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93 Cards in this Set
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36yo G2P2 BMI 31.4 w/ PMHx of HTN w/o meds. BP 130/90. c/o unpredictable bleeding depo and wants to discuss discontinuing. Next step?
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Reassurance that this is normal. Unregulated progesterone will cause thining of uterine lining and bleeding. But eventually resolves w/ 50% having amenorrhea after 1 year
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18 yo G0 reports unprotected sex last night (LMP 14 day ago). Wants long-term and emergency contraception. Advise her to take low dose of OCP. Instructions?
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Levonorgestrel can be take as a single or 2 doses 12h apart. Insert the second dose per vagina or take an antiemetic 1 hr before dosing to decrease nausea. start w/in 72 hrs. No later than 120 hrs.
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Who are ideal candidate for progestin-only pills?
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women who have contraindications to OCP w/ estrogen such as, thromboembolic disease, women lactating, women >35 w/ +smoking, or those report severe nausea.
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T/F: No caution required for progestin use in women w/ history of depression.
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Long-acting progestins may increased risk of post-partum depression.
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24 yo G1P1 wants contraception. FHx + for endometrial cancer. Denies EtOH/TOB/Drugs. Whats best method of contraception for this patient?
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Combined OCPs. Can decrease risk of developing ovarian and endometrial cancer. May have slight risk of CIN, but PID, endometriosis, ectopic reduced. Side effects include HTN, thromboembolisms.
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What are the non-contraceptive health benefits of female sterilization.
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Reduction in ovarian cancer, mechanism not understood.
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What is the strongest predictor of post-sterilization regret in women who request permanent sterilization.
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Age. For those under 25%, the rate was as high as 40%.
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32 yo G3P3 wants permanent sterilization. Married happily. H/o HTN and asthma (steroids). BP 140/94, BMI 41. Best method?
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Vasectomy for hubby. Both vasectomy and BTL are 99.8% effective. Vasectomies are outpatient procedure and she is morbidly obese w/ chronic dz so risk of anesthesia and surgery increased.
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35 yo G3P3 wants contraception. Hx of Wilson's disease, chronic HTN and anemia 2/2 menorrhagia. No meds. BP 144/96. Ideal contraceptive?
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Mirena. Decrease bleeding over long term (amenorrheic). Protects against endometrial cancer 2/2 progestin. No estrogen for her because HTN. No Paraguard 2/2 Wilson's.
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23 yo G0 wants patch. PMHx hypothyroid and mild HTN. H/o irregular menses. Obese (205lbs). Most compelling reason to use other form?
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weight. the patch has higher failure when used in women who weigh over 198lbs.
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What is biggest risk factor for cardiac disease in 37 yo who wants to restart OCPs? PM/Shx includes BTL, OCP use x10 years in her 20s, +TOB + EtOH.
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Smoking! Past pill use doesn't increase current risk. Red wine consumption actually decreases risk.
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23 yo 6 weeks amenorrhea presents w/ lower abd pain and +VB. 39C and cervix 1 cm dilated. Uterus 8 week size and tender. urine preg test +. Diagnosis?
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Septic abortion. fever + bleeding + dilated cervix + tender uterus = abortion.
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Define threatened abortions.
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+pregnancy test, VB and cervix closed and uneffaced.
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Define missed abortions.
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retention of POC for extended time.
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23 yo 6 weeks amenorrhea presents w/ lower abd pain and +VB. 39C and cervix 1 cm dilated. Uterus 8 week size and tender. urine preg test +. Best next step?
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uterine evacuation + borad spectrum antibiotics for septic abortion. Single agent not recommended until known species.
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29 G3P0 (all 1st trimester losses) and h/o DVT 2 years ago presents for eval. Next step in management.
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test for antiphospholipid antibodies (lupus, anticardiolipin and beta2GP) Get PTT and russel viper venom time.
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29 G3P0 w/ POBHx +APS wants to get pregnant. Best treatment appropriate?
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Aspirin and Heparin. 75% success rate. conflicting evidence regarding steroid use for treatment and heparin is more effective.
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compared to surgical abortion, what is increased in a woman undergoing a medical abortion?
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Blood loss.antiprogestin (mifepristone) followed by a prostaglandin (misoprostol) induce uterine contractions to expel. 96% effective. Neither types have effects on future fertility.
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What are contraindications to manual vacuum aspiration for surgical termination of pregnancy? (ex 36 yo G2P0 @ 11 wks GA)
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Gestational Age. Vacuum aspiration is effective in early pregnancy (less than 8 weeks). Although asherman's syndrome (IU adhesions increase) its not a contraindication.
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25 yo G1 @ 20w desires termination. + Trisomy 18. Desire autopsy. Next step?
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induction w/ intravaginal prostaglandins. If she wants autopsy, she needs intact fetus. Abortion is legal until 24 weeks unless anomaly inconsistent w/ life is seen.
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What GA is D&C appropriate? D&E? When is intraamniotic hypertonic saline indicated?
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less than 16 weeks. after 16 weeks by those trained. high morbidity, not performed anymore.
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23 yo G1P0 has medical termination @ 6w GA. 1 day later presents w/ bleeding (pad soaked x 5hrs) BP stable. Cervix dilated w/ active bleeding. Hct 29%. Next step?
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Bleeding secondary to meds is best managed thru D&C. Not symptomatic, thus, no need for transfusion.
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22 yo G1P0 wants elective abortion. LMP 6w ago, previously + urine pregnancy test. U/S today shows 8mm uterine stripe and no adnexal mass. Next step?
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hCG. no gestational sac in uterus therefore, establish pregnancy. Don't assume!
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24 yo G2P1 who had elective termination 2 days ago presents w/ abd and pelvic pain. +Fever, tachy, CMT+. CBC and cultures sent. Next step in management? After that?
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begin IV abx 2/2 endometritis from D&C. Next get an ultrasound to look for POC.
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32 yo presents w/ malodorous vaginal discharge x 3mo. No pruritus. gray discharge, vaginal pH < 4.5. +Clue cells. Medication?
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Metronidazole (flagyl). BV is MCC of vaginitis. Infection 2/2 incease in non-H2O2-producing lactobacilli which allows for anaerobic bacteria. Asx + smell (fishy). 500mg PO BID x 7d or gel 5g qhs x 5d
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64 yo G2P2 c/o vulvar pruritus x12 mo. No discharge. +dyspareunia. Loss of labia minora w/ resorption of clitoris. Atrophic vagina. Most likely diagnosis.
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Lichen sclerosus is a chronic inflammatory skin conditions seen in white premenarchal and postmenopausal females. etiology unknown. +vulvar pruritus and dyspareunia. Waxy sheen on labia minor and resorption of clitoris w/ hypopigmentation. Rx: high potency topical steroids. 5% risk for SCC
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Erythematous vagina w/ copious frothy yello discharge and petechiae on cervix. pH 7. saline wet mount: motile falgella and WBC. rx?
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Same as BV, use flagyl. This is T vaginalis. differentiate from BV because yellow color, and pruritic symptom. Get wet prep. treat partner.
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thick, curdish white vaginal discharge and pruritus. Treatment?
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azole cream. VVC is caused by C albicans usually. Look for itching, white thick discharge. wet prep or gram stain shows yeasts or pseudohyphae.
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52yo P0 c/o vulvar and vaginal pain. +dyspareunia, inflamed gingiva, white skin chage on buccal mucosa, papular rash on wrists b/l. white plaques w/ red erosions on labia minora. adhesions on vagina. Dx?
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Linchen planus - dermatolgoic disorder of hair-bearing skin, scap, oral mucosa and vulva. +mucocutaneous eruptions episodes. Look for lacy, reticulated pattern on labia and perineum. Rx: supportive + steroids
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27 yo P0 c/o dyspareunia x 3y. inability to use tampons 2/2 pain.+yeast infections during Abx for sinus infections. No mes. Normal exam except for tenderness of vestibule. diagnosis?
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vulvar vestibulitis - sx limited to VV, which include pain, erythema. treatment: TCA to block sympathetic afferent pain, biofeedback and topical anesthetics. Surgery if non of these work.
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30 yo G1P1 presens w/ hx of chronic vulvar pruritus. severe itching can't sleep. No discharge/dyspareunia. Increased skin markings (lichenification) and diffuse vuvlar edema/erythema. wet prep negative. Dx?
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Lichen simplex chronicus, common non-neoplastic disorder results from scratching and rubbing. Sx: pruritus, thickened labia. Diagnosis via biopsy. Treatment steroids and antihistamines.
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20 yo leaving for europe tmrw comes to ffice c/o thick yellow discharge and spotting mid cycle. +OCPs, new partner x 3mo. Negative findings in exams. Lab findings negative, G&C pending. Next step?
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Ceftriaxone and Azithromycin now. mucopurulent cervicitis is asx besides discharge and spotting. Worry about PID or upper genital tract infection so treat regardless if patient leaving country.
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37 yo P0 presents w/ 1 week hx of vulvar ucler. Recently started steroids fro vulvar dermatitis. Married, not hx of STDs, travel, or abnormal pap. Culture + HSV-2. Dx?
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recurrent HSV-2 episode. Most cases of genital are type 2. initial presents w/ systemic sx (f/ha/malaise/myalgias) and groups of lesions. Rx: acyclovir, famiclovir, valacyclovir.
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Genital condylomata or wars are typically caused by what virus (types)? If found whats next step?
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HPV 6, 11. 16,18,31,33 are associated w/ cervical cancer. VIN is associated in patients w/ cervical dysplasia, tobacco use and HIV status. always bx condylomata (warts).
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76yo G3P3 c/o worsening urinary incontinence x 3 mo. Increases in freq, urgency and nocturia. Exam mild cystocele and rectocele. Post void residual is 400cc. Diagnosis?
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Overflow incontinence. This is characterized by failure to empty bladder completely 2/2 to underactive detrusor muscle (neuro, DM, MS) or obstruction (postoperative or prolapse). Look for >300cc PVR!
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Whats a normal post void residual (PVR)? elevated PVR?
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50-60cc. > 300cc.
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Define stress incontnence.
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when bladder pressure > intraurethral pressure.
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76 yo G3P3 presents w/ worsening stress urinary incontinence x 3 mo. Exam +for cystocele and rectocele. PVR 50cc. Cystometrogram shows 2 bladder contractions while filing. diagnosis?
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Urge incontinence aka detrusor overactivity/instability. Simple test: fill 50-60cc via foley, if uninhibited contraction of thebladder occurs - urge incontinence.
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Define disease described as loss of urine due to increased abdominal pressure in the absence of a detrusor contraction.
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Genuine stress incontinence (GSI).
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What is the Q-tip test? How do you diagnose SUI? Rx?
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Tests for urethral hypermobility (bladder neck hypermobility) is present in women w/ primary SUI, shown by >30 degrees from horizon). retropubic urethropexy are best.
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In minority of patients w/ SUI 2/2 to intrinsic sphincteric deficiency, what is the treatment?
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urethral bulking procedure (you saw this procedure performed).
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In a patient who shows uninhibited detrusor contractions on cystometrogram, what is the best treatment?
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Oxybutynin - this patient has detrusor instability (urge incontinence). anticholinergics are drug of choice. TCA have anticholinergic properties but not as good as oxybutynin.
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A vaginal repair where the pubocervical fascia is plicated in the midline as well as laterally to the arcus tendineus fascia (white line) is a surgery to repair what defect?
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Cystocele.
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Defects in rectovaginal fascia are repaired in a surgery for what defect?
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rectocele
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What is the surgical treatment for uterine prolapse?
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hysterectomy
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Urine loss associated when standing or sitting and not w/ any specific activity.
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Urge incontinence caused by overactivity of detrusor muscle leading to uninhibited contractions.
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In a women with asymptomatic bladder prolapse (cystocele) What is the next step in management?
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Observation unless patient has symptoms.
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In patient w/ vaginal prolapse beyond the introitus and complicated by hydronephrosis what is the next step in management?
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Colpocleisis - where vagina is surgically oblitereated and can be performed under local anesthesia.
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What is the most appropriate first step for the treatment of this patient's prolapse?
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Pessary fitting - least invasive intervention for symptomatic prolapse.
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27 yo G0 c/o dysmenorrhea and dyspareunia w/ nodularity on back of uterus. No fever, hx of chlamydia @ age 19. Dx?
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Endometriosis, look for dysmenorrhea and dyspareunia. No fever so r/o endometritis.
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29 yo G0 presents c/o infertility, dysmenorrhea, dyspareunia x 1y. Hx of PID @ 19yo. FHx +OV CA. 5cm Left complex cyst and 2 simple cyst on right. Thin VSSAF. Pathophysiology of disease?
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Endometrial tissue outside of uterus. PID r/o no CMT. chronic r/o hemorrhagic cyst.
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63 yo G0 presents for annual exam. Previously healthy but h/o endometriosis and infertility. 10 post-menopause no HRT. Thin. U/S: 5 cm complex left ovarian cyst. Next step?
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Exploratory surgery. A complex ovarian mass in a post-menopausal women requires it. CTMRI will not add more information.
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27 yo G0, non smoker w/ endometriosis refractory to NSAIDs and tenderness in cul de sac. Next step in management. What if she was over 35 and a smoker.
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OCPs. provide negative feedback to pituitary-hypothalamic axis. Estrogen prevents ovulation and follicular development. Prog thins lining, thickens mucus and decreases tubal motility. Can't give OCPs if >35 and smoking.
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What is definitive diagnosis of endometriosis.
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Ex-lap. however, its usually treated based on clinical/ultrasound evidence.
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48 yo G0 presents for HME. Healthy. 21 days post LMP. FHx +endometriosis. No complains. Thin. 4 cm complex left and 2cm simple right ovarian masses. Likely Dx?
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Hemorrhagic cyst. Must r/o ovarian carcinoma first, but patient not post-menopausal and asx.
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48 yo G0 presents for HME. Healthy. 21 days post LMP. FHx +endometriosis. No complains, asx. Thin. 4 cm complex left and 2cm simple right ovarian masses. Next step in management.
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Repeat ultrasound in 2 mo. Most likely a hemorrhagic cyst (no sx) which will resolve on its own. CT/MRI don't provide any information and no indications for TAH/BSO.
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Sudden onset of RLQ pain and nausea and cyst on ultrasound. Moderate tenderness on RLQ. hCG negative, WBC wnl. afebrile. No hx STD. Dx? ... Free fluid in pelvis. Next step in management?
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Ovarian torsion. Although appendicitis must be r/o it, a WBC wnl and afebrile make it less likely. Ex-Lap is next step if she'f possibly bleeding!
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Patient w/ hx of endometriosis is unable to conceive. Negative workup for infertility (HSP and father's sperm normal). Next step?
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Clomiphene citrate (SERM) for ovarian stimulation. can add intrauterine insemination. If these fail consider IVF/adoption.
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17 yo G0 presents w/ hx of dysmenorrhea x 3years. On NSAIDs and OCP w/o improvement. Pelvic exam normal. Next step in management?
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Diagnostic laparoscopy. Chronic pelvic pain is the indication for ~40% of laparoscopies. Even though she is young, she was refractory to NSAIDs and OCPs for possible endometriosis. More invasive work-up validated.
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24 yo G0 presents w/ dyspareunia x 1 y. dysmenorrhea x 2y. Hx endometrosis refractory to OCPs. CO2 laser ablation. Increased urinary frequency, urgency and nocturia. UCx negative. VSSAF. besides endometriosis, additional diagnosis?
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Interstitial cystitis is a chronic inflammatory condition of bladder w/ symptoms of freq, urgency and nocturia w/ negative UCx. Can have pelvic pain and dyspareunia. eitology unknown, maybe autoimmune.
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32 yo G3P2 LMP 2w ago c/o abdominal pain x 6 mo. Relieved w/ defecation (watery stools). increase BM/day. No blood. +bloating/distention. VSSAF. Exam normal except for mild LLQ TTP. Diagnosis?
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IBS. relapsing abdominal/pelvic pain. one of the MCC of pelvic pain. Diagnosis based on Rome II: 12 wks duration or pain w/ 2/3 following: 1) relief w/ defecation 2) onset associated w/ BM freq 3) onset w/ change in BM appearance.
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22 yo G0 w/ endometriosis refractory to OCPs and laparoscopic ablation. Next step in management and mechanism of action.
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GnRH agonists in constant levels causes down regulation of production and release of LH/FSH --> decrease in estradiol levels. (nafarelin, goserelin and leuprolide)
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Does physical and sexual abuse contribute to increase incidence of pelvic pain?
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yes. 40-50% of women w/ chronic pain have hx of abuse. Mechanism unclear possibly somatization.
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Best surgical option for 48 yo G4P4 w/ endometriosis refractory to OCPs and ablation. SHx +BTL.
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TAH/BSO.
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62 yo G4P4 w/ nonspecific abdomino-pelvic sx, post-menopausal bleeding and FHx ov ca. Next step?
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TVUS. it is more sensitive than CT for evaluation of uterus and adnexa.
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29 yo G0 presents f/u. Hx PID and Right TOA 14 mo ago. c/o pelvic pain, dypareunia x 10 mo. U/S +right FT mass. desires fertility. Right adnexa normal. Most appropriate next step?
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Laparoscopic right sapingectomy and lysis of any adhesions. RSO not indicated because right ovary not involved and patient wants kids still.
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33 yo G2P2 reports dysmenorrhea, menorrhagia and pelvic pain following delivery x 2y. Pain radiates to RLQ into vagina, worse w/ standing, feels fullness. US: diated vessels traversing R broad ligament to lower uterus and cervix. Diagnosis?
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Pelvic congestion. Occurs in setting of pelvic varicosities. Pelvic veins are vulnerable to dilation and stasis. Cause unkown. High levels of estradiol inhibit vasoconstriction. pain aggravated by standing w/ associated "fullness"
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What are the nerves at risk during a low transverse incision? Signs and sx of each?
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iliohypogastric (T12, L1) and ilioinguinal nerves (T12, L1) at risk. Iliohypogastric provides sensation togroin and skin overlying pubis. ilioinguinal is below the iliohypogastric sensation and provides sensation to groin, symphysis, labia and upper inner thigh.
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68 yo healthy G3P3 c/o breast tenderness. mammogram 4mo ago was normal. FHx + for 70yo sister w/ Breast CA. Breast exam normal. Next step?
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Reassurance! No indication for repeat mammogram since last one 4 mo ago normal. US or MRI would not add new info in setting of normal exam/mammogram. No genetic testing since sister was post-menopausal at time of diagnosis
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Greatest risk factors for developing breast cancer?
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age and gender. Having first degree relative increases risk, but genetic mutations occur in a low percentage of population.
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In a 31 yo women w/ large pendulous breasts. what is the best position to enhance visualization of asymmetry on physical exam.
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leaning forward (allows breast to hang from chest wall).
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48 yo c/o white, watery nipple discharge x 4mo. Hx of firbocytstic changes. Elevated prolactin. Next step in management?
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Obtain fasting prolactin level.timulation of breast during exam may give rise to elevated prolactin. Always r/o a non significant benign elevation first. If fasting is elevated get brain MRI to r/o pituitary mass.
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42 yo G3P3 c/o breast mass after self-exam. FHx +first degree relatives w/ Breast CA. Exam shows 2cm mass. Mammogram shows no abnormalities. Next step in management?
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FNA. any solid dominant breast mass should be evaluated cytologically (FNA) or histologically (Bx). A normal mammogram does not r/o presence of cancer!
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In a 24 yo h/o cystic mastalgia and FCC c/o of breast pain of the following which contributes to her increasing pain: 1. EtOH 2. Vegetarian diet 3. FHx of Breast cancer in Mom @ 55 4. Caffeine intake. 5. Age of menarche (12yo)
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Caffeine intake! Fibrocystic changes are MC type of benign breast conditions and occur most often during reproductive years. Caffeine intake increases pain associated w/ FCC.
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54 yo w/ no FHx of breast cancer presents w/ breast mass. FNA shows bloody fluid and shrinks mass. Mammogram ordered. Next appropriate step?
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Excisional Biopsy! even though mass decreased in size after FNA, blood obligates the biopsy to r/o cancer. A normal mammogram does NOT r/o cancer, esp if bloody discharge present!
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23 yo G0 presents w/ painful mass in axilla x 3d. No FHx. No breast mass palpated. Large tender mobile lymph node palpated. Etiology?
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Infection. Axillary LAD is a sign of cancer, a tender mobile lymph node is associated w/ infection. LAD in cancer is usually firm and painless. Duct obstruction would be in differential if woman was breast feeding!
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In addition to starting Abx for mastitis in nursing mothers, what is the next step in management?
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Add ibuprofen/acetominophen for pain and encourage to continue breast feeding/pumping.
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Most appropriate antibiotic therapy for mastitis in breast-feeding mother?
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Dicloxacillin 2/2 to S.aureus. It is used due to penicillin resistance staph. Erythromycin may be used in penicillin resistant patients.
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42 G3P3 w/ 2cm dominant breast mass. Mammogram negative. FNA negative and mass persisted. Next step?
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Excisional biopsy should be performed when the results of mammogram and FNA are negative.
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Whats a breast ultrasound good for?
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distinguishing a cyst from solid mass. assisting a FNA it can distinguish a fibroadenoma from a cyst.
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28 yo G0 w/ Hx of LGSIL w/ HPV+ 6 mo ago here f/u. Normal cervical and bi-manual exam. Next step?
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LGSIL management is colposcopy. Pap smear is only a screening tool. 20% of LGSIL hav HGSIL on colposcopy. 50% w/ LGSIL on pap have negative colposcopy.
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What is tissue diagnosis is required before a cold knife or loop electrosurgical excision procedure is performed?
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Requires tissue diagnosis of dysplasia.
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34 yo G2P2 w/ HGSIL (CIN III) on colposcopy w/ biopsy and endocervical curettage showed benign endocervical cells. next step in management?
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Loop electrosurgical excision procedure. Its performed in office w/ local intracervical anestesia. designed to remove transformation zone and dysplastic area identified during coloposcopy.
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When is an endometrial biopsy indicated?
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When suspecting endometritis, polyps or carcinoma. If risk factors for carcinoma present, do this before ablation or hysterectomy.
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In a women w/ significant menstrual bleeding, Hct 30, BP 138/84 Pulse 82, is EPO or transfusion recommended?
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Nope. her anemia can be corrected using ferrous sulfate over a period of months as well as diagnosing the cause.
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Guidelines for offering mammograms
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annually starting at age 50 and at least every 2 years b/w age 40-50.
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26 yo G0 w/ LGSIL and coposcopy w/ cervical bx which showed CIN I and no endocervical involvement and ECC showed benign cells. Next step?
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f/u pap in 6 mo and 12 mo or HPV DNA testing at 12 mo.
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Indications for cold knife conization (CKC).
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positive ECC, HGSIL either too large for LEEP or patient can't tolerate LEEP in office, lesion extending into endocervical canal or r/o invasive cancer.
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vulvar lesion unresponsive to treatment (trichloroacetic acid, Imiquimod cream). next step?
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biopsy. perform before treatment if condyloma diagnosis is uncertain.
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Attempt to remove IUD (no string visible, but visible on ultrasound in uterus) w/ hook fails. Next step in management?
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hysteroscopy. direct visualization can be performed int he office or OR. Perform laparoscopy if IUD seen outside of uterus.
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Next step in management in 42 yo w/ mass in right breast. mammogram negative. +FHx of aunt w/ breast CA @ 50.
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FNA. Excisional biopsy may follow depending on results.
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Next step in management in chronic pelvic pain for 42 yo women w/ endometriosis refractory to medical treatment, no desire for fertility who desire definitive treatment.
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TAH/BSO. definitive treatment for pelvic pain 2/2 endometriosis.
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Next step in management of 38 yo G1P1 w/ increased urinary freq. Right adnexa mass noted on pelvci exam. Negative UA, negative u-preg and normal pap.
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TVUS is the best way to work-up incidental adnexal mass.
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