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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. most common cause of hyperthyroidism in pregnant women
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
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

2. Major cause of PPH
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications

3. time of last tetanus booster >10 or unknown
80% develop psychiatric illness - depression
Crosses placenta - cause bilat congenital deafness -
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
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

4. selection bias
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc
Participants selected are not representative; more or less in a particular population; prevention; randomization
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Mouth flora anerobes and aerobes

5. history of preeclampsia
Hepatic cirrhosis
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Likely viral meningitis
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)

6. complications of PMS?
80% develop psychiatric illness - depression
Yea. except valproate. give high dose folic acid patient is conneuing preg
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required

7. pruritus in pregnancy
Hepatic cirrhosis
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Increase serum free T4; serum Tsh <0.01
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

8. dx postpartum endometritis
FSH - LH is increased at certain point of regular mens
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta

9. What is centor's criteria?
Lactating women
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep

10. should patient continue antiepileptic during pregnancy?
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Yea. except valproate. give high dose folic acid patient is conneuing preg

11. complication of amniocentesis?
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Control group gets tx or intervention - thus decreases difference between control vs tx
Eqinovarus foot - amniotic fluid loss

12. 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
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products

13. SAAG <1.1
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
No.

14. Estrogen

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15. long term prognosis of congenital HOCM
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m

16. When to dx gestational thrombocytopenia?
2g po single dose; discontinue breast feeding for 12-24 hours
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Atrophic vaginitis 50-60%; endometrial ca 10%

17. Who uses progesterone only pills or mini pill
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Lactating women
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
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)

18. unilateral breast discharges
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy

19. What is the recommendation for Ca and vitamin supplement >50yrs women
Ca 1200mg and vitamin 400-80o IU
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Very bad. both animals and human studies showed fetal risk
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.

20. what drugs used to tx UTI in pregnacy
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Nitrofurantoin-first gen cephalosporn
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep

21. OCP
Pregancy test
Crosses placenta - cause bilat congenital deafness -
Retinal hemorrahge. represents vascular damage -
Decreases risk of breast and ovarian ca

22. differential trichominiasis and cadiidiasis?
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
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;

23. pregnancy risk category B drugs
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
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

24. What is cdc recommendation for chlamydia screen in pregnancy
Hepatic cirrhosis
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis

25. congenital dilated cardiomyopathy
Inherited metabolic disorders - intrauterine infections - cri du chat
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Pregnancy - contraception - STD - substance abuse - emotional illness
Don't give a patient with intact uterus. increases endometr hyperplasia/ca

26. breast development but no pubic/axillary hair

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27. bacteriuria diagnosed incidentaly during pregnancy with no symptoms
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
Eqinovarus foot - amniotic fluid loss

28. What is extremely ominous sign of preecalmsia/eclampsia
Hypoplastic left heart syndrom
Retinal hemorrahge. represents vascular damage -
Ca 1200mg and vitamin 400-80o IU
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

29. What is shoulder dystocia?
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
Failure of fetal shoulder to pass through maternal pelvis
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
If patient has positive PPD and no active TB in CXR or sputum

30. Klinefelter
Male phenotype - smalle testes - gynecomastia
Yea. except valproate. give high dose folic acid patient is conneuing preg
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Control group gets tx or intervention - thus decreases difference between control vs tx

31. hemophillia- mom carrier and dad healthy
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Participants selected are not representative; more or less in a particular population; prevention; randomization
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)
Mother taken lithium during pregnancy

32. Tx of UTI in pregnancy
Eqinovarus foot - amniotic fluid loss
Low risk women with satisfactory pap and negative cytology result
Amoxi - cephalexin - nitrofurantoin
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient

33. breast feeding with anti-epileptic drugs?
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
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

34. how ppd works?
Pregnancy - contraception - STD - substance abuse - emotional illness
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
RCT shows no fetal risk or possiblity

35. pg I2 and throboxane A2 ratio
Increase in pregnancy; decreases in preeclam/eclamsia
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
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
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo

36. What are the absolute contraindication of OCP?
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
Increase serum free T4; serum Tsh <0.01
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow

37. When to dx ttp?
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Yes. zido - lami and saquinavir are not teratogenic; efavirenz and delavirdine should be avoided
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene

38. what anti-TB drugs are contraindicated in pregnancy?
Magneisium sulphate; give antihypergensive when bp >160/105
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Ultrasound for detail anatomic survey

39. does normal HbA1c eliminate need for dm screening
No.
95 and 120
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

40. what insulin is given in pregnancy?
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.

41. How to dx septic abortion
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli

42. Tx of LSIL with unsatisfactory colpo
Ultrasound for detail anatomic survey
Carbamazepine and valproate - ask why
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF

43. risk factor for postpartum endometritis
On or after 37 weeks;
Clue cells in the vaginal smear
Bacterial vaginosis; 5-60 women and 10-29% pregnant women
Route of delivery (3% of vaginal birth and 15-30% of c-section)

44. rectocele
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis

45. pregnancy category D drugs
0.4-4mg daily for >1m prior conception to entire first trimester
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta

46. parameters measured in subsequent visit of pregnancy?
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
Hepatic cirrhosis
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

47. vaginal disch - ph>4.5 - presence of clue cells in wet mount - foul smelling fishy odor - koh application-amine odor
Inherited metabolic disorders - intrauterine infections - cri du chat
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
X linked recessive due to deficiency of factor VIII
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli

48. straberry cervix
Retinal hemorrahge. represents vascular damage -
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Low risk women with satisfactory pap and negative cytology result
Trichomonas; petetchia in vagina and cervix

49. pregnancy category X
Very bad. both animals and human studies showed fetal risk
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
95 and 120
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down

50. when an adolescent will get care without parental consent
Pregnancy - contraception - STD - substance abuse - emotional illness
Hepatic cirrhosis
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg