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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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1. if AFP inc - next step?
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Ultrasound for detail anatomic survey

2. When to bact vaginosis
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Platelet <50k - or develop early in pregnancy

3. standard test performed in prenatal visit?
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
RCT shows no fetal risk or possiblity

4. What are the recommended FBS and 2h posprandial BG in pregnant?
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
95 and 120
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine

5. When to dx gestational thrombocytopenia?
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc
10 days course of ab x immediatly
Nitrofurantoin-first gen cephalosporn

6. how ppd works?
0.4-4mg daily for >1m prior conception to entire first trimester
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles

7. rate of transmission of HPV from anogenital wart during delivery
Mouth flora anerobes and aerobes
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Yea. except valproate. give high dose folic acid patient is conneuing preg
<1%; no special measure is taken if prevent transmission

8. excessive mentrual bleeding in adolescent
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
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
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy

9. time of last tetanus booster <10 yrs
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
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
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.

10. What is extremely ominous sign of preecalmsia/eclampsia
Retinal hemorrahge. represents vascular damage -
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
FSH - LH is increased at certain point of regular mens
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester

11. criteria of hyperthyroidism in pregnancy?
Trichomonas; petetchia in vagina and cervix
Nitrofurantoin-first gen cephalosporn
Copper intrauterine device
Increase serum free T4; serum Tsh <0.01

12. What is most frequent vaginal infecton
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
Copper intrauterine device
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required

13. when delivery is failure to progress?

14. Klinefelter
Decreases risk of breast and ovarian ca
Very bad. both animals and human studies showed fetal risk
Carbamazepine and valproate - ask why
Male phenotype - smalle testes - gynecomastia

15. Tx of UTI in pregnancy
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Amoxi - cephalexin - nitrofurantoin
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

16. When to renal US in complicated UTI in preg

17. When to call a pap smear unsatisfactory?
<5000 well visualized squamus cells/contain blood
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
Increase serum free T4; serum Tsh <0.01

18. vaginal disch - ph>4.5 - presence of clue cells in wet mount - foul smelling fishy odor - koh application-amine odor
Route of delivery (3% of vaginal birth and 15-30% of c-section)
If patient has positive PPD and no active TB in CXR or sputum
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx

19. What is perimenopause?
Platelet <50k - or develop early in pregnancy
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Animal studies showed an adverse effect; but no studies done in pregnant women or animals

20. herpes gestationis or pemphigoid gestationis
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate
Eqinovarus foot - amniotic fluid loss
Cross placenta--concentrate in amniotic fluid---fetal arthopathy

21. what test is absolutely necessary before treating an woman at reproductive age
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Pregancy test
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

22. How to dx neural tube defects on baby
0.4-4mg daily for >1m prior conception to entire first trimester
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
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties

23. ebstein anomaly or atrialized right ventricle; p/w cyanosis in infancy
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Copper intrauterine device
Mother taken lithium during pregnancy
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS

24. differential trichominiasis and cadiidiasis?
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
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

25. What is the recommendation for Ca and vitamin supplement >50yrs women
Cross placenta--concentrate in amniotic fluid---fetal arthopathy
Increase serum free T4; serum Tsh <0.01
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Ca 1200mg and vitamin 400-80o IU

26. Tx of PMS/PMDD

27. dysmenorrhoea after years of painless menstruation
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
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
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
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy

28. hemophillia
Amniocentesis
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Retinal hemorrahge. represents vascular damage -
X linked recessive due to deficiency of factor VIII

29. pruritus in pregnancy
<1%; no special measure is taken if prevent transmission
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

30. Pap shows HGSIL
Likely viral meningitis
Carbamazepine and valproate - ask why
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
Crosses placenta - cause bilat congenital deafness -

31. breast development but no pubic/axillary hair

32. pregnancy risk category A
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Long h/o pruritus - 65-75 - vulvar lump/mass
RCT shows no fetal risk or possiblity
Ultrasound. since helical CT scan is contraindicated

33. How to dx septic abortion
Self sufficient - no longer living with parent. parents of children
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene

34. When to repeat pap in 12 months
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
No.
Low risk women with satisfactory pap and negative cytology result
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms

35. complications of PMS?
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI
RCT shows no fetal risk or possiblity
80% develop psychiatric illness - depression
Yea. except valproate. give high dose folic acid patient is conneuing preg

36. congenital constrictive pericarditis in children
Intrauterine exposure to virus causing pericarditis
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo
Carbamazepine and valproate - ask why

37. What is shoulder dystocia?
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Giving zidovudine to pregnant and newborn; it deceased by 70%.
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;
Failure of fetal shoulder to pass through maternal pelvis

38. Major cause of PPH
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Intrauterine exposure to virus causing pericarditis
They have glycogen deposition in myocardium mostly affected inthe interventricular septum
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%

39. what anti-TB drugs are contraindicated in pregnancy?
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Lactating women

40. What is definitive dx of down syndrome?
Hepatic cirrhosis
Chorionic villous sampling or amniocentesis for fetal karyotyping
10 days course of ab x immediatly
Intrauterine exposure to virus causing pericarditis

41. How to dx overflow incontinence?
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Yea. except valproate. give high dose folic acid patient is conneuing preg
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

42. How to dx stress incontinence?
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
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
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Hepatic cirrhosis

43. When do we screen gestational dm
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
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
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
Animal studies showed an adverse effect; but no studies done in pregnant women or animals

44. rectocele
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Fetal hyperinsulinemia and hypoglycemia and macrosomia
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester

45. what component of cervix has greatest risk for neoplasia?
Platelet <50k - or develop early in pregnancy
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
Nitrofurantoin-first gen cephalosporn
Junction of squamus and glandular cells at the external cervical os

46. pregnancy risk category B drugs
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
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
RCT shows no fetal risk or possiblity

47. How to measure SAAG?
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S

48. ASCUS on pap smear
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
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
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
Hypoplastic left heart syndrom

49. risks of maternal DM
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
Ca 1200mg and vitamin 400-80o IU
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;

50. unilateral breast discharges
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
X linked recessive due to deficiency of factor VIII