OB/GYN NBME #3

[MudPhud20XX]

A 23-year-old woman comes to the physician because of a 3-day history of pain and burning with urination. Two years ago. she had similar symptoms that resolved with trimethoprim-sulfamethoxazole therapy. She is sexually active and uses an oral contraceptive. Her temperature is 37°C (98.6°F). Examination shows no costovertebral angle tenderness. Urinalysis shows bacteria and pus. She requests advice about preventing future episodes. Which of the following is the most appropriate recommendation?
A. Drinking 6 ounces of cranberry juice daily
B. Voiding immediately after coitus
C. Antibiotic prophylaxis only after coitus
D. Daily trimethoprim-sulfamethoxazole prophylaxis
E. No preventive measures available 

So I am leaning toward B or C, any thought?


previously healthy 32 yo female comes to the physician b/c of a 2 day hx of vaginal bleeding and lower abdominal cramps. her last menstrual period was 7 wks ago. she is sexually active with one partner, and they use condoms for contraception consistently. she takes no meds. her pulse 90, bp 100/65, physical exam shows a soft abdomen and lower quadrant tenderness. speculum exam shows moderate vaginal bleeding and a closed cervical os. a pregnancy test is positive. transvaginal ultrasonography shows a fluid filled endometrial cavity and no gestational sac. her quantitative serum b-hCG conc is 2500, 48 hrs later, it is 2800, which is the most likely dx?

A. blighted ovum
B. complete spontaneous abortion
C. ectopic pregnancy
D. hydatidiform mole
E. normal intrauterine pregnancy

So the bhCG is not increasing enough to say this is normal preg, right? also, there is no endometrial cavity and no gestational sac, so A is the answer?


A 24 yo primigravid woman at 42 wk is admitted to the hospital for labor induction. her pregnancy has been uncomplicated. she has no hx of serious illness. on admission, her temp is 36.9C, pulse is 64, bp is 130/72. fetal nonstress testing is reactive. pelvic exam shows a closed, long, posterior cervix. the amniotic fluid index is 3.2 (N=9 - 31), which is the most appropriate next step?

A. discharge home and readmit in 1 wk
B. administer betamethasone
C. administer a prostaglandin
D. begin amnioinfusion
E. perform an immediate c section delivery

So I am debating btw C and D. Can oxytocin be given? If fetal monitoring shows like variable deceleration, I would definitely go for D, but not sure.

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[doyouhaveaflag]

A 23-year-old woman comes to the physician because of a 3-day history of pain and burning with urination. Two years ago. she had similar symptoms that resolved with trimethoprim-sulfamethoxazole therapy. She is sexually active and uses an oral contraceptive. Her temperature is 37°C (98.6°F). Examination shows no costovertebral angle tenderness. Urinalysis shows bacteria and pus. She requests advice about preventing future episodes. Which of the following is the most appropriate recommendation?
A. Drinking 6 ounces of cranberry juice daily
B. Voiding immediately after coitus
C. Antibiotic prophylaxis only after coitus
D. Daily trimethoprim-sulfamethoxazole prophylaxis
E. No preventive measures available 

So I am leaning toward B or C, any thought?


previously healthy 32 yo female comes to the physician b/c of a 2 day hx of vaginal bleeding and lower abdominal cramps. her last menstrual period was 7 wks ago. she is sexually active with one partner, and they use condoms for contraception consistently. she takes no meds. her pulse 90, bp 100/65, physical exam shows a soft abdomen and lower quadrant tenderness. speculum exam shows moderate vaginal bleeding and a closed cervical os. a pregnancy test is positive. transvaginal ultrasonography shows a fluid filled endometrial cavity and no gestational sac. her quantitative serum b-hCG conc is 2500, 48 hrs later, it is 2800, which is the most likely dx?

A. blighted ovum
B. complete spontaneous abortion
C. ectopic pregnancy
D. hydatidiform mole
E. normal intrauterine pregnancy

So the bhCG is not increasing enough to say this is normal preg, right? also, there is no endometrial cavity and no gestational sac, so A is the answer?


A 24 yo primigravid woman at 42 wk is admitted to the hospital for labor induction. her pregnancy has been uncomplicated. she has no hx of serious illness. on admission, her temp is 36.9C, pulse is 64, bp is 130/72. fetal nonstress testing is reactive. pelvic exam shows a closed, long, posterior cervix. the amniotic fluid index is 3.2 (N=9 - 31), which is the most appropriate next step?

A. discharge home and readmit in 1 wk
B. administer betamethasone
C. administer a prostaglandin
D. begin amnioinfusion
E. perform an immediate c section delivery

So I am debating btw C and D. Can oxytocin be given? If fetal monitoring shows like variable deceleration, I would definitely go for D, but not sure.

Lol, I'm back! Man, you're doing these practice NBMEs back to back. OK, here are the answers I put:

She requests advice about preventing future episodes. Which of the following is the most appropriate recommendation?
A. Drinking 6 ounces of cranberry juice daily
B. Voiding immediately after coitus
C. Antibiotic prophylaxis only after coitus
D. Daily trimethoprim-sulfamethoxazole prophylaxis
E. No preventive measures available 
So I am leaning toward B or C, any thought?

Answer = B. I waffled between B and C as well, but put B and it was not keyed as incorrect. However, I think the question blows. If I remember correctly back from M2, C is actually something that is offered to women who get post-coital UTIs.


Transvaginal ultrasonography shows a fluid filled endometrial cavity and no gestational sac. her quantitative serum b-hCG conc is 2500, 48 hrs later, it is 2800, which is the most likely dx?
A. blighted ovum
B. complete spontaneous abortion
C. ectopic pregnancy
D. hydatidiform mole
E. normal intrauterine pregnancy
So the bhCG is not increasing enough to say this is normal preg, right? also, there is no endometrial cavity and no gestational sac, so A is the answer?

Answer = C. In 48 hours, you expect bHCG to increase at least 60% and often double, so this is not a normal pregnancy. You also expect to see a uterine pregnancy if bHCG levels are above 1500-2000 (sources seem to disagree on the level). So this must be an ectopic pregnancy.


Which is the most appropriate next step?
A. discharge home and readmit in 1 wk
B. administer betamethasone
C. administer a prostaglandin
D. begin amnioinfusion
E. perform an immediate c section delivery
So I am debating btw C and D. Can oxytocin be given? If fetal monitoring shows like variable deceleration, I would definitely go for D, but not sure.

Answer = C. She's post term, which is why labor is being induced (and also why there's oligohydramnios). The question indicates her cervix is completely closed, so step 1 of labor induction has to be ripening of the cervix, which is typically done with a prostaglandin like misoprostol (cytotec) or dinoprostone (cervadil). Once it's started to open, you can insert a foley bulb to manually get it to dilate some more. Sometimes, these steps are enough to kick ladies into labor. If not, that's when you go to oxytocin (not an answer offered).

 

[MudPhud20XX]

38 yo gravida 3 para 1 aborta 1 admietted at 33 wk b/c of suspected pyelonephritis as evidenced by temp to 38.9 C and back pain. she has had costovertebral angle tenderness for 10 days and mild contractions for 4 hours. IV ampicillin therapy is started. UA is consistent with UTI. the fetal heart rate is 180 with minimal variation. which of the following is the most likely explanation for this pattern?

A. fetal hypoxia
B. maternal age
C. maternal fever
D. prerterm gestation
E. reaction to antibiotic

So fetal tachy is caused by either infection or rxn to drugs, so I am debating between C and E. Does fetal hypoxia necessarily cause tachy? Also, I am not comfortable with C since it sounds like it's the fever that causes tachy not the infection, any thoughts?


A 26 yo gravida 3, para 2, comes for her first prenatal visit at 11 wks. her previous preg and deliveries, were uncomplicated. her blood type is O, Rh neg. She received Rho(D) immune globulin after her 1st delivery. which of he following is the most appropriate test to evaluate her Rh status?

A. determination of husband's Rh genotype
B. measurement of fetal hemoglobin conc
C. measurement of serum bilirubin conc
D. indirect antiglobulin (Coombs) test
E. Kleihauer Betke acid elution test

So I am debating btw D and E, any thoughts? KB elution test is a quantitative test right? I am not sure about Coombs though...


A 16-year-old girl is brought to the physician by her mother because she has never had a menstrual period. She also has had moderate lower abdominal pain during the past 5 months. She has no history of serious illness and takes no medications. She is 163 cm (5 ft 4 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. Breast development is Tanner stage 4. Examination shows coarse pubic and axillary hair. The external genitalia appear normal. The vaginal canal cannot be visualized. Rectal examination shows an anterior tender, central mass. Which of the following is the most likely explanation for these findings?

A. Androgen insensitivity syndrome
B. Complete müllerian agenesis
C. Hormonally active ovarian tumor
D. Imperforate hymen
E. Normal development 

So I am leaning toward D, but what is that mass???


a 37 year old woman, Gravida 5, para 3, aborta 1, at 40 wks gestation is admitted in labor. Contractions began 2 hours ago. She has not had vaginal bleeding or loss of fluid. Her pregnancy has been uncomplicated. Her las child was delivered vaginally at term and weight 4300 g(9lb 8oz). at her last prenatal visit 1 week ago, the cervix was 50% effaced and 1 cm dilated, and the vertex was at -2 station. Examination now shows contractions that occur every 5 minutes. the cervix is 50% effaced and 6 cm dilated; no presenting part can be felt. a fetal heart tracing shows no abnormalities. Which of the following is the most appropriate next step in management?

a) ABG analysis of umbilical artery
b) fetal scalp stimulation
c) ultrasonography of the pelvis
d) amniotomy
e) Cesarean delivery


A 32-year-old woman with type 1 diabetes mellitus has had increasingly severe perineal pain over the past 3 days. Her temperature is 39°C (102.2°F). Pelvic examination shows a 5 x 5-cm tense cystic mass in the posterior right labium majus with cellulitis extending past the right pubic hairline. Which of the following is the most serious complication of this condition?

A. Bartholin gland abscess
B. Chlamydial sepsis
C. Gram-positive sepsis
D. Necrotizing fasciitis
E. Perirectal abscess 

So is this a bartholin gland abscess with infection?


18 yoF comes bc of irregular menses over the past 3 months; menses occur at 14- to 40-day intervals. Menstrual flow varies from spotting to heavy cramping and bleeding; the latter sxs have caused her to miss shool. Her LMP was 3 weeks ago. Menarche was at age 12 and menses had occurred at regular 28-day intervals for 6 years. She has sedentary lifestyle. She is 165cm (5ft5in) and weighs 63kg (139lb); BMI is 23. Pelvic exam is normal. Urine preg test negative. Which is the best next step in management?

a) Conjugated estrogen therapy
b) Cyclic progesterone therapy
c) Hysteroscopy
d) Endometrial biopsy
e) Dilation and currettage

I really have no clue with this. Any thoughts?

 

[MudPhud20XX]

Can anyone help me out? Any help is greatly appreciated.

 

[doyouhaveaflag]

38 yo gravida 3 para 1 aborta 1 admietted at 33 wk b/c of suspected pyelonephritis as evidenced by temp to 38.9 C and back pain. she has had costovertebral angle tenderness for 10 days and mild contractions for 4 hours. IV ampicillin therapy is started. UA is consistent with UTI. the fetal heart rate is 180 with minimal variation. which of the following is the most likely explanation for this pattern?

A. fetal hypoxia
B. maternal age
C. maternal fever
D. prerterm gestation
E. reaction to antibiotic

So fetal tachy is caused by either infection or rxn to drugs, so I am debating between C and E. Does fetal hypoxia necessarily cause tachy? Also, I am not comfortable with C since it sounds like it's the fever that causes tachy not the infection, any thoughts?


A 26 yo gravida 3, para 2, comes for her first prenatal visit at 11 wks. her previous preg and deliveries, were uncomplicated. her blood type is O, Rh neg. She received Rho(D) immune globulin after her 1st delivery. which of he following is the most appropriate test to evaluate her Rh status?

A. determination of husband's Rh genotype
B. measurement of fetal hemoglobin conc
C. measurement of serum bilirubin conc
D. indirect antiglobulin (Coombs) test
E. Kleihauer Betke acid elution test

So I am debating btw D and E, any thoughts? KB elution test is a quantitative test right? I am not sure about Coombs though...


A 16-year-old girl is brought to the physician by her mother because she has never had a menstrual period. She also has had moderate lower abdominal pain during the past 5 months. She has no history of serious illness and takes no medications. She is 163 cm (5 ft 4 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. Breast development is Tanner stage 4. Examination shows coarse pubic and axillary hair. The external genitalia appear normal. The vaginal canal cannot be visualized. Rectal examination shows an anterior tender, central mass. Which of the following is the most likely explanation for these findings?

A. Androgen insensitivity syndrome
B. Complete müllerian agenesis
C. Hormonally active ovarian tumor
D. Imperforate hymen
E. Normal development 

So I am leaning toward D, but what is that mass???


a 37 year old woman, Gravida 5, para 3, aborta 1, at 40 wks gestation is admitted in labor. Contractions began 2 hours ago. She has not had vaginal bleeding or loss of fluid. Her pregnancy has been uncomplicated. Her las child was delivered vaginally at term and weight 4300 g(9lb 8oz). at her last prenatal visit 1 week ago, the cervix was 50% effaced and 1 cm dilated, and the vertex was at -2 station. Examination now shows contractions that occur every 5 minutes. the cervix is 50% effaced and 6 cm dilated; no presenting part can be felt. a fetal heart tracing shows no abnormalities. Which of the following is the most appropriate next step in management?

a) ABG analysis of umbilical artery
b) fetal scalp stimulation
c) ultrasonography of the pelvis
d) amniotomy
e) Cesarean delivery


A 32-year-old woman with type 1 diabetes mellitus has had increasingly severe perineal pain over the past 3 days. Her temperature is 39°C (102.2°F). Pelvic examination shows a 5 x 5-cm tense cystic mass in the posterior right labium majus with cellulitis extending past the right pubic hairline. Which of the following is the most serious complication of this condition?

A. Bartholin gland abscess
B. Chlamydial sepsis
C. Gram-positive sepsis
D. Necrotizing fasciitis
E. Perirectal abscess 

So is this a bartholin gland abscess with infection?


18 yoF comes bc of irregular menses over the past 3 months; menses occur at 14- to 40-day intervals. Menstrual flow varies from spotting to heavy cramping and bleeding; the latter sxs have caused her to miss shool. Her LMP was 3 weeks ago. Menarche was at age 12 and menses had occurred at regular 28-day intervals for 6 years. She has sedentary lifestyle. She is 165cm (5ft5in) and weighs 63kg (139lb); BMI is 23. Pelvic exam is normal. Urine preg test negative. Which is the best next step in management?

a) Conjugated estrogen therapy
b) Cyclic progesterone therapy
c) Hysteroscopy
d) Endometrial biopsy
e) Dilation and currettage

I really have no clue with this. Any thoughts?

Yep!

The fetal heart rate is 180 with minimal variation. which of the following is the most likely explanation for this pattern?
A. fetal hypoxia
B. maternal age
C. maternal fever
D. prerterm gestation
E. reaction to antibiotic
So fetal tachy is caused by either infection or rxn to drugs, so I am debating between C and E. Does fetal hypoxia necessarily cause tachy? Also, I am not comfortable with C since it sounds like it's the fever that causes tachy not the infection, any thoughts?

Answer = C. I had never actually heard of fetal tachycardia being caused by drug reaction, but maternal fever is definitely a cause of tachycardia (regardless of the infection) so that's why I chose it. To my knowledge, fetal hypoxia is more likely to cause bradycardia.
_____________

She received Rho(D) immune globulin after her 1st delivery. which of he following is the most appropriate test to evaluate her Rh status?
A. determination of husband's Rh genotype
B. measurement of fetal hemoglobin conc
C. measurement of serum bilirubin conc
D. indirect antiglobulin (Coombs) test
E. Kleihauer Betke acid elution test
So I am debating btw D and E, any thoughts? KB elution test is a quantitative test right? I am not sure about Coombs though...

Answer = D. The Coomb's test will give an answer to the question of whether or not she's made anti-Rh Abs. From what I understood from the APGO questions, the Kleihauer-Betke test is only used to determine if a greater than standard dose of RhoGam is needed following procedures (amniocentesis, etc) or complications (like placental abruption).
______________

The vaginal canal cannot be visualized. Rectal examination shows an anterior tender, central mass. Which of the following is the most likely explanation for these findings?
A. Androgen insensitivity syndrome
B. Complete müllerian agenesis
C. Hormonally active ovarian tumor
D. Imperforate hymen
E. Normal development 
So I am leaning toward D, but what is that mass???

Answer = D. You're right. Ignore the NBME's attempts at making it more difficult to arrive at the answer. I assumed that the mass was the volume of trapped blood in the vaginal canal, but who knows. None of the other answers make sense.
________________

The cervix is 50% effaced and 6 cm dilated; no presenting part can be felt. a fetal heart tracing shows no abnormalities. Which of the following is the most appropriate next step in management?
a) ABG analysis of umbilical artery
b) fetal scalp stimulation
c) ultrasonography of the pelvis
d) amniotomy
e) Cesarean delivery

Answer = C. I think this is actually really similar to one of the questions in NBME4. Any time they say "no presenting part can be felt" when a woman is that dilated, what they mean is "baby is not vertex". Next step is always find out what the hell baby is doing in there, which you do with U/S. Incidentally, amniotomy is always the wrong answer here given the risk of cord prolapse if the head is not well applied to the cervix.
____________

Pelvic examination shows a 5 x 5-cm tense cystic mass in the posterior right labium majus with cellulitis extending past the right pubic hairline. Which of the following is the most serious complication of this condition?
A. Bartholin gland abscess
B. Chlamydial sepsis
C. Gram-positive sepsis
D. Necrotizing fasciitis
E. Perirectal abscess 
So is this a bartholin gland abscess with infection?

Answer = D. Yep, it's a bartholin gland abscess plus cellulitis. The worry about cellulitis in this area is always Fournier gangrene aka nec fasc of the private parts.
_____________

She is 165cm (5ft5in) and weighs 63kg (139lb); BMI is 23. Pelvic exam is normal. Urine preg test negative. Which is the best next step in management?
a) Conjugated estrogen therapy
b) Cyclic progesterone therapy
c) Hysteroscopy
d) Endometrial biopsy
e) Dilation and currettage
I really have no clue with this. Any thoughts?

Answer = B. For whatever reason, she's having anovulatory cycles. It doesn't actually matter why, the answer is that you have to allow regular shedding of the endometrium to prevent hyperplasia and possible carcinoma. You do that with either combined OCPs (note that A is estrogen alone, not combo pills) or monthly progesterone (answer B).

 

[MudPhud20XX]

Thank you very much! Here are some few more qs:

A 42-year-old woman with systemic lupus erythematosus comes to the physician for a follow-up examination. Two weeks ago, prednisone therapy was begun because of a flare-up of her disease; this is her third course of prednisone during the past 18 months. Today, the patient is feeling well. Menses occur at regular 28-day intervals. Her only other medications are vitamin D and calcium. She has no other history of serious illness, and there is no family history of serious illness. She has no known allergies. She does not smoke cigarettes or drink alcohol. She is 165 cm (5 ft 5 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Her pulse is 70/min, and blood pressure is 108/64 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy to prevent osteoporosis in this patient?
A) Alendronate now
B) Calcitonin now
C) Estrogen and progesterone now
D) Estrogen alone at the onset of menopause
E) Raloxifene now

I want to choose E since it is not only used for osteoporosis but also can prevent breast and endometrial ca, but not really sure what the question is really asking.....

 

[doyouhaveaflag]

Thank you very much! Here are some few more qs:

A 42-year-old woman with systemic lupus erythematosus comes to the physician for a follow-up examination. Two weeks ago, prednisone therapy was begun because of a flare-up of her disease; this is her third course of prednisone during the past 18 months. Today, the patient is feeling well. Menses occur at regular 28-day intervals. Her only other medications are vitamin D and calcium. She has no other history of serious illness, and there is no family history of serious illness. She has no known allergies. She does not smoke cigarettes or drink alcohol. She is 165 cm (5 ft 5 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Her pulse is 70/min, and blood pressure is 108/64 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy to prevent osteoporosis in this patient?
A) Alendronate now
B) Calcitonin now
C) Estrogen and progesterone now
D) Estrogen alone at the onset of menopause
E) Raloxifene now

I want to choose E since it is not only used for osteoporosis but also can prevent breast and endometrial ca, but not really sure what the question is really asking.....

Yeah, that question sucks. I kinda guessed A (alendronate) and got it right. My reasoning was that you pretty much always start with bisphosphonates for decreased bone density if you go beyond calcium and vitamin D. I really don't have a fantastic explanation though, sorry.

 

[MudPhud20XX]

A 26-year-old nulligravid woman has had infertility for 2 years. Menses occur at regular 25-day intervals. Serum progesterone concentration is 8 ng/mL (n>5) on menstrual day 21. An endometrial biopsy specimen on menstrual day 24 is most likely to show which of the following in this patient?

A. Atrophic endometrium
B. Decidual endometrium
C. Hyperplasia of endometrium
D. Proliferative endometrium
E. Secretory endometrium

So what is going on here? so she is infertile b/c of high progesterone right? So D or E?

 

[doyouhaveaflag]

A 26-year-old nulligravid woman has had infertility for 2 years. Menses occur at regular 25-day intervals. Serum progesterone concentration is 8 ng/mL (n>5) on menstrual day 21. An endometrial biopsy specimen on menstrual day 24 is most likely to show which of the following in this patient?

A. Atrophic endometrium
B. Decidual endometrium
C. Hyperplasia of endometrium
D. Proliferative endometrium
E. Secretory endometrium

So what is going on here? so she is infertile b/c of high progesterone right? So D or E?

Answer = E. An serum progesterone >5 on menstrual day 21 indicates ovulation occurred (corpus luteum formed --> makes the progesterone). If progesterone is present, she would be in the secretory phase of the uterine cycle and would have a secretory endometrium preparing to shed. Another clue that she is not anovulatory is that she has regular cycles, even though they are closely spaced.

 

[MudPhud20XX]

a 19 yo primigravid woman comes to the ER b/c of 1 wk hx of nausea and persistent vomiting. her last menstrual period was 15 wks ago, but she has had daily vaginal bleeding for the past month, she has not received prenatal care. her temp is 37C, pulse is 80, RR 20, bp 140/90, exam shows pedal edema, pelvic exam shows a uterus consistent in size w/ 20 wk gestation, there is no adnexal tenderness, as serum pregnancy test is positive, UA shows 1+ protein, utrasonography shows bilateral multilocular ovarian cysts and echogenic structures in the uterus, which of the following is the most likely dx?

A. combined ectopic and intrauterine preg
B. hydatidiform mole
C. multiple gestation
D. ovarian hyperstimulation syndrome
E. placenta accreta
F. polyhydramnios

So what can cause both proteinuria and multiocular ovarin cysts??? I really have no clue....

A 17 yo is brought to the physician by her mother because she has never had her menstrual period. She is otherwise healthy. Both of her older sisters had normal pubertal development. Examination shows absent breast development and scant pubic hair. Her serum FSH is 105. Which of the following is the most appropriate next step in diagnosis?
A. GnRH stimulation test
B. Karyotype Analysis
C. Measurement of serum electrolyte concentrations
D. LH concentration
E. TSH concentration

So B would be the right answer, right?

 

[MudPhud20XX]

a 19 yo primigravid woman comes to the ER b/c of 1 wk hx of nausea and persistent vomiting. her last menstrual period was 15 wks ago, but she has had daily vaginal bleeding for the past month, she has not received prenatal care. her temp is 37C, pulse is 80, RR 20, bp 140/90, exam shows pedal edema, pelvic exam shows a uterus consistent in size w/ 20 wk gestation, there is no adnexal tenderness, as serum pregnancy test is positive, UA shows 1+ protein, utrasonography shows bilateral multilocular ovarian cysts and echogenic structures in the uterus, which of the following is the most likely dx?

A. combined ectopic and intrauterine preg
B. hydatidiform mole
C. multiple gestation
D. ovarian hyperstimulation syndrome
E. placenta accreta
F. polyhydramnios

So what can cause both proteinuria and multiocular ovarin cysts??? I really have no clue....

A 17 yo is brought to the physician by her mother because she has never had her menstrual period. She is otherwise healthy. Both of her older sisters had normal pubertal development. Examination shows absent breast development and scant pubic hair. Her serum FSH is 105. Which of the following is the most appropriate next step in diagnosis?
A. GnRH stimulation test
B. Karyotype Analysis
C. Measurement of serum electrolyte concentrations
D. LH concentration
E. TSH concentration

So B would be the right answer, right?

So I chose D OHSS and got it wrong. The second one B is the correct answer. Any thoughts on the 1st q?

 

[doyouhaveaflag]

So I chose D OHSS and got it wrong. The second one B is the correct answer. Any thoughts on the 1st q?

Sorry, I was late on the uptake. The first one was a mole. Any time you see a uterine size greater than estimated gestational age, consider a molar pregnancy (or multiples, or polyhydramnios). Also note the "echogenic structures in the uterus". I think they're trying to tell you there's a snowstorm appearance without using buzzwords.
1+ proteinuria can be a physiologic finding in pregnancy, although molar pregnancy increases risk for pre-eclampsia which could also cause proteinuria. The cysts could be theca-lutein cysts, which are seen with moles due to the high bHCG levels and are often bilateral and multiloculated.

(and yes, the second question is B because the extremely high FSH is pointing you toward ovarian failure --> think Turner in primary amenorrhea)

 

[MudPhud20XX]

50 yo gravida 3, para 2, aborta 1 has had loss of urine with coughing, straining, or lifting since the birth of her last child 9 yr ago, the symptoms has progressively worsened over the past 2 yrs. during exam, she loses urine in small spurts with coughing, but the anterior and posterior vaginal walls appear well supported. a cotton tipped applicator placed in the urethra moves in an arch of 45 degree with the horizontal during valsalva maneuver, which is the dx?

A. cystocele
B. enterocele
C. femoral hernia
D. fourth degree obstetric laceration
E. hiatal hernia
F. indirect inguinal hernia
G. rectocele
H. urethrocele

So with positive q tip test this is stress incontinence and I chose A and was wrong. Any thoughts?


37 yr old primigravid woman at 31 wks comes to the physician for a routine prenatal visit. she reports a 4 day hx of mild difficulty breathing, especially when in the reclining position. she has no hx of serious illness. her only medication is a prenatal vitamin. her temp is 37C, pulse is 90, resp 18, and bp 130/80. fundal height is 37 cm, pelvic exam shows no cervical dilation or effacement. ultrasonography shows a normal appearing fetus. the amniotic fluid index is 35 (N: 10-20). which is the most appropriate next step in management?

A. complete bed rest until delivery
B. recommendation to limit dietary sodium intake
C. antenatal testing
D. diuretic therapy
E. weekly amniocentesis for removal of fluid

I chose E and was wrong, so C would the answer?

 

[MudPhud20XX]

Sorry, I was late on the uptake. The first one was a mole. Any time you see a uterine size greater than estimated gestational age, consider a molar pregnancy (or multiples, or polyhydramnios). Also note the "echogenic structures in the uterus". I think they're trying to tell you there's a snowstorm appearance without using buzzwords.
1+ proteinuria can be a physiologic finding in pregnancy, although molar pregnancy increases risk for pre-eclampsia which could also cause proteinuria. The cysts could be theca-lutein cysts, which are seen with moles due to the high bHCG levels and are often bilateral and multiloculated.

(and yes, the second question is B because the extremely high FSH is pointing you toward ovarian failure --> think Turner in primary amenorrhea)

Thanks man, I really appreciate you taking your time and explaining this.

 

[doyouhaveaflag]

50 yo gravida 3, para 2, aborta 1 has had loss of urine with coughing, straining, or lifting since the birth of her last child 9 yr ago, the symptoms has progressively worsened over the past 2 yrs. during exam, she loses urine in small spurts with coughing, but the anterior and posterior vaginal walls appear well supported. a cotton tipped applicator placed in the urethra moves in an arch of 45 degree with the horizontal during valsalva maneuver, which is the dx?

A. cystocele
B. enterocele
C. femoral hernia
D. fourth degree obstetric laceration
E. hiatal hernia
F. indirect inguinal hernia
G. rectocele
H. urethrocele

So with positive q tip test this is stress incontinence and I chose A and was wrong. Any thoughts?


37 yr old primigravid woman at 31 wks comes to the physician for a routine prenatal visit. she reports a 4 day hx of mild difficulty breathing, especially when in the reclining position. she has no hx of serious illness. her only medication is a prenatal vitamin. her temp is 37C, pulse is 90, resp 18, and bp 130/80. fundal height is 37 cm, pelvic exam shows no cervical dilation or effacement. ultrasonography shows a normal appearing fetus. the amniotic fluid index is 35 (N: 10-20). which is the most appropriate next step in management?

A. complete bed rest until delivery
B. recommendation to limit dietary sodium intake
C. antenatal testing
D. diuretic therapy
E. weekly amniocentesis for removal of fluid

I chose E and was wrong, so C would the answer?

A cotton tipped applicator placed in the urethra moves in an arch of 45 degree with the horizontal during valsalva maneuver, which is the dx?
A. cystocele
B. enterocele
C. femoral hernia
D. fourth degree obstetric laceration
E. hiatal hernia
F. indirect inguinal hernia
G. rectocele
H. urethrocele
So with positive q tip test this is stress incontinence and I chose A and was wrong. Any thoughts?

Answer = H. Cystocele can be a cause of stress incontinence, but the stem told you that the "anterior and posterior vaginal walls appear well supported", essentially ruling it out. The only other answer that makes any sense is a urethrocele.


The amniotic fluid index is 35 (N: 10-20). which is the most appropriate next step in management?
A. complete bed rest until delivery
B. recommendation to limit dietary sodium intake
C. antenatal testing
D. diuretic therapy
E. weekly amniocentesis for removal of fluid
I chose E and was wrong, so C would the answer?

Answer = C. Next step is to try to figure out why there is polyhydramnios. I don't think therapeutic amniocentesis is routinely done given the risk of chorio, etc. Sucks for mom.

 

[MudPhud20XX]

21 yo woman comes to physician b/c of 2 wk hx of small amount of vaginal discharge and itching, her sx began immediately before her last menstrual period. she has had 2 sexual partners over the past 2 months and uses an oral contraceptive. one month ago, she had pain on urination and urinary frequency that resolved after a 7 day course of cephalexin. exam shows red introitus and vulva. there are erythematous vaginal walls w/ a normal amount of vaginal discharge. the cervix and cervical are normal. vaginal pH is 4.5, the addition of KOH to the discharge produces no odor, wet mount prep shows no motile organism. what is the most likely causal organism.

A. candida albicans
B. chlamydia trachnomatis
C. gardnerella vaginalis
D. neisseria gonorrhoeae
E. trichomonas vaginalis
--> So I chose B and got wrong. So what is the significance of "red introitus and vulva?" Strawberry cervix? So is it E?

previously healthy 42 yr old female comes b/c of irregular menses during the past 7 months. she also has had intense mood changes and occaisonal hot flashes during this time. her last menstrual period was 6 wks ago. she is sexually active w/ one male partner and they usually use barrier contraception. exam including pelvic exam, shows no abnormalities. which of the following is the most appropriate next step in dx?

A. measurement of serum estradiol conc
B. measurement of serum testosterone conc
C. pregnancy test
D. transvaginal ustrasonography
E. endometrial biopsy

I chose A and was wrong, so either B or D? not sure....


12 1/2 yo girl is brought to the physician b/c she has not had a menstrual period for 5 months, menarche was at the age of 11 yrs and menses had occurred at irregular 30 to 90 day intervals and lasted 1 to 5 days. she plays softball in the spring and participates in physical education class at school 2 times/weeks, she is not sexually active, she is at the 60th percentile for height and 40th percentile for weight. exam shows no abnormalities, which is the dx?

A. anorexia nervosa
B. athletic amenorrhea
C. congenital adrenal hyperplasia
D. hyperthyroidism
E. hypothyroidism
F. polycystic ovarian syndrome
G. prolactin secreting tumor
H. normal development
--> I chose B and was wrong. Any idea? E?

28 yr old woman, gravida 1 para 1 has been amenorrheic and has had hot flashes for the past 6 months, she takes thyroid meds for chronic lymphocytic thyroiditis (Hashimoto), after using an oral contraceptvie for 2 yrs, she discontinued taking it 3 yrs ago. serum studies show:

FSH 62
Estradiol 15 (N: 20 - 60)
TSH 1.5
Prolactin 5

Which of the following is the most likely cause of this pt's condition?

A. autoimmune ovarian failure
B. hypothalamic dysfunction
C. inadequate control of hypothyroidism
D. post-pill amenorrhea
E. pure gonadal dysgenesis

I chose B and was wrong. TSH and prolactin are normal but low estrogen and high FSH, so is it A or C???


at 37 wks gestation, 28 yo woman w/ gestation diabetes delivers a 4500 g newborn who develops hyaline membrane dz. the mother had postprandial serum glucose conc of 180 - 200 mg/dl during the last half of preg. the macrosomia and pulmonary dz are most closely related to an increased serum conc of which of the following in the fetus?

A. cortisol
B. growth hormone
C. human placental lactogen
D. insulin
E. reverse triiodothyronine

--> I chose C and got it wrong, now I can see the answer is D. So hPL does not really affect fetus I guess right?


52 year old woman comes to physician b/c of 6 month hx of urinary urgency. she often has a strong urge to void but passes only a small amount of urine. sometimes, she is unable to reach a bathroom quickly enough after feeling the sudden need to void. she says she often feels hot at night and occasionally during the day. she has not had any other symptoms. she has no hx of serious illness and takes no meds. last menstrual period was 12 months ago. she is not sexually active. she is 168 cm and 68 kg, BMI 24. her temp is 37.1C puls 70, RR 12, bp 90/50. pelvic exam shows moderate tenderness and vaginal atrophy. uterus is normal sized. no vulvar vaginal or cervical lesions or adnexal masses. the remaineder of the exam including rectal shows no abnormalities. test of stool for occult blood is neg. wet mount prep of vaginal fluid shows numerous leukocytes. urine culture is negative. her postvoid residual volume is 50 ml, which is the most likely underlying cause of these findings?

A. atonic bladder
B. estrogen def
C. prolapse of the pelvic floor
D. trichomoniasis
E. UTI

I chose E and was wrong. So either A or B?

 

[MudPhud20XX]

Anyone? thank you very much in advance.

 

[doyouhaveaflag]

21 yo woman comes to physician b/c of 2 wk hx of small amount of vaginal discharge and itching, her sx began immediately before her last menstrual period. she has had 2 sexual partners over the past 2 months and uses an oral contraceptive. one month ago, she had pain on urination and urinary frequency that resolved after a 7 day course of cephalexin. exam shows red introitus and vulva. there are erythematous vaginal walls w/ a normal amount of vaginal discharge. the cervix and cervical are normal. vaginal pH is 4.5, the addition of KOH to the discharge produces no odor, wet mount prep shows no motile organism. what is the most likely causal organism.

A. candida albicans
B. chlamydia trachnomatis
C. gardnerella vaginalis
D. neisseria gonorrhoeae
E. trichomonas vaginalis
--> So I chose B and got wrong. So what is the significance of "red introitus and vulva?" Strawberry cervix? So is it E?

previously healthy 42 yr old female comes b/c of irregular menses during the past 7 months. she also has had intense mood changes and occaisonal hot flashes during this time. her last menstrual period was 6 wks ago. she is sexually active w/ one male partner and they usually use barrier contraception. exam including pelvic exam, shows no abnormalities. which of the following is the most appropriate next step in dx?

A. measurement of serum estradiol conc
B. measurement of serum testosterone conc
C. pregnancy test
D. transvaginal ustrasonography
E. endometrial biopsy

I chose A and was wrong, so either B or D? not sure....


12 1/2 yo girl is brought to the physician b/c she has not had a menstrual period for 5 months, menarche was at the age of 11 yrs and menses had occurred at irregular 30 to 90 day intervals and lasted 1 to 5 days. she plays softball in the spring and participates in physical education class at school 2 times/weeks, she is not sexually active, she is at the 60th percentile for height and 40th percentile for weight. exam shows no abnormalities, which is the dx?

A. anorexia nervosa
B. athletic amenorrhea
C. congenital adrenal hyperplasia
D. hyperthyroidism
E. hypothyroidism
F. polycystic ovarian syndrome
G. prolactin secreting tumor
H. normal development
--> I chose B and was wrong. Any idea? E?

28 yr old woman, gravida 1 para 1 has been amenorrheic and has had hot flashes for the past 6 months, she takes thyroid meds for chronic lymphocytic thyroiditis (Hashimoto), after using an oral contraceptvie for 2 yrs, she discontinued taking it 3 yrs ago. serum studies show:

FSH 62
Estradiol 15 (N: 20 - 60)
TSH 1.5
Prolactin 5

Which of the following is the most likely cause of this pt's condition?

A. autoimmune ovarian failure
B. hypothalamic dysfunction
C. inadequate control of hypothyroidism
D. post-pill amenorrhea
E. pure gonadal dysgenesis

I chose B and was wrong. TSH and prolactin are normal but low estrogen and high FSH, so is it A or C???


at 37 wks gestation, 28 yo woman w/ gestation diabetes delivers a 4500 g newborn who develops hyaline membrane dz. the mother had postprandial serum glucose conc of 180 - 200 mg/dl during the last half of preg. the macrosomia and pulmonary dz are most closely related to an increased serum conc of which of the following in the fetus?

A. cortisol
B. growth hormone
C. human placental lactogen
D. insulin
E. reverse triiodothyronine

--> I chose C and got it wrong, now I can see the answer is D. So hPL does not really affect fetus I guess right?


52 year old woman comes to physician b/c of 6 month hx of urinary urgency. she often has a strong urge to void but passes only a small amount of urine. sometimes, she is unable to reach a bathroom quickly enough after feeling the sudden need to void. she says she often feels hot at night and occasionally during the day. she has not had any other symptoms. she has no hx of serious illness and takes no meds. last menstrual period was 12 months ago. she is not sexually active. she is 168 cm and 68 kg, BMI 24. her temp is 37.1C puls 70, RR 12, bp 90/50. pelvic exam shows moderate tenderness and vaginal atrophy. uterus is normal sized. no vulvar vaginal or cervical lesions or adnexal masses. the remaineder of the exam including rectal shows no abnormalities. test of stool for occult blood is neg. wet mount prep of vaginal fluid shows numerous leukocytes. urine culture is negative. her postvoid residual volume is 50 ml, which is the most likely underlying cause of these findings?

A. atonic bladder
B. estrogen def
C. prolapse of the pelvic floor
D. trichomoniasis
E. UTI

I chose E and was wrong. So either A or B?

It's going to be a problem when you move on to NBME 2. I never did that one!

The cervix and cervical are normal. vaginal pH is 4.5, the addition of KOH to the discharge produces no odor, wet mount prep shows no motile organism. what is the most likely causal organism.
A. candida albicans
B. chlamydia trachnomatis
C. gardnerella vaginalis
D. neisseria gonorrhoeae
E. trichomonas vaginalis
--> So I chose B and got wrong. So what is the significance of "red introitus and vulva?" Strawberry cervix? So is it E?

Answer = A. The key here is the Keflex. Antibiotics are a huge risk factor for yeast infections because they disrupt the balance of yeast:bacteria and allow yeast to take over. Yeast infections typically don't affect the pH and they cause pruritus and irritation, leading to the external signs of red introitus and vulva. Note that the stem said the cervix was normal, so this is a vaginitis not a cervicitis.
_________


Which of the following is the most appropriate next step in dx?
A. measurement of serum estradiol conc
B. measurement of serum testosterone conc
C. pregnancy test
D. transvaginal ustrasonography
E. endometrial biopsy
I chose A and was wrong, so either B or D? not sure....

Answer = C. She's only 42. It could be that she's experiencing menopause fairly young (which you would typically measure FSH for rather than estradiol), but step one in secondary amenorrhea should always be to rule out pregnancy, particularly if the method of contraception isn't especially reliable.
_________


She plays softball in the spring and participates in physical education class at school 2 times/weeks, she is not sexually active, she is at the 60th percentile for height and 40th percentile for weight. exam shows no abnormalities, which is the dx?
A. anorexia nervosa
B. athletic amenorrhea
C. congenital adrenal hyperplasia
D. hyperthyroidism
E. hypothyroidism
F. polycystic ovarian syndrome
G. prolactin secreting tumor
H. normal development
--> I chose B and was wrong. Any idea? E?

Answer = H. The hypothalamic-pituitary-gonadal axis takes a while after menarche to fully mature, and it's completely normal to experience anovulatory cycles. I think the criteria for secondary amenorrhea is six months with prior irregular menses, so she doesn't yet qualify. PE twice a week with weight in 40th percentile isn't quite to the level of where you'd see hypothalamic hypogonadism.
_________


28 yr old woman, gravida 1 para 1 has been amenorrheic and has had hot flashes for the past 6 months, she takes thyroid meds for chronic lymphocytic thyroiditis (Hashimoto), after using an oral contraceptvie for 2 yrs, she discontinued taking it 3 yrs ago. serum studies show:
FSH 62
Estradiol 15 (N: 20 - 60)
TSH 1.5
Prolactin 5
Which of the following is the most likely cause of this pt's condition?
A. autoimmune ovarian failure
B. hypothalamic dysfunction
C. inadequate control of hypothyroidism
D. post-pill amenorrhea
E. pure gonadal dysgenesis
I chose B and was wrong. TSH and prolactin are normal but low estrogen and high FSH, so is it A or C???

Answer = A. High FSH indicates ovarian failure. I had never heard of autoimmune ovarian failure, but I guess it makes sense with the Hashimoto. Hypothalamic dysfunction and inadequate control of hypothyroidism would have low FSH with low estradiol.
_________


The macrosomia and pulmonary dz are most closely related to an increased serum conc of which of the following in the fetus?
A. cortisol
B. growth hormone
C. human placental lactogen
D. insulin
E. reverse triiodothyronine
--> I chose C and got it wrong, now I can see the answer is D. So hPL does not really affect fetus I guess right?

Answer = D, you're correct. Not sure about the hPL affecting the fetus. I wouldn't think so because its function is essential to get baby more glucose as fuel and get mom to use alternative fuel sources, if my understanding is correct.
_________


Wet mount prep of vaginal fluid shows numerous leukocytes. urine culture is negative. her postvoid residual volume is 50 ml, which is the most likely underlying cause of these findings?
A. atonic bladder
B. estrogen def
C. prolapse of the pelvic floor
D. trichomoniasis
E. UTI
I chose E and was wrong. So either A or B?

Answer = B. The description is pretty classic urge incontinence. UTI can sometimes be a cause, but the stem tells you urine culture (the most sensitive test for UTI) was negative. It's usually due to destrusor hyperactivity, but estrogen deficiency can contribute. The exam showing vaginal atrophy indicates estrogen deficiency.

 

[MudPhud20XX]

thanks so much doyou, that's all my qs from #4. I really appreciate it man.

 

[turayza]

I've got one more if anyone can help...

A 27-year-old woman, G2P1, at 30w gestation comes to the physician because of chronic fatigue for 2 months; she has had a 4.5kg weight loss during this period. She has had no prenatal care. She has a history of alcoholism and drug abuse. BMI 21. She appears chronically ill. Examination shows pallor. The uterine fundal height is 28cm. The fetal heart rate is 140/min. Labs:
Hb 6
Mean corpuscular Hb 30
MCV 101
Leuk count 4300
Retic count .1%
Plt 130,000
PT 13 sec
Bili 1.0
ALT 16

Which of the following is the most likely cause of this patient's anemia?

A) bone marrow hypoplasia
B) cirrhosis
C) folic acid deficiency
D) hepatitis
E) iron deficiency
F) vitamin B12 deficiency

I chose A and was incorrect. My first thought was HIV. Are we looking at vitamin B12 (F) because of the high MCV? How to differentiate between that and folate (other than hx of alcoholism)? Liver fx looks normal.

 

[GuiltySpark]

I've got one more if anyone can help...

A 27-year-old woman, G2P1, at 30w gestation comes to the physician because of chronic fatigue for 2 months; she has had a 4.5kg weight loss during this period. She has had no prenatal care. She has a history of alcoholism and drug abuse. BMI 21. She appears chronically ill. Examination shows pallor. The uterine fundal height is 28cm. The fetal heart rate is 140/min. Labs:
Hb 6
Mean corpuscular Hb 30
MCV 101
Leuk count 4300
Retic count .1%
Plt 130,000
PT 13 sec
Bili 1.0
ALT 16

Which of the following is the most likely cause of this patient's anemia?

A) bone marrow hypoplasia
B) cirrhosis
C) folic acid deficiency
D) hepatitis
E) iron deficiency
F) vitamin B12 deficiency

I chose A and was incorrect. My first thought was HIV. Are we looking at vitamin B12 (F) because of the high MCV? How to differentiate between that and folate (other than hx of alcoholism)? Liver fx looks normal.

She has a megaloblastic anemia because her MCV > 100. It would be a toss up between B12 or Folate deficiency. You have years worth of storage of B12 in your liver which makes Folate deficiency the more likely choice. Also, the stem states that she has not received any prenatal care which you can translate into 'No prenatal Vitamins'.

 

[Barrel Proof]

Yeah, that question sucks. I kinda guessed A (alendronate) and got it right. My reasoning was that you pretty much always start with bisphosphonates for decreased bone density if you go beyond calcium and vitamin D. I really don't have a fantastic explanation though, sorry.

It's because she is on prednisone so she is at higher risk of osteoporosis

 

[Chicharito123]

Yeah, that question sucks. I kinda guessed A (alendronate) and got it right. My reasoning was that you pretty much always start with bisphosphonates for decreased bone density if you go beyond calcium and vitamin D. I really don't have a fantastic explanation though, sorry.

Not entirely sure and sorry if it is too late, but maybe because Raloxifene is known to also increase risk of thromboembolic disease? Not sure if SLE would play a role in this.

Additionally, according to Uworld, Raloxifene is just less effective than Alendronate and other bisphos, or if they cannot tolorate bisphosphonate therapy.

However, if the pt had increased risk for invasive breast cancer, I would have choose Alendronate instead (2 for 1 kind of thing)