UWISE UNIT 1:Patient Flashcards
A 52 year-old G3P2 reports irregular vaginal spotting and bleeding after intercourse for the past 18 months. She stopped having menses at the age of 48 and has never been on hormone replacement therapy. She also notes new onset low back pain. She has smoked two packs a day for the past thirty years. Her last gynecologic exam was 10 years ago. On physical examination, she is a thin female who appears older than her stated age. She weighs 120 pounds and is 5 feet 6 inches tall. Her pelvic examination reveals atrophy of the external genitalia and vagina, and a minimal amount of dark brown blood in the vault and a large parous cervix with a friable lesion on the anterior lip of the cervix. The uterus is normal size, immobile and fixed in a retroverted position. There are no palpable adnexal masses, but there is firm nodularity in the posterior cul-de-sac on rectal examination. Which of the following is the most appropriate next step in the management of this patient?
A. Computerized tomography of the lower spine and pelvis B. Pap smear C. Colposcopy D. Cervical biopsy E. Pelvic ultrasound
Correct answer is D.
This patient is at high-risk for cervical cancer. Her risk factors include tobacco use and a poor screening history. The symptoms of postmenopausal and postcoital bleeding should be taken seriously, and a cervical biopsy of the suspicious cervical lesion performed. Her physical examination with fixation of the uterus and thickening of the rectovaginal septum and back pain suggests involvement of the parametria (Stage II) and possible extension to the sidewall (Stage III). A Pap smear should not be used to exclude cervical cancer, as it is a screening test and not a diagnostic test, and colposcopy would not be useful since a clinically visible lesion is already present. Although a CT scan may ultimately be needed as part of the evaluation of cervical cancer, a diagnosis must first be made by biopsy. Ultrasonography may be helpful in the diagnostic evaluation of post-menopausal bleeding, but not in the setting of an obvious cervical lesion.
A 17 year-old G0 high school student is brought in by her mother for her first gynecologic examination. She began her menses at age 12 and has had regular periods for the past three years. For privacy, you ask to examine the patient without her mother. Further history is obtained in the examination room. She admits that she has been sexually active with her boyfriend for the past three years. She uses condoms occasionally and is fearful about possible pregnancy. She requests that her mother not be informed about her sexual activity. On physical examination, she is anxious, but normally developed. Her pelvic examination reveals no vulvar lesions, minimal non-malodorous vaginal discharge, and a nulliparous appearing cervix. The bimanual examination reveals a slightly enlarged uterus, and her adnexa are non-tender and not enlarged. Urine pregnancy test is negative. What is the next best step in the management of this patient?
A. Order a pelvic transvaginal ultrasound B. Obtain a Pap smear C. Initiate empiric treatment with doxycycline and ceftriaxone D. Insert an intrauterine device E. Obtain DNA probes for gonorrhea and chlamydia
Correct answer is E.
Counseling about and screening for sexually transmitted infections is the best next step. This patient does not require treatment due to a lack of diagnostic criteria. Guidelines for initiation of cervical cancer screening is recommended at age 21 regardless of coitarche. A pelvic ultrasound would not be indicated at this time especially since the pregnancy test is negative and given her lack of menstrual or pelvic symptoms. Discussions about various contraceptive methods are always recommended in this setting.
A 68 year-old G2P2 who has recently moved in with her daughter (a long-standing patient of yours) comes in for an annual examination. A vaginal hysterectomy was done in her fifties for uterine prolapse. She is not sure if her ovaries were removed. She has never had an abnormal mammogram or Pap smear and has had yearly exams. She stopped hormone replacement therapy 10 years ago. She was recently widowed after being married for 50 years. She does not smoke or drink. Her diabetes is well-controlled with Metformin; she takes a daily baby aspirin and is on a lipid-lowering agent. On examination, she is a thin elderly woman with a dowager’s hump. Her breast exam is unremarkable. Her lower genital tract is notable for atrophy. No masses are noted on bimanual and recto-vaginal exam. A fecal occult blood test is negative. Which of the following tests is not necessary?
A. Bone density B. Colonoscopy C. Pap smear D. Mammogram E. Annual bimanual and recto-vaginal exam
he correct answer is C.
Pap smear screening is not indicated in patients who have had a hysterectomy, unless it was done for cervical cancer or a high-grade cervical cancer precursor. Patients with a uterus can discontinue cervical cancer screening between the ages of 65 – 70 if they have had three consecutive negative smears and no history of high-grade cervical intraepithelial neoplasia or cancer. Patients still need yearly bimanual and rectovaginal exam. Mammograms are done annually, as breast cancer increases with age. Colon cancer screening is recommended at age fifty. The patient has an exaggerated thoracic spine curvature, termed a dowager’s hump, likely secondary to thoracic compression fractures secondary to osteoporosis. If this is confirmed on a bone density test, she may benefit from the addition of bisphosphonates.
49 year-old G3P2 presents for annual examination and reports irregular periods for the past year with associated hot flashes. Her husband had a vasectomy. She notes erratic bleeding every two to three weeks, with just a day of spotting or several days of moderate flow. She reports no significant pain, fever or discharge. She had two vaginal deliveries and one early miscarriage. A Pap smear several years ago had to be repeated but have been normal for the past three years. Review of systems is positive for insomnia and new onset anxiety. She has borderline hypertension and is followed closely by her family practitioner. Her mother died of breast cancer. She smokes a pack of cigarettes a day and has for the past 22 years. On examination, she is thin, pulse is 110, blood pressure is 160/100. She weighs 120 pounds and is 5 feet 6 inches tall. Her pelvic exam reveals blood flowing from the cervical os and a moderate amount of bright red blood in the vault. No cervical lesions are apparent. Bimanual examination reveals an upper limit of normal size, non-tender uterus. The adnexa are not palpable. Her recto-vaginal exam is unremarkable. Which of the following studies are indicated at this visit?
A. Schedule for a dilation and curettage B. Thyroid stimulating hormone and Beta-hCG C. Pelvic ultrasound D. Pap smear E. Complete blood count and coagulation studies
The correct answer is B.
This patient has signs and symptoms very suspicious for hyperthyroidism; therefore, a thyroid stimulating hormone test and a pregnancy test would be the most appropriate choice. She is thin, tachycardic with frequent irregular menses, temperature instability, and anxiety and sleep disturbance. Another possible explanation would be perimenopause. Since she has active heavy vaginal bleeding, the Pap smear should be rescheduled for a time when she is not bleeding. Blood, inflammation and drying artifact can hamper the cytopathologist’s ability to interpret the smear. The remaining tests may be necessary later, but not at this visit.
25 year-old G0 is scheduled to discuss her recent abnormal Pap smear which showed atypical squamous cells of undetermined significance (ASCUS). She has had negative Pap smears on a yearly basis since age 21. Her only significant gynecologic history is genital warts that have not responded to treatment with local application of trichloroacetic acid. She has had eight sexual partners. She uses condoms and oral contraceptives. She has smoked a pack a day for the past two years. Which of the following is the most appropriate next step in the management of this patient?
A. HPV typing B. Repeat Pap smear in 1 year C. Cone biopsy D. Cryotherapy E. Loop Electrosurgical Excision Procedure (LEEP)
The correct answer is A.
HPV typing is indicated in the initial triage of the finding of atypical squamous cells of undetermined significance (ASCUS) on a Pap smear. If a high-risk HPV type is detected, then the patient needs a colposcopy with biopsies. An alternative approach can be close surveillance with repeat Pap smears in 6 months and 12 months and if both are negative, she may return to annual screening. Colposcopy is indicated for any cytological abnormality. Initiation of treatment by way of cone biopsy, LEEP, or cryotherapy is not indicated at this time without a biopsy-confirmed diagnosis of cervical dysplasia.
19 year-old G0 presents due to lower abdominal cramping. The pain started with her menses and has persisted, despite resolution of the bleeding. She thinks she may have a fever, but has not taken her temperature. No urinary frequency or dysuria is present. Her bowel habits are regular. She denies vomiting, but has mild nausea. A yellow blood-tinged vaginal discharge preceded her menses. No pruritus or odor was noted. She is sexually active, uses oral contraceptives and states that her partner does not like condoms. On examination, her temperature is 100.2°F (37.9°C), pulse 90, blood pressure 110/60; she is well-developed and nourished, and appears acutely ill. No flank pain is elicited. Her abdomen has normal bowel sounds, but is very tender with guarding in the lower quadrants. No rebound is present. Pelvic examination reveals a moderate amount of thick yellow discharge. The cervix is friable with yellow mucoid discharge at the os. Cervical motion tenderness is present and the adnexa are tender without masses. The uterus is tender. Urine dip is negative for nitrates. Urine pregnancy test is negative. What is the most likely diagnosis?
A. Vulvovaginal candidiasis B. Acute salpingitis C. Trichomonas vaginitis D. Gonorrhea cervicitis E. Bacterial vaginosis
The answer is B.
This patient has findings suggestive of acute salpingitis (pelvic inflammatory disease) including lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, and vaginal discharge. Mucopurulent cervicitis with exacerbation in the symptoms during and after menstruation is classically gonorrhea. Chlamydia is frequently associated with gonorrhea and also causes cervicitis and pelvic inflammatory disease. Trichomonas may cause a yellow frothy discharge, and Candida may cause a thick white cottage cheese like discharge, but neither would cause fever and abdominal pain.
39 year-old G0 presents to the clinic reporting non-tender spots on her vulva for about a week. No pruritus or pain is present. She also notes a brownish rash on the palms of her hands. She admits to IV drug abuse. She was diagnosed as HIV-positive two years ago, but has not been compliant with suggested treatment. On examination, three elevated plaques with rolled edges are noted on the vulva. They are non-tender. A brown macular rash is noted on the palms of her hands and the soles of her feet. What is the most appropriate next step in the management of this patient?
A. Obtain a treponemal-specific test B. Biopsy of the lesion C. Colposcopic evaluation of the vulvar lesions D. Culture the base of the lesion E. Perform a wet prep
The answer is A.
The diagnosis of syphilis is often established by serologic testing. Non-treponemal tests (VDRL or RPR) are non-specific. In this patient with high suspicion for syphilis, specific testing with treponemal antibody can confirm infection. The classic coiled spirochete is easily seen with dark-field microscopy but availability is limited. A characteristic finding is a macular rash on the palms and soles that are often described as copper penny lesions. Colposcopy would not be diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic. Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly would not be the most expedient way to make the diagnosis.
24 year-old G0 presents with multiple painful ulcers involving the vulva. The sores initially were fluid filled, but are now open, weeping and crusted. She reports a fever and is having difficulty voiding due to pain. She uses a vaginal ring for contraception. She has multiple sexual partners and uses condoms for vaginal intercourse. She is distraught that she may have a sexually transmitted infection. She is healthy and does not smoke or use drugs. On physical exam, she is in obvious distress. Temperature is 100.2°F (37.9°C), pulse 100. Examination of the genital tract is limited due to her discomfort. Multiple ulcers and erosions of variable size are localized to the perineum, labia minora and vestibule. Swelling is diffuse. The lesions are eroded, some with a purulent eschar. There is exquisite tenderness to touch. What further testing should be offered to this patient?
A. RPR (rapid plasma regain) B. HIV C. Herpes culture D. Cervical DNA probe for gonorrhea and chlamydia E. All of the above
E. All of the above
This patient has classic primary herpes with painful genital ulcerations, fever and dysuria. Given the presence of one sexually transmitted infection, screening should be offered for other STIs. Resolution of the acute episode is required before a speculum can be inserted to allow endocervical sampling for gonorrhea and chlamydia. If it was a high-risk exposure, prophylactic empiric treatment could be offered to cover gonorrhea and chlamydia. The patient should be counseled that primary herpes can be acquired despite condoms and even by oral-genital inoculation. Hepatitis B vaccination should be offered to protect her against any future exposures. She should be encouraged to discuss her diagnosis with all sexual partners and to continue to reliably use latex condoms.
38 year-old G0 comes to the office because she noted a persistent yellow, frothy discharge associated with mild external vulvar irritation. She denies any odor. She tried over the counter anti-fungal medication without success. The discharge has been present for over three months, gradually increasing in amount. Douching has resulted in temporary relief, but the symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix. A sample of the discharge is examined under the microscope. What is the most likely finding?
A. Strong amine “fishy” odor when KOH applied to sample B. Marked polymorphonuclear cells with multi-nucleate giant cells C. Motile ovoid protozoa with flagella D. Budding yeast and pseudo-hyphae E. Clue cells
The answer is C.
This patient most likely has trichomoniasis. The erythematous patches on the cervix are characteristic of “strawberry cervicitis.” Trichomonads are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide must be examined immediately. The discharge is mixed with saline and placed on the slide with a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green vaginal discharge with a strong odor. Clue cells are seen on a saline wet mount in women who have bacterial vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation may be herpes.
23 year-old G0 reports having a solitary, painful vulvar lesion that has been present for three days. This lesion has occurred twice in the past. She states that herpes culture was done by her doctor during her last outbreak and was negative. She is getting frustrated in that she does not know her diagnosis. She has no significant previous medical history. She uses oral contraceptives and condoms. She has had four sexual partners in her lifetime. On physical examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. How do you explain the negative culture?
A. Cultures were taken too early B. The more definitive test would be serum herpes antibody testing C. The cultures were refrigerated prior to transport to the lab D. Herpes cultures have a 10-20% false negative rate E. The herpes virus cannot be recovered with recurrent infections
The answer is D
Culture is the gold standard in the diagnosis of herpes. They are highly specific, yet sensitivity is limited. It is best to culture the lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The herpes virus can theoretically be isolated from both primary and recurrent infections. This patient very likely presented too late in the course for a useful culture. Serum antibody screening only indicates lifetime exposure and would not answer the question as to the etiology of the specific lesion. Alternatively, DNA studies such as the polymerase chain reaction can be done, if available.
A 27-year-old G1P0 at 34 weeks gestation is brought in by ambulance after a motor vehicle accident. Although restrained in the car with a safety belt, she suffers a significant head laceration. When she arrives in the emergency room, her initial trauma survey is completed. On her secondary survey, there is bright red blood coming from the vagina. Her abdomen is noted to be tense. Subsequent documentation of the fetal heart tones reveals fetal tachycardia. Abruption is suspected and the patient is rushed to the operating room for an emergent Cesarean section. After delivery, the nurse notes that an informed surgical consent was never signed. Which of the following is true?
a. Informed consent is valid if the doctor-patient discussion occurred soon after the patient received intravenous morphine for pain relief b. Informed consent is unnecessary in an emergency situation if a delay in treatment would risk the patient’s health/life c. Informed consent is only required for invasive procedures d. Informed consent would not have been valid anyway because the patient sustained a head laceration e. In an emergency situation, informed consent documents can be signed after the procedure is over and the patient is stable
Correct answer is B.
Informed consent needs to be obtained for all procedures while patient is fully alert and has not received any narcotics or other medications that may affect her decision-making. The only exception is in true emergency situations that would risk the patient’s life. Obtaining informed consent does not necessarily protect the provider from lawsuits and should never be signed after a procedure is already completed.
36-year-old G3P2 presents in active labor at full term with a known placenta previa. She reports brisk vaginal bleeding. Evaluation shows that fetus and patient are currently hemodynamically stable. She has had two normal vaginal deliveries in the past. She declines your recommendation to undergo Cesarean section. Which of the following is not advisable during your initial management of this patient?
a. Soliciting her reasons for not undergoing a Cesarean section b. Obtaining hospital Ethics Committee recommendation c. Proceeding with an emergency Cesarean section d. Explaining your reasons for recommending a Cesarean section e. Informing risk management of the situation that has developed
Correct answer is C.
You should not perform any procedure on the patient without her consent. It is best in these situations to explain your reasons for the recommended Cesarean section and elicit the patient’s reasons for not wanting to undergo the procedure. A court order should only be obtained as a last resort.
27-year-old G1 at 12 weeks gestation presents for first prenatal care visit. She is previously healthy and takes no medications. An ultrasound is performed and a viable pregnancy is confirmed. At the end of the visit, the patient discusses with you her desire to have a Cesarean section for delivery, as she does not wish to go through the pain of labor. Her husband, an orthopedic surgeon, expresses concerns as they desire to have at least three children and he is worried about potential complications with repeated Cesarean sections. What is the most appropriate next step in the counseling of this patient?
a. Agree with her decision after proper counseling and perform a Cesarean section at 39 weeks gestation b. Agree with her decision after proper counseling and perform a Cesarean section at 41 weeks gestation if she has not gone into labor by then c. Advise her that it is not possible to plan a Cesarean section for delivery d. Advise her to listen to her husband and plan for a vaginal birth e. Refer her to psychiatric counseling
Correct answer is A.
Elective cesarean section on demand has been getting more popular among women for a variety of reasons. Although, it might sound unreasonable to undergo a Cesarean section for being afraid of pain, the patient has the right to request it and the physician’s duty is to make sure she understands all the risks and potential complications associated with such a decision. Her husband is appropriately concerned but it is up to her to make the decision regarding an elective procedure.
25-year-old G3P2, who had recently undergone a primary Cesarean section, had her HIV status revealed to her mother when a nurse left her chart open in the recovery room. She speaks to patient relations and is thinking about seeking damages through legal avenues. When trying to explain the concept of patient privacy, which of the following statements is correct?
a. Patient privacy is based on the ethical principle of justice b. Patient privacy is protected by federal law, primarily with the Federal Emergency Medical Treatment and Labor Act (EMTALA) statute c. Patient privacy is the responsibility of physicians; physicians may be fined and/or assessed criminal penalties for violating the privacy of a patient’s protected health information d. The patient cannot win a lawsuit in this case because the mother should not have looked at the open record e. Patient privacy is based on the ethical principal of beneficence
Correct answer is C.
Patient privacy is the responsibility of physicians. Physicians may be fined and/or assessed criminal penalties for violating the privacy of a patient’s protected health information. It was the responsibility of the physicians and the other health care providers in this case to make sure the chart is not left open so someone walking by sees the information.
38-year-old G1P0 is admitted at 42 weeks gestation with an anencephalic infant for induction of labor. The attending physician decides not to monitor the baby’s heart rate during labor because he would not intervene with a Cesarean section in the event of fetal distress or demise. The physician’s action is justified by which one of the following concepts?
a. Beneficence to the fetus b. Disability rights c. Maleficence to the fetus d. Non-maleficence to the patient e. Justice for the patient
The answer is D
The non-maleficence principle expresses the concept that professionals have a duty to protect the patient from harm. Since an anencephalic infant will not survive, performing a
Cesarean section on this patient will cause her harm. Beneficence principle expresses the concept that professionals have a duty to act for the benefit of others, and, in this case, performing a Cesarean section will not benefit the fetus.
