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USMLE Step3 Gynecology Obstetrics

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. How to confirm bacterial vaginosis
Clue cells in the vaginal smear
Congenital L to R shunt (VSD/PDA/ASD) untreated for long; pulmonary vascular resistance exceed systemic vascular system--reversal of shunt (R to L) and cyanosis
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx

2. how lactating mother will get metronidazol
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
2g po single dose; discontinue breast feeding for 12-24 hours
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.

3. What is most common cause of ascitis in us
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Hepatic cirrhosis
Clue cells in the vaginal smear

4. Why fluoroquinoloes contraindicate in pregnancy?
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Cross placenta--concentrate in amniotic fluid---fetal arthopathy
FSH - LH is increased at certain point of regular mens

5. congenital constrictive pericarditis in children
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Copper intrauterine device
Intrauterine exposure to virus causing pericarditis

6. what body fluid exposure needs standard precautions
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo
On or after 37 weeks;
Atrophic vaginitis 50-60%; endometrial ca 10%

7. most common cause of hyperthyroidism in pregnant women
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Ca 1200mg and vitamin 400-80o IU
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
Lactating women

8. pregnant adolescent
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Incr perinatal mortality - pretem delivery - premature and LBW

9. What is likelihood ratio?
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided

10. parameters measured in subsequent visit of pregnancy?
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate
On or after 37 weeks;

11. Should women continue HAART during pregnancy?
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided

12. Klinefelter
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
Male phenotype - smalle testes - gynecomastia

13. what drugs are used to decrease riks of infant resp distress syndrome in cases of preterm delivery
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
Betamethason - dexamethason IM
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

14. complication of amniocentesis?
Trichomonas; petetchia in vagina and cervix
1-2% chance of cervical ca already occured; do colposcopy with endo cervial currettage - if unsatisfactory - LEEP/cone - if satisfactory - cin 2/3 - cryotherapy; other cases-leep/cone or coloposcopy at 6m
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Eqinovarus foot - amniotic fluid loss

15. How to dx septic abortion
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
If patient has positive PPD and no active TB in CXR or sputum
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used

16. When to dx gestational thrombocytopenia?
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
10 days course of ab x immediatly
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

17. laser cone biopsy for CIN and hx of spont abortion
If patient has positive PPD and no active TB in CXR or sputum
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.

18. What is definitive dx of down syndrome?
Chorionic villous sampling or amniocentesis for fetal karyotyping
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
FSH - LH is increased at certain point of regular mens
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination

19. SAAG <1.1
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination

20. criteria for gestational transient thyrotoxicosis?
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc

21. time of last tetanus booster >10 or unknown
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Pregancy test

22. pregnancy category C drugs
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Animal studies showed an adverse effect; but no studies done in pregnant women or animals
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles

23. when an adolescent will get care without parental consent
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Ultrasound. since helical CT scan is contraindicated
Pregnancy - contraception - STD - substance abuse - emotional illness

24. What is shoulder dystocia?
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Failure of fetal shoulder to pass through maternal pelvis
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

25. Tx of UTI in pregnancy
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
X linked recessive due to deficiency of factor VIII
Amoxi - cephalexin - nitrofurantoin

26. when endometrial bx indicated in perimenopause?
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
0.4-4mg daily for >1m prior conception to entire first trimester
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy

27. patient on ocp - How to adjust levothyroxine dose?
Decreases risk of breast and ovarian ca
Measure tsh levels 12 weeks after ocp - increase levo dose accordingly - estrogen component of levo increases TBG - increases in total t4 and decrease in free t4. hypothyroid unable to produce more hormone in response to low free t4. levo dose needs
Ultrasound. since helical CT scan is contraindicated
If patient has positive PPD and no active TB in CXR or sputum

28. who is emancipated minor?
80% develop psychiatric illness - depression
Yea. except valproate. give high dose folic acid patient is conneuing preg
Self sufficient - no longer living with parent. parents of children
Male phenotype - smalle testes - gynecomastia

29. Tx of chlamydia in pregnancy
Atrophic vaginitis 50-60%; endometrial ca 10%
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
80% develop psychiatric illness - depression
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

30. pregnancy category X
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Very bad. both animals and human studies showed fetal risk
Mouth flora anerobes and aerobes
Chorionic villous sampling or amniocentesis for fetal karyotyping

31. 6 cm cervical dilation - no improv in 2 h -fetus in zero station
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Likely viral meningitis
Most will be in cephalic by 34-36 weeks - by 36 weeks 6% will be in breech and one third will be convert to cephalic during delivery

32. How to dx anogenital warts (condyloma acuminata)
Warty projection in vaginal or ana area; p/w pruritus - bleeding -burning - tenderness - vaginal disch and pain. large lession can p/w difficulty in defecation - intercourse; apply acetic acid to lesion - if it turns white - confirms dx
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S

33. When to give INH prophylaxis
Control group gets tx or intervention - thus decreases difference between control vs tx
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
If patient has positive PPD and no active TB in CXR or sputum

34. When to dx ITP?
10 days course of ab x immediatly
Platelet <50k - or develop early in pregnancy
Giving zidovudine to pregnant and newborn; it deceased by 70%.
Crosses placenta - cause bilat congenital deafness -

35. complication of sickle cell during pregnancy
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Chorionic villous sampling or amniocentesis for fetal karyotyping
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate

36. How to evaluate nephrolithiasis in pregnancy?
DUB resulting from anovulation. anovulation means no progesterone release from C luteum--so unopposed estrogen causes excessive endometrial growth and ultimately outgrows blood supply...tear them down...cause heavy bleeding tx; ocp
Ultrasound. since helical CT scan is contraindicated
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Eqinovarus foot - amniotic fluid loss

37. stress incontinence
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Indinavir; it precipitate in urine and obstruct urinary flow.
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD

38. vaginal disch - ph>4.5 - presence of clue cells in wet mount - foul smelling fishy odor - koh application-amine odor
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Clue cells in the vaginal smear
Male phenotype - smalle testes - gynecomastia
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli

39. dysmenorrhoea after years of painless menstruation
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Ultrasound for detail anatomic survey
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
X linked recessive due to deficiency of factor VIII

40. Tx of complicated UTI (fever/flank pain)
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
X linked recessive due to deficiency of factor VIII
Hypoplastic left heart syndrom
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk

41. indication of chorionic villous sampling
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down
<1%; no special measure is taken if prevent transmission
Pregancy test
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks

42. Tx of PID
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
10 days course of ab x immediatly
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur

43. When do we screen gestational dm
24-28w; screeing at first with 50g GTT - >140 BG after 1h - should have 3h GTT with 100gm on a fasting state. measure at 0 -1 -2 -3 hr; values more than 95 - 180 - 155 - 140 are abnormal; more than 2 values diagnostic
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose

44. what insulin is given in pregnancy?
Pregancy test
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Betamethason - dexamethason IM
Received inadequate dose post partum in the events of fetomaternal hemorrhage; rosette test-qualiatively detemine and Kleihauer-Betke use cytometry of fetal red cells; dose of anti-D should adjusted based on KB test.

45. teratogenicity of genta
Crosses placenta - cause bilat congenital deafness -
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m

46. pg I2 and throboxane A2 ratio
Increase in pregnancy; decreases in preeclam/eclamsia
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
RCT shows no fetal risk or possiblity
On or after 37 weeks;

47. risks of maternal DM
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
No.
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.

48. congenital hypoplastic left heart; normal at birth then develop heart failure
Hypoplastic left heart syndrom
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
They have glycogen deposition in myocardium mostly affected inthe interventricular septum
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI

49. straberry cervix
Most will be in cephalic by 34-36 weeks - by 36 weeks 6% will be in breech and one third will be convert to cephalic during delivery
Trichomonas; petetchia in vagina and cervix
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Yea. except valproate. give high dose folic acid patient is conneuing preg

50. ASCUS on pap smear
Hypoplastic left heart syndrom
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Do hpv testing --if neg - routine f/you every year - if positive colposcopy---cin2/cin3--tx; if CIN1--repeat pap in 6/12 months---two negative smear--- f/you routine screening - if ASCUS again--colposcopy