Unit 1: Approach to the patient

A 17-year-old female comes to your office for her first gynecologic visit. She has been sexually active for the last year and always uses condoms. What is the most appropriate management regarding Pap smear screening for this patient? A. Pap smear at age 21 B. Pap smear at this visit and then anually C. Pap smear now and then every 3 years E. Pap smear at age 18 D. Pap smear now and then every other year

A. Regardless of cloitarche, Pap smears start at 21

A 72-year-old G3P1 woman has progressive ovarian cancer. She and her husband have already completed a medical power of attorney form. However, the patient did not complete a living will or any other documents expressing her wishes for the initiation of mechanical ventilation or cardioversion in the event of a respiratory or cardiac arrest. Unfortunately, the patient is brought into the hospital after suffering an incapacitating seizure. She is not arousable when she reaches the oncology unit. Her husband Jim is present and willing to act as Mary's surrogate decision-maker. When he decides on the proper course of care, the husband should make decisions based primarily on which of the following? A. What Mary would have chosen B. Mary's best interest C. Hospital Ethics Committee's recommendation D. The family's wishes E. His own wishes

A. A person who has power of attorney should make decisions based on what the patient would have wanted for herself, regardless of what they think her best interests might be.

A 27-year-old G1P0 woman at 12 weeks gestation presents for first prenatal care visit. She is previously healthy and takes no medications. An ultrasound is performed and a viable pregnancy is confirmed. At the end of the visit, the patient discusses with you her desire to have a Cesarean section for delivery, as she does not wish to go through the pain of labor. Her husband, an orthopedic surgeon, expresses concerns as they desire to have at least three children and he is worried about potential complications with repeated Cesarean sections. What is the most appropriate next step in the counseling of this patient? A. Agree with her decision after proper counseling and perform a Cesarean section at 39 weeks gestation B. Agree with her decision after proper counseling and perform a Cesarean section at 41 weeks gestation if she has not gone into labor by then C. Advise her that it is not possible to plan a Cesarean section for delivery D. Advise her to listen to her husband and plan for a vaginal birth E. Refer her to psychiatric counseling

A. Elective Cesarean section on demand has been getting more popular among women for a variety of reasons. Although, it might sound unreasonable to undergo a Cesarean section for being afraid of pain, the patient has the right to request it and the physician's duty is to make sure she understands all the risks and potential complications associated with such a decision. Elective delivery should not be scheduled prior to 39 weeks due to risks associated with prematurity. Her husband is appropriately concerned, but it is up to her to make the decision regarding an elective procedure.

A 24-year-old G0 woman is considering pregnancy in the next year. Her medical history and physical examination are normal. She is unaware of any significant family history. She is vegetarian, exercises regularly and does not smoke or drink alcohol. Which of the following is the next best step in the management of this patient? A. Folate supplementation is recommended for this patient B. Most patients get an adequate intake by diet alone C. She is not currently planning a pregnancy and does not need to worry about folate D. Current grain supplementation adequately prevents neural tube defects E. Folate does not need to be started until after a pregnancy is documented

A. Folate lowers homocysteine levels. The Nurses Health Study showed fewer nonfatal MIs and fatal coronary events in women with adequate intake doses of folate and vitamin B6. Folate can also help prevent neural tube defects. Studies have shown that diet alone is not effective in achieving adequate levels, and routine folate supplementation is therefore recommended. Women of reproductive age should take a daily 400-microgram supplement. Adequate levels are especially important prior to pregnancy and during the first four weeks of fetal development. Folic acid levels may be used to diagnose B12 or folate deficiency and are not routinely check to guide folic acid supplementation prior to pregnancy unless a patient is suspected to have a deficiency.

A 48-year-old G3P3 woman presents to the office for a health maintenance examination. Her past medical history is negative. Her family history is significant for hypertension in her father and diabetes mellitus in her mother. Her grandfather passed away from colon cancer at the age of 82. She is worried about getting colon cancer and desires to undergo screening. Her body mass index (BMI) is 23 and her physical exam is normal. What is the most appropriate next step in the management of this patient? A. Recommend a colonoscopy at age 50 and, if normal, repeat every 10 years B. Recommend a colonoscopy at age 50 and then every two years C. Order a colonoscopy now and, if normal, repeat in five years D. Order a sigmoidoscopy now and, if normal, repeat in five years E. Recommend a sigmoidoscopy at age 50 and then every two years

A. For patients with average risk for colon cancer, the recommended screening is to begin colonoscopy at age 50 and then every 10 years, if normal. Despite having a grandfather who passed away from colon cancer, this patient is not necessarily at increased risk and does not need to be screened at different intervals than the general population. If there is a history of a first degree relative with colon cancer before age 60, then begin screening with colonoscopy at age 40, or 10 years before the youngest relative diagnosis, and repeat every five years. Although a sigmoidoscopy can be an acceptable screening procedure, it would still begin at age 50 and repeat every five years, if normal.

A 36-year-old G0 woman who is a health worker presents for a health maintenance examination. She is sexually active and not using contraception. She doesn't think she is pregnant, but would be happy if she were. As part of her general preventive care, you discuss immunizations. Which vaccination is contraindicated if this patient gets pregnant now? A. Measles-Mumps-Rubella (MMR) B. Pneumococcus C. Hepatitis B D. Polio E. Influenza

A. Pregnancy, or the possibility of pregnancy, within four weeks is a contraindication to the MMR and varicella vaccinations. Tetanus, Hepatitis B, Polio and Pneumococcal vaccinations would not be contraindicated.

A 28-year-old G0 woman has a pap test which is reported as high-grade squamous intraepithelial lesion (HSIL). She is currently sexually active. She has had six sexual partners and has been in a monogamous relationship with her fiancé for the last year. What is the next most appropriate next step in the management of this patient? A. Colposcopy B. Cryotherapy C. Reflex HPV testing D. Repeat Pap test in one month E. Repeat Pap test in six months

A. The American Society for Colposcopy and Cervical Pathology guidelines recommend immediate LEEP or colposcopy for women with HSIL cytology test results. A diagnostic excisional procedure is recommended for women with HSIL cytology test results when the colposcopic examination is inadequate. Unlike a LEEP, cryotherapy is inadequate as this procedure does not provide a tissue specimen. Repeat cytology testing alone or reflex HPV testing is unacceptable. For women not managed with immediate excision, colposcopy is recommended regardless of HPV result obtained at co-testing.

A 39-year-old G0 woman presents to the clinic reporting non-tender spots on her vulva for about a week. No pruritus or pain is present. She also notes a brownish rash on the palms of her hands. She admits to IV drug abuse. She was diagnosed as HIV-positive two years ago, but has not been compliant with suggested treatment. On examination, three elevated plaques with rolled edges are noted on the vulva. They are non-tender. A brown macular rash is noted on the palms of her hands and the soles of her feet. What is the most appropriate next step in the management of this patient? A. Obtain a treponemal-specific test B. Biopsy of the lesion C. Colposcopic evaluation of the vulvar lesions D. Culture the base of the lesion E. Initiate empiric treatment with doxycycline and ceftriaxone

A. The diagnosis of syphilis is often established by serologic testing. Non-treponemal tests (VDRL or RPR) are non-specific. In this patient with high suspicion for syphilis, specific testing with treponemal antibody can confirm infection. The classic coiled spirochete is easily seen with dark-field microscopy but availability is limited. A characteristic finding is a macular rash on the palms and soles that are often described as copper penny lesions. Colposcopy would not be diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic. Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly would not be the most expedient way to make the diagnosis. Penicillin G is the preferred drug for treating all stages of syphilis.

You are asked to give a lecture on a new chemotherapy drug that has demonstrated a reasonable efficacy in women with advanced cervical cancer. The day before giving the lecture, you realize that you own stock in the company that makes the drug. Which of the following statements about conflict of interest is true? A. Pharmaceutical companies can support the costs of medical conferences in which physicians receive continuing medical education credits B. b. Physicians should engage in agreements in which companies make a substantial donation to an educational activity, when the donation is contingent on the physician's use or advocacy of a product C. c. The hospital may not interfere with a physician's decision to use a new surgical device D. d. An investigator may not own stock in a company if he/she does research for that company E. e. Physicians are not required to disclose any potential conflict of interest before speaking in a national forum

A. The relationship of physicians and hospitals with pharmaceutical companies is a sensitive one, as there is potential for conflict of interest. It is acceptable for pharmaceutical companies to support conferences in which physicians receive CME credit. Physician participation in those activities should not be contingent upon physician use or advocacy of the product. An investigator may own stock in a company if he/she does research for that company, as long as he/she declares the conflict of interest and the conflict of interest is addressed.

A 40-year-old G2P2 woman presents for her first health maintenance examination. She denies any new complaints or symptoms. She has no history of any gynecologic problems. Family history is significant for a father with hypertension and a mother, deceased, with breast cancer diagnosed at age 56. A paternal aunt has ovarian cancer which was diagnosed at age 83. A physical exam is unremarkable. What screening test should be offered to this patient next? A. Breast MRI B. Mammogram C. Transvaginal pelvic ultrasound D. Breast ultrasound E. BRCA-1/BRCA-2 testing

B. ACOG recommends that women aged 40 years and older be offered screening mammography annually. Ultrasonography is an established adjunct to mammography. It is useful in evaluating inconclusive mammographic findings, in evaluating young patients and other women with dense breast tissue, and in differentiating a cyst from a solid mass. Breast ultrasound is not recommended as a primary screening modality for women at average risk of developing breast cancer. A combination of first and second-degree relatives on the same side of the family diagnosed with breast and ovarian cancer (one cancer type per person) increases the risk of BRCA mutation. Based on the limited history provided, this patient does not meet the criteria published by ACOG for genetic cancer risk assessment. A more detailed family history regarding risk factors should be obtained to determine whether the patient should be referred for genetic counseling.

A 27-year-old G1P0 woman at 34 weeks gestation is brought in by ambulance after a motor vehicle accident. Although restrained in the car with a safety belt, she suffers a significant head laceration. When she arrives in the emergency department, her initial trauma survey is completed. On her secondary survey, there is bright red blood coming from the vagina. Her abdomen is noted to be tense. Subsequent documentation of the fetal heart tones reveals fetal tachycardia. Abruption is suspected and the patient is rushed to the operating room for an emergent Cesarean section. After delivery, the nurse notes that an informed surgical consent was never signed. Which of the following is true? A. Informed consent is valid if the doctor-patient discussion occurred soon after the patient received intravenous morphine for pain relief B. Informed consent is unnecessary in an emergency situation if a delay in treatment would risk the patient's health/life C. Informed consent is only required for invasive procedures D. Informed consent would not have been valid anyway because the patient sustained a head laceration E. In an emergency situation, informed consent documents can be signed after the procedure is over and the patient is stable

B. Informed consent needs to be obtained for all procedures while patient is fully alert and has not received any narcotics or other medications that may affect her decision-making. The only exception is in true emergency situations that would risk the patient's life. Obtaining informed consent does not necessarily protect the provider from lawsuits and should never be signed after a procedure is already completed.

A 28-year-old G0 woman presents to the office for a health maintenance examination. She is currently on oral contraceptive pills, but reports a history of irregular menses prior to starting them. Her past medical history is otherwise non-contributory. On physical examination, she is 5 feet 2 inches tall and weighs 180 pounds. She has an area of velvety, hyperpigmented skin on the back of her neck and under her arms. What is the next best step in the management of this patient? A. Complete blood count B. Diabetes screen C. Biopsy pigmented area D. Pelvic ultrasound E. Lipid profile

B. The patient is obese, with a BMI of 33. In addition, the skin changes are consistent with acanthosis nigricans, which is closely associated with insulin resistance. Given these risk factors, she should be tested for diabetes.

A 19-year-old G0 woman presents with lower abdominal cramping. The pain started with her menses and has persisted, despite resolution of the bleeding. She thinks she may have a fever, but has not taken her temperature. No urinary frequency or dysuria are present. Her bowel habits are regular. She denies vomiting, but has mild nausea. A yellow blood-tinged vaginal discharge preceded her menses. No pruritus or odor was noted. She is sexually active, uses oral contraceptives and states that her partner does not like condoms. On examination: temperature is 100.2°F (37.9°C); pulse 90; blood pressure 110/60. She is well-developed and nourished and in mild distress. No flank pain is elicited. Her abdomen has normal bowel sounds, but is very tender with guarding in the lower quadrants. No rebound is present. Pelvic examination reveals a moderate amount of thick yellow discharge. The cervix is friable with yellow mucoid discharge at the os. Cervical motion tenderness is present. Uterus and the adnexa are tender without masses. Urine dip is negative for nitrates. Urine pregnancy test is negative. What is the most likely diagnosis? A. Vulvovaginal candidiasis B. Acute salpingitis C. Trichomonas vaginitis D. Cervicitis E. Bacterial vaginosis

B. This patient has findings suggestive of acute salpingitis (pelvic inflammatory disease) including lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, and vaginal discharge. Mucopurulent cervicitis with exacerbation in the symptoms during and after menstruation is classically gonorrhea. Chlamydia is frequently associated with gonorrhea and also causes cervicitis and pelvic inflammatory disease. Cervicitis alone would not explain this patient's constellation of findings. Trichomonas may cause a yellow frothy discharge, and Candida may cause a thick white cottage cheese-like discharge, but neither would cause fever and abdominal pain.

A 32-year-old G2P2 woman presents for a health maintenance examination. She is in good health and has no concerns. She does not have a history of abnormal Pap test and her last one was three years ago. Her examination is normal including her pelvic exam. A Pap test is performed and returns as normal with HPV negative. What is the most appropriate screening recommendation for cervical cancer in this patient? A. Pap test and HPV testing in one year B. Pap test and HPV testing in three years C. Pap test and HPV testing in five years D. HPV testing alone in one year E. HPV testing alone in three years

C. According to the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) guidelines for the Prevention and Early Detection of Cervical Cancer, women ages 30 to 65 years should be screened with cytology and HPV testing (''co-testing'') every five years (preferred) or cytology alone every three years (acceptable). Screening by HPV testing alone is not recommended for most clinical settings and there is insufficient evidence to change screening intervals in this age group following a history of negative screens.

A 60-year-old G2P2 postmenopausal woman has an appointment for a health maintenance examination. She wants to discuss bone density screening for osteoporosis. Her medical history is significant for hypertension for the last 10 years that is well controlled with antihypertensive medications. Which of the following is the most appropriate recommendation for this patient regarding initial bone mineral density screening? A. Obtain a DEXA scan now B. Obtain a DEXA scan now only if her blood pressure is not well controlled C. Obtain a DEXA scan at age 65 D. Bone density screening is only necessary if she presents with a fracture E. Recommend bone density screening five years after the onset of menopause

C. Bone density screening is recommended for women beginning at age 65 unless they have pre-existing risk factors which warrant earlier screening. Risk factors for osteoporosis are early menopause, glucocorticoid therapy, sedentary lifestyle, alcohol consumption, hyperthyroidism, hyperparathyroidism, anticonvulsant therapy, vitamin D deficiency, family history of early or severe osteoporosis, or chronic liver or renal disease. These factors would institute early screening in a patient for osteoporosis. A postmenopausal patient presenting with fractures should alert you to suspect osteoporosis.

A 17-year-old G0 high school student is brought in by her mother for her first gynecologic examination. She began her menses at age 12 and has had regular periods for the past three years. Her last menstrual period was one week ago. For privacy, you ask to examine the patient without her mother. Further history is obtained in the examination room. She admits that she has been sexually active with her boyfriend for the past three years. She uses condoms occasionally and is fearful about possible pregnancy. She requests that her mother not be informed about her sexual activity. On physical examination, she is anxious, but normally developed. Her pelvic examination reveals no vulvar lesions, minimal non-malodorous discharge, and a nulliparous appearing cervix. The bimanual examination reveals a normal size uterus, and her adnexa are non-tender and not enlarged. Urine pregnancy test is negative. In addition to discussing contraception. What is the next best step in the management of this patient? A. Obtain a serum Beta-hCG level B. Obtain a Pap test C. Obtain DNA probes for gonorrhea and chlamydia D. Initiate treatment with doxycycline and ceftriaxone E. Order a pelvic

C. Counseling about and screening for sexually transmitted infections is the best next step. This patient does not require treatment due to a lack of diagnostic criteria. A serum Beta-hCG is not indicated in the setting of normal menstrual cycles with last menstrual period a week ago and a negative urine pregnancy test. Guidelines for initiation of cervical cancer screening is recommended at age 21 regardless of coitarche. A pelvic ultrasound would not be indicated at this time especially since the pregnancy test is negative and given her lack of menstrual or pelvic symptoms.

A 26-year-old G0 woman presents to the reproductive endocrinology clinic seeking an infertility evaluation for failing to conceive after 14 months of unprotected intercourse with her boyfriend, who has fathered two other children. She works as a janitor in a nearby elementary school and currently has Medicaid for her health insurance. The physician discourages her from pursuing treatment because she will likely have to pay for her visit with cash, check or charge, and is told that treatment for infertility often involves procedures and technology that are very expensive. She is also informed that, in most states, many of these therapies are not covered by insurance or Medicaid. This situation violates which of the following ethical principles? A. Patient autonomy B. Beneficence C. Justice D. Physician autonomy E. Non-malfeasance

C. Justice requires that we treat like cases alike. It is the physician's duty to educate the patient about all her treatment options in a non-judgmental way regardless of the nature of the treatment and her socioeconomic status.

A 68-year-old G2P2 woman who has recently moved in with her daughter (a long-standing patient of yours) comes in for a health maintenance examination. A vaginal hysterectomy was done in her fifties for uterine prolapse. She is not sure if her ovaries were removed. She has never had an abnormal mammogram or Pap test and has had yearly exams. She stopped hormone replacement therapy 10 years ago. She was recently widowed after being married for 50 years. She does not smoke or drink. Her diabetes is well-controlled with Metformin; she takes a daily baby aspirin and is on a lipid-lowering agent. On examination, she is a thin elderly woman with a dowager's hump. Her breast exam is unremarkable. Her lower genital tract is notable for atrophy. No masses are noted on bimanual and recto-vaginal exam. A fecal occult blood test is negative. Which of the following tests is not necessary? A. Bone density B. Colonoscopy C. Pap test D. Mammogram E. Annual bimanual and recto-vaginal exam

C. Pap test screening is not indicated in patients who have had a hysterectomy, unless it was done for cervical cancer or a high-grade cervical dyspalsia. Patients with a uterus can discontinue cervical cancer screening between the ages of 65-70 if they have had three consecutive negative smears or two negative consecutive cotesting in the last 10 years and no history of high-grade cervical intraepithelial neoplasia or cancer. Patients still need yearly bimanual and rectovaginal exam. Mammograms are done annually, as breast cancer increases with age. Colon cancer screening is recommended at age fifty. The patient has an exaggerated thoracic spine curvature, termed a dowager's hump, likely secondary to thoracic compression fractures secondary to osteoporosis. If this is confirmed on a bone density test, she may benefit from the addition of bisphosphonates

A 25-year-old G3P2 woman, who had recently undergone a primary Cesarean section, had her HIV status revealed to her mother when a nurse left her chart open in the recovery room. She speaks to patient relations and is thinking about seeking damages through legal avenues. When trying to explain the concept of patient privacy, which of the following statements is correct? A. Patient privacy is based on the ethical principle of justice B. Patient privacy is protected by federal law, primarily with the Federal Emergency Medical Treatment and Labor Act (EMTALA) statute C. Patient privacy is the responsibility of physicians; physicians may be fined and/or assessed criminal penalties for violating the privacy of a patient's protected health information D. The patient cannot win a lawsuit in this case because the mother should not have looked at the open record E. Patient privacy is based on the ethical principal of beneficence

C. Patient privacy is the responsibility of physicians. Physicians may be fined and/or assessed criminal penalties for violating the privacy of a patient's protected health information. It was the responsibility of the physicians and the other health care providers in this case to make sure the chart is not left open so someone walking by sees the information.

A 38-year-old G0 woman comes to the office because she noted a persistent yellow, frothy discharge associated with mild external vulvar irritation. She denies any odor. She tried over the counter anti-fungal medication without success. The discharge has been present for over three months, gradually increasing in amount. Douching has resulted in temporary relief, but the symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix. A sample of the discharge is examined under the microscope. What is the most likely finding? A. Strong amine fishy odor when KOH applied to sample B. Marked polymorphonuclear cells with multi-nucleate giant cells C. Motile ovoid protozoa with flagella D. Budding yeast and pseudo-hyphae E. Clue cells

C. This patient most likely has trichomoniasis. The erythematous patches on the cervix are characteristic of "strawberry cervicitis." Trichomonads are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide must be examined immediately. The discharge is mixed with saline and placed on the slide with a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green vaginal discharge. Clue cells are seen on a saline wet mount in women who have bacterial vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation may be herpes.

A 51-year-old G4P4 woman presents for her health maintenance examination. She has not seen a physician for the past two years as she was caring for her sick husband who passed away two months ago. Her last menstrual period was four years ago and she denies any bleeding since that time. Her past medical and surgical histories are negative. Her mother was diagnosed with ovarian cancer and died at age 54. Her Pap smears have always been normal. Her last one was two years ago and it was negative for high-risk HPV types. Her exam is normal. Which of the following is the most appropriate screening test for this patient? A. Pelvic ultrasound B. Endometrial biopsy C. Colonoscopy D. DEXA scan e. Pap smear

C. Women should be offered colorectal cancer screening starting at age 50. Options include yearly hemoccult testing, flexible sigmoidoscopy every five years, or colonoscopy every 10 years. Ultrasound is not a good screening modality for pelvic pathology. An endometrial biopsy is indicated if a patient is experiencing irregular bleeding. A DEXA scan is only recommended in patients with risk factors for osteoporosis prior to age 65. This patient's history does not indicate that she is high risk. A Pap smear is not indicated as she has no recent history of abnormal Pap smears, and her last one with HPV testing was two years ago.

A 36-year-old G3P2 woman presents in active labor at full term with a known placenta previa. She reports brisk vaginal bleeding. Evaluation shows that fetus and patient are currently hemodynamically stable. She has had two normal vaginal deliveries in the past. She declines your recommendation to undergo Cesarean section. Which of the following is not advisable during your initial management of this patient? A. Soliciting her reasons for not undergoing a Cesarean section B. Obtaining hospital Ethics Committee recommendation C. Proceeding with an emergency Cesarean section D. Explaining your reasons for recommending a Cesarean section E. Informing risk management of the situation that has developed

C. You should not perform any procedure on the patient without her consent. It is best in these situations to explain your reasons for the recommended Cesarean section and elicit the patient's reasons for not wanting to undergo the procedure. A court order should only be obtained as a last resort.

A 16-year-old female has a new boyfriend and comes in to discuss contraception. She is well aware of the importance of preventing sexually transmitted infections and specifically wants to know about prevention of pregnancy. Other than abstinence, the most effective method of birth control in this patient is: A. The male condom B. The diaphragm with spermicide C. Oral contraceptives D. Depo-Provera E. The contraceptive ring

D. Contraceptive methods with <1% pregnancy rates (typical use) are Depo-Provera, IUD, sterilization (male or female), and Implanon. Oral contraceptives have a 3-5% pregnancy rate with typical use, and the male condom has a 12% pregnancy rate. Eight percent of women will experience an unintended pregnancy after one year of typical use with a contraceptive ring. Of the methods listed, the diaphragm with spermicide has the highest failure rate (18%) with typical use.

A 23-year-old G0 woman reports having a solitary, painful vulvar lesion that has been present for three days. This lesion has occurred twice in the past. She states that herpes culture was done by her doctor during her last outbreak and was negative. She is getting frustrated in that she does not know her diagnosis. She has no significant previous medical history. She uses oral contraceptives and condoms. She has had four sexual partners in her lifetime. On physical examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. How do you explain the negative culture? A. Cultures were taken too early B. Oral contraceptives affect the growth of the virus C. The cultures were refrigerated prior to transport to the lab D. Herpes cultures have a 10-20% false negative rate E. The herpes virus cannot be recovered with recurrent infections

D. Culture is the gold standard in the diagnosis of herpes. They are highly specific, yet sensitivity is limited. It is best to culture the lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The herpes virus can theoretically be isolated from both primary and recurrent infections. This patient very likely presented too late in the course for a useful culture. Oral contraceptives do not affect the growth of viruses. While serum antibody screening can be performed, it indicates lifetime exposure and would not answer the question as to the etiology of the specific lesion. Alternatively, DNA studies such as the polymerase chain reaction can be done, if available.

A 42-year-old G2P2 woman presents for a health maintenance examination. Her past medical history is negative. Her family history is significant for hypertension and hypercholesterolemia in her father and diabetes mellitus in her mother. Her body mass index (BMI) is 23. What lifestyle modification is most important for this patient? A. Starting a weight loss diet B. Starting a sugar-free and cholesterol-free diet C. Recording a daily blood pressure D. Starting an aerobic exercise program E. Recording a weekly blood pressure

D. Heart disease is the number one killer of women. Lifestyle modifications to reduce her risk, especially considering her family history, are important proactive changes that she can make. Studies show an inverse relationship between the level of physical activity and incidence of death from coronary disease. Exercise would be an appropriate first step with this patient. She does not need to lose weight (normal BMI) and does not need to be on a special diet (normal labs). Recording daily or weekly blood pressures is not necessary, but her blood pressure should be checked once a year.

A 23-year-old G1P0 comes into the office after having some light inter-menstrual spotting and cramping. She is currently sexually active and has had unprotected intercourse with two different partners over the past three months. A urine pregnancy test is positive. She does not desire to keep the pregnancy and, after an ultrasound scan in the office reveals a six-week viable intrauterine pregnancy, the patient asks about an abortion, but has no health insurance. What is the most appropriate next step in the management of this patient? A. You inform her that state Medicaid programs are not allowed to cover this service; therefore, you cannot perform the procedure B. You recommend against the procedure due to potential complications with future infertility C. You request she seeks the opinion of both of her partners before undergoing the procedure D. You support her decision for abortion after appropriate counseling E. e. You inform her that abortion should only be performed after six weeks gestation

D. Patients requesting abortion should be counseled appropriately regardless of their insurance status and do not have to obtain the consent of their partner to undergo the procedure. Although there are complications associated with pregnancy termination, they are significantly fewer than complications with carrying a pregnancy. Fewest complications occur when termination is done in the first trimester. From 1990 (the year in which the number of abortions was highest) to 1995, the annual number of legally induced abortions in the United States declined by 15%. Since 1990, factors contributing to the continued decrease in the proportion of pregnancies that ended in abortion might include a decrease in the number of unintended pregnancies, changes in contraceptive practices (including an increased use of condoms among young women), reduced access to abortion services and possible changes in attitudes concerning abortion. Clinical guidelines from the Society of Family Planning state that surgical abortion can be performed successfully and safely as early as three weeks from the onset of last menses if a protocol exists that includes sensitive pregnancy testing, immediate and meticulous examination of the aspirate, and assiduous follow-up of questionable specimens to rule out ectopic pregnancy or continuing gestation.

Mary is a 65-year-old G2P2 woman with lung metastases from cervical cancer. She was recently weaned from mechanical ventilation after being on the ventilator for four weeks. She has a tracheostomy. Mary currently has worsening pulmonary function and needs to go back on the ventilator or she will die within a few days. Mary's husband, Jim, has power of attorney for Mary's health care decisions. The attending offers Mary a choice of either no ventilation with morphine for comfort or resumption of mechanical ventilation. Mary decides she prefers to go back on the ventilator. Jim prefers that she does not go back on the ventilator because the doctor has said that Mary may never wean off of the ventilator again. Who should make the decision about whether to put Mary back on the ventilator? A. Jim B. All of them together C. Mary's doctor in consultation with Jim D. Mary E. If Jim and Mary cannot agree, consult the hospital ethics committee

D. Since Mary is still competent, she can make her own decisions despite the fact that her husband has power of attorney.

A 38-year-old G1P0 woman is admitted at 42 weeks gestation with an anencephalic infant for induction of labor. The attending physician decides not to monitor the baby's heart rate during labor because he would not intervene with a Cesarean section in the event of fetal distress or demise. The physician's action is justified by which one of the following concepts? A. Beneficence to the fetus B. Respect for autonomy to the patient C. Maleficence to the fetus D. Non-maleficence to the patient E. Justice for the patient

D. The non-malfeasance principle expresses the concept that professionals have a duty to protect the patient from harm. Since an anencephalic infant will not survive, performing a Cesarean section on this patient will cause her harm. Beneficence principle expresses the concept that professionals have a duty to act for the benefit of others, and, in this case, performing a Cesarean section will not benefit the fetus.

A 28-year-old G2P2 woman returns today for follow up on her abnormal Pap test which reveals atypical squamous cells of undetermined significance (ASCUS). Reflex HPV testing is positive for high risk type. She has never had a prior abnormal Pap test, and has been following the recommended screening guidelines. She is asymptomatic. Her pelvic exam reveals a normal cervix with a small amount of cervical mucous. What is the next best step in the management of this patient? A. Routine screening B. Repeat Pap test in one year C. Repeat HPV testing in one year D. Repeat co-testing with Pap and HPV in one year E. Colposcopy

E. Colposcopy is indicated for all abnormal Pap test results including ASCUS Pap test when HPV is positive. Reflex HPV testing for high-risk DNA types should be performed in patients with ASCUS. If negative, then co-testing with cytology and HPV can be repeated in three years. Repeat cytology in one year is also an acceptable option for ASCUS if HPV testing cannot be done. http://www.asccp.org/Portals/9/docs/ASCCP%20Updated%20Guidelines%20Algorithms%206.3.13.pdf

A 24-year-old G0 woman presents with multiple painful ulcers involving the vulva. The sores were initially fluid filled, but are now open, weeping and crusted. She reports a fever and is having difficulty voiding due to pain. She uses a vaginal ring for contraception. She has multiple sexual partners and uses condoms for vaginal intercourse. She is distraught that she may have a sexually transmitted infection. She is healthy and does not smoke or use drugs. On physical exam, she is in obvious distress. Temperature is 100.2°F (37.9°C); pulse 100. Examination of the genital tract is limited due to her discomfort. Multiple ulcers and erosions of variable size are localized to the perineum, labia minora and vestibule. Swelling is diffuse. The lesions are eroded, some with a purulent eschar. There is exquisite tenderness to touch. What further testing should be offered to this patient? A. RPR (rapid plasma regain) B. HIV C. Herpes culture D. DNA probe for gonorrhea and chlamydia E. All of the above

E. This patient has classic primary herpes with painful genital ulcerations, fever and dysuria. Given the presence of one sexually transmitted infection, screening should be offered for other STIs. Resolution of the acute episode is required before a speculum can be inserted to allow endocervical sampling for gonorrhea and chlamydia. If it was a high-risk exposure, prophylactic empiric treatment could be offered to cover gonorrhea and chlamydia. The patient should be counseled that primary herpes can be acquired despite condoms and even by oral-genital inoculation. Hepatitis B vaccination should be offered to protect her against any future exposures. She should be encouraged to discuss her diagnosis with all sexual partners and to continue to reliably use latex condoms.