Mehl. OBGYN bullet point in general nr 2 Flashcards
31F + gave birth two days ago + exclusively bottle-feeding neonate + breasts are engorged and tender + fever of 101F + Sx of dysuria + suprapubic tenderness + urinalysis normal; Dx?
breast engorgement
every student gets this wrong because it sounds like obvious infection; learning point is: can present with fever; occasional Sx of dysuria + normal U/A are not atypical in women.
What does progestin withdrawal test mean?
if progestin is given then withdrawn, bleeding should
occur (hormonal stabilization of lining followed by allowing it to slough, akin to forcing a
menstruation);
Progestin withdrawal = if bleeding occurs???
if bleeding occurs, estrogen is not deficient and the Dx is anovulation (PCOS is just
anovulation leading to 11+ cysts bilaterally + hirsutism; anovulation as independent term is same mechanism as full-blown PCOS.
if anovulation occurs, there’s no corpus luteum and therefore no progesterone released -> cannot establish endogenous rise + fall of progestin, therefore no sloughing/menstruation
Progestin withdrawal = if bleeding does not occur??
either estrogen is deficient (primary ovarian failure or hypogonadotropic disorder) or the uterus is scarred (Asherman).
18F + no bleeding after progestin withdrawal test; Q asks, if not Tx over ten years, what is patient at risk for???
osteoporosis (progestin withdrawal result means low estrogen).
Question shows you a graph where basal body temperature increases ~0.5F mid-cycle and stays at this higher temp; why?
answer = progesterone (ovulation).
27F + spontaneous abortion at 10 weeks’ gestation complicated by postpartum endometritis + sharp D/C to remove infected material; patient is subsequently at increased risk for what?
amenorrhea (Asherman syndrome).
Neonate born with cretinism; what could have prevented this?
“routine newborn screening”; yes, on obgyn shelf.
24F + pregnancy visualized in the corneum of the uterus; Dx?
27F + pregnancy visualized in the parametrium of the uterus; Dx?
ectopic pregnancy.
Corneum = vieta kur jungiasi kiausintakis i gimda
Parametrium = isorine gimdos raumens dalis/pavirsius.
When 2 boluses of steroids?
two boluses of steroids must be given within 24 hours of delivery <34 weeks.
When 1 bolus steroid?
34 0/7 – 36 6/7 weeks, give one bolus of steroids;
Magnesium, weeks?
<32
39F + pregnant + Sx of pulmonary embolism + V/Q scan performed showing segmental defects; next best step in Dx?
answer = spiral CT; student says “wait but I thought we don’t do CT in pregnancy.” Right, we don’t. But if they ask for next best step after V/Q scan, that’s still the answer they want.
35F + C-section 6 weeks ago + required 3 units of transfused RBCs + 9kg weight loss + has cold intolerance + could not breastfeed; Dx?
Arrows?
Sheehan syndrome
(arrow Q on shelf; answer is decr. for prolactin, ACTH, GH, FSH, TSH);
should be noted tangentially that on newer NBME for Step 1, Q with Sheehan syndrome has incr. for aldosterone (not hyperaldosteronism, but higher baseline to compensate for lower cortisol).
If 15F + never had menstruations + abdominal pain + Low BP + bluish bulge in vagina = Dx?
Same case but normal BP = Dx?
Low BP = HEMATOMETRA vagal response causes low BP
Normal BP = HEMATOCOLPOS
collection in the vaginal canal, but not backed up to the uterus like hematometra
Tx for both = cruciate incision of the hymen.
22F + uncomplicated delivery of newborn + heavy vaginal bleeding + placenta shows large, non- tapering vessel extending to margin of membranes; Dx?
succenturiate placental lobe;
students says wtf? just need to know sometimes placenta can have auxiliary lobe with connecting vessels; this is a cause of vasa previa, in addition to velamentous cord insertion.
- 27F + triad of third-trimester painless bleeding + ROM + fetal bradycardia; Dx?
answer = vasa previa (fetal vessels overlying the internal cervical os); associated with velamentous cord insertion (vessels not protected by Wharton jelly).
When to screen for gestational diabetes (GD) for normal risk women?
24-28 weeks’ gestation.
42F + HTN managed with meds + often forgets to take meds + wants contraception; what is most appropriate recommendation?
answer = levonorgestrel IUD (for patients with poor pharmacologic adherence).
27F + Hx of difficulty remembering to take daily meds + wants contraception + Tx for chlamydia three
months ago; Q asks most appropriate form of contraception; answer =?
“Depo medroxyprogesterone”;
IUD not ideal because of Hx of infection past three months.
Important contraindication to IUD? 3
active STI/PID or Hx of infection within past 3 months;
current pregnancy (obvious);
Hx of gynecologic malignancy.
37F + vaginal bleeding + hydroureter; Q asks for what kind of cancer; answer =?
cervical SCC (impingement on the ureter).
37F + C-section two days ago + incision site erythematous + abdomen tender + vitals normal + two palpable lymph nodes in groin; Dx?
“normal postoperative course.”
69F + Caucasian + nulliparous + on beta-blocker + drinks daily + compression fracture of vertebra; what is strongest predisposing risk factor (family Hx not discussed or listed)?
race; white race confers higher risk of osteoporosis; wrong answers are alcohol use, beta-blocker, nulliparity, HTN.
42F + 8-month Hx of severe pelvic pain and heavy bleeding during menses + regular periods + two kids + does not want more kids + husband to get vasectomy soon + no other abnormalities; Next best step?
endometrial ablation.
14F + 4x6cm mass in left breast + slightly tender + vitals normal + aunt died of breast cancer; next
best step?
follow-up in 6 months -> virginal breast hypertrophy is normal response to increased estrogens in adolescence (also seen in males; asked on peds and FM shelves).
Amenorrhea in patient with anorexia = LF, FSH, Estrogen?
Decr. GnRH => Decr LH, FSH, Estrogen
premature ovarian
failure, Turner syndrome, and menopause = FSH, estrogen?
High FSH
low Estrogen
45F + unilateral rusty nipple discharge + jau paimta biopsy shows stellate morphology; Dx?
answer = invasive
ductal carcinoma, not intraductal papilloma.
Jeigu tik dischage iki biopsy = papilloma until proven othervise
42F + recurrent miscarriage + SLE; Dx? Tx?
Antiphospholipid syndrome (lupus anticoagulant)
“uteroplacental insufficiency” as the answerà
Tx with aspirin or heparin; warfarin is contraindicated in pregnancy (bone abnormalities + bleeding in fetus).
Uteroplacental insufficiency can cause what issue on the fetal heart tracing?
late decelerations (fetal hypoxia).
early decelerations = ?
fetal head compression
variable decelerations = ?
cord compression
late decelerations = ?
fetal hypoxia.
External cephalic version = only performed after 36 weeks, as the fetus can spontaneously engage cephalically prior.
.
What is internal podalic version?
reorienting fetus within the womb during a breech delivery; may be attempted for transverse and oblique lies when C-section not performed; also used for delivery of second twins. I’ve never seen this as correct answer on NBME assessment; it just shows up a lot as an incorrect answer choice, so I’m mentioning it here because students always ask, “what’s that?”
.
21F + 41 weeks’ gestation + 4cm dilated + variable decels; next best step?
amnioinfusion
44F + painless unilateral cyst in breast that drains brown serous fluid; Dx? Tx?
fibrocystic change = buvo kazkada sitas case kai sprendziau kad dar green, gal CMS formoj.
Tx is supportive (Evening Primrose oil / warm bath); histological descriptors can be: sclerosing adenosis; blue dome cysts; apocrine metaplasia.
<30F + rubbery, mobile, painless mass in breast; Dx?
Fibroadenoma -> first Dx with USS only if age <30
> 30F + rubbery, mobile, painless mass in breast; Dx?
Fibroadenoma -> first Dx do USS +/- mammogram if age >30;
<30 arba >30F + rubbery, mobile, painless mass in breast; = Fibroadenoma. Imaging done. Next step?
do FNA next;
if confirmed, Tx = surgical excision;
should be noted that guidelines vary (i.e., observe for change, etc.), but excision is definitive. Obgyn shelf will only ask you for Dx based on presentation.
Mammogram guidelines?
start age 50 + every two years until age 75.
Important drug causing hyperprolactinemia apart from antipsychotics?
metoclopramide = D2
antagonist.
25F + sharp pain in outer quadrant of right breast + exam shows 2cm tender area in right breast but no mass found; Dx?
answer = fibrocystic change.
47F + breast lump self-palpated + breast USS shows 3cm complex cyst + FNA performed of the cyst revealing straw-colored fluid + mass still present after aspiration, next step?
answer = biopsy of the mass.
jeigu po aspiration subliuksta = tada nieko, all good. Piktybine mase nedingtu
