WH Quiz 2
A 31-year-old obese African American female G0P0 with no significant past medical history presents to the clinic with dysmenorrhea and menorrhagia for the past 6 months. She mentions that she is "trying to get pregnant," but has not been successful. She complains of dyspareunia, constipation, and frequent urination as well. You notice her abdomen looks slightly swollen. Bimanual examination reveals a palpable large, irregular mass in the pelvis. Urine human chorionic gonadotropin (hCG) is negative. At this point in time, what is the most likely diagnosis for this patient? A. Leiomyoma B. Adnexal torsion C. Dermoid cyst D. Ovarian cyst
A
A 35 y/o female, G1P1, presents to the OBGYN for her annual exam. She was diagnosed with HIV in September 2018. Her first cervical cytology results in March 2019 were normal. When does she need to get her next cervical cytology? A. September 2019 B. March 2022 C. September 2020 D. Her first cervical cytology was negative, so she does not need to have it tested again.
A
A 46-year-old G1P1002 perimenopausal female comes into the office complaining of pelvic pain for the last 4 months but says it has gotten worse in the past week especially with sitting and walking. She also says that her stomach seems to have gotten bigger, and she has gained 8 lbs despite regular exercise and dieting. Upon physical examination of the pelvis, you note a palpable mass on the right ovary. Her lab results showed normal CA125 levels (20 U/mL) and were negative for pregnancy (hCG = 4 mIU/mL). Mucinous Cystadenoma is high on your differential. Based on this diagnosis, what would be the most appropriate treatment and why? A) Oophorectomy of the right ovary - the mass may be frankly malignant. B) Observation and follow-up because the mass isbenign,and surgery will do more harm than good. C) Chemo and/or radiation - the mass may be malignant and should be shrunk before further action is taken. D) Oophorectomy of the left ovary - the mass may be frankly malignant.
A
A 57-year-old postmenopausal G3P2103 female presents to your clinic complaining of itching in the vulvar area and pain during intercourse. She has a 20 pack-year history of smoking tobacco and a history of lichen sclerosis. You perform a biopsy of the vulva and that tests positive for cancer. What is the most likely diagnosis and best treatment plan? A. Squamous cell carcinoma of the vulva; treat with vulvectomy with or without radiation B. Squamous cell carcinoma of the vulva; treat with chemotherapy C. Melanoma of the vulva; treat with vulvectomy with or without radiation D. Melanoma of the vulva; treat with chemotherapy
A
A 60-year-old G4P3013 female patient presents to your clinic complaining that she feels a sense of pressure and fullness coming from her bladder. She has small dribbling episodes and doesn't really get the urge to go to the bathroom as much anymore. While taking her history she informs you that she is currently on an ace inhibitor for her high blood pressure and she has had prior pelvic surgery before. You perform a bladder stress test on the patient by asking her to cough. Sure enough, urine begins to dribble down the exam table. What is the next step in treating this patient? A) Perform a cystourethroscopy to look for an obstruction B) Recommend patient to stop taking the ace inhibitor drug C) Have patient undergo a "bladder sling" procedure D)Place patient on a bulkingagent
A
A 76-year-old Caucasian female, G2P2002, presents to clinic complaining of vaginal pressure, lower back pain, urinary retention, and difficulty with lifting objects. She states that she has not been sexually active in years and does not care to be sexually active again. She was diagnosed with a cystocele 6 months ago with uterine prolapse and was given a pessary with vaginal estrogen therapy. The patient states she is ready to do something else because she doesn't think the pessary is working. The patient has no chronic conditions. What would be the next appropriate step for this patient? a) Colpocleisis b) Remove the pessary and continue vaginal estrogen therapy c) Oxybutynin d) Uterine Artery Embolization
A
A G2P2 002 58 year old woman presents to the clinic complaining of severe pelvic pain that has been going on for about 6 months. She claims that her last menstrual period was 7 years ago. She claims that the pain is worsening and that she is now bleeding from her vagina. She also states that she has had many sexual partners over the years and that she first began having sex around age 14. She also claims that she is a smoker and that her mother took some kind of drug called DES when she was pregnant with her. After examination, she tests positive for HPV 16. What is her most likely diagnosis based on her history and examination? A. Cervical Cancer B. Vaginal Cancer C. Uterine Fibroids D. Delusions of parasitosis leading to vaginal bleeding
A
A post-menopausal 69 year old G2P1011 female presents to the clinic complaining of vaginal bleeding. On workup, the TVUS shows an endometrial thickness of 6 mm and on the endometrial biopsy, the patient has adenomatous hyperplasia with atypia. What is the best treatment of choice for this patient? A: Abdominal hysterectomy and bilateral salpingo-oophorectomy B: Observation C: Oral contraception pill D: Chemotherapy
A
An 80-year-old G5P5005 woman presents to your clinic with vaginal pressure, urinary retention and a "mass sensation" associated with perineal pain. She has a BMI of 30 and has been diagnosed with COPD. Upon examination, you diagnose her with uterine prolapse. Which of the following is the best treatment indicated for this patient? A. Placement of a pessary device B. Kegel exercises C. Colpocleisis D. Placement of ureteral stents
A
An 87-year-old post-menopausal female G3P3003 presents to the clinic complaining that "my organs are falling out of me". She has a past medical history of coronary artery disease, stroke, and myocardial infarction. After performing a physical exam and diagnosing the patient with a stage IV pelvic organ prolapse, which treatment option is most appropriate for this patient? A. Pessary B. Sacrocolpopexy C. Bladder sling D. Kegel exercises
A
Becky Goodhair, a 34 year old female G2P2002, comes in to your clinic for her annual well-woman exam. After performing a pap smear, you discover that she is positive for HPV-18. You perform a Colposcopy and find she has low-grade squamous intraepithelial lesions (LSIL). According to the Cervical Intraepithelial Neoplasia (CIN) classification system, what grade would this patient receive? A. CIN 1 B. CIN 2 C. CIN3 D. Atypical Squamous Cells of undetermined significance (ASC-US)
A
Mary, a 72-year-old G2P2002 Caucasian female comes into your primary care clinic for a routine physical. Toward the end of the exam, you ask her if she's had a recent gynecological exam and Pap smear. She rolls her eyes at you and asks when she can "stop getting y'all to scrape pieces of my lady bits off." After all, she has not had an abnormal Pap smear in over 30 years. You look in her chart and see that at age 40, Mary had abnormal cytology suggesting CIN 2, but subsequent testing in the years since (cytology and HPV DNA co-testing every 5 years) has been normal. Her most recent co-testing was 5 years ago. What can you tell Mary? A. She does not have to have continue cervical cancer screenings. B. Because of her history of moderately abnormal cervical cytology, she needs to continue having Pap smears. C. Because her most recent testing was over 3 years ago, she will need one more negative Pap smear before you can tell her she no longer has to get them. D. Refer her to gynecology so they can decide if she no longer needs cervical cancer screenings.
A
Your patient is a 32 year old G0P0 female who presents with pain and pressure in her abdomen. The patient says the pain has appeared over the last month and has gotten worse over time. She says she has tried to be patient and wait for it to go away on its own, but that now "the pain is out of control" and that she has sometimes has trouble focusing at work due to the pain. The patient has a family history of breast cancer and her BMI is 31. The patient reports a "regular month-long cycle" with "light flow", and her last menstrual period was 2 weeks ago. You perform a physical exam and not a mobile, nontender, cystic mass on the patient's right abdomen. Labs reveal that the patient's glycoprotein CA 125 levels are elevated and that her serum BhCG is 0. A transvaginal ultrasound reveals an ovarian cyst that is black in appearance (not chocolate-colored). Now you plan to discuss treatment options with her. Which of the following treatment plans is most appropriate for this patient? A: Observation B: Hysterectomy and BSO: Surgery is not indicated in this patient, as she is pre- C: Oral contraceptives D: Progesterone
A
9 year old female presents to the emergency department with mother complaining of intermittent lower abdominal pain that has been going on for the past 3 days. Patient denies having started her menses yet and any symptoms of dysuria and vaginal bleeding. When performing the physical exam, a mobile tender mass was palpated lateral to the uterus. The next step taken was performing an ultrasound to check what is going on. What would you expect to see on ultrasound? A. Hazy appearing structure B. Dark fluid filled structure C. Dark structure filled with debris D. Fetal sac
B
A 23-year-old female G0P0 presents to your office complaining of itching in her vaginal area for the past week. She only finds relief from scratching. She hasn't noticed any whitish areas or ulcers, but that is because she "hasn't been able to get a good look." She also complains of dyspareunia. Your patient is currently sexually active with her husband of 2 years and has no history of sexually transmitted infections. She denies any recent weight loss or fatigue. However, she has started wearing a new type of underwear because she thinks it is "cute." Pelvic examination reveals an erythematous vulva and labia majora with no atrophic lesions or white lacy bands. There is no anal involvement. The lower one-third of the vagina is mildly erythematous. The cervix is pink and without discharge or lesions and there is negative cervical motion tenderness. The abdomen is flat without visible or palpable masses. You think this may be a benign vulvar disease. Which of the following would you not include in the initial, first-line treatment for this patient? A. Topical clobetasol (Clobex) B. Biopsy C. Discontinue wearing the new underwear D. Use a warm washcloth lightly to relieve itching and scratching
B
A 24 year old G0P0 female patient presents to your clinic presenting with sharp lower abdominal pain that appears to be localized to her right side. She mentions the pain appeared suddenly this morning around 4:00am, and describes the pain as gradually worsening over the following 4 hours. After performing a pelvic exam, you as the provider palpate a mass in her right lower quadrant and suspect adnexal torsion. A transvaginal ultrasound with doppler confirms your suspicion. Which of the following would be the most appropriate next step? A: Removal of the adnexa B: Detorsion C: Begin patient on Lupron therapy to reduce mass D: Endometrial ablation
B
A 26 year old African American G1P0010 woman with a BMI of 34 presents to the clinic complaining of intermittent "pressure" like pelvic pain that's worse on her right side. She also has worsening episodes of constipation and has had painful menses over the past year. When asked about her menses, she states she will have months between cycles, but they are fairly normal regarding length of flow (4 days) and amount of blood lost (less than 80mL). After a full workup, you discover her human chorionic gonadotropin level is less than 5 mIU/mL and her white blood cell count is 4.5 billion cells per liter, indicating no infection. You order a saline ultrasound due to her symptoms and observe a gray circle about the size of a softball centered within the uterine walls on the patient's right side. What diagnosis does this patient most likely have? A. Endometriosis B. Leiomyoma C. Endometrial Polyps D. Serous cystadenoma
B
A 26 year old nulligravid female presents to the ED with acute pelvic pain. She denies any menstrual abnormalities and states that the beginning of her last menstrual cycle was 18 days ago. She denies any current medical conditions and is not on any medications. A pregnancy test is ordered and her BhCG is 1.0 mIU/mL. A transvaginal ultrasound is completed and reveals a 4cm dark, grainy cyst with scant lines. What is the best treatment for this patient? a. Start the patient on an OCP b. Analgesics and reassurance that this is self limiting c. Ovarian cystectomy d. Oophorectomy
B
A 30 year old nulliparous woman with a body mass index of 35 comes to the clinic because she is experiencing pain with her periods and during sex. She denies any alcohol use but does admit to smoking a few cigarettes a day. She states that her and her husband have been trying to get pregnant for the past 8 months and have not been successful. You perform a pelvic exam and a transvaginal ultrasound which reveals a uterine mass. What component of the patient's history would support the fact that the uterine mass is a leiomyoma instead of an endometrial polyp? A. Infertility B. Age C. Obesity D. Smoking status
B
A 30-year-old G0P0 female presents to clinic after failing to achieve pregnancy for the past 15 months. She reports a history of monthly, cyclic pelvic pain, dyspareunia, dysmenorrhea for 2 years, which seems to be worsening. She denies fever, vaginal discharge, or history of STI. On examination her temperature is 98°F, HR is 90 bpm, BP is 110/72 mmHg, and BMI is 18. Due to the patient's infertility concerns, a definitive diagnosis of the most likely cause should be obtained using which of the following? A. Transvaginal ultrasound B. Laparoscopy C. Vaginal cultures & cervical swabs D. Pelvis MRI
B
A 30-year-old female G2P1102 presents with a chief complaint of intense pruritis in the vulvar area. Upon inspection, you notice that the vulva has greatly atrophied bilaterally with an appearance of parchment paper, and there are four very small lesions present. Vaginal inspection is remarkable, and no masses are felt upon bimanual exam. Based on this information, which of the following is considered the first line of management for the patient at this time? A. Provide the patient a prescription for a topical steroid B. Take a biopsy of the area and provide a topical steroid prescription if the biopsy is negative C. Provide the patient with a prescription for topical estrogen D. Perform a colposcopy exam
B
A 32 year old nulliparous African American female with a BMI of 31 presents with a chief complaint of "trying to get pregnant for the last 2 years," and she also notes pressure in her pelvic region and dysmenorrhea. Her last menstrual period was 3 weeks ago. She was diagnosed with polycystic ovarian syndrome (PCOS) 3 years ago. She denies alcohol, recreational drugs, caffeine and tobacco use. Her Beta-hCG serum levels came back at 0.1 mIU/ml. A pelvic exam and transvaginal ultrasound are performed, and a uterine mass is discovered. Based on history, which uterine mass MOST LIKELY is the cause of her infertility (in conjunction with her PCOS)? A. Benign cystic teratoma B. Submucosal leiomyoma C. Intraligamentary leiomyoma D. Ovarian follicular cyst
B
A 32 year-old female G3P2012 presents to your clinic with sharp, unilateral abdominal pain that started post-coital about 5 hours ago. Her and her husband have been trying to conceive their fourth child for the past 6 months but have been unsuccessful. She is worried that her previous miscarriage at 12 weeks decreased her chances for another successful pregnancy. She states that the pain has been getting worse over the last few hours. She complains of nausea but no vomiting and says she has felt feverish but didn't take her temperature prior to coming. You decide to take an US of her abdomen and notice an intra abdominal mass that is 7 cm. Which of the following statements is most accurate in terms of the diagnosis you have in mind given the patient's history and presentation? A. The patient will most likely complain of pain on the left side due to the gastric anatomy, as the right adnexa is limited in movement by the cecum and appendix. B. The labs that should be ordered include a CBC, LFT, and amylase lipase levels. C. This is a medical emergency, therefore, the first line treatment is adnexal removal to prevent rupture, hemorrhage, and necrosis that can put the patient's fertility and other abdominal structures at risk. D. The adnexal torsion causes venous compression that can lead to fever and elevated WBC counts in the patient, indicating necrosis.
B
A 35-year-old female G0P0 comes into the clinic today complain of itching in the vaginal area. She says it has been going on for the past couple of weeks and came into the office today because she just couldn't stand it anymore. She has not been able to find anything that makes the itching better. You do a pelvic examination and find the vulva is very thin bilaterally with whitish epithelia areas. There is no abnormal discharge. You also notice there is scratch marks around the anal canal. You ask her if she is also experiencing itching in this area. She confirms this and says she forgot to mention it earlier. Based on these findings, what would be your next step? A) Treat with a topical steroid B) Biopsy C) Pap smear D) Trans-vaginal ultra sound (TVUS)
B
A 37 year old G1P1001 African American female presents to clinic complaining of constipation, difficulting urinating, dyspareunia and abnormal spotting. She had her menarche at age 9 and has polycystic ovary syndrome but has no other medical conditions. She has a 12 pack year history and drinks an average of 3 beers a week. The patient denies fever, headaches, and any heat intolerances. A transvagial ultrasound was performed and the patient was diagnosed with a right sided cervical leiomyoma. Which component of the patient's history is not a risk factor for her diagnosis? A. Medical comorbidity B. Her Smoking history C. Her race D. Her Early Menarche
B
A 54 year old postmenopausal female G2P2 presents to the clinic complaining of severe itching around her vagina. You conduct a physical exam which reveals that the vulva is very thin and whitish with a "cigarette paper" appearance. After doing a biopsy to rule out malignancy, which is the most appropriate treatment for this patient? a. Premarin cream b. Clobetasol cream c. Clotrimazole cream d. Lupron
B
A 55-year old G5P4014 female presents to her primary care provider complaining of uterine bleeding for the past two weeks. Prior to this bleeding, she had not menstruated for over two years. Her BMI is 35 and she was diagnosed with polycystic ovary syndrome at age 22. After obtaining an endometrial biopsy, the provider diagnoses the patient with complex endometrial hyperplasia with atypia. Which of the following is the best next step? A. Prescribe oral contraception pills B. Surgical removal of the uterus, fallopian tubes, and ovaries C. Wait for the bleeding to stop on its own D. Do a transvaginal ultrasound
B
A 58-year-old G1P1001 postmenopausal women presents to the clinic complaining of vaginal bleeding that is not excessive. A transvaginal ultrasound is performed, and the endometrial thickness is 6mm. Fluid collection is also identified, so a hysteroscopy and biopsy are performed. The endometrium is determined to be complex hyperplasia without atypia. What is the best management for this condition? A. Observation B. Progesterone C. Abdominal hysterectomy and bilateral salpingo-oophorectomy D. Cytoreductive surgery
B
A 59 year old G2P2002 female comes in to the office complaining of pain during intercourse and notes that there is vaginal bleeding afterwards. She states that she has a history of vulvar cancer at age 54. Upon physical exam, you note that there is a red, ulcerated lesion in the vagina. What is the most appropriate next step that should be done? A. Prescribe acyclovir B. Colposcopy with direct biopsy same CIN C. Advise patient to watch and wait to see if condition worsens D. Test for chlamydia and gonorrhea
B
A 59 year old postmenopausal woman, G3P3003, presents to the clinic with complaints of consistent vulvar pain and pruritus, dyspareunia, post coital bleeding, and a noticeable amount of vaginal discharge for the past 6 months. She is not currently on any medication and had no relevant personal or family history. She has been tested for STDs and autoimmune disorders, which were all negative. During the vaginal exam you note some atrophy of the introitus and labia minora as well as erythematous ulcerated-like lesions with whitish, lacy bands on the vulva and vaginal wall. She also had extreme pain during the examination. What is the most likely diagnosis for this patient? a) Paget disease. b) Lichen Planus c) Lichen Sclerosus d) Lichen Simplex Chronicus
B
A 67-year-old African American female G0P0 who is ten years postmenopausal presents to the clinic complaining of abnormal vaginal bleeding. She describes it as "heavy bleeding" and says it has been "going on and off for the past three months." Her body mass index is 37 and she was prescribed estradiol during menopause. You decide to perform a transvaginal ultrasound (TVUS), which reveals an endometrial stripe greater than 6 mm. You get an endometrial biopsy via hysteroscopy. What cytology result would have the highest risk of progression to endometrial cancer and what would be the associated treatment of these results? A. Simple hyperplasia of the endometrium has the highest risk of cancer progression. Observation is often preferred. B. Complex hyperplasia with atypia has the highest risk of cancer progression. Treatment includes abdominal hysterectomy and bilateral salpingo-oophorectomy. C. Complex hyperplasia without atypia has the highest risk of cancer progression. Treatment includes oral progesterone. D. Complex hyperplasia with atypia has the highest risk of cancer progression. Treatment is an oral contraceptive, such as Yasmin.
B
A 76 year old female, G0P0, comes into clinic with complaints of irritation and discomfort in the genital area. Her last menstrual cycle was 20 years ago and no longer has menopausal symptoms. She describes the discomfort as itchy and burning. She quit smoking 5 years ago due to being diagnosed with chronic obstructive pulmonary disorder but had smoked 1 pack per day for 30 years prior. Upon examination, you note a white ulcerative lesion on the posterior aspect of both labia majora. Biopsy results of the lesion indicate malignancy. What is the most common type of cancer that is associated with this form of malignancy? A. Melanoma B. Squamous cell carcinoma C. Adenocarcinoma D. Human papillomavirus
B
A nulliparous 28 year old female presents to the office for follow up appointment after her well woman exam last week. She denies history of sexually transmitted infections or multiple sex partners. Pap smear histology revealed atypical squamous cells with undetermined significance. You run human papillomavirus testing which comes back negative. What is the next step in management of her abnormal pap smear results? A. Repeat cytology in 3 years. B. Repeat cytology and human papillomavirus testing in 3 years. C. Repeat cytology in 1 year. D. Repeat cytology and human papillomavirus testing in 1 year.
B
A nulliparous 30 year old female recently had her pap smear with HPV testing completed. She was informed that she tested positive for HPV and is extremely concerned about developing cervical cancer. What types of HPV are most likely to lead to cervical cancer? A. Type 6 and 11 B. Type 16 and 18 C. Type 40 and 42 D. Type 54 and 61
B
Hannah Montana, a 60 year-old female G3P2103, comes into your office complaining of urinary incontinence. She reports that she has tried kegels in the past, but they have not given her adequate relief from her symptoms. She would like to try a different treatment. After further questioning, you discover that your patient is having brief spurts of urine loss that correspond to stress, such as coughing, laughing, or picking up her grandchildren. She denies any other associated symptoms. What would be the best first line treatment for this patient? A. Mirabegron B. Bladder Sling C. Bulking agents D. Clean Intermittent Catheterization
B
This is a 31-year-old African American female G3P2103 who presents with complaints of dysmenorrhea and menorrhagia. She reports she and her husband are wanting to start trying to get pregnant again, but she is concerned this heavy bleeding might be a problem. Her last menstrual cycle was 14 days ago. She has had 3 vaginal deliveries, the most recent baby was born at 33 weeks 6 months ago. Her past medical history is significant for gestational diabetes and preeclampsia with her last pregnancy. She reports a 5 pack-year history of smoking, adding that she "quit during my pregnancies of course," Upon physical exam the patient has a BMI of 31. Pelvic exam is remarkable for an enlarged uterus on bimanual exam. BhCG is <5mIU/mL. Transvaginal ultrasound shows a 44mm submucosal mass consistent with a leiomyoma. What part of the patient's history increased her risk for this finding? A. Pregnancy history of G3P2103 with her last vaginal delivery 6 months ago. B. Being an African-American female. C. Reporting a 5 pack-year history of smoking. D. Being obese with a BMI of 31.
B
A 72-year-old female G4P3013 comes to your clinic complaining of wetting her pants during the day and at night. She states that no matter what position she is in, she can't stop it from happening. When asked how much urine is lost, she states that it is always a large amount. What is the cause of this type of incontinence? A. Obstruction B. Structural C. Cystocele D. Loss of bladder inhibition
D
33-year-old female G3P3003 presents to your clinic for cervical cancer screening. She tells you her last pap smear was done at the age of 25 and was normal. She admits to having multiple sex partners since then but received the human papillomavirus vaccination in the past. She denies any previous surgical procedures. What screening method is the best option for this patient? A. No screening required because she has been vaccinated B. Only screening by human papillomavirus testing is needed C. Human papillomavirus and cytology co-testing every 5 years D. Only cytology is necessary every year
C
A 17 year old nulliparous female comes in complaining of aching pain on the lower right side of her abdomen. She states that she has never been sexually active and is not on any contraceptive medicines. Her last menstrual period was 2 weeks ago, and she states that it was normal. She denies any abnormal discharge, foul odor, itching, or fever. She says the pain makes her feel nauseous, and gets worse when she stretches out her abdomen. On physical exam, you are able to palpate a mobile mass in the right adnexal space. The results of the CA 125 came back as 30 U/mL (normal is <46 U/mL). You then performed a transvaginal ultrasound on the patient and found a dark, fluid filled follicular ovarian cyst that is 6 cm on the right side. What is the best treatment option for this patient? A. Ovarian cyst aspiration B. Ovarian cystectomy C. Observation and OCP D. Oophorectomy to avoid any cyst development
C
A 17-year-old female G0P0 reports to the clinic complaining of chronic pelvic pain for the past three years. She says the pain normally starts a day or two before menstruation. Nonsteroidal anti-inflammatory drugs do not relieve the pain. She has no past sexual history and says that she is currently taking no medications. During the bimanual exam, pelvic palpation reveals uterosacral ligament nodularity. The most likely diagnosis at this time is: A. Pelvic inflammatory disease B. Ovarian cyst C. Endometriosis D. Ectopic pregnancy
C
A 19-year-old thin Hispanic female G0P0 presents with cyclic, premenstrual pelvic pain for the past 7 months. She reports dyspareunia and denies any medical conditions or surgeries. Physical examination reveals a fixed, tender adnexal mass. Urine human chorionic gonadotropin (hCG) is negative. A transvaginal ultrasound is ordered to evaluate the mass, revealing a smooth-walled, dark-brown cyst with a hazy appearance. Which of the following is the most appropriate treatment option at this point in time? A. Total abdominal hysterectomy B. Prescribe a gonadotropin-releasing hormone (GnRH) agonist (Lupron, Zoladex) C. Prescribe combined oral contraceptive pills (OCPs) and non-steroidal anti-inflammatory drugs (NSAIDs) D. Prescribe Clomiphene
C
A 20 y/o G0P0 sexually active female comes in to your clinic for a pap smear and sexually transmitted disease testing. After her results come back, you discover that she has human papillomavirus, but you reassure her that these types will not cause her to have cervical cancer. What are likely these types of human papillomavirus? a) 16 and 18 b) 11 and 16 c) 6 and 11 d) 6 and 18
C
A 21-year-old G0P0 female presents for a well-woman visit including her first Papanicolaou (Pap) smear. She is sexually active with multiple partners and her Pap smear results are abnormal, indicating atypical squamous cells of undetermined significance (ASC-US). Reflex human-papillomavirus (HPV) testing is performed and the results are positive. What treatment plan is indicated? A. Colposcopy immediately following results B. Repeat cytology in 3 years C. Repeat cytology in 12 months D. Endocervical curettage immediately following results
C
A 21-year-old slender Caucasian female G0P0 comes to the clinic for her first Pap smear. She mentions she started having intercourse at the age of 18. No erythema, lesions, or masses are noted during an inspection of the external female genitalia. The vaginal mucosa is pink without any discharge or lesions. A Pap smear is performed and you send the specimen to the cytopathology lab. The bimanual examination is insignificant. About 1 week later, the cytology results come in, revealing a low-grade squamous intraepithelial lesion (LSIL). What is the next best step in the management of this patient? A. Schedule an immediate follow-up appointment to perform an endocervical curettage. B. Schedule an immediate follow-up appointment to perform a colposcopy. C. Repeat cytology in 12 months and manage according to the new findings. D. Schedule an immediate follow-up appointment to perform a loop electrosurgical excision procedure.
C
A 25 year old Caucasian G5P5 female with a BMI of 23 and a 5 pack-year history complains of vaginal bleeding, painful intercourse, and constipation for the past week. She states that her menses began when she was 9 years old, but have been fairly regular since and she has never had anything like this before. After taking a thorough medical history and performing a physical exam, you diagnose your patient with multiple leiomyomas. Which of the following aspects of the patient's history is a risk factor for leiomyomas? A. 5 pack-year history B. BMI C. Age at the time of menarche D. Number of full term pregnancies
C
A 26 year old female presents to the emergency department with a complaint of pelvic pain. She reports that she missed her last period, which was supposed to start two weeks ago, and in the last 2 weeks she has had a crampy pain over the right side. She states that just 10 minutes ago, she had a sudden onset of severe right-sided pelvic pain and now has pain in her shoulder. She says she is also starting to feel dizzy. With this information, what diagnosis would be at the top of your differential? A. Pelvic inflammatory disease B. Appendicitis C. Ruptured ectopic pregnancy D. Kidney stone
C
A 29-year-old G3P2012 female presents to the clinic today. She has no complaints and is simply here for her yearly check-up. She is a smoker, and like any good medical professional, you advise her to break this bad habit due to the health risks. What gynecologic risk is shockingly lowered due to smoking? A) Risk of endometrioma B) Risk of ovarian cancer C) Risk of leiomyoma D) Risk of endometrial polyps
C
A 30-year-old G4P2023 woman presents to the clinic complaining of amenorrhea for the past three months. She is currently on Yasmin and has a history of trophoblastic disease. Her lab results show that her human chorionic gonadotropin levels are 100,000 mIU/mL and a transabdominal ultrasound shows multiple 6-7cm round, black masses around both of her ovaries. Which of the following is most likely her diagnosis? A. Ovarian cancer B. Follicular cyst C. Theca Lutein cyst D. Luteal phase corpus luteum cyst
C
A 32 year-old Caucasian G0P0 female presents to the emergency department with complaints of "excruciating pain" in her right lower abdomen. She states that the pain started out dull last night, but has become sharp over the past few hours. She also has vomited twice since this morning, but denies diarrhea, constipation, fever, or chills. Her menstrual cycles are 28 days, and has not had any spotting or amenorrhea. Patient is sexually active, but is on oral contraceptives and her partner uses condoms. After taking a thorough history, the provider should perform: A. A pelvic exam B. An MRI of the pelvis C. An abdominal exam with Obturator and Psoas signs D. An ovarian ultrasound
C
A 32-year-old female G0P0 with a BMI of 17 presents to your clinic complaining of bilateral mild pelvic pain and dyspareunia, especially during the onset of her period. Upon physical exam you palpate an adnexal mass and note specific tenderness along her uterosacral ligament. Which on the following imaging studies would be the best initial choice to help diagnose this patient? A. Magnetic Resonance Imaging (MRI) B. Computed Tomography (CT) C. Transvaginal Ultrasound (TVUS) D. Plain film radiograph (X-Ray)
C
A 46 year old G4 P3104 Caucasian female presents to your office for her annual women's exam. She tells you that she is embarrassed because she has been, "Wetting my pants a little bit when I laugh or sneeze," over the past couple of months and it is making her very self conscious. Upon physical exam, it appears that she has an approximately 1 cm wide bulge in the anterior wall of her vagina. She tells you that she has heard there is a surgery to help fix that, but she is not looking to jump right into surgery if she doesn't have to. What is a non-surgical intervention to help treat her type of urinary incontinence? A. Clean intermittent catheterization B. Chronic transurethral catheterization C. Kegel exercises +/- weighted vaginal cones D. Botulinum toxin injections into detrusor
C
A 49-year-old G4P3104 female patient presents to the office complaining of incontinence x 2 years. She has seen a provider about this issue before who recommended dietary changes and behavior therapy, including Kegel exercises. Despite her efforts, she reports she still leaks any time she laughs, coughs, or sneezes, and it's getting worse. Now, she feels like she cannot go outside her home, and she is too embarrassed to wear pads. Given her ongoing symptoms, which treatment plan would be the next best step? A. Prescribe mirabegron B. Sacral neuromodulation C. Injectable bulking agents D. Suburethral sling
C
A 52-year-old nulligravid female presents to clinic complaining of vaginal bleeding. As you collect a thorough history, she indicates that her sister was diagnosed with breast cancer at the age of 46. She has not been tested for the BRCA mutation but her sister's test was negative. She denies any pain, bloating, urinary changes or prior surgeries. Her last menstrual period was 16 months ago, adding that she thought her days of bleeding were over. To that end, she asks if the progesterone therapy her best friend was talking about might solve her own problem. On physical exam you find no masses or tenderness, but speculum exam reveals a scant amount of blood in the cervical os. You order a BhCG test just to be sure and the result is negative (below detectable limits). Considering her complaint and history above, what would be the most conservative next step? a. Begin her on progesterone therapy after fully reviewing the risks and benefits with her b. Have her tested for the BRCA gene mutation to assess her risk for ovarian cancer c. Order a trans-vaginal ultrasound for additional evaluation d. Order a hysteroscopy and biopsy for additional evaluation
C
A 57 y/o postmenopausal patient presents to your clinic with complaints of abnormal vaginal bleeding. She has no other signs or symptoms associated with her condition. You decide to perform a transvaginal ultrasound (TVUS) and it shows endometrial thickness of > 4mm. The abnormal endometrial thickness calls for further evaluation and obtaining histologic examination through a hysteroscopy and endometrial biopsy (EMB). The biopsy confirms Complex Hyperplasia with Atypia. What is the best treatment option for this condition? A. Observation B. Oral contraceptive pill (OCP) C. Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy D. Weight loss
C
A G0P0 17 year-old female presents to the OB-Gyn clinic after being told by her primary care provider she has a palpable unilateral adnexal mass. She has had no pain or fever and her menstrual cycles are normal. After a CT scan you identify a dermoid cyst. Which of the following is the best course of treatment? A. Oral contraceptive pill, to prevent cyst development B. Wait & watch, cyst should disappear in 1-2 month C. Ovarian cystectomy D. Oophorectomy
C
A G0P0 female patient comes into the Emergency Department complaining of severe pelvic pain and pressure. Having previously worked in gynecology, your instincts are leading you to believe that her symptoms are gynecological in nature. You therefore order a transvaginal ultrasound which shows a moderate sized leiomyoma. Which patient profile would be at greatest risk of getting a leiomyoma? A. 62-year-old Caucasian female who is post-menopausal B. 32-year-old Hispanic female who smokes a pack a day C. 27-year-old African American female with a BMI of 41 D. 9-year-old Asian female who has not yet had her first menses
C
A nulliparous 26 year old female presents to your clinic complaining of pain following intercourse over the last 2 months. A transvaginal ultrasound indicated two intramural uterine masses. When discussing treatment options with the patient, she indicated she does want to have children in the near future and would rather not be on birth control right now. What would be the best treatment option for her currently? A. Uterine artery embolization B. Hysterectomy C. Observation and close monitoring of the masses D. Start patient on a desogestrel and ethinyl estradiol combination pill
C
London Marriott, a 38-year-old female, presents to clinic for a well-woman visit. She has not had a pelvic exam in approximately 10 years. During your medical interview, she reports an unknown number of sexual partners through the years, with her first encounter at 16 years old. She has an 8 year smoking pack history. She knows she received some vaccines as a kid, but she does not know if she received Gardasil. She thinks she had chlamydia or gonorrhea a few years ago but picked up some pills at one of the ports on her Caribbean cruise that "took care of it." She relies on condoms as her sole source of preventative birth control. When the condom is forgotten, she picks up some Plan B the next morning. In addition to a bimanual pelvic exam, sexually transmitted disease testing, and patient education, what cervical cancer screening method is indicated? A. Human Papillomavirus (HPV) testing alone every 3 years B. Pap Smear + HPV co-testing every 5 years C. Pap Smear every 1 year D. Pap Smear alone every 2 years
C
4. A 50-year-old G3P2012 overweight Caucasian female presents to the clinic for a routine pelvic exam. She states that it has been almost 10 years since her last exam because she did not previously have health insurance. She is sexually active and states that she is married and has had only one male sexual partner for the last 32 years. She does not remember how old she was at menarche. Her last menstrual period was last week, and it was normal. She denies any changes to her menstrual cycle. She denies weight loss, fatigue, abdominal or pelvic pain, bloating, hot flashes, dyspareunia, dysuria, urinary frequency/urgency, or abnormal bleeding or spotting. She denies any history of sexually transmitted diseases. She states that she does not use birth control because her husband had a vasectomy after their second child. She was diagnosed with type 2 diabetes in 2012 and she is well-controlled on Metformin. She also takes Lisinopril/HCTZ every morning for hypertension. The patient's bimanual was unremarkable with no masses/lesions or tenderness. The cervix and vagina appeared normal on speculum exam with no discolorations, discharge, masses/lesions, or atrophy. A PAP smear was sent off and the results showed the presence of atypical squamous cells of undetermined significance (ASC-US) on cytology. What is the next step for this patient? a) Observe patient for now. Repeat the PAP smear in 6 months. b) LEEP procedure to remove the cancerous lesion. c) Cervical biopsy. d) HPV testing.
D
A 19 year old nulliparous Caucasian female reported to the clinic complaining of a heavy period that has lasted 12 days. She reports needing to change her tampon roughly every 2 hours. She reports that she did not start to worry until she began experiencing severe nausea and vomiting 3 days ago and then started to experience cramping in the lower abdomen yesterday. She states that she is sexually active and her partner's condom broke a few weeks ago but could not remember exactly when. Upon pelvic exam, you note blood clots in the vagina and the cervix is dark blue in color. You then decide to exam the patient with ultrasound and you see a snowstorm pattern upon visualization of the uterus and suspect a molar pregnancy. What karyotype would you expect to see in this specific case? A. 69 XXY B. 45 X C. 46 XY D. 46 XX
D
A 21-year-old African American female, G0P0, presents to your clinic with pain in her abdomen for the past 8 days, and dyspareunia. You gather a thorough history, do a full physical, including an abdominal exam with no abnormal findings, and decide to do a pelvic exam as your next step. During the pelvic exam, you find an irregularity in the shape of your patient's uterus. After deciding to get an ultrasound, you notice a small, intramural leiomyoma on her uterus. What is the BEST treatment option for your patient, considering that she mentioned she wants to have children in the distant future? a) Uterine Artery Embolization b) Hysterectomy c) Myomectomy d)Observation
D
A 22 year-old nulliparous woman presents with right-sided pelvic pain and irregular menses. She states that her last menstrual period was 2.5 months ago. She has had irregular, periodic spotting, but no true menstrual cycle in 2.5 months. She states that she is sexually active with her boyfriend of 4 years and that they use condoms for protection. She is not currently on any OCPs and denies taking birth control before. You obtain a urine hCG which is negative and perform a speculum exam which is consistent with no pathological findings and no anatomical abnormalities. Upon performing a transvaginal ultrasound, you appreciate a 1cm x 0.8 cm mass interrupting the otherwise normal right ovarian tissue and you agree with the radiologist's interpretation of the mass being consistent with an ovarian cyst. What brief description below is most accurately paired with the type of functional ovarian cyst that it is describing? A. Theca Lutein- related to post-ovulatory phase of menstrual cycle B. Corpus Luteum- typically resolves on its own and involves transient secondary amenorrhea C. Neoplastic cyst- most often associated with pregnancy D. Follicular- associated with anovulation; treated with OCPs
D
A 70 year-old G4P3013 female patient with a history of cervical cancer comes into your office complaining of vaginal bleeding and painful urination. She states that she went through menopause at age 52 and has not had any vaginal bleeding since. On physical exam you find multiple white hyperplastic lesions lining the upper vaginal wall. Which of the following is true about the condition she most likely has? A. Squamous cell carcinoma is the most common cause of her symptoms B. This condition presents more commonly in older patients C. Treatment of this condition includes a total or partial vaginectomy D. All of the above
D
A 25 year old nulliparous female presents at the clinic complaining of lower abdominal pain and irregular menstrual bleeding for the past 3 months. She also reports that 2 months ago and 2 days before her period began she experienced a day of intense pain unlike any she had felt before, but it was gone when she woke up the next morning. She is not taking any medication. When performing the bimanual exam, the provider notes severe tenderness on the patient's right side, as well as a palpable mass. After performing lab tests, her urinalysis results were the following: appearance is clear, color is amber yellow, no odor, pH 6.0, protein 1 mg/dL, specific gravity 1.005; negative for leukocyte esterase, hemoglobin, nitrites, ketones, bilirubin, urobilinogen, no crystals, casts, or glucose present; white blood cells are 1 per low-power field, red blood cells are 1, and there are no white blood cells casts or red blood cell casts. The test for Beta-human Chorionic Gonadotropin (BhCG) is negative. With this information, what should the provider be thinking is the top differential diagnosis? A. Theca Lutein cyst B. Urinary Tract Infection (UTI) C. Ectopic pregnancy D. Follicular cyst
D
A 26 year old nulligravid female presents today for her annual physical. She received a pap smear at her last annual physical and it came back normal. Past medical history reveals that the patient has a history of gonorrhea, has had multiple sexual partners, received her HPV vaccine when she was 16, and that she had a total hysterectomy last year because she doesn't want children. She is HIV negative and does not currently have an STD. What screening if anything should be done for this patient? a. You should perform a pap smear on this patient today in clinic. b. You don't need to screen her/perform a pap smear for another 2 years. c. You should perform a pap smear and HPV testing today in clinic. d. No screening is necessary.
D
A 30-year-old G0P0 female presents to your clinic to establish care as a new patient. She states she has not had any abnormal pap smears and her last test was done 3 years ago. She reports her mother was diagnosed with ovarian cancer at age 40. The patient's mother just heard about genetic testing and is considering getting it. The patient states she is struggling financially but does not want to put her health on the line and asks if she should get genetic testing done now. Besides a routine pap smear, what other testing would you recommend today? A. The patient has a family history of ovarian cancer, so a transvaginal ultrasound should be obtained for screening. B. The patient is between the ages of 25-35, so a CA-125 level should be obtained today. C. The patient is between the ages of 25-35, so she should obtain genetic testing now. D. Inform the patient that her mother needs to obtain genetic testing and should get genetic testing if her mother tests positive for BRCA1 and BRCA2 gene mutations.
D
A 36-year-old African-American female G1P1001 comes to your clinic complaining of heavier-than-normal vaginal bleeding and increased urinary urgency. Her BMI is 31. You perform a bimanual exam and palpate a large mass in her uterus. It is a slow day in clinic so you are also able to order a same-day transvaginal ultrasound, which shows a single submucosal fibroid. After diagnosing her with leiomyoma, she tells you that she wants relief of her symptoms and preservation of her fertility. Which of the following is the best treatment option for this patient? A. Hysterectomy B. Observation with follow-up in 6 months C. Ibuprofen (Advil) and weight loss D. Medroxyprogesterone (Provera)
D
A 45-year-old G2P2 female presented to your office 2 weeks ago for a routine cervical cytology study. She has no known history of HPV or HIV and her previous Pap smears have been unremarkable. However, on her most recent cervical cytology, the pathologist noted atypical squamous cells and could not exclude high-grade squamous intraepithelial lesions (ASC-H). How would you classify this result per the CIN classification system? A. CIN I B. CIN II C. CIN II/III D. None of the above
D
A 54 year old nulliparous female presents to your clinic for a well-woman exam. She reports she has been post-menopausal for 2 years. On physical exam, you palpate a mobile, nontender cystic mass lateral to the uterus. You order an ultrasound to confirm your diagnosis of an ovarian cyst. Your patient prefers to watch the cyst and denies treatment at this time. You agree as long as which of the following criteria are met? a. Ultrasound shows thin walled, unilocular cyst b. Cyst diameter is <5 cm c. Normal CA 125 d. All of the above
D
A 56-year-old postmenopausal female G1P1001 presents to clinic with abnormal uterine bleeding (AUB), which she describes as worse than ever before. From her medical interview, you discover she has a family history of breast cancer. You perform a transvaginal ultrasound and visualize fluid collection as well as endometrial thickness greater than 4 mm. You perform a hysteroscopy and endometrial biopsy. The results allow you to assure your patient there is only a 1% risk of their condition progressing to cancer. What will your first step in treatment be for this patient? A) Perform a hysterectomy and bilateral salpingo-oophorectomy on this patient to eliminate the risk of malignancy. B) Only perform a hysterectomy to resolve her excessive abnormal uterine bleeding. C) Observe the patient to ensure her condition does not worsen. D) Administer Progesterone and an oral contraceptive to this patient to control their bleeding.
D
A 60 year old G0P0 caucasian female who underwent a total hysterectomy is due for her well-woman examination. She does not have a cervix. Patient does not have a history of CIN (cervical intraepithelial neoplasia) I, CIN (cervical intraepithelial neoplasia) II, adenocarcinoma in situ, or cancer in the past twenty years. Based on the current guidelines and the patient's history, what is the recommended cervical cancer screening method? A. Cytology alone every 3 years B. Human papillomavirus and cytology co-testing every five years C. Cytology alone every 8 years D. No screening is necessary
D
A 60-year-old G2P2002 Caucasian female presents to your office complaining of postmenopausal bleeding x 3 months. Upon further questioning, the patient reports no previous history of oral contraceptive use and no significant surgical history. She has always had normal Pap smears and underwent normal physiologic menopause at age 58. Physical examination reveals a normal appearing cervix and nonpalpable ovaries. A transvaginal ultrasound is performed in the office and endometrial thickness of 5mm is visualized. What is the next best step in her treatment plan? A. Prescribe medroxyprogesterone (Provera) B. Schedule total abdominal hysterectomy and bilateral salpingo-oophorectomy C. Observation with follow-up if symptoms don't resolve. D. Schedule hysteroscopy with endometrial biopsy
D
Patient is a 36-year-old Caucasian female G2P1102 who presents to her primary care office for her annual well-woman exam. While talking to her physician, the patient mentions that she was recently diagnosed with HIV approximately 2 months ago. The physician tells her many of the risks associated with HIV including the increased risk for cervical cancer. What is the best description of the cervical cancer screening method needed for this patient due to their recent HIV diagnosis? A. Human papillomavirus and cytology co-testing every 5 years B. Cervical cytology testing every 3 months after diagnosis, then every 6 months after 2 consecutive normal test results C. Cytology alone every 3 years D. Cervical cytology testing every 6 months after diagnosis, then annually after 2 consecutive normal test results
D
Your patient is a 24 year old G0P0 female presents to your clinic for her well-woman exam and triennial Pap smear. The cytology testing reveals atypical squamous cells of undetermined significance (ASC-US). What is the best recommendation for this patient? A: Repeat cytology in 12 months B: Colposcopy C: Routine screening D: Reflex HPV testing
D
Your patient is a 32 year old G0P0 female. When discussing her in depth medical history she tells you that she is sexually active, and has multiple different partners every month. She also tells you that she has had multiple sexually transmitted disease infections and that she has never received any type of vaccine in her life. Your patient has also been smoking 3 packs of cigarettes a day for 14 years. You are concerned that she may have been infected with HPV (Human Papillomavirus) and is at risk for cervical cancer. In following with recommended screening methods for this patient's age you decide to screen using human papillomavirus and cytology co testing. Your results show the presence of highest-risk HPV DNA which have been identified as the cause of cervical cancer. What are the two highest risk viral genotypes of HPV? A: 40 and 42 B: 6 and 18 C: 6 and 11 D: 16 and 18
D
