NBME Flashcards
32yo G5P4 at 18WGA comes for routine visit. Rh negative. Previous pregnancies required C sections between 33-35WGA for premature labor and breech presentation. Otherwise uncomplicated. Received RhoGam during each pregnancy. No medical history, current pregnancy uncomplicated. Her father has HTN, mother had DM2. HR 68, BP 110/60. Physical and pelvic exam normal. US shown intrauterine pregnancy of single fetus with normal anatomy in breech presentation. Uterus is bicornate. Pt is at increased risk for:
preterm labor and deliver
47 yo comes in 2 weeks after finding breast lump on self exam. Started estrogen replacement therapy 3 months ago and has had breast engorgement since that time. Exam of left brest shows 2cm tense, mobile, cyst like structure at 11oclock position. No breast discharge of palpable axillary nodes. Right breast is normal. Mammography 3 months ago showed normal findings. Next step:
FNA bx of cyst
OR
mammo?
3 days after C section at term because of failure to progress, a 27yo woman has temp of 101.8 (38.8) and mild pain with urination. Has not had urinary urgency or frequency She is bottle feeding. Physical shows clean intact incision site with no erythema. Lungs CTAB. Breasts are tense, erythematous, and tender. Uterus is firm, nontender, and consistent in size with 20WGA. Labs: Hgb: 10.5 WBC: 6500 with normal diff Urnie RBC: 10-15/hpf WBC: 1-2/hpf Diagnosis:
breast engorgement
27 yo primigravid at 14WGA comes in to ED for 24hr history of nausea and right sided abdominal pain. Also has loss of appetite x2days. Has not had vomiting, pregnancy is uncomplicated. TEmp is 100.8 (38.2), HR 94, RR 20, BP 120/80. Fetal heart tones are heard. Abdomen exam shows RLQ tenderness with no rigidity or rebound. Labs: Hgb: 13.2 WBC: 16500 (80% neutron) Urine: sg: 1.030 protein: trace RBC: 1-2/hpf WBC: numerous Nitrites: negative Bacteria: none Diagnosis?
appendicitis
42yo G3P3 comes in for routine exam. Over past year menses have occurred at irregular 2 to 3 month intervals and have lasted 7-21 days. LMP was 6 weeks ago. Has DM2 treated with metformin. BMI 32. Physical exam shows no other abnormalities. Pelvic exam shows an irregular enlarged uterus measureing 12x8x6cm. Endometrial biopsy shows atypical complex hyperplasia. Which of the following is stronges predisposing factor for this patients condition?
anovulation
25yo woman who is HIV+ comes in because of thin, clear vaginal discharge and increased urinary frequency for 2 weeks. LMP was 6 weeks ago. MEnses occurred at regular 28 day interbals. Meds include antiretrovirals but she has been noncompliant. Uses condoms occasionally. Exam shows friable cervix. Uterus slightly enlarged and the adnexa are normal bilaterally. Diagnosis?
pregnancy
3 days after C section because of CPD a 27yo woman has temp of 101.1 (38.4). /no cough, SOB, urinary frequency, urgency, or dysuria. Labor lasted 18 hours. Lungs CTAB. Abd soft nontender without rebound. Exam of incision shows erythema and induration. Minimal tenderness of uterus on palpation and no CVA tenderness. Labs:
WBC: 14,800 (87% neutron)
Urine WBC: 5-10/hpf
Diagnosis?
wound infection
32 yo primigravid at 6WGA comes in for 3 day history of moderate vaginal bleeding. Last seen in ED 1 week ago with similar symptoms. Pelvic US at that time showed thickened endometrial stripe and no fetal pole. BHCG was 450. Today HR is 80, BP 110/60. Pelvic exam shows closed cervix and nontender uterus consistent in size with 6WGA. No palpable adnexal masses. Today hgb is 11.8, BHCG is 90. Next step?
3rd measurement of b-hCG in 1wk
Previously healthy 57yo woman comes in 2 month history of vulvar itching. Otherwise asymptomatic takes no meds. Menopause occurred 7 years prior. Not bee sexually active for 10 years. Exam shows a 1x1.5cm ulcerated lesion in inner right labium majus surrounded by mild erythema. No other lesions noted. No inguinal adenopathy. Diagnosis?
Vulvar condylomata acuminate
22 yo G3P1A1 at 33WGA comes in for routine care. Pregnancy uncomplicated, received care since 7WGA. US at 24WGA was normal. DM1 and postprandial serum glucose was 95 at 28WGA. BP 110/72. Fundal height 38cm. Blood A+. Diagnosis?
polyhydraminos
36hr post C section due to prolonged labor 22yo woman has abdominal cramping and nausea and vomiting. Temp 101.8 (38.8) HR 98 BP 110/64. Exam shows diffuse lower abdomen tenderness with some coluntary guarding but no rebound. Incision is CDI. WBC is 15000. Urine cath in place, urinalysis shows multiple RBS. Next step?
IV amp and gent
dx: endometritis
21yo primigravid at 40WGA admitted in labor. Cervix 100% effaced 5cm dilated. Leopold maneuvers show fetus in transverse presentation with back towards pelvis. Next step?
c-sxn
16 yo girl brought in by mom for never having a period. Otherwise healthy. 5’9” (175cm) and 135lbs (61kg). Breasts are tanner stage 3. No axillary or pubic hair. Pelvic exam shows vagina 2cm in length. Pelvic US shows no uterus. Diagnosis?
AIS
24yo woman G3P3 comes in for not having a period since birth of third child 13 months ago via vaginal delivery. Delivery complicated by postpartum hemorrhage requiring D%C. Breast fed infant for 4 months. Long standing hx of bloating and mood changes with menses. Sexually active with husband, uses condoms. No other med hx. BMI 28. Remp 98.5, HR 64, BP 120/70. Normal sized thyroid. Breast, abdomen, pelvic exam normal. TSH, FSH, prolactin levels normal. BHCG negative. Progestin challenge test shows no withdrawal bleeding. Diagnosis?
Asherman syndrome
47 yo woman comes in for routine exam. Sometimes feels hot at night and sometimes during day. No other symptoms. No med hx no medications. LMP was 4 months ago. Sexually active with one male partner, no contraception. BMI 24. Temp 98.7 (37.1, HR 70, RR 12, BP 90/50. Moderate discomfort during pelvic exam due to vaginal dryness. Uterus enlarged and mildly boggy. No vulvar, cervical, vaginal lesions, or adnexal masses. Remainder of exam normal. FOBT negative. Next step?
b-hCG
7-year-old girl at student health services because of moderately severe pelvic pain with nausea and vomiting during menses since menarche at the age of 13yrs. Symptoms begin soon after onset of menses and last 48 hours. Ibuprofen provides moderate relief. No fever. Menses regular. Never sexually active. Pelvic exam normal. Dx?
primary dysmenorrhea
32-year-old nulligravid has not had a menstrual period since she stopped taking OCP 6 months ago. Menses were regular. Has had increased libido, increased facial acne, increased facial hair growth that requires shaving every other day, and scalp hair loss. 11.3-kg weight gain. Sexually active with 1 partner. BMI 33. Has hair between breasts and above the umbilicus. Pelvic exam shows clitoris protruding completely from the clitoral hood. U/S shows 2-cm solid mass in right ovary. Measurement of which serum hormone will be abnormal?
testosterone
32-year-old primigravid at 10 weeks’ gestation with 5-day history of nausea and vomiting and decreased appetite. Unable to keep solids or liquids down. No fever, chills, sweating, abdominal pain, or vaginal bleeding. NKDA. T 37C, HR 95/min, BP 100/65. Uterus consistent with 10wk gestation. Labs:
Hb 11.5, WBC 8.5k, platelets 168k, Na 130, Cl 95, K 2.8, HcO3 30. Large Urine ketones.
Serum thyroid-stimulating hormone and free thyroxine pending. Next step?
- Admission to the hospital for intravenous hydration and parenteral antiemetic therapy
67-year-old woman with moderate vulvar itching for 2 years. Otherwise healthy. 1-cm areas of white epithelium over the left labium majus. No inguinal adenopathy or vulvovaginal discharge. Next step?
punch bx of affected areas
27-year-old G2P1 3 days after episode of bright red vaginal bleeding with no uterine contractions or cramping. Has had increasing breast size, morning sickness, and extreme fatigue. LMP 8 weeks ago. Vaginal ultrasonography shows normal fetal heart activity. Dx?
normal pregnancy
23-year-old 3 weeks after diagnosed with a urinary tract infection. Rx with trimethoprim-sulfamethoxazole has relieved her symptoms. This is her third UTI over the past year. No serious illness. T 37 C. No flank tenderness. U/A normal. Daily administration of which is prophylaxis?
TMP-SMX
67-year-old woman with 9-month hx of persistent vulvar itching despite rx with OTC zinc oxide, vitamin E, hydrocortisone cream, and miconazole. Has type 2 DM and hypercholesterolemia. BMI 53. Erythematous, swollen vulva, papules and pustules on the medial aspect of the thights, and several excoriations. KOH shows pseudohyphae and budding yeast. Underlying cause of Rx failure?
DM2?
57-year-old woman routine exam. HTN, Type 2 DM, and generalized anxiety disorder. Great-aunt has a history of breast cancer. Pt receiving hormone therapy with conjugated estrogen and medroxyprogesterone daily since menopause 5 years ago. On HCTZ, metformin, and various herbal medications. Breast shows no masses or nipple discharge. Greatest risk factor for breast cancer?
hormone therapy
dx trich how?
wet mount, and possibly KOH
hypoT, low O2, low CO2 post-delivery
PE
pt is 34 week gestation. with no contraction but good fetal movement. smokes througout pregnancy. Fundal height is 30 cm. BP is 100/55, fetal hr is 150. Next step
NST - sees if there is enough oxygen required for fetal activity and heart rate to be with in normal ranges. When o2 levels are low, the fetus may not respond normally. Low oxygen levels can often be caused by problems with the placenta or umbilical cord?
pt is 28 weeks and she had a sudden gush of fluid. fetus is in breech. Nitraine + . IM steroids and IV abx are given. Next step?
second administrations of CS is 24hrs
valproic acid in newborns = ? defect?
neural tube defects
tx of endometritis post-preg
IV amp (clinda) and gent
MCV changed in preg?
no
1) ____ = multiple cysts and bilateral - increased testosterone and DHEAS
2) ____ = unilateral - 1 mass - increased testosterone
(sertoli cell tumor) v. pcos)
PCOS is multiple cysts and bilateral - increased testosterone and DHEAS
Sertoli cell tumor is uniltaeral - 1 mass - increased testoasterone
fibroids that cause urinary sx
subserosal
blood characteristic differences between placenta previa and abruption
dark v. light red blood
dark red blood - abuption.
light red blood - previa (or cervical trauma after sex)
anovulation can lead to what in endometrium?
complex atypical hyperplasia
bright red vaginal bleeding for 4 hrs. blood is in the posterior fornix. Next step
fetal U/s
three effects of estrogen
1) cardiovascular effects - increased risk for stroke/MI over time
2) increase risk of Breast cancer
3) increased risk of endometrial cancer ( increased unopposed estrogen)
vaginal itching, yellow discharge, pH 5, fishy
trichomonas
tx partner
HSV primary v. secondary course - time frame
secondary - regress by 1wk
primary - regress in three weeks
