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A 32-year-old nulliparous woman with a last menstrual period three weeks ago, presents with a three-month history of a malodorous vaginal discharge. She reports no pruritus or irritation. She has been sexually active with a new partner for the last four months. Her past medical history is unremarkable. Pelvic examination reveals normal external genitalia without rash, ulcerations or lesions. Some discharge is noted on the perineum. The vagina reveals only a thin, gray homogeneous discharge. The vaginal pH is 5.0. A wet prep is shown in the image below. Which of the following is the most appropriate treatment for this patient?
A. Ceftriaxone B. Doxycycline C. Metronidazole D. Azithromycin E. Penicilli - ✔✔✔ANSWER-C A 28-year-old G2P2 woman returns today for follow up on her abnormal pap smear which reveals atypical squamous cells of undetermined significance (ASCUS). Reflex HPV testing is positive for high risk type. She has never had a prior abnormal pap smear, and has been following the recommended screening guidelines. She is asymptomatic. Her pelvic exam reveals a normal cervix with a small amount of cervical mucous. What is the next best step in the management of this patient? A. Routine screening B. Repeat Pap smear in one year C. Repeat HPV testing in one year D. Repeat co-testing with Pap and HPV in one year E. Colposcopy - ✔✔✔ANSWER-E. Colposcopy A 17-year-old G0 high school student is brought in by her mother for her first gynecologic examination. She began her menses at age 12 and has had regular periods for the past three years. Her last menstrual period was one week ago. For privacy, you ask to examine
being married for 50 years. She does not smoke or drink. Her diabetes is well-controlled with Metformin; she takes a daily baby aspirin and is on a lipid-lowering agent. On examination, she is a thin elderly woman with a dowager's hump. Her breast exam is unremarkable. Her lower genital tract is notable for atrophy. No masses are noted on bimanual and recto-vaginal exam. A fecal occult blood test is negative. Which of the following tests is not necessary? A. Bone density B. Colonoscopy C. Pap sme - ✔✔✔ANSWER-C Pap smear screening is not indicated in patients who have had a hysterectomy, unless it was done for cervical cancer or a high-grade cervical dyspalsia. Patients with a uterus can discontinue cervical cancer screening between the ages of 65 - 70 if they have had three consecutive negative smears or two negative consecutive cotesting in the last 10 years and no history of high-grade cervical intraepithelial neoplasia or cancer. Patients still need yearly bimanual and rectovaginal exam. Mammograms are done annually, as breast cancer increases with age. Colon cancer screening is recommended at age fifty. The patient has an exaggerated thoracic spine curvature, termed a dowager's hump, likely secondary to thoracic compression fractures secondary to osteoporosis. If this is confirmed on a bone density test, she may benefit from the addition of bisphosphonates.
A 32-year-old G2P2 woman presents for a health maintenance examination. She is in good health and has no concerns. She does not have a history of abnormal Pap smears and her last one was three years ago. Her examination is normal including her pelvic exam. A Pap smear is performed and returns as normal with HPV negative. What is the most appropriate screening recommendation for cervical cancer in this patient? A. Pap smear and HPV testing in one year B. Pap smear and HPV testing in three years C. Pap smear and HPV testing in five years D. HPV testing alone in one year E. HPV testing alone in three years - ✔✔✔ANSWER-C According to the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) guidelines for the Prevention and Early Detection of Cervical Cancer, women ages 30 to 65 years should be screened with cytology and HPV testing (''cotesting'') every five years (preferred) or cytology alone every three years (acceptable). Screening by HPV testing alone is not recommended for most clinical settings and there is insufficient evidence to change screening intervals in this age group following a history of negative screens. A 25-year-old G0 woman is scheduled to discuss her recent abnormal Pap smear which showed atypical squamous cells of undetermined significance (ASCUS). She has had one Pap smear at
mild nausea. A yellow blood-tinged vaginal discharge preceded her menses. No pruritus or odor was noted. She is sexually active, uses oral contraceptives and states that her partner does not like condoms. On examination: temperature is 100.2°F (37.9°C); pulse 90; blood pressure 110/60. She is well-developed and nourished and in mild distress. No flank pain is elicited. Her abdomen has normal bowel sounds, but is very tender with guarding in the lower quadrants. No rebound is present. Pelvic examination reveals a moderate amount of thick yellow discharge. The cervix is friable with yellow mucoid disch - ✔✔✔ANSWER-B This patient has findings suggestive of acute salpingitis (pelvic inflammatory disease) including lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, and vaginal discharge. Mucopurulent cervicitis with exacerbation in the symptoms during and after menstruation is classically gonorrhea. Chlamydia is frequently associated with gonorrhea and also causes cervicitis and pelvic inflammatory disease. Cervicitis alone would not explain this patient's constellation of findings. Trichomonas may cause a yellow frothy discharge, and Candida may cause a thick white cottage cheese like discharge, but neither would cause fever and abdominal pain. A 39-year-old G0 woman presents to the clinic reporting non-tender spots on her vulva for about a week. No pruritus or pain is present. She also notes a brownish rash on the palms of her hands. She admits to IV drug abuse. She was diagnosed as HIV-positive two years ago, but has not been compliant with suggested treatment. On examination, three elevated plaques with rolled edges are noted on
the vulva. They are non-tender. A brown macular rash is noted on the palms of her hands and the soles of her feet. What is the most appropriate next step in the management of this patient? A. Obtain a treponemal-specific test B. Biopsy of the lesion C. Colposcopic evaluation of the vulvar lesions D. Culture the base of the lesion E. Initiate empiric treatment with doxycycline and ceftriaxone - ✔✔✔ANSWER-A The diagnosis of syphilis is often established by serologic testing. Non-treponemal tests (VDRL or RPR) are non-specific. In this patient with high suspicion for syphilis, specific testing with treponemal antibody can confirm infection. The classic coiled spirochete is easily seen with dark-field microscopy but availability is limited. A characteristic finding is a macular rash on the palms and soles that are often described as copper penny lesions. Colposcopy would not be diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic. Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly would not be the most expedient way to make the diagnosis. Penicillin G is the preferred drug for treating all stages of syphilis. A 24-year-old G0 woman presents with multiple painful ulcers involving the vulva. The sores initially were fluid filled, but are now open, weeping and crusted. She reports a fever and is having difficulty voiding due to pain. She uses a vaginal ring for
vulvar irritation. She denies any odor. She tried over the counter anti-fungal medication without success. The discharge has been present for over three months, gradually increasing in amount. Douching has resulted in temporary relief, but the symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix. A sample of the discharge is examined under the microscope. What is the most likely finding? A. Strong amine fishy odor when KOH applied to sample B. Marked polymorphonuclear cells with multi-nucleate giant cells C. Motile ovoid protozoa with flagella D. Budding yeast and pseudo-hyphae E. Clue cells - ✔✔✔ANSWER-C This patient most likely has trichomoniasis. The erythematous patches on the cervix are characteristic of "strawberry cervicitis." Trichomonads are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide must be examined immediately. The discharge is mixed with saline and placed on the slide with a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green vaginal discharge. Clue cells are seen on a saline wet mount in women who have bacterial vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation may be herpes.
A 23-year-old G0 woman reports having a solitary, painful vulvar lesion that has been present for three days. This lesion has occurred twice in the past. She states that herpes culture was done by her doctor during her last outbreak and was negative. She is getting frustrated in that she does not know her diagnosis. She has no significant previous medical history. She uses oral contraceptives and condoms. She has had four sexual partners in her lifetime. On physical examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. How do you explain the negative culture? A. Cultures were taken too early B. Oral contraceptives affect the growth of the virus C. The cultures were refrigerated prior to transport to the lab D. Herpes cultures have a 10-20% false negative rate E. The herpes virus cannot b - ✔✔✔ANSWER-D Culture is the gold standard in the diagnosis of herpes. They are highly specific, yet sensitivity is limited. It is best to culture the lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The herpes virus can theoretically be isolated from both primary and recurrent infections. This patient very likely presented too late in the course for a useful culture. Oral contraceptives do not affect the growth of viruses. While serum antibody screening can be performed, it indicates lifetime exposure and would not answer the question as to the etiology of the specific
A 36-year-old G3P2 presents in active labor at full term with a known placenta previa. She reports brisk vaginal bleeding. Evaluation shows that fetus and patient are currently hemodynamically stable. She has had two normal vaginal deliveries in the past. She declines your recommendation to undergo Cesarean section. Which of the following is not advisable during your initial management of this patient? a. Soliciting her reasons for not undergoing a Cesarean section b. Obtaining hospital Ethics Committee recommendation c. Proceeding with an emergency Cesarean section d. Explaining your reasons for recommending a Cesarean section e. Informing risk management of the situation that has developed - ✔✔✔ANSWER-C You should not perform any procedure on the patient without her consent. It is best in these situations to explain your reasons for the recommended Cesarean section and elicit the patient's reasons for not wanting to undergo the procedure. A court order should only be obtained as a last resort. A 27-year-old G1 at 12 weeks gestation presents for first prenatal care visit. She is previously healthy and takes no medications. An ultrasound is performed and a viable pregnancy is confirmed. At the end of the visit, the patient discusses with you her desire to have a Cesarean section for delivery, as she does not wish to go through the pain of labor. Her husband, an orthopedic surgeon, expresses concerns as they desire to have at least three children and he is
worried about potential complications with repeated Cesarean sections. What is the most appropriate next step in the counseling of this patient? a. Agree with her decision after proper counseling and perform a Cesarean section at 39 weeks gestation b. Agree with her decision after proper counseling and perform a Cesarean section at 41 weeks gestation if she has not gone into labor by then c. Advise her that it is not possible to plan a Cesarean section for - ✔✔✔ANSWER-A Elective cesarean section on demand has been getting more popular among women for a variety of reasons. Although, it might sound unreasonable to undergo a Cesarean section for being afraid of pain, the patient has the right to request it and the physician's duty is to make sure she understands all the risks and potential complications associated with such a decision. Her husband is appropriately concerned but it is up to her to make the decision regarding an elective procedure. A 25-year-old G3P2, who had recently undergone a primary Cesarean section, had her HIV status revealed to her mother when a nurse left her chart open in the recovery room. She speaks to patient relations and is thinking about seeking damages through legal avenues. When trying to explain the concept of patient privacy, which of the following statements is correct? a. Patient privacy is based on the ethical principle of justice
c. Maleficence to the fetus d. Non-maleficence to the patient e. Justice for the patient - ✔✔✔ANSWER-D The non-maleficence principle expresses the concept that professionals have a duty to protect the patient from harm. Since an anencephalic infant will not survive, performing a Cesarean section on this patient will cause her harm. Beneficence principle expresses the concept that professionals have a duty to act for the benefit of others, and, in this case, performing a Cesarean section will not benefit the fetus. Mary is a 65-year-old G2P2 with lung metastases from cervical cancer. She was recently weaned from mechanical ventilation after being on the ventilator for four weeks. She has a tracheostomy. Mary currently has worsening pulmonary function and needs to go back on the ventilator or she will die within a few days. Mary's husband, Jim, has power of attorney for Mary's health care decisions. The attending offers Mary a choice of either no ventilation with morphine for comfort or resumption of mechanical ventilation. Mary decides she prefers to go back on the ventilator. Jim prefers that she does not go back on the ventilator because the doctor has said that Mary may never wean off of the ventilator again. Who should make the decision about whether to put Mary back on the ventilator? a. Jim b. All of them together
c. Mary's doctor in consultation with Jim d. Mary e. If Jim and Mary cannot agree, consult the hospital ethic - ✔✔✔ANSWER-D Since Mary is still competent, she can make her own decisions despite the fact that her husband has power of attorney. A 72-year-old G3P1 has progressive ovarian cancer. She and her husband have already completed a medical power of attorney form. However, the patient did not complete a living will or any other documents expressing her wishes for the initiation of mechanical ventilation or cardioversion in the event of a respiratory or cardiac arrest. Unfortunately, the patient is brought into the hospital after suffering an incapacitating seizure. She is not arousable when she reaches the oncology unit. Her husband Jim is present and willing to act as Mary's surrogate decision-maker. When he decides on the proper course of care, the husband should make decisions based primarily on which of the following? a. What Mary would have chosen b. Mary's best interest c. Hospital Ethics Committee's recommendation d. The family's wishes e. His own wishes - ✔✔✔ANSWER-A
You are asked to give a lecture on a new chemotherapy drug that has demonstrated a reasonable efficacy in women with advanced cervical cancer. The day before giving the lecture, you realize that you own stock in the company that makes the drug. Which of the following statements about conflict of interest is true? a. Pharmaceutical companies can support the costs of medical conferences in which physicians receive continuing medical education credits b. Physicians should engage in agreements in which companies make a substantial donation to an educational activity, when the donation is contingent on the physician's use or advocacy of a product c. The hospital may not interfere with a physician's decision to use a new surgical device d. An investigator may not own stock in a company if he/she does research for that company e. Physicians are not required to disclose any potential conflict of interest before speaking in a - ✔✔✔ANSWER-A The relationship of physicians and hospitals with pharmaceutical companies is a sensitive one, as there is potential for conflict of interest. It is acceptable for pharmaceutical companies to support conferences in which physicians receive CME credit. Physician participation in those activities should not be contingent upon physician use or advocacy of the product. An investigator may own stock in a company if he/she does research for that company, as
long as he/she declares the conflict of interest and the conflict of interest is addressed. A 23-year-old G1P0 comes into the office after having some light inter-menstrual spotting and cramping. She is currently sexually active and has had unprotected intercourse with two different partners over the past three months. A urine pregnancy test is positive. She does not desire to keep the pregnancy and, after an ultrasound scan in the office reveals a six-week viable intrauterine pregnancy, the patient asks about an abortion, but has no health insurance. What is the most appropriate next step in the management of this patient? a. You inform her that state Medicaid programs are not allowed to cover this service; therefore, you cannot perform the procedure b. You recommend against the procedure due to potential complications with future infertility c. You request she seeks the opinion of both of her partners before undergoing the procedure d. You support her decision for abortion after appropriate counseling e. - ✔✔✔ANSWER-D Patients requesting abortion should be counseled appropriately regardless of their insurance status and do not have to obtain the consent of their partner to undergo the procedure. Although there are complications associated with pregnancy termination, they are significantly fewer than complications with carrying a pregnancy.
