USMLE clinical mastery series obgyn question discussion

[vincentannie]

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1. 20yo woman 3yr history of mild-to-moderate hair growth over face, breasts, lower abdomen that becomes worse during the past 2 years. No history of serious illness, takes no medications. Menses regular 28d interval. P/E excessive hair growth over upper lip, chin, lower abdomen, and pubic area. 3 days after onset of menstrual period, serum:

FSH 10, LH12, DHEAS 1.5 (N=0.5-5.4), 17-hydroxyprogesterone 25 (N=20-300), testosterone 2.8 (N<3.5). cause of her hair growth ?

a) Decreased aromatase activity

b) Decreased progesterone concentration

c) Increased estrogen concentration

d) Increased 5alpha-reductase activity

e) Increased testosterone concentration

2. 32yo woman G2P1 at 26wk gestation comes to ED 2 hours after she was awakened by worst pain. Pain started on left side of her back, radiating to left inguinal area and left labium. She is sweating, nausea, vomiting, felt faint. Her pregnancy had been uncomplicated. 37C, pulse 122, respiration 12 110/65. Moderate tenderness in left back and flank. No gross hematuria. Diagnosis?

a)acute porphyria

b)aortic aneurysm

c)appendicitis

d)bowel perforation

e)diverticulitis

f)intussusceptions

g)pancreatitis

h)pyelonephritis

i)ruptured ectopic pregnancy

j)ruptured ovarian cyst

k)ruptured uterus

l)ureterolithiasis

3. previously healthy 57yo woman comes to physician because of 6 month history of urinary urgency and loss of urine that requires use of absorbent pad. She typically awakens once each night to void. She has not had fever, pain with urination, or blood in her urine. She says her urine stream is normal. 37C, P/E no abnormalities. U/A no abnormalities. Pelvic ultrasound shows 3cm anterior uterine mass consistent with benign leiomyoma uteri. Cause of her incontinence?

a)detrusor instability

b)leiomyoma uteri

c)urethral hypermobility

d)urinary retention with overflow

e)UTI

4. 32yo G3P2 woman in labor. Contractions every 3 minutes for past 8 hours. 37C, pulse 80, R 20, BP 120/80. Cervix 100% effaced and 4cm dilated, vertex -2 station. Membrane suddenly rupture, yielding large amount of clear fluid. Fetal heart rate decreases to 90/min. next step?

a)pelvic exam

b)external cephalic version of fetus

c)internal podalic version of fetus

d)atropine therapy

e)oxytocin therapy

f)forceps delivery

 

[Distant]

1) D [The only theoretical explanation]
2) L
3) C [The fibroid is an incidental finding and would cause obstructive symptoms, if any] EDIT: A.
4) E [Induction of Vaginal Delivery ASAP, the fetus is deteriorating]

 

[vincentannie]

1) D [The only theoretical explanation]
2) L
3) C [The fibroid is an incidental finding and would cause obstructive symptoms, if any]
4) E [Induction of Vaginal Delivery ASAP, the fetus is deteriorating]

I picked E for #4 and it was wrong
For #3, you mean C or D? it says pt urine stream is normal. Should obstructive sx cause high volume urine?
Could you explain more on #1? Thanks!

 

[CaliAtenza]

I picked E for #4 and it was wrong
For #3, you mean C or D? it says pt urine stream is normal. Should obstructive sx cause high volume urine?
Could you explain more on #1? Thanks!

Maybe #4 is F then?

 

[CaliAtenza]

I picked E for #4 and it was wrong
For #3, you mean C or D? it says pt urine stream is normal. Should obstructive sx cause high volume urine?
Could you explain more on #1? Thanks!

For #3, D is what you would pick in Overflow Incontinence, which is seen in long standing diabetics, in those who have recieved epidural anasthesia, etc.

 

[Distant]

I picked E for #4 and it was wrong
For #3, you mean C or D? it says pt urine stream is normal. Should obstructive sx cause high volume urine?
Could you explain more on #1? Thanks!

For 3 I change my answer to A ... [Urine urgency = Urge incontinence = Detrosal instability "Hyperactivity"] this patient does not have DM nor is Post-OP

5 alpha reductase is the hormone that converts Testosterone to the more potent, DiHydro Testosterone Which can cause all the symptoms seen in this patient. The only other Hormone capable of causing these symptoms is Testosterone, which is Normal in this patient.

For Question 4, I did not choose F because, to my knowledge, you cant use vaccume or forceps unless the fetus is in station +2 or lower. but is this case an exception, I have no idea.


***You would Pick "Urine Retention with Overflow" in Severe Chronic BPH.

 

[CaliAtenza]

For 3 I change my answer to A ... [Urine urgency = Urge incontinence = Detrosal instability "Hyperactivity"] this patient does not have DM nor is Post-OP

5 alpha reductase is the hormone that converts Testosterone to the more potent, DiHydro Testosterone Which can cause all the symptoms seen in this patient. The only other Hormone capable of causing these symptoms is Testosterone, which is Normal in this patient.

For Question 4, I did not choose F because, to my knowledge, you cant use vaccume or forceps unless the fetus is in station +2 or lower. but is this case an exception, I have no idea.


***You would Pick "Urine Retention with Overflow" in Severe Chronic BPH.

I also remember that point about forceps not being used unless the fetus is at +2 or lower, but if E is wrong, what else could it be?

Wiki does state that fibroids can cause overflow incontinence in women, but its rare.

 

[WANDOC]

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[WANDOC]

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[WANDOC]

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[WANDOC]

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[WANDOC]

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[PeurtoRico]

A 23 y/o primigravid woman at 32 weeks' gestation is admitted to the hospital because of irregular uterine contractions for 3 hrs. Her temperature is 38.2. The uterus is moderately tender to palpation. The fetal heart rate is 170/min. The cervix is 80% effaced and 2cm dilated; the vertex is at -1 station. Fundal height is 31cm. There is a watery vaginal discharge that tests positive to nitrazine.

A. Abruptio placentae
B. Cervicitis
C. Chorioamnionitis
D. Fetal anomaly
E. Idiopathic preterm labor
F. Incompetent cervix
G. Placenta previa
H. Polyhydramnios
I. Pyelonephritis

I guessed E which was incorrect

C sounds right here.

 

[PeurtoRico]

A previously healthy 27 y/o woman, gravida 2, para 1, at 36 weeks' gestation comes to the physician because of a 2hr history of intermittent vaginal bleeding. She has received no prenatal care. The fundal height is 35cm. The fetal heart rate is 135/min. Examination of the lower genital tract and cervix shows the bleeding to be of uterine origin. Laboratory studies are w/in the reference range. Her blood group is O, Rh-negative, and antibody screening is negative. Fetal nonstress test is reactive, and fetal biophysical profile score is 8/8. Which of the following is the most appropriate next step in management?

A. Coagulation studies
B. Measurement of fetal hemoglobin concentration
C. Contraction stress test
D. Administration of betamethasone
E. Administration of Rh0(D) immune globulin

I chose B, thinking I should quantify fetal Hb first do determine the amount of Rho(D) immune globulin (E.) to administor but that wasn't right.

Is the answer D?

E looks right here but I'm not sure. I think a standard RhoGAM dose for ante-partum hemorrhage is fine. D is wrong, steroids are only gestational age <34. C wrong since the NST and BPP are already normal.

 

[PeurtoRico]

Need some help w/ OBGYN form 1

A 27 year old primigravid woman at 14 week's gestation comes to the ED because of a 24 hr history of nausea and right-sided abdominal pain. She also has had loss of appetite for the past 2 days She has not had vomiting, and pregnancy had been uncomplicated. Her temperature is 38.2, pulse is 94/min, respirations are 20/min, and blood pressure is 120/80 mmHg. Fetal heart tones are heard. Abdominal examination shows RLQ tenderness w/ no rigidty or rebound. Laboratory studies show:
Hb 13.2
Leukocyte count 16500
Seg neutrophils 80%
Bands 10%
Lymphocytes 10%

Urine
SG 1.030
Protein trace
RBC 1-2/hpf
WBC numerous
Nitrites negative
Bacteria none

Which is the most likely diagnosis?
A. appendicitis
B. Cholecystitis
C. Chorioamnionitis
D. Pyelonephritis
E. Salpingitis

I guessed D and got it wrong, is it appendicitis?

Tough one! If it's not pyelo, I don't know what's causing numerous WBCs in urine. Apart from pyuria, the case looks like Appendicitis.

 

[Jdoc511]

Hey guys I was hoping you all would be able to help me out with these questions

32. Three days after a ceaseran delivery at term because of failure to rpgoress a 27 year old women has a temp of 101.8 and mild pain with urination. she has not had urinary urgency or urinary frequency. she is bottle feeding. physical examination shows a clean intact incision site with no erythema. the lungs are clear to ausculation. the breasts are tense, erythematouns and thender. the uterus is firm, nontender and consistent in size with 20 week gestation. laboratory studies show
Hemoglobin 10.5 g/dL
leukocyte counte 6500/mm3 with a normal differential
Urine RBC of 10-15/hpf and WBC 1-2/hpf.

What is the most likely diagnosis
A. breast engorgement
B. cystitis
C. endometritis
D. mastitis
E. wound cellulitis

I went with B which was wrong

 

[ABQ9988]

Breast engorgement can cause mild fever. Patient is bottle feeding so makes sense

 

[geckcgt]

Kinda a necro-post butt....

With #4, I'm not sure, but I think it's pelvic exam (A). The pt had a rupture of membranes resulting in fetal bradycardia, which could mean, as the membranes ruptured, the water drained, the head lowered, and the uterine cord got caught between the head and the cervix resulting uterine cord prolapse.

I think the solution is to first perform a pelvic exam to confirm this, then push up the fetus' head and elevate the pelvis to keep pressure off the cord then emergency C section...

 

[MENIIA]

A 32-year-old nulligravid woman comes to the physician because she has not had a menstrual period since she stopped taking an oral contraceptive 6 months ago. Menses had occured at regular 28-day intervals. She also has had increased libido, increased facial acne, increased facial hair growth that requires shaving every other day, and scalp hair loss, especially on the crown. She has had an 11.3-kg (25-lb) weight gain during this period. She is sexually active with one partner, and they use condoms for contraception. She is 163 cm (5 ft 4 in) tall and weighs 86 kg (190); BMI is 33 kg/m2. Her vital signs are within normal limits. Physical examination shows increased development of upper shoulder muscles. There is hair between the breasts and above the umbilicus. Pelvic examination shows the clitoris protruding completely from the clitoral hood. US shows a 2-cm solid mass in the R ovary. Measurements of which of the following serum hormone concs is most likely to be abnormal?
A) Cortisol
B) DHEA Sulfate
C) Prolactin
D)Testosterone
E) TSH

I picked B, which was incorrect. Now that I've typed it out, I'm pretty sure it's D. I'd appreciate any input. Thank you!

 

[1dayatatime]

The answer is indeed testosterone and for the question regarding umbilical cord prolapse, it is pelvic exam. I didn't get these answers in my extended feedback, meaning i got them right.

 

[Red Husky]

Hi Help with these s really appreciated

A 27-year-old primigravid woman at 30 weeks' gestation comes to the physician because of a 3-week history of pain in her arms and numbness in her hands that awaken her from sleep. She says that her hands feel as though she had been sleeping on them. Her pregnancy has been otherwise uncomplicated. Examination shows mild weakness of thumb abduction bilaterally. Sensation is decreased to pinprick in the index finger on the right. Which of the following is the most likely diagnosis?

A) Carpal tunnel syndrome
B) Cervical radiculopathy
C) Mononeuritis multiplex
D) Reflex sympathetic dystrophy
E) Thoracic outlet syndrome


Apparently correct answer is A. But why the arm pain? Is it just due to edema?

A 21-year-old primigravid woman at 41 weeks' gestation is admitted to the hospital in labor. Her pregnancy has been uncomplicated. Contractions occur every 3 minutes. The cervix is 100% effaced and 4 cm dilated; the vertex is at +1 station. The membranes rupture yielding moderately thick meconium-stained fluid. The fetal heart rate has a baseline of 130/min with variable decelerations lasting 45 seconds and decreasing to 60/min. Which of the following is the most appropriate next step in management?

A) External cephalic version
B) Forceps delivery
C) Amnioinfusion
D) Amniocentesis
E) Cordocentesis