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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. when endometrial bx indicated in perimenopause?
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI
Ultrasound for detail anatomic survey
Low risk women with satisfactory pap and negative cytology result
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx

2. fetus in breech presentation in 28 weeks
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
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
RCT shows no fetal risk or possiblity

3. 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
Ca 1200mg and vitamin 400-80o IU
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
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

4. What is definitive dx of down syndrome?
Chorionic villous sampling or amniocentesis for fetal karyotyping
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Not encouraged; no clear study

5. When to give INH prophylaxis
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
Hypoplastic left heart syndrom
If patient has positive PPD and no active TB in CXR or sputum
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles

6. 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.
Magneisium sulphate; give antihypergensive when bp >160/105
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Clue cells in the vaginal smear

7. bilateraal breast discharge
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy
Giving zidovudine to pregnant and newborn; it deceased by 70%.
If patient has positive PPD and no active TB in CXR or sputum

8. Tx of PMS/PMDD

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9. risks of maternal DM
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
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)
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
<5000 well visualized squamus cells/contain blood

10. congenital constrictive pericarditis in children
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
Long h/o pruritus - 65-75 - vulvar lump/mass
Intrauterine exposure to virus causing pericarditis
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine

11. stress incontinence
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Giving zidovudine to pregnant and newborn; it deceased by 70%.
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine

12. When to dx ttp?
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Mouth flora anerobes and aerobes

13. What is shoulder dystocia?
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.
Increase serum free T4; serum Tsh <0.01
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Failure of fetal shoulder to pass through maternal pelvis

14. parameters measured in subsequent visit of pregnancy?
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo
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
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose

15. How to dx septic abortion
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Result is influenced by observer's prior knowledge of the details of studs
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
Cervix hasn't dilated beyond 4 cm in 2 h

16. Tx of complicated UTI (fever/flank pain)
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
Failure of fetal shoulder to pass through maternal pelvis

17. rate of transmission of HPV from anogenital wart during delivery
Mouth flora anerobes and aerobes
Amoxi - cephalexin - nitrofurantoin
<1%; no special measure is taken if prevent transmission
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

18. should patient continue antiepileptic during pregnancy?
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
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Yea. except valproate. give high dose folic acid patient is conneuing preg

19. teratogenicity of sulphonylurea?
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Likely viral meningitis
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream

20. primary and secondary HIV thrombocytopenia and
Trichloroacetic acid - repeated use - if doesn't improve electrocautery/surgery; don't use podophyllin to mucosal surface or in pregnanc
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

21. long term prognosis of congenital HOCM
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester

22. excessive mentrual bleeding in adolescent
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis
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

23. time of last tetanus booster <10 yrs
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Decreases risk of breast and ovarian ca
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy

24. Estrogen

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25. history of preeclampsia
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.
FSH - LH is increased at certain point of regular mens
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.

26. first step in shoulder dystocia?

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27. contamination bias
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Control group gets tx or intervention - thus decreases difference between control vs tx
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common

28. lower lobe pneumonia- possible etiology
Trichomonas; petetchia in vagina and cervix
Not encouraged; no clear study
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS

29. what insulin is given in pregnancy?
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
If patient doesn't improve in 48h to r/o perinephric abscess or calculi

30. pregnancy category X
Very bad. both animals and human studies showed fetal risk
Magneisium sulphate; give antihypergensive when bp >160/105
Crosses placenta - cause bilat congenital deafness -
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk

31. How HIV risk of transmission to newborn is decreased
Giving zidovudine to pregnant and newborn; it deceased by 70%.
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
10 days course of ab x immediatly

32. What is the cause infertility in PCOD
Ultrasound. since helical CT scan is contraindicated
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used

33. observer bias

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34. vulvar ca
Long h/o pruritus - 65-75 - vulvar lump/mass
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy
Crosses placenta - cause bilat congenital deafness -
Indinavir; it precipitate in urine and obstruct urinary flow.

35. selection bias
Increase in pregnancy; decreases in preeclam/eclamsia
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Participants selected are not representative; more or less in a particular population; prevention; randomization
Amniocentesis

36. Tx of HELLP syndrome micorangi hem anemia - inc LFT - dec platelet
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Magneisium sulphate; give antihypergensive when bp >160/105
<1%; no special measure is taken if prevent transmission

37. When to repeat pap in 12 months
Eqinovarus foot - amniotic fluid loss
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Low risk women with satisfactory pap and negative cytology result
Ultrasound for detail anatomic survey

38. Is ocp contraindicated in migraine?
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
They have glycogen deposition in myocardium mostly affected inthe interventricular septum
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene

39. differential trichominiasis and cadiidiasis?
Not encouraged; no clear study
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Pregancy test

40. does normal HbA1c eliminate need for dm screening
Nitrofurantoin-first gen cephalosporn
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
No.
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.

41. Tx of chlamydia in pregnancy
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Pregnancy - contraception - STD - substance abuse - emotional illness
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Pregancy test

42. hemophillia- mom carrier and dad healthy
Magneisium sulphate; give antihypergensive when bp >160/105
Very bad. both animals and human studies showed fetal risk
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Giving zidovudine to pregnant and newborn; it deceased by 70%.

43. congenital dilated cardiomyopathy
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Inherited metabolic disorders - intrauterine infections - cri du chat
Decreases risk of breast and ovarian ca
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

44. what anti-TB drugs are contraindicated in pregnancy?
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
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)
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version

45. rec for folate supple during preg
RCT shows no fetal risk or possiblity
Crosses placenta - cause bilat congenital deafness -
No.
0.4-4mg daily for >1m prior conception to entire first trimester

46. What contraception is best for sickle cell patient
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Decreases risk of breast and ovarian ca
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases

47. When to dx ITP?
Pregnancy - contraception - STD - substance abuse - emotional illness
Intermediate acting NPH insulin qhs. efficacy of long acting glargine not known.
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
Platelet <50k - or develop early in pregnancy

48. ASCUS on pap smear
2g po single dose; discontinue breast feeding for 12-24 hours
Transverse limb anomaly; risk depends on age of gestation; the risk greatest <9 wks - lowest if >11wks
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
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

49. Who uses progesterone only pills or mini pill
FSH - LH is increased at certain point of regular mens
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Lactating women

50. differential dx of increased AFP in pregnant mom?
Ultrasound. since helical CT scan is contraindicated
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy