pain contributing to feelings of depression and social isolation, and depression worsening the experience of pain and quality of life; CBT therapy has been short to be beneficial as a multidisciplinary approach to pain treatment

A 35 year-old G2P1 woman presents for her first prenatal visit at 17 weeks gestation. She is worried about delivering a child with Down syndrome, given her maternal age. She has no significant medical, surgical, family, or social history. The patient desires genetic testing for Down syndrome. What is the next best step in the management of this patient? A. Cell-free DNA screen B. Triple screen C. Quadruple screen D. Maternal serum alpha fetoprotein level E. Nuchal translucency measurement with serum PAPPA (pregnancy associated plasma protein A) and free beta-hCG level

A. Cell-free DNA screen Cell-free DNA screening is the most effective screening test for Down syndrome. The test may be performed as early as 9 weeks gestation until delivery and it detects more than 99% of cases of Down syndrome

A 35-year-old G1P1 woman has a history of endometriosis based on laparoscopic diagnosis at age 28. She has cyclic pelvic pain that was previously well-controlled on oral contraceptive pills and ibuprofen, but her pain has grown increasingly severe and unresponsive to these remedies. She is otherwise in good health and takes no other medications. Her examination is unremarkable other than posterior uterine tenderness with some nodularity noted in the cul-de-sac. Which of the following medications is likely to improve her pain soonest? A. Elagolix B. Goserelin C. Leuprolide D. Nafarelin E. Norethidrone

A. Elagolix Elagolix (a GnRH antagonist) has the fastest onset of action as it blocks GnRH receptors reducing GnRH secretion immediately Goserelin, leuprolide, and nafarelin are all competitive agonist which initially result in an increase in GnRH secretion and a symptomatic flare before ovarian hormones are suppressed after 2-4 weeks.

A 58-year-old G3P3 woman who has been menopausal since age 50 comes to your office for a health maintenance examination. She is in good health, eats a balanced diet, exercises regularly, and smokes 2 packs of cigarettes per day for the last 20 years. Her mother has a history of osteoporosis. Her physical examination is unremarkable. Her T-score for the spine on dual energy X-ray absorptiometry is -1.7. She wants to discuss treatment for her osteopenia. What is the next step in the management of this patient? A. Evaluate her risk factors for fracture B. Determine her frequency of exercise C. Assess her exogenous dietary intake of estrogen D. Assess her exogenous dietary intake of progesterone E. Repeat DEXA scan in one year

A. Evaluate her risk factors for fracture A FRAX score can be calculated and therapy recommended for a 10-year probability of a hip fracture equal or greater than 3% or a 10-year probability of a major osteoporosis-related fractures equal or greater than 20%

A 36 y/o G1P1 woman presents 8 weeks postpartum for evaluation of a breast mass. She noted the mass in her right breast two weeks ago while in the shower. She had an uncomplicated vaginal delivery and has been exclusively breast feeding her infant. She reports no breast pain, fever, or chills. Vital signs are temperature 98.6*F and pulse 72 beats/minute. Physical exam demonstrates a firm, well circumscribed 3cm mass in the upper outer quadrant of the right breast. There is no erythema or lymphadenopathy. What is the next step in evaluation of this patient? A. Order breast ultrasound B. Order mammogram C. Prescribe antibiotics D. Reassurance E. Perform a needle aspiration

A. Order a breast ultrasound Breast ultrasound is the first-line imaging choice in pregnant and lactating patients when evaluating a palpable mass. Mammogram is not as sensitive or specific during lactation. A palpable breast mass found during lactation, especially if persistent, should be evaluated to avoid a delay in the diagnosis of a pregnancy-associated breast cancer.

A 21-year-old G1P0 woman is diagnosed with a molar pregnancy and undergoes suction curettage. She recovers well and is placed on oral contraceptive pills for birth control. Within two months, her quantitative beta-hCG level drops from 168,000 mIU/mL to 32 mIU/mL. The following week, the level rises to 68 mIU/mL. What is the next best step in her management? A. Repeat the test in 48 hours B. Repeat the S&C C. Administer methotrexate D. Increase her oral contraceptive dose E. Obtain a pelvic ultrasound

A. Repeat the test in 48 hours Before any treatment it is important to rule out a new pregnancy so repeating beta-hCG is necessary. At this beta-hCG level you would not expect to see a developing intrauterine pregnancy but repeating the level in 48 hours could determine the rate of rise. After a molar pregnancy beta-hCG levels should be followed to zero after evacuation of the uterus and patients should wait at least 6 months to conceive

A 40 y/o G1 woman comes in for her first prenatal visit. This is an unplanned pregnancy and she had a positive urine pregnancy test a week ago. She is 16 weeks gestation based on her last menstrual period. She elects to have screening for aneuploidy and open neural tube defects. Her cell-free DNA test returns negative. Her maternal serum alpha-fetoprotein (MSAFP) is increased (2.6 MoM). What is the next best step in the management of this patient? A. Ultrasonic assessment of gestational age B. Amniocentesis C. Termination of pregnancy D. CVS E. Middle cerebral dopplers

A. Ultrasonic assessment of gestational age 90-95% of cases of elevated MSAFP are caused by conditions other than neural tube defects including under-estimation of gestational age, fetal demise, multiple gestation, ventral wall defects, and tumor or liver disease in the patient. Incorrect dating is the most common explanation for an elevated MSAFP.

A 16-year-old female goes to the doctor to discuss why she has not had a menstrual cycle. She is healthy and plays weekend volleyball. She studies hard and gets good grades in school. She has a good relationship with her parents. She denies any pain. On examination she is 5 feet, 1 inch tall and weighs 80 pounds. She has a normal physical examination, including breast and pubic hair growth at a Tanner stage II. Her pelvic examination is normal. What is the most likely reason this patient has not had any menses? A. Inadequate body weight B. Imperforate hymen C. Turner's Syndrome D. Mullerian agenesis E. Excessive exercise

A. inadequate body weight The patient does not weigh enough, as a body weight of 85 to 106 lbs is needed before menses begins

A 26 y/o Black G1P0 woman presents at 7 weeks gestation with her husband who is also Black. The patient's brother has sickle cell anemia, and had been hospitalized on numerous occasions with painful crises requiring narcotic pain medications and blood transfusions. What are the odds that this couple will have a child with sickle cell anemia if the carrier rate for sickle cell disease in the Black population is 1/10? A. 1 in 15 B. 1 in 60 C. 1 in 100 D. 1 in 160 E. 1 in 400

B. 1 in 60 Since the patient is unaffected she has a 1/3 chance of not being a carrier and 2/3 chance of being a carrier The patient's husband had a 1/10 chance of being a carrier (the general population risk for Black individuals. Anytime two carrier parents for an autosomal recessive condition conceive there is a 1/4 chance of having an affected child. Chance this couple will have an affected child = 1/4 * 2/3 * 1/10

A 51-year-old G3P3 woman presents for evaluation of severe hot flashes and vaginal dryness. Her last menstrual period was 18 months ago, and she is otherwise in good health. She has no family history of breast or ovarian cancer. She is a non-smoker and takes no other medications. Her physical examination is notable for a normal clinical breast examination and pelvic examination with vaginal atrophy, a non-enlarged uterus, and no adnexal masses. In counseling her about the risks and benefits of combination hormone replacement therapy, which of following conditions, given her history, is she at highest risk of developing? A. Ovarian cancer B. Breast cancer C. Colon cancer D. Endometrial cancer E. Cognitive function decline and dementia

B. Breast cancer Women's health initiative found an increase risk in breast cancer and reduction in colon cancer with combination HRT; Initiation of menopausal HRT (combines estrogen/progestin therapy) is considered to be a safe option for healthy, symptomatic women who are within 10 years of menopause or younger than 60 years and w/o contraindications (coronary heart disease, breast cancer, prior DVT, stroke, or active liver disease)

A 26-year-old G0 woman presents due to increasing facial hair growth and irregular menstrual cycles. She has gained 40 pounds over the last three years. Her symptoms began late in adolescence and have gradually worsened. She has never been pregnant and is not currently on any medications. On physical examination, she is overweight with dark hair growth at the sideburns and upper lip. The pelvic examination is normal. Which of the following would you expect to find in this patient? A. Decreased luteinizing hormone levels B. Elevated free testosterone C. Increased sex hormone binding globulin D. Increased ovarian estrogen production E. Elevated 17-hydroxyprogesterone

B. Elevated free testosterone PCOS patients have testosterone levels at the upper limits of normal or slightly elevated. Free testosterone is elevated often because sex hormone binding globulin is decreased by elevated androgens. LH is increased in a pulsatile manner which causes increased ovarian androgen production by the theca cells of the ovary

A 38-year-old G0 woman presents to the office for a health maintenance examination. She is healthy and not taking any medications. She has no history of abnormal Pap tests or sexually transmitted infections. Her menstrual cycles occur monthly with mild cramping. Her mother was diagnosed with endometriosis and had a hysterectomy and removal of the ovaries at age 38. She is 5 feet 4 inches tall and weighs 130 pounds. On pelvic examination, the patient has a palpable and mildly tender left adnexal mass. An ultrasound was obtained, which showed a 4 cm left ovarian cyst that has an echogenic but homogeneous "ground glass" appearance. What is the most likely diagnosis in this patient? A. Follicular cyst B. Endometrioma C. Serous cystadenoma D. Mature teratoma E. Polycystic ovaries

B. Endometrioma The patient most likely has an endometrioma considering her ultrasound findings and history. Endometrioma can be painful but may also be asymptomatic and found incidentally.

An 18 year old nulligravid woman presents to her physician complaining of vague right sided abdominal pain. She is otherwise healthy. On examination, a moderately tender mass is palpated just above the symphysis on the right side. Pelvic exam confirms an 8cm mildly tender adnexal mass. On ultrasound, there is a predominately solid irregular tumor arising from the right ovary. From what histological derivation is this lesion most likely? A. Epithelial cell B. Germ cell C. Sex cord-stromal cell D. Extracellular matrix E. Leiomyoma

B. Germ cell Patient too young for a straight up epithelial lesion. Sex-cord stromal cell would result in some kind of hyperestrogenic symptomology. Germ cell - form solid tumors

A 39-year-old G1P1 woman comes to the office for increased bleeding due to her known uterine fibroids, especially during her menses. She reports that her bleeding is so heavy that she has to miss two days of work every month. She has been using oral contraceptives and NSAIDs. Her most recent hematocrit was 27%. She is undecided about having more children. Short and long-term options to decrease her bleeding are reviewed. What is the next best step in the management of this patient? A. Blood transfusion B. GnRH agonist C. Endometrial ablation D. Uterine artery embolization E. Hysterectomy

B. GnRH agonist This patient has failed more conservative therapy with NSAIDs and OCPs. The next most conservative option would be a trial of medical management with GnRH agonist. GnRH agonist therapy is only recommended for a short period of time, typically before a surgical procedure or to bridge a woman who is close to menopause. In this case, it is the best short term option. Although she is anemic, she is asymptomatic and able to work.

A 30-year-old G2P1 woman presents for a voluntary termination of her pregnancy. She reports that her last menstrual period was 10 weeks ago. She had a positive pregnancy test two days ago and has been experiencing some lower abdominal cramping. She has a history of irregular periods. She is otherwise healthy and has had no surgeries. Which of the following is the next most appropriate step in her management? A. Confirm a urine pregnancy test B. Perform a pelvic US C. Perform a manual vacuum aspiration D. Perform a laparoscopy E. Administer misoprostol and mifepristone

B. Perform a pelvic US The next step in management of this patient is to perform a pelvic ultrasound. Dating the pregnancy, especially in a patient with a hx of irregular periods is important for determining which is the best method of termination. Additionally, determining the location of the pregnancy is important to rule out ectopic pregnancy.

A 29 y/o G1P1 lactating woman presents for evaluation of bleeding and cracked nipples. She had an uncomplicated delivery for breech presentation five days ago. She began breastfeeding immediately postpartum, and is feeding every two to four hours while lying on her side. She is wearing a supportive nursing bra day and night. Her only other concern is incisional pain. Which of the following is the most likely cause of her bleeding and cracked nipples? A. Feedings not frequent enough B. Poor positioning of infant C. Feedings too frequent D. Inadequate milk production E. Irritation from her bra

B. Poor positioning of infant Although the side lying position is a good one for breastfeeding, it is important for mother and baby to be belly-to-belly in order for the infant to be in a good position to latch appropriately, taking a larger part of the areola into its mouth. The pain experienced by the patient from her C-section may be interfering with appropriate positioning and she should be counseling about a different, more comfortable position.

A 35 y/o G1P0 woman at 32 weeks gestation is hospitalized for glycemic management. Her prenatal course has been complicated by chronic hypertension and T2DM. She has had difficulty with her diabetes regimen. She reports her insulin regimen as 2 units NPH in the morning. She receives 20 units due to incorrect entry of the order by the intern. She is found two hours later shaky and sweaty in her bathroom by the nurse. Her blood glucose level is 55 mg/dL. She is given appropriate management and recovers without incident. In addition to disclosing the error to the patient, which of the following is the most appropriate next step in management? A. Call a meeting of the nursing staff B. Report the incident to risk management C. Ask a different doctor to care for the patient D. Perform a root cause analysis E. No additional action required

B. Report the incident to risk management This would be considered an adverse event or occurrence in which care to the patient was inconsistent with expected care. An incorrect dose of medication was given to a patient, and the patient suffered temporary harm as a result. With the goal of improving patient safety and care, this type of incident would require a report to be filed. While a root cause analysis may be warranted it is not the next best step.

A 62-year-old G0 postmenopausal woman is being referred to your gynecologic oncology colleague after an office endometrial sample demonstrated hyperplasia with atypia and a focus of endometrioid adenocarcinoma. The patient has no significant medical, surgical, or other gynecologic history. She does not smoke and drinks only occasionally at social events. She takes a multivitamin. Her physical examination is unremarkable. Which of the following is the next best step in the management of this patient? A. Repeat endometrial biopsy B. Total hysterectomy with bilateral salpingo-oophorectomy C. Pelvic MRI D. Endometrial ablation E. Hysteroscopic resection

B. Total hysterectomy with bilateral salpingo-oophorectomy Once a pathologic diagnosis of endometrial cancer is confirmed by biopsy, definitive treatment by total hysterectomy with BSO is recommended. A staging procedure to include lymph node dissection is also part of the treatment, depending on the depth of invasion and grade of the tumor.

A 33-year-old G3P1 homeless woman presents to the Emergency Department complaining of daily vaginal bleeding. Her last menstrual period was 12 weeks ago. She moves from shelter to shelter, and has no consistent venue for receiving medical care. Ultrasound reveals multiple internal echoes consistent with a "snowstorm" appearance within the 20-week sized uterus, as well as bilateral 6 cm multicystic ovaries. Beta-hCG level is 200,000 mIU/mL. Dilation and curettage is performed and final pathology reveals a complete molar pregnancy. In addition to performing this procedure, what other step may be taken to prevent persistent gestational trophoblastic disease? A. External beam radiation B. Perform ovarian cystectomy C. Administer methotrexate D. Prescribe high dose folate E. Prescribe high dose progestin

C. Administer methotrexate Although very effective in evacuating complete and partial molar pregnancies, S&C may not be completely curative and up to 20% of complete moles may persist as GTD. Prophylactic treatment with methotrexate may be administered in high risk situations such as with a non-compliant patient who is likely to be lost to follow up

A 66-year-old G1P1 woman presents for an annual examination. Her last Pap test was 15 years ago. She underwent menopause at age 51 and has no concerns. When she was 50, she underwent a LEEP procedure for persistent CIN I, but had a normal Pap test afterwards. She considers the referral unnecessary and asks when she may discontinue having Pap tests. When should she no longer return for cervical screening tests? A. After age 75 B. If the current test is normal C. 20 years after her treatment for CIN I if cytology is normal D. After 2 negative cytology results with negative HPV co-tests at five year intervals E. She no longer needs a pap test

C. After two negative cytology results with negative HPV co-test at five year intervals This women should continue to have pap tests until she has had 10 years of normal results. Women may discontinue cervical screening after age 65 if they have no history of high grade disease or cancer and they have either three negative cytology tests in a row or two negative co-tests in a row within the past 10 years.

A 36 y/o G1 woman presents at 15 weeks gestation for her routine prenatal visit. She had a first trimester screen that indicated her risk was 1/400 of having a baby with Down syndrome, but she remains very concerned about her risk because of her age. She is otherwise healthy. Her blood pressure is 120/80, BMI 38 kg/m2. She desires the most accurate test for Down syndrome. Which of the following is the next best step in the management of this patient? A. Cell-free DNA testing B. Chorionic villus sampling C. Amniocentesis D. Sequential screen E. Detailed sonogram at approximately 18-20 weeks gestation

C. Amniocentesis Amniocentesis is a diagnostic test that may detect Down syndrome as well as other chromosomal abnormalities with the highest sensitivity. While free-cell DNA testing detects over 99% of cases of Down syndrome, there is a higher risk of not enough cells in women with higher BMIs.

A 45-year-old G3P3 woman comes to the office because she has been unable to conceive for the last two years. She is healthy and has three children, ages 10, 12 and 14, whom she conceived with her husband. She used a copper IUD after the birth of her last child and had it removed two years ago, hoping to have another child. She has no history of sexually transmitted infections or abnormal Pap tests. Her cycles are regular every 28 to 32 days. She is not taking any medications. She has been married for the last 16 years, and her husband is 52 years old and in good health. Her physical examination, including a pelvic examination, is completely normal. In addition to a semen analysis, which of the following is the most appropriate next step in the management of this patient? A. Hysteroscopy B. Hysterosalpingogram C. Anti-mullerian hormone levels D. Sperm penetration assay E. Basal body temperatures for six months

C. Anti-mullerian hormone levels This patient most likely has decreased ovarian reserve due to her age. Anti-mullerian hormone levels will help determine ovarian reserve.

A 46-year-old G2P2 woman presents with menstrual pain, heavy menstrual bleeding, and intermenstrual bleeding. She describes the pain as pressure and cramps. Ibuprofen improves the pain, but does not entirely eliminate the discomfort. Her periods last 10 days and are heavy, requiring her to change a pad every hour for the first two days. In addition, she spots in between her periods, and says she bleeds more days than not in the course of a typical month. Pelvic examination reveals a 14-week size uterus with irregular contour. Pelvic ultrasound confirms the diagnosis of fibroids. What is the most appropriate next step in the management of this patient? A. Myomectomy B. CT scan of the pelvis C. Endometrial biopsy D. GnRH agonist E. Hysterectomy

C. Endometrial biopsy The patient has classic symptoms of leiomyomata including heavy menstrual bleeding, however she is also experiencing intermenstrual bleeding. An endometrial biopsy should be performed on all women over age 45 with abnormal uterine bleeding to rule out endometrial carcinoma. A myomectomy may be a future step in treating this patient, but not until endometrial hyperplasia or cancer is ruled out with endometrial biopsy.

A 47-year-old G1P1 woman presents with severe menstrual cramps, heavy bleeding, and intermenstrual spotting. She is sexually active with her husband of 20 years. Her past medical history is significant for hypertension, which is well controlled with hydrochlorothiazide. Her blood pressure is 130/80, pulse 70 beats/minute, respiratory rate 18/minute, and BMI 41 kg/m2. On physical examination, her uterus is normal size, mobile, and non-tender. Which of the following is the most likely diagnosis in this patient? A. Adenomyosis B. Endometriosis C. Endometrial polyp D. Subserosal fibroid E. PID

C. Endometrial poly The patient's symptoms are most consistent with an endometrial poly. Polyps are common in women between the ages of 40 and 50 and cause increased menstrual flow, frequently accompanied by increased cramping and intermenstrual spotting.

A 49-year-old G5P5 woman presents for her first health maintenance examination since she had her last child 10 years ago. She has no symptoms to report. She has had two sexual partners. She smokes three to five cigarettes per day, and has been smoking for the past 15 years. Last month, her mother underwent a radical hysterectomy for stage IB cervical carcinoma. Her pelvic examination is normal, except for mucopurulent discharge and genital warts. Which of the following factors places the patient at greatest risk for developing cervical cancer? A. Family hx of cervical cancer B. Smoking history C. Genital warts D. Multiparity E. Age

C. Genital warts The majority of risk factors for cervical cancer are related to HPV exposure. In this patient with multiple risk factors, the presence of an HPV-related condition (genital warts) already indicates infection with HPV. Although the HPV type associated with condyloma is typically a low risk strain (6 and 11), she is also at risk of having been associated to high-risk types that are typically associated with high grade dysplasia and cervical cancer (16 and 18). Although smoking is a risk factor for cervical cancer, its effect is only seen in the presence of prior infection with HPV.

A 36-year-old G2P0 woman at 11 weeks gestational age requests a surgical termination of pregnancy. She had a manual vacuum aspiration last year and would like to undergo the same procedure again. She has chronic hypertension and diabetes that are well-controlled on medications. Her blood pressure is 120/80, and fasting blood glucose is 100 mg/dL. Which of the following is a contraindication for manual vacuum aspiration of this patient? A. Age B. Parity C. Gestational age D. Chronic hypertension E. Diabetes

C. Gestational age Manual vacuum aspiration is more than 99% effective in early pregnancy (less than 8 weeks EGA). Complications of pregnancy termination increases with increasing gestational age.

An 18-year-old G1P0 woman presents due to bleeding in early pregnancy. She is certain her last menstrual period was eight weeks ago. On examination, her blood pressure is 140/90, and on bimanual examination her uterus is 14-weeks size. Speculum examination reveals a slightly dilated cervix with hydropic, grape-like tissue at the cervical os. A small amount of vaginal blood is present. Her quantitative beta-hCG is 80,000 mIU/mL. A thyroid stimulating hormone (TSH) level is 0.05 mU/l (normal 0.5 - 5.0 mU/l). Which of her findings is pathognomonic for molar pregnancy? A. Beta-hCG > 50,000 mlU/mL B. Elevated BP in first trimester C. Hydropic villi at the cervical os D. Size greater than reliable dates E. TSH level < 0.08 mU/l

C. Hydropic at the cervical os Although US is generally performed to confirm the diagnosis of molar pregnancy, the passage of hydropic villi through the cervical os is pathognomoic for molar pregnancy and does not occur in any other disease state

A 21-year-old transman desires to begin contraception. He has chosen to retain his uterus and ovaries for future childbearing. He would prefer to not have a period. His past medical history and surgical history is negative. He does not smoke or use recreational drugs. He drinks alcohol very infrequently. He currently takes testosterone daily. Which of the following is the best form of contraception for this patient? A. Testosterone B. Copper IUD C. Levonorgestrel IUD D. Depot medroxyprogesterone acetate E. Combination oral contraceptive pills

C. Levonorgestrel IUD Levonorgestrel IUD is the best option for this patient. Excessive or cyclic bleeding can occur with copper IUD, depot medroxyprogesterone acetate, and combination OCPs. It is also preferable for transmen to not take systemic female hormones.

A 52-year-old G0 woman presents with long-standing vulvar and vaginal pain and burning. She has been unable to tolerate intercourse with her husband because of pain at the introitus. She has difficulty sitting for prolonged periods of time or wearing restrictive clothing because of worsening vulvar pain. She recently noticed that her gums bleed more frequently. She avoids any topical over-the-counter therapies because they intensify her pain. Her physical examination is remarkable for inflamed gingiva and a whitish reticular skin change on her buccal mucosa. A fine papular rash is present around her wrists bilaterally. Pelvic examination reveals white plaques with intervening red erosions on the labia minora as shown in the picture. A speculum cannot be inserted into her vagina because of extensive adhesions. The cervix cannot be visualized. Which of the following is the most likely diagnosis in this patient? A. Squamous cell hyperplasia B. Lichen sclerosus C. Lichen planus D. Genital psoriasis E. Vulvar cancer

C. Lichen planus Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes, and vulva. Disease manifest as inflammatory mucocutaneous eruptions characterized by remissions and flares. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain, and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum w/ or w/o scarring and erosions

A representative from an intimate partner violence outreach program asks for your help in distributing information, including a hotline to call, if needed. Where is the best place for this information to be made available? A. Office waiting room B. Communication to all patients at time of making appointment C. Office patient restroom D. Letters sent to all your patients E. Posters in front of your office

C. Office patient restroom The best place to have literature is where there is the most privacy. In the other areas cited, an abuser may see the information and prevent his/her spouse or partner from obtaining it

A 58-year-old G2P2 woman reports developing increased itching on her vulvar over the past three months. She also reports that she has noted some spotting on her undergarments. She has tried over-thecounter antifungals without any improvement. On physical examination, there is a 2 cm red velvety lesion on her right labium majus. She undergoes a biopsy that reveals adenocarcinoma. Which of the following is the most likely etiology of her lesion? A. Melanoma B. HPV C. Paget's disease D. Sarcoma E. HSV

C. Paget's disease This patient has Paget's disease of the vulva. Typically described as a red velvety appearing lesion with a discharge.

A 21-year-old G0 woman presents for her first pelvic examination. She is completely asymptomatic, healthy, and reports having only one sexual partner. She uses condoms for contraception. On examination, the patient has a normal appearing cervix except for minimal, non-malodorous vaginal discharge. Chlamydia and gonorrhea screening is performed, as well as a Pap test. The Pap test is read as ASCUS (atypical squamous cells of undetermined significance), HPV negative and her cultures are negative. Which of the following is the most appropriate management strategy for this patient? A. Repeat the pap in four to six week after antibiotic treatment for BV B. Pap test in one year C. Pap test in three years D. Colposcopy with endocervical curettage and directed biopsies E. Cervical conization

C. Pap test in three years Management options for ASCUS include performing HPV DNA testing or repeat cytology at 12 months following the abnormal pap. IF the HPV testing is negative then routine screening can be resumed at three years. If the HPV test is positive or if repeat cytology reveals ASCUS or worse then colposcopy should be performed. For women ages 21 to 24 if HPV is positive then repeat cytology at 12 months is recommended.

A 42 y/o G2P2 woman presents with chronic pelvic pain of two years duration. She describes pain as constant ever since she underwent a laparoscopic-assisted vaginal hysterectomy for menorrhagia and dysmenorrhea. She did not have any evidence of endometriosis or obvious ovarian pathology at the time of surgery. During the postoperative period, she developed pelvic pain and fever, and was diagnosed with a pelvic/vaginal cuff abscess that was treated with antibiotics and percutaneous drainage. Her pain persisted in the subsequent months. Follow-up imaging over the next two years indicated resolution of the abscess. Her abdominal examination is notable for mild-moderate tenderness across the lower quadrants, and her pelvic examination is notable for severe tenderness at the vaginal cuff. Which of the following is the most likely diagnosis in this patient? A. Endometriosis B. Pelvic inflammatory disease C. Pelvic adhesive disease D. Ovarian remnant syndrome E. Vaginismus

C. Pelvic adhesive disease Patient most likely has pelvic adhesive disease as a result of her prior hysterectomy. The development of postoperative pelvic infection likely contributed to the further development of pelvic adhesions involving the tubes and ovaries that were retained.

A 17-year-old G0 female presents with vaginal spotting for the last three days. Her last menstrual period was six weeks ago. Vitals signs are normal. Abdominal and pelvic examination reveals a 10-week sized uterus. Beta-hCG is 80,000 mIU/mL. What is the best next step in the management of this patient? A. Repeat beta-hCG in 24 hours B. Repeat beta-hCG in 48 hours C. Pelvic ultrasound D. Dilation and curettage E. Prescribe low dose aspirin

C. Pelvic ultrasound With discrepancy between dates and uterine size, a pelvic ultrasound is indicated to confirm dates and exclude multifetal gestation, uterine abnormalities, and molar pregnancy .With a beta-hCG greater than 2000 mlU/mL, an intrauterine pregnancy should be identifiable on transvaginal ultrasound.

A 20 y/o G1P0 woman at 18 weeks gestation with a history of epilepsy has conceived while taking valproic acid. This is a very desired pregnancy. She is concerned because she read on the internet that valproic acid is associated with congenital defects. Which of the following is the next best step in her care? A. Termination of pregnancy B. Add folate supplementation C. Perform a fetal survey D. Discontinue valproic acid E. Reassure that congenital defects are rare

C. Perform a fetal survey Valproic acid use during pregnancy is associated with a 1-2% incidence of neural tube defects, specifically lumbar menigomyelocele. Fetal ultrasound examination at approximately 16 to 18 weeks gestation is recommended to detect neural tube defects. Folate supplementation is important in a patient on valproic acid but by 18 weeks the neural tube should be closed and additional folate will not correct an open neural tube defect.

A 16-year-old female is seen by her family physician for a complaint of dysuria. She is otherwise healthy with a normal examination. Urine testing is positive for chlamydia. On further questioning, she admits to having a 19-year-old boyfriend with whom she has had consensual vaginal intercourse. Which of the following would be an appropriate course of action for the physician? A. Provide a prescription for ampicillin B. Notify the patient's parents or her closest relative or friend C. Provide a prescription for anti-retroviral medication D. Counsel the patient regarding the practice of "safe behavior", including not walking in deserted areas alone E. Offer the patient testing for HSV

C. Provide a prescription for anti-retroviral medication Antibiotic prophylaxis to prevent gonorrhea, chlamydia, trichomonas, and HIV is appropriate.

A 36-year-old G1P1 woman comes to the office due to hair loss. She delivered a healthy infant girl three months ago. She is currently on a progestin-only oral contraceptive pill because she is breastfeeding. In the last month, she has noticed a large amount of hair on her brush each morning. Her father has male pattern baldness and her mother, who is postmenopausal, has had some thinning of her hair, as well. Testosterone and TSH levels are within the normal range. Which of the following is the next best step in the management of this patient? A. Thyroid supplementation B. Discontinue progestin-only pill C. Reassurance D. Minoxidil treatment E. Stop breastfeeding

C. Reassurance High estrogen levels in pregnancy increase the synchrony of hair growth. Postpartum telogen effluvium (hair loss) affects 40-50% of women postpartum therefore, hair grows in the same phase and is shed at the same time. Occasionally this can result in significant postpartum hair loss at one to five months postpartum, with three months after delivery being the most common.

A 7-year-old female is undergoing evaluation for vaginal bleeding. On physical examination, she has Tanner stage III breasts, tall stature and an otherwise normal examination. An MRI of the brain and a pelvic ultrasound are normal. LH and FSH levels are in the pubertal range, and she has normal DHEAS and androgen levels. What is the most likely diagnosis in this patient? A. Pituitary adenoma B. Congenital adrenal hyperplasia C. True precocious puberty D. McCune Albright Syndrome E. Ovarian neoplasm

C. True precocious puberty True precocious puberty is a dx of exclusion where the sex steroids are increased by the HPO axis, with increased pulsatile GnRH secretions McCune Albright Syndrome is characterized by premature menses before breast and pubic hair development

An 18-year-old G0 woman presents to discuss contraception. Her best friend's mother was just diagnosed with ovarian cancer. The patient is healthy and does not have any significant medical history. She does not have a family history of ovarian, breast, or any other malignancies. She uses condoms for birth control. She would like to know what she can do to minimize her risk for developing ovarian cancer. Which of the following recommendations is the most appropriate for this patient? A. Become pregnant soon B. Use an intrauterine device C. Use oral contraceptives until she is ready to have children D. Have a risk reducing salpingo-oophorectomy once childbearing is complete E. There are no proven means to reduce the risk of ovarian cancer

C. Use oral contraceptives until she is ready to have children Factors associated with development of ovarian cancer include low parity, delayed childbearing. Long-term suppression of ovulation appears to be protective against the development of ovarian cancer. Oral contraceptives that suppress ovulation provide protection against the development of ovarian cancer. Removal of ovaries might be considered for a women with a strong family history and/or BRCA mutation.

A 35-year-old G0 woman presents with irregular menses and hirsutism of three months duration. The patient has no family history of hirsutism. She reports regular menses. On examination, the patient's BMI is 25 kg/m2 and has terminal hair growth on her chest and recently had laser treatment to remove similar hair on her chin. Her total testosterone is 76 ng/dl (normal), and her DHEAS is 1500µg/dl (elevated). Which of the following is the most likely diagnosis in this patient? A. Prolactinoma B. Ovarian tumor C. Cushing's syndrome D. Adrenal tumor E. Constitutional hirsutism

D. Adrenal tumor The short duration of symptoms and significantly elevated DHEAs supports the diagnosis of an adrenal tumor as the etiology of the patient's symptoms

A 29-year-old G1P0 woman at 37 weeks gestation presents to labor and delivery with decreased fetal movement for two days. The nurse is unable to find fetal heart tones. Ultrasound confirms absent fetal cardiac activity and an intrauterine fetal demise (IUFD) is diagnosed. Examination shows the cervix is closed, 20% effaced, and the presenting part is at -2 station. The patient is understandably devastated, and condolences are offered. What is the best next step in the management of this patient? A. Begin oxytocin induction immediately B. Begin oxytocin induction when the patient is ready C. Begin misoprostol induction immediately D. Begin misoprostol induction when the patient is ready E. Await spontaneous labor

D. Begin misoprostol induction when the patient is ready The parents do not have to be rushed into management of the birth unless there is a serious maternal medical concern such as preeclampsia Waiting for spontaneous labor to begin is an option and may avoid issues associated with induction, however waiting also increases the risk of developing coagulation abnormalities, particularly if the dead fetus is retained for several weeks Her cervix is not favorable for induction so oxytocin is not the best method to start an induction

A 29-year-old G4P4 woman desires contraception. She reports that she and her husband no longer desire to have children. Her past medical history is significant for being positive for BRCA1. She has previously been on a progestin-only pill but doesn't like taking a pill every day. Which of the following contraceptive methods is the most appropriate for this patient? A. Depot medroxyprogesterone acetate B. Copper IUD C. Levonorgestrel IUD D. Bilateral salpingectomy E. Vasectomy

D. Bilateral salpingectomy Bilateral salpingectomy is the best option for this patient given her age and BRCA 1 positivity. Reduced risk of ovarian cancer by 80-90% and breast cancer by 50% but she would become prematurely menopausal with an increased risk for osteoporosis, CV disease, and lifestyle issues with menopausal symptoms (usually recommended at or after 35 years of age if childbearing is complete)

A 38-year-old G2P2 woman presents for counseling regarding her risk of ovarian cancer. Her maternal grandmother died of breast cancer diagnosed prior to the age of menopause, and her mother was diagnosed with ovarian cancer at age 50. The patient underwent genetic counseling and tested positive for the BRCA1 mutation. She would like to know what to do to minimize her risk of getting ovarian cancer. What should her physician recommend to reduce her risk? A. Placement of levonorgestrel IUD now, with oophorectomy at menopause B. Bilateral salpingectomy now, with oophorectomy at menopause C. Hysterectomy now, with oophorectomy at menopause D. Bilateral salpingo-oophorectomy now E. Annual pelvic sonogram, with oophorectomy if any abnormality seen

D. Bilateral salpingo-oophorectomy now Women with the BRCA 1 mutation have a 40-45% chance of getting ovarian cancer by age 70. Most effective risk-reduction strategy is bilateral salpingo-oophorectomy. Because the risk of ovarian cancer increases markedly for BRCA-1 positive women in their 40's, this surgery is recommended between the ages of 35 and 40.

A 25-year-old G1P0 woman at six weeks gestation comes to the office because of undesired pregnancy. The risks and benefits of surgical versus medical abortion using misoprostol and mifepristone are discussed with the patient. Compared to surgical abortion, which of the following is increased in a woman undergoing a medical abortion? A. Post-abortion pain B. Lower failure rate C. Long term psychological sequelae D. Blood loss E. Future infertility

D. Blood loss Medical abortions are associated with higher blood loss than surgical abortion. Surgical termination is required in the event of failure or excessive blood loss.

A 24-year-old woman complains of cyclic mastalgia since the onset of her period at age 12. The symptoms have increased over the years but were less troublesome when she took oral contraceptives a few years ago. Currently, she takes no medications and is not sexually active. She is a strict vegetarian and eats soy products. She does not smoke, and drinks three glasses of wine per week and several diet sodas every day. Her mother was diagnosed with breast cancer at age 55. Her breast examination is normal, except for some mild fibrocystic changes. Which of the following elements in her history contributes to her increasing pain? A. Alcohol intake B. Vegetarian diet C. Family hx of breast cancer D. Caffeine intake E. Age of menarche

D. Caffeine intake Fibrocystic changes are the most common benign breast cancers and occur most often during the reproductive years. It is often associated with cyclic mastalgia possibly related to pronounced hormonal response. Caffeine intake can increase the pain associated with fibrocystic breast changes.

A 23-year-old woman presents with complaints of a bilateral nipple itchy sensation for six months. There is no nipple discharge or dry skin. She reports her nipple appears to be swollen at times and there is an erythematous fine rash. She had breast implants placed five years ago, but otherwise has no significant medical problems or surgical history. What is the most likely cause of her symptoms? A. Fibroadenoma B. Breast cancer C. Rupture of breast implants D. Chemical irritants E. Mastitis

D. Chemical irritants Nipple itch is a common symptom of allergies, dry skin, inflammation, or physical irritation. Most common cause is a chemical irritant such as laundry detergents, soaps, or perfumes.

A 54-year-old G4P4 woman who has been menopausal for four years recently underwent a total vaginal hysterectomy and bilateral salpingo-oophorectomy for uterine prolapse. She comes in for a postoperative check-up and complains of hot flashes, wondering why she is experiencing menopause again. Which of the following best explains why she is experiencing these symptoms? A. Increased postoperative liver metabolism B. Decreased adrenal estrogen production C. Removal of an occult estrogen-producing tumor D. Decreased circulating androgens E. Cessation of ovarian estrogen production

D. Decreased circulating androgens Estrogen production by the ovaries does not continue beyond menopause. However, estrogen levels in postmenopausal women can be significant due to the extra-glandular conversion of androstenedione and testosterone to estrogen which occurs by peripheral fat cells thus body weight is correlated to circulating estrone and estradiol. But menopausal ovaries are known to continue production of androgens, surgical removal or postmenopausal ovaries may result in the resurgence of menopausal symptoms from the abrupt drop in circulating androgens.

A 23-year-old G0 woman presents to the office because she has not had any menses for four months. She has a long history of irregular menstrual cycles since menarche at age 14. She is otherwise in good health and is not taking any medications. She is thin and has chronic anxiety with a BMI 16 kg/m2. Her beta-hCG is less than 5 mIU/mL, and her prolactin and TSH levels are normal. What would be the next best diagnostic test to order? A. 17-OH progesterone B. Progesterone C. GnRH D. FSH E. Dehydroepiandrosterone sulfate

D. FSH The causes of hypothalamic-pituitary amenorrhea are function (weight loss, obesity, excessive exercise), drugs (marijuana and tranquilizers), neoplastic (pituitary adenomas), psychogenic (chronic anxiety and anorexia nervosa), and other certain chronic medical conditions In this case the next step to make a diagnosis is to obtain FSH which would be expected to be low. GnRH is not directly measured in peripheral blood because of its short half-life in minutes and its confinement to pituitary circulation

A 30-year-old G2P0 woman presents with a concern for worsening dysmenorrhea. Her periods occur regularly every 28 days, but she experiences severe central cramping pain in the week preceding and during her menses. Her gynecologic history is notable for chlamydia infection at age 19, and cervical dysplasia at age 25. Two years ago, she underwent a LEEP procedure that resulted in cervical stenosis. Her medical history is notable for Hodgkin's lymphoma at age 21, treated with doxorubicin and bleomycin. Her family history is notable for a maternal aunt with ovarian cancer. Which of the following is a risk factor for her to have endometriosis? A. Chlamydia infection B. Family history of ovarian cancer C. History of bleomycin exposure D. History of LEEP procedure E. HPV infection

D. History of LEEP procedure Cervical stenosis which may be the result of prior cervical surgery may lead to retrograde menstrual flow which results in endometrial cells entering the peritoneal cavity and potentially causing endometriosis

A 50-year-old G0 presents to the office for health maintenance examination. She has no complaints and still has regular menses. Her past medical history is significant for lymphoma at age 22, and she is status post chest wall irradiation without evidence of recurrence. Her family history is significant for an older sister who developed breast cancer at age 61. On examination, you palpate a 1 cm mobile, slightly tender, cystic mass in the left breast in the upper outer quadrant. In addition to mammography, which of the following factors would be an indication for breast MRI? A. Nulliparity B. Family history of a first degree relative with breast cancer C. Palpable mass on examination D. History of chest wall irradiation E. Age of the patient

D. History of chest wall irradiation American cancer society recommends offering breast MRI and mammogram to women in certain high risk groups = BRCA mutation carriers, first degree relatives of BRCA mutation carriers, genetic mutations such as Li-Fraumeni syndrome, women with 20-25% lifetime risk of breast cancer (based on risk prediction model), or women with a history of chest radiation between 10-30 y/o

A 24-year-old G0 woman presents because she has not had her menses for six months. She is in good health and not taking any medications. She is not sexually active. She does well in graduate school, despite her demanding new program. Her height is 5 feet 6 inches, and her weight is 104 pounds. Her vital signs are normal. Her physical examination, including a pelvic examination, is completely normal. What is the most likely reason for her amenorrhea? A. Ovarian dysfunction B. Thyroid disease C. Premature ovarian failure D. Hypothalamic-pituitary dysfunction E. Pregnancy

D. Hypothalamic pituitary dysfunction Anorexia nervosa or significant weight loss may cause hypothalamic-pituitary dysfunction that can result in amenorrhea. Lack of normal pulsatile secretion of GnRH leads to decreased stimulation of the pituitary gland to produce FSH and LH which leads to anovulation and amenorrhea.

A 32-year-old G2P2 woman complains of depression, weight gain, and premenstrual bloating. She has suffered from these symptoms for 18 months, and they have not responded to dietary changes and avoidance of alcohol and caffeine. Her only medications are multivitamins and herbs to increase her energy. She is very concerned about fatigue that often interferes with caring for her two children. A prospective symptom diary completed by the patient indicates mood symptoms, fatigue and bloating almost every day of the past two months, and regular menstrual cycles accompanied by breast tenderness. She denies feelings of wanting to hurt herself or others. Physical examination is unremarkable. Which of the following conditions is the most likely explanation for this patient's symptoms? A. Prolactinoma B. Anxiety disorder C. Anemia D. Hypothyroidism E. PMDD

D. Hypothyroidism Symptoms of hypothyroidism can mimic typical symptoms of PMS but symptoms occur more constantly throughout the cycle. Fatigue is associated with anemia but her presentation is not consistent with this diagnosis.

A 27-year-old G0 woman presents to the clinic because of concerns that she has not been able to get pregnant for the last year. She has been married for two years and had been using birth control pills for contraception. She stopped using birth control pills when she decided to attempt pregnancy one year ago. She is in good health and her only medication is a prenatal vitamin. Her periods are regular, every 28 days, with normal flow, and her last period was two weeks ago. She has no history of sexually transmitted infections and no abnormal Pap tests. Her husband is also healthy with no medical problems. She is 5 feet, 4 inches tall and weighs 230 pounds. Her examination, including a pelvic examination, is completely normal. Laboratory results show normal thyroid function tests and normal prolactin level. What is the most appropriate next step in the management of this patient? A. Reassurance and observation B. Perform a pelvic ultrasound C. Order a hysterosalpingogram D. Order a semen analysis E. Hemoglobin A1C level

D. Order a semen analysis This patient has primary infertility bc she has not been able to conceive for one year. She does not appear to have underlying pathology to explain why she has not conceived and her husband's semen has not yet been examined. The male factor plays a role in about 30% of infertility cases. Hysterosalpingogram might be ordered in the future, the male factor needs to be ruled out.

A 24-year-old G0 woman presents with amenorrhea of six months' duration. She is sexually active with a male partner. She is using no medications. Examination reveals a BMI of 20 kg/m2, normal genitalia and normal bimanual pelvic exam. Her lab tests include a negative urine pregnancy test, TSH 1.2 mU/ml, FSH 3 mIU/mL, LH 2 mIU/mL, prolactin 12 ng/mL. Which of the following is she most at risk for? A. Breast cancer B. Endometrial cancer C. Diabetes mellitus D. Osteoporosis E. Unintended pregnancy

D. Osteoporosis The patient has very low gonadotropin levels indicating that she has hypothalamic amenorrhea and would be hypoestrogenic. Her low estrogen levels put her at risk for osteoporosis.

A 38-year-old G0P0 woman presents with worsening dysmenorrhea. Her menstrual cycles are regular, but increasingly painful with cramping that is unresponsive to NSAIDs. She is monogamous with her husband but notes deep dyspareunia with every act of coitus. She is otherwise healthy and uses no medications. On examination, tenderness at which of the following sites would be most consistent with a diagnosis of endometriosis? A. Anterior vagina B. Levator muscle C. Ischial spines D. Posterior fornix E. Vaginal vestibule

D. Posterior fornix Nodules of endometriosis are most commonly found in the posterior cul-de-sac and along the uterosacral ligaments. Tenderness would be expected in the posterior fornix and posterior aspect of the uterus

A 68-year-old G3P3 woman presents with breast tenderness. She is in good health and is not taking any medications. Her 70- year-old sister was recently diagnosed with breast cancer. On breast examination, her breasts have no lesions, and there are no palpable masses, nodules, or lymphadenopathy. Her last mammogram was four months ago and was normal. What is the most appropriate next step in the management of this patient? A. Order a mammogram B. Order a breast ultrasound C. Obtain genetic testing D. Reassurance E. Order a breast MRI

D. Reassurance Age and gender are the greatest risk factors for developing breast cancer. Having one first degree relative with breast cancer does increase the risk. Transient breast tenderness is not a symptom of breast cancer. Mammogram is not indicated because the patient's last mammogram 4 months ago was normal and there is no palpable mass

A 22-year-old G0 woman presents with painful menstruation that limits her activities each month. She describes the pain as spasmodic, occurring on days one to three of bleeding since her cycles began. Other symptoms include nausea, nervousness, diarrhea, and headache occurring at the same time. Her abdominal examination shows a soft, non-tender abdomen. Bimanual examination reveals a fixed uterus with uterosacral ligament nodularity. There are no adnexal masses noted. Which of the following is the most likely diagnosis in this patient? A. Premenstrual syndrome B. Premenstrual dysphoric disorder C. Primary dysmenorrhea D. Secondary dysmenorrhea E. Adenomyosis

D. Secondary dysmenorrhea The restricted uterine motion found on exam suggests the possibility of endometriosis or pelvic scarring from inflammation or adhesions. In a patient with primary dysmenorrhea the physical examination is normal with no palpable abnormalities on abdominal, speculum, pelvic, bimanual, and rectal examinations

A 64-year-old G2P2 post-menopausal woman presents for a health maintenance examination. She notes the new onset of a lump in her vagina, but denies any pain, abnormal bleeding, or vaginal discharge. She has well-controlled diabetes mellitus and hypertension. She is recently sexually active with a new partner since the death of her husband three years ago. She smokes a half-pack per day, and has done so since age 18. On examination, she is noted to have a firm and fixed non-tender 5 cm mass on her labium majus at the level of the Bartholin gland on the right. There is no associated erythema or discharge, and the remaining vulvar and pelvic examinations are unremarkable. Her groin examination reveals no adenopathy. What is the most likely diagnosis? A. Lipoma B. Fibroma C. Gartner's ductal cyst D. Vulvar abscess E. Bartholin gland malignancy

E. Bartholin gland malignancy The finding of a mass in the Bartholin gland is highly suspicious for malignancy and requires excision/biopsy, especially in postmenopausal women. Primary vulvar adenocarcinomas most likely arise from the Bartholin gland but other histologies can also arise from this location.

A 22 y/o G2P1 woman presents to the clinic with her three-month-old daughter. She was breastfeeding without problems until two weeks ago, when she developed sore nipples and burning pain in the breast. The pain is worse when breastfeeding. On physical examination, she is afebrile. The breast appear normal except for the tips of the nipples which are pink and shiny with peeling noted at the periphery. Which of the following organisms in the most likely cause of these findings? A. GAS B. GBS C. Staph aureus D. Staph epidermidis E. Candida

E. Candida This presentation is classic for candidiasis and should prompt an inspection of the baby's oral cavity. Candida of the nipple is associated with severe discomfort and pain. All the other organisms are associated with classic mastitis and do not usually cause intense nipple pain Tx mom: antifungal topical medication, topical antibiotic ointment because nipple fissures can concurrently present with candida of the nipples and S. aureus is significantly associated with nipple fissures, and a topic steroid cream to facilitate healing in cases where the nipples are very red and inflamed. Tx infant: oral nystatin followed by oral fluconazole

A 32-year-old G2P1 woman is at 20 weeks gestation. Her prior pregnancy was complicated by postpartum endometritis and her son was diagnosed with early-onset neonatal sepsis due to group B streptococcus. Which of the following management options regarding group B streptococcus is most appropriate for this patient? A. Recto-vaginal culture at 35 to 37 weeks and antibiotic treatment during labor if positive B. Recto-vaginal culture at 35 to 37 weeks and antibiotic treatment at the time the culture result returns if positive C. Rectovaginal culture at 24 to 28 weeks and antibiotic treatment during labor if positive D. Recto-vaginal culture at 24 to 28 weeks and antibiotic treatment at the time the culture result returns if positive E. Do not perform recto-vaginal cultures and treat with antibiotics during labor

E. Do not perform recto-vaginal cultures and treat with antibiotics during labor Cultures for GBS are not required in women who have group B streptococcal bacteriuria during the current pregnancy or who have previously given birth to a neonate with early onset GBS disease. Universal screening with a recto-vaginal culture at 36 to 37+6 weeks of gestation is recommended for all women who do not already have an indication for intrapartum antibiotic prophylaxis. All women with positive cultures for GBS should receive intrapartum antibiotics in labor unless a C-section is performed before the onset of labor in a women with intact amniotic membranes.

A 34-year-old G2P1 woman at 40 weeks gestation was admitted to labor and delivery in active labor two hours ago. Her cervix was 4 cm dilated and 100% effaced on admission. Her fetus was vertex and -3 station. After she experiences spontaneous rupture of membranes, she is examined and found to be 9 cm dilated, and the fetal head is occiput anterior (OA) at +1 station. A 5 cm long section of umbilical cord is palpated in the patient's vagina. The fetal heart tracing is Category I. The patient is having regular uterine contractions every two to three minutes. She has an epidural and is not feeling the contractions. What is the most appropriate next step in the management of this patient? A. Allow for passive descent of the fetal head with continuous fetal monitoring B. Have the patient start pushing with the contractions C. Gentle attempt to replace the umbilical cord segment back up into the uterus D. Perform a forceps assisted vaginal delivery E. Elevate the fetal head with a vaginal hand and perform a cesarean delivery

E. Elevate the fetal head with a vaginal hand and perform a cesarean delivery The patient has an umbilical cord prolapse. Although fetal surveillance is reassuring, the most appropriate management is to continue to elevate the fetal head with a hand in the patient's vagina and call for assistance to perform an urgent cesarean delivery. It is important to elevate the fetal head in an attempt to avoid compression of the umbilical cord.

A 21-year-old G1P0 woman presents to labor and delivery at 39 weeks gestation with a chief complaint of decreased fetal movement over the last two days. An ultrasound shows a fetus with biometry consistent with 34 weeks gestation with no cardiac activity. The head circumference and biparietal diameter are consistent with 37 weeks, and the abdominal circumference, femur, and humerus lengths are all lagging by approximately five weeks. The amniotic fluid volume is slightly decreased. No other abnormalities are identified. The patient's medical history is notable for a deep venous thrombosis, which she had three years ago while she was using oral contraceptives. She had a risk-reducing quad screen. She denies any history of fever or viral illnesses during the pregnancy. The patient had a fetal ultrasound at 20 weeks gestation. At that time, all of the fetal anatomy was wellvisualized and no abnormalities were identified. Which of the following is the most likely explanation for the fetal demise in this case? A. Trisomy 21 B. Trisomy 18 C. Poorly controlled undiagnosed diabetes mellitus D. Fetal parvovirus infection E. Factor V Leiden mutation

E. Factor V Leiden mutation This patient is most likely to have an AD factor V Leiden mutation based on her history. FVL is the MC inherited thrombophilic disorder in the US affected approximately 5% of white women. Associated with obstetric complications including still birth, preeclampsia, placental abruption, and IUGR.

A 25-year-old G1 woman is at 18 weeks gestation. A 4 cm subserosal fibroid was noted on the anterior fundal wall of her uterus at the time of her obstetric ultrasound at 17 weeks gestation. Which of the following treatment options for the uterine fibroid is most appropriate? A. Obtain a follow up ultrasound every six weeks to follow growth of the fibroid B. Laparoscopic myomectomy now C. Perform a cesarean delivery at term D. Perform a cesarean delivery at term with removal of the fibroid after delivery of the baby and placenta E. No further treatment is necessary

E. No further treatment is necessary Most uterine fibroids are asymptomatic and do not require any treatment. Pregnant patients with fibroids are usually asymptomatic and do not have complications related to the fibroids. Fibroids may grow or become symptomatic in pregnancy and become hemorrhagic but this is uncommon for smaller fibroids. Uncommonly, fibroids can be located below the fetus in the lower uterine segment or cervix causing a soft tissue dystocia necessitating a cesarean delivery. It is not necessary to follow the growth of fibroids during pregnancy except for the rare cases when the fibroid is causing symptoms or appear to be located in a position likely to cause dystocia.

A 35-year-old G3P3 woman requests contraception. Her youngest child is nine months old. Her periods have been regular since she discontinued breastfeeding five months ago. Her past medical history includes depression, which is controlled with fluoxetine, and a history of deep venous thrombosis. She reports having heavy periods and confirms that she does not smoke or use alcohol. In the past, oral contraceptive pills have caused her to have severe gastrointestinal upset. Which of the following is the next best step in her management? A. Condoms B. Copper IUD C. Low dose combined OCPs D. Medroxyprogesterone acetate E. Progestin-only contraceptive pills

E. Progestin-only contraceptive pills Ideal candidates for progestin-only pills include women who have contraindications to using combined OCPs (hx of thromboembolic disease, women >35 who smoke, women who develop severe nausea w/ combined OCPs. Copper IUD can lead to heavier menstrual flow. Depression is a relative contraindication to medroxyprogesterone acetate

A 24-year-old G1P0 woman presents for a new prenatal appointment. She has no significant medical problems. She appears anxious and repeatedly states that she has to get home before her husband gets back. Physical examination is normal except for an appropriately sized 12-week uterus and the presence of ecchymoses around her neck, shoulders and upper arms. When asked whether she feels safe at home, she quickly answers "yes," and vehemently denies violence from her husband or anyone else. What is the most appropriate next step for her obstetrician to take? A. Call an interpersonal violence hotline on her behalf B. Call the friend she has listed as an emergency contact to get more details C. Start a new line of questioning that prompts her to admit that she is a victim D. Notify the police E. Provide support and readdress the issue at her next visit

E. Provide support and readdress the issue at her next visit Even when IPV is suspected, the victim may not be ready to admit the fact until a trusting relationship has been built. Providing supporting information and maintaining channels of communication is the best approach. If there is no threat of immediate harm to the patient, it is inappropriate to notify police or intervene on her behalf.

A 75-year-old G3P3 woman with arthritis undergoes an MRI scan of the hip, and the radiologist makes an incidental report of a cyst on the right adnexa. She has no abdominal or pelvic symptoms, and her examination is non-contributory. Pelvic ultrasound is performed, which reveals a 2 cm simple echolucent cyst of the right ovary with no solid components. No ascites is present. CA 125 is normal. What is the next best step in the management of this patient? A. Perform diagnostic laparoscopy B. Perform exploratory laparotomy C. Percutaneous drainage of cyst D. Repeat CA 125 in three months E. Repeat sonogram in six months

E. Repeat sonogram in 6 months Simple asymptomatic cysts are present in as many as 20% of postmenopausal women. Provided other tumor markers are normal, reassurance in usually all that is needed. However follow-up to ensure stability is warranted. Ovarian cysts are never drained percutaneously due to the risk of seeding the peritoneum with neoplastic cells.

A 25-year-old G3P2 woman delivered a healthy infant with Apgars of 9 at one minute and 9 at five minutes 40 minutes ago. She sustained no lacerations and had no episiotomy. Her placenta has not delivered, despite active management of her third stage. Her EBL is 350cc. Vital signs are temperature 98.6°F (37.0°C) blood pressure 100/60, pulse 79 beats/minute, respiratory rate 14/minute. Which of the following best describes this patient's condition? A. Postpartum hemorrhage D. Placenta percreta C. Normal third stage of labor D. Prolonged second stage of labor E. Retained placenta

E. Retained placenta This patient has a prolonged third stage of labor with retained placenta. The patient has met criteria for retained placenta since >30 minutes has elapsed with active management of her third stage. Active management of third-stage labor consists of early cord clamping, controlled cord traction during placental delivery, and immediate administration of prophylactic uterotonics. The goal of this triad is to limit postpartum hemorrhage.

A 46-year-old G2P0 woman presents for a routine health maintenance examination with no concerns. Her medical history is unremarkable, and her family history is notable only for a maternal aunt with breast cancer. On examination, there is an incidental finding of a non-tender cystic mass that is palpable in the cul-de-sac, approximately 8 cm in diameter. A pelvic ultrasound is ordered. Which of the following sonographic characteristics would be most consistent with a benign ovarian neoplasm? A. Ascites B. Thick septations C. Mural nodules D. Cystic and solid components E. Size <10 cm

E. Size <10 cm Complexity with solid components, size greater than 10cm, mural nodules or excrescences, presence of ascites, bilaterally all increases the index of suspicion for cancer. Smaller unilateral cysts that are simple and unilocular or that have septations less than 3mm are usually benign.

A 27 y/o G3P1 woman is admitted to the orthopedic service after open reduction and internal fixation of her femur status post a MVA. Her past medical hx if significant for diabetes (controlled with metformin) and a hx of DVT three years ago while taking an oral contraceptive. She has been receiving ibuprofen for pain control and oxycodone for breakthrough pain as well as docusate sodium. Additionally, anticoagulation therapy was begun with IV heparin and is not therapeutic on warfarin. At a follow-up visit, she has a positive pregnancy test and an ultrasound confirms a six-week intrauterine pregnancy. Which of the following medication should be discontinued now? A. Metformin B. Docusate sodium C. Ibuprofen D. Oxycodone E. Warfarin

E. Warfarin Warfarin is contraindicated at this gestational age Ibuprofen is safe to take until around 32 weeks gestation when premature closure of the ductus arteriosus in a risk

A 17-year-old female presents to her family physician for a health maintenance examination. In discussing her social history, the patient admits that she has begun dating another female in her class. She lives with her widowed father and has to work after school to help support the family. Her examination is normal, though her physician notices a bruise on her shin. At the end of the examination, the physician administers a screener for intimate partner violence (IPV). Which of the following characteristics is the best reason for performing this screen? A. LGBT status B. Living with opposite sex parent C. Low SES D. Presence of bruise E. IPV screening is done for all patients

Intimate partner violence is a public health problem that affects women of all ages, SES, race, religion, sexual orientation, and educational background. All women regardless of background should be screened for intimate partner violence regularly at health care encounters

An 81-year-old G3P3 woman presents to your office with a history of light vaginal spotting. She states this has occurred recently and in association with a thin yellow discharge. She has not experienced any vaginal bleeding since menopause at the age of 52 and denies ever having been on hormone replacement therapy. She has osteoporosis, well-controlled hypertension, and diabetes. She is physically active and still drives to all her appointments. She is no longer sexually active since the death of her husband two years ago. On examination, she is noted to have severe atrophic changes affecting her vulva and vagina. A small Pederson speculum allows for visualization of a normal multiparous cervix, and the bimanual examination is notable for a small, mobile uterus. Rectovaginal examination confirms no suspicious adnexal masses or nodularity. Which of the following is the most appropriate management for this patient? A. Pelvic CT scan B. Office endometrial biopsy C. Reassurance and observation for further bleeding D. Vaginal estrogen therapy E. Oral estrogen therapy

Postmenopausal bleeding or discharge accounts for the presenting symptom in 80-90% of women with endometrial cancer. However, the most common causes of postmenopausal bleeding are atrophy of the endometrium (60-80%), hormone replacement therapy (15-25%), endometrial cancer (10-15%), polyps (2-12%) and hyperplasia (5-10%). Any history of vaginal bleeding requires a thorough history, pelvic/physical exam, and assessment of the endometrium. Ideally done via office endometrial sampling as part of the initial work-up. A pelvic transvaginal ultrasound can provide information on structure changes and for which a dx of endometrial cancer would be less likely if the endometrial thickness is less than 5 mm.

A 52-year-old G3P2 woman reports vaginal spotting and bleeding after intercourse for the past 18 months. She stopped having menses at the age of 48 and has not been on menopausal hormone therapy. She also notes new onset low back pain. She has smoked two packs a day for the past 30 years. Her last gynecologic examination was 10 years ago. On physical examination, she is a thin female who appears older than her stated age. She weighs 120 pounds and is 5 feet 6 inches tall. Her pelvic examination reveals atrophy of the external genitalia and vagina, a minimal amount of dark brown blood in the vault and a large parous cervix with a friable lesion on the anterior lip of the cervix. The uterus is normal size, non-mobile and fixed in a retroverted position. There are no palpable adnexal masses, but there is firm nodularity in the posterior cul-de-sac on rectal examination. Which of the following is the most appropriate next step in the management of this patient? A. CT of the pelvis B. Pap test C. Colposcopy D. Cervical biopsy E. Pelvic ultrasound

The patient most likely has cervical cancer. Her risk factors include tobacco use and an inconsistent screening hx. The symptoms of postmenopausal and postcoital bleeding should be taken seriously and a cervical biopsy of the suspicious lesion should be performed. Her physical exam with fixation of the uterus and the thickening of the rectovaginal septum and back pain suggests involvement of the parametria (stage II) and possible extension to the side wall (stage III)

A 17-year-old G0 sexually active female presents to the Emergency Department with acute right lower quadrant pain and nausea for 12 hours. Her periods have always been irregular, with her last one two weeks ago. She is otherwise completely healthy. She appears in mild distress. Physical examination: temperature 98.6°F (37.0°C), blood pressure 110/60, heart rate 108 beats/minute. She has moderate abdominal tenderness with right greater than left pelvic tenderness. Pelvic examination reveals mild cervical motion tenderness and fullness in the right adnexa with moderate tenderness and some voluntary guarding. Ultrasound demonstrates a 6 cm complex ovarian cyst with no demonstrable flow to the ovary on Doppler. What is the most likely ovarian lesion in this scenario? A. Endometrioma B. Tubo-ovarian abscess C. Ectopic pregnancy D. Mature cystic teratoma E. Serous cystadenocarcinoma

This description is typical of ovarian torsion. Torsion usually occurs in the setting of an enlarged ovary with a dermoid cyst being a common etiology in young women. These cysts often contain oily contents that are less dense than surrounding tissue, rising to a more anterior position and creating instability of the infundibulopelvic ligament.

Fetal valproate syndrome

spina bifida, cardiac defects, facial clefts, hypospadias, craniosynostosis, and limb defects (radial aplasia)