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USMLE Step 2 > O&G incorrects > Flashcards

O&G incorrects Flashcards

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USMLE® Step 1 flashcards
1
Q

First step in management of woman of reproductive age with abdominal pain? BP = 110/80

A

Hemodynamically stable thus = BHCG !!

If deemed pregnant then TVUSS
If not then other imaging to rule out other causes. Also need to know if pregnant to use other imaging modalities

Unstable = straight to resus, laparoscopy if ectopic suspected f

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2
Q

Why is decreased uterine mobility and uterosacral ligament thickening seen in endometriosis?

A

Inflammation of excess tissue and fibrosis and adhesions

Adhesions are extrauterine!

Intrauterine = pelvic inflammatory disease

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3
Q

Raloxifene is used in post menopausal osteoporosis especially in patients at risk of? However this drug increase the risk of?

A

Breast cancer

VTE risk due to estrogen agonist activity. Avoid in history of

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4
Q

38 year old. Amenorrhea 3 months. Bitemporal hair thickening, coarse hair on upper lip. Abdominal bloating and cramping. Large pelvic mass extending through left lower quadrant. No tenderness or ascites. Urine pregnancy test negative. Diagnosis?

A

Serotoli leydig cell tumour (deepening of voice, male pattern baldness, increased muscle bulk and clitoromegaly may be present and help distinguish from PCOS)

Not PCOS as you would have bilateral ovarian symptoms and symptoms happen over a longer period

Not struma ovarii as you have hyperthyroidism not virilisation

Choriocarcinoma = positive pregnancy test

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5
Q

Pregnant woman, shortness of breath doing household chores or walking 2/6 systolic murmur. 2+ pitting Edema. Bloods show respiratory alkalosis? Next step in management?

A

Provide reassurance only

Chronic hyperventilation occurs in pregnancy due to elevated progesterone and gives the sensation of dyspnea

Murmur = physiological, edema is normal due to urterine compression of vena cava

Patient did not have pulmonary embolism as PaO2 was high !! And you would expect a low one/hypoxia Pe

Patient did not have heart failure as auscultation of the lungs was clear with no crackles

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6
Q

Urethral diverticulum symptoms?

A

Dysuria
Post voidal dribbling
Dyspareunia
Anterior vaginal wall mass
Purulent/bloody urethral discharge

Stress inncontinence in contrast = +ve valsalva

Vesicovaginal fistula = continuous urine flow, no vaginal mass

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7
Q

managment of pregnant patient with no increase in dilation from 8cm in 4 hours?

A
  • Proceed to ceasarean delivery!! -> patient is in active phase arrest (active phase is 6cm - 10cm)
  • oxytocin is used to enhance contractions if less than 200 montevideo units, it is used in protracted labour eg rate of <1cm every 2 hours, but NOT arrested

prostaglandin is just used for cervical ripening in early labour induction

  • operative vaginal delivery only an option at 10cm dilation eg expedite delivery in cat 3 tracings, maternal exhaustion etc
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8
Q

insert notes on google drive for incorrects

A
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9
Q

patients are at risk of lead exposure need lead levels monitored if they live in house built before?

A

1978!!

past question put date 1983 of a house as trick option

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10
Q

at first prenatal visit, how is syphilis screened for?

A

rapid plasma reagin test

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11
Q

30 weeks pregnant, twin pregnancy
RUQ pain, severe nausea and vomiting

  • elevated liver enzymes - scleral icterus
  • Thrombocytopenia!!! (due to dic)
  • profound hypoglycemia!!! - helps distinguish
  • leukocytosis!!! - helps distinguish
  • anemia (hemolytic anemia due to dic)
  • raised creatinine (AKI)

next step in management?

A

immediate delivery!!

patient has acute fatty liver of pregnancy

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12
Q

pregnant patient with new onset htn >20 weeks with no signs of end organ damage, minimal proteinuria +1

next step in management?

A

24 hour urine protein collection!!!

clinical signs of end organ damage = headache, visual changes, RUQ

lab signs of end organ damage = raised creatinine or transaminases, elevated platelet count

protein of at least +2 is diagnostic!!

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13
Q

10 weeks pregnant, thrombocytopenia, no other symptoms. blood smear shows clumping of platelets

most likely diagnosis?

A

pseudothrombocytopenia

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14
Q

intrauterine demise management?

A

IOL for vaginal delivery, ideally within a week

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15
Q

when a pregnant mother tests positive for carrying an autosomal recessive gene for a condition eg tay sachs, next step in management?

A

test father
if positive, then CVS or amnio

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16
Q

tuboovarian abscess symptoms

A

cystic masses with distortion of adnexal structures , fever, abnormal discharge, cervical motion tenderness

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17
Q

management of adnexal mass on ultrasound for mass with benign features vs malignant features

A

malignant -> (solid components, thick septations, increased vascularity) = immediate laparoscopy

benign = reassurance and observation if premenopausal, ca-125 if post menopausal

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18
Q

irregular menses with spotting
sexually active with a partner
lower abdominal pain 5 days ago -> now RUQ pain
fevers, chills, vomiting

diagnosis?

A

Pelvic inflammatory disease!

sti can present with irregular menstrual bleeding -> subtle sign

ascending infection to uterus -> fever and lower abdominal pain

further ascension -> perihepatitis/fitz hugh curtis syndrome = nausea, vomiting RUQ

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19
Q

other than pregnancy, what other obstetric condition may present with preeclampsia with severe features?

management?

A

hydatidiform mole

suction currettage

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20
Q

name some beniign physiological conditions that develop in pregnancy

A

increased upper lip hair, PUPP (itchy abdomen in straie), spider angioma, melasma

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21
Q

what is pathological nipple discharge?
how is it investigated?

how is physiological nipple discharge investigated?

A

unilateral, bloody discharge, spontaneous OR associated with breast abnormalities (palpable mass, skin changes)

<30 = ultrasound
>30 = mammogram
>/= 40 =. ultrasound and mammogram

if normal ultrasound/mammogram -> MRI of breast!!!

physiological = measure serum prolactin and TSH!, do a pregnancy test

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22
Q

describe breast cyst management pathway

A

breast ultrasound is 1st line imaging if <30 years
helps determine if complex cyst (thick walled, septated, solid and cystic components) or simple cyst (thin walled, anechoic/fluid filled, no echogenic debris or solid components)

  1. complex = biopsy
  2. simple:
    - asymptomatic simple cyst = observe
    - Tender simple cyst = FNA for pain relief. if non bloody aspirate and the cyst resolves no additional management. if it doesnt resolve = biopsy and additional imaging!!!. If Bloody aspirate = biopsy and additional imaging.
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23
Q

management of non cyclic unilateral focal breast bain?

A

mass -> biopsy

no mass -> imaging

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24
Q

cyclical lower abdominal pain and pain with defecation 13 year old, no menarche yet, firm mass protruding between labia majora which swells with valsalva maneuevre

most likely diagnosis/

A

imperforate hymen

  • collecting blood -> pain on defecation, back pain, pelvic pressure due to pressure on surrounding organs
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25
Q

forceps delivery with 3rd degree laceration which was sutured

presents 4 weeks later with malodorous vaginal discharge

dark red area on pasterior vaginal wall associated with malodorous tan brown discharge

most likely diagnosis?

A

rectovaginal fistula

discharge = feces passing through vagina

dark red velvety lesion = rectal mucosa that is visible

vesicovaginal fistulas in contrast = clear watery liquid (urine) and located on anterior vaginal wall

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26
Q

what are the indications for GBS prophylaxis in pregnancy?

name all 5

A

1.GBS bacteriuria or GBS urinary tract infection in current pregnancy regardless of treatment
+ve GBS rectovaginal culture in current pregnancy

2.prior infant that had GBS-infection eg neonatal sepsis

unknown GBS Status plus any of:
3.- <37 weeks gestation
4.- intrapartum fever
5. - rupture of membranes for 18 hours or more

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27
Q

60 year old woman, large ovarian mass and post menopausal bleeding. endometrial hyperplasia with no atypia on biopsy. most likely diagnosis?

A

granulosa cell tumour (seen in a granny!) -> endometrial hyperplasia and cancer risk due to unopposed estrogen secretion by tumour!! histology = call exner bodies/cells in rosette pattern

emryonal carcinoma and yolk sac tumour = young people!! different symptoms

note!! when granulosa cell tumour occurs in young child = precocious puberty = make them a granny/adult

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28
Q

management of pregnant patient, history of hypertriglyceridemia. now presenting with pancreatitis like symptoms. RUQ ultrasound normal. next step in management?

A

Lipid panel!!

pregnant women, particularly those with history of high triglycerides are at increased risk of triglyceride induced pancreatitis

not ERCP as this is used to for gallstones and in case of gallstones, ultrasound will likely not be normal -> it may show biliary tree dilatation, biliary sludge, some gallstones etc

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29
Q

management of patient with hypothyroidism wishing to become pregnant?

A

increase levothyroxine dose when patient becomes pregnant

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30
Q

treatment for gonorrhea and chlamydia?

A

ceftriaxone and doxycycline which covers both pathogens

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31
Q

pregnant woman, asymptomatic. booking bloods were normal. now has AST of 300, ALT OF 254. Alk phos is normal.

next step in management of patient?

A

viral hepatitis serology!!

due to hepatocellular pattern of injury!! (normal alk phos)

infection could have been contracted after initial tests

LFTs are not severely raised suggesting move from active to chronic phase of the disease

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32
Q

woman pregnant

in first pregnancy had placental abruption and was given anti d immunoglobulin

now she has anti D antibodies. what does this mean?

A

inadequate dose of anti d immunoglobulin given after first pregnancy

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33
Q

woman that has been trying to concive for years

reports morning sickness, abdominal distension and positive pregnancy test

however hosptial pregnancy tests are negative and ultrasound shows thin endometrial stripe

most likely diagnosis?

A

pseudocyesis

NOT a missed abortion as ultrasound will show an unviable fetus. morning sickness would have resolved and pregnancy test will be positive

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34
Q

treatment for asymptomatic bacteuria in pregnancy?

A

nitrofurantoin, fosfomycin!! or trimethroprim sulfomexazole - drug depends on gestation!!!. eg at 10 weeks can use fosfomycin

trimethorprim sulfomexaxzole avoided in first semester as it interferes with folic acid metabolism

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35
Q

ABO hemolytc disease occurs in a woman with blood group X and a fetus with blood group __ ?

describe symptoms

A

O -> wOman

A or B -> fetus

asymptomatic, mild anemia, jaundice = mild disease typically

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36
Q

neonatal graves disease symptoms?

risk factors?

course of disease

A

low birth weight
tachycardia
high bp or goitre may be seen

mother who has or had graves disease

self resolves within months!!. treat in intermim with methimazole, beta blockers etc

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37
Q

1st line preventative therapy for migraines in pregnancy?

A

beta blockers -> propranolol, metoprolol

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38
Q

Pyelonephritis management during pregnancy?

if clinical improvement shown (no fever for 48 hours), what is further management?

A

broad spectrum IV antibiotics -> Ceftriaxone!!!

further management = oral beta lactam!! eg cephalosporins eg cephalexin!! or penicillins!! (as they are safe during all trimesters)

then cephalexin prophylaxis for rest of pregnancy

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39
Q

a pregnant patient with fever, nausea, vomiting and RUQ pain most likely has?

management?

A

acute appendicitis!!

urgent surgery!! -> risk of fetal demise

differentiate from Preeclampsia as in appendicitiis peritoneal signs (rebound, guarding) may be present and fever is present

if it was placental abruption -> uterine tenderness and uterine tachysystole (decelerations with uterine contractions) would occur

ureteral obstruction -> colicky symptoms, abnormal urinalysis

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40
Q

trichomonas treatment?

A

meTRonidazole!! - also for BV

not doxycycline!!!

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41
Q

a post partum patient with fever, leukocytosis and right sided pain most likely has?

A

acute appendicitis!!

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42
Q

amennorrhea of at least 3 months (secondary amenorrhea), after a negative pregnancy test, what is the next step in management?

A

FSH, TSH, and PROLACTIN!
to rule out HPO disfunction

if patient described has a bit of acne that could be normal AND acne worsens after stopping OCP

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43
Q

irregular menses, hirsutism, acne AND elevated 17-hydroxyprogesterone is seen in?

A

non classic congenital adrenal hyperplasia!!! (partial deficiency of 21 hydroxylase activity)

mild so electrolytes and bp normal

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44
Q

post hysterectomy
right sided back pain
costovertebral angle tenderness
urinalysis is normal

most likely diagnosis?

other way it may present?

A

hydronephrosis -> due to ureteral injury during surgery!!!! and resulting outflow obstruction

also seen post c section

can have abdominal distension(pain and bloating), large volume of intraabdominal fluid on ultrasound, eatery vaginal discharge due to overflow, and fever and nausea due to peritoneal irritation

normal urinalysis as only one ureter affected

conduct renal ultrasound

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45
Q

management for a woman in labour with an active genital herpes lesion?

A

c section!!

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46
Q

post partum 10 days, severe headache + seizure + papilledema + history of DVT in mother. normal BP
normal CT scan
next step in management?

A

do MRI of brain with MR VENOGRAPHY (concerned for Cerebral venous thrombosis!)
CT normal in 30% of cases
may also present with stroke

AVOID thrombolytics! Risk of intracerbral hemorrhage due to thin walled venous structures

treatment = heparin

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47
Q

Vaginal spotting and mild cramping common in first trimester. benign in patient with closes cervix and intrauterine normal gestation

A
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48
Q

post partum woman with irregular vaginal bleeding, enlarged uterus, pulmonary symptoms and multiple infliltrates on CXR. next step in diagnosis?

A

BHCG -> most likely choriocarcinoma

can occur after normal pregnancy and spontaneous abortion!! as well as molar pregnancy

pulmonary symptoms = metastasis!! -> lungs is most common site

p.e would not explain bleeding or pulmonary symptoms

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49
Q

in choriamonionaitis after broad spectrum antibiotics, what is the next step in management?

A

labour augumentation

NOT c section -> this is reserved for obstetric indications eg non reassuring fetal ctg, breech presentation, prior uterine surgeries etc. fetal tachycardia alone is not sufficient to warrant this

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50
Q

pre eclampsia can present with severe features (low plateletets, low hemoglobin or elevated wbcc due to inflammation)

when eclampsia occurs with this (new onset siezures)

how do you manage?

A

magnesium sulfate AND prompt delivery

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51
Q

what is the criteria for second stage arrest of labour?

causes?

A

3 or more hours of pushing in primagravida
2 or more hours of pushing in multip

  1. cephalopelvic disproportion -> suggested by moulding and caput
  2. fetal malposition
  3. inadequate contractions = <200 montevideo units over 10 minutes
  4. maternal exhaustion
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52
Q

amniotic fluid embolism presents with resp failure (profound hypoxia may cause siezure), shock/hypotension and dic in labour or postpartum period

1st step in management?

A

intubation! with mechanical ventilation!! -> correct hypoxemia

after that: vasopressors for BP, transfusion to correct DIC

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53
Q

effect of pregnancy on blood pressure?

diagnosis of pregnant woman at 14 weeks with BP reading of 138/92?

A

decreases!

Chronic hypertension as diastolic blood pressure is >/= 90!

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54
Q

most common risk factors for pprom?

A

genital tract infection - asymptomatic bacturia, BV
history of pprom

(also antepartum bleeding)

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55
Q

next step in a patient with history of lichen sclerosis and a new vulval lesion (white firm plaque) - > next step in management?

A

vulval biopsy!!! to evaluate for vulval cancer. as lichen sclerosis is a risk factor

if benign lichen sclerosis found -> continue high dose corticosteroids!

malignant but non invasive -> imiquimod or laser ablative therapy

malignant and invasive -> excision

vulval cancer symptoms -> pruritus, plaque/ulcer, bleeding

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56
Q

repeat screening for stis in 3rd trimeter eg 28 weeks is done for which pregnant woman?

A

age <25
prior sti
high risk sexual activity

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57
Q

distinguish between mullerian agenesis
5 alpha reductase deficiency

A

mullerian agenesis -> female ranging testosterone levels!! normal pubic hair!!. 46 XX. breasts present. absent uterus cervix and upper vagina BUT ovaries present!!

5 alpha reductase -> virilazation at puberty (clitoremegaly, acne, male pattern hair development) will be present!! absent development of breasts!! due to testosterone receptors. 46 XY. normal pubic hair!!. male ranging testosterone levels
(5 alpha reductase cant convert testosterone to DHT so undescended testes and phenotypically female but male internal genitalia)

Androgen insensitivtiy syndrome -> breast development due to aromoatization of testosterone to estrogen!!.(think of this one as insensitive so you do the things you wouldnt normally do like grow breasts - the androgen receptor in the breast is not working so it doesnt inhbit breast growth) minimal pubic hair!! due to insensitivity to androgen. 46 XY. male ranging testosterone levels.
No clitoromegaly here/virilization as the testosterone receptor is non functional!! No female internal organs so no uterus or ovaries

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58
Q

intrauterine fetal demise with fetus showing multiple limb fractures and a hypoplastic thoracic cavity is most likely?

A

type 2 osteogenesis imperfecta

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59
Q

contraindications to COCP?

A

increased VTE risk including smoking

increased cardiovascular risk including uncontrolled hypertension, stroke, ischemic heart disease, migraine with aura. (cocp can worsen htn and thus increase risk of MI and stroke).

medical conditions negatively affected by increased estrogen - active breast cancer, active liver disease (acute hepatitis, liver cancer)

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60
Q

post partum

initial couple of months anxiety and excessive worry about child

followed by fatigue, weight gain despite normal exercise, constipation

exam -> bradycardia, lower extremetiy edema

most liklely diagnosis?
next step in management?

A

postpartum thyroiditis -> brief hyperthyroid then hypo then euthyroid. condition associated with anti-tpo antibodies. goitre may be present

thyroid function studies!

postpartum thyroiditis and postpartum depression may have overlapping symptoms. PT should be excluded first

also note: painless/ silent thyroiditis is similar to postpartum thyroiditis however no association to pregnancy so is not diagnosed within 1 year of pregnancy

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61
Q

7 year old precocious puberty and ovarian mass. diagnosis?

A

granulosa cell tumour

a dysgerminoma doesnt cause this and they differentiate into scincitiotrophoblasts so secrete lactate dehydrogenase and b-hcg

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62
Q

emergency c section, 2 days later fever of 38.3
uterine is soft and fundus is tender. headeache and fatigue

what intervention would have been most effective at preventing this presentation?

A

preoperative antibiotics

patient has postpartum endometritis = fever >24 hours postpartum + uterine tenderness

offensive lochia may also occur and headahce/malaise

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63
Q

pregnant woman with 24 hour urinary output of 5.5 after an intake of 3. specific gravity 1.001

all other labs normal

what is the diagnosis?

A

Diabetes insipidus

polyuria/urinary output> 3. AND specific gravity aka urine density <1.006 indicating dilute urine

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64
Q

37 weeks pregnant
no prenatal care
rupture of membranes 2 days ago which is now meconium stained
in active labour 6 cm

next step in management?

A

administer penicillin!!!

prophylaxis as GBS status uknown and she has rupture of membreanes for >18 hours

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65
Q

How to interpret the quadruple screen test for

  1. downs syndrome
  2. Trisomy 18/Edwards
  3. neural tube/abdominal wall defect
A
  1. the child with down syndrome says HI! = ELEVATED HCG and inhibin A . (others low). thick of it as excited to say hi
  2. Edward is a low HEAp = low hcg, low estradiol, low afp
  3. neural tube defect = elevated AFP only

multiple pregnancy increases afp due to more fetal tissue present.

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66
Q

why does providing obstetricians with clinical performance data compared to national benchmarks help improve quallity of care?

A

data driven feedback is very effective!!

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67
Q

describe treatment of moderate or severe menopause

A

contraindications to estrogen eg breast cancer, VTE = Paroxetine (an ssri)

no contraindications = estrogen only HRT if no uterus, estrogen + progesterone if uterus

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68
Q

mangnesium sulfate may cause hypermagnesmia due to?

A

renal insuffficiency

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69
Q

oxytocin toxicity causes?

A

SIADH

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70
Q

a low lying placenta with myometrial thinning and numerous lacunae indictes what condition?

name a serious potential complication

A

placenta accreta

postpartum hemorrhage

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71
Q

ace/arb use in pregnancy fetal complication vs presentation of ARPKD

A

ACE/or ARB -> bilateral UNDERDEVELOPED kidneys and oligohydramnios

ARPKD -> bilaterally ENLARGED polycystic kidneys and oligohydramnios

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72
Q

describe options for contraception after a baby and the side effects/ positive effects

A

medroxyprogesterone injection - induces anovulation (decreased menstural bleeding) by high levels of progesterone which is appetite stimulant -> weight gain, mood changes!!

copper IUD -> increased menstrual bleeding and dysmennorrhea

progestin-releasing IUD -> locally acting not systemic so decreased risk of weight gain, mood changes. decreases heavy menstrual bleeding! by inducing ammenorrhea. but the bleeding may be irregular

COCP - 1st line for premenstrual syndrome

progestin only methods can be initiated at any time after delivery whilst COCP only after 6 weeks due to VTE risk

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73
Q

when would you screen a pregnant patient for diabetes at 1st prenatal visit (eg at 10 weeks)?

What test is used to screen?

A

obesity (BMI>/=30)!!!!! + at least one of:

  1. prior macrosomic infant = birth weight >/= 4kg!!
  2. PCOS -> suggested by irregular menstrual cycles
  3. age >/= 40
  4. prior GDM
  5. family history of type 2 diabetes

1-hr 50g GCT NOT fasting blood glucose level
gct >/= 200 is diagnostic

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74
Q

what is the amniotic fluid index for oligo and polyhdramnios?

A

oligo = </= 5 cm
poly = >/= 24 cm

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75
Q

what is the pathology behind PCOS?

A

failure of follicle maturation and oocyte release

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76
Q

Tamoxifen is used as an adjuvant treatment for breast cancer and prevention of breast cancer in high risks patients. what are the side effects?

(T amoxifen T reats breast cancer)

A

Hot flashes! = most common!! “Hot tamale”
VTE! - “hot tamale -> think red hot sauce”
Endometrial cancer NOT ovarian. (a serm)
uterine sarcoma

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77
Q

Raloxifene is used for postmenopausal osteoporosis. and prevention of breast cancer in what are the side effects?

A

hot flushes
and VTE

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78
Q

postpartum endometritis antibiotic regimen?

A

Ceftriaxone + clindamycin

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79
Q

hypothalamic dysfunction eg due to intense exercise is unlikely to be the cause of infertility in a woman with regular menses.

POI = amennorrhea

hyopthyroidism also = irregular menses

A
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80
Q

what is uterine synechia?

causes?
presentation

A

aka ashermans syndrome -> endometrial scarring and intrauterine adhesions -> light menses/ammenorrhea

d&c risk factor

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81
Q

what are the contraindications to these drugs used for PPH

  1. methylergonovine
  2. Carboprost
  3. tranexamic acid
A
  1. hypertensive patients
  2. asthma
  3. caution in hypercoagulable conditions

(note oxytocin first line and misoprostol second line. both have note contraindications)

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82
Q

an older woman with vulvar pain and pruritus
erythematus vulvar lesions with white border
erythematus vagina that is stenotic
oral ulcers

what is the diagnosis?

A

lichen planus!

a different variant presents as just small puritic papules with purple hue

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83
Q

patient with rupture of membranes resulting in bright red amniotic fluid. sinusoidal pattern on ctg? what is the most likely cause of this pattern?

management?

A

fetal blood loss. sinusoidal pattern = fetal anemia
blood loss in this case = ruptured vasa praevia

urgent c section -> risk of fetal hypoxemia
it is a cat 3 tracing!!!

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84
Q

36 year old, worsening pelvic pressure and dyspareunia
pelvic mass that extends to umbilicus, it is mobile with several palpable protuberances

what is the diagnosis?

why is it not ovarian cancer?

A

palpable protuberances = irregular uterine contour
extending to umbilicus = severe uterine enlargement

mass effect may cause pelvic pressure, pain with intercourse, urinary frequency, constipation

ovarian cancer = FIXED mass due to invasive spread into nearby structures. AND fluid wave on examination! (ascites)

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85
Q

sudden severe unilateral lower abdominal pain. ultasound shows thin walled ovarian cyst. free fluid in the pelvis

what is the most likely diagnosis?
management?

A

ruptured ovarian cyst! -> due to free fluid

hemodynamically stable with no signs of infection -> observation and reassurance!!

hemodynamically unstable eg continued bleeding from ruptured cyst -> cystectomy

86
Q

post partum endometritis symptoms?

A

fever
uterine tenderness
offensive lochia

87
Q

name the causes of secondary post partum hemorrhage
(PPH >24 hours!!! after delivery)

A
  1. RPC - heavy bleeding +/- uterine atony. intraamniotic infection is a risk factor!!! as causes adherence of placental membrane. differentiate from retained placenta with causes primary PPH
  2. placental site subinvolution -heavy bleeding, uterine atony
  3. postpartum endometritis - intramniotic infection is risk factor!!. but expect fever, uterine tenderness etc
88
Q

fetal ultrasound shows?

edematous scalp
single deepest pocket of amniotic fluid is 12 cm
echolucent abdominal fluid (ascites)
no other dismorphic features

most likely diagnosis?

A

hydrops fetalis due to alpha thalessemia major!!!

achondroplasia would present with hydrops fetalis + macrocephaly + shortened long bones

turners syndrome could present with hydrops fetalis but also cystic hygroma + nuchal thickening

89
Q

effect of pregnancy on serum blood urea, creatinine and nitrogen?

explain it

A

decreases these.

in pregnancy you increase cardiac output to prepare for blood loss in delivery. so increased blood flow to kidneys and increased GFR and urine protein excretion

note! pregnancy is associated with leukocytosis possibly due to inflammation

90
Q

risk factors for cervical stenosis?
symptoms?

A

LEEP/conization

dsymennorrhea/amennorrhea -> impedement of menstruation blood flow

infertility -> sperm cant travel up

91
Q

dyspareunia
painful periods
cervical motion tenderness
laterally displaced cervix

what is the most likely diagnosis?

A

endometriosis!! -> fibrosis and adhesions causes pelvic anatomy distortion -> lateral displacement of cervix

PID -> can cause dyspareunia and cervical motion tenderness BUT cervix will appear inflamed (cervicitis) and fever would likely be present!!

92
Q

periventricular intracranial calcifications
intrahepatic calcifications
fetal growth restriction

maternal flu like symptoms from first son who got it in nursery

most likely diagnosis?

A

CMV

93
Q

what is the criteria fro choriamnionitis!!!

note the presence of this criteria would indicate urgent c section delivery!!

A

maternal fever + at least one of:

  1. fetal tachycardia!! >160 per min - may just be this present!!
  2. maternal leukocytosis!!
  3. purulent amniotic fluid
94
Q

management of asymptomatic patient with placenta preavia at early gestation?

A

routine obstetric care! -> 90% cases resolve spontaneously
repeat ultrasound done in 3rd trimester ie >28 weeks gestation to check for resolution

95
Q

when is a doppler ultrasound used in pregnancy screening?

A

for surveillance of fetal growth restriction = estimated fetal weight <10th percentile

it is an ultrasound of the umbilical artery

96
Q

prolapsed fibroid symptoms?

A

labor like pain due to cervical dilatation

97
Q

menopausal woman with dysuria, urgency incontinence, nocturia and recurrent utis
reduced vulvar elasticity, labia retraction
patchy erythema of vagina
not sexually active

most likely diagnosis?
pathology?

A

genitourinary syndrome of menopause!!! OR atrophic vaginitis

other possible symptoms: vaginal dryness, dyspareunia, vaginal bleeding, pelvic pressure

pathology = estrogen deficiency!!

98
Q

management of patients with asymptomatic endometriosis?

A

reassurance and observation

99
Q

placental abruption in previous pregnancy. had a c section

now presents at 38 weeks gestation with severe abdominal pain, vaginal bleeding and abdomen has an irregular mass

history of smoking and cocaine use

what risk factor likely contributed to presentation?

A

PRIOR UTERINE SURGERY!!!

IRREGULAR MASS -> UTERINE RUPTURE = protruding fetal mass
not seen in placental abruption

100
Q

complications of hyperemesis gravidarum and inappropriate weight gain or underweight

A

fetal growth restriction
preterm delivery

101
Q

8 months pregnant painless vaginal bleeding
normal ctg
smokes
irregular contractions

most likely diagnosis?

A

placenta praevia

placental abruption = painful AND ctg will show decelerations

decelerations also seen in uterine rupture

102
Q

management of patient requesting a c section in absence of maternal or fetal indications?

A

refer patient to another O&G specialist

103
Q

irregular menstrual bleeding every 60 days
heavy
weight = 120kg -> pay attention to kg weight!
everything else normal

most likely cause?

A

anovulation due to obesity
and abnormal uterine bleeding due to obesity

104
Q

42 year old
fatigue and hot flushes!
cranky and intermittent bloating
menses regular every 30 days
LMP 3 weeks ago
smoker

most likely condition?

next best step in management?

A

premenstrual syndrome!

A symptom diary = 1st step!!!
then = SSRI

COCP can be used but avoid with contraindications!! -> >/= 35 years, smoking

105
Q

define preeclampsia

what is the criteria for preeclampsia with severe features?

A

new HTN >/= 20 weeks + proteinuria OR signs of renal dysfunction. you don’t need symptoms eg headache to have preeclampsia!

severe = creatinine >1.1 OR Transaminases >2x normal !

106
Q

patient with preeclampsia
pulse is 53/min
an episode of emesis

what is best next step in management?

A

IV Hydralazine!!! -> avoid labetalol due to presence of bradycardia (HR<60)

Avoid nifedipine (oral drug) due to emesis

not patient also requires MGS

107
Q

41 year old
heavy vaginal bleeding
LMP 4 months ago
hot flushes, night sweats, smooth warm skin, palpitations
TSH is 0.1
blood in vaginal vault with closed cervix
positive hcg
no fetal heartbeat
uterus enlarged at the level of the umbilicus
roux en y gastric bypass 7 years ago

most likely diagnosis?

A

symptoms point to Hyperthyroidism. HM can present with hyperthyroidism + vaginal bleeding. (can also present with theca lutein cysts, preeclampsia with severe features)
roux en y surgery -> vitamin A deficiency = risk factor

NOT an inevitable abortion as cervix will be dilated and these typically occur in the first trimester

108
Q

In addition to colposcopy and endocervical curretage,
when would you perform an endometrial biopsy

if ATYPICAL GLANDULAR CELLS (AGCS) are seen on a pap test?

A

> /= 35!!!!

OR
<35 AND risk factors for endometrial cancer
- obesity
- anovulation

the AGCs could be caused by cervical or endometrial cancer

but if you see ENDOMETRIAL CELLS and the patient is post menopausal -> you MUST do an endometrial biopsy

109
Q

uncomplicated delivery 2 months ago
hyperthyroid symptoms
enlarged and non tender thyroid
URTI 2 weeks ago
low uptake on radioactive iodine scan

most likely diagnosis

A

postpartum thyroiditis!! - can present as hypertyroid, hyper then hypo, or just hypo!! thyroid peroxidase antibody test = diagnostic

note: de quervains presents after URTI but thyroid will be tender!!

110
Q

pregnancy causes an increase in T3 and T4 and decreased TSH (hyperthyroid like state) but you are asymptomatic!! also free T4 is unchanged

A
111
Q

describe features suggesting a secondary cause of dysmennorrhea eg endometriosis, rather than primary

how does primary dysmennorhea present?

A

age >25 at onset
unilateral pelvic pain
abnormal uterine bleeding -> intermenstrual, post coital
no systemic symptoms -> eg nausea fatigue

primary:
- after menstrual cycles have established
- pain radiating to bilateral legs
- fatigue, nausea, vomiting, diarrhea

112
Q

what are the contraindications to breastfeeding?

A

Active substance abuse
active untreated TB
HIV infection
active varicella infection
herpetic breast lesion
chemo or radiotherapy

113
Q

28
bilalteral yellow nipple discharge
no axillary or clavicular lymphadenopathy
pregnancy test is negative
galactorea evaluation (TSH and prolactin are normal)
on sertraline for anxiety and depression

next step in management?

A

no further management required -> transient idiopathic galactorrhea

note antispychotics are associated with nipple discharge not SSRIs

114
Q

infertility, irregular menses
low FSH, LH and estradiol
no other symptoms, normal physical exam
what is the most likely diagnosis?

A

hypogonadotrophic hypogonadism!!

NOT POI as FSH levels will be raised and menopausal symptoms present!

115
Q

what is the pathophysiology behind hypotension (an adverse reaction) after epidural administration?

A

vasodilation and venous pooling in lower extremeties!!!
due to sympathetic blockade

116
Q

pregnant women with history of herpes but no active infection. management?

A

Aciclovir suppressive therapy from 36 weeks until delivery

117
Q

dyspareunia and dryness during sex after delivering a baby is due to?

A

hypoestrogenism!! (secondary to lactation)

in breastfeeding patients, elevated prolactin levels suppress GnRH causing low FSH, LH and estrogen

low gnrh = lactational amenorrhea
hypoestrogenism = menopausal like symptoms + vulvovaginal atrophy

118
Q

preeclampsia can present up to 6 weeks postpartum as htn and a headache. patients at increased risk of stroke

A
119
Q

in what scenario would screening be carried out for ovarian cancer?

A

family history suggestive of a hereditary cancer syndrome, so at least 1 of:
- male breast cancer
- bilateral breast cancer
- breast cancer diagnosed aged <50
- multiple members on 1 side of family with breast or ovarian cancer
- azkenazi jewish ancestry
- at least 3 relatives with a lynch syndrome associated cancer

120
Q

first step in management of uterine inversion?

A

manual reduction!!!

if fails -> laparotomy

121
Q

fever
abdominal pain
high wcc
tender uterus
tender right adnexal mass
ultrasound = large, thick walled multiloculated mass filled with debris obliterating the right adnexa
sexually active

most likely diagnosis?

A

tuboovarian abscess! -> ultrasound findings key

a complication of PID

PID symptoms:
- fever
- cervical, uterine or adnexal tenderness
- purulent dischage

no vomiting and nausea = rules out appendiceal abscess

122
Q

proper response to mother asking for reason for childs sti clinic visit

A

i need permission from daughter to discuss this with you - confidentiality is key

DONT say i recommend you discuss this with daughter as you are avoiding a proper response to mother

123
Q

when fetal hydrops is present,
what test can be done to rule out Rh maternal antibodies as the cause?

A

indirect coombs test !

124
Q

what are the 2 causes of symmetric growth restriction?
how do you differentiate the 2 in a question?

A

chromosomal abnormalities - more common
congenital infection - less common due to spontaneous abortion, ultrasound will have findings eg ventriculomegaly, intracranial calcifications

125
Q

too much or prolonged oxytocin exposure can cause cerebral edema, tonic clonic siezures and severe hyponatremia!

A
126
Q

sudden onset unilateral pelvic pain + vomiting + adnexal tenderness. most likely diagnosis?

A

ovarian torsion!
- you dont need a palpable mass!

127
Q

what contraception is contraindicated in women with active breast cancer?

A

avoid hormonal contraceptives -> estrogen or progesterone or cocp

copper iud recommended

128
Q

if a uterine massage and high dose oxytocin fail to resolve uterine atony, what is the next best step in management?

A

tranexamic acid!! -> antifibrinolytic

if this fails then give a second line uterotonic like carboprost but remember to avoid this in asthma

129
Q

BPP is preformed in patients at risk of uteroplacental insufficiency eg >/= 41 weeks pregnant.

abnormal BPP scores, particularly </=4 suggest severe hypoxemia with imminent risk of stillbirth. in these cases delivery is indicated.

also note in uteroplacental insufficienty -> blood flow in fetus is diverted away from kidneys and to brain, thus oligohydramnios is common

BPP has 5 criteria each scored 0 for abnormal or 2 for normal. max score is 10.

A
130
Q

describe some absolute contraindications to pregnancy

A

pulmonary arterial hypertension
peripartum cardiomyopathy
HF with LVEF <30%
severe coarctation
severe mitral stenosis
severe symptomatic aortic stenosis
severe aortic dilation (Marfans syndrome)

if pregnant already, discuss abortion

131
Q

how do you determine menopause in a woman without previous menses eg due to hysterectomy?

A

measure serum FSH - elevated

132
Q

sheehans syndrome typicall presentation?

A

lactation failure
hypotension and anorexia -> secondary adrenal insufficiency

133
Q

state fetal and maternal complications of placental abruption

A

fetal -> hypoxia, preterm birth, fetal demise
maternal -> DIC!! maternal hemorrhage,

134
Q

Pregnant
right sided abdominal pain
fever
nausea

tenderness over right flank
but no abdominal pain or guarding

most likely diagnosis?

A

acute pyelonephritis!!

not appendicitis as NO rebound or guarding (peritoneal signs)

135
Q

management of recurrent urinary tract infection in a post menopausal woman?

A

vaginal estrogen -> improves genitourinary atrophy

136
Q

when patients request a nonindicated test or imaging, you should ask them if theyve had any concerns about their health!! -> dont respond saying sometimes patients are anxious because that is presumptious

A
136
Q

a failed 10 day medroxyprogesterone challenge indicates a deficiency of what?

estrogen deficiency put the patient at risk of what?

A

deficiency of estrogen!!

(in an athlete with secondary amennorrhea, this points to FHA as the cause).

estrogen deficieny -> decreased bone mineral density

137
Q

thin fused labia minora in a 2 year old is what conditions?
what causes it?

risk factors?

A

labial adhesions
low estrogen production

poor hygeine, diaper rasher, infection/vaginitis, stradle injury

risk of utis
symptomatic -> topical estrogen

138
Q

how does the complication of epidural analegesi (local anesthetic systemic toxicity) present?

A

CNS overactivity -> perioral numbness, metallic taste, tinnitus

tonic clonic siezures!!!

risk of cardiovascular collapse

139
Q

in a PUL where imagining has been non diagnostic, what is the next best step in management?

A

repeat b hcg in 48 hours

140
Q

intertrigo common cause?

risk factors
treatment?

A

candida albicans
systemic cortocsteroids, DM = immunosuppressed

topical azoles

doxycycline = hidradenitis supporative treatment
estrogen = vulvovaginal atrophy/ genitourinary syndrome of menopause
trichloraceatic acid = condyloma acuminata
trimethorprim-sulfomexazole = used in cellulitis -> typicall unilateral not bilateral lesion

141
Q

how to reduce the complication rates for shoulder dystocia?

A

simulation drills with entire clinical team -> teach them to respond quickly safely and effectively

142
Q

a patient had myomectomy for fibroids 8 months ago, now has amennorrhea/ light spotting infertility and a negative progesterone withdrawal test. cyclic pelvic pain without bleeding

what is the most likely diagnosis?

management?

A

ashermans syndrome - complication of uterine surgery eg curretage, myomectomy

other risk factors -> infection (septic abortion, endometritis)

(negative progesterone test occurs despite normal estrogen and progesterone)

hysteroscopy and lysis of adhesions

note: condition may also cause recurrent pregnancy loss

143
Q

why are progestin subdermal implant and estrogen transdermal patch not used for emergency contraception?

A

slow release of hormones

144
Q

copper IUD, progestin IUD and __ are the medications for emergency contraception that have the longest efficacy window at up to 120 hours.

A

ulipristal

145
Q

estrogen containing contraceptives eg estrogen containing ring is contraindicated in patient with htn

A
146
Q

watery discharge throughout the day and night following a hysterectomy.

most likely diagnosis?

A

vesicovaginal fistula

contrast to vaginal cuff dehiscence which also occurs after hysterectomy and causes vaginal fluid BUT the vaginal apex would appear inflamed, indurated or open!

147
Q

pregnant woman with a postive interferon gamma release assay

next best step in management?

A

Obtain CXR!!! -> differentiate active or latent TB!

(If active, then you need to get sputum cultures)

NOTE: Tuberculin skin testing and IGRA are both diagnostic. once one of them is positive, go straight to CXR

148
Q

patient in labour on epidural analgesia
- fetal tracing showing late decelerations
- maternal hypotension

next best step in management?

A

Phenylephrine!!! (vasopressor)

(+ iv fluids and left lateral positioning)

symptoms due to sympathetic block from epidural

(maternal hypotension causes decreased placental perfusion -> late decelerations = sign of uteroplacental insufficiency!!)

149
Q

at what endometrial thickness would you be concerned for endometrial cancer?

A

> 4 cm

150
Q

in sexually active patients with primary dysmennorhea first line treatment?

A

COCP!
not nsaids due to need for contraception

note: COCP does NOT cause weight gain

151
Q

next step in management for a fetus with anencephaly in breech position? mother is in labour

A

vaginal delivery!!! & no fetal monitoring
- fetus is not viable so preserve maternal mortality
- if fetus is born alive = palliative care

other lethal fetal conditions which require this management:
- acardia
- bilateral renal agenesis
- holoprosencephaly
- intrauterine fetal demise
- pulmonary hypoplasia
- thantophoric dwarfism

152
Q

how does acute cervicitis present?

A

spotting
bloody yellow/discharge from cervical os

153
Q

c section earlier today
now lightheaded and need to immediately lie down
low blood pressure
pulse 124
pale cold skin
minimal lochia and no clots
uterine fundus is firm
no bleeding from incisional site

next best step in management?

A

emergency laparotomy!!!

retroperitoneal hematoma! -> uterine artery injury
(rare cause of PPH)
PPH supported by hypovolemic shock findings

154
Q

most common risk factor for endometrial cancer?

A

obesity! (estrogen exposure)

(and then chronic annovulation/PCOS)

155
Q

chronic pelvic pain and pressure for 8 months
stopped OCP 2 years ago but hasnt been able to have kids -> hinting at infertility!!

ultrasound = unilocular hypoechoic mass

most likley diagnosis?

A

endometriosis!! (endometrioma seen)

NOT epithelial ovarian carcinoma -> would have septate mass on ultrasound with solid and cystic components.

NOT mature teratoma -> would not cause infertility. would have calcifications and hyperechoic nodules on ultrasound

156
Q

unexplained vaginal bleeding eg irregular pattern, imb, is a contraindication to IUD insertion

A
157
Q

management of maternal concern of decreased fetal movement?

A

non stress test

decreased movement may be due to hypoxemia/acidemia -> conserving energy for brain -> increased risk of fetal demise

158
Q

during pregnancy, which conditions require low dose aspirin from 12 weeks gestation until delivery?

(preeclampsia prophylaxis!)

in this high risk group, what screening is also done at first prenatal visit?

A

prior preeclampsia
CKD1
chronic HTN!
Diabetes mellitus - type 1 and 2!!
multiple gestation!!!
autoimmune disease!!

24 hour urine protein collection

159
Q

post operative incisional pain in the absence of signs of infection is managed with observation and reassurance

A
160
Q

how to differentiate between ovarian torsion and ruptured ovarian cyst?

A

ruptured cyst = free fluid on ultrasound!!!!
bleeding may be seen. observation and reassurance if no sign of infection. surgery if infection or hemodynamically unstable

ovarian torsion = enlarged ovary with decreased or absent blood flow on ultrasound
- may also have tender mass on exam

161
Q

primary dysmenorrhea pathophysiology?

A

increased endometrial prostaglandin production

162
Q

gastroenteritis following food consumption + intrauterine fetal demise is most likely caused by infection by which organism?

A

Listeria

163
Q

if pregnant mother is exposed to varicella but has positive IgG then no further treatment required. Varicella vaccine is contraindicated in pregnancy

A
164
Q

what vaccines do you administer during pregnancy?

A

influenza -> asap
Tdap and antiD -> 3rd trimester

don’t administer MMR as live attenuated

165
Q

vaginal cancer risk factors?

A

age >60
smoking
in utera DES exposure -> clear cell carcinoma only!! not squamous cell

166
Q

risk associated monochorionic monoamniotic twins?
management?

A

twin to twin transfusion - monochorionic
cord entanglement and fetal demise - monoamniotic

in patient monitoring (from 28 weeks)
c section at 32–34 weeks

167
Q

management of adolescents eg age 15 concerned by irregular heavy menstrual bleeding due to immature hpo axis?

A

oral progesterone therapy

168
Q

management of recurrent cystitis with negative cultures after course of antibiotics (resolving cystitis)

A

daily antibiotic prophylaxis
post coital antibiotics

169
Q

management of asymptomatci pelvic organ prolapse?

A

observation and reassurance only

170
Q

urinary frequency, back pain and groin pain (round ligament pain) can be physiological in pregnancy.

if ultrasound showing bilateral hydronephrosis with right kidney larger than left what is next step in management?

A

nothing -> physiological

171
Q

differentiate

epidural associated hypotension
local anaesthetic toxicity
and high spinal anaesthesia

A

local anesthetic toxicity = cns symptoms eg perioral numbness, tinnitus + siezure + cardiovascular collapse

high spinal anesthesia - UPPER extremity weakness (ascending paralysis) + respiratory paralysis

*lower extremity weakness is EXPECTED with epidural

172
Q

what happens to fibroids as you near menopause?

A

spontaneous regression

(due to decreased estrogen levels)

173
Q

complications of shoulder dystocia?

A
  1. fractured clavicle - crepitus, decreased moro reflex due to pain
  2. fractured humerus -> crepitus, decreased moro reflex due to pain
  3. erb palsy -> decreased moro and biceps reflex. waiters tip sign! intact grasp reflex. injury to 5th and 6th cervical nerves!
  4. Klumpke palsy -> claw hand + horners syndrome!!!. injury to C8 and T1!!. note damage to sympathetic fibres runing along these causes horners
  5. perinatal asphyxia -> AMS, poor tone, seizures
174
Q

management of recurrent variable decelerations?

A
  1. maternal repositioning -> first line-> to resolves the umbilical cord compression!
  2. if insufficient -> amnioinfusion

note: c section is not indicated/not cat 3 unless variability is absent as well!

175
Q

treatment of syphilis if penicillin allergic?

A

skin testing and peniciliin desensitization

176
Q

80 years old
friable perineal laceration
vulva edema and tenderness
post menopausal bleeding
refusing to bathe etc

most likely diagnosis?
management?

A

elder abuse

sexual abuse screening

note: vulvar cancer/ lichen sclerosis -> typically preceeded by months to years of vulvar pruritis and plaque like lesions

177
Q

congenital uterine abnormalities increases risk of what pregnancy complication?

A
  1. preterm labour!!! - small cavity
  2. fetal growth restriction and recurrent pregnancy loss -> poorly vascularized uterues
178
Q

patients with bipolar disorder during pregnancy should be switched from valproate to which medication?

A

lamotrigine!

179
Q

11 year old

thin white skin with excoriations -> adherence of labia at midline
small anal fissure noted

most likely diagnosis?

A

lichen sclerosis!

(seen in hypoestrogenic populations = prepubertal and post menopausal)
can also cause dyuria, dyspareunia, painful defecation

treat with corticosteroids

biopsy only needed in adults as they are the ones at risk of vulvar cancer

NOT! Labial adhesions -> these are seen in girls peak incidence age 2-3 are not associated with lichenification and have no anal involvement. treated with topical estrogen

180
Q

persistent fever in the post partum period unresponsive to broad spectrum antibiotics with a negative infectious screen suggests what condition?

risk factors?

differentiation from surgical site infection?

A

septic pelvic thrombosis (diagnosis of exclusion)

thrombosis of deep pelvic or ovarian veins which becomes infected

rfs: c section, chorioamnionitis/endometritis

SSI will have fever but also incisional site erythema or induration

181
Q

PPROM is indicated when rupture of membranes and contractions could be present but they are IRREGULAR and the cervix is closed.

management from 34 weeks?

management before 34 weeks if uncomplicated?

A

34 weeks = delivery! GBS prophylaxis with penicillin G!! (+/- corticosteroids)

before 34 weeks = expectant!, latency antibiotics!! with azithromycin and ampicillin!! (+ corticosteroids) (+inpatient monitoring)

*mgs only given for preterm DELIVERIES <32 weeks

182
Q

Hyperemesis gravidarum can cause hypoglycemia and elevated serum transaminases, also a complication of HG is wernickes encephalopathy

A
183
Q

at what point is preterm labour treated with expectant managment rather than tocolysis?

A

> /= 34 weeks -> expectant management

184
Q

management of women under/ <45 with menopausal symptoms and abnormal uterine bleeding?

A

must exclude endocrine disorder -> measure FSH, TSH and Prolactin

> /= 45 -> clinical diagnosis, give HRT/patient education

185
Q

treatment for chlamydia only infection?

treatment for gonorrhea only infection?

A
  1. doxyclyline, (azythromycine in pregnancy). use the acronym CAD.
  2. ceftriaxone
186
Q

all women regardless of psychiatric history require screening for post partum depression

A
187
Q

what are the indications to offer cell free fetal DNA testing at the first prenatal visit?

it is offered from gestation >/= 10 weeks

A

age >/= 35
abnormal serum screening test (quadruple test)
ultrasound findings associated with fetal aneuploidy
prior pregnancy with fetal aneuploidy
parental-balanced robertsonian translocation

  • if cffdna is +ve -> CVS or amniocentesis
188
Q

patient diagnosed with mullerian agenesis, next best step in management?

A

renal ultrasound

urogenital structures develop from the same embryological origin!

189
Q

what are the indications for cervical cerclage placement?

A

> /= 2 prior painless second trimester losses

OR

Painless cervical dilation

OR

second trimester ultrasound </= 2.5 + a prior preterm delivery

190
Q

unilateral bloody discharge without coexisting mass or lymphadenopathy is most likely what diagnosis?

how would you differentiate this from
1. invasive ductal carcinoma?
2. mammary ductal ectasia?

A

benign intraductal papilloma! (discharge can also be non bloody)

(line and project into duct and when the duct stalk twist, they bleed)

not palpable due to intraductal location and small size!, also NOT visualised on mammography!!!

  • ultrasound and mri important for evaluation of duct pathology!!!!
  1. invasive ductal carcinoma -> same symptoms BUT also irregular breast mass and lymphadenopathy
  2. mammary duct ectasia -> blue or blue green discharge!! + sub-areola lump
191
Q

abnormal uterine bleeding eg irregular, spotting OR postmenopausal bleeding + ovarian mass

diagnosis?

A

granulosa cell tumour

192
Q

abdominal pain, vaginal bleeding and contractions after abdominal trauma is most likely what condition?

patient has gone into hemorrhagic shock.
after IV fluids, what is next step in management?

A

placental abruption

transfuse blood products!!

vasopressor is contraindicated in isolated hemorrhagic shock!! this is because peripheral vascular tone is already increased.
can also decrease uterine blood flow and impair fetal oxygenation (it is, however used in epidural reaction causing maternal hypotension!)

193
Q

pregnant woman
type 2 diabetes
BMI 36
Enlarged liver
ultrasound = hyperechoic appearing liver
AST = 115
ALT = 125
all else normal

most likely diagnosis?

why not gallstones?

why not Alcoholic hepatitis?

A

NAFLD - rfs, ultrasound findings, AST/ALT <1

if it were gallstones -> most likely have bladder wall thickening and if ascending cholangitis fever, leukocytosis

alcoholic hepatitis characterised by AST predominance and moderate alcohol intake wont cause it

194
Q

What is the medical term for genital warts?

A

condylomata accuminata (think of accumulating!)

condylomata lata = secondary syphilis

195
Q

in an abnormal lie, at what time will most babies spontaneously turn into normal lie on their own?

A

at term!!!

= >/= 37 weeks!!!!

196
Q

abdominal pain in a woman that is relieved with urination and is associated with dyspareunia is most likely what condition?

normal urinalysis

A

interstitial cystitis (idiopathic chronic bladder pain). may also be associated with urinary frequency and urgency

not a cystocele -> as positive valsalva would be expected = prolapse sign

197
Q

44
premenopausal
dyspareunia
dry vagina
saline eye drops for chronic dry eyes
dental caries

most likely diagnosis?

A

inadequate vaginal secretions!!!
(sjogrens)

198
Q

fetal ultrasound showing dilated fluid fild segment and dilate proximal intestinal segment + polyhydramnios
37 year old woman

what additional ultrasound finding may be observed?

A

Ventricular septal defect!!!

this is a description of duodenal atresia!! (double bubble sign) -> associated with down syndrome which is associated with heart defects

199
Q

what are some absolute contraindications to exercise in pregnancy?

A
  1. risk of preterm birth
    - cervical insufficiency or cerclage
    - preterm labour during current pregnancy
    - PPROM
  2. risk of antepartum bleeding
    - placenta praevia
    - persistent second or 3rd trimester bleeding
  3. underlying condition that could be exacerbated by exercise
    - severe anemia
    - preeclampsia
    - lung disease, heart disease
200
Q

a diagnostic dilation and curettage is done for a pregnancy of unknown location.

if after this procedure, b hcg level continues to rise, what is the managment?

A

methotrexate! -> indicates ectopic pregnancy

if it were to fall instead, it would indicate a non viable intrauterine pregnancy. this group require reassurance and observation as non viable tissue has been removed by d&c.

if intrauterine tissue analysis shows no chorionic villi = ectopic pregnancy

if chorionic villi = non viable intrauterine pregnancy

201
Q

treatment of asymptomatic BV?

A

no additional management

202
Q

management of suspicious cervical lesion?

A

cervical biopsy

203
Q

chronic pelvic/lower abdominal pain and abnormal vaginal bleeding (with wiping, post coital) is most likely what diagnosis?

what are the other signs seen on examination?

A

PID!!!! (2 key symptoms. due to cervicitis)

  • cervical, uterine or adnexal tenderness
  • mucopurulent discharge
  • fever
204
Q

Toxic shock syndrome like syphilis, will cause a widespread maculopapular rash that covers palms and soles. However,

A
205
Q

in a complete abortion, why might a small cyst be seen in the adnexa and fluid in the pelvis?

A

cyst = corpus luteum

free fluid -> retrogade bleeding from spontaneous abortion

206
Q

last week cephalic presentation

now in labour with cervical dilation but only a taught bulging amniotic sac is felt. next step in management?

A

transvaginal ultrasound -> to be sure about the presenting part as things can always change

must be done before amniotomy to prevent umbilical cord prolapse

207
Q

recurrent candidiasis, next step in investigation?

A

hemoglobin A1C

208
Q

management of patients who have their corpus luteum removed before at least 10 weeks gestation during their pregnancy?

A

progesterone supplementation

209
Q

indications for hospitalisation for PID?

A

Pregnancy
failed outpatient treatment
risk of non adherence to outpatient therapy
severe presentation -> high fever!!, vomiting!!(inability tolerate oral antibiotics), dehydration (dry mucous membranes, long cap refill)
complications -> tuboovarian abscess, perihepatitis

USMLE Step 2 (12 decks)

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