Block 19 Explanations
1) A 31-year-old woman comes to the physician because she has not had a menstrual period for 7 months. She previously had normal cycles. She also states that over the past year she has felt increasingly weak and tired. She notes that she always feels cold and that her hair has been thinning over the course of the year. She also complains of constipation, weight gain, and depression. Her temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 56/minute, and respirations are 10/minute. Examination is significant for brittle hair and delayed deep tendon reflexes. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is 20 µU/mL. Prolactin is normal. Which of the following is the most likely cause of this patient’s amenorrhea?
A. Hyperprolactinemia
B. Hypothyroidism
C. Kallmann syndrome
D. Polycystic ovarian syndrome
E. Pregnancy
Explanation:
The correct answer is
B. Secondary amenorrhea is defined as the absence of menses for 6 cycle intervals or 12 months in a woman who previously had regular cycles. This patient, therefore, has secondary amenorrhea. She also has a constellation of signs and symptoms that are highly suggestive of hypothyroidism. Patients with hypothyroidism often complain of some combination of weakness, fatigue, cold intolerance, constipation, weight gain, depression, or thinning of the hair. Physical examination can reveal bradycardia and low blood pressure. Laboratory evaluation often shows an elevated TSH as the pituitary attempts to stimulate the underfunctioning thyroid. However, many patients with hypothyroidism will be asymptomatic and the thyroid abnormality is found by thyroid function tests. Hypothyroidism likely leads to amenorrhea through changes in GnRH production. Treatment with thyroid replacement will often return these patients to regular menses. Hyperprolactinemia (choice A) is the cause of secondary amenorrhea in approximately 20% of cases. This patient, however, has a normal prolactin level. Kallmann syndrome (choice C) is a rare cause of primary amenorrhea. This syndrome is characterized by gonadotropin deficiency, anosmia or hyposmia, cleft lip or palate, and minimal sexual development. This patient does not have primary amenorrhea. Polycystic ovarian syndrome (choice D) is often characterized by obesity, hirsutism, infertility, and oligomenorrhea. Thyroid dysfunction is not part of this syndrome. Pregnancy (choice E) is, by far, the most common cause of secondary amenorrhea. This patient has a negative urine hCG.
2) A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?
A. Hormone replacement therapy
B. Oral contraceptive pill
C. Hysteroscopy
D. Laparoscopy
E. Hysterectomy
Explanation:
The correct answer is
C. This patient is likely having irregular spotting secondary to the polyp. Endometrial polyps are projections of endometrial tissue that protrude into the endometrial cavity. They can be seen in women of any age, but are most commonly seen in perimenopausal women. This problem should be addressed for 2 reasons: 1. The bleeding per vagina is distressing to the patient. 2. There are some atypical cells from the biopsy that may represent cancer and polyps can contain malignant cells within them. Therefore, the polyp should be removed. The question then becomes how best to remove it. A hysteroscopy can be performed under monitored anesthesia care (MAC), an approach that provides adequate anesthesia without requiring the patient to have general anesthesia. It would be preferable to avoid general anesthesia in a patient with so many medical conditions. Hysteroscopy would allow visualization of the entire uterine cavity and removal of the polyp. A curettage should be performed afterward to fully sample the cavity. Hormone replacement therapy (choice A) would not be the most appropriate next step. First, the polyp must be removed and histologic evaluation of the polyp and endometrial tissues performed to rule out malignancy prior to instituting hormone replacement therapy. The oral contraceptive pill (choice B) would not be appropriate management for a 75-year-old woman, as the dose of hormones is higher than necessary. Laparoscopy (choice D) would not be indicated. This patient is having spotting, which is an intrauterine process. Laparoscopy allows visualization of only the external, serosal uterine surface. Hysterectomy (choice E) would not be the most appropriate management. Hysterectomy would take care of the patient’s spotting and would provide tissue for pathologic diagnosis. However, in this patient with multiple medical problems, the same goals can be achieved with the less invasive procedure of hysteroscopy.
3) A 31-year-old woman, gravida 1, para 0, at 36-weeks’ gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient?
A. Both vaginal delivery and cesarean delivery are acceptable.
B. Cesarean delivery is mandated because the fetuses are > 2000g.
C. Cesarean delivery is mandated because the second twin is breech.
D. Vaginal delivery is mandated because the fetuses are > 2000g.
E. Vaginal delivery is mandated because the first twin is vertex.
Explanation:
The correct answer is
A. Mode of delivery with twin gestations is an area that has generated controversy over time. Patients with vertex-vertex twins are generally allowed to have a vaginal delivery. Patients with a presenting twin that is non-vertex are generally advised to have a cesarean delivery. Patients with the presenting twin vertex and the non-presenting twin non-vertex may decide which mode of delivery they would prefer. Once the presenting (vertex) twin has delivered, there are essentially 2 options for delivery of the second (non-vertex) twin. The first option is an external cephalic version, in which the head of the second twin is guided into the pelvis so that it becomes a vertex presentation. The second option is a breech extraction of the second twin. Breech extraction may be performed so long as there is an adequate pelvis, a fetal weight greater than 2,000g, an experienced physician, a flexed fetal head, and available general anesthesia. To state that cesarean delivery is mandated because the fetuses are > 2000g (choice B) is incorrect. The fact that the fetuses are > 2000g makes a vaginal delivery with a non-vertex second twin possible. To state that cesarean delivery is mandated because the second twin is breech (choice C) is incorrect. As explained above, vertex-nonvertex twins may be delivered vaginally so long as certain criteria are met. To state that vaginal delivery is mandated because the fetuses are > 2000g (choice D) is incorrect. Vaginal delivery is possible because the fetuses are > 2000g, but the mother may still choose to have a cesarean delivery. To state that vaginal delivery is mandated because the first twin is vertex (choice E) is incorrect. With the first twin vertex, vaginal delivery is possible, but with a non-vertex second twin, cesarean delivery would also be entirely appropriate.
4) A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management?
A. Observation only
B. Spinal magnetic resonance imaging (MRI) scan
C. Outpatient management with oral trimethoprim-sulfamethoxazole
D. Hospital admission and initiation of IV trimethoprim-sulfamethoxazole
E. Hospital admission and administration of a 2-week course of IV tetracycline
Explanation:
The correct answer is
D. This patient has a presentation that is most consistent with pyelonephritis. Patients with pyelonephritis typically complain of some combination of back pain, fevers, chills, dysuria, nausea, and vomiting. Examination will often show an elevated temperature, costovertebral angle tenderness, and an elevated leukocyte count. Urinalysis may demonstrate positive nitrite and leukocyte esterase testing. Urine sediment often reveals white blood cells, red blood cells, and white cell casts. Pyelonephritis can be managed on an outpatient basis if the patient is otherwise healthy, has no complicating factors, and is reliable to return if her condition worsens. A patient cannot be managed as an outpatient if there is any evidence of sepsis. This patient, with her high fevers, shaking chills, and elevated leukocyte count may have sepsis and should therefore be admitted to the hospital for intravenous antibiotics. Treatment is with IV trimethoprim-sulfamethoxazole, IV ceftriaxone, IV gentamicin with or without ampicillin, or an IV fluoroquinolone. Once the patient is afebrile, her condition is improving, and she is able to tolerate oral intake, she may be converted to an oral antibiotic regimen to complete a 14-day course. Observation only (choice A) would not be correct for this patient. This patient has pyelonephritis, which is unlikely to resolve without antibiotic therapy. Spinal MRI (choice B) is often used to evaluate patients with back pain. This patient, however, has back pain that is almost certainly related to a renal infection, therefore spinal MRI would not be necessary. Outpatient management with oral trimethoprim-sulfamethoxazole (choice C) is appropriate in some cases of uncomplicated pyelonephritis, as explained above. This patient, however, is quite ill and possibly septic. She, therefore, requires hospital admission. Hospital admission and administration of a 2-week course of IV tetracycline (choice E) would not be appropriate. Tetracycline is not a drug-of-choice in the treatment of pyelonephritis.
5) A 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered “unacceptable,” so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?
A. Prescribe a benzodiazepine
B. Prescribe estrogen
C. Prescribe haloperidol
D. Reassure her that time will change her feelings
E. Refer her for psychological counseling
Explanation:
The correct answer is
E. Sexual orientation is an issue of tremendous importance in the life of an individual. Patients often come to physicians for advice and input regarding questions of sexual orientation. It is essential that the physician try to address these issues in an unbiased manner that will allow the patient to express her feelings. However, it is also essential that a physician realize his or her limitations in being able to deal with complex questions regarding sexuality, self-expression, and family dynamics. This patient has issues not only regarding her sexual orientation, but also her family and the impact her sexual orientation may have upon them. She would, therefore, be most likely to benefit from psychological counseling, where a full evaluation could be conducted encompassing the personal and family issues. To prescribe a benzodiazepine (choice A) would not be the most appropriate next step in management. This patient is not complaining of acute anxiety or sleep disturbance. Rather, she has complex issues regarding her sexuality and family dynamics. To simply prescribe an anxiolytic medication rather than address the deeper psychological issues would not be appropriate. To prescribe estrogen (choice B) would not be the most appropriate next step in management. This patient does not have a disease process that would require estrogen for therapy. To prescribe haloperidol (choice C) would not be appropriate. This patient does not require an anti-psychotic medication as she has no evidence of psychosis or psychotic behavior. To attempt to reassure her that time will change her feelings (choice D) would not be appropriate. First, her issues regarding sexual orientation may not change with time. Second, there is no indication that a change of feelings is what she needs. Her present feelings and issues must be addressed and this could be done appropriately with psychological counseling.
6) A 68-year-old woman comes to the physician because of a painful lump in her vagina. She states that the lump has been there for a few months, but has recently begun to cause her pain. She has hypertension, for which she takes a diuretic, but no other medical problems. Examination shows a 4 cm cystic mass near the patient’s introitus by the right labia. The mass is mildly tender. The remainder of the pelvic examination is normal. Which of the following is the most appropriate next step in management?
A. Expectant management
B. Sitz baths
C. Oral antibiotics
D. Biopsy of the mass
E. Word catheter placement
Explanation:
The correct answer is
D. This patient has findings that initially seem to be consistent with a Bartholin’s gland cyst or abscess. The Bartholin’s glands are paired glands found on the posterolateral aspect of the vagina at the introitus. These glands normally secrete mucus into the vagina, particularly with sexual stimulation. They grow rapidly during puberty and shrink after the menopause. In a young woman it would be reasonable to assume that this cystic mass represents a Bartholin’s cyst or abscess. However, one cannot make this assumption in a postmenopausal patient. A cystic mass on the vulva in a postmenopausal woman must be biopsied as there is a higher likelihood that this lesion represents a Bartholin’s gland carcinoma. Primary carcinoma of the Bartholin’s gland accounts for about 5% of vulvar malignancies. Delay in diagnosis is common because many clinicians and patients assume the mass is a benign cyst. Any persistent mass in this region, especially in women greater than 40 years of age, should be biopsied. Expectant management (choice A) would not be appropriate. First, the patient is symptomatic and therefore requires something for relief. Second, there is the possibility that this mass represents a malignancy and it, therefore, should be biopsied. Sitz baths (choice B) can be recommended to patients with certain vulvar lesions. However, this mass must first be biopsied to rule out malignancy. Oral antibiotics (choice C) would not be the most appropriate next step in management. To simply assume that this mass represents an infectious process without obtaining tissue for pathologic diagnosis would not be correct. Word catheter placement (choice E) would be acceptable in a young woman with this lesion. In a woman older than 40, however, the lesion must be biopsied first.
7) A 28-year-old primigravid woman at 8 weeks’ gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management?
A. There is nothing to offer this couple
B. Offer testing of the parents
C. Offer MRI of the fetus
D. Offer 2nd trimester amniocentesis
E. Offer termination of the pregnancy
Explanation:
The correct answer is
D. Fragile X syndrome is the most common inherited form of mental retardation. Down syndrome may cause more absolute cases of mental retardation, but it results from a spontaneously occurring trisomy and most cases are not considered inherited. The gene for fragile X syndrome is located on the long arm of the X-chromosome. It has a complex inheritance pattern that is related to the number of repeating cytosine-guanine-guanine triplets. When greater than 200 repeats are present, a person will have the full mutation and have phenotypic fragile X syndrome. A patient with 50-200 repeats is phenotypically normal and is said to have a premutation. Along with mental retardation, related features of the fragile X syndrome include autistic behaviors, speech and language problems, facial anomalies, and macroorchidism in adult males. DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed on cultured amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliable for the diagnosis of fragile X syndrome because of different methylation patterns in the trophoblast compared with the fetus. To state that there is nothing to offer this couple (choice A) is incorrect. As detailed above, amniocentesis can be used to allow for prenatal diagnosis of fragile X syndrome. To offer testing of the parents (choice B) would not be correct. Based on the history provided, the parents have already been tested and are known to be carriers. Their concern at this point is whether the fetus will have fragile X syndrome, and that can only be determined by genetic analysis of the fetus. To offer MRI of the fetus (choice C) would be incorrect. The diagnosis is made based on DNA-based molecular analysis and not an imaging study. To offer termination of the pregnancy (choice E) would be incorrect. This is a desired pregnancy. This patient is seeking prenatal diagnosis at this point, not termination.
A 17-year-old female comes to the physician because she has not yet had a menstrual period. She also complains of a lack of breast development. Past medical history is significant for anosmia and color blindness. Past surgical history is significant for a cleft palate that was repaired in childhood. She takes no medications and has no allergies to medications. Examination is significant for absent breast development, and a hypoestrogenic vulva and vagina. Urine hCG is negative. Which of the following is the most likely diagnosis?A. Anorexia nervosa
B. Kallmann syndrome
C. Polycystic ovarian syndrome
D. Pregnancy
E. Testicular feminization syndrome
Explanation:
The correct answer is
B. Patients with Kallmann syndrome (i.e., isolated gonadotropin deficiency or familial hypogonadotropic hypogonadism) can present with primary amenorrhea. Primary amenorrhea is defined as the absence of menses in a female by the age of 16. Associated findings in Kallmann syndrome may include anosmia or hyposmia, color blindness, and cleft lip or cleft palate. These findings are attributable to the fact that during embryogenesis the GnRH neurons originally develop in the epithelium of the olfactory placode and normally migrate into the hypothalamus. Thus exists the link between the midline defects and the amenorrhea. Physical examination may reveal absent to minimal breast development. Treatment of the patient with Kallmann syndrome is with exogenous estrogen and progestin replacement therapy. If pregnancy is desired, ovulation induction can be brought about with the pulsatile administration of exogenous GnRH. Anorexia nervosa (choice A) can cause amenorrhea and a reduction in breast size, but it is not associated with anosmia, color blindness, and cleft palate. These features are associated with Kallmann syndrome. Polycystic ovarian syndrome (choice C) is characterized by oligomenorrhea, hirsutism, infertility, and obesity. This patient does not have a presentation consistent with polycystic ovarian syndrome. Pregnancy (choice D) should always be the first thought when a potentially fertile woman presents with amenorrhea. However, this patient has a negative urine pregnancy test and no findings consistent with pregnancy. Testicular feminization syndrome (choice E) represents complete androgen insensitivity. This syndrome occurs in individuals with a 46, XY karyotype. Affected males have a female appearance with breast development.
9) A 21-year-old woman, gravida 2, para 1, at 28 weeks’ gestation comes to the physician because of spotting after intercourse and a foul-smelling vaginal discharge. Her prenatal course has, up to now, been uncomplicated, and she has no medical problems. Speculum examination shows inflammation of the cervix with a mucopurulent cervical discharge. A gonorrhea and Chlamydia test is performed which comes back positive for chlamydia. Which of the following is the most appropriate pharmacotherapy?
A. Azithromycin
B. Doxycycline
C. Levofloxacin
D. Penicillin
E. Streptomycin
Explanation:
The correct answer is
A. This patient has Chlamydia cervicitis. Chlamydia is the most common sexually transmitted bacterial organism in the United States. It is essential to detect and treat chlamydial infection during pregnancy because maternal chlamydial infection is associated with several complications of pregnancy including preterm premature rupture of the membranes (PPROM) and preterm labor. Chlamydial infection is also associated with neonatal conjunctivitis, which results from the fetus passing through an infected birth canal. The partner of the patient must be treated as well as the patient herself in order to prevent reinfection. A test of cure (TOC) should be performed 4 to 6 weeks after treatment is given to ensure that the organism has been completely eradicated from the patient and her partner or partners. Azithromycin has a prolonged tissue half-life and therefore it can treat chlamydia in a single dose. This single dose treatment allows far greater compliance than the multiple doses that are required if erythromycin or amoxicillin is used. The single dose treatment with azithromycin also allows the treatment to be “observed” (i.e., the patient can be watched taking the medication). While the safety and effectiveness of azithromycin during pregnancy has not been as well proven as that of erythromycin or amoxicillin, it is believed to be safe and its single dose quality makes it the drug of choice. Doxycycline (choice B) is contraindicated during pregnancy because of its effects on fetal teeth and bone. Levofloxacin (choice C) and the other fluoroquinolones are contraindicated during pregnancy because of their association with arthropathies. Penicillin (choice D) is safe during pregnancy but is not considered to be as effective against Chlamydia as are azithromycin, erythromycin, and amoxicillin. Streptomycin (choice E) is contraindicated during pregnancy because of its relationship to eighth cranial nerve damage.
10) A 38-year-old woman comes to the physician because of burning with urination. She states that the burning started about 2 days ago and has been growing worse since. She has no frequency or urgency. She had one episode of pyelonephritis in the past but no other medical problems. On examination there is no costovertebral angle or abdominal tenderness. The examination is significant for a thick, white vaginal discharge with erythema and excoriations of the labia. Urinalysis is negative. KOH/Normal saline smear demonstrates pseudohyphae. Which of the following is the most likely diagnosis?
A. Candida vaginitis
B. Hemorrhagic ovarian cyst
C. Pelvic inflammatory disease
D. Pyelonephritis
E. Urinary tract infection
Explanation:
The correct answer is
A. A patient with candidiasis classically presents with complaints of a thick, white, “cottage cheese-like” discharge. Such patient may also complain of vulvar pruritus and burning. Dysuria is often seen in cases of candidiasis because there is pain when the acidic urine comes in contact with the inflamed vaginal mucosa. This dysuria is often confused for a urinary tract infection. The keys to distinguishing between the two are the examination and laboratory studies. Examination on a patient with candidiasis often shows a thick, white, discharge as well as erythema of the vagina and vulva, as this patient has. The excoriations that this patient has are likely present because the patient has been scratching the area. In a urinary tract infection, examination of the vagina and vulva will most often be unremarkable. The KOH preparation will demonstrate pseudo-hyphae in cases of candidiasis. The urinalysis should be negative in cases of candidiasis, although if there is contamination of the sample, abnormalities may be seen. A hemorrhagic ovarian cyst (choice B) typically causes abdominal pain and tenderness. It usually does not cause burning with urination. The diagnosis of pelvic inflammatory disease (choice C) is made when a sexually active female has abdominal tenderness, cervical motion tenderness, and adnexal tenderness along with a fever, an elevated white blood cell count, a positive gonorrhea or Chlamydia test, or a mucopurulent cervical discharge. This patient does not have these findings. This patient does have a history of pyelonephritis (choice D) and therefore, pyelonephritis and urinary tract infection (choice E) would be considerations. However, the patient has no fever, costovertebral angle tenderness, or abnormal urinalysis, the three findings most helpful for the diagnosis of pyelonephritis. Also, while dysuria can often be a symptom of a urinary tract infection, this patient’s negative urinalysis and findings consistent with another process (namely candidiasis) make UTI less likely.
11) A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?
A. 0%
B. 1%
C. 20%
D. 80%
E. 100%
Explanation:
The correct answer is
D. The Pap test is an excellent method of screening for cervical cancer. It has a relatively low-cost and is noninvasive and effective. Use of the Pap for screening over the past 50 years has resulted in a 70% decrease in the mortality from cervical cancer. However, the test is not without its flaws. The primary drawback of the test is its high false-negative rate. In the case of the Pap, a false-negative is a woman who has abnormal cervical cells but is declared to have a normal Pap smear. These false-negative results can be caused by any of the steps in the process, including errors in sampling, preparation, screening, and interpretation. The larger the number of false-negative results, the lower is the sensitivity of a test. Sensitivity of a test is calculated by dividing the number of patients who have the disease and test positive for the disease by the total number of patients that have the disease. In the above example, four women who have abnormal cervical cells will test positive for abnormal cervical cells. This number (4) should then be divided by the total number of women with truly abnormal cells (5). This gives a result of 4/5 or 0.8 or 80%. To state that the sensitivity of the Pap test is 0% (choice A) or 1% (choice B) is incorrect. If this were the case, it would mean that the Pap test would correctly identify none or only 1 of every 100 women with truly abnormal cervical cytology. This would make the Pap test a very poor or completely meaningless screening test. A screening test that is 20% (choice C) sensitive is also a very poor screening test. A screening test should ideally have high sensitivity and specificity. A test that is has only 20% sensitivity would identify only 20 of every 100 women with a given disease. This would make it a very poor screening test. A screening test that has 100% (choice E) sensitivity for a disease would be ideal. If the Pap test were 100% sensitive, it would mean that every woman with abnormal cervical cells would be correctly identified. However, this is not the case because of the possible errors that were described above. Also, efforts to increase the sensitivity of a screening test often lead to a loss of specificity and an increases in the percentage of false positives.
12) A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward with a gush of blood, abdominal pain, and irregular, painful contractions. Her prenatal course was significant for her being Rh negative and antibody negative. Her temperature is 37 C (98.6 F), pulse is 110/minute, blood pressure is 110/70 mm Hg, and respirations are 12/minute. Abdominal examination shows a tender abdomen and cervical examination shows the cervix to be closed and long with a significant amount of blood in the vagina. The fetal heart rate is in the 170s with moderate to severe variable decelerations with contractions. The diagnosis of placental abruption is made and an emergent cesarean delivery is performed. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?
A. Apt test
B. Complete blood count
C. Kleihauer-Betke
D. Partial thromboplastin time
E. Serum potassium
Explanation:
The correct answer is
C. Women that are Rh negative are at risk for developing Rh isoimmunization. Rh isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother’s immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother’s immune system may “attack” the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death. To prevent Rh isoimmunization from occurring, Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin) at 28 weeks of gestation, within 72 hours after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis. RhoGAM should also be strongly considered in cases of threatened abortion, antenatal bleeding, external cephalic version, or abdominal trauma. The amount that is usually given after the delivery of an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL-especially in cases such as manual removal of the placenta or placental abruption (as this patient had). To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given. An apt test (choice A) is used to differentiate fetal from maternal blood. It can be used in the diagnosis of vasa previa or with neonatal melena. A complete blood count (choice B) will demonstrate the amount of maternal hemorrhage, but not the amount of fetal to maternal hemorrhage. Partial thromboplastin time (choice D), and serum potassium (choice E) do not allow for the determination of the amount of fetal to maternal hemorrhage.
13) A 32-year-old woman, gravida 4, para 3, at 39 weeks’ gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?
A. Blood transfusion
B. Glucose
C. Naloxone
D. Penicillin
E. Sodium bicarbonate
Explanation:
The correct answer is
C. Meperidine can be used as a systemic analgesic during labor. It is an opioid and readily crosses the placenta; therefore, the fetus is exposed to the medication. As an opioid, it causes respiratory depression. Neonates are at greatest risk for respiratory depression when delivery occurs approximately 2 to 3 hours after meperidine is administered to the mother. This neonate was born approximately 2 hours after maternal administration of meperidine, which makes neonatal respiratory depression likely. Naloxone is a pure opioid antagonist that displaces the opioid from its receptor sites and can help to reverse the opioid-induced respiratory depression. It has a short duration of action so repeat doses may be necessary. Blood transfusion (choice A) would not be indicated. Blood transfusions are used when there is evidence that the neonate is anemic. This neonate appears to have respiratory depression and not anemia. Therefore, naloxone, and not blood transfusion, would be indicated. Glucose (choice B) should be given when there is evidence that the neonate is severely hypoglycemic. This neonate, given that its mother received an opioid 2 hours ago, is most likely to have respiratory depression from the opioid and not hypoglycemia. Penicillin (choice D) is an antibiotic that may be given when there is evidence of infection. This neonate has a presentation that is most consistent with opioid-induced respiratory depression and not infection. Sodium bicarbonate (choice E) should be given to a neonate for documented metabolic acidosis. It is often used during a prolonged resuscitation. The first step for this neonate, however, would be to try to reverse the respiratory depression with naloxone.
14) A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient?
A. Does your husband know you are using these alternative medications?
B. Do you realize how dangerous alternative medicines are?
C. Which alternative medications do you use?
D. Why don’t you stick with traditional medicines?
E. Why haven’t you revealed your use of alternative medications before?
Explanation:
The correct answer is
C. Some estimates indicate that roughly 50% of Americans use some forms of complementary and alternative medicine (CAM). The categories of these include mind-body interventions, such as yoga, alternative systems of medical practice such as Chinese medicine, pharmacologic treatments such as medicinal plants, herbal medicine such as St. John’s wort, diet therapies such as vegetarianism, manual healing methods such as massage, and bioelectromagnetic applications such as magnets for musculoskeletal pain. It is essential for the physician to work with the patient regarding the use of CAM. The first step is to find out which methods the patient uses. This patient has told the physician that she uses alternative medications. Many patients do not offer this information, assuming that the usual physician will not support CAM. It is therefore important to ask the patient whether she is using, or considering using, CAM. Because the field of CAM is so broad, it is essential to ask which types of CAM the patient uses. One cannot assume that all alternative therapies are equivalent. Thus, the most appropriate question to ask this patient is “Which alternative medications do you use?” This is a non-threatening question that will allow her to further detail her use. To ask, “Does your husband know you are using these alternative medications?” (choice A) is inappropriate. The physician’s role is to care for the patient. Whether the patient reveals her use of alternative medicines to her husband is not the prime concern to the physician. This question is more likely to create conflict than reveal needed information for the physician. To ask, “Do you realize how dangerous alternative medicines are?” (choice B) is incorrect. This question is confrontational and judgmental. Many alternative therapies are safe and effective. To ask, “Why don’t you stick with traditional medicines?” (choice D) is inappropriate. If a patient has a condition and there is a remedy from the conventional medical system (known as allopathy in North America) available, then it is reasonable to offer this remedy as a possibility for the patient. However, inquiring as to why the patient doesn’t “stick” with traditional medicine is likely to cause confrontation and a worsening of the patient-doctor relationship. To ask, “Why haven’t you revealed your use of alternative medications before?” (choice E) is also somewhat challenging and confrontational. Perhaps the patient did not think a conventional physician would be accepting of CAM. The important step at this point is to identify the medications and discuss their risks, benefits, and side effects with the patient, as one would with traditional medications.
15) A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child has delayed physical development. In particular, the mother is concerned because her daughter has not yet had a menstrual period. The daughter began developing breasts at age 10, but has not had her first period. The daughter has no medical problems and takes no medications. Examination shows developing breasts and normal external female genitalia. Which of the following is the most appropriate response to the mother?
A. Breast development at age 10 is abnormally early.
B. Breast development at age 10 is abnormally late.
C. Evaluation for late menses should be started immediately.
D. Evaluation for late menses should be started at age 15.
E. Her child’s sexual development is none of her business.
Explanation:
The correct answer is
D. Sexual development is variable from woman to woman, although there are certain ranges of normal. Thelarche, also known as breast-budding, is usually the first sign of secondary sexual development and this occurs on average between the ages of 8 and 10 years of age. The growth spurt usually follows after breast budding and menarche is one of the last stages, occurring, on average, between the ages of 12 and 13. This young woman began developing breasts at age 10, which is entirely appropriate. That she has not had her first menstrual period yet is not abnormal. The general rule is that evaluation for delayed sexual development should be started if there is no breast development by the age of 13 or menses by the age of 15. This general rule can be adapted to fit the circumstances if there are tempo or sequence abnormalities. In this case, with breast development occurring normally and development appearing to proceed in a standard fashion, the mother can be reassured and evaluation for late menses delayed until age 15, if it has not come before that time. To state that breast development at age 10 is abnormally early (choice A) or that breast development at age 10 is abnormally late (choice B) is incorrect. In North America, thelarche occurs, on average, between ages 8 to 10. Therefore, this young woman, who began breast development at age 10, falls into the normal range. To state that evaluation for late menses should be started immediately (choice C) is incorrect. The general rule for evaluation of delayed puberty is that evaluation should take place if thelarche has not occurred by age 13 or menarche by age 15. These ages represent roughly a 2.5 standard deviation from the mean and therefore warrant evaluation. To tell this mother that her child’s sexual development is none of her business (choice E) would not be appropriate. While there are certain sexual issues where confidential discussion with an adolescent is appropriate, concerns regarding delayed sexual development are appropriate issues for a parent to be concerned with.
16) A 23-year-old woman, gravida 2, para 1, at 6 weeks’ gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?
A. No treatment is necessary
B. Intramuscular ceftriaxone, oral doxycycline, and discharge home
C. Intravenous cefotetan and doxycycline and hospital admission
D. Intravenous clindamycin and gentamicin and hospital admission
E. Laparoscopy
Explanation:
The correct answer is
D. Pelvic inflammatory disease rarely occurs during pregnancy. The incidence of PID during pregnancy is far lower than in the nonpregnant state, likely because of the relative protection that the pregnancy provides against ascending infection from the cervix. However, while PID during pregnancy is rare, it is not impossible. This patient has the findings that are most consistent with a diagnosis of PI
D. She has abdominal tenderness, cervical motion tenderness, and adnexal tenderness. She also has a fever, a mucopurulent cervical discharge, and an elevated white blood cell count. She also has a history of gonorrhea and chlamydia. The correct management of a pregnant woman with PID is hospital admission and treatment with intravenous medications. Clindamycin and gentamicin should be used. To state that no treatment is necessary (choice A) is absolutely incorrect. A patient with PID certainly needs treatment. And a pregnant patient with PID requires hospitalization and intravenous antibiotics. To give intramuscular ceftriaxone, oral doxycycline, and discharge home (choice B) would not be appropriate. Nonpregnant patients that develop PID may be treated with intramuscular ceftriaxone and an extended course of doxycycline (14 days). This is a standard outpatient treatment for PI
D. A pregnant patient, however, must be admitted to the hospital for intravenous antibiotics. To provide intravenous cefotetan and doxycycline and hospital admission (choice C) is incorrect. Doxycycline is a class D drug that should not be used during pregnancy. Laparoscopy (choice E) would not be the most appropriate next step in management. The diagnosis of PID in this patient’s case is reasonably certain given the presentation. The next step, therefore, is treatment with intravenous antibiotics. If these fail, surgical alternatives may be considered.
17) A 25-year-old woman, gravida 2, para 2, comes to the physician to discuss birth control options. She and her partner have tried to use condoms; however, they find it difficult to use them consistently and she would like to try another form of contraception. She has no medical problems, takes no medications, and has no family history of cancer. Her examination is within normal limits. After a discussion with the physician, she chooses to take the oral contraceptive pill (OCP). She stays on the pill for the next three years. She now has most significantly decreased her risk of developing which of the following malignancies?
A. Bone cancer
B. Breast cancer
C. Cervical cancer
D. Endometrial cancer
E. Liver cancer
Explanation:
The correct answer is
D. Numerous studies have demonstrated that use of the oral contraceptive pill significantly decreases a woman’s likelihood of developing endometrial cancer. Overall, use of the oral contraceptive pill appears to decrease the risk by approximately 50%, with greatest effects in those using the pill for more than 3 years. One theory to explain the decreased endometrial cancer risk in oral contraceptive users is that the oral contraceptive pill provides almost continuous exposure of the endometrium to progestins. The major factor in the development of endometrial cancer is estrogen exposure, whether endogenously (e.g., due to obesity or chronic anovulation) or exogenously (e.g., from unopposed estrogen replacement therapy). By providing almost daily exposure to progestins, the oral contraceptive pill works to counteract the effects of estrogens. Over time, women on the OCP develop thinner endometrial linings and have a lower risk of developing endometrial cancer. There is no clear relationship between bone cancer (choice A) and OCP use. The relationship between breast cancer (choice B) and oral contraceptives remains unclear at this time. There is some evidence that current users and those who have recently stopped may be at some increased risk of breast cancer. However, there is also evidence that when breast cancer is diagnosed in an oral contraceptive user, it tends to be more localized than in a nonuser. The relationship between cervical cancer (choice C) and the OCP also remains unclear at this time. Overall the results have been inconclusive. All sexually active patients should have regular screening for cervical dysplasia with a Pap smear starting at age 18 or with the onset of sexual intercourse. The OCP does not protect against liver cancer (choice E). The OCP is believed to increase the risk of certain benign liver tumors.
18) A 26-year-old primigravid woman at 35 weeks’ gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a “ferning” pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?
A. Expectant management
B. Oxytocin augmentation
C. Forceps delivery
D. Vacuum delivery
E. Cesarean section
Explanation:
The correct answer is
A. This patient has a compound presentation, which happens when an extremity prolapses alongside the fetal presenting part. In this case, the compound presentation is the fetal vertex along with a fetal arm. Compound presentation occurs in approximately 1 in 1000 deliveries and is brought about when the pelvic inlet is not completely occluded by the fetal head. Most often this occurs with premature fetuses. A compound presentation can be allowed to undergo a normal labor and delivery. The prolapsed arm should be left alone, as it will not interfere with the labor and delivery in most cases. Often the arm will rise out the way as the vertex descends further. Oxytocin augmentation (choice B) would not be appropriate management. This patient is in active labor, with painful contractions every 2 minutes and 4 cm of cervical dilation. Oxytocin is used in cases in which there is a need to augment labor (e.g., when contractions are not adequate) or to induce labor (e.g., when there are no contractions present.) This patient has adequate contractions. Forceps delivery (choice C) is not indicated at this point. The patient’s cervix is not fully dilated, and the presence of the fetal arm, if it persists, would prevent proper application of the forceps. Vacuum delivery (choice D) would not be appropriate. As with forceps, vacuum is not used unless the cervix is fully dilated and the vertex is at +2 to +3 station. This patient is only 4 cm dilated, and the vertex is at 0 station. There is no fetal or maternal indication at this point for vacuum delivery. Cesarean delivery (choice E) is not indicated. As noted above, most women with a compound presentation, with a hand presenting by the fetal head, can undergo a normal labor and delivery.
19) A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?
A. Folic acid, 4 mg/day starting preconceptionally
B. Folic acid, 4 mg/day starting in the first trimester
C. Vitamin A, 10,000 IU/day starting preconceptionally
D. Vitamin A, 10,000 IU/day starting in the first trimester
E. No supplements are needed
Explanation:
The correct answer is
A. Several studies have established a relationship between folic acid and the prevention of neural tube defects. The presence of adequate levels of maternal folate appears to play a role in the correct development and closure of the neural tube. Based on these studies, in 1992, the United States Centers for Disease Control recommended that all women of child-bearing age should consume 0.4 mg/day of folic acid starting preconceptionally and continuing for the first 3 months of pregnancy. Women who have already had a child with a neural tube defect, however, fall into a different category. This patient had a child with spina bifida 2 years ago. For a woman such as this, the recommendation is that 4.0 mg of folic acid be taken daily, starting one month before the planned time of conception and continuing on for the first 3 months of pregnancy. It is believed that this level of supplementation will decrease the risk of having another child with a neural tube defect by 60 to 70%. To recommend folic acid, 4 mg/day starting in the first trimester (choice B) would be incorrect. This patient, because she has had a prior child with a neural tube defect, should indeed be taking 4 mg/day during the first 3 months of pregnancy. However, she shouldn’t start when she is pregnant, rather, she should be taking this level of folic acid supplementation starting preconceptionally. It is important that the pregnant woman’s folate stores are being supplemented prior to the time of conception. To recommend vitamin A, 10,000 IU/day starting preconceptionally (choice C) or vitamin A, 10,000 IU/day starting in the first trimester (choice D) would be incorrect. First, vitamin A deficiency is very rare in the United States. Second, vitamin A supplementation with levels of 10,000 IU/day and above has been associated with birth defects. Supplements taken by pregnant women should contain 5,000 IU/day or less. To state that no supplements are needed (choice E) is incorrect. This patient has a previous child with a neural tube defect. She should therefore take 4.0 mg of folic acid/day starting one month before conception and continuing through the first 3 months of pregnancy to help prevent having another child with a neural tube defect.
20) A 25-year-old woman comes to the physician because of pain and burning with urination. She states that the symptoms started two days ago and have worsened since. She has no fever or chills and has never had these symptoms before. She has hypothyroidism for which she takes thyroid hormone replacement. Otherwise she has no medical problems. Her temperature is 37 C (98.6 F). Examination is unremarkable including a normal pelvic examination. A KOH and normal saline “wet prep” is performed on her vaginal discharge and is negative. Urinalysis reveals numerous white blood cells. Which of the following is the most likely pathogen?
A. Escherichia coli
B. Neisseria gonorrhoeae
C. Pseudomonas species
D. Staphylococcus saprophyticus
E. Trichomonas vaginalis
Explanation:
The correct answer is
A. This patient has findings that are most consistent with a lower urinary tract infection. A lower urinary tract infection refers to infection of the bladder (cystitis) or urethra (urethritis). The principal complaints for women with lower urinary tract infections are dysuria, urgency, and frequency. Most often examination will be unremarkable. Occasionally, suprapubic tenderness may be present. A urinalysis will often reveal a positive leukocyte esterase or nitrite test. The microscopic analysis will show white blood cells. The most significant risk factors are related to sexual activity and hypoestrogenism. These factors lead to invasion by pathogenic organisms.
E. coli is by far the most common causative organism in cases of acute uncomplicated cystitis. It is responsible for approximately 80% of these cases. N. gonorrhoeae(choice B) is often associated with cervicitis and pelvic inflammatory disease. Yet, it can also cause urethritis. However, N. gonorrhoeae is a far less frequent cause of acute uncomplicated cystitis than
E. coli. Pseudomonas species (choice C) can cause urinary tract infections. It is often seen in patients with metabolic or anatomic abnormalities. In a routine case of UTI, however, it is not the most common pathogen. Staphylococcus saprophyticus(choice D) is a somewhat common cause of acute, uncomplicated UTIs. It accounts for approximately 10% of cases. Trichomonas vaginalis(choice E) is an organism that is most often associated with vaginitis, but can also cause a urethritis. This patient, however, has a negative normal saline “wet prep.” Patients with trichomoniasis usually have visible organisms on the “wet prep.” Also, while Trichomonas vaginalis can cause urethritis, it is not nearly as common a cause as is
E. coli.
21) A 33-year-old woman comes to the physician because she has not had a menstrual period for 8 months. She had menarche at the age of 12 and, after a few years of irregular menses, has since had normal monthly menses. She has no medical problems and takes no medications. Examination reveals a normal-appearing female with no abnormalities noted. Urine human chorionic gonadotropin (hCG) is negative. Serum thyroid stimulating hormone (TSH) and prolactin are also normal. The patient is given a 10-day course of medroxyprogesterone acetate. Upon completing the 10 days, she has a heavy menstrual period. This patient’s withdrawal bleeding in response to the progesterone provides good evidence for which of the following?
A. Asherman syndrome
B. Endogenous estrogen production
C. Endometrial carcinoma
D. Menopause
E. Pregnancy
Explanation:
The correct answer is
B. Primary amenorrhea is defined as the lack of spontaneous uterine bleeding by the age of 16. Secondary amenorrhea is defined as the absence of a menstrual period for 6 months or more in a woman who previously had normal periods or the absence of menses for 12 months or more in women with previously irregular menstrual periods. This patient, given that she previously had normal menstrual periods, has secondary amenorrhea. The most common cause of missed menses in previously cycling women is pregnancy. Therefore, it is absolutely essential that a pregnancy test be performed on any woman with this complaint. Hyperprolactinemia is the cause of amenorrhea in 10 to 20% of cases, so it is also important that a prolactin level be checked. And, because thyroid dysfunction can also cause a loss of menses, a TSH should also be checked. This patient, however, is not pregnant and has normal TSH and prolactin levels. At this point, some physicians would perform a progesterone withdrawal test. This consists of giving a woman an intramuscular injection of progesterone or oral progesterone for 5 to 10 days and then checking to see if the patient has withdrawal menstrual bleeding. If withdrawal bleeding occurs within 7 days, then patients are assumed to have adequate levels of endogenous estrogen production. Most patients with amenorrhea, adequate endogenous estrogen production, and withdrawal bleeding after the administration of progestins will have some form of polycystic ovarian syndrome (PCOS). Asherman syndrome (choice A) describes the condition in which menstrual periods do not occur because the uterine cavity has become obliterated with adhesions. These adhesions result from trauma to the basal level of the endometrium, most often occurring at the time of dilation and curettage. Patients with this syndrome would not be expected to have menses in response to progesterone. Endometrial carcinoma (choice C) typically presents with heavy, irregular bleeding or as postmenopausal bleeding. Menopause (choice D) represents the loss of menstrual periods as ovarian function decreases. Postmenopausal patients would not be expected to have withdrawal menses after progesterone exposure. This patient’s bleeding does not provide good evidence of pregnancy (choice E). Her negative urine hCG and withdrawal bleeding after progesterone make it extremely unlikely that she is pregnant.
22) A 41-year-old woman, gravida 4, para 3, at term is admitted to the labor and delivery ward with regular contractions every 2 minutes. Examination shows that her membranes are grossly ruptured and that her cervix is 5 cm dilated. Over the following 3 hours, she progresses to full dilation and +2 station. A fetal bradycardia develops, and the decision is made to proceed with vacuum-assisted vaginal delivery. A 7 pound, 8 ounce boy is delivered. APGAR scores are 8 at 1 minute and 9 at 5 minutes. Which of the following best represents an advantage of vacuum extraction over the forceps for expediting delivery?
A. The vacuum can be used at higher stations
B. The vacuum can be used for fetuses in breech presentation
C. The vacuum can be used in face presentations
D. The vacuum can be used with intact membranes
E. The vacuum does not occupy space next to the fetal head
Explanation:
The correct answer is
E. Both forceps and the vacuum extractor can be used to expedite the delivery of a fetus. These instruments are most often used when there are fetal indications, such as a non-reassuring fetal heart rate tracing, or maternal indications, such as maternal exhaustion or maternal contraindications to pushing (such as maternal cardiac disease.) The choice of forceps or vacuum depends most on the experience and preference of the physician. In certain cases, one instrument is favored or mandatory. For example, forceps may be used in face presentation with a mentum anterior presentation; in such a case, vacuum is contraindicated. Those who favor vacuum delivery make several arguments. For example, as opposed to forceps, the vacuum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissues. Also, attempted delivery with the vacuum in a situation of true cephalopelvic disproportion (i.e., the fetus cannot be delivered through the maternal pelvis) will lead to a loss of suction and failure of the procedure; forceps do not necessarily dislodge and this could lead to continued efforts being made with increased likelihood of maternal or fetal morbidity or mortality. To state that the vacuum can be used at higher stations (choice A) is incorrect. Both the vacuum and forceps should preferably be used only in low- or outlet- situations (i.e., with the fetal vertex at +2 station or lower.) To state that the vacuum can be used for fetuses in breech presentation (choice B) is incorrect. Neither the vacuum nor forceps should be used when the fetus is presenting as a breech. To state that vacuum can be used in face presentations (choice C) is not correct. Vacuum cannot be used when the fetus is presenting face first. Forceps may be used as long as the fetus is in mentum-anterior position (i.e., with the chin facing toward the maternal pubic symphysis.) To state that the vacuum can be used with intact membranes (choice D) is incorrect. Neither forceps nor vacuum should be used with intact membranes.
23) A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?
A. Evaluation in one year
B. Follow beta-hCG levels to 0
C. Dactinomycin
D. Methotrexate
E. Hysterectomy
Explanation:
The correct answer is
B. The term gestational trophoblastic disease encompasses a number of related diseases originating from the placenta. These diseases include complete and partial hydatidiform moles, invasive moles, placental site trophoblastic tumors, and choriocarcinomas. This patient presents with findings consistent with a complete mole. The most common symptom is vaginal bleeding and examination often demonstrates a uterus that is larger than expected for gestational dates. Laboratory evaluation often shows a significantly elevated beta-hCG and ultrasound reveals the absence of a fetus and the presence of a “snowstorm” pattern with multiple echogenic areas of villi and clots. Treatment is with dilation and evacuation of the mole. Once there is pathologic confirmation of the diagnosis, it is essential that the patient continued to be followed weekly until the beta-hCG value returns to 0. The patient should then be followed monthly for an additional year to ensure that the values stay at 0 and that there is no evidence of persistent or metastatic disease. Evaluation in one year (choice A) would not be appropriate. This patient may have malignant gestational trophoblastic disease, in which case the beta-hCG values will remain elevated and not return to 0 after the evacuation. To postpone further evaluation for one year risks a significant delay in diagnosis and management of persistent or malignant disease. Dactinomycin (choice C) is often used as an alternative therapy to methotrexate in patients with malignant gestational trophoblastic disease. As long as this patient’s beta-hCG values fall to 0 appropriately and stay at 0, there is no need to treat with Dactinomycin. Methotrexate (choice D) is used as the first-line agent in patients with malignant trophoblastic disease. Again, there will be no need for chemotherapy in this patient as long as the beta-hCG values fall to 0 and stay at 0. Hysterectomy (choice E) would not be indicated in a 23-year-old patient with benign gestational trophoblastic disease who desires future fertility.
24) A 22-year-old woman, gravida 3, para 2, at 22 weeks’ gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient?
A. Administer erythromycin
B. Administer levofloxacin
C. Administer metronidazole
D. Administer tetracycline
E. Desensitize the patient and then administer penicillin
Explanation:
The correct answer is
E. This patient has a presentation that is consistent with primary syphilis. Syphilis is caused by the organism Treponema pallidum, which is a highly contagious spirochete. The incubation period for the organism is anywhere from 10 to 90 days, after which a chancre, which is a raised, painless ulcer, will appear. T. pallidum cannot be cultured, but it can be identified with darkfield microscopy or fluorescent antibody staining from obvious lesions. Serologic tests can also be used, such as the RPR and VDRL tests, which are not specific for T. pallidum infection and may be positive in patients with collagen vascular disease, intravenous drug abuse, bacterial and viral infections, a history of blood transfusions, and even pregnancy. Because the RPR and VDRL are not specific, a treponemal specific assay such as the FTA-ABS or MHA-TP should also be used for confirmation. When these are positive and the patient has no history of treatment, it is absolutely essential that treatment be given because syphilis in pregnancy is associated with a number of complications including fetal demise, IUGR, preterm delivery, and congenital infection. Treatment during pregnancy must be with penicillin as no other drug permits safe and effective treatment of the fetus as well as the mother. In a patient who is allergic to penicillin, oral desensitization must be performed first in a hospital setting with appropriate facilities. To administer erythromycin (choice A), levofloxacin (choice B), or metronidazole (choice C) would not be proper management. These are not drugs that will effectively treat syphilis in pregnancy. Furthermore, levofloxacin is contraindicated during pregnancy, as are all fluoroquinolones, because of the possible relationship between maternal use and arthropathies in the offspring. To administer tetracycline (choice D) would be appropriate in the non-pregnant patient with syphilis who is allergic to penicillin. Tetracycline is considered a reasonable alternative in that situation. However, in the pregnant patient, tetracycline cannot be used because of effects on the fetal teeth and bones. Only penicillin is considered adequate for the treatment of syphilis in pregnancy.
25) A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad “flu” with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?
A. Daily oral acyclovir
B. Daily oral estrogen
C. Daily topical estrogen
D. Daily oral ferrous sulfate
E. Daily oral penicillin
Explanation:
The correct answer is
A. This patient has a classic presentation of herpes genitalis, a venereal disease caused by herpes simplex virus type II (90% of cases) or type I (10%). Initial infection usually results in generalized illness including malaise, myalgias, and low-grade fever along with the perineal lesions. These lesions start out as clear vesicles that progress to ulcers over the following days. The ulcers may then coalesce to form a larger, shallow, painful ulcer. After the initial infection, the virus resides in the dorsal root sacral ganglia. From there it is periodically reactivated. Recurrent episodes are characterized by a prodrome of tingling, burning, or itching prior to the appearance of the lesions. There is no “cure” for herpes genitalis. Acyclovir can be used to shorten the duration of symptoms. In patients who have more than 6 outbreaks per year, daily oral acyclovir is recommended to prevent these frequent outbreaks. Daily oral estrogen (choice B) or daily topical estrogen (choice C) would not be appropriate pharmacotherapy for these outbreaks. Estrogen (oral and topical) is used for patients with atrophic vaginitis. Atrophic vaginitis is characterized by pale vaginal mucosa with a loss of rugae. It is associated with estrogen deficient states such as menopause. This patient has no evidence of estrogen deficiency and therefore estrogen would not be recommended. Daily oral ferrous sulfate (choice D) is appropriate pharmacotherapy for patients with iron-deficiency anemia. Sufficient iron stores are necessary for effective erythropoiesis. There is no evidence that this patient is iron deficient and the most appropriate pharmacotherapy to prevent recurrent herpes outbreaks is acyclovir, not ferrous sulfate. Daily oral penicillin (choice E) would not be appropriate pharmacotherapy for this patient. This patient has herpes genitalis and not a bacterial infection. Thus, acyclovir, and not penicillin, would be indicated.
26) A 34-year-old primigravid woman at 30 weeks’ gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patient is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?
A. Decreased childhood intelligence
B. Increased maternal insulin requirement
C. Maternal infection
D. Neonatal adrenal suppression
E. Neonatal infection
Explanation:
The correct answer is
B. Corticosteroids are known to lead to more difficult glucose control in diabetic women. To ensure that these patients do not develop diabetic ketoacidosis, blood glucose levels should be checked regularly, and elevated values treated with insulin. This will often require hospitalization, which is usually required by the condition for which they received the corticosteroids in the first place (e.g., preterm labor or preterm premature rupture of membranes). In patients who do not have diabetes, the hyperglycemic effect will last 2-3 days. Studies have been performed to determine whether antenatal treatment with corticosteroids leads to decreased childhood intelligence (choice A). There is no evidence that this relationship exists. Because of the immunosuppressive properties of corticosteroids, there has been concern that their use may increase rates of maternal infection (choice C) or neonatal infection (choice E). There is no definitive proof that corticosteroid use leads to higher rates of infection in either the mother or fetus. And, although there may be some instances of maternal or neonatal infection in some cases of corticosteroid administration, the increased maternal insulin requirement occurs almost without exception. Neonatal adrenal suppression (choice D) has not been proven to result from antenatal corticosteroid administration.
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