ROSH - OB/GYN

A 36-year-old woman presents to labor and delivery at 34 weeks and 2 days gestational age for new-onset headache and severe right upper quadrant pain. She reports this headache has been going on the last two days and has not resolved with oral acetaminophen. Her blood pressure on admission is 165/112 mm Hg, and repeat four hours later is 172/115 mm Hg. She has never been pregnant before and has no significant past medical history. Which of the following is the most likely diagnosis?

Preeclampsia with severe features

At what age should routine annual pelvic exams begin in nonpregnant women?

21 years

A 28-year-old G2P1 Rh-negative woman presents to the clinic for an initial prenatal visit. Which of the following should be performed at this visit?

Anti-D antibody screen Notes: Rh Isoimmunization: Rh-negative mothers exposed to Rh-positive blood → anti-Rh antibodies Subsequent pregnancies: jaundice, anemia, fetal hydrops, fetal death Anti-D globulin at 28 weeks (and w/in 72 hrs of delivery if infant Rh+)

A 32-year-old P0 woman at 33 weeks gestation has confirmed rupture of membranes. The patient is not in labor, and the fetal status is reassuring with a category 1 tracing. The fetus is vertex, and the cervix appears to be closed and long. What is the best next step in the management?

Antibiotics, betamethasone Notes: Nearly half of PPROM patients deliver within one week of rupture of membranes. A single course of betamethasone should be administered to patients with evidence of rupture between 24 and 37 weeks gestation. Latency antibiotics should be given to all patients with evidence of rupture of membranes prior to 34 weeks.

A pregnant 26-year-old woman presents for an ultrasound at 16 weeks gestation. She has a past medical history significant for a pregnancy loss at 22 weeks gestation prior to her current pregnancy. Ultrasound confirms a shortened cervix. Following cervical cerclage, what additional lifestyle modifications should be recommended for this patient?

Avoid coitus Notes: Cervical Cerclage: Procedure to stitch the cervix to prevent premature delivery or miscarriage Used for women with cervical insufficiency, short cervix, previous preterm labor Shirodkar procedure: transvaginal approach, requires paracervical dissection for placement of the suture as close to the internal cervical os as possible May be left in place if cesarean delivery is planned and future pregnancies are desired McDonald procedure: transvaginal approach, no dissection required, purse string suture placed midway into the cervical stroma as high up as possible Removed prior to labor Transabdominal procedure: open or laparoscopic approach, suture is placed at the cervicoisthmic junction, delivery is by cesarean May be left in place if future pregnancies are desired

A 25-year-old woman presents to the emergency room two weeks postpartum complaining of fevers and breast tenderness. On exam, she is febrile to 102.1°F (39°C) with right-sided breast tenderness and a 4 cm x 4 cm fluctuant mass next to her nipple. What is the best next step in diagnosis?

Breast ultrasound Notes: The diagnosis is made via ultrasonography demonstrating a fluid collection. Management of an abscess requires drainage along with antibiotics, and the method of drainage depends on the state of the skin overlying the abscess and its depth.

A 19-year-old sexually active woman presents with lower abdominal pain and purulent vaginal discharge of two weeks duration. Temperature is 98.6 °F, heart rate is 70 beats per minute, and blood pressure is 122/74 mm Hg. On exam, the patient expresses tenderness to palpation in right and left lower abdominal quadrants, has purulent cervical discharge, and expresses extreme tenderness with uterine cervical movement. Urine pregnancy test is negative. Which of the following options is the most appropriate therapy?

Ceftriaxone 500 mg IM + doxycycline 100 mg PO twice daily for 14 days

A 38-year-old woman with a 20-year history of smoking one pack of cigarettes per day and with a history of iron deficiency anemia presents to the office to discuss contraceptive methods. She has two children and is otherwise healthy. Medical history reveals that her father had a heart attack at the age of 52. Which of the following is a contraindication to starting combination oral contraceptives in this patient?

Cigarette smoking Notes: Contraindications (unacceptable health risks): Age ≥ 35 years and ≥ 15 cigarettes/day Breast cancer Decompensated cirrhosis Ischemic heart disease Liver cancer History of stroke or complicated valvular heart disease Hypertension (CDC: ≥ 160/100 mm Hg) Migraine with aura Current or high risk for VTE

A 25-year old woman presents with dysuria and purulent vaginal discharge for four days. Which of the following physical exam findings would best support the diagnosis of acute cervicitis?

Edematous and erythematous uterine cervix Notes: The most common causes of infectious cervicitis are Neisseria gonorrhoeae and Chlamydia trachomatis, although herpes simplex virus (HSV) and Trichomonas vaginalis are also frequent culprits. The cervix may appear swollen and erythematous on exam due to increased vascularity and edema. The diagnosis of acute cervicitis is clinical and based upon the presence of purulent or mucopurulent cervical exudate and/or sustained endocervical bleeding (friability) easily induced by gently touching the area with a swab.

A 46-year-old woman presents to your office for a second opinion. She has been experiencing abnormal uterine bleeding for more than two years. Her periods are heavy, prolonged, and associated with clotting. Imaging of her uterus was unremarkable. A recent endometrial biopsy was negative for infection or malignancy. She has three children, all born by uncomplicated vaginal deliveries, and is not interested in future conception. She declines hormonal therapy and would like to proceed with surgical therapy. Which of the following is recommended?

Endometrial ablation Notes: If premalignancy and malignancy are ruled out, surgical interventions affecting the endometrial lining can be considered.

A 55-year-old postmenopausal woman presents to the clinic complaining of frequent episodes of vaginal spotting, which she began noticing over the past month. She has a history of diabetes and hypertension. She denies any history of abnormal Papanicolaou smears. A pelvic examination reveals a small amount of blood coming from the external os, but is otherwise normal. What is the best way to diagnose this condition?

Endometrial biopsy Endometrial cancer is the most common gynecologic malignancy in developed countries. Adenocarcinoma of the endometrium (lining of the uterus) is the most common type. Risk factors include unopposed estrogen stimulation (exogenous estrogen-only therapy, tamoxifen use), polycystic ovarian syndrome, increasing age, menopause after age 55, nulliparity, diabetes mellitus, and obesity. Patients most commonly present with abnormal vaginal bleeding.

A 32-year-old woman presents with complaints of painful lumps in her breasts that worsen with her menstrual cycle. Which of the following hormones is considered a causative factor in the development of the suspected diagnosis?

Estrogen Notes: Estrogen is a causative factor, which is indicated by the resolution of the condition in postmenopausal women.

A 28-year-old woman, G1P0, presents at 38 weeks gestation complaining of painful contractions and mild vaginal bleeding. Her prenatal care course is complicated by cocaine and tobacco use. On physical exam, her uterus is firm. Fetal heart rate tracing reveals a baseline of 135 bpm with moderate variability in the absence of accelerations. Tocometer reveals regular contractions. A vaginal exam performed reveals a cervix that is 7 cm dilated and a fetus in cephalic presentation. A transabdominal ultrasound is suspicious for placental abruption as the etiology of her vaginal bleeding. Which of the following is the most appropriate management?

Expectant management

A 21-year-old woman presents for a routine exam. She is noted to have a two centimeter, singular, circular, mobile, nontender mass in her left breast at the five o'clock position. The overlying skin is normal. She denies knowledge of this lesion prior to this visit. She also denies constitutional symptoms, breast tenderness, firmness, nipple changes or discharge, or heaviness with her menstrual cycle. What is the most likely diagnosis?

Fibroadenoma Notes: Fibroadenomas are the most common benign breast tumors in women. They typically occur in females between 15 and 35 years of age.

A 29-year-old woman is in active labor. Her history is significant for shoulder dystocia during the birth of her previous child. Which of the following would best diagnose shoulder dystocia in her current labor?

Gentle downward traction on the fetal head fails to deliver the anterior shoulder Notes: In normal circumstances, gentle downward traction on the head of the fetus is all that is needed for delivery of the shoulders.

Risk factors for squamous cell carcinoma of the vulva are human papillomavirus (types 16, 18, and 33), early age at first intercourse, multiple sexual partners, human immunodeficiency virus infection, and cigarette smoking

Ibuprofen Notes: First-line treatment for primary dysmenorrhea is with non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral hormonal contraceptives. NSAIDs inhibit prostaglandin synthesis by inhibiting cyclooxygenase.

Which of the following best describes a normal physiologic change of pregnancy?

Increased red blood cell mass Notes: Normal Pregnancy Increased blood volume, cardiac output, tidal volume Decreased functional residual capacity, systemic vascular resistance Respiratory alkalosis: third trimester Doppler heart tone at 10 weeks HR increased 10-15 bpm BP decreased in second trimester, normalizes in third Serum beta-hCG: doubles every 2 days in early pregnancy Fundal height:12 weeks: pubic symphysis20 weeks: umbilicus20-32 weeks: height (cm) above symphysis = gestational age (weeks) Transvaginal ultrasound: IUP visualized when beta-hCG > 1,500 IU/L Transabdominal ultrasound: IUP visualized when beta-hCG > 4,000 IU/L

Which of the following is associated with a decreased risk for endometriosis?

Increasing consumption of long-chain omega-3 fatty acids

A 30-year-old woman presents with a new thin vaginal discharge with a foul odor for the past two weeks. The woman is 24 weeks pregnant. The pregnancy has been uncomplicated. She denies any associated pain or vaginal bleeding. Vaginal swab is obtained for point of care microscopy which shows the presence of clue cells. Which of the following is the best next step in management?

Initiate metronidazole orally

A 36-year-old woman presents to the office for a painful right breast for the past two days. She is one month postpartum. The patient reports swelling and redness of the right breast in addition to pain. She is febrile to 101.2°F. On physical examination, the lower lateral quadrant of the right breast is erythematous, firm, warm, and markedly tender to palpation. Enlarged right axillary lymph nodes are noted on exam. In addition to cool compresses, which of the following would be the most appropriate course of treatment?

Initiation of dicloxacillin 500 mg four times daily Notes: Initiation of dicloxacillin 500 mg four times daily is the treatment of choice for postpartum women with lactational mastitis who do not have a penicillin allergy.

A 55-year-old woman presents to her primary care physician with a complaint of incontinence. She states that it is worse when she sneezes or when she lifts anything heavy. What is the best initial treatment to help alleviate these symptoms?

Kegel exercises

A 48-year-old woman presents to the clinic worried that she has not had a period in over a year. In the past, she had irregular periods for several years. She reports vaginal dryness, insomnia, and increased irritability. Vitals are normal, but she is 12 lbs heavier than she was at her last appointment six months ago. Serum human chorionic gonadotropin and prolactin levels are normal, but follicle-stimulating hormone is elevated. Which of the following is the most likely diagnosis?

Menopause Notes: Menopause, the permanent cessation of menstrual periods, is determined after a woman has experienced 12 months of amenorrhea without any other obvious pathological or physiological cause. It typically occurs between 48-55 years of age, with the average age of 51 in the U.S. Typical symptoms include: hot flashes (most common symptom), mood swings, vaginal dryness, painful intercourse, loss of libido, poor sleep and weight gain. Menopause is a clinical diagnosis. Laboratory studies are not routine but may be helpful. Typically with menopause, follicle-stimulating hormone will be elevated, estradiol will be low, prolactin and thyroid-stimulating hormone levels will be normal.

A 23-year-old woman with a diagnosis of polycystic ovarian syndrome and a history of infertility presents to her primary care provider with a positive pregnancy test. She began treatment for her diabetes mellitus type 2 a few months ago. What medication to treat her diabetes may have helped her to achieve pregnancy?

Metformin Notes: While the addition of metformin can assist in weight loss and enhance ovulation, it is not as effective as clomiphene, a selective estrogen receptor modulator, in aiding in pregnancy. Clomiphene is the drug of choice for treating infertility.

A 23-year-old G0 woman presents to the emergency department with lower abdominal pain for the past three days. She reports associated foul-smelling vaginal discharge. Her medical history is significant for chlamydia, which was treated three years ago, and an appendectomy when she was 12 years old. Her social history is significant for THC use and 15 lifetime sexual partners. A urine pregnancy test is negative. On pelvic examination, you note a mucopurulent discharge from the cervical os, two strings protruding from the cervical os, and cervical motion tenderness on bimanual exam. Which of the following historical risk factors places this patient at the highest risk for the suspected diagnosis?

Multiple sexual partners Notes: Women with multiple sexual partners are at the highest risk of developing pelvic inflammatory disease (PID)

A 38-year-old G3P2 at 16 weeks' gestation presents to the clinic for a regular prenatal visit. She describes symptoms of morning sickness that are "worse than with my other two pregnancies." Vitals are normal. On exam, her fundal height measured 18 cm. Labs show an elevation in human chorionic gonadotropin hormone and maternal serum alpha-fetoprotein. Which of the following is the next best step?

Order abdominal ultrasound Notes: Order abdominal ultrasound would be the next step in the work-up of suspected multiple gestations pregnancy. Multiple gestations has become more common due to older maternal age at childbirth and the expanded use of fertility treatments

A 28-year-old woman presents with a persistent painless labial lesion for one week. She denies dysuria or any change in her vaginal discharge. On exam, she has one erythematous ulcerated sore on the labia majora with a punched-out appearance. The rest of physical exam is unremarkable. Which of the following is the most appropriate therapy?

Penicillin G benzathine IM Notes: A single dose of intramuscular penicillin G benzathine is the treatment of choice for early syphilis. For late syphilis, penicillin G benzathine IM once weekly for three weeks is standard therapy. Neurosyphilis should be treated with penicillin G intravenously for 10 to 14 days.

A 32-year-old woman is having abnormal uterine bleeding for several weeks after a normal vaginal delivery. Serum hCG levels are tested and found to be elevated. They remain elevated at persistently low levels when retested after 2 months. A pelvic ultrasound reveals a hyperechoic intrauterine mass. Which of the following is the most likely diagnosis?

Placental site trophoblastic tumor Notes: Placental site trophoblastic tumors cause very low, persistent levels of hCG. These are malignant tumors that most commonly occur after a non-molar abortion or pregnancy.

Which of the following factors is more indicative of secondary dysmenorrhea than primary dysmenorrhea?

Progressive worsening of pain severity Primary dysmenorrhea is crampy midline lower abdominal or pelvic pain during menses without another disease process that could account for those symptoms. Secondary dysmenorrhea involves the same symptoms but occurs in women with a disorder that could account for their symptoms, such as endometriosis, adenomyosis, or uterine fibroids.

During which period of labor progression does a pregnant woman deliver her fetus?

Second stage Notes: Normal Labor and Delivery Labor stagesFirst stage: slow cervical dilation to full dilation (10 cm)Second stage: 10 cm dilation to delivery of babyThird stage: delivery of placentaFourth stage: postpartum Delivery stages (six cardinal movements): engagement, descent, flexion, internal rotation, extension, external rotation. Anterior shoulder delivered first

A 25-year-old woman presents to her primary care physician complaining of nausea and breast tenderness. She is sexually active, last unprotected sexual intercourse was 9 days ago. She states she does not remember the date of her last menstruation and that her cycles are irregular. A home pregnancy test this morning was negative as is the in-office urine pregnancy test. Which of the following is the best next step in management?

Urine pregnancy test 14 days after last unprotected intercourse Notes: In a patient with irregular menstrual cycles or unknown date of last menstruation, the last date of intercourse should be used as the marker for repeating a urine pregnancy test. A urine pregnancy test 14 days after last intercourse would minimize the possibility of a false negative.

A 25-year-old woman is recovering from uncomplicated vaginal delivery she had 24 hours ago. Which of the following physiologic changes is a major mechanism preventing postpartum hemorrhage?

Uterine involution

A 58-year-old postmenopausal woman presents to the clinic complaining of a vulvar lesion and pruritus that has become progressively worse. She does not recall when the mass first appeared, but states that it has now become painful and occasionally bleeds. She has a history of an abnormal Papanicolaou smear and previous positive human papillomavirus testing. A complete pelvic examination is performed and reveals a unifocal, firm, skin-colored ulcerating nodule on the left labium majus. The remainder of the pelvic examination is normal. Which of the following is the most likely diagnosis?

Vulvar cancer Notes: Risk factors for squamous cell carcinoma of the vulva are human papillomavirus (types 16, 18, and 33), early age at first intercourse, multiple sexual partners, human immunodeficiency virus infection, and cigarette smoking

A 25-year-old G1P0 at 39 weeks' gestation has been admitted to the labor and delivery department. On admission, a digital cervical examination was performed. Which of the following best describes the appropriate time for repeat cervical examinations during labor?

When the woman feels the urge to push

Which of the following would be considered normal when taking a focused gynecologic history from a patient? A.) Intermenstrual bleeding B.) Lack of menarche by age 16 C.) Postmenopausal bleeding D.) Whitish, watery, odorless discharge

Whitish, watery, odorless discharge

A 24-year-old woman, G1P0, presents to your office at 27 weeks gestation for a prenatal visit. Her body weight prior to pregnancy was within the normal range, and her gestational weight gain has been appropriate. You order a one-hour glucose challenge test with a 50 g oral glucose load to screen for gestational diabetes. For which of the following results would you recommend a diagnostic three-hour glucose tolerance test?

145 mg/dL Notes: These cutoffs range between 130 and 140 mg/dL at 1-hour postprandial. A result of 145 mg/dL, being just above the normal range, warrants further evaluation with a 3-hour glucose tolerance test.

A 25-year-old G1P0 at 33 weeks' gestation presents to her obstetrician for follow up visit. She states she has been having menstruation-like cramping and lower back pain every ten minutes or so for the last 24 hours. On physical exam, her cervix is dilated to 4 cm. Qualitative fetal fibronectin is positive. Which of the following confirms preterm labor?

5 uterine contractions every 20 minutes, cervical dilation of 4 cm, and cervical length of 18 mm on transvaginal ultrasound

Which person is statistically most likely to be phenotypically Rh(D)-negative?

A 40-year-old woman from the Basque Country

A 22-year-old woman presents with irregular vaginal bleeding and pelvic pain. Her last menstrual period was six weeks ago and she states that her menstrual cycle is typically 26 to 28 days in length. A urine pregnancy test is positive and a pelvic examination reveals mild right adnexal tenderness. Transvaginal ultrasound shows a right adnexal mass. Serum human chorionic gonadotropin (hCG) level is 3,520 IU/L. Which of the following is the next best step in managing this patient?

Administer methotrexate

Which of the following would increase the chance of intrauterine device expulsion or failure?

Age of 25 years or less

A 48-year-old woman presents to the office for her annual physical exam. She has not had a period for over 12 months. Which of the following hormonal changes are likely to occur during the menopausal transition?

An increase in estrone, decrease in estradiol, and no change in testosterone

A 24-year-old woman had an uncomplicated vaginal delivery 20 minutes prior to your shift starting. The placenta delivered spontaneously and the reported estimated blood loss was 400 mL. Shortly after receiving sign out, the patient's nurse calls you about bleeding. You present bedside to evaluate. An additional 200 mL of blood is on the peripad, the patient appears pale, and she has ongoing minimal bleeding. Her vital signs are notable for a heart rate of 120 beats per minute and a blood pressure of 95/50 mm Hg. Which of the following characteristics gives this patient a diagnosis of postpartum hemorrhage?

Bleeding associated with signs or symptoms of hypovolemia within 24 hours of delivery

A 17-year-old G1 woman presents at 36 weeks gestation for routine prenatal care. She has no significant past medical history. Blood pressure is 146/92 mm Hg and she has 2+ protein on urine dipstick. She denies headache or visual changes. Which of the following must be present to meet the diagnostic criteria for preeclampsia?

Blood pressure greater than or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic at least four hours apart Notes: Risk factors for preeclampsia include nulliparity, preeclampsia in previous pregnancy, extremes of maternal age (> 40 or < 18 years), preexisting hypertension, pregestational diabetes, multifetal gestation, chronic kidney disease, antiphospholipid syndrome, lupus, and high prepregnancy body mass index.

A 55-year-old postmenopausal woman presents to the clinic for her annual physical exam. She has a history of estrogen receptor-positive infiltrating ductal carcinoma and is status post lumpectomy and radiation therapy. Following local treatment, she was started on anastrozole. The patient remains asymptomatic and her most recent mammogram was normal. Which of the following screening evaluations is the most appropriate recommendation for this patient?

Bone density scan

A 28-year-old woman presents to clinic for follow-up of a palpable breast mass. A diagnostic mammogram revealed a suspicious lesion in her right breast, and follow-up ultrasound was concerning for malignancy. During a discussion of surgical options with the patient, she states that she would like further imaging with breast magnetic resonance imaging. Which of the following is an advantage of magnetic resonance imaging in this patient's case?

Breast magnetic resonance imaging is more sensitive than mammogram and ultrasound

A 65-year-old woman undergoes primary surgical cytoreduction for epithelial ovarian cancer. She has suboptimally cytoreduced disease with greater than 1 cm of residual disease still present. Which of the following is the best pharmaceutical treatment option for this patient?

Carboplatin and paclitaxel intravenously Notes: Carboplatin and paclitaxel intravenously is the preferred first-line chemotherapy in women who have suboptimally cytoreduced disease after surgical cytoreduction for epithelial ovarian cancer. Platinum and taxane agents are used first-line. Ovarian Cancer: Patient will be complaining of vague gastrointestinal symptoms, early satiety, bloating, abdominal or pelvic pain Adnexal mass Most common histologic type is epithelial carcinoma Tumor marker: CA 125 Comments: The most common cause of gynecologic death Routine screening not recommended (lack of benefit)

A 28-year-old G1P0 at 18 weeks gestation presents to the clinic to follow up on her Pap smear results. The cervical cytology report results indicated "atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion." Which of the following is the most likely next step in diagnosis?

Colposcopy

A 35-year-old woman presents for routine gynecologic screening. Cervical cytology shows atypical squamous cells of undetermined significance. Reflex human papillomavirus testing is positive for strain 16. Which of the following is the best next step in management?

Colposcopy Notes: Colposcopy is recommended for HPV 16 or 18 with any Pap result because these aggressive types of HPV confer moderate risk of severe dysplasia even with normal cytology.

A 30-year-old G1P0 at 36 weeks gestation presents to the clinic for a routine check-up. Fetal position cannot be determined during the abdominal exam. Transabdominal ultrasound reveals fetal head in the fundus with both hips and knees flexed. Which of the following describes this fetal position?

Complete breech Notes: Complete breech presentation describes a fetus whose head is in the fundus of the uterus and both hips and knees are flexed.

A 25-year-old woman presents for her initial prenatal visit. What is the most accurate method for determining her estimated date of delivery?

Crown-rump length

A 30-year-old woman who just delivered a 9 lb 12 oz baby vaginally after a prolonged labor suddenly develops heavy vaginal bleeding, tachycardia and altered mental status. What finding is most likely to be present to confirm the underlying cause of hemorrhage?

A boggy, enlarged uterus upon palpation of the pelvis

A 24-year-old woman presents to clinic for her annual gynecologic exam. She has no complaints and takes no medications. She is sexually active with women only. During her pelvic exam, her physician palpates an irregular uterine contour. Further ultrasound workup reveals one 3 cm intramural fibroid. Which of the following is the most appropriate next step?

Expectant management Notes: Treatment of fibroids is based on the severity of the symptoms. For asymptomatic women as this patient, no treatment is necessary.

A 26-year-old woman presents to your office for health care maintenance. She reports chronic pelvic pain. A review of her records reveals several emergency room visits for acute pelvic pain with a negative evaluation. You are suspicious for domestic violence. She does not report abuse. Her physical examination is normal. Which of the following is the best next step?

Ask about specific types of abuse

An 18-year-old woman presents to the clinic with heavy and painful periods for the past two years. She has never been pregnant and a pregnancy test in the office is negative. The patient has a normal body mass index and Pap smear, and her pelvic ultrasound and pelvic examination are unremarkable. Which of the following is the most likely diagnosis?

Abnormal uterine bleeding

A 16-year-old G1P0 woman presents to clinic with her mother and father. Her point-of-care pregnancy test is positive, and she states that she found out she was pregnant this week and tried to get an abortion while accompanied by her mother but was told at that clinic that she was "too far along." Dating by ultrasound shows a 28-week-sized fetus with positive heart tones. When asked if she would consider adoption, she shakes her head no and states she doesn't want the baby to "end up like me." Which of the following is the most appropriate next step?

Ask her parents to step out of the room so you can interview her privately Notes: Sexual Assault Male victim reported in 5% of cases (recent data suggests this can be as high as 22% due to significant lack of reporting) Toluidine blue: detects vulvar tears Wood lamp: detects semen stains Standard treatment covers gonorrhea, chlamydia, and trichomonas Standard vaccination is to start hepatitis B series if non-immunized Consideration of post-exposure prophylaxis for human immunodeficiency virus and hepatitis B Pregnancy testing is indicated Consideration of emergency contraception Infections considered diagnostic for abuse in pre-pubescent population: syphilis, human immunodeficiency virus, gonorrhea, and chlamydia

A 24-year-old woman presents for her annual checkup. She weighs 290 lb after losing 20 lb since starting a new exercise routine. She was recently informed by one of her sexual partners that he tested positive for gonorrhea. What treatment regimen would you offer to her?

Ceftriaxone 500 mg IM once with doxycycline 100 mg bid PO for 7 days Notes: According to CDC and Prevention recommendations, the tx of gonorrhea is ceftriaxone 500 mg IM once for patients < 300 lbs (150 kg), or 1 g IM if ≥ 300 lbs. If chlamydia cultures are negative, no further antibiotics are required. If chlamydia infection has not been excluded, doxycycline 100 mg bid PO for 7 days is recommended. If the patient is pregnant, azithromycin should be used over doxycycline.

A 25-year-old G1P0 at 39 weeks' gestation presents to the hospital as she believes she is in labor. Which of the following would suggest that the woman should be admitted to the labor and delivery unit?

Cervical dilation of 4 cm Notes: The determination of active labor compared to false labor is based on multiple criteria. Cervical dilation of > 4 cm typically marks the beginning of the active phase. Uterine bleeding, Abnormal fetal heart rate pattern Ruptured membranes.

A 29-year-old G2P1011 woman is two days postpartum from a spontaneous vaginal delivery. She had a prolonged labor course and was diagnosed with intraamniotic infection intrapartum. Today, the nurse informs you that the patient is febrile and complaining of abdominal pain. On evaluation, you note uterine tenderness. She is exclusively breastfeeding her infant. What is the most appropriate treatment?

Clindamycin and gentamicin Notes: Diagnosed by the presence of maternal fever, uterine tenderness, and abdominal pain. The infection is usually polymicrobial, including anaerobic bacteria, and should be treated empirically without the need for blood or uterine cultures. Postpartum Endometritis Patient will be postpartum, early-onset disease < 48 hours after delivery (C-section more common) Fever, abdominal pain, foul-smelling lochia PE will show uterine tenderness Labs will show leukocytosis Most common postpartum infection Treatment is clindamycin + gentamicinGBS colonized: add ampicillin or use ampicillin-sulbactam

A 60-year-old G2P2 woman presents to the clinic for a progressively worsening bulge sensation in her vagina for the past eight months and urinary incontinence when she laughs. Vaginal exam reveals a palpable break in the anterior vaginal fascia which becomes more prominent with Valsalva. Which of the following historical aspects put this woman most at risk for the most likely diagnosis?

Connective tissue disorders Notes: Risk factors for prolapse are increased parity, vaginal delivery, advanced age, connective tissue disorders (eg: Ehlers-Danlos), and obesity.

A 24-year-old woman with a two-week-old infant who was born six weeks premature presents to your office with localized redness, swelling, and pain to the right breast. What information would you give this patient on how to care for her condition at home?

Continue breastfeeding from the affected breast to help clear out the ducts Notes: Mastitis Patient will be a breastfeeding mother Breast erythema, tenderness, fever Most commonly caused by Staph. aureus Management includes cool compresses and analgesics between feedings Antibiotics: dicloxacillin, cephalexin, TMP-SMX (MRSA), clindamycin (PCN allergy) Continue breast feeding to avoid progression to abscess

A previously healthy 29-year-old G2P1A0 at 37 weeks and 4 days gestation presents to obstetric triage complaining of right upper quadrant pain that has been consistent since this morning. She also endorses a mild headache. Her blood pressure is 161/90 mm Hg and then 165/93 mm Hg on repeat 10 minutes later. Her pulse is 80 beats per minute. The fetal heart tracing is reassuring. Her physical exam is notable for hyperreflexia and her laboratory testing is remarkable for platelets at 80,000 platelets/microL. Which of the following is the best next step?

Delivery Notes: Preeclampsia Patient will be pregnant > 20 weeks gestation Complaining of visual disturbances, severe headaches, or asymptomatic PE will show new-onset hypertension (>140/90 mm Hg) with proteinuria (> 300 mg/24 hr) Treatment is the prevention of seizures with magnesium sulfate and prevention of permanent maternal organ damage Comments: New onset hypertension < 20 weeks gestation suspect molar pregnancy

A 59-year-old G2P2 woman presents to clinic complaining of difficulty urinating. She states that she feels she is not completely emptying her bladder when she voids. Her medical history is significant for two vaginal deliveries and chronic obstructive pulmonary disease. In addition to her problems voiding, she senses a vaginal bulging when she coughs. Which of the following would you expect to find on physical exam?

Downward displacement of the anterior vaginal wall on speculum exam during Valsalva maneuver Notes: Pelvic organ prolapse is defined as the herniation of the bladder, urethra, uterus, or rectum into the vaginal vault. This occurs due to laxity of the endopelvic fascia, muscles, and ligaments of the pelvis. Risk factors include increasing age and parity, chronic increases in abdominal pressure (e.g., chronic obstructive pulmonary disease), as well as low-estrogenic states such as menopause. Estrogen is responsible for maintaining elasticity of pelvic structures. Absence of this hormone can lead to atrophy and thus prolapse. The most common presenting symptoms are pelvic pressure and vaginal bulge. These symptoms may worsen with increased abdominal pressure, as during coughing. Prolapse of the bladder and urethra ("cystocele" and "urethrocele," respectively) additionally present with difficulty voiding, as in this patient. Using a split-speculum exam, a cystocele would appear as an inward movement of the anterior vaginal wall during Valsalva maneuver. This is because the bladder is located anteriorly to the vaginal vault.

A 24-year-old woman presents with fever, chills, and painful lumps to the groin area for the past three weeks. She is sexually active with men only. Pregnancy test is negative. Upon physical examination, you note tender inguinal and femoral lymphadenopathy bilaterally with some anal fissures. There are no lesions noted on labia majora or minora. Which of the following is the treatment of choice for this patient?

Doxycycline

A 22-year-old woman presents to the emergency department for one day of abdominal pain and vaginal spotting. The woman reports she is sexually active with one partner, but uses a non-hormonal intrauterine device to prevent pregnancy. Heart rate is found to be 126 bpm with a blood pressure of 88/60 mm Hg. Physical examination reveals right-sided adnexal tenderness and minimal blood in the vaginal vault. Cervical os is closed. Laboratory values reveal an hCG of 4,100 mU/mL. No intrauterine pregnancy is visualized on transvaginal ultrasound. What is the most likely diagnosis?

Ectopic pregnancy

A 45-year-old woman presents for her annual physical exam and is diagnosed with iron deficiency anemia. Upon further questioning, the patient reveals that she has been having heavy and irregular periods for the past year. She has three children and does not plan to have any more. Pelvic examination is normal. You order a pelvic ultrasound. Which of the following findings is not consistent with the diagnosis of abnormal uterine bleeding?

Endometrial lining thickness of four mm Notes: Abnormal Uterine Bleeding Patient will report heavy menstrual bleeding or intermenstrual bleeding Etiology may be structural or nonstructuralStructural causes: polyp, adenomyosis, leiomyoma, malignancy or hyperplasia (PALM) Nonstructual causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified (COEIN) Minimum laboratory assessment: pregnancy test, CBC, TSH Endometrial tissue sampling for all women age ≥ 45 years First-line imaging study: transvaginal ultrasound Treatment is combination OCPs, IV estrogen, progestins

A 24-year-old woman presents to the clinic complaining of cyclical pelvic pain and painful intercourse for the past year. She states that the pelvic pain occurs a few days prior to the start of menstruation. She denies any menorrhagia, abdominal pressure or vaginal discharge. She denies any history of sexually transmitted infections. Vital signs are within normal limits. Pelvic examination reveals lateral displacement of the cervix but is otherwise normal. Which of the following is the most likely diagnosis?

Endometriosis

A 68-year-old woman presents to the clinic with progressive lower abdominal bloating for the past six months. Ascites is present on exam, and a right-sided adnexal mass is palpable. Pelvic ultrasonography reveals a solid complex mass on the right ovary and confirms presence of associated ascites. Which of the following is the most likely diagnosis?

Epithelial carcinoma Notes: The incidence of ovarian cancer grows with increasing age, and at least 30 percent of all ovarian neoplasms in women over age 50 are malignant.

A 53-year-old woman presents to the office complaining of hot flashes. She states that they interfere with her daily activities as well as with her sleep at night. Her past medical and surgical history is significant for asthma and a vaginal hysterectomy for abnormal uterine bleeding. Which of the following is the best option for this patient to provide the most relief?

Estrogen Notes: This patient would likely benefit most from estrogen alone. Since she has had a hysterectomy, she does not need progesterone for endometrial protection, and progesterone use may potentially increase her risk of breast cancer. Menopause Patient will be a woman over 45-years-old With a history of amenorrhea for 12 months Complaining of hot flashes, sleep disturbances, depression, or vaginal dryness Labs will show decreased estrogen and elevated follicle-stimulating hormone levels

A 50-year-old woman with no history of endocrine disease presents complaining of insomnia, fatigue, and hot flashes for the past year and a half, and she hasn't had a menstrual period in over a year. She denies galactorrhea. Physical exam is unremarkable. Which of the following laboratory findings is most likely to be increased?

Follicle-stimulating hormone Notes: Menopause Patient will be a woman over 45-years-old With a history of amenorrhea for 12 months Complaining of hot flashes, sleep disturbances, depression, or vaginal dryness Labs will show decreased estrogen and elevated follicle-stimulating hormone levels

A 20-year-old woman presents to the clinic for well-woman exam. The patient states that she has not had a period in over 90 days. She was 12 years old when she had her first menstrual bleeding. The patient is active on her college cross country team, and runs about 80-100 miles per week. She is a vegan and tries to eat regularly, but due to her demanding class load and practice schedule, she often skips meals. Upon physical examination, the patient is well-developed but is noticeably thin with a body mass index of 18. You do not note any other abnormalities. A pregnancy test is negative. Based on patient's history, which of the following is the most likely diagnosis?

Functional hypothalamic amenorrhea

A 42-year-old woman with a history of hypertension and a body mass index of 32 presents to the office with her fourth incidence of vaginal candidiasis in the past year. Besides a wet mount and fungal culture, which of the following screening test should be ordered?

Glycated hemoglobin Notes: Diabetes mellitus is a predisposing factor for recurrent vulvovaginal candidiasis since hyperglycemia enhances the ability of Candida albicans to bind to vaginal epithelial cells.

A 72-year-old G5P5005 woman presents to the office with the complaint of a bulge "down there." She states she has had it for a while now but has noticed some vaginal bleeding and is now concerned. On exam, you note the cervix has descended halfway past the hymen, and there are multiple small ulcerations. What grade of the Baden-Walker halfway system would you give her prolapse, based on her physical exam?

Grade 3 Notes: Grade 0: no prolapse and this is a normal position. Grade 1 is descent halfway to the hymen. Grade 2 is descent to the hymen. Grade 3 is descent halfway past the hymen. Grade 4 is the maximum possible descent.

A 42-year-old woman presents to your office for a health care maintenance visit. You counsel her on perimenopause, symptoms, and management. Which of the following is the most common symptom of this perimenopause?

Hot flashes Notes: Perimenopause 3-5 years Prolonged heavy menstruation with episodes of amenorrhea ↓ Fertility ↓ Estrogen ↑ FSH and LH

A 32-year-old pregnant woman who is 28 weeks presents with an elevated blood pressure to the emergency room at the direction of her clinician. Her last two office visits blood pressures have been 172/112 mm Hg and 168/110 mm Hg. Which of the following medications would be the best choice to use initially in this patient?

Hydralazine Notes: When treating a pregnant patient with new onset of acute hypertension or preeclampsia, intravenous hydralazine has been used extensively and is relatively safe. It can also be used orally. Gestational Hypertension PE will show new-onset SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg at ≥ 20 weeks gestation If proteinuria or signs of end-organ damage develop: preeclampsia If BP elevation persists > 12 wks postpartum: chronic hypertension If BP returns to normal by 12 wks postpartum: transient hypertension of pregnancy

A 60-year-old woman presents to her gynecologist with postmenopausal bleeding. She is currently taking tamoxifen following recent breast cancer treatment and is on estrogen replacement therapy for symptoms of menopause. An endometrial biopsy shows Stage 1 adenocarcinoma. Which of the following is the most appropriate intervention for this patient?

Hysterectomy and bilateral salpingo-oophorectomy Notes: One of the risk factors for endometrial cancer is continuous unopposed estrogen. Tamoxifen, a medication used to treat breast cancer, acts to increase estrogen in the uterus and would increase the risk of developing uterine cancer. Diagnosis is made by biopsy. Adenocarcinoma is most common. The management is determined by staging of the endometrial cancer. Stage 1 cancers are treated with hysterectomy and bilateral salpingo-oophorectomy with or without radiation. Stage 2 cancers are treated with hysterectomy and bilateral salpingo-oophorectomy, lymph node excision and radiation. The depth of the tumor determines prognosis.

A 68-year-old woman presents to clinic to discuss surgical management of her pelvic organ prolapse. She has had stage III prolapse of the uterus for the past five years. Pelvic muscle exercises and pessary use have not relieved her symptoms of heaviness and discomfort. Her past medical history is significant for sarcoidosis for which she takes oral prednisone. Which of the following is the most appropriate surgical option for this patient?

Hysterectomy with uterosacral ligament suspension

A 37-year-old woman presents for a routine gynecologic visit. She mentions that she has had multiple genital warts that have been treated in the past using an immune-mediated therapy. She is unsure what exactly was used but would like the same treatment. Which of the following is an immune-mediated therapy used to treat human papillomavirus?

Imiquimod

A 32-year-old woman presents to the emergency department with vaginal bleeding. She is 10 weeks pregnant and began spotting this morning. The bleeding has become heavier throughout the day and now she has pelvic discomfort and cramping. A pelvic exam is completed and the cervix is found to be dilated with products of conception in the cervical canal. What is the most likely diagnosis?

Incomplete abortion Notes: Abortion Threatened abortion: vaginal bleeding with closed internal os Inevitable: vaginal bleeding with open os Incomplete: partial passage of products of conception (POC) Complete: complete passage of POC Missed: fetal death < 20 weeks without POC passage Missed abortion complications: infection, coagulopathy Rh-negative women → Rho(D) immune globulin

Activation of the hypothalamic-pituitary-adrenal axis through excess fetal or maternal stress has been implicated as one causative factor of preterm labor. Which of the following best describes the physiologic cascade triggered by stress in a pregnant patient?

Increased cortisol leads to increased corticotropin-releasing hormone, which activates prostaglandins that cause cervical change and rupture of membranes

A 54-year-old woman presents with progressively worsening vaginal irritation and dyspareunia for three years. She denies dysuria or urinary frequency. She has no past medical history of abnormal cervical cytology, and hasn't had any vaginal bleeding in the past two years. She hasn't tried any over the counter treatments for her symptoms. There is introital narrowing on external genital exam, and pelvic exam reveals dry, smooth and shiny vaginal epithelium. What is the best next step in management?

Initiate non-hormonal vaginal moisturizer and lubricant therapy Notes: Genitourinary Syndrome of Menopause (Atrophic Vaginitis) Patient will be a postmenopausal woman Dyspareunia, dryness, bleeding, itching PE will show a pale, dry, shiny epithelium Most commonly caused by a decrease in estrogen Treatment is lubricants, moisturizers, topical estrogen

A 20-year-old woman with a known history of chronic abnormal uterine bleeding presents to the emergency department with tachycardia, hypotension, heavy vaginal bleeding, and hemoglobin of 6.2 g/dL. Pregnancy test is negative. The patient was started on fluids and given a blood transfusion. A uterine curettage was performed, but bleeding still persisted. Which of the following is the most appropriate next step?

Intravenous estrogen Notes: Abnormal Uterine Bleeding Patient will report heavy menstrual bleeding or intermenstrual bleeding Etiology may be structural or nonstructuralStructural causes: polyp, adenomyosis, leiomyoma, malignancy or hyperplasia (PALM)Nonstructual causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified (COEIN) Minimum laboratory assessment: pregnancy test, CBC, TSH Endometrial tissue sampling for all women age ≥ 45 years First-line imaging study: transvaginal ultrasound Treatment is combination OCPs, IV estrogen, progestins

Which of the following best represents a positive prognostic variable for successful external cephalic version of a breech fetus?

Non-longitudinal fetal position

A 31-year-old woman presents to the clinic complaining of groin pain. The patient states that she returned from a trip to the Caribbean three weeks ago, and had unprotected sex with a male partner during her trip. She noticed a painless genital ulcer that appeared prior to returning home, but states that it was gone three days later. A few days ago, she noticed some pain and swelling in her groin, which has become progressively worse. On physical examination, there are inflamed superficial and deep inguinal lymph nodes forming a "groove" sign bilaterally. Which of the following is the most likely diagnosis?

Lymphogranuloma venereum Notes: Lymphogranuloma venereum is a sexually transmitted infection caused by Chlamydia trachomatis serotypes L1, L2, and L3. It causes lymphangitis which subsequently leads to areas of necrosis within the lymph nodes and ultimately causes abscess formation. It is most commonly found in tropical and subtropical areas of the world (e.g., Caribbean, East and West Africa).

A 26-year-old woman is newly diagnosed with gestational diabetes mellitus at 26 weeks gestation. Her past medical history is otherwise benign and she is on no chronic medications. Which of the following is the most appropriate first-line treatment for this patient?

Medical nutritional therapy Notes: Glucose targets include the following: fasting blood glucose of less than 95 mg/dL, 1-hour postprandial blood glucose level of less than 140 mg/dL, or 2-hour postprandial glucose level of less than 120 mg/dL.

A 23-year-old female presents to her clinician for an annual physical for work. She reports that she became sexually active at the age of 21, has had 4 sexual partners in the last 3 months, consumes 6 alcoholic beverages per day, and regularly douches. Which of the following factors in the patients history increases her risk for cervical cancer?

Multiple sex partners

A 23-year-old woman presents with several erythematous, painful ulcers on the vaginal introitus which have been present for seven days and began as small red papules, which then evolved to pustules and then ulcerations. There is marked lymphadenopathy of bilateral inguinal nodes. Polymerase chain reaction for herpes simplex virus is negative. Which of the following additional diagnostic tests is necessary before diagnosing chancroid in this patient?

Negative venereal disease research laboratory test Notes: Chancroid is a sexually transmitted disease which results in painful genital ulcers. The causative pathogen is Haemophilus ducreyi, a gram-negative rod which is very contagious but rarely found in the developed world.

A baby is delivered via cesarean section at 39 weeks of gestation due to the mother's history of a previous cesarean section. At one minute after birth the baby is found to have an Apgar score of seven. The score is to be reassessed at the five-minute mark. The baby is found to be actively moving and pulls away with minor stimulation. The baby is pink without cyanosis and vigorously crying. Heart rate is 96 bpm. What is the baby's five-minute Apgar score?

Nine Notes: The scores range from 0 to 10. A baby with a score of ten (1) is actively moving; (2) has a heart rate > 100 bpm; (3) sneezes, coughs, and pulls away; (4) is pink all over, and (5) is breathing normally and crying. APGAR Appearance, pulse, grimace, activity, respiration Calculated at 1 and 5 minutes after birth Score of 0, 1, or 2 per section Baby with low score may require intervention

A 28-year-old G2P1 woman at 38 weeks of gestation presents to labor and delivery after experiencing a gush of vaginal fluid at home. The patient reports she has not yet experienced contractions. A sterile speculum examination is performed which shows pooling of fluid in the vaginal vault. No cord prolapse is visualized on speculum examination. Which of the following can be used to further confirm the diagnosis?

Nitrazine test Notes: Nitrazine test is used to confirm the diagnosis of premature rupture of membranes (PROM), in addition to visual inspection on speculum examination. Prelabor Rupture of Membranes (PROM) Membrane rupture prior to labor Preterm PROM (PPROM): PROM occurring at < 37 weeks Fluid ferning + blue nitrazine paper = amniotic fluid Admission, OB consultation

A 22-year-old woman presents with persistent purulent vaginal discharge for one week which began after having intercourse with a new partner. On exam, her cervix is erythematous and edematous and there is a purulent cervical discharge. There is no cervical motion tenderness. Which of the following is the most appropriate diagnostic test?

Nucleic acid amplification testing of cervical discharge

An obese, 56-year-old woman presents to the clinic with a new and persistent non-tender mass in her right breast, which she had noticed a month ago. Past medical history is significant for menarche at age 16 years, first pregnancy at age 17 years, and breastfeeding all of her children. On exam, there is one firm, immovable mass in the right breast as well as right axillary adenopathy. Diagnostic mammogram reveals a spiculated soft-tissue mass. Which of the following risk factors likely increased this woman's risk for the most likely diagnosis?

Obesity

An asymptomatic G2P2 58-year-old woman presents to the clinic for routine gynecologic examination. Pelvic exam reveals a posterior vaginal bulge and a palpable break in the rectovaginal fascia. Which of the following interventions is the best next step?

Observe with yearly examination Notes: Rectocele is the anterior protrusion of the rectum into the posterior vaginal wall. Observation with yearly examinations is appropriate management for asymptomatic women or for women with mild symptoms and a mild prolapse because the majority of these women may never experience prolapse progression.

A 32-year-old woman who is 35 weeks pregnant presents for a routine prenatal examination. Upon palpation of the uterus, the firm resistance of the fetal head is not able to be felt above the symphysis pubis. Upon further palpation, the fetal head seems to be located in the left upper quadrant. Which of the following is the next best step?

Order an abdominal ultrasound Notes: Ordering an abdominal ultrasound to confirm a transverse fetal lie is the next best step in caring for this patient. Ultrasound allows the practitioner to determine the precise position of the fetus. Imaging also allows for determination of potential underlying causes including maternal pelvic abnormalities, uterine abnormalities, and placenta previa.

A 24-year-old woman presents with sudden onset of lower right sided abdominal pain, nausea, and vomiting. She is not currently sexually active and pregnancy test is negative. She is found to have a right adnexal mass on exam. A pelvic ultrasound reveals an heterogenous enlarged ovary with decreased doppler flow. Which of the following is the most common risk factor for the suspected diagnosis?

Ovarian mass Notes: Ovarian torsion is one of the most common gynecologic emergencies. It occurs when the ovary rotates on its ligamentous supports, which often blocks its blood supply. The primary risk factor for ovarian torsion is an ovarian mass (neoplasm or cyst), and the risk of torsion increases with the size of the mass.

A 30-year-old G2P1 at 36 weeks' gestation with a history of tobacco use and chronic hypertension presents to the emergency department with acute onset of vaginal bleeding, abdominal pain, and contractions. Physical exam reveals patient in a moderate distress. Vital signs are temperature 37°C, heart rate 95 beats per minute, respiratory rate 16 breaths per minute, blood pressure 130/85 mm Hg, and pulse oximetry 100% on room air. Pelvic exam reveals firm and tender uterus with blood visualized in vaginal vault. Which of the following is the most likely explanation for these findings?

Placental abruption Notes: Placental Abruption Patient will be in her third trimester With a history of hypertension, trauma, or cocaine use Complaining of painful vaginal bleeding Labs will show hypofibrinogenemia Tx: fetal monitoring, hemodynamic stabilization, delivery

What is the most common risk associated with gestation of multiples?

Premature birth Notes: Premature birth is the most common risk associated with multiple gestations. The risk increases as the number of multiples increases. Premature birth can result in hypothermia, low birth weight, intracranial hemorrhage, cardiac abnormalities, and respiratory difficulty.

A 23-year-old woman presents to the clinic complaining of abdominal bloating, fatigue, insomnia, mood swings, and persistent irritability for the past nine months. Symptoms have been occurring during the week leading up to her period and remit completely within a few days after onset of menses. She requests a note excusing her from work because she has missed several days due to these symptoms. She has no pre-existing endocrine or psychiatric disorders, and she has sought care at the clinic for several years only for routine screening and infrequent acute illnesses. Which of the following is the most likely diagnosis?

Premenstrual dysphoric disorder

A 22-year-old woman presents to the clinic complaining of abdominal bloating, nausea, irritability, and anxiety for the past six months. She reports that symptoms consistently happen for the week leading up to her period and then stop quickly after she starts her period. She has no history of mood disorders and denies suicidal ideation. Which of the following is the most likely diagnosis?

Premenstrual syndrome Notes: physical and behavioral symptoms that interfere with some aspect of the woman's life and occur cyclically during the luteal phase (second half) of the menstrual cycle. Affective and behavioral symptoms include mood swings, irritability, anxiety, and depressed mood, and typical somatic symptoms include abdominal bloating, breast pain, nausea, fatigue, and headache.

Which of the following factors is more indicative of premenstrual dysphoric disorder than premenstrual syndrome?

Presence of symptoms for most of the preceding year Notes: Premenstrual Dysphoric Disorder (PMDD) Five or more symptoms present during the week prior to menses resolving within a few days after menses starts Symptoms being present for most of the preceding year Patients who require treatment have symptoms associated with significant distress and interference with work, school, and relationships Management includes lifestyle modifications and pharmacologic options (SSRIs are first line) Comments: Key point between premenstrual syndrome and premenstrual dysphoric disorder is PMDD symptoms usually hinder personal/professional life (unlike premenstrual disorder)

A 28-year-old G2P1 woman at 23 weeks gestation presents to the emergency room for painless vaginal bleeding. Prior to performing a digital vaginal examination, an ultrasound of the uterus is performed, which reveals placental tissue lying over the internal cervical os. Based on the ultrasound findings, what would you expect to learn from the patient's history that would put her at increased risk of the likely diagnosis?

Previous cesarean section Notes: Placenta Previa: Patient will be a pregnant woman in her third trimester Complaining of painless vaginal bleeding Diagnosis is made by ultrasound (transvaginal > transabdominal) Comments: Do not do a digital vaginal exam

A 25-year-old patient presents to the walk-in clinic for vaginal bleeding. She has been on low-dose combined oral contraceptive pills but has been noncompliant to her medication recently. She is unsure when her last menstrual period was since she only gets minimal spotting while on birth control. Her urine pregnancy test is positive, and a serum quantitative beta-human chorionic gonadotropin level is 1,032 IU/L. A transvaginal ultrasound is performed and reveals an empty endometrial cavity. Her gynecologic history is significant for one episode of chlamydia cervicitis treated by antibiotics at the age of 18 with a negative test of cure, and an ectopic pregnancy at the age of 23 treated by methotrexate. She smokes 10 cigarettes per day. Which of the following is the strongest risk factor for recurrence of ectopic pregnancy?

Previous history of ectopic pregnancy Notes: Ectopic Pregnancy Patient with a history of prior ectopic, PID, tubal surgery, IUD Presents with vaginal bleeding, abdominal pain, amenorrhea PE will show adnexal tenderness or unexplained hypotension Labs will show positive pregnancy test and lower than expected serum beta-hCG levels Diagnosis is made by ultrasound Most commonly located in a fallopian tube Treatment is methotrexate or surgery

A 32-year-old woman with bilateral breast pain that is worse before her period and resolves after her period is diagnosed with fibrocystic breast disease. Which of the following descriptions would describe fibrocystic breast changes on ultrasound?

Prominent fibroglandular tissue with small cysts but no discernable mass Notes: Fibrocystic Breast Disease Patient will be a woman 30-50 years old Intermittent breast pain and tenderness that peak before each menstruation Ultrasound shows dense, prominent, fibroglandular tissue with cysts but no discernible mass Most commonly caused by fluctuating estrogen levels during menstrual cycles Treatment is well-fitting supportive bras, applying heat to the breasts, or over-the-counter pain relievers Most common lesion of the breastFibrocystic changes are generally benign and do not increase risk for breast cancer

A 24-year-old woman recently treated with an antibiotic for a urinary tract infection presents with severe vaginal itching and burning for two days. Upon physical examination, you note thick, white, curd-like vaginal discharge. Which of the following microscopic findings you would most likely see on a wet mount?

Pseudohyphae Notes: Vaginal candidiasis Diagnosis can be made clinically and is confirmed with a presence of Candida on wet mount; adding 10% potassium hydroxide (KOH) facilitates recognition of budding yeast and pseudohyphae. Vulvovaginal Candidiasis: Patient with a history of diabetes, HIV, recent abx use Complaining of pruritus, dysuria, dyspareunia PE will show white, cottage cheese-like discharge Labs will show pH < 4.5, pseudohyphae, spores Most commonly caused by Candida Treatment is fluconazole

A 19-year-old woman presents to the clinic for evaluation of ongoing vaginal irritation and discharge. She reports that the discharge has been thin, yellow, and foul smelling. She is currently sexually active with one partner. Vaginal pH is 5.5. Amine test is positive. Wet mount reveals motile trichomonads with absence of hyphae and clue cells. Based on the most likely diagnosis, what other physical examination finding would you likely discover in the patient?

Punctate hemorrhages on the cervix Notes: Trichomoniasis Patient will be a woman complaining of malodorous vaginal discharge PE will show frothy, green/yellow discharge, "Strawberry cervix" Labs will show pH > 5, flagellated, motile, pear shaped Diagnosis is made by wet mount Most commonly caused by Trichomonas vaginalis Treatment is metronidazole

A 62-year-old G4P4 woman presents to the clinic with a persistent pressure sensation in her vagina for the past year. She also reports that she has to push against the inside wall of her vagina in order to defecate. She reports no rectal or vaginal bleeding. Past medical history is significant for four vaginal deliveries. Which of the following is the most likely diagnosis?

Rectocele

A 24-year-old woman who gave birth to a premature baby girl at 30 weeks gestation presents to your office for a follow-up visit after being diagnosed with mastitis three days ago. You had prescribed her amoxicillin, but after taking it as directed, she has not had any improvement of symptoms. The patient now has a fever of 103℉ with increased pain to the left breast. Physical exam shows a severely tender fluctuant mass in the breast that is red and warm to touch. What is the most appropriate next step for treatment of this patient?

Refer patient to a surgeon for incision and drainage Mastitis Patient will be a breastfeeding mother Complaining of breast erythema, tenderness, fever Most commonly caused by Staph. aureus Management includes cool compresses and analgesics in between feedings Antibiotics: Dicloxacillin, cephalexin, TMP-SMX (MRSA), clindamycin (PCN allergic) Comments: continue breast feeding to avoid progression to abscess

A 21-year-old non-pregnant woman presents for her first Papanicolaou screening test. Cervical cytology shows low-grade squamous intraepithelial lesions. Which of the following is the best next step in management?

Repeat cervical cytology in one year Notes: Abnormal Cervical Cancer Screening Results Atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesions (LSIL)Management based on immediate risk of high-grade abnormality Positive HPV 16 or HPV 18 with any cytology result: colposcopy Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H): colposcopy High-grade squamous intraepithelial lesion (HSIL): colposcopy or loop excision* Atypical glandular cells of undetermined significance (AGC): colposcopy and endocervical sampling*Endometrial biopsy* for age ≥ 35 years

A 22-year-old woman with history of an ovarian cyst presents to the ED with sudden onset of sharp right lower quadrant pain. She is not sexually active and denies vaginal discharge or bleeding. Vital signs are normal. Physical exam findings include bowel sounds present throughout all four quadrants. Abdomen is tender to palpation in the right lower quadrant with no rebound or guarding. Pelvic exam reveals right adnexal mass. Urine pregnancy test is negative. Which of the following is the most likely diagnosis?

Ruptured ovarian cyst Notes: Ovarian Cysts Follicular: Most common ovarian mass, nonneoplastic, regress spontaneously Corpus luteum: Most common ovarian mass in pregnancy, nonneoplastic, regress spontaneously Dermoid: teratoma Theca lutein: bilateral, ovarian enlargement Endometroid: endometriosis within ovary, "chocolate" cyst Ultrasound

A 24-year-old woman presents to the clinic with complaints of nausea, headache, fatigue, and mood swings that have been occurring during the week leading up to her period. She has routinely had to miss work due to her symptoms. Her symptoms go away shortly after menses begin. She denies suicidal ideation. She has no pre-existing endocrine or mood disorders. Which of the following is the best initial treatment for this patient?

Selective serotonin reuptake inhibitor Notes: Premenstrual Syndrome 1-2 weeks prior to menstrual cycle Sleep disturbances, decreased focus, emotional lability, breast tenderness, or HA that resolves after menstruation begins Treatment is decreased caffeine intake, exercise, stress reduction, NSAIDs, SSRIs, OCPs Comments: Symptoms do not hinder personal/professional life (unlike premenstrual dysphoric disorder)

A 30-year-old woman presents to the clinic with concerns about preterm delivery. She suffered premature rupture of membranes with her first pregnancy. Which of the following would be the best choice for anticipatory guidance in this patient?

Smoking cessation Notes: Prelabor Rupture of Membranes (PROM) Membrane rupture prior to labor Preterm PROM (PPROM): PROM occurring at < 37 weeks Fluid ferning + blue nitrazine paper = amniotic fluid Admission, OB consultation Risk factors for PROM: infection and inflammation, pathologic uterine distention, placental abruption, vaginal bleeding, low socioeconomic status, smoking, activation of the hypothalamic-pituitary-adrenal (HPA) axis through stress, and pathologic cervical changes.

What is the most common pathogen involved in infective lactational mastitis?

Staphylococcus aureus Notes: Mastitis Patient will be a breastfeeding mother Breast erythema, tenderness, fever Most commonly caused by Staph. aureus Management includes cool compresses and analgesics between feedings Antibiotics: dicloxacillin, cephalexin, TMP-SMX (MRSA), clindamycin (PCN allergy) Continue breast feeding to avoid progression to abscess

A 32-year-old woman presents to the ED at 39 weeks of gestation in active labor. Her axillary temperature is 98.6°F, pulse is 88 beats per minute, and blood pressure is 120/80 mm Hg. Upon vaginal examination, an umbilical cord is noted to be protruding from the cervix which is dilated to five centimeters. While awaiting a surgical suite for an emergency cesarean section, which of the following agents would be most appropriate to administer?

Subcutaneous terbutaline Notes: tocolytic terbutaline 0.25 mg can be given subcutaneously to decrease uterine contractions and alleviate pressure on the cord. Umbilical Cord Prolapse Patient with a history of malpresentation, PROM Cord precedes presenting part, increasing cord pressure and leading to fetal anoxia Treatment is emergent C-sectionIf delay in C-section: Trendelenburg position, knee-chest position, bladder filling, elevation of presenting fetal part

A 32-year-old woman presents to your office for a follow-up visit regarding her complaints of painful breasts bilaterally occurring right before she menstruates and resolving after her period. She has no family history of breast cancer. Which of the following is the best treatment for her symptoms?

Supportive bra and analgesics Notes: Fibrocystic breast changes, more commonly known as fibrocystic breast disease, is the most common lesion of the breast and does not represent a pathological disorder. It is common in women 30-50 years of age.

A 23-year-old woman returns to her obstetrician seven days postpartum. She is concerned with severe pain in the perineum and discharge following the sensation of "popping" in that area. She has been running a fever for the past day. A fourth-degree laceration was repaired following labor. Physical exam shows separated sutures and an erythematous perineal wound. What is the appropriate management of this patient?

Systemic antibiotics, debridement, and secondary repair Notes: A first-degree tear involves only the skin in the perineal area. A second-degree tear involves the superficial perineal area as well as deeper tissues. Third and fourth-degree lacerations go beyond the perineal area and into the muscle of the rectal sphincter. A fourth-degree laceration will breach the mucosa of the rectum increasing the risk of infection.

A 28-year-old primigravida presents in her 34th week of gestation with dichorionic twins. Her prepregnancy body mass index was 20 kg/m². Her blood pressure is 120/80 mm Hg and her hemoglobin is 11 g/dL. Which of the following represents the best counseling to offer this patient?

Take two prenatal vitamins with iron daily instead of one Notes: Multiple gestation pregnancies put patients at increased risk of nearly all pregnancy complications, such as premature labor, preeclampsia, congenital birth defects, and anemia

A 22-year-old woman presents with a new lump in her right breast that she noticed while she was doing a self-exam in the shower about one week ago. The lump has not changed in size. Upon physical exam, you note a 2 cm discrete lump that is round, mobile and nontender to palpation to the upper outer quadrant of the right breast. The lump is solitary and you do not notice any other abnormalities. Which of the following statements is most likely given the suspected diagnosis?

They usually regress after menopause Notes: Fibroadenomas are common benign breast tumors frequently found in young women in their 20s and 30s although they can be diagnosed at any age. Typically, fibroadenomas range from 1-5 cm in size, are round or ovoid, rubbery in texture, discrete, mobile and nontender.

A 31-year-old G1P1 woman at 39 weeks gestation has a normal spontaneous vaginal delivery. The patient is evaluated immediately after delivering for possible obstetric perineal laceration. On physical examination, the patient is found to have a laceration through the perineal fascia and musculature extending into the external anal sphincter. Based on the description of the laceration, which of the following would be the patient's correct diagnosis?

Third-degree laceration Notes: First-degree: skin of the perineum, no muscle involvement Second-degree: fascia/musculature of the perineal body, anal sphincter muscles are not involved Third-degree: through the fascia/musculature of the perineal body and involve the anal sphincter Fourth-degree: involve the perineal structures, external anal sphincter, internal anal sphincter, and the rectal mucosa

Which of the following tests would be performed first in a reverse-sequence screening algorithm for syphilis?

Treponemal enzyme immunoassays (EIA) Notes: Some clinical laboratories have adopted reverse-sequence screening algorithms for syphilis using treponemal tests, typically treponemal enzyme immunoassays (EIA) or chemiluminescence immunoassays. This approach can identify individuals previously treated for syphilis and those with untreated or inadequately treated syphilis.

A 48-year-old premenopausal woman is being evaluated for an adnexal mass palpated on bimanual exam. A pelvic ultrasound reveals a fixed right ovarian 6 cm complex mass and a large amount of free fluid. CA-125 is 193 units/mL, (carcinoembryonic antigen) CEA is 2.8 ng/mL. Which of the following supports referral to a gynecologic oncologist?

Ultrasound findings Notes: Women presenting with complex adnexal masses suspicious for malignancy who require surgical management have been shown to have improved overall survival rates when managed by a gynecologic oncologist. Referral criteria in premenopausal women include CA-125 > 200 units/mL, ultrasound findings suggestive of malignancy (free fluid consistent with ascites, or a nodular fixed mass), or evidence of distant metastases.

A 60-year-old woman presents to her gynecologist with complaints of urinary frequency, urgency and incontinence. A cystocele is diagnosed on pelvic exam. The patient has undergone pelvic floor muscle training but symptoms have only improved slightly. What is the mainstay of nonsurgical treatment for this patient?

Vaginal pessary

A 28-year-old woman at 38 weeks gestation is laboring at labor and delivery. Part of her cardiotocograph is shown above. What type of decelerations are seen on the cardiotocograph?

Variable

A 25-year-old woman presents to her obstetrician for her first prenatal visit. She is advised to begin taking prenatal supplements. Which of the following supplements has been proven to be teratogenic if taken in excess?

Vitamin A Notes: Vitamins and supplements are often recommended during pregnancy as many are crucial to the normal development of the fetus. In excess, however, certain supplements may have adverse effects. Vitamin A is teratogenic in high doses. Foods high in vitamin A, such as liver, should also be avoided during pregnancy.