Patient Mngmnt In The Office

Question 1

Time difference in postpartum blues va depression

Answer 1

Blues should resolve around PPD10, if depression exceeds 10 days consider postpartum depression

Question 2

BMI cutoff for ulipristal acetate?

Answer 2

35

Question 3

Treatment for Graves’ disease (IgG ab activated thyrotropin receptors increasing production of t3/4)

Answer 3

PTU, methimazole, radioiodine therapy, thyroidectomy

(Pregnancy: PTU in first tri to avoid birth defects of methimazole, then switch to methimazole for second/third tri to avoid liver toxicity of PTU)

Question 4

In addition to known birth defects caused by methimazole, what structure should be evaluated by US in a fetus who’s mother is talking PTU or methimazole during pregnancy?

Answer 4

US should evaluate for presence of goiter at 28-32 weeks because both PTU and methimazole cross placenta and can cause hypothyroidism in the neonate possibly resulting in goiter formation- caf obstruct newborn airway

Question 5

This SSRI is the only one found to increase risk of incidence of fetal anomalies, particularly __.

Most neonatal complications are transient including jitters, respiratory depression, however SSRIs have been recently associated with ___.

Answer 5

Paroxetine (Paxil). Cardiac defects.

Persistent pulmonary hypertension.

Question 6

Management of bacterial vaginals is evident on Pap smear cytology:

Answer 6

Assess for symptoms, if none, not necessary to treat

Question 7

What is a main risk of the estrogenic properties of tamoxifen in all users?

Answer 7

VTE- lowered levels of antithrombin III and protein C

Endometrial proliferation is mostly seen in post menopausal users (RR 4)

Question 8

Next step in adolescent dysmenorrhea resistant to medical management after 3-6months?

Answer 8

Diagnostic lap

Question 9

Does a lower dose of estrogen in OCP confer less risk in a hypertensive woman >35yo?

Answer 9

No

Question 10

As little as __% weight loss can improve metabolic complications of PCOS and cycle regularity

Answer 10

5%

Question 11

Laboratory criteria for APS?

Answer 11

+ lupus anticoagulant, B2 glycoproteins, or anticardiolipin x2 >12 weeks apart

Additionally for lupus anticoagulant And anti-beta2 glycoprotein, enzyme assays for igG and IgM should be obtained

Question 12

Lifetime risk of developing ovarian cancer (low risk):

Answer 12

1 in 70

Question 13

A woman has genital herpes, but her new partner does not, what is best management? How effective?

Answer 13

Daily suppressive therapy for her- reduces transmission to a discordant, unintended partner by 50%.

Condoms also help!

Question 14

Primary HPV testing may even be better for women aged _____, but it does have a higher risk of unnecessary colposcopy.

Answer 14

25-29.

Question 15

Compared to baseline the most well known risks of IVF are:

Answer 15

Twin (30 fold, mostly dizygotic), congenital heart defects (1-3% compared to 0.3-1%),

Question 16

Recurrent pregnancy loss workup

Answer 16

Karyotype of products of conception; APS testing; assessment of uterine cavity

Question 17

What treatment for genital wart is safe in pregnancy?

Answer 17

Trichloroacetic acid or cryotherapy

Iniquidad (not indicated for unteach I am use) has not been studied in pregnancy
Podophyllin (antimitotic) and 5FU (pyrimidine anti metabolite) are not safe in pregnancy

Question 18

How should patients be counseled who would like to continue using depo provera for longer than 2 years?

Answer 18

Studies have demonstrated 5% BMD loss at 5 yrs of use but it seems to be recoverable after it is discontinued.

No studies have clearly demonstrated increased fracture risk.

Estrogen supplementation and DEXA scans are not recommended.

Discuss ways to improve BMD such as weight bearing activities, Ca and VitD, smoking cessation

They do not have to stop taking it

Question 19

Treatment for pediatric vulvar lichen sclerosis:

Answer 19

Clobetasol propionate ointment twice daily for 2-12 weeks with frequent reassessment then step down management to less potent steroids as soon as possible

Sitz baths and avoiding irritants for prevention

Question 20

Management of 17 unvaccinated nulligravida exposed to chicken pox- management:

Management for pregnant woman:

Answer 20

Vaccination within 3-5 days is 90->70% effective. 2 doses required 6-8 weeks apart.

CI to vaccinate pregnant women because vaccine is live attenuated. Immune globin can be given.

Question 21

Breast ca screening for known BRCA carriers beginning at __yo:

Answer 21

25yo

MRI annually. Adding annual mammography at age 30

Up to 95% detection rate

Question 22

Most widely studied combination therapy for adolescent depression:

Answer 22

Fluoxetine (prozac )and cognitive behavioral therapy

Question 23

Of the thrombophilias which should be evaluated in the event of VTE, which are not useful to test for in pregnancy, acute thrombosis, or if a patient is anticoagulated:

(Protein C, S, prothrombin gene mutation, antithrombin, factor V Leiden)

Answer 23

Factor v Leiden (dna yet only) and prothrombin gene mutation can be assessed regardless

Protein c and s can be assessed in pregnancy (s varies by trimester) but NOT during acute VTE or when anticoagulated

Question 24

The rate of healing esophagitis from GERD is 30% heater with ___ compared to ___.?

Answer 24

PPIs compared to H2 blockers

Question 25

Screening fir women with extremely dense breasts:

Answer 25

Digital mammography

Question 26

Best non hormonal treatment for vasomotor sx in menopausal woman taking tamoxifen for h/o breast cancer

Answer 26

Venlafaxine because, unlike paroxetine, it does not inhibit CYP2D6 preventing tamoxifen conversion to its active metabolite

Question 27

When to start treating for osteoporosis based on screening-

Answer 27

T-score: -2.5 or less FRAX: 10yr risk of major fracture of 3% or more; OR risk of hip fracture 20% or more

Question 28

Empiric therapy for otitis media

Answer 28

Amoxicillin or if sx persist of amoxicillin, add clavulonic acid

Question 29

Most common karyotype associated with _____; an overriding aorta, VSD, pulmonary artery stenosis

Answer 29

Normal karyotype, most fetus with isolated cardiac abnormality will be euploid Tetrology of Fallot Risk of aneuoidy is 20% Pts should undergo genomic microarray if interested in genetic testing

Question 30

Risk of fetal cardiac anomaly if parent had structural heart malformation

Answer 30

2-3% Similar for siblings

Question 31

Elevated risk of breast cancer according to the Gail model

Answer 31

5yr risk of >1.67% (avg risk of women at age 60) or lifetime risk >20%

Question 32

Main risk factors for use of tamoxifen and reloxifene in women 35+ yo without prior breast ca but increased risk for invasive breast cancer

Answer 32

VTE (both) cataracts and endometrial cancer (tamoxifen only)

Question 33

Management of symptomatic urethral caruncle (as opposed to observation)

Answer 33

Topical estrogen cream for 2-3mo this If no improvement- excision, careful reapproximation of urethra to avoid stenosis

Question 34

Endometrial stripe

Answer 34

4mm

Question 35

Normal puberty can begin as early as __yo in black and __yo in White girls.

Answer 35

6 and 7 years old (Avg age is 10 and 12.5yo)

Question 36

How to differentiate between central and peripheral precocious puberty.

Answer 36

GnRH stimulation... if LH/FSH rise, then likely central. If LH/FSH remain low, likely peripheral. Central also tends to have accelerated timing but normal sequence of pubertal events

Question 37

Further diagnosis and management of precocious puberty:

Answer 37

Central- get head MRI to rule out mass. Peripheral- ultrasound to rule out ovarian mass. 17-OHP to rule out CAH

Question 38

Management of labial agglutination:

Answer 38

Typically spontaneously resolves with endogenous estrogen at 5-6yo; treatment reserved for symptomatic patients with voiding problems. Topical Estrogen cream applied twice daily to area of adhesion. Avoiding irritants. Avg of 2-4 month treatment. Success 80-100%, then bland ointment. Potential adverse effects are thelarche, vaginal bleeding

Question 39

Normal spermanalysis values

Answer 39

``` Concentration of 15 million At least 39 million spermatozoa 32% progressive motility 40% total motility 4% normal morphology 58% vitality 1.5 mL ``` This is the 5th percentile, below these values is abnormal

Question 40

Next step after patient has immunohistochemistry staining of endometrial cancer specimen absent for MLH1

Answer 40

Test for MLH1 methylation. 20-30% of absence of MLH1 will be due to methylation. If methylation present, not Lynch, no further testing. If methylation absent- further germline testing for protein absence

Question 41

Typical antiemetic which can used to increase breast milk supply:

Answer 41

Metoclopramide- dopamine antagonist Effect Will typically last 7-14days

Question 42

For single dose MTX protocol, what should the minimum fall in BHCG between day 4-7

Answer 42

15%

Question 43

Treatment with lowest risk of recurrence for C diff

Answer 43

Fidaxomicin Other tx include metronidazole and vancomycin

Question 44

Best mood stabilizer to initiate for bipolar disease after prep ganan y in a mom who intends to breastfeed

Answer 44

Valorous acid - safe in breastfeeding Lithium L4 (breastfeeding category), lamotrigine L3, Quetiapine L4

Question 45

Primary amenorrhea definition

Answer 45

Absence of menses by age 15, no menarche within 3 years of thelarche, no thelarche by age 13

Question 46

Causes of primary amenorrhea:

Answer 46

Without breast development, high FSH: turners, swyer’s (types of gonadal dysgenesis) Without breast development, low FSH: constitutional delay, prolactinoma, Kallman, CNS depression with anorexia/weight loss, CAH, PCOS Breast development: outflow obstruction, mullerian agenesis or MRKH, androgen insensitivity syndrome

Question 47

When to recommend bariatric surgery

Answer 47

BMI 40+ or 35 with obesity related comorbidities

Question 48

Management of G1P0 with negative HBsAg and anti-HBsAg...

Answer 48

Give HBV vaccine in pregnancy or give booster

Question 49

MOA and main sfx of spironolactone?

Answer 49

Aldosterone antagonist, competitive inhibition of androgen receptors and inhibition of 5a-reductase Menstrual irregularities, hyperkalemia, diuresed, postural hypotension, teratogenic feminization of male fetus

Question 50

When do we stop screening for breast cancer according to ACOG?

Answer 50

We don’t, if the patient is predicted to live more than 10 yrs and the risks of detecting non-life threatening disease are discussed, annual mammography is recommended

Question 51

How effective is medical management of early pregnancy loss?

Answer 51

About 85%

Question 52

Management of vulvodynia ina patient taking OCPs

Answer 52

COCs May be an exacerbating cause of vulvodynia, trial of stopping COCs is warranted for 3-6months. Needs other contraceptive

Question 53

If a patient received Tdap vaccine at 12 weeks of pregnancy after she stepped on a rusty nail, does it need to be repeated in her pregnancy?

Answer 53

No, normally given at 27-36 weeks, no need to repeat. DTap has considerably higher antigen concentration- normally given to infants and children <7yo. Local reaction risk in adults

Question 54

When to treat suspected bacterial sinusitis?

Answer 54

Severe sx of fever, nasal discharge and sinus pain lasting for >10 days

Question 55

Primary ovarian insufficiency is cessation of menses prior age —- yo and evidence of hypergonadotropism. It accounts for —-% of secondary amenorrhea. The most common genetic etiologies are: and

Answer 55

40 years old 2-10% Tuner’s and Fragile X permutation (other abnormalities include Swyers syndrome and trisomy x)

Question 56

When to stop cervical cancer screening

Answer 56

65yo+ with negative testing for ten years prior with the last being performed within 5 years. OR after total hysterectomy if they have never had CIN2+ within the past 20 years. (If they have had CIN2+ in past 20 years, continue screening for 20 yrs after first post-hyst screen is reasonable)

Question 57

Colon ca screening for lynch syndrome patients:

Answer 57

Colonoscopy q1-2 years starting at age 20-25 or 2-5 yrs prior to earliest cancer diagnosis in family