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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.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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. congenital dilated cardiomyopathy
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Not encouraged; no clear study
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
Inherited metabolic disorders - intrauterine infections - cri du chat

2. How to dx down syndrom?
Prenatal screening; us at 10 weeks for measurement of nuchal translucency; serum markers first trimester (papp-A); and 2nd trimester (alpha feto protein - hcg - unconjugated estriol - dimeric inhibin-A)
RCT shows no fetal risk or possiblity
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate

3. What is most common cause of ascitis in us
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
Hepatic cirrhosis
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy

4. if ultrasound neg or inconclusive in increasd AFP - next step
Speed vaginal delivery - nothing as effective as this. if they ask What is the next step answer is mag suplph - hydralazin/labetolol for bp control;
Intrauterine exposure to virus causing pericarditis
Amniocentesis
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;

5. cause of amenorrhoea in athelet
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

6. failure rate of OCP
Young females - due to inadequate urethral support. incr intra abd pressure--leakage of urine; dx ask patient to give vigorous cough - leakage of urine..suggest stress incontinence
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Incr perinatal mortality - pretem delivery - premature and LBW
Long h/o pruritus - 65-75 - vulvar lump/mass

7. risk factor for postpartum endometritis
Pregancy test
Speed vaginal delivery - nothing as effective as this. if they ask What is the next step answer is mag suplph - hydralazin/labetolol for bp control;
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Incr perinatal mortality - pretem delivery - premature and LBW

8. risks of maternal DM
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Ca 1200mg and vitamin 400-80o IU
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF

9. High anti D titre despite receiving anti-D immunoglobulin
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.
0.4-4mg daily for >1m prior conception to entire first trimester
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap

10. first step in shoulder dystocia?

11. pruritus in pregnancy
They have glycogen deposition in myocardium mostly affected inthe interventricular septum
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
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
Fetal hyperinsulinemia and hypoglycemia and macrosomia

12. vaccine sched for infants of HepB pos mother
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Result is influenced by observer's prior knowledge of the details of studs
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI

13. When to renal US in complicated UTI in preg

14. when young female can develop osteoporosis?
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
Women with low body weight develop amenorrhoea if they engaged in sports/physical activity; exercise ---dec pulsatile secretion of LH---dec estrogen---osteopenia/osteoporosis/amenorrhoea
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.

15. What are the recommended FBS and 2h posprandial BG in pregnant?
Result is influenced by observer's prior knowledge of the details of studs
Magneisium sulphate; give antihypergensive when bp >160/105
95 and 120
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1

16. How HIV risk of transmission to newborn is decreased
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate
Giving zidovudine to pregnant and newborn; it deceased by 70%.

17. copious frothy green vaginal discharge - fishy odor - vulvar and vaginal pruritus - or dysuria
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Male phenotype - smalle testes - gynecomastia

18. for what drugs do you need supplementation of high dose folic acid during pregnancy
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down
Not encouraged; no clear study
Carbamazepine and valproate - ask why
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable

19. pregnancy category D drugs
Increase serum free T4; serum Tsh <0.01
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
10 days course of ab x immediatly

20. When to dx gestational thrombocytopenia?
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
<1%; no special measure is taken if prevent transmission
Prenatal screening; us at 10 weeks for measurement of nuchal translucency; serum markers first trimester (papp-A); and 2nd trimester (alpha feto protein - hcg - unconjugated estriol - dimeric inhibin-A)
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

21. eisenmenger syndrome
Androgen insensitvity due to mutation of AR gene; 46xy but testosterone doesn't work and converted to estrogen. female phenotype - pw amenorrhoes - inguinal mass (testes) - bind vaginal pouch
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
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Retinal hemorrahge. represents vascular damage -

22. what component of cervix has greatest risk for neoplasia?
Large fetus - hyperextended head - footling breech - fetal distress
<1%; no special measure is taken if prevent transmission
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Junction of squamus and glandular cells at the external cervical os

23. differential trichominiasis and cadiidiasis?
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Giving zidovudine to pregnant and newborn; it deceased by 70%.

24. budd chiairi syndrom
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common

25. Klinefelter
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Long h/o pruritus - 65-75 - vulvar lump/mass
Magneisium sulphate; give antihypergensive when bp >160/105
Male phenotype - smalle testes - gynecomastia

26. if AFP inc - next step?
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Ultrasound for detail anatomic survey

27. Tx of UTI in pregnancy
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Amoxi - cephalexin - nitrofurantoin
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

28. hemophillia- mom carrier and dad healthy
Carbamazepine and valproate - ask why
Young females - due to inadequate urethral support. incr intra abd pressure--leakage of urine; dx ask patient to give vigorous cough - leakage of urine..suggest stress incontinence
FSH - LH is increased at certain point of regular mens
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%

29. When do we screen gestational dm
Retinal hemorrahge. represents vascular damage -
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
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

30. 6 cm cervical dilation - no improv in 2 h -fetus in zero station
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;

31. Can patient with sickle cell disesase get ocp?
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
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Not encouraged; no clear study

32. retroverted uterus

33. pg I2 and throboxane A2 ratio
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
Increase in pregnancy; decreases in preeclam/eclamsia
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
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

34. What is shoulder dystocia?
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Failure of fetal shoulder to pass through maternal pelvis
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
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities

35. stress incontinence
Speed vaginal delivery - nothing as effective as this. if they ask What is the next step answer is mag suplph - hydralazin/labetolol for bp control;
<1%; no special measure is taken if prevent transmission
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
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

36. history of preeclampsia
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Women with low body weight develop amenorrhoea if they engaged in sports/physical activity; exercise ---dec pulsatile secretion of LH---dec estrogen---osteopenia/osteoporosis/amenorrhoea
Incr perinatal mortality - pretem delivery - premature and LBW

37. unilateral breast discharges
Large fetus - hyperextended head - footling breech - fetal distress
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
Lactating women

38. how maternal dm cause HOCM in infants
Speed vaginal delivery - nothing as effective as this. if they ask What is the next step answer is mag suplph - hydralazin/labetolol for bp control;
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
They have glycogen deposition in myocardium mostly affected inthe interventricular septum

39. complications of PMS?
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
80% develop psychiatric illness - depression
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli

40. bacteriuria diagnosed incidentaly during pregnancy with no symptoms
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common

41. How to measure SAAG?
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose

42. 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
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Amoxi - cephalexin - nitrofurantoin

43. herpes gestationis or pemphigoid gestationis
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
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Magneisium sulphate; give antihypergensive when bp >160/105
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg

44. Tx of chlamydia
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Decreases risk of breast and ovarian ca
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
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

45. patient on ocp - How to adjust levothyroxine dose?
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
Magneisium sulphate; give antihypergensive when bp >160/105
Nitrofurantoin-first gen cephalosporn
0.4-4mg daily for >1m prior conception to entire first trimester

46. laser cone biopsy for CIN and hx of spont abortion
RCT shows no fetal risk or possiblity
Speed vaginal delivery - nothing as effective as this. if they ask What is the next step answer is mag suplph - hydralazin/labetolol for bp control;
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Women with low body weight develop amenorrhoea if they engaged in sports/physical activity; exercise ---dec pulsatile secretion of LH---dec estrogen---osteopenia/osteoporosis/amenorrhoea

47. what anti-TB drugs are contraindicated in pregnancy?
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Clue cells in the vaginal smear

48. Tx of LSIL with unsatisfactory colpo
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC

49. when an adolescent will get care without parental consent
Pregnancy - contraception - STD - substance abuse - emotional illness
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Women with low body weight develop amenorrhoea if they engaged in sports/physical activity; exercise ---dec pulsatile secretion of LH---dec estrogen---osteopenia/osteoporosis/amenorrhoea
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;

50. When to bact vaginosis
Control group gets tx or intervention - thus decreases difference between control vs tx
Ultrasound. since helical CT scan is contraindicated
Inherited metabolic disorders - intrauterine infections - cri du chat
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD