Other questions Flashcards
a 63yo female comes to the office for routine annual examination. The patient feels well and has no concerns. she underwent menopause at age 50. The patient exerciese multiple days a week and has no urinary or fecal leakage. On pelvic exam, vulvar atrophy is present, and the vagina appears pale but has no lesions. the Cervix appears normal. On valsalva maneuver, there is a bulge of the naterior vaginal wal to the introitus. postvoid bladder and reanl US is normal. Which of the following is the best next step in management of this patietns pelvic organ prolapse?
a. HRT
b. Pessary placement
c. Reassurance and observation
D. Surgical repair
E. Urodynamic testing
C. reassurance and observation
This patinet has pelvic organ prolapse (POP), ther herniation of the pelvic organs into the vagina due to weakened pelvic floor msucles from chronic, increase intraabdominal pressure. Risk factors including increaseing parity, obesity and advancing age. woman wiht anterior vaginal wall prolapse such as this patinet can have plevic pressure and urinary symtpms. Many patients with POP are asymptomatic and incidentally diagnosed on routine exam. if pt is asymptomatic - reassurance and observation. if pt is symptomatic - kegel exercises, pessary placement and surgical management are advancing options.
A 36yo female, G3P2, at 35weeks gestation comes to the ED due to leakage of fluid and painless vaginal bleeding. The patient had rupture of membranes 30 minutes ago; the fluid was initially clear but became bloody a few minutes later. she had normal fetal movement earlier today. her 2 previous pregnancies were term cescarean deliveries. temp is 97F, BP is 140/96, HR is 92/min. Uterus is nontender. Speculum examination confirms rupture of membranes; the cervical os is 1cm dilated with minimal vaginal bleeding. US is unable to dettect fetal heart tones. which of the following is the most likely cause of this patients presentation?
A. abruptio placentae
b. intraamniotic infection
c. threatened abortion
d. uterine rupture
e. vasa previa
e. vasa previa
normal fetal cessels travel in the umbilical cord surrounded by thick, gelatinous tissue that protects the vessels. In contrast, vasa previa is an aberrant condition in which fetal cessels overlie the cervix surrounded only by thin fetal membranes. Their location over the cervix and lack of protection by Wharton jelly makes these vessels prone to tear with rupture of membranes or contractions. usually dx on fetal anatomy US at 18-20 weeks gestation and patients normally require third trimester, inpt management wtih early cesarean delivery at 34-35 weeks. vasa previa may be clinically dx when patients present with rupture of membranes accompanied by painless, minimal vaginal bleeding that primarily reflects fetal blood loss from a torn fetal vessel.
A 38yo, previously healthy woman is seen for follow-up for cervical dysplasia. Last month, pap testing revealed a high-grade squamous epithelial lesion. Coploscopy confirmed high-grade cervical intraepithelial neoplasia grade 3 (CIN3). the pathology report after cervical conization showed CIN 3, wiht all surgical margins free of disease. Which of the following is the best next step in management of this patient?
a. endocervical curettage
b. HPV based testing at 6 months
c. hysterectomy
d. no further pap testing
e. pap testing alone in 3 years
b. HPV based testing at 6 months
CIN 3 is a high grade cervical dysplasia associated with HPV infection, particularly the high-risk oncogenic strains. pts with CIN 3 require cervical conization, which is a diagnostic and therapeutic procedure. pts with positive surgical margins have residual cervical dysplasia that can progress to cancer - therefore these patients require further surgical excision or hysterectomy. those with negative surgical margins are still at high risk for recurrent cervical dysplasia and cancer - therefore require more frequent cervical cancer screening with HPV-based testing.
39yo female, G1P0, at 38 weeks gestation comes to hospital for induction of labor. after prolonged labor, she delivers a 9lb healthy boy via forcepts-assisted vaginal deliver. during delivery of placenta, excessive traction is placed on cord, causing it to avulse, and the placenta is manually extracted in pieces. an US after extraction shows no placental tissue. 60 minutes after deliver, the pt soaks her perineal pad. during bimanual uterine examination, 300mL of clotted blood is expressed from lower uterine segment. the uterus is soft and 4cm above umbilicus after expressing the clots. which of the following is the most likely cause of this patients bleeding?
A. coagulopathy
b. retained placenta
c. uterine atony
d. uterine inversion
e. uterine rupture
c. uterine atony
risk factors for uterine atony - prolonged labor, chorioamnionitis, uterine overdistention. Exam: enlarged, boggy uterus. Managment: bimanual uterine massage, uterotonic medications
Post partum hemorrhage (PPH) is an obstetrical emergency and a major cause of maternal mortality. Hemostasis after placental delivery is achieved by clotting and by compression of the placental site blood vessels by myometrial contraction. PPH occuring <24hours after delivery and most commonyl caused by uterine atony.
56yo woman, G2P2, comes to the office due to breast mass that she discovered while being intimate with her partner. Pt had normal mammo 6 months ago. menopausal for 2 years and is taking estogen therapy for vasomotor symptoms. at age 41, the pt had a hysterectomy with overian preservation due to symptomatic uterine fibroids. fhx negative for breast and ovarian cancer. vitals are normal. BMI is 24. brease exam shows a 2-cm mass in upper outer quadrant of left breast approximately 6cm from the nipple. no nipple discharge and exam of the right breast is normal. which of the following is the best next step in management of this patient?
a. breast US
b. discontinue estrogen therapy
c. FNA
d. mammography
e. repeast breast exam in 1 month
d. mammography
BC is the most common in postmenopausal pts because the risk of BC increases with age. Mammography is gold standard evaluation of a new breast mass in woman >30.
24yo woman comes to the office for routine prenatal visit at 32 weeks gestation. last week, she was evaluated for postcoital spotting. cervix was closed and there was no evidence of preterm labor. Chlamydia trachomatis NAAT testing perfromred at that visit was positive. routine C trachomatis testing performed at initial pregnatal visit was negative. today, the patient has no vaginal bleeding, leakage of fluid or contractions. BP is 110/70, HR is 72/min. Fundal height is 32 cm. fetal HR is 140bpm. urine dipstick negative for glucose and protein. if left untreated, this patient is as increased risk for whcih of the following pregnancy complciations?
a. abruptio plaentae
b. acute pyelonephritis
c. intrauterine fetal demise
d. postpartum hemorrhage
e. preterm prelabor rupture of membranes
e. preterm prelabor rupture of membranes
first line tx during preganncy with chlamydia infection confirmed by NAAT is Azithromycin. confirming response to tx during pregnancy is important becasue untreated chlamydia infection can result in obstetric complications including preterm premature rupture of membranes, preterm labor and postpartum endometritis. in addition, vertical transmission via contact between the fetus and infected maternal discharge during delivery can result in complcations including neonatal pneumonia and neonatal conjunctivitis - the most common infectious cause of blindness.
a 53yo woman, G1P1, comes to your office for routine GYN exam. the pt says that she feels well. menopause was at age 50. the pt is sexually active with a new partner of 6 months; her husband of 18 years died several years ago. vitals WNL. pelvic exam wihtout abnormalities. pap test is performed and cervical cytology report specifes that there are “atypical squamous cells of undetermined significance”. which of the following is the best next step in management of the patient?
a. colposcopy
b. dx excisional procedure
c. endocervical curettage
d. HPV testing
e. repeat cervical cytology in 3 years
D. HPV testing
ASCUS is the most common abnormal pap test result. to determine whether these atypical cells indicate a increased risk for cercival intraepitheial neoplasia (CIN) or cervical cacner, HPV testing is performed. pts age >25yo with ASCUS pap and negative HPV test are low risk for CIN and cervical cancer and can be followed with PAP and HPV co-testing in 3 years. IN pts with postive HPV testing are at increase risk for malignancy and require further evaluation - colposcopy and endocervical curettage for those at increased risk for CIN/cervical cancer.
A 28yo woman comes to the office for a preconception visit. she has never been pregnant and would like to know how to improve her chances of conceiving. Menarche was at age 13. menstruates every 28 days, and bleeding lasts 4 days. she has had no prior surgeries or STIs. the couple has intercourse several times a month. Which of the following hormones would increase the most in concentratio after ovulation?
a. androstenedione
b. estrogen
c. FSH
d. LH
e. progesterone
e. progesterone
primary hormones involved in the menstrual cycle are FSH and LH and progesterone and estrogen. following ovulation, the granulosa and theca cells of the ovarian follicule luteinize to form the corpus luteum; this secretes relatively high levels of progesterone and moderate levels of estrogen for the next 14 days. Progesterone stimulates the endometrium to transform from proliferative to secretory to become a hospitable environment for implantation.
A 29yo nulligravid woman comes to the office because she has not menstruated since stopping birth control. Menarche was at age 14, and she had irregular, heavy menstrual periods from age 14-16. the patient then took combination oral contraceptives until 8 months ago. Since stropping her medication, she has had more frequent headaches but has had no weigh changes, pelvic pain or abnormal hair loss or growth. BMI is 22. A few open comedones are seen on the forehead, but no inflammatory acne or increased facial hair. the remainder of the physical examination, including pelvic exam are normal. urine pregnancy test is negative and pelvic ultrasound is normal. Which of the following is the best next step in evaluation of this patient?
a. karyotype analysis
b. MRI of pituitary
c. no further evaluation indicated
d. serum 17-hydroxyprogesterone level
e. serum FSH, TSH and prolactin level
e. serum FSH, TSH and prolactin level
the patient has secondary amenorrhea, defined as amenorrhea for >3months in women with previously regular menses. most woman have return of spontaneous menses within 1-3 months after cessation of oral contraceptives; those who do not have return of menses require further evaluation. Most common cause is pregnancy, followed by hypothalamic-pituitary-overian (HPO) axis dysfunction and endocrine abnormalities that affects the HPO axis.
19yo nulligravid woman comes to the office due to abnormal vaginal discharge for the last 2 weeks. She had an episode of postcoital vaginal bleeding a few days ago, followed by return of abnormal yellow discharge. PE shows mucopurulent cervical discharge. The cervix is friable and bleeds easily on cotton tip manipuation. Urine pregnancy test is negative. NAAT is no available. a sample of the discharge is obtained for microscopic examination. Which of the following is the most liekyl finding in this patient?
a. clue cells
b. intracellular diplococci
c. pseudohyphae
d. spirochetes
e. trichomonads
b. intracellular diplococci
this patient has acute cervicitis, which is most commonly caused by chlamydia trachomatis and Neisseria gonorrhoeae. Light microscopy is not typically diagnostically helpful in acute cervicitis as it has low sensitivity for identifying N gonorrhoeae on endocervical smears; hoever, it may show the gram-negative intracellular diplococci of N gonorrhoeae when visible. Ctrachomatis is an obligate intracellular pathogen and therefore no organisms will be visualized.
A 24yo female comes to the office for emergency contraception. the pt had unprotected intercourse with her boyfriend 2 nights ago after a condom broke. she is not using any form of contraception other than condoms with spermicide. her last menstrual period was 2 weeks ago. vital WNL. BMI 26. On speculum examination, there is a mucopurulent discharge at the cervical os; no vaginal bleeding is noted. The uterus is small and mobile. there are no adnexal masses or tenderness. urine pregnancy test is negative. Which of the following is the best next step in management of this patient?
a. combo OCP
b. copper-contraining intrauterine device
c. etonogestrel subdermal implant
d. levonorgestrel-only pill
e. methotrexate injection
d. levonorgestrel-only pill
the most efffective emergency contraction is a copper-containing IUD. However copper-containing IUD is contraindicated in pts with acute cervicitis or active pelvic infection due to increased risk of ascending infection. Sincle dose of oral levonorgestrel (Plan B), due to its high efficacy, availablilty, ease to use and low side effect profile. Levonorgestrel should be given wtihin 72 hours of unprotected intercourse.
A 38yo woman comes to the office to discuss management of her hypertensions. She has chronic HTN, which is managed with a stable dose of enalapril. The patient is nulligravid, but she and her partner are currently planning pregnancy within the next few months. BP is 130/81; repeat BP is 128/77. BMI is 26. PE unremarkable. Labs show: Cr 0.8, Potassium 3.7, A1c 5.7%.
Which of the following is the most appropriate management of the patients HTN?
a. add spironolactone
b. continue current therapy
c. switch to chlorthalidone
d. switch to extended release nifedipine
e. switch to valsartan
d. Switch to extended release nifedipine
in pregnancy, chronic (preexisting) HTN is HTN dx prior to or during first 20 weeks or preesenting >12weeks postpartum. this patient who is planning pregnancy should have her meds changed to ER nifedipine, a CCB safe for use in pregnancy. other first line options in pregnancy include methyldopa and labetalol. if after conception, the pts BP decreases significantly - med may be reduced or dicontinued.
14yo girl brought to the office due to heavy vaginal bleeding. Since menarche at age 13, menses have been irregular but no painful. her last menstrual period was 6 weeks ago, and her current menses started 7 days ago. She is soaking through a thick pad every 2 or 3 hours and bled through her clothing overnight. she has no hx of recurrent epistaxis or bruising. vital signs are normal. the abdomen has no masses. On pelvic exam, there is dark red bleeding from cervical os. urine pregnancy test is negative. which of the following is the most likely cause of this patients symptoms?
a. acute cervisitis
b. adenomyosis
c. hypothalamic-pituitary-ovarian axis immaturity
d. uterine fibroids
e. von willebrand disease
C. Hypothalamic-pituitary-ovarian axis immmaturity
this pt presents with AUB, defined during adolescence as menstrual vleeding <21 days or >45 days apart. In adolescence who have recently undergone mencharce, immaturity of the hypothalamic-pituitary-ovarian axis fails to produce appropriate quantities and ratios of gonadotropin-releasing hormone, and therefor the LH and FSH, to induce ovulation. as a result, during the frist few years post menarche, the majority of menstrual cycles are anovulatory and present as painless, irregular, heavy bleeding
23yo women, G3P2, at 35 weeks gestation comes to the ED due to vaginal bleeding that started after intercourse 2hours prior to arrival and has soaked through 3 perineal pads. the pt reports normal feetal movement and mild intermittent cramping but no leakage of amniotic fluid. her only prenatal visit was at 7 weeks gestation. pt has a hx of IVDU. BP is 130/70, HR 98bpm. fetal HR tracing is normal. the tocometer shows contractiosn every 5 minutes. on exam the pt is in no distress. abdomen is gravid, soft and nontender. there is frank blood on pts perineal pad. which of the following is next best step in management of this patient?
a. digital cervical examination
b. fetal fibronectin testing
c. induction of labor
d. TVUS
e. urine toxicology screen
d. TVUS
pt has painless vaginal bleeding at >20 weeks gestation, a presentation consistent with placental previa. pts with vaginal bleeding at >20 weeks and no previous anatomy SU require TVUS to exlude placenta previa. a digital cervical examination is contraindicated to to entracne into the endocervical canal which would result in hemorrhage.
38yo nulligravid women comes to the office due to persistent abnormal uterine bleeding. pts menstrual periods previously occurred monthly and consisted of 4 days of moderate bleeding and light cramping. However, the past 8 months, she has had intermenstrual spotting and bleeding that has occurered at varying intervals and lasts 3-7 days. she was started on OCPs 4 months ago which have not improved the bleeding pattern. BMI 24. Speculum exam shows dark red blood in posterior vaginal value; remainder of pelvic exam is normal. Hemoglobin level is 13. TSH and prolactin are normal. Urine pregnancy is negative. pelvic US shows anteverted uterus and no adnexal masses. which of the following is the best next step in management of this patient?
a. coagulation studies
b. endometrial ablation
c. endometrial biopsy
d. hysteosalpingogram
e. no additional management indicated
c. endometrial biopsy
in women <45 with AUB the absolute risk of endometrial hyperplasia/cancer is low; therefore they can be started on OCPs without evaluation of endometrium. when women have continued irregular mensstural bleeding while on OCPs - it is because endometrial lining is too thick for progestin to completely shed the endometrium during mensturation. the unshed endometrium continues to undergo dyregularted proliferation, resulting in increased risk of hyperplasia/cancer. therefore pts <45 wtih AUB who have failed medical management require biopsy.
