The following are strategically designed review questions to assess whether
the student is able to integrate the information presented in the cases. The
explanations to the answer choices describe the rationale, including which
cases are relevant.
www.myuptodate.com568 CASE FILES: OBSTETRICS AND GYNECOLOGY
R-4. If the patient in R3 is prescribed and takes a 28-day package of combination oral contraceptive pills, which of the following is most likely to occur?
A. The patient will have bleeding during the drug-free (placebo) phase
(days 21-28).
B. The patient will have no bleeding during any of the days of the pills.
C. The patient will have bleeding during the first half the pills (days 1-14).
D. The patient will have light bleeding throughout the pills.
R-5. A 23-year-old woman is noted to have 4 months of amenorrhea. Her pregnancy test is negative. Oral progestin is given for 7 days leading to vaginal
bleeding after the progestin therapy. Which of the following is most likely
to be found in this patient’s examination prior to the progestin therapy?
A. Gonadotropin levels elevated in the menopausal range
B. Vaginal pH < 4.5 range
C. Ultrasound shows the endometrial stripe to be thin (< 5 mm)
D. Atrophy noted of the vulvar and vaginal epithelium
R-6. A 55-year-old woman is noted to have an abdominal mass and increased
abdominal girth. On examination, there is shifting dullness and a fluid
wave. Which of the following malignancies is most likely to be found in
this patient?
A. Colon cancer
B. Endometrial cancer
C. Cervical cancer
D. Ovarian cancer
E. Vulvar cancer
R-7. A 29-year-old G1P0 woman is noted to be at 39 weeks’ gestation, and
comes into the hospital complaining of significant shortness of breath. On
examination, her heart rate (H R) is 120 bpm and respiratory rate is 32 and
labored. Her O
2 saturation is 85% (normal 95%). The chest radiograph
reveals bilateral pulmonary infiltrates and also an enlarged cardiac silhouette. Which of the following is the mechanism for this patient’s symptoms?
A. Decreased cardiac contractility
B. Bronchospasm and reactive airway disease
C. Capillary leakage and pulmonary injury, acute respiratory distress syndrome
D. Inflammation, interstitial pneumonitis
E. H ypercoagulable state
www.myuptodate.comSECTION III: REVIEW QUESTIONS 569
R-8. A 33-year-old G2P1 woman at 29 weeks’ gestation is seen in the office for
a prenatal visit. The fundal height is 35 cm and fetal parts are difficult to
palpate. On ultrasound, there are two cystic structures noted in the fetal
abdomen—one on the left side, and another cystic structure on the right
side. Which of the following is most accurate regarding this pregnancy?
A. The fetus likely has a fetal kidney abnormality.
B. The fetus is at increased risk for leukemia.
C. The fetus likely has an elevated middle cerebral artery Doppler velocity.
D. The fetus likely has been infected with parvovirus.
R-9. A 19-year-old G1P0 woman at 7 weeks’ gestation is seen in the emergency
center for vaginal spotting. The patient is noted to have an ultrasound that
reveals no gestational sac and no adnexal masses. Which of the following
statements is most accurate regarding the management for this patient?
A. This patient should have a laparoscopy for probable ectopic pregnancy.
B. This patient should have a repeat human chorionic gonadotropin
(hCG) level in 48 hours.
C. This patient should be offered methotrexate for ectopic pregnancy
provided her vital signs are normal.
D. There is insufficient information to manage this patient at this time.
R-10. A 38-year-old woman is seen in the office desiring contraception. She has a
7-year history of chronic hypertension, which is controlled with sustained
release nifedipine (Procardia). She smokes about a pack of cigarettes each
day. She complains of dysmenorrhea and heavy menses with clots. Which
of the following is the best contraceptive agent for this patient?
A. Copper intrauterine device (IUD)
B. Levonorgestrel IUD
C. Combination oral contraceptive agent
D. Condom (barrier method)
R-11. A 48-year-old woman has a 1-cm right breast mass noted on physical examination. Stereotactic biopsy reveals intraductal carcinoma. Which of the
following would indicate a poor prognostic finding for this patient?
A. Her2/ neu positive
B. Outer breast involvement
C. The patient is postmenopausal
D. Estrogen receptor positive
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R-12. A 22-year-old nulliparous woman is seen by her gynecologist and given a
routine Pap smear. The Pap smear revealed LSIL, and a colposcopy is performed. A biopsy at 3:00 shows CIN 2. Which of the following is the best
therapy for this patient?
A. Conization of the cervix with top hat to address any endocervical
involvement
B. LEEP excision of the cervix
C. Offer hysterectomy
D. Repeat Pap smear in 6 months
R-13. A 28-year-old G2P1 woman at 34 weeks’ gestation is noted to have chronic
hypertension. H er weekly fetal assessment includes a nonstress test (NST ),
which shows a fetal heart rate of 140 bpm, and no accelerations, and no
decelerations. What is the best next step for this patient?
A. Schedule for cesarean delivery immediately
B. Schedule for induction of labor in the next 24 hours
C. Repeat the NST in 1 week
D. Perform a biophysical profile
R-14. A 27-year-old G3P2 woman at 12 weeks’ gestational age comes in for her
first prenatal visit. On exam, her BP is 110/ 60 and urine dips 2+ glucose.
The fetal heart tones are 150 bpm. Which of the following is the most
likely explanation for the glucosuria?
A. The patient likely has gestational diabetes.
B. The patient likely has pregestational diabetes.
C. The patient likely has a degree of renal insufficiency.
D. The patient’s increased glomerular filtration rate (GFR) is responsible
for the finding.
R-15. A 34-year-old woman is hospitalized for presumed PID. On ultrasound,
she is noted to have a 7-cm left adnexal mass. The patient is treated with
intravenous antibiotics and on hospital day 2, the nurses call you due to the
patient being confused and having tachycardia. On exam, the BP is 84/ 44
and H R is 130 bpm. Which of the following is the best therapy for this
patient?
A. Interventional radiology to drain the ovarian cyst
B. Immediate surgery
C. Change the antibiotics due to probable medication adverse effect
D. Administer digoxin for probable atrial fibrillation
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R-16. A 28-year-old patient sees you in the office and states that although born
as a male, she identifies more as a woman. She has been using “street hormones” to have the appearance of a female. She says she has always thought
of herself as a female even at a young age. Which of the following is the
most likely diagnosis?
A. Androgen insensitivity syndrome
B. Cross-dressing
C. Gender dysphoria
D. Gender mutilation syndrome
E. Intersex disorder
R-17. A 17-year-old G0P0 female complains of severe pain with her menses, and
misses school for 4 days per month. Oral contraceptives and nonsteroidal
anti-inflammatory drugs (N SAIDs) are prescribed and after 6 months, the
pain is unchanged. Which of the following is the best next step?
A. Continued expectant management
B. GnRH agonist therapy
C. Laparoscopy
D. Opiate medication during menses
E. Psychiatric referral
R-18. A 35-year-old G0P0 presents to her doctor for infertility. She also has
heavy vaginal bleeding that persisted for 3 weeks. She has a long history of
oligomenorrhea. An endometrial biopsy shows Grade 1 endometrial carcinoma. Which of the following is the best treatment for this patient?
A. Clomiphene citrate
B. Combination chemotherapy
C. Progestin therapy
D. Radiation therapy
E. Surgical staging
ANSWERS
R-1. B. This child presents with precocious puberty, which is defined as secondary sexual characteristics prior to age 8. The most common cause is
idiopathic, which means the hypothalamic GnRH pulse generator initiates
too early. The diagnosis is of exclusion, and other causes must be ruled
out including central nervous system (CN S) tumors, head trauma or CN S
infections, ovarian or adrenal tumors. Idiopathic precocious puberty is
treated with a GnRH agonist, which downregulates the hypothalamus and
pituitary hormone secretion. With precocious puberty, it is important to
assess whether it is purely female characteristics (estrogen) versus hirsutism (androgens).
www.myuptodate.com572 CASE FILES: OBSTETRICS AND GYNECOLOGY
It is important to remember that the most common cause of precocious
puberty is idiopathic, but the most common cause of delayed puberty is a
pathological cause such as gonadal dysgenesis.
Please also see Cases 54 (Delayed Puberty—Note Tanner I Breasts) and
55 (Primary Amenorrhea—Tanner IV Breasts).
R-2. D. The most common cause of postpartum hemorrhage overall is uterine
atony, which is treated by uterotonic agents, and if unresponsive, then intrauterine balloon or surgical therapy. The most common cause of postpartum
hemorrhage with a well-contracted uterus is a genital tract laceration, usually
involving the cervix. Surgical therapy, usually involving suturing the defect,
is the most appropriate treatment for lacerations. See Case 6 (Postpartum
H emorrhage) for more discussion on postpartum hemorrhage. The other
common causes of PP hemorrhage include retained products of conception, placenta accreta (Case 12), and inverted uterus (Case 3).
R-3. B. When a patient has regular menses and has an isolated amenorrhea, the
most common cause is hypothalamic dysfunction, causing GnRH inhibition. Causes include hypothyroidism, hyperprolactinemia, excessive exercise, malnutrition from an eating disorder, stress, and some drugs. The
evaluation of secondary amenorrhea (no menses for 3 months in a woman
who has previously had menses) includes: (a) pregnancy test, (b) thyroidstimulating hormone, and (c) prolactin level. If these are normal, then the
next step is typically to assess luteinizing hormone and follicle-stimulating hormone and administer progestin to see if the outflow tract (uterus)
responds normally and has sufficient estrogen to have caused proliferation of the endometrium (see Cases 49-51; Case 49 contains a diagnostic
algorithm). Bleeding after progestin alone indicates anovulation, typically
caused by polycystic ovary syndrome (PCOS) (see Case 52).
R-4. A. Because the patient in R-3 most likely has a hypothalamic dysfunction as discussed, she is in a hypoestrogenic state. Hence, progestin alone
will not lead to bleeding because there is no endometrium to shed. However, because she has a normal outflow tract (uterus), she should respond
normally to the oral contraceptive agent and bleed normally during the
drug-free days (days 21-28). In other words, because the combination OC
contains both estrogen and progestin, this regimen will stimulate growth of
the endometrium, and the progestin withdrawal during the drug-free pills
will lead to bleeding. A patient with intrauterine adhesions (see Case 49)
will not have bleeding after the combination OCP.
R-5. B. This patient has bleeding following progestin therapy indicative of
anovulation, and indicative of the presence of sufficient estrogen to have
caused endometrial growth. The presence of estrogen causes a normal
endometrial stripe (6-12 mm), normal rugae, and growth of the vulvar and
vaginal epithelium. The normal estrogen environment also promotes Lactobacilli growth, which lowers the vaginal pH to < 4.5. This patient likely has
PCOS with anovulation and estrogen excess. In contrast, the postmenowww.myuptodate.comSECTION III: REVIEW QUESTIONS 573
pausal hypoestrogenic state is associated with an elevated vaginal pH > 4.5
and a thin and atropic vulvar and vaginal epithelium (see Cases 49-51).
R-6. D. Ovarian cancer is associated with a pelvic mass and ascites. The majority
occurs in older (postmenopausal) women, and the majority are epithelial in
nature. Symptoms of epithelial carcinoma are subtle including early satiety,
bloating, and increased abdominal girth. The cancer cells spread early to
the peritoneal cavity, the bowel, and the omentum. The peritoneal seeding
incites ascites. The most common way that ovarian cancer kills women is by
cachexia (starvation) as a result of widespread small bowel metastasis. The
most common way that cervical cancer kills is by bilateral ureteral metastases, leading to uremia (see Case 59, Ovarian Cancer (Epithelial)).
R-7. A. A dilated cardiac silhouette is highly suggestive of a cardiomyopathy,
and when it occurs in pregnancy, it is commonly due to peripartum cardiomyopathy. The etiology of peripartum cardiomyopathy is unknown, but it
is a four-chamber dilated cardiomyopathy and thus has a negative effect on
cardiac contractility. Treatment is diuretics, digoxin, and afterload reduction. The majority of patients will improve and the cardiac output normalizes, but there is a significant recurrence of the cardiomyopathy with future
pregnancies.
R-8. B. This patient has hydramnios (also known as polyhydramnios). The combination of size greater than dates, and fetal parts being difficult to palpate
indicates hydramnios. H ydramnios may be caused by fetal intestinal abnormalities because the baby eliminates amniotic fluid by swallowing. The
ultrasound showing cystic areas in both the right and the left abdomen is
consistent with duodenal atresia, which is a sonographic finding oftentimes
referred to as the “double bubble sign.” Duodenal atresia is associated with
Down syndrome, and children with Down syndrome are at risk for leukemia. Fetal kidney anomalies are associated with oligohydramnios because
fetal urine is the main component of amniotic fluid. Increased middle cerebral artery flow is associated with fetal anemia, which should not occur
with this situation (see Case 19, Parvovirus Infection in Pregnancy).
R-9. D. This is an important question to assess whether the student has a clear
understanding of the role of the hCG and vaginal ultrasound in assessing
early pregnancy bleeding. A patient with a threatened abortion in the first
trimester will have one of three possible causes: (a) a normal intrauterine
pregnancy and the bleeding will stop (about 50% of cases), (b) an abnormal
intrauterine pregnancy or miscarriage (about 40% of cases), or (c) an ectopic pregnancy (about 10% of cases). The scenario notes the transvaginal
ultrasound results, but does not give the hCG level to be able to interpret
the ultrasound findings. For instance, if the hCG level is below the “discriminatory zone” of 1200 to 1500 mIU/ mL (see Cases 42-43), then in a
stable patient, a follow-up hCG in 48 hours is the appropriate next step. If
instead the hCG level is above the threshold (Case 43), then the next step
is laparoscopy because the risk of ectopic pregnancy is high.
www.myuptodate.com574 CASE FILES: OBSTETRICS AND GYNECOLOGY
R-10. B. This patient is over the age of 35 and a heavy smoker (> 15 cigarettes/ d),
and thus the oral contraceptive and any estrogen containing contraceptive
agent is contraindicated. The presence of dysmenorrhea and menorrhagia
would be made worse with the copper IUD, which causes inflammation.
Condoms (barrier method) is acceptable but has a higher failure rate. The
levonorgestrel IUD would be ideal in this patient because there would not be
an increased risk of thrombosis, and the progestin would thin the endometrium and decrease the menstrual blood flow (see Case 44, Contraception).
R-11. A. Breast cancer that is her2/ neu positive tends to be more aggressive.
Estrogen receptor (ER) and progesterone (PR) receptor positive tumors
tend to be less aggressive and respond to hormonal therapy. Breast cancers
that are ER, PR, and her2/ neu negative (so-called triple negative) have a
poor prognosis (see Cases 46-48). A majority of breast cancers are located
in the upper/ outer quadrant of the breast; however, this does not affect
prognosis.
R-12. D. The trend recently is to be less aggressive with cervical dysplasia in
younger patients less than age 25. Women less than age 25 with CIN2 have
been observed to clear the cervical intraepithelial neoplasia 70% to 80% of
the time, and thus observation with surveillance Pap smears is a reasonable management approach. Also for younger women, the treatment such
as LEEP excisions of the cervix can lead to preterm labor or cervical insufficiency (see Case 58, Cervical Cancer).
R-13. D. The nonstress test is a good test for assurance of fetal well-being when
it is reactive with accelerations present. H owever, the N ST is not reliable
when there is an absence of accelerations and decelerations, so-called nonreactive. More than half of the time, the fetal status is normal with a nonreactive N ST. Thus, another fetal test such as biophysical profile should be
used to further assess fetal well-being. N ST and BPP are both tests of fetal
well-being and used in settings when there is an increased risk of stillbirth
(see also Cases 14 and 22 for fetal testing).
R-14. D. Glucose in the urine is a common finding due to the 50% increase in
GFR and increased glucose to the renal tubules, which is greater than the
resorption capability. Whereas glycosuria may be a finding of diabetes mellitus in a nonpregnant individual, it is not indicative of diabetes in pregnancy. The next step in this patient is either fingerstick glucose to assess
glucose level, or screening test for diabetes (see Case 28, Prenatal Care).
R-15. B. This patient likely has a tubo-ovarian abscess, a complication of PID. The
patient is treated with intravenous (IV) antibiotics which is the appropriate therapy. There is no description of the type of antibiotics, but anaerobic
coverage is important. This patient develops a shock-like picture with confusion, hypotension, and tachycardia which is likely due to rupture of the
TOA. Immediate surgical management is important in this setting, due to
high mortality without prompt treatment. IV antibiotic therapy successfully
treats the majority of patients with a TOA (see Case 36, Salpingitis, Acute).
www.myuptodate.comSECTION III: REVIEW QUESTIONS 575
R16. C. This patient describes findings consistent with gender dysphoria, in
which an individual identifies with the opposite gender from their chromosomal (anatomical) gender, and does not have intersex disorder, such as
ambiguous genitalia due to 21 hydroxylase deficiency or true hermaphroditism. Typically, the gender identification occurs at a young age, and DSM
V criteria indicate that this occurs prior to puberty. Cross-dressing is not
the same as gender dysphoria in that these individuals are aware of their
chromosomal gender and do not necessarily desire to be the opposite gender. This topic is not currently covered in case files, but has emerged as an
important area within our specialty (see Table R-1).
R-17. C. In an adolescent with dysmenorrhea, the most likely etiology is primary
dysmenorrhea with the etiology is elevated prostaglandin F2-alpha in the
endometrium and myometrium leading to intense uterine contractions.
The best treatment is NSAIDs, which is typically very helpful. Oral contraceptive agents, particularly used continuously, also offer relief. When
an adequate trial of NSAID and oral contraceptive therapy is unhelpful, a
large fraction of these adolescents will have endometriosis. Laparoscopy is
the appropriate procedure for diagnosis. GnRH agonist therapy should not
be used “blindly” due to the side effects and also the importance of establishing a diagnosis (see Case 37, Chronic Pelvic Pain).
R-18. C. In a patient who strongly desires child-bearing and has a low grade
(Grade 1), minimally invasive cancer, high-dose progestin therapy followed by frequent endometrial sampling is possible. After child-bearing
is complete, definitive surgic
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