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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. laser cone biopsy for CIN and hx of spont abortion
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Frequent cervical exam in 2nd trimester - place cerclage at 13-17 weeks gestation if required
Lactating women
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine

2. contamination bias
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%
Control group gets tx or intervention - thus decreases difference between control vs tx
Endomtriosis; endometrial tissu in ovaries - fallopian tubes - or other abnormal sites; dx laparoscopy; tx ocp/GnRH analog; severe cases hysterectomy
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

3. Why fluoroquinoloes contraindicate in pregnancy?
Cross placenta--concentrate in amniotic fluid---fetal arthopathy
Incr perinatal mortality - pretem delivery - premature and LBW
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
Male phenotype - smalle testes - gynecomastia

4. first step in shoulder dystocia?

5. criteria for gestational transient thyrotoxicosis?
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Bacterial vaginosis; imbalance between normal vaginal flora and decrease in hydrogen peroxide producing lactobacilli
Graves disease; 0.2% - present during first trimester - less common and milder in last trimester
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis

6. How to dx down syndrom?
Malignancy until proven otherwise; screen with mammogram - if mass found - do need aspiration or open breast biopsy
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
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)
Most common bugs - N. gonorrhoea and chlamydia... abx should cover them cefoxitin+doxy or ceftriaxone+doxy doc; surg eval if tubo ovarian abscess

7. time of last tetanus booster >10 or unknown
Intrauterine exposure to virus causing pericarditis
Incr perinatal mortality - pretem delivery - premature and LBW
Retinal hemorrahge. represents vascular damage -
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

8. How to confirm bacterial vaginosis
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
Papular urticarial papules and plaques in pregnancy (PUPPP) pruritic erythematous papules within stria gravidarum - may spread to extremities
Clue cells in the vaginal smear

9. complications of PMS?
80% develop psychiatric illness - depression
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Ca 1200mg and vitamin 400-80o IU
Semen - vaginal fluid - any fluids contain visible vlood; not applicable to urine - sweat - tears - sptum - vomitus - nasal secretio - feces with no visible lboo

10. OCP
Anovulation due to decrease androgen production; tx weight reduction-restores infertility - if fails clomiphene citrate
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
Minor wound; nothing - dirty wound-vaccine if <5yrs; no exceptions for pregnant
Decreases risk of breast and ovarian ca

11. parameters measured in subsequent visit of pregnancy?
Two to eight years before menopause and one year after last mens; normal ovulatory cycle interpersed with anovulatory cycles
Weight height - uterine fundal height - fetal hear sound - fetal presentaion - urine glucose
11%; doesn't increase risk of abortion; repositioned from retroverted to anterior position at 12-16w
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.

12. Klinefelter
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI
Male phenotype - smalle testes - gynecomastia
Participants selected are not representative; more or less in a particular population; prevention; randomization
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization

13. bugs for aspiration pneumonia?
Mouth flora anerobes and aerobes
Crosses placenta - cause bilat congenital deafness -
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common

14. When to repeat pap in 12 months
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Low risk women with satisfactory pap and negative cytology result
Clue cells in the vaginal smear
Ultrasound for detail anatomic survey

15. 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.
Fetal hyperinsulinemia and hypoglycemia and macrosomia
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
Blood type - cbc - bmp - rubulla titer - screening symphilis - chlamysdia - HIV - hepatitis panel - lipid panel - urine - pap

16. What is centor's criteria?
Tonsillar exudate - tender ant cervical lymhadenopathy - fever - no cough; presence of 3/4 of these critera have 50% ppd for diagnosis of strep
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
0 1 6 ; test immunity at 9m; if anti-HBS then immune to HepB - if HBsAg +ve refer GI

17. bacteriuria diagnosed incidentaly during pregnancy with no symptoms
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
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
Perfect user (never misses a pill) 99.9 % ; user who misses pill 5%

18. High anti D titre despite receiving anti-D immunoglobulin
Mouth flora anerobes and aerobes
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
Low risk women with satisfactory pap and negative cytology result
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.

19. Tx of PMS/PMDD

20. what drugs are used to decrease riks of infant resp distress syndrome in cases of preterm delivery
Carbamazepine and valproate - ask why
Bladder US; postvoid residual >200 cc ---detrusor muscle weakness/obstruction--bladder overflow
Betamethason - dexamethason IM
The probability of a given test result to occur; >10= strong evidente to rule in <0.1= strong evidence to rule out

21. SAAG <1.1
X linked recessive due to deficiency of factor VIII
Low risk women with satisfactory pap and negative cytology result
Clue cells in the vaginal smear
Peritoneal carcinomatosis - peritoneal tv - nephrotic syndrom - pancreatitis - serositis

22. susceptibility bias
Amoxi - cephalexin - nitrofurantoin
Experimental and control groups are different in susceptibilty to tx/intervention due to confounding variable
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
Junction of squamus and glandular cells at the external cervical os

23. who is emancipated minor?
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
Self sufficient - no longer living with parent. parents of children
Mother taken lithium during pregnancy
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.

24. risk factor for postpartum endometritis
Increases risk of MI - DVT - Strokes - breast ca in postmenopausal but not premat ova failur
Route of delivery (3% of vaginal birth and 15-30% of c-section)
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

25. budd chiairi syndrom
Ultrasound for detail anatomic survey
<1%; no special measure is taken if prevent transmission
Thrombosis of hepatic vein/suprahepatic venacava----portal htn - SAAG >1.1
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.

26. congenital dilated cardiomyopathy
Lactating women
Anencephaly - spina bifida - congenital nephrosis - vent wall defects - dermato disorder - tumor - multiple gestation
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

27. congenital hypoplastic left heart; normal at birth then develop heart failure
Ask mother not to push - then do McRoberts; two people grab mother's legs and flex thigh against abdomen. 42% success rate
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
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

28. What is the recommendation for Ca and vitamin supplement >50yrs women
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
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
Ca 1200mg and vitamin 400-80o IU
Result is influenced by observer's prior knowledge of the details of studs

29. Pap shows HGSIL
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
Foul smelling vagianl disch - fever - uterine tenderness - leukocytosis tx; cefriaxone/levo and metro - in breastfeeding women - clinda and genta
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Bacterial vaginosis; 5-60 women and 10-29% pregnant women

30. observer bias

31. When to bact vaginosis
Incr perinatal mortality - pretem delivery - premature and LBW
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
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;

32. breast feeding with anti-epileptic drugs?
Chorionic villous sampling or amniocentesis for fetal karyotyping
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Primary -similar to ITP; secondary- infection - malignancy hypersplenism - ttp or DIC
Pregancy test

33. association of myelomeningocele?
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
No.
Budd chiari and hydrocehalus; tx; surgical closure 24-48h after birth
Amoxi - cephalexin - nitrofurantoin

34. what to test in perimenopause - FSH or LH
Animal studies showed an adverse effect but it wasn;t confirmed in controlled studies in pregnant women
2g po single dose; discontinue breast feeding for 12-24 hours
FSH - LH is increased at certain point of regular mens
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;

35. cause of amenorrhoea in athelet
Amoxi - cephalexin - nitrofurantoin
If patient doesn't improve in 48h to r/o perinephric abscess or calculi
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID

36. pregnant adolescent
Encouraged although antiepileptis secrets through breast milk. benzo and phenobarb can sometime cause the child to become irritable and sleepy.
Incr perinatal mortality - pretem delivery - premature and LBW
0.4-4mg daily for >1m prior conception to entire first trimester
Male phenotype - smalle testes - gynecomastia

37. pregnant women with positive FTA-ABS or treponemal tests
Should be considered infected until proven otherwise; tx penicillin if allergic desensitization
AFP at 16-20 weeks. however low pos predictive value - also measure acetylecholinsterase level - present in neural tissue/blood cells/ muscle.
Progestin releasing IUD not copper IUD; dec menstual loss; but copper IUD increases
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%

38. teratogenicity of sulphonylurea?
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
Increase in pregnancy; decreases in preeclam/eclamsia
Doxy - fluoroquonolones - and erythromycin contraindicated - only azithro can be used
Fetal hyperinsulinemia and hypoglycemia and macrosomia

39. How to tx anogenital warts

40. stress incontinence
Midley inc free t4 - slightly dec tsh; cause; presents in 8-11 - cause incr beta hcg which has mild thyroid stimulation properties
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Loss of vaginal support due to pelvic floor trauma--urethral hypermobility tx; pelvic muscle exercise - if fails alpha adrenoceptor agonist/amitryptaline/imipramine
Decreases pulsatile secretion of LH - dec GnRH---estrogen definition---infertility - osetoporo - vaginal atrophy - breast atrophy

41. hemophillia- mom carrier and dad healthy
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)
Arrest in delivery - if nuliparus- hypotonia-give oxytocin and amniotomy if fetus ok;
Offspring male 50% will have disease. chance of having male 50%. so chance of having a hemophillia child 25%
No. the syndrome associated with 30-40% mortality. all patient with cyanotic HD asked for elective termination

42. vulvar ca
Treat immediately. this may complicate cystitis and pyelonephritis - bugs; e coli most common
Pregancy test
Only symptomatic patient needs tx; not necessary to treat sexual partner; not STD
Long h/o pruritus - 65-75 - vulvar lump/mass

43. Tx of LSIL with unsatisfactory colpo
Ablation with cryo or laser surgery; excision with knife or laser conizatio or LEEP
Pseudohyphe in candida and motile trichomonas and abundance of wbc in trichomoniasis
Participants selected are not representative; more or less in a particular population; prevention; randomization
Mild and asymptomatc - late in pregnancy - no hx blood disorder - resolved after child birth

44. When to dx ttp?
Minor/clean wound; only tetanus vaccine and dirty wound both vaccine +TID
Purpura - microangiopathic hemolytic anemia - renal failure - fever - neurologicas symptoms
Don't give a patient with intact uterus. increases endometr hyperplasia/ca
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;

45. history of preeclampsia
Hepatic cirrhosis
Hypoplastic left heart syndrom
7 times increased risk in susequent pregnancy; 15 times if previous episode id before 33 weeks.
All pregnany women - in their first prenatal visit - high risk women should have repeat testing at third trimester

46. indication of chorionic villous sampling
Biopsy of placenta for dna or karyotyping; to dx genetic disorders e g. down
Pregnancy - contraception - STD - substance abuse - emotional illness
Symptomatic tx pessary. - definitive tex ; surgical repair posterior colporrhaphy
Crosses placenta - cause bilat congenital deafness -

47. Can patient with sickle cell disesase get ocp?
Not encouraged; no clear study
A proocedure in which physician manipulates the fetus inside the uterine cavity from breech to cephalic version
Stroke - Liver disease - h/o estrogen dependent tumor - pregnancy -heavy smoking; age >35 relative CI
Don't give a patient with intact uterus. increases endometr hyperplasia/ca

48. complication of sickle cell during pregnancy
Hospitalize and give IV abx like ceftriaxone or ampi+genta until afebrile for 24h; po abx for remainder of preg
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
Acute crisis - endometritis - pyelonephritis - thromboembolic event. 46% develop complications
Increase in pregnancy; decreases in preeclam/eclamsia

49. retroverted uterus

50. criteria of hyperthyroidism in pregnancy?
Crosses placenta - cause bilat congenital deafness -
Increase serum free T4; serum Tsh <0.01
SSRI ...fluoxetine - 15% patient don't respond. give them alprazolam if still no improvment - give ovulation suppresing agents GnRH and Danazol (s/e acne)
Retinal hemorrahge. represents vascular damage -