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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. Tx of chlamydia in pregnancy
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
95 and 120
Crosses placenta - cause bilat congenital deafness -
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.

2. 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
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m
Not encouraged; no clear study
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.

3. rectocele
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
RCT shows no fetal risk or possiblity
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester

4. congenital constrictive pericarditis in children
Increase serum free T4; serum Tsh <0.01
Intrauterine exposure to virus causing pericarditis
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously

5. what test is absolutely necessary before treating an woman at reproductive age
80% develop psychiatric illness - depression
Incr perinatal mortality - pretem delivery - premature and LBW
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Pregancy test

6. differential dx of increased AFP in pregnant mom?
Trichomonas; petetchia in vagina and cervix
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
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose

7. What is perimenopause?
Male phenotype - smalle testes - gynecomastia
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI

8. straberry cervix
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Male phenotype - smalle testes - gynecomastia
Trichomonas; petetchia in vagina and cervix

9. bilateraal breast discharge
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy
Ultrasound for detail anatomic survey
Hypoplastic left heart syndrom

10. How to dx down syndrom?
Amoxi - cephalexin - nitrofurantoin
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)
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
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

11. emergency contraception
Male phenotype - smalle testes - gynecomastia
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
FSH - LH is increased at certain point of regular mens
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w

12. criteria of hyperthyroidism in pregnancy?
Increase serum free T4; serum Tsh <0.01
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;
Not encouraged; no clear study
2g po single dose; discontinue breast feeding for 12-24 hours

13. SAAG <1.1
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
Result is influenced by observer's prior knowledge of the details of studs
Increase in pregnancy; decreases in preeclam/eclamsia
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis

14. ASCUS on pap smear
Indinavir; it precipitate in urine and obstruct urinary flow.
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
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine

15. indication of cesarean section in breech?
Crosses placenta - cause bilat congenital deafness -
Large fetus - hyperextended head - footling breech - fetal distress
Participants selected are not representative; more or less in a particular population; prevention; randomization
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx

16. lower lobe pneumonia- possible etiology
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
Aspiration; look for hx of nausea vomiting - dysphagia - swallowing abnormalitites - bronch - endosopcy - intubation - AMS
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Amoxi - cephalexin - nitrofurantoin

17. vaginal disch - ph>4.5 - presence of clue cells in wet mount - foul smelling fishy odor - koh application-amine odor
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
Trichomonas; petetchia in vagina and cervix
Yea. except valproate. give high dose folic acid patient is conneuing preg
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli

18. risks of maternal DM
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
Clue cells in the vaginal smear
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy

19. How to dx overflow incontinence?
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Control group gets tx or intervention - thus decreases difference between control vs tx
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present

20. Klinefelter
Male phenotype - smalle testes - gynecomastia
Clue cells in the vaginal smear
Scalp anus - vulva - abdomen; cause-dermographism or urticaria; tx topical steroid - antihistamin - oatmeal bath - emolient
Nitrofurantoin-first gen cephalosporn

21. eisenmenger syndrome
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
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
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;

22. breast feeding with anti-epileptic drugs?
Purulent vaginal disch - dilated cervix - weeks of gestation; tx; clinda - genta - ampi or single therapy of pipercillin/or imipene
Route of delivery (3% of vaginal birth and 15-30% of c-section)
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
If patient doesn't improve in 48h to r/o perinephric abscess or calculi

23. pregnant adolescent
Incr perinatal mortality - pretem delivery - premature and LBW
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.
95 and 120

24. long term prognosis of congenital HOCM
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
Intrauterine exposure to virus causing pericarditis
Ca 1200mg and vitamin 400-80o IU

25. differences between PMS and PMDD
Fetal hyperinsulinemia and hypoglycemia and macrosomia
Amoxi - cephalexin - nitrofurantoin
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present

26. positive GBS culture in pregnancy
10 days course of ab x immediatly
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth
Clue cells in the vaginal smear

27. copious frothy green vaginal discharge - fishy odor - vulvar and vaginal pruritus - or dysuria
Retinal hemorrahge. represents vascular damage -
Ultrasound for detail anatomic survey
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk

28. What is shoulder dystocia?
Amoxi - cephalexin - nitrofurantoin
0.4-4mg daily for >1m prior conception to entire first trimester
Uterine atony-80%; tx fundal massage-stimulate atonic uterus; and oxytocin - other causes: perineal lac - uterine rupture - retained products
Failure of fetal shoulder to pass through maternal pelvis

29. if ultrasound neg or inconclusive in increasd AFP - next step
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
PMS tension - sleep disturbance -othe s/s one week before period resolve with mens bleeding; PMDD when anger and irritability present
Hypoplastic left heart syndrom
Amniocentesis

30. fetus in breech presentation in 28 weeks
Mother taken lithium during pregnancy
Pyrizinamide-no data; streptomycin-ototoxicity to fetus;
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
Chorionic villous sampling or amniocentesis for fetal karyotyping

31. How to dx neural tube defects on baby
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Male phenotype - smalle testes - gynecomastia
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
Intrauterine exposure to virus causing pericarditis

32. indication of chorionic villous sampling
Fetal hyperinsulinemia and hypoglycemia and macrosomia
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Likely viral meningitis
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down

33. When to call a pap smear unsatisfactory?
Excessive glycogen within myocardium deplete and the defect resolve spontnaeously
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
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
<5000 well visualized squamus cells/contain blood

34. pregnancy category X
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
Very bad. both animals and human studies showed fetal risk
Trichomonas; petetchia in vagina and cervix
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy

35. puppp
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Mouth flora anerobes and aerobes
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

36. atrophic vaginitis
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Once a person is infected his body develop a cell medicated immune response - this is detected by ppd
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
Trichomoniasis; tx both partners and patient - metronidazol doc 500mg po bid; this drug secrets in breast milk

37. history of preeclampsia
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
No.
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.

38. What is the cause infertility in PCOD
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
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.

39. parameters measured in subsequent visit of pregnancy?
Carbamazepine and valproate - ask why
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate

40. When to repeat pap in 12 months
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Hypoplastic left heart syndrom
Low risk women with satisfactory pap and negative cytology result
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.

41. can eisenmenger patient have pregnancy
80% develop psychiatric illness - depression
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)
Cervix hasn't dilated beyond 4 cm in 2 h
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination

42. What contraception is best for sickle cell patient
Levonorgestrol; efficacy within 48 hours (max at 12h) but can be give within 120 hours of intercourse. can prevent 85% of unexpected preg
Vaginal dryness - burining - dysparunia - dec secretion - labial fullness - pallor vaginal epithelium tx HRT - transvaginal estrogen cream
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Expectant mangeent if colpo satisafaory. most regresses spontaneously. repeat pap in 6-12m and HPD DNA testing in 12m

43. emergency contraception after 120 hours
Mother taken lithium during pregnancy
Copper intrauterine device
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Inherited metabolic disorders - intrauterine infections - cri du chat

44. What is internal podalic version
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Azithromycin 1gm po single or doxy 100mg po bidx7d - rarely ofloxicin - levofloxacin - erythromycin may be used.
Platelet <50k - or develop early in pregnancy
Lactating women

45. When to bact vaginosis
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
Inherited metabolic disorders - intrauterine infections - cri du chat
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine

46. congenital dilated cardiomyopathy
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Inherited metabolic disorders - intrauterine infections - cri du chat
Endocrine eg. prolactinoma or medication indcued or phsyiological eg pregnancy

47. who is emancipated minor?
Pregnancy - contraception - STD - substance abuse - emotional illness
Self sufficient - no longer living with parent. parents of children
Yes - it increases risk of stroke; which exacerbated by ocp; also it increases intensity of migraine
Hypoplastic left heart syndrom

48. Pap shows HGSIL
Clue cells in the vaginal smear
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
There is evidence of fetal risk but the benefits from use in pregnant women may be acceptable despite risk
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. when young female can develop osteoporosis?
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;
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
Serum albumin - ascitic fluid albumin; >1.1 high albumin gradient ascitic fluid or portal htn; S
Macrosomia - hypocalcemia - hypoglycemia - hypertrophic cardiomyopathy - CCF

50. when endometrial bx indicated in perimenopause?
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
If >6 months of irregular menses - heavy breakthrough bleeding - like DUB; do US if endometrial thickness >4mm do bx
Blistering dermatosis in 2nd and 3rd trimester. p/w abd pruritus - localized around umbilicus - contrary to its name not caused by virus - autoimmune.