ObGyn 25 MCQ (2)
26.A 19-year-old primigravid woman at 42 weeks' gestation comes the labor and delivery ward for induction of labor. Her prenatal course was uncomplicated. Examination shows her cervix to be long, thick, closed, and posterior. The fetal heart rate is in the 140s and reactive. The fetus is vertex on ultrasound. Prostaglandin (PGE2) gel is placed intravaginally. One hour later, the patient begins having contractions lasting longer than 2 minutes. The fetal heart rate falls to the 70s. Which of the following is the most appropriate next step in management?
a)Administer general anesthesia
e) Perform cesarean delivery
27. A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical and surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected aunt. Her husband has an affected cousin. Physical examination is unremarkable. Given her family history, she is concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis screening. Which of the following is the appropriate response?
a)Screening is available
b)Screening is inappropriate in her case
c)Screening is mandatory
d)Screening is not available
e)Screening is unnecessary: she has a 1 in 4 chance of having an affected child
28. A 52-year-old woman comes to the physician because of hot flashes. Her last menstrual period was 1 year ago. Over the past year, she has noted a persistence of her hot flashes, which come several times each day and are associated with a feeling of heat and flushing. They also awaken her at night and interfere with her sleep. She has no medical problems, takes no medications, and has no known drug allergies. She has a family history of cardiovascular disease and she does not smoke. Physical examination is unremarkable. She is started on estrogen and medroxyprogesterone acetate (Provera). The addition of a progestin is most likely to decrease her risk of which of the following?
29.A 21-year-old woman comes to the physician because of "bumps" on her vulva that she has just recently noticed. These bumps do not cause her symptoms, but she wants to know what they are and wants them removed. She has no medical problems, takes no medications, and has no allergies to medications. She smokes one-half pack of cigarettes per day. She is sexually active with 3 partners. Examination shows 3 cauliflower-like lesions on the right labia majora. Which of the following is the most appropriate next step in management?
30.A 29-year-old patient comes to the physician for an annual examination. She has normal menstrual periods every 30 days. She was 15 years old when she first began having intercourse. She uses condoms for contraception. Her past medical history is significant for multiple sclerosis. This condition has required her to use a wheelchair for the past 4 years, which makes pelvic examination somewhat difficult for her. She smokes one pack of cigarettes per day. Given her difficulty with the pelvic examination, she inquires as to how often she needs to have a Pap smear performed. Which of the following is the correct answer?
a)A Pap smear should be performed every year
b)A Pap smear should be performed every 3 years
c) A Pap smear should be performed every 5 years
d)A Pap smear should be performed only if there are symptoms
e) A Pap smear is not necessary
31.A 33-year-old woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had no bleeding or abdominal pain. She has no medical problems and takes no medications. She has no family history of congenital anomalies. Her husband is 55 years old. He is in good health and also has no family history of birth defects. The patient is concerned that her husband's age may place their fetus at increased risk of a chromosomal anomaly. She wishes to know the paternal age above which amniocentesis or chorionic villus sampling should be considered. Which of the following is the correct response?
a) Above age 30
b)Above age 35
c)Above age 40
d) Above age 45
e)There is no age cutoff for paternal risk
32.A 14-year-old girl comes to the physician for an annual examination. She has no complaints. She became sexually active during the past year and uses condoms occasionally for contraception. She has asthma, for which she occasionally takes an albuterol inhaler. She had an appendectomy at age 9. Physical examination is unremarkable including a normal pelvic examination. When should this patient begin having Pap testing?
c) Age 18
d) Age 20
e) Age 21
33.A 25-year-old nulliparous woman at 35 weeks' gestation comes to the labor and delivery ward complaining of contractions, a headache, and flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for an episode of first trimester bleeding that completely resolved. She has no medical problems.
Her temperature is 37 C (98.6 F),
blood pressure is 160/110 mm Hg,
pulse is 88/minute,
and respirations are 12/minute. Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she is contracting every 2 minutes.
The fetal heart tracing is in the 140s and reactive.
Urinalysis shows 3+ proteinuria.
Laboratory values are as follows:
platelets 101,000/mm3. Aspartate aminotransferase (AST) is 200 U/L,
and ALT 300 U/L. Which of the following is the most appropriate next step in management?
b)Discharge the patient
d)Start magnesium sulfate
34.A 33-year-old primigravid woman at 18 weeks' gestation comes to the physician for a prenatal visit. Her prenatal course has been uncomplicated thus far. She has no complaints. She has had no loss of fluid, bleeding, or contractions. She has hypothyroidism, for which she takes thyroid hormone replacement. The patient states that a friend of hers recently had a preterm delivery. The patient is quite concerned about preterm delivery and wants to know whether home uterine activity monitoring (HUAM) is recommended. Which of the following is the most appropriate response?
a) HUAM has been proven to cause preterm birth
b)HUAM has been proven to prevent preterm birth
c)HUAM has not been proven to prevent preterm birth
d)HUAM should be started immediately
e) HUAM should be started at 35 weeks
35. A 32-year-old nulliparous woman at 38 weeks' gestation comes to the labor and delivery ward with regular painful contractions after a gush of fluid two hours ago. Her temperature is 98.6 F (37 C). She is found to have gross rupture of membranes and to have a cervix that is 6 centimeters dilated. The fetus is in breech position. The patient is then brought to the operating room for cesarean delivery. Which of the following represents the correct procedure for antibiotic administration?
a) Administer intravenous antibiotics 30 minutes prior to the procedure
b)Administer intravenous antibiotics after the cord is clamped
c) Administer intravenous antibiotics immediately after the procedure
d)Administer intravenous antibiotics for 24 hours after the procedure
e)Administer oral antibiotics for 1 week following the procedure.
36. A previously healthy 21-year-old woman has a profuse, malodorous vaginal discharge. Examination shows a greenish gray "frothy" discharge with a "fishy" odor and petechial lesions on the cervix. There is no cervical motion tenderness. Her temperature is 37.5 C (99.4 F), blood pressure is 120/80 mm Hg, pulse is 60/min, and respirations are 16/min. Microscopic evaluation of the discharge is most likely to show which of the following?
a) "Clue cells"
d)Motile, flagellated organisms
e)Pseudohyphae or hyphae
37.A 21-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with painful contractions every three minutes. Her prenatal course was unremarkable. Examination shows her cervix to be 3 centimeters dilated and 90% effaced. The fetal heart rate tracing is in the 150s and reactive. 5 hours later cervical examination reveals that the patient is 9 centimeters dilated and at -1 station. The fetal heart rate tracing shows moderate variable decelerations with each contraction and decreased variability. Fetal scalp sampling is performed that yields fetal scalp pHs of 7.04, 7.05, and 7.06. Which of the following is the most appropriate next step in management?
c)Forceps-assisted vaginal delivery
d)Vacuum-assisted vaginal delivery
e) Cesarean delivery
38.A 31-year-old, HIV-positive woman, gravida 3, para 2, at 32-weeks' gestation comes to the physician for a prenatal visit. Her prenatal course is significant for the fact that she has taken zidovudine throughout the pregnancy. Otherwise, her prenatal course has been unremarkable. She has no history of mental illness. She states that she has been weighing the benefits and risks of cesarean delivery in preventing transmission of the virus to her baby. After much deliberation, she has decided that she does not want a cesarean delivery and would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in management?
a)Contact psychiatry to evaluate the patient
b)Contact the hospital lawyers to get a court order for cesarean delivery
c)Perform cesarean delivery at 38 weeks
d) Perform cesarean delivery once the patient is in labor
e) Respect the patient's decision and perform the vaginal delivery
39. A 26-year-old nulligravid woman comes to the emergency department because of severe right lower quadrant pain. She states that the pain started last night. This morning she was awakened from sleep with severe pain in the same area. During the episode of pain she also had nausea, vomiting, and diaphoresis. On admission to the emergency department she required 5 mg of morphine to control her pain. Examination is significant for right lower quadrant tenderness and a tender right adnexal mass on pelvic examination. Urine hCG is negative. Urinalysis is negative. Transvaginal ultrasound reveals an 8 cm right ovarian mass. Which of the following is the most likely diagnosis?
e)Pelvic inflammatory disease
40.An 18-year-old woman comes to the physician for advice regarding birth control. She has been sexually active since the age of 15 and has had numerous sexual partners since that time. She has tried the oral contraceptive pill twice, for approximately two cycles each time, but stopped because of irregular bleeding. She has had gonorrhea once and Chlamydia twice. She does not smoke. Physical examination is unremarkable. Which of the following forms of birth control should be recommended for this patient?
d)Oral contraceptive pill
41. A 44-year-old woman, gravida 4, para 3, at 8 weeks' gestation comes to the physician for her first prenatal visit. She has mild nausea and vomiting but no other complaints. Her obstetric history is significant for three full-term, normal vaginal deliveries of normal infants. She has no medical or surgical history and takes no medications. Physical examination reveals an 8-week-sized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of the fetus and wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place the patient at greater risk for which of the following?
a)Fetal Down syndrome
b)Fetal limb defects
c)Fetal neural tube defects
42.A pharmaceutical company sponsors a physician lecture concerning thrombotic complications of the oral contraceptive pill (OCP). At the start of the presentation, the company's representative makes a short presentation regarding their particular brand of OCP. He then proceeds to announce that his company would like to award a gift to the physician in the group who gives the largest number of prescriptions for this pill. Which of the following is the most appropriate action?
a) Acceptance of the gift
b)Attempt to get colleagues to prescribe the medication
c)Promise to prescribe more of the medication
d)Refusal of the gift
e) Request for money rather than a gift
43. A 24-year old woman comes to the physician because of burning with urination. She states that every time she urinates there is pain and that she has a feeling that she constantly needs to urinate even though only a little comes out. She has never had any similar symptoms before. She has no medical problems and no known drug allergies. Examination is unremarkable. Urinalysis demonstrates that the urine is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate pharmacotherapy?
c)Oral levofloxacin for 7 days
d)Oral trimethoprim-sulfamethoxazole for 3 days
e) Wait for the culture results to institute therapy
44. A 21-year-old woman comes to the physician because of abdominal pain. She states that the pain is in her right lower quadrant and has been getting worse over the past 3 months. She has no other symptoms and a normal appetite. Examination demonstrates mild right lower quadrant abdominal tenderness. Pelvic examination reveals mild right adnexal enlargement and tenderness. Urine human chorionic gonadotropin (hCG) is negative. A pelvic ultrasound is obtained that shows a 4-centimeter, heterogeneous hyperechoic lesion in the right adnexa with cystic areas. On transvaginal ultrasound, hair and calcifications are demonstrated within the cystic areas. Which of the following is the most likely diagnosis?
b)Benign cystic teratoma (dermoid)
c)Corpus luteum cyst
45.A 65-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period was at age 50 and that she has had no bleeding since. She has no medical problems and takes no medications. She is not sexually active. Examination is unremarkable, including a normal pelvic examination. After informed consent is obtained, an endometrial biopsy is performed. The patient complains of discomfort during and after the procedure but feels well enough to go home. Later that night, with her abdominal pain worsening, the patient comes to the emergency department. An ultrasound is performed that shows a normal uterus and adnexae but a complex fluid collection posterior to the uterus. Which of the following is the most likely diagnosis?
a) Bowel perforation
46.A 23-year-old female comes to the physician because of a swelling in her vagina. She states that the swelling started about 3 days ago and has been growing larger since. The swelling is not painful, but it is uncomfortable when she jogs. She has asthma for which she uses an albuterol inhaler, but no other medical problems. Examination shows a cystic mass 4 cm in diameter near the hymen by the patient's left labia minora. The mass is nontender and there is no associated erythema. The mass is freely mobile. The rest of the pelvic examination is unremarkable. Which of the following is the most likely diagnosis?
47. A 37-year-old woman, gravida 3, para 2, comes to her physician for follow-up on her ectopic pregnancy. She was diagnosed with an ectopic pregnancy 7 days ago and given methotrexate. She now presents with abdominal pain that started this morning. Examination is significant for moderate left lower quadrant tenderness. Laboratory analysis shows that her beta-hCG value has doubled over the past week. Transvaginal ultrasound shows that the ectopic pregnancy is roughly the same size but there is an increased amount of fluid in the pelvis. Which of the following is the most appropriate next step in management?
48. A 26-year-old woman comes to the physician because of a lump in her vagina. The lump is nontender but is uncomfortable when she walks. She states that for the last 6 years this lump has appeared about once a year. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She has no other medical problems. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. The rest of the pelvic examination is unremarkable. Which of the following is the most appropriate next step in management?
d)Incision and drainage
e) Bartholin's cyst marsupialization
49.A 25-year-old woman, gravida 2, para 2 is 4 days status post cesarean section and develops a temperature to 100.7 F (38.2 C). She had her cesarean section when she went into unstoppable preterm labor with a breech fetus. She had an uncomplicated postoperative course until this temperature elevation. Her pulse is 100/min, blood pressure is 110/70 mm Hg, and respirations are 16/min. There is discoloration and cyanosis around the incision. The area around the incision is completely numb. There is no uterine tenderness on bimanual exam. Which of the following is of the most concern in this patient?
e) Wound infection
50. A 32-year-old woman, gravida 2, para 2, comes to the physician for follow-up of an abnormal Pap test. One month ago, her Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy demonstrated acetowhite epithelium at 2 o'clock. A biopsy taken of this area demonstrated HGSIL. Endocervical curettage (ECC) was negative. The patient has no other medical problems, has never had cervical dysplasia, and takes no medications. Which of the following is the most appropriate next step in management?
a)Repeat Pap test in 1 year
b)Repeat Pap test in 6 months
c)Repeat colposcopy in 6 months
d)Loop electrode excision procedure (LEEP)
Answers for questions 26-48
The correct answer is
B. Once patients reach 42 completed weeks of gestation, many physicians will induce labor for post-term pregnancy. This is done to avoid the uncommon but catastrophic outcome of fetal demise and the higher rates of placental insufficiency that develop as patients get further post-term. Prostaglandin (PGE2) gel is an effective agent to use for labor induction. It has been shown to improve the Bishop's score, to shorten the length of labor and delivery, to decrease the amount of oxytocin needed, and to decrease the cesarean delivery rate. The main complication from its use is uterine hyperstimulation. This hyperstimulation is defined as an increased frequency of contractions (greater than 5 every 10 minutes) or an increased length of each contraction (greater than 2 minutes) with evidence of fetal distress. When this hyperstimulation occurs, the patient may be treated with IV or subcutaneous terbutaline. This medication usually has a rapid onset of action in resolving hyperstimulation. IV magnesium sulfate can also be used. To administer general anesthesia (choice A) would be incorrect. There are occasions in which the fetal heart rate tracing rapidly deteriorates and emergency cesarean delivery is needed. On these occasions, it may be necessary to administer general anesthesia to the mother during the cesarean. In this case, however, more conservative measures should be tried prior to cesarean delivery. To perform amnioinfusion (choice C) would be incorrect. Amnioinfusion can be used when a patient has ruptured membranes and decelerations of the fetal heart rate or thickened meconium. It is not used with intact membranes. To start oxytocin (choice D) would be contraindicated. Oxytocin is known to cause uterine hyperstimulation, as is prostaglandin (PGE2) gel. Oxytocin would not be given to a patient in the midst of uterine hyperstimulation. To perform cesarean delivery (choice E) would be incorrect for the reasons detailed above.
The correct answer is
A. Cystic fibrosis (CF) is an autosomal-recessive disease that is common in North American Caucasians of European ancestry. In this population, the frequency of the disease is 1 in 2500 live births. The carrier rate is approximately 1 in 25 individuals. The outcome of patients with CF is highly variable. Some will die in infancy from complications of meconium ileus, whereas others will live beyond the age of 50. The usual clinic manifestations include pulmonary disease with bronchiectasis, pancreatic insufficiency, and failure to thrive. The gene for the disease is known. However, there are more than 500 mutations that can cause C
F. The most common mutation, which causes 75% of cases in Caucasians, is referred to as delta-F508. The CF gene has been cloned, and it is possible to perform screening on couples. Genetic techniques can also be used to determine whether the fetus has the relevant mutations. In this patient, with her and her husband's family histories, screening would be available and appropriate. To state that screening is inappropriate in her case (choice B) is incorrect. This patient has relatives with CF and so does her husband. She is concerned about the possibility of having a child with this disease. Screening is available and appropriate in her case. To state that screening is mandatory (choice C) is inappropriate. Whether to undergo screening for a genetic disease is a very personal choice. This patient may not want to know whether she is a carrier or whether her fetus is affected. Many patients with genetic diseases or with family histories of genetic disease feel this way, and screening is certainly not mandatory. To state that screening is not available (choice D) is incorrect. As stated above, CF screening is available. To state that screening is unnecessary because she has a 1 in 4 chance of having an affected child (choice E) is incorrect. If she and her husband were both carriers with the same mutation, the risk would be 1 in 4. However, we do not know this. Although they both have positive family histories, neither may be a carrier.
The correct answer is
C. Unopposed estrogen is known to cause endometrial hyperplasia and cancer. Estrogen has direct effects on the growth and development of the endometrium. Studies have shown that the addition of a progestin can protect a woman from the development of endometrial hyperplasia and that the addition of a progestin to women with endometrial hyperplasia can lead the endometrium to revert to normal. Thus, any woman with a uterus who is on estrogen therapy should also be on a progestin to protect her endometrium. This is usually done by placing the patient on daily estrogen and progesterone or on cyclic progesterone. Progestins do not protect against the development of breast cancer (choice A). In fact, there is evidence that progestins may stimulate the growth of breast tumors. Breast pain (choice B) is often a result of progestin therapy. Mood changes (choice D) and weight gain (choice E) are well-known side effects of progestins.
The correct answer is
D. This patient has findings that are most consistent with condyloma acuminata, or genital warts. Condyloma acuminata is caused by the human papillomavirus. This virus, of which there are many different subtypes, infects epidermal cells and can cause warty growths. When the virus affects skin cells on the hands, the result is the common warts that are often seen in children. When the virus affects cells on the perineum, the result is condyloma acuminata. Diagnosis is made on the basis of the classic, verrucous (cauliflower-like) appearance of the lesions. Treatment is with local destruction. This local destruction can be achieved in a variety of ways including with cryotherapy (i.e. freezing of the skin), laser therapy, trichloroacetic acid (i.e. chemical destruction of the skin), or imiquimod. However, while the lesions themselves are often successfully treated with these locally destructive agents, the virus is not usually completely eradicated and recurrences of the lesions may occur. Acyclovir (choice A) is used to treat herpes viruses. Condyloma acuminata is caused by the human papillomavirus and, therefore, acyclovir is not used. Penicillin (choice B) is an antibiotic effective against bacteria, and not the human papillomavirus. Cone biopsy (choice C) is performed on the cervix when a patient has high-grade dysplasia or cancer. While there is an association between human papillomavirus infection and cervical dysplasia, cone biopsy would not be indicated for a patient on the basis of the presence of condyloma. Vulvectomy (choice E) is performed on patients for vulvar dysplasia or cancer. It is not indicated for patients with condyloma.
The correct answer is
A. It is essential that physicians who treat women with disabilities do not give them substandard care because of their disability. This woman has two risk factors that place her at greater risk of having cervical dysplasia: early age at first intercourse and smoking. Both of these characteristics have been shown to be associated with patients who develop cervical dysplasia. Current recommendations are that women begin having annual Pap smears at the onset of intercourse or age 18, whichever comes first. Some physicians believe that in certain low-risk women with three annual normal Pap smears, the interval of screening may be increased to every 3 years. Others argue that annual Pap smears should be performed in all women, regardless of risk status. For this patient, given her risk factors, annual Pap smears should be performed. The fact that pelvic examination is difficult for her because of her multiple sclerosis needs to be addressed by taking appropriate measures so that the examination can be made easier for her. She should not receive inadequate screening for cervical cancer because she has a disability. To state that a Pap smear should be performed every 3 years (choice B) is incorrect. This patient, with her early onset of first intercourse and current cigarette smoking, has risk factors for cervical dysplasia and needs annual screening. To state that a Pap smear should be performed every 5 years (choice C) is not correct. Because of the false-negative rate of the Pap smear, screening every 5 years would risk missing many cases of dysplasia or cancer. To state that a Pap smear should be performed only if there are symptoms (choice D) is incorrect. Progressing cervical dysplasia is typically an asymptomatic process, and awaiting symptoms prior to performing the Pap smear would miss most cases. To state that a Pap smear is not necessary (choice E) is not correct. All sexually active women or women older than 18 need to have screening with the Pap smear. Women with disabilities should not receive substandard care because of their disability.
The correct answer is
E. Increasing maternal age leads to an increased risk of chromosomal anomalies in the fetus. These anomalies include trisomy 13, 18, and 21. Advanced maternal age also leads to increased rates of the sex chromosome aneuploidies 47 XXY and 47 XXX. Because of this relationship between advanced maternal age and chromosomal anomalies, many experts suggest amniocentesis or chorionic villus sampling in women who will be 35 years of age or older at the time of their delivery. Paternal age has not been shown to be related to chromosomal anomalies. There is evidence that advanced paternal age is linked to an increased risk of autosomal dominant mutations, which lead to diseases such as neurofibromatosis, achondroplasia, Apert syndrome, and Marfan syndrome. Increasing paternal age also may be associated with X chromosome mutations that are transmitted through carrier daughters to affected grandsons. However, these risks are exceedingly small, and it is currently not possible to screen prenatally for all the autosomal dominant or X-linked diseases that advanced paternal age may be associated with. Therefore, unlike with women, in whom the age of 35 is usually given as the cutoff for chromosomal evaluation of the fetus, there is no age cutoff for paternal risk. To state that amniocentesis or chorionic villus sampling should be considered for a paternal age above age 30 (choice A), 35 (choice B), 40 (choice C), or 45 (choice D) is incorrect. As explained above, advanced paternal age is associated with autosomal dominant mutations and X-linked mutations. These mutations are very rare, and we are currently unable to screen for all of these mutations prenatally.
The correct answer is
A. Pap testing is used to screen women for cervical cancer. The development of cervical cancer is believed to be a gradual process in which the cervical cells gradually progress from dysplasia to carcinoma in situ to invasive cancer. Cervical cancer is certainly linked to sexual activity, as the human papillomavirus, which is transmitted through sexual contact, is believed to play a causative role. Sexual intercourse also allows exposure to other infectious diseases and carcinogens that may play a role in the process. Therefore, a patient should begin having Pap testing once she begins to engage in sexual intercourse. If a patient has not had sexual intercourse by the age of 18, Pap testing should begin then. Pap testing should be performed yearly, primarily because a single Pap test has a high false-negative rate (i.e., the Pap test has a low sensitivity). The sensitivity of Pap testing is often quoted as 80%. Therefore, 2 of 10 women with abnormal cervical cells will be missed with Pap testing. However, if the examination is repeated every year, as it should be, then the likelihood of missing the lesion over time is much lower. To start at age 16 (choice B), 18 (choice C), 20 (choice D), or 21 (choice E) is too late for this patient. Although the progression to cervical cancer is believed to be a gradual one, there are more aggressive forms that are more rapidly progressive. Also, if one waits until age 16, 18, 20, or 21, and the patient misses that next appointment or has a false negative on the Pap test, then the disease will be given even further time to progress. Also, to wait until later to do Pap testing with this patient is to miss an opportunity for cervical cancer screening. The patient may not return for follow-up. Therefore, screening should be performed now.
The correct answer is
D. This patient has severe preeclampsia. Preeclampsia is diagnosed on the basis of hypertension, edema, and proteinuria. Severe preeclampsia may be diagnosed when the patient has one of the following: a headache that does not respond to analgesics, visual changes, seizure, very elevated blood pressures, pulmonary edema, elevated liver function tests, severe proteinuria, oliguria, an elevated creatinine, thrombocytopenia, hemolysis, intrauterine growth restriction, or oligohydramnios. The management of severe preeclampsia after 32 weeks is with delivery. Prior to 32 weeks, consideration may be given to expectant management of the patient depending on the clinical circumstances. This patient is at 35 weeks' with headache, visual changes, elevated blood pressures, thrombocytopenia, and elevated liver function tests. She, therefore, needs to be delivered. She appears to already be in labor as she is contracting every two minutes and her cervix is dilated and effaced. At this point, magnesium sulfate should be started. Magnesium sulfate has consistently been demonstrated to be the most effective medication for seizure prophylaxis in women with preeclampsia. To administer oxytocin (choice A) would not be necessary for this patient. She appears to already be in labor with contractions every two minutes. To discharge the patient (choice B) would absolutely be incorrect. Severe preeclamptics need to be delivered or, at the very least, admitted to the hospital. There is no role for discharging a patient home in the management of severe preeclampsia. To encourage ambulation (choice C) would also be incorrect. Severe preeclamptics should be kept on bed rest. To start terbutaline (choice E) would not be appropriate. Terbutaline is used in obstetrics as a tocolytic agent to treat preterm labor. In this patient, contractions and labor are desirable and no attempt should be made to stop them, as she requires delivery.
The correct answer is
C. Home uterine activity monitoring (HUAM) became a controversial area of obstetrics during the 1990s. Of all liveborn neonates, approximately 7% will be less than 2500 g (low birth weight). Approximately 1% will be less than 1500 g (very low birth weight). Most of the infant mortality rate comes from these low birth weight and very low birth weight neonates. Preterm labor and delivery is the cause of many of these cases. Thus, strategies to prevent preterm delivery are very much sought after. One such strategy is HUAM. With this technique, women are monitored at home with a tocodynamometer (a way to measure uterine contractions). The theory is that this home monitoring will allow for preterm labor to be recognized and treated in its earliest stages, which may help to prevent preterm births. In practice, however, this has not been proven to be the case. Numerous studies have been performed, and HUAM has not been proven to prevent preterm birth. A possible benefit of HUAM may be the early recognition of preterm labor, which would allow for the administration of corticosteroids to bring about fetal pulmonary maturity, even if a preterm delivery could not be prevented. This question has not been fully answered. At present, therefore, HUAM has not been proven to prevent preterm birth, and its use is not recommended. To state that HUAM has been proven to cause preterm birth (choice A) is not correct. HUAM is a noninvasive technique for monitoring uterine activity, and it is used to try to prevent preterm birth. Side effects and complications are rare. To state that HUAM has been proven to prevent preterm birth (choice B) is incorrect. This is the central area of controversy for this technique, namely that it has not been proven to prevent preterm birth. To state that HUAM should be started immediately (choice D), or that HUAM should be started at 35 weeks (choice E) is incorrect. As explained above, HUAM has not been proven to prevent preterm delivery; therefore, its use is not currently recommended.
The correct answer is
B. One of the major risk factors for developing postpartum endometritis is cesarean delivery. Therefore, prophylactic antibiotics are recommended in all cases of nonscheduled cesarean delivery (i.e., a cesarean delivery that is not anticipated). This patient is having a cesarean delivery because she is a nulliparous woman in labor with a fetus in the breech position. The fact that her membranes broke a few hours ago, and that she has dilated to 6 centimeters puts her at even higher risk for postpartum endometritis because of the possible exposure that has occurred to the vaginal flora. Intravenous antibiotics will help to prevent infection of the mother if they are given before or after the umbilical cord is clamped. Therefore, to minimize fetal exposure to the antibiotics, the medication should be given after the umbilical cord is clamped. This patient has no evidence of chorioamnionitis; therefore there is no indication to give the antibiotics immediately. To administer intravenous antibiotics 30 minutes prior to the procedure (choice A) is proper management in a non-pregnant patient undergoing, for example, a hysterectomy. In the pregnant patient, administering the antibiotic prior to clamping the umbilical cord results in unnecessary fetal exposure. To administer intravenous antibiotics immediately after the procedure (choice C) is incorrect because there is a needless delay. Once the umbilical cord is clamped, there is no further concern regarding unnecessary fetal exposure and the antibiotic may be given immediately. To administer intravenous antibiotics for 24 hours after the procedure (choice D) is indicated when the patient has chorioamnionitis. This patient, however, has no evidence of being infected and the antibiotics are being given for prophylaxis. To administer oral antibiotics for 1 week following the procedure (choice E) is unnecessary. Once the single dose is given at the time of cord clamping, there is no need for further treatment.
The correct answer is
D. This patient has trichomoniasis. Trichomoniasis is caused by a motile, flagellated protozoan, Trichomonas vaginalis. The symptoms include a copious, malodorous ("fishy"), greenish-gray, "frothy" discharge. The vulvar and vaginal epithelium may be erythematous and edematous. Colposcopy may reveal petechial cervical lesions ("strawberry cervix"). A wet mount of the discharge often reveals motile trichomonads and polymorphonuclear leukocytes (PMNs). The treatment is metronidazole. Simultaneous treatment of the sexual partner reduces the risk of reinfection. "Clue cells" (choice A), vaginal squamous epithelial cells coated with coccobacillary organisms, are seen in bacterial vaginosis. The symptoms include a moderate amount of malodorous ("fishy"), white to gray, homogeneous vaginal discharge. An amine ("fishy") odor is present after mixing vaginal secretions with KOH. This is often called a positive whiff test. Saline preparations of the discharge reveal the "clue cells". The treatment is metronidazole.Simultaneous treatment of the sexual partner has not been shown to reduce recurrence. Gram-negative diplococci (choice B) are an indication of Neisseria gonorrhoeae. N. gonorrhoeae causes a mucopurulent cervical discharge in acute cervicitis and can lead to pelvic inflammatory disease (PID). PID is characterized by lower abdominal pain, fever, and cervical motion tenderness. Diagnosis is often made by Gram's stain of cervical secretions revealing gram-negative diplococci and polymorphonuclear leukocytes. Treatment is ceftriaxone IM once and doxycycline or azithromycin. The 2 latter drugs are given since concomitant chlamydial infection is common. Sexual partners must be treated. Gram-positive diplococci (choice C) are not a common cause of cervical discharge. Pseudohyphae or hyphae (choice E) is an indication of candidiasis. Vulvar pruritus, irritation, and a thick, white, cottage cheese-like discharge are the predominant symptoms. Diagnosis is made by KOH, saline, or Gram's stain evaluation of the vaginal fluid revealing fungi. Treatment is fluconazole PO or imidazole cream. Routine treatment of sexual partners is usually not indicated.
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E. Fetal scalp sampling (FSS) is a method of fetal assessment that is used during labor and delivery to obtain fetal blood for pH assessment. Normal labor and delivery is characterized by a lowering of the fetal pH as the labor progresses. However, most fetuses tolerate labor and delivery without a dangerous drop in pH (i.e. an acidosis that will result in organ damage). When the fetal heart rate tracing is not reassuring, FSS can be used to determine the acid-base status of the fetus, which will help with management of the labor. If the pH is > 7.25 then the patient may be managed expectantly with continued observation of the labor and the fetal heart rate. If the pH is between 7.20 and 7.25, the FSS should be repeated in 15 to 30 minutes. If the pH is < 7.20, steps should be taken to bring about delivery. Acidemia likely to cause damage to the fetus appears to occur at values < 7.00. However, by using a cutoff of 7.20, there is a margin for error to protect the fetus. This fetus has fetal scalp blood pHs of 7.04, 7.05, and 7.06. This level of acidemia is considered an indication for immediate delivery. Because the fetus is at -1 station, far too high for forceps or vacuum-assisted vaginal delivery, a cesarean delivery should be performed. Expectant management (choice A) would be inappropriate. This patient has a fetus at -1 station with scalp pHs consistently less than 7.20. Therefore, cesarean delivery should be performed. Episiotomy (choice B) would not be indicated. Episiotomy is sometimes used when forceps or vacuum-assisted vaginal delivery will be performed. It may also be performed to facilitate an uninstrumented vaginal delivery. In this case, however, the patient requires a cesarean delivery. Forceps-assisted vaginal delivery (choice C) or vacuum-assisted vaginal delivery (choice D) would be incorrect. Forceps and vacuum-assisted vaginal delivery should not be performed at stations higher than +2. Certainly, at -1 station, this fetus is "too high" to attempt an assisted vaginal delivery.
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E. Cesarean delivery has been shown to decrease the rate of transmission of HIV from an infected mother to her fetus. Some reports have shown that the transmission rate can be decreased to as low as 2% with the combination of antiretroviral medication and elective cesarean delivery prior to labor or rupture of membranes. However, although cesarean delivery benefits the infant by decreasing the risk of transmission, the risks of the surgery accrue to the mother. Risks of cesarean delivery include bleeding, infection, and injury to internal organs. HIV-infected women with low CD4 cell counts are known to have higher rates of postoperative complications. Thus, the decision of whether to have a cesarean ultimately belongs to the mother. This patient's autonomy must be respected and she should have a vaginal delivery if she so chooses. To contact either psychiatry to evaluate the patient (choice A) or the hospital lawyers to get a court order for cesarean delivery (choice B) would be incorrect. Patient autonomy must be respected when it comes to the decision of whether to have a cesarean delivery. This patient has weighed the benefits and risks and has put a great deal of deliberation into her decision. There is no need to involve the psychiatry department or the hospital lawyers in this decision. To perform cesarean delivery at 38 weeks (choice C) or once the patient is in labor (choice D) would not be correct. In HIV-positive women who do want an elective cesarean delivery, the delivery should be performed at 38 weeks to avoid the risk of labor or rupture of membranes. Once labor starts or the membranes are ruptured, the risk of HIV transmission increases. However, this patient does not want a cesarean delivery, so that operation should not be performed.
The correct answer is
D. This patient's presentation is most consistent with ovarian torsion. Ovarian torsion typically occurs in the setting of an adnexal mass. A mass changes the motion "dynamics" of the adnexae such that a twisting of the adnexa becomes possible. This mass can be a functional ovarian cyst, a dermoid, a paratubal cyst, or any number of other benign or malignant neoplasms. Once a complete torsion has occurred, the arterial supply to the ovary is occluded and necrosis can result. Patients with adnexal torsion can present with a history of intermittent pain that comes and goes as the adnexa twists. The pain is usually severe and often accompanied by episodes of nausea, vomiting, and diaphoresis, as this patient had. They may need narcotics to control the severe pain. A pelvic mass will almost always be found on physical examination or by ultrasound. If there is no adnexal mass, the diagnosis of ovarian torsion is highly unlikely. This is true because most normal ovaries do not have the motion "dynamics" that will allow them to twist. Appendicitis (choice A) should always be a consideration when a patient presents with right lower quadrant pain. However, in this case, the combination of the pain with the ovarian mass makes ovarian torsion, and not appendicitis, the most likely diagnosis. Ectopic pregnancy (choice B) should also be an important consideration when a young woman presents with abdominal pain. Some emergency departments have signs reading "Think Ectopic" to keep staff aware of this possibility. In this case, however, the patient is not pregnant (negative urine hCG) which excludes ectopic from the differential. Nephrolithiasis (choice C) can also cause excruciating pain, as does ovarian torsion. With nephrolithiasis, hematuria will often be present. In this patient, the absence of hematuria and the presence of the right adnexal mass make nephrolithiasis less likely. Pelvic inflammatory disease (choice E) is a diagnosis that merits consideration in a woman with abdominal pain with a negative hCG (it is far less common during pregnancy). However, the ovarian mass in this case makes torsion a more likely diagnosis than PI
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A. All of the above options will provide birth control for this patient. However, another major factor for this patient is the prevention of sexually transmitted disease. Other than abstinence, condoms provide the best protection against the acquisition of sexually transmitted diseases. This patient, with her early onset of intercourse at the age of 15 and her numerous sexual partners, is at high risk for HIV, hepatitis, herpes, chlamydia, gonorrhea, syphilis, human papillomavirus, and the eventual development of cervical cancer. It is absolutely essential that she be counseled regarding condom use and the importance of her protecting herself from sexually transmitted diseases as well as pregnancy. The diaphragm (choice B) is an effective method of birth control for motivated women who are able to use this method with each episode of intercourse. Because it covers the cervix, it provides some protection against disease. However, it does not provide as much protection against sexually transmitted diseases as condoms do. The intrauterine device (choice C) is absolutely contraindicated in a woman with numerous sexual partners and a recent history of sexually transmitted disease. Furthermore, it is highly suboptimal for young women, in whom a pelvic infection could lead to reduced or absent future fertility. The oral contraceptive pill (OCP) (choice D) would provide this patient with protection against pregnancy; however, it would not protect her from sexually transmitted diseases. An ideal approach may be to have her use both the OCP and condoms. However, consistent use of both can be difficult. Tubal ligation (choice E) would provide this patient with no protection against sexually transmitted disease. Furthermore, except in very rare circumstances, it is contraindicated for an 18-year-old.
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B. Chorionic villus sampling (CVS) is a procedure in which the chorionic villi are sampled through either a transabdominal or transcervical approach. Amniocentesis is a procedure in which amniotic fluid is removed. In both procedures, cells are removed and can be analyzed for chromosomal abnormalities. A major advantage of chorionic villus sampling is that it can be performed at 10-12 weeks, as opposed to amniocentesis, which is performed in the second trimester. CVS thus allows a woman to undergo an earlier termination than amniocentesis allows for. In the early 1990s, there were several reports linking chorionic villus sampling to limb reduction defects in the infants. Most of the large studies have shown no overall increased risk of limb deficiencies among infants whose mothers underwent CVS. However, there is some evidence that one subtype of limb defect, called transverse digital deficiency, is more common with CVS. The risk of fetal Down syndrome (choice A) is not increased by the procedure used to detect it. Whether CVS or amniocentesis is used, the fetus has a set risk of Down syndrome. The risk of fetal neural tube defects (choice C) is also not increased by the procedure used to detect them. However, CVS does not allow for the prenatal diagnosis of neural tube defects. Only amniocentesis allows for the evaluation of amniotic fluid alpha-fetoprotein, which is often necessary to make the diagnosis. Maternal sepsis (choice D) is not more likely with CVS compared with amniocentesis. The risk for either procedure is very low. Mid-second-trimester abortion (choice E) is more likely with amniocentesis than with CVS. Amniocentesis is performed later in pregnancy; therefore, termination based on the amniocentesis result is likely to occur later than with CVS (performed at 10-12 weeks).
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D. Pharmaceutical companies often provide funding for educational opportunities for physicians. This involvement is considered acceptable by some and unacceptable by others. Pharmaceutical company involvement, however, should never place the physician in a situation whereby the interests of the patient are not placed in a primary position. In the above scenario, the physician will be rewarded for giving the most prescriptions for this particular oral contraceptive pill (OCP). This reward system may place the physician's interest against that of the patient. For example, a given patient may benefit more from another OCP, but the physician will feel pressure to prescribe the pill that will bring him the gift. Thus, most specialty societies declare that physicians should not accept gifts if they are given secondary to the physician prescribing certain medications. Acceptance of the gift (choice A) would legitimize the approach of the company of providing gift incentives to physicians that prescribe their medication. This is considered unethical. An attempt to get colleagues to prescribe the medication (choice B) or a promise to prescribe more of the medication (choice C) to please the pharmaceutical company representative would also place the patient's interests in a secondary position. This is considered unethical. A request for money rather than a gift (choice E) is an example of direct conflict of interest behavior. The interest of the patient in this case is not primary. Therefore, schemes of reward such as that presented above are considered unethical.
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D. This patient likely has an uncomplicated urinary tract infection (UTI). Patients with UTIs often present with dysuria, frequency, and urgency. Physical examination is often unremarkable, although there may be some suprapubic tenderness if a cystitis is the predominant infection rather than a urethritis. Urine "dip" will often be positive for leukocyte esterase and nitrites. Microscopic urinalysis will often show the presence of white blood cells and red blood cells. Escherichia coli is the offending organism in about 80% of cases with Staphylococcus saprophyticus being the next most likely causative organism. Treatment of an uncomplicated urinary tract infection is with a 3-day course of oral antibiotics. Trimethoprim-sulfamethoxazole (Bactrim) has been shown to be safe, effective, and cost-effective in the treatment of uncomplicated UTIs. Intramuscular ceftriaxone (choice A) is used for the treatment of gonorrhea. This patient has findings consistent with urinary tract infection and not gonorrhea, and therefore, a 3-day course of oral antibiotics is indicated, rather than intramuscular ceftriaxone. Intravenous levofloxacin (choice B) can be used in cases of complicated urinary tract infections in patients that cannot take oral medications and oral levofloxacin (choice C) can be used when the patient is tolerating oral intake. Levofloxacin has roughly the same bioavailability when taken orally versus intravenously, so the route depends on the patient's status. However, this medication is used when patients have complicated urinary tract infections (i.e. with Pseudomonas or Proteus species) or when the patient has underlying medical illness. To wait for the culture results to institute therapy (choice E) would not be appropriate. The patient has symptoms and findings consistent with a UTI right now and therefore should be treated now. To wait 2 or more days for the culture results to come back would not be appropriate.
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B. This patient has a presentation and findings that are most consistent with a benign cystic teratoma (dermoid). Cystic teratomas are, by far, the most common type of ovarian neoplasm: cystic teratomas account for 25 to 40% of all ovarian neoplasms. They are a type of ovarian germ cell tumor, which can range in size from small masses that are noted incidentally on ultrasound and cause no symptoms to larger cysts that cause pain and pressure, as this patient has. A single germ cell gives rise to a teratoma. Because the germ cell is totipotential, the dermoid is characterized by all three germ cell layers: ectoderm, mesoderm, and endoderm. Gross examination of a dermoid will often reveal skin, bones, hair, and teeth, which can often be seen on ultrasound. The part of the dermoid that contains the largest number of different tissues is called Rokitansky's protuberance. Laparotomy is usually the most appropriate management of a patient with a dermoid because, as adnexal masses enlarge, the risk of ovarian torsion increases. Also, dermoids may cause symptoms of pain and pressure and, on that basis, should be removed. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. Appendicitis (choice A) is usually not a chronic process slowly developing over 3 months. Also, patients with appendicitis typically have anorexia and appear ill. A corpus luteum cyst (choice C) is a common cause of a complex adnexal mass in a young woman. However, this patient has a presentation and a mass with ultrasound characteristics that are classic for dermoid. Ectopic pregnancy (choice D) should always be considered when a woman of childbearing age presents with abdominal pain. A negative urine hCG effectively rules out ectopic pregnancy. Patients with a tubo-ovarian abscess (choice E) usually have fevers, significant abdominal and pelvic tenderness, and appear ill.
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E. This patient presents with postmenopausal bleeding. The majority of patients who have postmenopausal bleeding will not have endometrial hyperplasia or cancer. However, because postmenopausal bleeding is the most common presenting complaint of women with endometrial cancer, it is important to rule this out. A common way to evaluate the endometrium is with an endometrial biopsy. This can be performed with a small suction cannula that is introduced through the cervical os and into the uterine cavity to get a sample of the endometrium. The procedure is standard in the practice of gynecology but is not without risks. One of the risks of endometrial biopsy is uterine perforation (i.e. advancing the cannula too far such that it penetrates and perforates through the wall of the uterus). This patient has evidence of uterine perforation. First, she experienced significant pain during the procedure and continuing afterwards. While endometrial biopsy can cause considerable discomfort, it is usually of a crampy nature that should resolve shortly after the procedure. Second, her pelvic ultrasound now shows a complex fluid collection posterior to the uterus, which likely represents a collection of blood in the posterior cul-de-sac. If the patient has stable vital signs and an acceptable hematocrit, uterine perforation can be managed expectantly. If, however, the patient has evidence of hemodynamically significant bleeding, then she will require operative intervention. Bowel perforation (choice A) is a very unlikely complication with an endometrial biopsy. It's rare for the cannula to be advanced far enough to damage the uterus (uterine perforation), let alone damage the bowel. Endometritis (choice B) can be a complication of an endometrial biopsy. Patients undergoing endometrial biopsy should be counseled that infection is one of the risks of the procedure. However, this patient is afebrile and the pelvic fluid collection is more suggestive of a perforation than an endometritis. While it is possible that this patient has endometrial cancer (choice C), it is not likely that endometrial cancer is causing her acute problem. Again, most women with postmenopausal bleeding do not have endometrial cancer. And, this patient's sudden onset of pain and pelvic fluid collection after endometrial biopsy is most suggestive of endometrial cancer. A patient with a tuboovarian abscess (choice D) usually presents with abdominal pain and fevers, and ultrasound will reveal a pelvic mass. In a non-sexually active patient with no adnexal mass, tuboovarian abscess can be effectively ruled out.
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A. This patient has a presentation and findings that are most consistent with a Bartholin's cyst. Bartholin's cysts develop when a Bartholin's gland becomes obstructed. The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the vagina at the 5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the posterior vagina.They undergo rapid growth during the process of puberty and they shrink after the menopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst results. If the cyst becomes infected, the result is a Bartholin's abscess. These abscesses are usually polymicrobial in nature, although the gonococcus is implicated in about 25% of cases. Treatment of a symptomatic Bartholin's cyst is with placement of a Word catheter. This is a small balloon-tipped catheter device that is placed into a small hole that is punched into the cyst itself. This catheter allows drainage of the cyst and the formation of an epithelialized tract that will allow continued drainage once the catheter is removed. This tract should prevent the cyst from reforming. If Bartholin's cysts continue to form in spite of the use of the Word catheter, a marsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding skin to prevent re-closure and re-formation of the cyst. Condyloma lata (choice B) is a manifestation of secondary syphilis. They appear as coalesced, large, pale, flat-topped papules and not as a cystic mass. Granuloma inguinale (choice C) is also known as Donovanosis and is a sexually transmitted disease associated with the gram-negative bacillus Calymmatobacterium granulomatis. The disease is characterized by papules progressing to ulcers and not by a vulvar cyst. Hematocolpos (choice D) describes the condition in which there is blood filling the vagina. This is often seen with an imperforate hymen. Vulvar cancer (choice E) does not usually present as a single cystic mass at the introitus and, in young women, is far less common than Bartholin's cysts
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C. An ectopic pregnancy is a pregnancy that is located outside of the normal intrauterine location, most often in the fallopian tube. In a stable patient, an ectopic pregnancy may be treated medically or surgically. Medical management is with methotrexate. When methotrexate is given, it is essential to have the patient return for follow-up to ensure that the beta-hCG value is falling, the indication that the methotrexate is working. This patient not only has a beta-hCG value that is rising, but also has other signs and symptoms consistent with a rupturing ectopic pregnancy. The worsening abdominal pain and left lower quadrant tenderness are concerning for rupture as is the increased amount of fluid in the pelvis on the ultrasound. This fluid likely represents blood. The management for a ruptured ectopic is surgical. In this case laparoscopy could be performed to identify the ectopic pregnancy and either a salpingostomy (i.e. making a hole in the tube to remove the ectopic pregnancy) or a salpingectomy (i.e. removing the entire tube) could be performed. Expectant management (choice A) would be absolutely inappropriate, as this patient has a doubling beta-hCG value in spite of the methotrexate therapy and has findings consistent with a ruptured ectopic. Repeat methotrexate (choice B) can be given to women with an ectopic pregnancy that show persistently high levels of serum beta-hCG on a day 7 evaluation (i.e. 7 days after the first dose of methotrexate). However, this patient would not be a candidate, as she appears to be actively rupturing her ectopic pregnancy. Oophorectomy (choice D) and hysterectomy (choice E) are not the treatments of choice for women with an ectopic pregnancy. All reasonable steps should be taken to preserve the patient's uterus and ovaries during a surgery for ectopic pregnancy. Preferably, only the tube itself should be operated upon, with either a salpingectomy or salpingostomy being performed.
The correct answer is
E. This patient has a presentation that is most consistent with recurrent Bartholin's cysts. The Bartholin's glands are paired glands that are located in the vulvar tissue on both sides of the fourchette. They secrete mucus into the vagina. Bartholin's cysts occur when the opening to the duct becomes occluded and the gland swells from a buildup of mucus secretions. If the cyst becomes infected, the result is a Bartholin's abscess. These Bartholin's cysts and abscesses are the most common vulvar cysts. Some of these cysts are small and asymptomatic and do not require treatment. This patient, however, is uncomfortable when she walks and she also has continued recurrences. Therefore, surgical intervention is indicated. Often a Word catheter is used to drain the cyst and create an ostium to allow future drainage. However, as in this patient's case, once the catheter is removed the cyst may form once again. Consequently, this patient would be best served with a Bartholin's cyst marsupialization procedure. This is a surgical procedure in which the Bartholin's cyst wall is opened and the cyst itself is sewn open to the vaginal mucosa medially and the skin of the introitus laterally. This should allow free egress of the cyst fluid and prevent re-formation of the cyst. A portion of the cyst wall can be removed at the time of surgery and sent for pathologic evaluation to rule out malignancy, which, while highly unlikely in a young woman, is still a small possibility. Expectant management (choice A) would not be the best choice for this patient. She has had multiple recurrent Bartholin's cysts over the past several years and expectant management is unlikely to lead to resolution of the present cyst or long-term resolution of the problem. Oral antibiotics (choice B) or intravenous antibiotics (choice C) are not the most appropriate next step in the management of this patient. There is no evidence that this is a Bartholin's abscess, which is often characterized by tenderness and erythema of the mass. This appears to be simply a recurrent Bartholin's cyst. And, even if this were an abscess, the definitive management is with incision and drainage. Incision and drainage (choice D) is appropriate management of a Bartholin's abscess, as stated above. However, this patient has a Bartholin's cyst. To simply perform an incision and drainage of this cyst would likely lead to a recurrence of the cyst, as this patient has had several times in the past. The more definitive therapy would therefore be to do a marsupialization procedure.
49 and 50 answers
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C. Necrotizing fasciitis is a rare but potentially fatal complication of abdominal wound infection. It typically occurs in patients who are immunocompromised or who have diabetes or cancer. It is a clinical diagnosis that is characterized by discoloration and cyanosis around the incision with numbness of the area. It can be polymicrobial in nature, but anaerobes are frequently involved. It is considered to be a potentially fatal condition and aggressive treatment with broad-spectrum antibiotics and surgical debridement is essential. Endometritis (choice A) is characterized by abdominal pain, malaise, foul-smelling lochia, temperature elevation, and uterine tenderness on bimanual examination. This patient does not have uterine tenderness on bimanual examination and her disease process appears focused around the incision site. Therefore, endometritis would not be the process of most concern in this patient. Mastitis (choice B) is an infection of the breast that is characterized by breast pain, elevated temperature, erythema and edema of the breast. This patient's process is not involving the breast; therefore, mastitis would not be of concern here. Preeclampsia (choice D) is characterized by hypertension, edema, and proteinuria. The cure for preeclampsia is delivery of the fetus. This patient has no findings concerning for preeclampsia and is postpartum, which makes the development of preeclampsia much less likely. Wound infection (choice E) is certainly of concern here. However, this patient has features to her presentation that suggest a process that goes beyond simple wound infection. The discoloration of the wound edges and cyanosis, along with the loss of sensation around the wound point toward the more worrisome process of necrotizing fasciitis.
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D. There is a significant risk that a high-grade squamous intraepithelial lesion (HGSIL) will progress to invasive cervical cancer. Although only roughly 15% of patients with a low-grade squamous intraepithelial lesion (LGSIL) will have progression of the lesion, a significantly higher proportion of patients with HGSIL will progress to cervical cancer. Therefore, once colposcopically directed biopsy is performed, the diagnosis of HGSIL is confirmed, and the distribution of the lesion is known, removal or destruction of the entire transformation zone should be performed. This can be done with a loop electrode excision procedure (LEEP). In this procedure, a thin-wire loop electrode is used to excise the entire transformation zone. The removed tissue may then be sent to pathology. LEEP can thus be used as both a diagnostic and therapeutic procedure. A repeat Pap in 1 year (choice A) is the recommended follow-up for patients with a normal Pap test. This patient has HGSIL; therefore, follow-up in 1 year with a repeat Pap test would not be appropriate. A repeat Pap test in 6 months (choice B) may be appropriate follow-up for patients with atypical cells of undetermined significance (ASCUS) or LGSIL on their Pap test. It is not appropriate management for patients with HGSIL. Repeat colposcopy in 6 months (choice C) would not be correct. This patient has known, biopsy-proven HGSIL and therefore requires treatment of the lesion. Hysterectomy (choice E) would not be appropriate for this patient. HGSIL can usually be treated adequately without needing to perform hysterectomy. Hysterectomy may be appropriate in some patients with recurrent HGSIL or in those with lesions that cannot be adequately treated with local therapies. However, this patient is a young woman having her first episode of cervical dysplasia.