NBME OBGYN

Prior to discharge from the hospital following an uncomplicated delivery, a 30F, G1P1, states that she would like to resume the combo oral contraceptive she took prior to pregnancy. She plans to breast-feed for 6 months. In considering the combo of breast-feeding & this method of oral contraceptive, the physician should counsel the pt about which of the following potential problems? (Decreased protein content in breast milk OR Delayed uterine involution)

Decreased protein content in breast milk > This can be seen if milk production has not been established before continuing combo contraceptives Delayed uterine involution > Would be experienced if mom would not breastfeed at all (this pt plans to continue to breastfeed)

A 37F, primigravid, at 35 wks presents for a routine prenatal visit. She has been receiving routine prenatal care since 8 wks. Pregnancy has been complicated by the onset of HTN at 18 wks that has been well controlled w/ labetalol. She has an 18-yrs Hx of DM I. Her HbA1c at 8 wks was 5.7% BP is 140/90. Exam shows a soft uterus w/ a fundal ht of 32cm. The fetal heart rate is 140/min. Serum studies show a urea nitrogen conc of 8mg/dL & creatinine conc of 1mg/dL. A 24-hr urine collection shows a protein conc of 800mg. US shows a normal fetus at the 5th percentile for wt; the placenta is anterior & fundal. There is a mild decrease in the amount of amniotic fluid. Which of the following is the most likely cause of the US findings? (Placental dysfunction OR Trisomy 21)

- The US shows FGR - Both Placental dysfunction & trisomy 21 are potential causes of FGR (defined as *growth <10th percentile* (pt is at <5th percentile) - However they are the cause of FGR during different trimesters: -------a) Placental dysfunction (also maternal malnutrition)*occurs at 2nd or 3rd trimester* ------[pt is in 3rd trimester] -------b) Trisomy 21 (also Intrauterine infection) > *occurs in 1st trimester*

A 32F, primigravid, at 6wks, presents b/c of a 3- day history of moderate vaginal bleeding. She was seen in the ED 1 wks ago w/ similar symptoms. Pelvic US at at that time shows a thickened endometrial stripe & no fetal pole. Her serum B-hCG conc was 450mIU/mL. Today, her pulse is 80/min, BP is 110/60. PE shows a closed Cervix & a non-tender uterus consistent in size w/ a 6 wk gestation. There are no palpable adnexal masses. Today, her Hb conc is 11.8 g/dL & serum B-hCG conc is 90 mIU/mL. Which of the following is the most appropriate next step in MGMT? (3rd measurement of serum B-hCG conc in 1 week OR Administration of methotrexate)

3rd measurement if B-hCG in 1 week > Pt most likely has an ectopic pregnancy *b/c B-hCG levels should continue to rise during pregnancy; this pt has a decreasing B-hCG* >> usually associated with fetal demise of ectopic pregnancy > Standard MGMT is *3 B-hCG measurements* to confirm Administration of methotrexate > b/c the B-hCG levels have dropped & there is no fetal pole >> *there is no reason to induce labor*

A 21F, primigravid, at 8wks presents for her first prenatal visit. She has sickle cell & is concerned about the risk of transmitting the disease to her fetus. Her pregnancy has been uncomplicated. Exam shows a uterus consistent in size w/ an 8 wks gestation. Her husband Hb electrophoresis shows: - Hb A ---42% (N=95-98) - Hb A2---3% (N=2-3) - Hb F----2% (N=.8-2) - Hb S----53% (N=0) This pt should be counseled that the probability her fetus will have sickle cell is? (25% OR 50%)

50% > Both mom and dad are affected and have disease

A 16F, presents by mom b/c she has never had a menstrual period. She is otherwise healthy. She is 5ft 9in tall & weighs 135 lbs. Breast development is tanner stage 3; there is no axillary or pubic hair. PE shows a vagina that is 2cm in length. Pelvic US shows no uterus. Which of the following is the most likely Dx? (Paramesonephric (mullerian) duct agenesis OR AIS)

AIS - Typical Presentation includes primary amenorrhea in a phenotypical woman 1- Female external genitalia 2- Scant sexual hair 3- rudimentary vagina 3- Can have Absent ----a) Uterus --------(pt is said only to have absent uterus) ----b) Fallopian tubes, ----c) cervix* 4- Breasts → d/t ↑ estrogen 5- Testes → usually present w/in the labia majora or abdomen Labs --1) Normal FSH levels --2) INCREASED→ testosterone, LH, estrogen Paramesonephric (Mullerian) duct agenesis -Presents similarly to AIS → however the key differentiating factor is that MA presents w/ axillary & pubic hair -----[pt has NO axillary/pubic hair] - Pts typically present w/: ---a) primary amenorrhea at 15-17 yrs ---b) Normal secondary characteristics -------normal breast development -------+ axillary & pubic hair ----------[pt has NO PUBIC/AXILLARY HAIR] - Classically characterized by: ----1) Shallow vaginal pouch & absent Upper vagina --------[pt DOES have a shallow vagina (2-cm)] ----2) No uterus or cervix ----3) Normal ovaries ----4) Urological abnormalities -------(renal agenesis, horsehoe kidney) ----5) Skeletal abnormalities --------(scoliosis, spina bifida)

A 27F, G2P1A1, presents b/c of a 3-day Hx of increasing abdominal pain & a 1-day Hx of fever. 5 days ago, she underwent an uncomplicated abortion at 10 wks & received prophylactic antibiotics. Temp is 102.6F, pulse is 110/min, RR 24/min, BP is 90/50. PE shows a tender uterus consistent in size w/ a 12 wks gestation & no adnexal masses. Pelvic US shows a heterogenous endometrial mass. After IV antibiotic therapy is started, she undergoes suction dilatation & curettage followed by sharp curettage to remove the infected material. The pt is at greatest risk for which of the following conditions? (Amenorrhea OR Endometrial cancer OR Ovarian cancer)

Amenorrhea > Pt presents w/ *endometritis* >> which presents w/: 1- Most common genital infection after delivery or *abortion* (heterogenous endometrial mass is a baby, not a molar pregnancy) 2- Usually caused by retained products of conception 3- *Fever* 4- *Uterine Bleeding* 5- *pelvic pain* reason for amenorrhea > Pt has retained products of conception therefore would have increased B-hCG levels >> this would cause secondary amenorrhea Endometrial cancer OR Ovarian cancer > not associated w/ endometriosis or abortion >> would be good choice if pt had a molar pregnancy (which she does not)

A 21F, primigravid, at 41 wks is admitted to the hospital in labor. Her pregnancy has been uncomplicated. Contractions occur every 3 mins. The cervix is 100% effaced & 4 cm dilated; the vertex is at +1 station. The membranes rupture yielding moderately thick meconium-filled fluid. The fetal heart rate has a baseline of 130/min w/ variable decels lasting 45 sec & decreasing to 60/min. Which of the following is the most appropriate next step in MGMT? (Forceps delivery OR Amnioinfusion)

Amnioinfusion > Baby is showing *variable decels* >> which are d/t umbilical cord compression *amnioinfusion* (infusion of saline into uterine cavity following ROM) may help alleviate variable decels d/t cord compression Other MGMT of non-reassuring FHR tracing 1- Turn off oxytocin 2- Give amnioinfusion (saline) 3- Administer high flow O2 4- Turn mom to lateral decubitus position 5- Rule out prolapsed umbilical cord w/ vaginal exam Forceps delivery > May be used in cases where baby is stuck (shoulder dystocia)

A 24F, primigravid at term is admitted to the hospital in labor. She has not been screened for GBS infection. Pregnancy has been uncomplicated. The cervix is 80% effaced & 5 cm dilated; the vertex is at +1 station. Contractions occur at every 10 mins. The membranes ruptured 12 hrs ago. Exam shows areas of vaginal erythema. Cultures for GBS are pending. Which of the following is the most appropriate next step in regarding prevention of GBS sepsis in the newborn? (Antibiotic therapy if delivery has not occurred 18 hrs after rupture of membranes OR CS because lesions are present)

Antibiotic therapy if delivery has not occurred 18 hrs after rupture of membranes > neonatal sepsis can be prevented w/ penicillin, cefazolin, clinda, vanco >> *during labor* or in infected neonates CS b/c lesions are present - A CS is not needed b/c GBS transmission can be prevented w/ antibiotics

5 wks after the uncomplicated delivery of her newborn, a 25F, G1P1, presents w/ concerns about insomnia, restlessness, extreme fatigue, irritability, & depression. She has not been eating well. She finds the baby's crying increasingly annoying & has been letting him cry alone in the crib for long periods of time. She is having difficulty w/ her memory & ability to concentrate. while her husband has been supportive, she has had difficulty involving him in the care of the baby. She is afraid that she may hurt her child & says that maybe she "would be better off dead." Which of the following is the most appropriate initial step in management? (Prescribe immediate antidepressant therapy OR Arrange for an immediate psychiatric eval)

Arrange for an immediate psychiatric eval > pt has admitted to possibly harming the baby >> warrants immediate eval and/or hospital admission Prescribe immediate antidepressant therapy > even if prescribed, it may take weeks before the meds take effect >> pt poses immediate danger to herself and baby

A 32F, primigravid, at term has a cervix that has remained 5 cm dilated over the past 4 hrs despite the admin of oxytocin. Contractions occur every 3 mins & are 55 to 64 mmHg by intrauterine pressure catheter. Exam shows a somewhat molded vertex & considerable caput succedaneum. Which of the following is the most likely Dx? (Arrest of active phase OR Protracted latent phase)

Arrest of active phase *active phase can be 4-8cm* > Oxytocin is used in active phase > Molded vertex (abnormal shaped head) & considerable caput succedaneum (fluid in scalp) Protracted latent phase > latent phase can be 0-3 cm

18 hs after an uncomplicated CS for breech presentation, a 23F, G1P1, has fever. Temp is 100.4F, BP is 112/74. Decreased breath sounds are heard bilaterally w/ no crackles pr rhonchi. CV exam shows a regular rhythm w/ no murmurs, rubs, or clicks. The fundus is non-tender and 2cm below the umbilicus. The incision site is dry, intact, & mildly tender. Exam of the LE shows 2+ pitting edema to the mid calves bilaterally w/ no cyanosis or clubbing. Foley & right IV antecubital catheters are in place. Which of the following is the most likely Dx? (Atelecatsis OR Thrombophlebitis)

Atelectasis > The most common cause of atelectasis in hospitals is inadequate respirations >> *can be seen in post-operative pts in whom atelecatsis is very common* > *Classically considered the most common cause of post-op fever during post-op day 1* > Pt presents w/: 1- *Decreased breath sounds* 2- *Lower leg edema* Thrombophlebitis > Common cause of post-op fever *>/= 1 wk after surgery*

2 days after a CS for fetal distress, a 27F, has a temp of 100.8F. She had an 8-hr labor complicated by mild meconium-stained amniotic fluid. Membranes ruptured 2 hrs after admission. Breath sounds are decreased at both lung bases. Abd exam shows mild tenderness below the umbilicus & a well-healing incision. There is a moderate amount of lochia w/ no odor. Exam of the LE shows edema & no tenderness. Hb conc is 10.8, Leukocyte is 18K. A urine catheter specimen is neg. Which of the following is the most likely Dx? (Atelectasis OR Endometritis?

Atelectasis > Typically presents w/: 1- Post op fever (classically day 1) 2- *Dyspnea* 3- Pleuritic chest pain 4- Tachycardia 5- Hypoxia 6- Asymptomatic PE findings 1- Dullness to percussion 2- *Decreased breath sounds at lung bases* 3- Crackles on auscultation Endometritis > Associated w/ CS delivery *RF* presents w/: 1- *Purulent lochia* (pt has, but it is moderate amount) 2- Uterine tendernes 3- Midline lower abd pain >> *not associated w/ decreased breath sounds*

A 28F, G1P1, has been amenorrheic & has had hot flashes for the past 6 months. She takes thyroid meds for Hashimoto (chronic lymphocytic thyroiditis). After using an OCP for 2 years, she discontinued taking it 3 years ago. Serum studies show: - FSH---------62mIU (N = 4.7-21.5, in pts still menstruating) - Estradiol----15 (N = 20-60) - TSH---------1.5 (N 0.4-4) - Prolactin---5ng/mL -------N = <25 (non-pregnant women) -------N = 80-400 (pregnant women) Which of the following is the most likely cause of this pt's condition? (Autoimmune ovarian failure OR Hypothalamic dysfunction)

Autoimmune ovarian failure > A cause of premature ovarian failure (menopause <40 yrs) >> Autoimmune disease associated w/ Premature ovarian failure are: 1- Hypothyroid (25-60%) 2- Addisons * and others* Hypothalamic Dysfunction > Would show *low FSH levels* (pt has high FSH levels)

A 52F, presents for a routine exam. She has mild hyperthyroidism well controlled w/ levothyroxine. 5 yrs ago, she was Dx'd w/ stage I BC; she completed tamoxifen therapy 1 yr ago & is currently in remission. Menopause occurred 4 yrs ago. Her mother sustained a femoral fracture in a bicycle collision at the age of 55. The pt has smoked two ciggs weekly for 25 yrs. Ht is 4ft 11in & weighs 95 lbs. BMI is 19. Exam shows no thyromegaly. There is a small, well-healed surgical scar over the upper outer quadrant of the left breast. The remainder of the breast & pelvic exam shows no abnormalities. Which of the following historical findings is the greatest risk factor for osteoporosis? (BMI OR Tamoxifen)

BMI > RF for osteoporosis are 1- Age 2- Gender 3- FH (hip fracture) 4- Bone structure and *BMI* Tamoxifen > Is protective in the bone (agonist) >> increased risk of endometrial cancer

A 52F, post-menopausal, presents for a routine health exam. She does not smoke, drink, or use drugs. Her diet is low in fat. She receives estrogen & progestin replacement therapy for vasomotor symptoms. BP is 130/76. Exam shows no abnormalities. This pt is at greatest risk for which of the following types of cancer? (Breast cancer OR Endometrial cancer)

Breast cancer > Increased risk w/ combo estrogen + progestin therapy Endometrial cancer > Increased risk w/ *estrogen only hormone therapy* no increased risk w/ combo estrogen + progestin therapy

3 days after a CS at term b/c of failure to progress, a 27F has a temp of 101.8F & mild pain w/ urination. She has not had urinary urgency or frequency. She is bottle-feeding. PE shows a clean intact incision site w/ no erythema. The lungs are clear to auscultation. The breasts are tense, erythematous, & tender. The uterus is firm, nontender, & consistent w/ in size w/ a 20-wk gestation. Labs show: - Hb---------------10.5 - Leukocyte-------6500 Urine - RBC--------------10-15 - WBC-------------1-2 Which of the following is the most likely Dx? (Breast Engorgement OR Cystitis OR Mastitis)

Breast engorgement > On days 2-5 *1st wk* after birth >> progesterone levels fall as milk is produced >> most common times for breast engorgement if breasts not drained properly during nursing or mechanical pumping >> presents as 1- *warm swollen breasts* (painful breast fullness) 2- *Transient Low grade fever* Mastitis > presents in *2nd or 4th* post- partum week - Fever > 38.3C (pt has 101.8 so does qualify) - *Unilateral red, tender, swollen breast* - Constitutional symptom (myalgia, chills, malaise) Cystitis > pt would have presented with 1- Frequency & urgency 2- Dysuria 3- Suprapubic pain Labs would show: - Increased Nitrites - Increased leukocyte esterase - WBC (not casts)

An 18F, primigravid woman at 10 wks gestation presents for a follow-up exam. At her first prenatal visit 2 wks ago, serum HIV antibody testing was positive. On exam today, the lungs are clear to auscultation & percussion. There is no axillary or cervical lymphadenopathy. A PPD skin test shows a 9 mm induration at 48 hrs. Which of the following is the most appropriate next step in MGMT? (Second PPD skin test in 2 months OR Culture of sputum for acid fast bacilli OR CXR)

CXR > Clinical disease of TB often presents d/t immunosuppression (pt has HIV) >> but pt has no signs of current infection (cough, fever, hemoptysis) >> CXR will often be normal but can show cavitary lesions - Even tho pt is pregnant you still do CXR PPD test interpretation *≥ 15mm or less* → positive 1- People with no known RF's for TB *≥10mm of less* → positive for 1- Recent immigrants from high-risk prevalence 2- Residents & employees of high-risk areas 3- IV drugs abusers 4- Children <5 5- People who work in TB labs *≥ 5mm or less* → positive 1- People w/ suppressed immune systems 2- HIV infected people 3- People w/ changes seen on CXR that are consistent w/ previous TB 4- Recent contacts of people w/ TB 5- Organ transplant pts Secondary PPD skin test in 2 months > Won't make a difference >> outcome will be the same Culture of sputum for acid fast bacilli > would not work b/c *pt does not have active infection*

A 21F, presents b/c of 2-wks Hx of small amount of itching & vaginal discharge; her last symptoms began immediately before her last menstrual period. She has had two sexual partners over the past 2 months & uses an OCP. 1 month ago, she had pain on urination & urinary frequency that resolved after a 7-day course of cephalexin. Exam shows a red introitus & vulva. There are erythematous vaginal walls w/ a normal amount of vaginal discharge. The cervix & cervical discharge are normal. Vaginal pH is 4.5. The addition of KOH to the discharge produces no odor. A wet mount prep shows no motile organisms. Which of the following is the most likely causal organism? (Candida OR Gardnerella)

Candida >Most common cause of vaginitis (Overgrowth of *abnormal organisms* >> presents w/: 1- Vaginal discomfort/ *Pruritus* 2- *Normal pH* (pH 4.5) 3- *Vaginal discharge* (can be white & thick) 4- *recent antibiotic use* (DM, Immunosuppression) Gardnerella (B.Vaginosis) > Presents as mainly asymptomatic >> but may include: 1- Off-white/ grayish, thin, & homogenous vaginal discharge 2- +/- fishy vaginal odor 3- pH >4.5 4- Positive Whiff test 5- Clue cells

A 27F, primigravid, at 30 wks presents b/c of a 3wks Hx of pain in her arms & numbness in her hands that awaken her from sleep. She says that her hands feel as though she had been seeping on them. Her pregnancy has been uncomplicated. Exam shows mild weakness of thumb abduction bilaterally. Sensation is decreased to pinprick in the index finger on the right. Which of the following is the most likely Dx? (Carpal tunnel syndrome OR Cervical radiculopathy OR Mononeuritis multiplex)

Carpal tunnel > *Associated w/ inflammatory conditions such as pregnancy & hypothyroid* >> presents w/: 1- pain/ paresthesia supplied by the *median nerve* (first 3 digits of the hand & radial half of the 4th digit) 2- *Symptoms worse at night* 3- Weakness of thenar muscles (which manifests as difficulty grasping) Cervical radiculopathy > common cause of neck pain >> most commonly caused by cervical spondylosis & disc herniation ----[pt does not have Hx of trauma] Mononeuritis multiplex - Associated w/ MS -----[pt does not have Hx of MS] > Presents w/ peripheral nerve damage >> usually associated w/ *microscopic polyangitis* not associated w/ pregnancy

A 27F, presents b/c of a 4-month Hx of increasingly severe pain during her menses. Menses occur at regular 28 day intervals & last 5-7 days w/ light flow. Her last menstrual period was 25 days ago. She underwent loop excision of the cervical transformation zone for cervical dysplasia 6 months ago; Exam of the biopsy showed CIN 2 w/ negative margins. She is sexually active & uses condoms & spermicidal foam. PE shows a normal vagina & a small, scarred cervical os. The uterus is slightly enlarged & tender. Which of the following is the most likely cause of this pt's symptoms? (Cervical stenosis OR Recurrent dysplasia)

Cervical stenosis (also insufficiency) > *Present as a late complication of* cervical ablation or *excision w/ LEEP* or cold knife conization Recurrent dysplasia > Cervical dysplasia would presents w/: 1- Vaginal bleeding (post-coital or spontaneous) 2- Pelvic pain 3- Cervical discharge 4- A palpable cervical mass > Biopsy Findings showing koilocytes (cells w/ clear halo surrounding hyper chromatic, atypical nuclei)

A 24F, primigravid, at 30 wks is admitted to the hospital b/c of bright red vaginal bleeding that she first noticed as spotting on her underwear 12 hrs ago after sexual intercourse. Since then, the bleeding has increased, and she has had to wear a sanitary pad. Her pregnancy has been otherwise uncomplicated. US at 20 wks showed a fundal placenta. Pulse is 64/min, BP is 110/60. The uterine fundus is nontender; the fundal ht is 30cm. The fetal HR is 150/min w/ moderate variability. External fetal monitoring shows two contractions during the next hour. Which of the following is the most likely cause of the pt's bleeding? (Cervical trauma OR Placental previa OR Preterm labor)

Cervical trauma > *Pain during or after sex* > *Abnormal vaginal Bleeding* Bleeding after sex or between periods > Grayish or pale vaginal discharge > Difficult, painful, or frequent urination Placenta previa > previous US (at 20 wks) should a fundal placenta >> *placenta previa would be seen in US at 16-20 wks* Preterm labor > would present w/: 1- Constant low back pain 2- Feeling of lower abdominal or pelvic pressure 3- Regular cramping/contractions 4- Cervical dilation & effacement

A sexually active 21F, college student requests an OCP. There are no contraindications based in her PMHx. In addition to Pap, which of the following is the most appropriate test for her at this time? (Chlamydia test OR Serologic test for syphilis)

Chlamydia > Chlamydia & Gonorrhea are the most common *Silent* infections >> So should always test for this Serologic test for Syphilis > Pt would present w/ Primary syphilis symptoms including: 1-A painless, non-exudative ulcer w/ a raised, indurated margin 2- Painless bilateral inguinal lymphadenopathy

A 23F, primigravid, at 32 wks is admitted to the hospital b/c of irregular uterine contractions for 3 hrs. Temp is 100.8F. The uterus is moderately tender to palpation. The fetal HR is 170/min. The cervix is 80% effaced & 2cm dilated; the vertex is at -1 station. Fundal ht is 31cm. There is watery vaginal discharge that tests positive for nitrazine. What is the most likely cause of the findings? (Chorioamnionitis OR Placenta Previa)

Chorioamnionitis > PROM classically presents as gush of *clear or yellow fluid* from vagina > Nitrazine paper can be used to *detect amniotic fluid* in vaginal fluid >> will turn blue > Chorioamnionitis typically Dx by: - Presence of maternal fever Plus at least one of following: 1- *Fetal tachy (>160min)* 2- Maternal leukocytosis 3- Purulent amniotic fluid Placenta previa > pt would present with painless bleeding (pt not bleeding)

A previous healthy 22F, presents d/t a bump on her vulva for 1 week. She has been sexually active w/one partner for 2 years. She uses an oral contraceptive. Exam shows multiple 0.25 cm raised, crusty papules on the posterior fourchette. A Pap shows low-grade squamous intraepithelial lesions. Which of the following is the most likely Dx? (Condylomata acuminata OR Herpes OR Molluscum contagiosum)

Condylomata accuminata > Can be from HPV (accuminata) or Syphilis (Latum) >> Accuminata >> warty growths on the external genitals or at the anus >> consisting of fibrous over growths covered by thickened epithelium showing koilocytosis *pt has low grade squamous intraepithelial lesions* >> *herpes* not associated w/ these changes >> Latum - Eruption of flat-topped papules, found at the anus & wherever the contiguous folds of skin produce heat & moisture Herpes/Molluscum contagiosum > Not associated w/ Low-grade SIL (squamous intraepithelial lesions)

A 20F, presents b/c of a 1-wk Hx of vaginal discharge. She is sexually active w/ one partner, and they use condoms inconsistently. She reports that he was recently treated for syphilis. PE shows no abnormalities. PE shows white verrucous lesions over the upper vaginal wall & cervix. A Pap is reported as atypical squamous cells. HPV testing is negative for high-risk types. Which of the following is the most likely Dx? (CIN 2 OR Condylomata acuminata)

Condylomata acuminata (HPV) > Verrucous/ Warty growths on the ext genitals or anus >> consist of fibrous overgrowth covered by thickened epithelium showing koilocytosis CIN 2 > would only be seen in biopsy and as moderate dysplasia >> may present w/ *malodorous discharge & irregular bleeding >> often post-coital* -HPV testing would be POSITIVE [pt is negative]

A 42F, presents b/c of a 3-month Hx of urinary urgency & frequency & occasional incontinence & a 2-month Hx of numbness below her waist. She has had to get up at least 3 times at night to void. She has not had any fever, pain w/ urination, or cloudy urine. She has relapsing-remitting MS; symptoms have included double vision 10 yrs ago & right sided leg weakness 3 yrs ago. Sensation & vibration is decreased over both feet. Deep tendon reflexes are 3+ at the knees. Urinalysis is normal. Her postvoid residual volume is 45mL. Which of the following is the most likely cause of this pt's urinary findings? (Detrusor Hyperreflexia OR Detrusor hypotonia)

Detrusor Hyperreflexia (overactivity) *Urge incontinence* > *associated w/ MS* > *results in frequent production of small volume of urine* > Presentation 1- *Increased urinary frequency* 2- *Urgency* 3- Small volume voids 4- *Nocturia* Detrusor hypotonia (overflow incontinence) >> caused by two ways 1- detrusor under-activity (impaired contractility (neurogenic bladder) 2- Obstruction of bladder outlet (BPH, Tumor, Cystocele) Presentation 1- Perpetual urine dribbling 2- Low urine flow

A previous healthy 57F, presents b/c of a 6 months Hx of urinary urgency & loss of urine that requires the use of an absorbent pad. She rarely leaves her house b/c she is afraid of having loss of urine in public. She typically awakens once each night to void. She has not had fever, pain w/ urination, or blood in urine. She says her urine stream is normal. Temp is 98.6F. PE is normal. Urinalysis is normal. Pelvic US shows a 3-cm, anterior, uterine mass consistent w/ a benign leiomyoma uteri. Which of the following is the most likely cause of the incontinence? (Detrusor instability OR Leiomyoma uteri OR Urinary retention w/ overflow)

Detrusor instability > Pt has overflow incontinence >> the inability to properly empty the bladder d/t to poor bladder contractions >> resulting in over-distended bladder that leaks or dribbles constantly >> Pt would present w/ 1- perpetual urine dribbling 2- low urine flow 3- Increased post-void residual volume → leading to urinary urgency Pathophysio --1) Impaired detrusor muscle contractility → (lower motor neuron disease, epidural, meds) --2) Urethral Obstruction → (BPH, strictures) Urinary retention w/ overflow > pt would present w/ inability to urinate Leiomyoma uteri > pt would have symptoms that resemble urinary retention > They would be responsive to estrogen >> no symptoms of that in this pt

A 27F, primigravid, at 14 wks, presents for an initial prenatal visit. Endovaginal exam shows a viable twin gestation consistent in size w/ an 8-wk gestation. There are two yolk sacs & a thick dividing membrane. The pt most likely has which of the following types of twin gestations? (Dichorionic OR Monochorionic OR Monochorionic-Monoamniotic)

Dichorionic > 2 placenta >> *would have Thick dividing membrane present* Monochorionic > 1 placenta >> would not have thick dividing membrane present >> babies would share same space Monochorionic-Monoamniotic > 1 placenta + 1 amniotic sac > least common type of twin pregnancy >> Would not have thick divining membrane present

A 17F, primigravid, presents b/c she has had decreased fetal mvmt over the past 2 days. She does not recall the date of her last menstrual period & has had only one previous prenatal visit. Exam shows a uterus consistent in size w/ a 32-wks gestation. US shows a biparietal diameter consistent w/ a 31-wks gestation. There is a duodenal bubble & flaccid tone of the fetus. Which of the following is the most likely cause of these findings? (Congenital megacolon OR Down syndrome)

Down syndrome > Associated with duodenal atresia (Also Congenital rubella & Prader-Willi syndrome) Toxic megacolon (Hirschsprung) > not associated w/ duodenal atresia (double bubble sign)

A 57F, G2P2, presents b/c of pelvic pressure & a feeling of a mass in the vagina for 2 months. These symptoms are worse while standing for a long period of time & are relieved by lying down. She had a vaginal hysterectomy 10 yrs ago. She has no urinary tract symptoms & no difficulty w/ her bowel mvmts. Exam shows no anterior vaginal relaxation. Valsalva maneuver produces a large bulging posterior vaginal mass that has its origin high in the vaginal vault. Which of the following is the most likely Dx? (Cystocele OR Enterocele OR Ureterocele OR Uterine prolapse)

Enterocele > basically a vagina hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space >> *usually seen after hysterectomy*>> may present w/ 1- A feeling of fullness, heaviness or pain in the pelvic area 2- Lower back pain 3- Bulging in vagina Uterine prolapse - Also presents w/ pelvic pressure & a palpable bulge & is associated w/ previous surgeries (but more closely associated w/ child bearing -----however bulge is not specific to posterior vault - Also, presents w/: 1- KEY SYMPTOM → Urinary/bowel incontinence ----[pt has NO URINARY SYMPTOMS] 2- Dyspareunia ----[pt does not have pain w/ intercourse] 3- Low back pain ----[pt has no back pain] Cystocele > usually associated w/ giving birth (not hysterectomy) >> presents w/: 1- urine leakage 2- Incomplete emptying of bladder ----[pt has NO URINARY symptoms] Ureterocele - Usually presents w/ Stress incontinence symptoms -----[pt has NO URINARY symptoms]

A 32F, G1P1, at 34 wks is admitted to the hospital in labor. Pregnancy had been complicated by blurred vision & a 5 lbs wt gain over the past wk. Last routine prenatal visit was 1 month ago & showed no abnormalities. Temp is 98.6F, BP is 150/110. Exam shows retinal arteriolar spasms & pedal edema. Labs show: - Hb---------12.5 - Leukocyte--8K - Plts---------200K - Creatinine--1.2 - Urine protein--2+ This pts fetus is at greatest risk for which of the following obstetric complications? (FGR OR Pulmonary hypoplasia)

FGR > Maternal RF for asymmetric FGR include: 1- *HTN* 2- DM 3- SLE 4- CV disease 5- Smoking & cocaine Placental RF for asymmetric FGR include: *uteroplacental insufficiency* *severe maternal malnutrition* *oligohydraminos* both 1- Infarction 2- Abruption 3- Velamentous cord insertion 4- Twin-twin transfusion syndrome Pulmonary hypoplasia > *seen w/ oligohydraminos* (but pt has HTN not oligohydraminos)

A 32F, G5P4 at 21 wks, presents to ED b/c of bright red vaginal bleeding for 4 hrs. She has received no prenatal care. Vitals are normal. The fetal HR is 140/min. External fetal monitoring shows no contractions. Speculum exam shows bright red blood in the posterior fornix of the vagina. There is no bleeding from the cervix. Visual exam of the vagina & cervix shows no other abnormalities. Which of the following is the next step in MGMT? (Vaginal swab for fetal fibronectin OR Fetal US)

Fetal US > Pt seems like has *placenta previa* or preterm labor (less likely) >> MGMT *of either* should include 1- *US* to determine the placental location & Verify fetal well being Fetal fibronectin > Only tested when pt is in preterm labor >> pts in preterm labor would present w/: 1- Constant low back pain 2- Feeling of Lower abd or pelvic pressure 3- Regular contractions/cramping 4- Cervical dilation & effacement

A 22F, primigravid, at 39 wks had had ROM for 5 hrs w/out contractions. Her prenatal course was uncomplicated. Her cervix is 80% effaced & 2cm dilated. The fetal position is right occipitoposterior. Fetal heart pattern shows non-reactive stress test w/ low variability, no accels, & no decels. Which of the following is the most likely explanation for this pattern? (Chorioamnionitis OR Fetal sleep state)

Fetal sleep state > will show as Non-Reactive NST (can also be d/t to hypoxia & meds) Chorioamnionitis - Fetal Heart rate would be > 160 - Mom would have fever - baby would have fever - Mom would have purulent amniotic fluid - mom would leukocytosis

A 28F, G2P1, presents for her 1st prenatal visit. Last menstrual period was 10 wks ago. Her first child, a 10 lbs male, was born by CS b/c of an arrest of descent. During this pregnancy, she is at increased risk for which of the following? (GDM OR PROMs)

GDM >> Previous baby was 10 lbs >> so mom probably had GDM >> increased risk for GDM on this pregnancy PROM >> RF's include: 1- Previous PROM 2- Genital tract infection 3- Antepartum bleeding 4- Smoking

1 month after an uncomplicated vaginal delivery of a 7 lbs 8oz newborn, a 32F, G2P2, presents b/c of a 7-day history of a tender mass in her left breast. Her pregnancy had been complicated by abdominal trauma sustained in a MVC. A 2nd-degree midline vaginal laceration was repaired w/out difficulty after delivery. She is breast feeding. Temp is 98.6F. Exam shows a 3x3 cm fluctuant mass in the lateral aspect of the left breast. The mass is mildly tender to palpation. The breast is not warm or erythematous. The breasts are symmetric. Which of the following is the most likely Dx? (Abscess OR Galactocele OR Mastitis)

Galactocele > A non-infected collection of milk that is caused by an obstructed milk duct >> will present w/ Fluctuant mass but with *Absence of* 1- Fever 2- Erythema 3- Tenderness Mastitis - Also presents in the *2nd & 4th* postpartum week - However, it is characterized by: 1- Fever 2- Unilateral, red, tender, swollen breast 3- Constitutional symptoms (Myalgia, chills, malaise) ---[pt has none of these symptoms] Abscess > Are collections of pus that occur w/in breast tissue *as a complication of mastitis ----[pt does not have Hx of mastitis] - Most common organisms include: 1- Staph/ Strep >> Superficial infections 2- Anaerobic >> Sub-areolar infections Presentation 1- fever & malaise (nil pt) 2- Breast tenderness 3- Purulent drainage (Nil pt) RF are 1- Maternal age > 30 2- First pregnancy 3- Gestational age > 41 wks 4- Mastitis 4- Smoking

A 27F, primigravid, at 7wks presents for her first prenatal visit. She has no Hx of serious illness; & pregnancy has been uncomplicated. She began taking a prenatal vitamin 3 wks ago. PE, including pelvic exam, shows no abnormalities. Labs show: - Hb-------10.1 - Hct------30% - MCV----72 Serum - Ferritin---110 (N) - Fe+-------130 (N) Which of the following is the most appropriate next step in Dx? (a-globin DNA testing OR Hb electrophoresis)

Hb electrophoresis > *part of initial prenatal visit* > *should be performed in pregnant women in addition to CBC is pts are at risk for hemoglobinopathy* alpha-globin DNA testing > not part of first prenatal visit > Beta- thalassemia is more common than alpha-thalassemia >> so testing for alpha-globin change is necessary

A 57F, presents for a routine check up. She has HTN, DM II, & GAD. Her great aunt has a Hx of breast cancer. The pt has been receiving hormone therapy w/ conjugated estrogen and medroxyprogesterone daily since menopause 5 yrs ago. Additional meds include Hydrochlorothiazide, metformin, & various herbal meds. Her BP is 136/84. Breast exam shows no masses or nipple discharge. Which of the following historical findings is the greatest RF for breast cancer in this pt? (FHx of breast cancer OR Hormone therapy)

Hormone therapy > Increased estrogen exposure is greater RF than FHx of breast cancer

A 19F, primigravid, presents to the ED b/c of a 1-wk Hx of nausea & persistent vomiting. Last menstrual period was 15 wks ago, but she has had daily vaginal bleeding for the past month. She has not received prenatal care. Temp is 98.6F, Pulse is 80/min, RR are 20/min, BP is 140/90. Exam shows pedal edema. PE shows a uterus consistent in size w/ a 20 wks gestation; there is no adnexal tenderness. A serum pregnancy test is positive. Urinalysis shows 1+ protein. US shows bilateral multi ocular ovarian cysts & echogenic structures in the uterus. Which of the following is the most likely Dx? (Combined ectopic & intrauterine pregnancy OR Hydatidiform mole)

Hydatidiform mole > Symptoms include: *first trimester* 1- *Vaginal bleeding* (most common) 2- *Enlarged uterus* (size > dates) 3- Pelvic discomfort 4- *Hyperemesis gravidarum* 5- *Positive pregnancy test* (b/c has rise in B-hCG) *2nd trimester* 1- Hyperthyroidism 2- *Bilateral theca lutein ovarian cysts* 3- *Preeclampsia* US findings 1- *Echogenic uterine mass w/ numerous anechoic cystic spaces* (snowstorm or Swiss cheese) 2- *Bilateral Theca lutein ovarian cysts* 3- No embryo or fetus 4- No amniotic fluid > RF's include 1- extremes of maternal age *<20* or > 35 2- Prior molar pregnancy 3- Asian/ American Indian Combined intrauterine & ectopic pregnancy > US Would not show cystic spaces >> would have presence if fetus in sac

36 hrs after CS b/c of prolonged labor, a 22F, has abd cramping & nausea & vomiting. Temp is 101.8F, Pulse is 98/min, BP is 110/64. Exam shows diffuse lower abdominal tenderness w/ some voluntary guarding but no rebound. The incision is clean, dry, & intact. Leukocyte count is 15K. A urinary catheter is in place; urinalysis shows multiple RBC's. Which of the following is the most appropriate next step in MGMT? (IV administration of ampicillin & gentamicin OR Surgical exploration)

IV administration of ampicillin & gentamicin > Pt presents w/ postpartum fever >> causes include *7 w's* 1- Wind: pneumonia, atelecatsis 2- Womb: endometritis 3- Water: UTI 4- Wound: Cellulitis 5- Walking: DVT, PE, SPT 6- Weaning: mastitis, breast engorgement 7- Wonder drugs: misoprostol > pt probably has *endometritis* >> RF's include: 1- *prolonged labor* 2- *CS delivery* Presents w/ 1- Purulent lochia 2- *uterine tenderness* 3- *Midline lower abd pain* TMT First line >> Clinda + gentamicin *Ampicillin* can be substituted

36 hrs after CS b/c of prolonged labor, a 22F, has abd cramping & nausea & vomiting. Temp is 101.8F, Pulse is 98/min, BP is 110/64. Exam shows diffuse lower abdominal tenderness w/ some voluntary guarding but no rebound. The incision is clean, dry, & intact. Leukocyte count is 15K. A urinary catheter is in place; urinalysis shows multiple RBC's. Which of the following is the most appropriate next step in MGMT? (IV administration of ampicillin & gentamicin OR Surgical exploration)

IV administration of ampicillin & gentamicin > Pt presents w/ postpartum fever >> causes include *7 w's* 1- Wind: pneumonia, atelecatsis 2- Womb: endometritis 3- Water: UTI 4- Wound: Cellulitis 5- Walking: DVT, PE, SPT 6- Weaning: mastitis, breast engorgement 7- Wonder drugs: misoprostol > pt probably has *endometritis* >> RF's include: 1- *prolonged labor* 2- *CS delivery* Presents w/ 1- Purulent lochia 2- *uterine tenderness* 3- *Midline lower abd pain* TMT First line >> Clinda + gentamicin *Ampicillin* can be substituted Surgical exploration > Would be correct If pt presented w/ acute abdomen

A 22F, primigravid, at 24 wks has had fullness in the lower pelvic area for 12 hours. She has no contractions. Fundal Ht is 20 cm. Fetal heart tones are good. Exam shows the fetus in a breech position. No cervix is palpated. Which of the following is the most likely Dx? (Incompetent cervix OR Placenta previa)

Incompetent cervix > Discomfort or spotting over the course of several days or weeks *starting at 2nd trimester* (14-20wks) >> presents w/: 1- *No cervix palpated* b/c it is dilated 2- *Sensation of pelvic pressure* 3- New backache 4- Mild abd cramps 5- Change in vaginal discharge 6- Light vaginal bleeding Placenta Previa > does not present w/ *fullness in the lower pelvic area* > would present w/ massive painless bleeding in 3rd trimester

A 20F, presents b/c of a 3 yr Hx of mild-to-moderate hair growth over her face, breasts, & lower abdomen that has become slightly worse during the past 2 years. She has no Hx of serious illness & takes no meds. Menses occurs at regular 28-day intervals. Exam shows excessive hair growth over the upper lip, chin, lower abdomen, & pubic area. 3 days after the onset of her menstrual period, serum studies show: - FSH-----------------10 - LH------------------12 - DHEA sulfate ------1.5 (N 0.5-5.4) - 17-alpha Hydroxy--25 (N 20-300) - Testosterone-------2.8 (N<3.5) Which of the following is the most likely cause of this pt's hair growth? (Decreased aromatase activity OR Decreased progesterone conc. OR Increased 5alpha reductase activity

Increased 5 alpha reductase > Pt is showing signs oh increased androgens >> but testosterone levels are normal >> this means DHT must be elevated >> *5 alpha reductase converts testosterone to DHT* Decreased Aromatase activity (CAH) > Would show high serum testosterone and androstenedione > 17- alpha levels would be elevated > FSH levels would be elevated > *pt would have exaggerated virilization at puberty* Decreased progesterone levels > pt would present with irregular or absent periods (pt's are regular)

A 15F, presents b/c of a 3-day Hx of fever, abdominal pain, & nausea. She also has had a thick, white vaginal discharge. Menarche was at the age of 13 yrs, & her menses occur at irregular 28 to 40 day intervals. She became sexually active 1 months ago & uses condoms inconsistently. Temp is 103.2F, pulse is 108/min, RR 20/min, BP is 102/80. Exam shows lower abd tenderness. PE shows pain w/ cervical motion & adnexal tenderness w/ a 3-cm mass. A gram stain shows gm- diplococci. Which of the following is the most likely explanation for this pt's susceptibility to this condition? (Increased cervical cell vulnerability to infections OR Latex hypersensitivity)

Increased cervical cell vulnerability to infections > Pt presents w/ PID >> PID is caused by recurrent STD infections w/ gonorrhea/chlamydia -> these infections increase the vulnerability of the cervix to infection Latex Hypersensitivity > If this was "pt doesn't use condoms d/t latex hypersensitivity* it may be correct

A 26F, G3P2 presents for her first prenatal visit at 11 wks. Previous pregnancies & deliveries were uncomplicated. Her blood type is O-. She received Anti-D immune globulin after her first delivery. Which of the following it the most appropriate test to evaluate her Rh status? (Indirect antiglobulin Coombs test OR Kleihauer-Betke acid elution test)

Indirect antiglobulin Coombs test > used to detect very low conc of antibodies present in a pt's plasma/serum > *in this case, we want to determine if pt has antibodies now* Kleihauer-Betke acid elution test > used to assess for fetomaternal hemorrhage in women w/ unexplained intrauterine fetal demise > usually performed on a Rh- mothers to determine the required dose of anti-D needed to inhibit formation of Rh antibodies >> to prevent Rh disease in *future Rh+ children* (we need to know pts *current status*)

A 20F, G2P1 at 42 wks is admitted to the hospital in labor. She reports severe abdominal pain. She has received no prenatal care. She has no Hx of serious illness & takes no meds. Leopold maneuvers indicate a fetus at term. The cervix is 10 cm dilated & 100% effaced; the vertex is at +2 station. After pushing for 3 hours, low-forceps-assisted delivery is performed b/c of non-reassuring fetal heart tones, severe variable decels, & maternal exhaustion. The operative vaginal delivery of a 9.3 lbs newborn is complicated by shoulder dystocia that requires 8 minutes to reduce. On exam, the newborn does not move the right arm. The forearm is pronated, & the arm is adducted & internally rotated at the shoulder. Which of the following is the most likely cause of these findings in this newborn? (Injury to the eighth cervical root & first thoracic root OR Injury to the fifth and sixth cervical roots)

Injury to the 5th & 6th cervical roots > Classic waiter's tip position of the arm Injury to the 8th cervical and 1st thoracic root > Klumpke's palsy >> would present as claw hand

A 32F, primigravid, presents at 30 wks b/c of a 10 day history of decreased appetite, intermittent nausea, & generalized itching. She has no Hx of serious illness, & her pregnancy has been otherwise uncomplicated. Pulse is 98/min & regular, & BP is 104/64. Exam shows excoriations on the left shoulder. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard best at the left sternal border. The uterus is consistent in size w/ a 30 wks gestation. Labs show: - Hb------------11 - MCV----------86 - Leukocyte----10,2K - Plts------------114K Serum - Total bilrubin-----2.1 - ALP---------------206 - AST---------------30U/L - ALT---------------26U/L Abd US shows no abnormalities. Which of the following is the most likely explanation for her symptoms? (HELLP syndrome OR Intrahepatic cholestasis)

Intrahepatic cholestasis > Cholestatis in pregnancy appears in *3rd trimester* >> symptoms are: 1- *Severe itching* on hands & feet 2- Dark urine color 3- Pain in RUQ (w/out gallstones) 4- Pale/ light colored stools 5- *Fatigue/ nausea* 6- *Loss of appetite* 7- Depression Cholestatic pattern of liver disease is shown via: 1- *Markedly elevated ALP* 2- *Only mildly elevated ALT & AST* HELLP syndrome - Usually as a consequence of preeclampsia/Eclampsia (however, not always) -Also presents w/ hemolysis & low plts - However, Usually also includes presents w/ ----2) Elevated Liver enzymes (AST/ALT) --------[pts AST/ALT are normal] --------[Not associated w/ ↑ ALP] - Other symptoms include: 1- Nausea 2- Vomiting 3- RUQ pain (d/t capsular distention) ---[Pt has none of these] ---[HELLP is not associated w/ itching]

A 20F, primigravid, at 40 wks is admitted to the hospital in labor. The cervix is 4cm dilated; the vertex is at 0 station. Two liters of lactated ringer solution are administered. An epidural catheter is placed, and a test dose of lidocaine & epi is injected. She immediately has tinnitus & a metallic taste in her mouth. Her pulse is now 110/min, BP is 140/100. Which of the following is the most likely cause of these findings? (Anesthetic-induced anaphylactic reaction OR Intravascular injection of anesthetic)

Intravascular injection of anesthetic > Most common cause of toxic levels >> can cause: --1) CNS excitation >> *tinnitus*, disorientation, seizures --2) Light headedness, visual & auditory disturbances --3) *Metallic taste*, Tongue numbness --4) CV → *HTN*, peripheral vasodilation Anesthetic induced anaphylactic reaction > Pt would have presented w/ 1- *Bronchospasm* 2- Hypotension -----[pt has HTN] 3- Angioedema

A 47F, presents for a routine health exam. She says that she sometimes feels hot at night & occasionally during the day. She has not had any other symptoms. She has no sig PMHx & takes no meds. Her last menstrual period was 4 months ago. She is sexually active w/ one male partner, & they do not use contraception. She is 5ft 6in tall & 150lbs. BMI is 24, Temp is 98.7F, Pulse is 70/min, RR 12/min, BP is 90/50. She has moderate discomfort during the pelvic exam bc of vaginal dryness. The uterus is enlarged & mildly boggy. There is no vulvar, vaginal, or cervical lesions or adnexal masses. The remainder of the exam shows no abnormalities. Test of the stool for occult blood is negative. Which of the following is the most appropriate next step in Dx? (Measurement of serum FSH OR Measurement of serum B-hCG)

Measurement of serum B-hCG - Pt is showing signs of pregnancy - Signs include: --1) Decrease in BP --2) Enlarged Uterus Measurement of serum FSH - Would be used if menopause was suspected - However, *Menopause is defined as *12 months of amenorrhea on the absence of other biological or physiological changes* ----[pt only has 4 months amenorrhea] - Menopause DOES NOT present w/: enlarged uterus or hypotension

A 23F, presents for a follow-up exam 3 wks after being Dx'd w/ a UTI. TMT w/ TMP-SMX has relieved her symptoms. This is her third UTI over the past year. She has no history of serious illness. She was married 3 months ago. Temp is 98.6F. Exam shows no abdominal pain or flank tenderness. Urinalysis is w/in normal limits. Daily administration of which of the following agents is most appropriate for prophylaxis against recurrence of this condition? (Phenazopyridine OR Propantheline OR TMP-SMX)

TMP-SMX Propantheline > Approved for PUD Phenazopyridine > used to treat pain, burning, and the feeling of needing to urinate urgently & frequently >> *does not treat the cause, only used to alleviate symptoms*

An 11F, is brought for a well-child exam. She has had recent mood changes, & her mother is concerned that her daughter's menstrual periods will start soon. The mother's menarche occurred at the age of 14 yrs. The pt is at the 75th percentile for ht & 90th percentile for wt. Breast & pubic hair development is tanner stage 3. Exam shows no abnormalities. The pt's recent pubic hair development is most predictive of which of the following? (Menarche is imminent OR Precocious puberty)

Menarche is imminent > From 8-11 yrs LH, FSH, & estrogen levels begin to increase >> This time marked by *breast development & pubic & axially hair growth* >> menarche follows - Breast budding (10.8 yrs) - Pubic hair/axillary hair (11 yrs) - Growth spurt (11.8 yrs) - *Menarche* (12.9 yrs) Precocious puberty > would occur if any of the above (Thelarche (breast budding), pubic hair/axillary hair growth, menarche) would happen before the correct age

A 32F, w/ DM I has had increasingly severe perianal pain over the past 3 days. Temp is 102.2F. PE shows a 5x5 cm tense cystic mass in the posterior right labium majus w/ cellulitis extending past the right pubic hairline. Which of the following is the most serious complication of this condition? (Gram-positive sepsis OR Necrotizing fasciitis OR Bartholin gland abscess)

Necrotizing fasciitis > Pt presents w/ an abscess that *causes cellulitis (staph or strep)* >> Strep (part of normal flora of vagina) if left untreated will cause necrotizing fasciitis in the baby Gram positive sepsis > more closely associated with Toxic Shock from staph Bartholin gland abscess > polymicrobial >> would not cause cellulitis

A previously healthy 32F, presents b/c of a 2 month history of dull right-sided pelvic pain. The pain is most severe during menses. Her last menstrual period was 3 wks ago. She takes no meds. Exam shows fullness in the right adnexa & tenderness to palpation. Urine B-hCG testing is negative. Pelvis US shows a 5-cm simple cyst in the right adnexa. She says she is anxious about paying for TMT b/c her medical insurance expires in 23 wks. Which of the following is the most appropriate next step in MGMT? (Oral contraceptive therapy & a second pelvic examination in 6 weeks OR US-guided drainage of cyst)

Oral contraceptive therapy & a second pelvic exam in 6 wks > Asymptomatic simple cysts *10cm or less* may be managed w/ close follow up regardless of pts age + oral contraceptives *for suppressive therapy* US guided drainage of cyst > Only if contraceptive therapy did not help or it continued to rapidly increase in size

A widowed 37F, G3P3, whose youngest child is 10 years old, had had increasingly heavy but regular menstrual periods for the past 3 years. Her last menses occurred 2.5 weeks ago. She reports a 2-day Hx of labor-like pains accompanied by a small amount of vaginal bleeding. Speculum exam shows that the cervix is moderately effaced & 2 cm dilated, w/ some beefy red tissue at the os. Which of the following is the most likely Dx? (Carcinoma of the cervix OR Pedunculated submucous leiomyoma uteri OR Sarcoma of the uterus (Leiomyosarcomas)

Pedunculated submucous leiomyoma uteri > Would present w/ menses b/c respond to estrogen > If prolapsed, would show as *Beefy red tissue at the os* > Can present w/ 1- *Abnormal uterine bleeding* that is present/ worsens w/ menses 2- Bulk-related symptoms 3- Infertility & obstetric issues Carcinoma of the cervix > Can present w/" 1- *Vaginal bleeding* (post-coital or spontaneous) But usually presents as an ulcer 2- Is more likely in older pts 3- Pelvic pain 4- Cervical discharge 5- A palpable cervical mass > Would increase or coincide w/ menses Sarcoma of the uterus (Leiomyosarcomas) > Would be *in the uterus* and would most likely cause the uterus to be irregularly shaped* > would respond to hormones

A 32F, G3P2 at term is admitted to the hospital in labor. Contractions have occurred at every 3 mins for the past 8 hrs. Temp is 98.6F, Pulse is 80/min, RR is 20/min, BP is 120/80. The cervix is 100% effaced & 4 cm dilated; the vertex is at -2 station. The membranes suddenly rupture, yielding a large amount of clear fluid. The fetal heart rate decreases to 90/min. Which of the following is the most appropriate next step in MGMT? (Pelvic Exam OR Forceps delivery)

Pelvic Exam - pt is in ACTIVE labor & has ROM - However, ROM is NOT an indication for Forceps delivery → must wait to see if pt progresses - If pt enters into a prolonged latent phase, is - >20 hrs (nulliparous) - >14 hrs (multiparous) > so pt should not be induced at this point Forceps delivery - not indicated in unless/until all other alternative methods to induce pregnancy are exhausted

A 27F, Primigravid, at 38 wks is admitted to the hospital in labor. She had SROM 2 days ago. On arrival, temp is 102.3F. The cervix is 100% effaced & 4 cm dilated; the vertex is at +1 station. Abd exam shows exquisite tenderness of the uterine fundus. PE shows mucopurulent cervical discharge. The fetal heart rate is 180/min w/ good variability. TMT w/ IV ampicillin & gentamicin is begun. 2 hrs after admission, the cervix remains 4 cm dilated. She undergoes CS for arrest of active phase & delivers a healthy newborn. 6 hrs after delivery, the pt's temp is 102F. Which of the following is the most likely cause of this pt's fever? (E.coli OR Polymicrobial)

Polymicrobial infection - Pt most likely presents w/ Endometritis - Endometritis is a polymicrobial infection* caused by ascension or aerobes & anaerobes from the genital tract > Pt presents w/ endometritis *postpartum fever (temp > 100.4F, on any 2 of the first 10 days postpartum) - Polymicrobial infections do not respond to ampicillin/gentamicin E.coli > not cause of endometritis or chorioamnionitis - Responds to antibiotic TMT w/ ampicillin/gentamicin ----[pt still has signs of infection after administration of these meds] SIDE NOTE: Chorioamnionitis > Not a cause of postpartum fever > *also a polymicrobial infection* Presents w/ *maternal fever plus* 1- Fetal tachy 2- Maternal leukocytosis (<15K) 3- Purulent amniotic fluid

A 32F, G2P1, at 18 wks comes for routine prenatal visit. US shows a triplet gestation w/ no abnormalities. All three fetuses have fetal heart tones & are appropriate in size & gestational age. For which of the following complications is this pt at increased risk for? (Placenta previa OR Premature labor)

Premature labor > *Most common and serious complication* associated >> other complications include: 1- FGR 2- Congenital anomalies 3- Miscarriage Placenta previa >> Is a placental abnormality that is associated w/ multiple gestations but *Premature labor is most common* Other placenta abnormalities 1- Placenta previa 2- Vasa previa 3- Velamentous cord insertion

A 32F, G5P4, at 18 wks presents for a routine prenatal visit. She is Rh-. Her previous pregnancies required CS between 33-35 wks for premature labor & breech. Deliveries were otherwise uncomplicated. She received Rh(D) immune globulin during each pregnancy. She has no other sig PMHx & her current pregnancy has been uncomplicated. Her father has HTN, & her mom has DM II. Pulse is 68/min, BP is 110/60. PE shows no abnormalities. US shows an intrauterine pregnancy of a single fetus w/ normal anatomy in a breech presentation; the uterus is bicornuate. This Pt is at increased risk for which of the following obstetric complications? (Preterm labor & delivery OR Rh isoimmunization)

Preterm labor and delivery > RF for preterm is *previous preterm* Rh isoimmunization > The mom is already known to be Rh- >> so an Rh rxn can be easily prevented > Mom would be anemic and Fetus would have hepatosplenomegaly on US (fetus US shows now abnormalities)

A 14F, presents b/c of painful episodes of menstrual cramping over the past 5 months; the pain has caused her to miss several days of school monthly. Menarche was at the age of 12. Last menstrual period was 5 days ago. Exam shows no abnormalities. Which of the following is the most likely cause of her pain? (Endometriosis OR Prostaglandin production)

Prostaglandin production > *Idiopathic menstrual pain w/ no identifiable underlying pathology is thought to be related to prostaglandin release* Endometriosis > pain usually begins 1-2 days *before menstruation* > Would present the same as this pt >> *However PE findings are normal in this pt* >> PE findings in endometriosis would show 1- Uterosacral nodularity 2- Fixed, retroverted uterus 3- Fixed adnexal mass (tender, cystic )

3 days after a CS b/c of fetal distress, a hospitalized 42F, is found unconscious. She is 5 ft 4 in tall & weighs 180 lbs. BMI is 31. Temp is 100.4F, pulse is 120/min, RR is 26/min, BP is 60/40. Bilateral wheezing is heard on auscultation. Cardiac exam shows a pleural friction rub. The fundus is firm. Labs are normal. ABS shows: - pH----------------7.26 - PCO2-------------28 - PO2---------------60 Blood smear is normal. CXR shows atelectasis. An ECG shows tachy w/ for pulmonale. Which of the following is the most likely Dx? (Amniotic fluid embolism OR Pulmonary embolism)

Pulmonary embolism > Usually associated w/ the Normal hyper-coagulable state seen in pregnancy >> there is also increased risk due to Virchows triad: 1- Hyper coagulable state 2- Vascular injury during delivery 3- Increase in venous stasis (legs) > B/c of this complications that are seen are 1- PE 2- Thrombocytopenia & trombosis Amniotic fluid embolism - classic presentation includes: a woman in late stages of labor (or recently postpartum) who Gasps for air followed by: ----a) seizures ----b) Cardiac arrest ----c) DIC ---------[pt is 3 days postpartum] ---------[pt has none of the "CLASSIC" presentation symptoms] - Characterized by 1- Hypotension 2- Hypoxia 3- DIC - RF for amniotic fluid embolism are: ----1) Rapid labor ----2) Meconium-stained amniotic fluid ----3) Tears into large pelvic veins (uterine)

A previously healthy 39F, at 37 wks presents to the ER 2 hrs after the onset of acute pain in the left hemithorax. She says that the pain is exacerbated by breathing. Temp is 100.8F, pulse is 120/min, RR 24/min, BP is 110/70. Fetal heart tones are 170/min. Exam shows no abnormalities. CSR shows no abnormalities. ECG shows non-specific changes. ABG on room air shows - pH----------7.43 - PCO2-------35 - PO2---------70 Which of the followings the most likely Dx? (Costochondritis OR Pulmonary embolus)

Pulmonary embolus > Commonly result from Virchows triad *seen in pregnancy* >> presents w/: 1- *Dyspnea, tachypnea >> most common* 2- *Pleuritic chest pain* 3- Rales, cough 4- *Sinus Tachycardia, S4* 5- Hemoptysis 6- *No abnormalities on CXR* ABG results >> Hypoxemia - pH Near normal - Hypocapnia - Low O2 Costochondritis > Inflammation of the cartilage of the rib cage Presentation 1- Chest pain in the upper & middle rib area on either side of the breastbone >> pain may radiate to the back or abdomen > *Pleuritic chest pain* Caused by 1- Physical trauma 2- physical strain from activity 3- Respiratory conditions &/or viruses (TB/ syphilis) 4- Arthritis 5- Tumors

A 32F, G2P1, at 27 wks is brought to the ED b/c of a 3 Hrs Hx of painful contractions every 5 mins. She has not had vaginal discharge or itching. During her first prenatal visit, routine urine culture grew 10K colonies of GBS. She was not treated at that time b/c she was asymptomatic. She has no Hx of serious illness. Pregnancy had been otherwise uncomplicated. She takes no meds & has an allergy to penicillin. Her first pregnancy ended in spontaneous vaginal delivery at 33 wks. Temp is 100F, pulse is 100/min, BP is 90/50. Abd exam shows tenderness to percussion over the right flank. The uterus is nontender & consistent in size w/ a 27 wks gestation. The fetal heart rate is 160/min. Uterine contractions occur every 5 mins & last 45 sec. On PE, the cervix is 2 cm dilated & 75% effaced; the vertex is at 0 station. Which of the following is the most likely cause of this pts symptoms? (Chorioamnionitis OR Pyelonephritis)

Pyelonephritis *fever & flank pain* are indicative of acute pyelonephritis > Pt presents w/ - Painful contractions - Hx of GBS - Temp of 100F - Tachycardia - Hypotension - Tenderness to percussion of the right flank RF for pyelonephritis include 1- *History of UTI* Presents w/ 1- *Flank pain* 2- CVA tenderness 3- Urinary symptoms (frequency, urgency, dysuria) 4- Chills 5- Nausea 6- *Fever* Chorioamnionitis > Dx'd with *maternal fever* + 1- Fetal tachy *>160* (fetus here is at 160) 2- Maternal leukocytosis (>15K) (nil pt) 3- Purulent amniotic fluid (nil pt)

A healthy 18F, nulligravid, presents for a routine physical exam. She states that she typically has pain in one of the adnexal regions that occurs during days 13 & 14 of her menstrual cycle. She describes the pain as brief & sharp. Menarche was at age 13 & menses occur at regular 28 day intervals w/ moderate flow for the first 2 days. She has never been sexually active. Physical and pelvic exams show no abnormalities. Which of the following is the most appropriate next step in MGMT? (Reassurance OR Pelvic US)

Reassurance > Pt is feeling the effects of ovulation >> which occur on days 13/14 Pelvic US > not needed b/c pt does not have any abnormalities

A 47F, primigravid, at 10 wks presents for a routine prenatal visit. She conceived following oocyte donation from her 32 yrs old sis. Menopause was 3 yrs ago. Pulse is 78/min, BP is 123/78. The uterine fundus is 15 cm above the pubic symphysis. The fetal HR is 160/min. Which of the following is the most appropriate next step in MGMT? (US OR Amniocentesis)

US > Pt is showing or for initial prenatal testing (< 14 wks) >> A dating US should be scheduled >> *specifically b/c the baby is 15cm and should inly be 10cm* Amniocentesis > This test is only performed as a follow up to an *abnormal prenatal screening* >> no history in pt

A 24F, primigravid at 28 wks presents to the ER 4 hrs after she felt a sudden gush of fluid from her vagina. She is concerned that her membranes have ruptured. Her pregnancy had been uncomplicated, and she has had good fetal mvmt & no contractions. She has no Hx of medical or gynecologic illness or abnormal Paps. Temp is 98.5F, pulse is 64/min, BP s 110/60. Fundal Ht is 28 cm. The fetus is in breech. External fetal monitoring shows a fetal HR of 150/min w/ moderate variability. There are no uterine contractions. The uterus is nontender to palpation. Sterile speculum exam shows pooling of fluid in the vagina & a closed cervix. Nitrazine testing of the fluid is positive & ferning is seen under the microscope. Pelvic US shows an amniotic fluid index of 5 cm (N = 8-24). After administration of intramuscular corticosteroids & IV antibiotics, which of the following is the most appropriate next step in MGMT? (Second administration of Corticosteroids in 24 hrs OR Immediate CS)

Second administration of corticosteroids in 24 hrs > Pt presents w/ PPROM (rupture of membranes before 37 wks) >> MGMT includes: *Managed expectantly < 34 wks* followed by induced delivery >> expectant mgmt includes 1- Antenatal corticosteroids 2- Prophylactic antibiotics 3- Hospitalization Immediate CS > indications for immediate delivery are: 1- Intrauterine infection (chorioamnionitis) 2- Abruptio placentae 3- Non-reassuring fetal testing 4- High risk of cord prolapse

A 30F, G3P2, at 10 wks has had fever, minimal vaginal bleeding, & severe pelvic pain for 36 hrs. She says that this is an unintended pregnancy. 4 months ago, she was treated w/ oral antibiotics for a pelvic infection. Temp is 104F. Exam shows a foul-smelling vaginal discharge & a small laceration on the cervix. The uterus is extremely tender & consistent in size w/ a 10 wks gestation. Leukocyte count is 18K w/ a left shift. Which of the following is the most likely Dx? (Acute appendicitis OR Septic abortion)

Septic abortion > Occurs when an abortion is complicated by severe intrauterine infection >> symptoms include: 1- *Fever* 2- *Pelvic pain* 3- *Foul-smelling Purulent cervical discharge* 4- Leukocytosis (but can be seen in any infection) 5- Pt commented that the pregnancy was unplanned Acute appendicitis > would *not present w/ foul smelling discharge* >> would present w/: 1- Initial colicky abd pain (pain shift from mid-umbilical to RLQ) 2- Fever 3- Nausea & vomiting 4- Leukocytosis (but can be seen in any infection)

A 23F, primigravid, at 30 wks is brought to ER b/c of headache, blurred vision, & constant RUQ pain for 12 hrs. Pulse is 92/min, RR 14/min, BP is 138/95. Exam shows moderate edema of the face & fingers. Deep tendon reflexes are 3+. Labs show: - Plts. -------40K - AST. ------1200 - ALT --------365 - LDH -------1954 Which of the following is the most likely Dx? (Immune thrombocytopenic purpura OR Severe preeclampsia)

Severe preeclampsia (severe features) - Low Pts *<100K* - Transaminitis → (severe RUQ pain) - *Blurred vision and headache* (visual or cerebral disturbances) - Impaired deep tendon reflexes -Creatinine > 1.1 mg/dL or 2x baseline - HTN → presents as ---SBP ≥ 140* OR ---DBP ≥ 90* Immune thrombocytopenic purpura - Usually presents w/ decreased plts ONLY -----[Pt has Many more symptoms] - Also presents w/: --1) IgG antibodies Pt would present w/ --2) Petechial rash, Easy bruising, Bleeding > pt would have Hx of gingival hemorrhage, menorrhagia, easy bruising, epistaxis

A 37F, G8P8, presents to ED b/c of increasing vaginal bleeding over the past 5 hrs. Abd exam shows no abnormalities. Bimanual & rectal exam shows an 8-cm mass of the upper cervix & right parametrium. No ovary is palpated separately. A CT shows a right hydroureter above the level of the mass. Which of the following is the most likely Dx? (Adenocarcinoma of the endometrium OR Squamous cell carcinoma of the cervix OR Transitional cell carcinoma of the bladder)

Squamous cell carcinoma of the cervix > 80% of cervical carcinoma is squamous cell >> may present w/ 1- *Vaginal bleeding* (post-coital or spontaneous) 2- Pelvic pain 3- Cervical discharge 4- *Palpable cervical mass* >> Can invade the bladder & ureters causing ureteral obstruction >> leading to hydronephrsis & post-renal failure Endometrial cancer > associated with endometrium >> so signs/symptoms would be related w/ estrogen levels -----[pt has no estrogen related signs] Transitional cell carcinoma > Cancer of the urinary collecting system >> would present w/ painless hematuria -----[pt has no urinary symptoms] - pt would have history of exposure chemicals or drugs, such as: 1- Phenacetin 2- Smoking 3- Aromatic amines (aniline dyes, benzidine, 2-naphthylamine) 4- Cyclophosphamide

A 57F, G6P6, presents b/c of a 6 month Hx of immediate loss of urine when she coughs or exercises. Her children were born vaginally. Last menstrual period was 10 yrs ago, & she has never received estrogen therapy. PE shows a normal-sized uterus & ovaries. There is downward mobility of the urethral vesicle junction w/ valsalva maneuver. Which of the following is the most likely Dx? (Detrusor instability OR Stress incontinence OR Urethrocele)

Stress incontinence > *urethral hypermobility* or *intrinsic sphincter deficiency* > would present w/ downward mobility of the urethral vesicle junction w/ valsalva Detrusor instability > If under-active/ neurogenic = overflow incontinence > If over-activity = Urge incontinence Urethrocele > Pt would have visible prolapse w/ urinary symptoms (stress incontinence, frequency) 1- Vaginal or valvar irritation 2- Feeling of fullness or pressure in the pelvis 3- Aching discomfort in the pelvic area 4- Painful sex

A 32F, G3P2, at 30 wks presents to the ED b/c of pain in the right mid abdomen for 12 hrs; She has had one episode of diarrhea since that time. Temp is 101.3F. PE shows diffuse tenderness in the RLQ w/ minimal guarding. Rectal & pelvic exams show right-sided tenderness. Leukocyte count is 14K w/ a shift to the left. US of the abdomen shows fluid in the right paracolic gutter; the appendix cannot be visualized. Which of the following is the most appropriate next step in MGMT? (Broad spectrum antibiotic therapy & observation OR Surgical exploration)

Surgical exploration > pt probably has Ruptured appendix *cannot be visualized* >> presents w/: 1- Right sided LQ pain 2- Pain that shifts from mid abdomen to RLQ US findings include 1- Target appearance 2- Dilated lumen 3- *Pariappendiceal fluid collection* Labs 1- *leukocytosis w/ left shift* TMT of choice 1- For ruptured appendix >> *appendectomy* Broad spectrum antibiotic therapy > would be correct if appendicitis was not yet proven *and only suspected* >> but this pt has ruptured *must remove*>> would also remove if proven and not suspected

A 37F, G5P3A1, at 40 wks is admitted into labor. Contractions began 2 hrs ago. She has not had vaginal bleeding or loss of fluid. Pregnancy has been uncomplicated. Her last child was delivered vaginally at term and weighed 9 lbs 8 oz. At her last prenatal visit 1 wk ago, the cervix was effaced 50% & 1cm dilated, and the vertex was at -2 station. Exam now shows contractions that occur every 5 mins. The cervix is 50% effaced & 6 cm dilated; no presenting part can be felt. A fetal heart tracing shows no abnormalities. Which of the following is the most appropriate next step in MGMT? (US of the pelvis OR CS delivery)

US of the pelvis > Pt has only been in labor for two hours >> she is not in active labor and has not met the criteria for active labor arrest >> which is - >/= 4hrs w/ adequate contractions - >/= 6hrs w/ inadequate contractions >> *best next step is US for fetal well-being* CS delivery > would be appropriate is pt was in active phase arrest

A 50F, G3P2012, has had loss of urine w/ coughing, straining, or lifting since the birth of her last child 9 yrs ago; the symptom has progressively worsened over the past 2 years. During exam, she loses urine in small spurts w/ coughing, but the anterior & posterior vaginal walls appear well supported. A cotton-tipped applicator placed in the urethra moves in an arch of 45 degrees w/ the horizontal during valsalva maneuver. Which of the following is the most likely Dx? (Cystocele OR Enterocele OR Urethrocele)

Urethrocele > prolapse of female urethra into the vagina >> signs (if present) are: 1- *Stress incontinence* 2- Increased urinary frequency 3- Urinary retention 4- Pain during sex *often caused by childbirth* Cystocele > Occurs when the wall between the bladder & vagina weakens allowing the bladder to droop into the vagina >> would present w/ *urge incontinence* 1- Urine leakage (dribbling) 2- Incomplete emptying of bladder Enterocele > *small bowel prolapse into the vagina* extends into the pouch of Douglas (recto-vaginal pouch) >> symptoms include: 1- Pulling sensation in pelvis that eases when you lie down 2- Feeling of pelvic fullness, pressure, or pain 3- Low back pain that eases when you lie down 4- Soft bulge in vagina 5- Dyspareunia

A 27F, primigravid, at 33wks presents for routine prenatal visit. She has had SLE for 8 years but has been in remission for the past year. Her pregnancy has been uncomplicated except for a fundal ht that began to lag 2 months ago. US at 20 wks showed a fetus that had a normal anatomy & was consistent in size w/ gestational age. The pt's BP today is 100/62. Pelvic Exam shows no abnormalities. The fundal Ht is 26cm. There is no ferning on light microscopy of vaginal secretions. US shows oligohydraminos & a fetus consistent in size w/ a 30 wk gestation. Urinalysis shows no protein. Which of the following is the most likely cause of the oligohydraminos? (Fetal renal agenesis OR Fetal urinary obstruction OR Uteroplacental insufficiency)

Uteroplacental insufficiency - Fetus presents w/ FGR & oligohydraminos - Oligohydraminos* Can cause *intrauterine fetal growth restriction* - Causes of oligohydraminos include: 1- PROM (most common) 2- Uteroplacental insufficiency 3- Fetal urinary tract abnormalities (Agenesis, Polycystic kidneys, Posterior urethral valves) Fetal renal agenesis - Fetus would have ABNORMAL ANATOMY → seen in US as multiple cysts & an atretic ureter ----[Pts US shows NORMAL ANATOMY & oligohydraminos] - Fetal renal agenesis would occur as complication of oligohydraminos → leading to Potter sequence - Potter sequence presents w/: 1- Pulmonary hypoplasia 2- Oligohydraminos 3- Twisted face (flat "parrot-beak", Low set ears, Micrognathia) 4- Twisted skin 5- Extremity defects (rocker-bottom feet, talipes equinovarus) 6- Renal failure (in utero) ---[pt does not have signs of renal failure] Fetal urinary tract obstruction > Pt would have hydronephrosis of affected kidney seen on US d/t ureterocele

A 32F, primigravid, at 32 wks presents for a routine prenatal visit. She has HTN treated w/ nifedipine & hypothyroidism controlled w/ levothyroxine. Four wks ago at her last exam, fundal ht was lagging. She was started on an 1800 calorie diet after results of a 3 hr glucose tolerance test showed abnormalities. She is 5ft 2 in tall. She has had a 20 lbs weight gain during her pregnancy. Pulse is 92/min, BP is 160/96. Exam shows a fundal ht of 27 cm. During the past 2 wks, her blood glucose concentrations have been less than 120 mg/dL 1 hr after meals. US shows an estimated fetal weight at the 5th percentile for 32 wks gestation. Which of the following is the most likely cause of the fetal growth restriction? (Maternal hypothyroidism OR Maternal malnutrition OR Uteroplacental insufficiency)

Uteroplacental insufficiency > Main causes of fetal growth restriction are: > 1st trimester (symmetric) 1- Aneuploidy 2- Intrauterine infections >2nd/3rd trimester 1- *Uteroplacental insufficiency* Poorly functioning placenta that cannot provide adequate nutrition 2- Severe maternal malnutrition Maternal RF for asymmetric FGR are: 1- *HTN* 2- GDM 3- SLE 4- CV disease 5- smoking/ Cocaine Maternal Hypothyroidism > not a RF for asymmetric FGR Maternal malnutrition > mom has gained 20 lbs >> which means she cannot be malnourished

An 18F, primigravid, at 39 wks delivers a newborn 2 days after developing chicken pox. The pregnancy had been otherwise uncomplicated. Which of the following is the most appropriate care for the newborn? (Observation for signs of infection OR VZV immune globulin therapy)

VZV immune globulin > Advisory committees, both in the US & Canada, have recommended the *prophylactic administration of VZIG to neonates whose mothers develop varicella between 5 days before & 2 days after delivery* Observation > no b/c of recommendations

A 5F, presents by dad 1 day after he noticed some blood on her underpants. He reports that she has been rubbing & scratching her genital area for the past 5 days & that the irritation has progressed despite TMT w/ topical Vit. A & D & warm baths. On questioning, she says that she has had a foul-smelling discharge & burning & itching in the area, which is worse when she urinates. She also has had a runny nose during this period. She has not had any fever & has no Hx of serious illness. Temp is 98.6F. Exam shows green vaginal discharge & diffuse inflammation of the vulva. The hymen appears intact. There are no lacerations, ecchymoses, or other signs of trauma. A wet mount preparation of the discharge shows occasional RBC's & numerous leukocytes. Culture of the discharge shows a polymicrobial infection. Which of the following is the most likely cause of these symptoms? (Inoculation from an URI OR Vaginal foreign body)

Vaginal foreign body > Pt presents w/ an abscess >> she would not get that from inoculation from a URI > RBC's are present >> shows trauma Inoculation from an URI > wrong for above reasons + Pt has no fever

A 27F, primigravid, at 37 wks is admitted in labor after an uncomplicated pregnancy. Fetal heart tones are reactive. SROM occurs w/ moderate blood-stained fluid, followed by a deep, persistent fetal heart bradycardia. The uterus is soft & nontender. The cervix is 3cm dilated; there is a vertex presentation. Which of the following is the most likely Dx? (threatened abortion OR Vasa previa)

Vasa Previa > Classically present w/ *vaginal bleeding immediately following rupture of the membranes* > w/ fetal heart rate abnormalities *most commonly sinusoidal patter or bradycardia* Threatened abortion > Pt would complain of cramping & bleeding but no tissue has passed & the fetus remains viable (+ fetal cardiac activity) > Cervical os is closed (pt's is dilated 3cm)

A 23F, presents b/c of 3-day Hx of pain & burning w/ urination. Two years ago, she had similar symptoms that resolved w/ TMP-SMX. She is sexually active & uses OCP. Temp is 98.6F. Exam shows no CVA tenderness. Urinalysis shows bacteria & pus. She requests advice about preventing future episodes. Which of the following is the most appropriate recommendation? (Voiding immediately after sex OR Daily TMP-SMX)

Voiding after sex > First line action to help prevent UTI's Daily TMP-SMX > second line in preventing UTI's

A previous healthy 57F, presents d/t a 2 month history of vulvar itching. She is otherwise asymptomatic & takes no meds. Menopause occurred 7 yrs ago. She has not been sexually active for 10 years. Exam shows a 1 x 1 1/2 ulcerated lesion on the inner right labium majus surrounded by mild erythema; no other lesions are noted. There is no inguinal adenopathy. Which of the following is the most likely Dx? (Primary syphilis OR Vulvar carcinoma OR Vuvlar condylomata acuminata)

Vulvar carcinoma > present as leukoplakia >> usually associated w/ long standing lichen sclerosis >> may present as: 1- Chronic irritation (pt has mild erythema) 2- *Scratching/ itching of vulva* Vulvar condylomata acuminata > Associated w/ either HPV 6 & 11 >> presents as: >> warty growths on the external genitals or at the anus >> consisting of fibrous over growths covered by thickened epithelium showing koilocytosis >> pt may show *low grade squamous intraepithelial lesions* Primary syphilis > presents as: 1- Painless non-exudative ulcer w/ a raised, indurated margin + 2- Painless bilateral inguinal lymphadenopathy (pt specifically said to have none)