Obstetrics and Gynecology Self-Assessment PDF

Exam Section : Item 1 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Asses...

Exam Section : Item 1 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 1. Thirty minutes after an uncomplicated spontaneous vaginal delivery of a newborn at term , a 22-year-old primigravid woman has the sudden onset of heavy vaginal bleeding. Pregnancy and labor were uncomplicated. Prior to the onset of bleeding, the placenta delivered spontaneously with a nontapering vessel extending to the margin of the membranes. Examination now shows no vaginal or cervical lacerations. The uterus has moderate tone and is consistent in size with a 24-week gestation. Which of the following is the most likely diagnosis? A) Abruptio placentae B) Placenta accreta C) Placenta percreta D) Placenta previa E) Succenturiate placental lobe Correct Answer: E. Succenturiate placental lobes are accessory lobes of the placenta that develop separately from the main placenta, although they are connected via fetal vessels. There can be one or more accessory lobes. It is associated with first trimester bleeding, polyhydramnios, placenta previa or vasa previa, abruptio placentae, and postpartum hemorrhage caused by retained placental tissue. Risk factors include advanced maternal age, leiomyomata, and previous uterine surgery. It can be diagnosed by ultrasonography and is commonly managed by cesarean delivery as a result of the high risk for maternal and fetal mortality associated with hemorrhage when discovered antepartum. If, however, it goes undiagnosed until delivery, the mother may require oxytocin and manual extraction of the placenta and accessory lobes. Incorrect Answers: A, B, C, and D. Abruptio placentae (Choice A) presents with vaginal bleeding, severe uterine pain, tetanic contractions, and fetal demise, typically in the third trimester. It commonly results from lower abdominal trauma, smoking, or cocaine use. Placenta accreta (Choice B) and placenta percreta (Choice C) refer to the abnormal attachment of the placenta to the myometrium or through to the serosa and potentially adjacent organs (eg, bladder), respectively, rather than to just the decidualized endometrium. It is commonly diagnosed on prenatal ultrasonography but can present with postpartum hemorrhage because of retained placental tissue. Placenta previa (Choice D) is an abnormal positioning of placental tissue such that the placenta partially or entirely overlies the internal cervical os. Placenta previa is usually detected on routine prenatal ultrasonography. Its most common presenting symptom is third trimester painless vaginal bleeding. Educational Objective: Succenturiate placental lobes are accessory lobes of the placenta (one or more) that are connected to the main placenta by fetal vessels. It commonly presents with postpartum hemorrhage because of retained placental tissue, and it is associated with an increased risk for placenta previa, vasa previa, and placental abruption. " , ~ F' r , Next Score Report Lab Values Calculator Help Pause Exam Section : Item 2 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 2. A previously healthy 19-year-old woman comes to the physician because of a 2-day history of fever, chills, and severe burning vulvar pain with urination. She is sexually active with one male partner and does not use contraception. Her temperature is 38.5°C (101.3°F), pulse is 110/min, respirations are 14/min, and blood pressure is 110/60 mm Hg. Examination shows bilateral , tender, firm inguinal lymphadenopathy. There are several erythematous, coalescing labial vesicles bilaterally. Which of the following is the most likely causal organism? A) Chlamydia trachomatis B) Gardnerella vagina/is C) Haemophi/us ducreyi D) Herpes simplex virus E) Neisseria gonorrhoeae F) Treponema pallidum G) Trichomonas vagina/is CorrectAnswer: D. This patient's vesicular lesions on the labia are likely caused by herpes simplex virus in the form of genital herpes, which also commonly causes fever, chills, and inguinal lymphadenopathy. Infection typically begins with the formation of vesicles, which lyse and progress to shallow, painful ulcers with an erythematous border. Genital herpes often causes vu Ivar pain with urination because of irritation of the vesicles and, later, ulcers. HSV-1 and HSV-2 are both members of the herpesvirus family of double stranded DNA, enveloped viruses. Genital herpes is most often caused by HSV-2 but can also be caused by HSV-1. In contrast, herpes labialis is most often caused by HSV-1 but can be caused by HSV-2. Coinfection with both strains is also possible. Genital herpes is transmitted through sexual contact and perinatally. HSV may be latent in the sacral ganglia until reactivation, when it causes painful vesicles and erosions on the genitalia with associated inguinal lymphadenopathy. Systemic manifestations are also possible, including viral meningitis and encephalitis. Treatment for herpetic infections involves drugs that inhibit viral DNA polymerase, classically by guanosine analogs such as acyclovir, valacyclovir, and famciclovir. Incorrect Answers: A, B, C, E, F, and G. Lymphogranuloma venereum is caused by infection with Chlamydia trachomatis (Choice A) subtypes L 1, L2, and L3. It presents as small painless genital ulcers with tender inguinal lymphadenopathy, while this patient's vesicular lesions are painful. Bacterial vaginosis is a common gynecologic condition characterized by a shift of vaginal flora and overgrowth of a particular bacterial species, most commonly Gardnerella vagina/is (Choice B). Bacterial vaginosis presents with gray, thin, malodorous vaginal discharge and may cause vulvovaginal pruritus. Vaginal pH is typically above 4.5, and a fishy odor is detected upon KOH testing. The identification of clue cells on wet mount preparation is diagnostic. It does not cause painful genital vesicles or ulcers. Chancroid presents with an exudative painful genital ulcer with inguinal lymphadenopathy. It is caused by infection with the organism Haemophilus ducreyi (Choice C). This patient's erythematous, vesicular lesions are more classic of genital herpes. Neisseria gonorrhoeae (Choice E) is a sexually transmitted bacterium that can cause cervicitis, urethritis, septic arthritis, and pelvic inflammatory disease. Pelvic inflammatory disease induced by Neisseria gonorrhoeae can present with fever, mucopurulent cervical discharge, and pelvic organ tenderness. However, Neisseria gonorrhoeae does not cause painful vesicles. Syphilis, caused by an infection with the spirochete Treponema pallidum (Choice F), demonstrates multiple stages with varying symptoms, including primary with a painless chancre, secondary with fever, lymphadenopathy, and condylomata lata, and tertiary with tabes dorsalis, aortitis, and gummas. The chancre of primary syphilis typically presents as a painless ulcerative genital lesion, unlike the painful lesions seen in this patient. Trichomonas vagina/is (Choice G) is the cause of trichomoniasis, a sexually transmitted infection that causes vaginitis and cervicitis in women and urethritis in men. Trichomoniasis can lead to overactive bladder (frequency, urgency, urge incontinence) and dysuria. Trichomoniasis presents with green, malodorous vaginal discharge and motile trichomonads on wet mount, not painful genital vesicles or ulcers. Educational Objective: Genital herpes infections present with painful vesicles and erosions, which may be accompanied by dysuria. Other symptoms include fever, chills, and inguinal lymphadenopathy. HSV-2 r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 2 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment erythematous, coalescing labial vesicles bilaterally. Which of the following is the most likely causal organism? A) Chlamydia trachomatis B) Gardnerella vagina/is C) Haemophi/us ducreyi D) Herpes simplex virus E) Neisseria gonorrhoeae F) Treponema pallidum G) Trichomonas vagina/is CorrectAnswer: D. This patient's vesicular lesions on the labia are likely caused by herpes simplex virus in the form of genital herpes, which also commonly causes fever, chills, and inguinal lymphadenopathy. Infection typically begins with the formation of vesicles, which lyse and progress to shallow, painful ulcers with an erythematous border. Genital herpes often causes vu Ivar pain with urination because of irritation of the vesicles and, later, ulcers. HSV-1 and HSV-2 are both members of the herpesvirus family of double stranded DNA, enveloped viruses. Genital herpes is most often caused by HSV-2 but can also be caused by HSV-1. In contrast, herpes labialis is most often caused by HSV-1 but can be caused by HSV-2. Coinfection with both strains is also possible. Genital herpes is transmitted through sexual contact and perinatally. HSV may be latent in the sacral ganglia until reactivation, when it causes painful vesicles and erosions on the genitalia with associated inguinal lymphadenopathy. Systemic manifestations are also possible, including viral meningitis and encephalitis. Treatment for herpetic infections involves drugs that inhibit viral DNA polymerase, classically by guanosine analogs such as acyclovir, valacyclovir, and famciclovir. Incorrect Answers: A, B, C, E, F, and G. Lymphogranuloma venereum is caused by infection with Chlamydia trachomatis (Choice A) subtypes L 1, L2, and L3. It presents as small painless genital ulcers with tender inguinal lymphadenopathy, while this patient's vesicular lesions are painful. Bacterial vaginosis is a common gynecologic condition characterized by a shift of vaginal flora and overgrowth of a particular bacterial species, most commonly Gardnerella vagina/is (Choice B). Bacterial vaginosis presents with gray, thin, malodorous vaginal discharge and may cause vulvovaginal pruritus. Vaginal pH is typically above 4.5, and a fishy odor is detected upon KOH testing. The identification of clue cells on wet mount preparation is diagnostic. It does not cause painful genital vesicles or ulcers. Chancroid presents with an exudative painful genital ulcer with inguinal lymphadenopathy. It is caused by infection with the organism Haemophilus ducreyi (Choice C). This patient's erythematous, vesicular lesions are more classic of genital herpes. Neisseria gonorrhoeae (Choice E) is a sexually transmitted bacterium that can cause cervicitis, urethritis, septic arthritis, and pelvic inflammatory disease. Pelvic inflammatory disease induced by Neisseria gonorrhoeae can present with fever, mucopurulent cervical discharge, and pelvic organ tenderness. However, Neisseria gonorrhoeae does not cause painful vesicles. Syphilis, caused by an infection with the spirochete Treponema pallidum (Choice F), demonstrates multiple stages with varying symptoms, including primary with a painless chancre, secondary with fever, lymphadenopathy, and condylomata lata, and tertiary with tabes dorsalis, aortitis, and gummas. The chancre of primary syphilis typically presents as a painless ulcerative genital lesion, unlike the painful lesions seen in this patient. Trichomonas vagina/is (Choice G) is the cause of trichomoniasis, a sexually transmitted infection that causes vaginitis and cervicitis in women and urethritis in men. Trichomoniasis can lead to overactive bladder (frequency, urgency, urge incontinence) and dysuria. Trichomoniasis presents with green, malodorous vaginal discharge and motile trichomonads on wet mount, not painful genital vesicles or ulcers. Educational Objective: Genital herpes infections present with painful vesicles and erosions, which may be accompanied by dysuria. Other symptoms include fever, chills, and inguinal lymphadenopathy. HSV-2 followed by HSV-1 are the most common viral culprits. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 3 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 3. A 21-year-old woman , gravida 1, para 0, aborta 1, comes to the emergency department because of vaginal spotting and lower abdominal pain for 3 hours. She is sexually active and does not use contraception. Menarche was at the age of 13 years. Menses occur at regular 30-day intervals; her last menstrual period was 6 weeks ago. Pelvic examination shows slightly blood-tinged vaginal discharge. There is cervical motion tenderness with a firm cervix and a closed cervical os. The uterus is firm and tender and consistent in size with a 6-week gestation. The right adnexa is tender. Urine pregnancy test is positive. Which of the following is the most likely diagnosis? A) Appendicitis B) Ectoi:>ic pregnancy C) Hemorrhagic corpus luteal cyst D) Hydatidiform mole E) Pelvic inflammatory disease Correct Answer: B. Pregnancy is suspected when there is a missed or delayed menstrual period. An ectopic pregnancy often presents with vaginal bleeding and abdominopelvic pain. Ectopic pregnancy is an abnormal pregnancy in which the fertilized ovum implants in the fallopian tube (most common), on the ovary, within the peritoneal cavity, or in any non-endometrial location. ~-human chorionic gonadotropin (~-hCG) is produced by the placenta, is undetectable in the serum of nonpregnant patients, and doubles approximately every 48 hours during an early normal pregnancy. Serum ~-hCG concentrations do not increase as expected in ectopic pregnancy, often lagging the normal expected doubling. Ultrasonography can be used to confirm an intrauterine pregnancy and may visualize an ectopic pregnancy. In a normal pregnancy, an intrauterine gestational sac should be visible by 5 weeks gestational age on transvaginal ultrasonography, or when the ~-hCG concentration exceeds 1000 to 2000 mlU/mL. Ectopic pregnancy is nonviable. Ectopic pregnancy can be managed medically, using methotrexate for small, early pregnancies, but may require salpingectomy or evacuation with laparoscopy for larger pregnancies, in cases of medical treatment failure, or in any case of complication. Complications of ectopic pregnancy include rupture, bleeding, and hemoperitoneum. Severe cases can result in hemorrhagic shock. Incorrect Answers: A, C, D, and E. Appendicitis (Choice A) can present with right lower quadrant pain, nausea, vomiting, and anorexia. However, ectopic pregnancy is more likely in a patient with a positive urine pregnancy test, vaginal bleeding, and adnexal tenderness. Hemorrhagic corpus luteal cysts (Choice C) can occur when a corpus luteum does not involute following release of an ovum during the menstrual cycle. The cyst can rupture and cause peritoneal irritation and abdominopelvic pain but would less likely be associated with vaginal bleeding and a positive pregnancy test. Hydatidiform moles (Choice D) are caused by the fertilization of an empty egg by a single sperm followed by duplication of the paternal DNA resulting in 46 chromosomes (complete) or by the dual fertilization of a normal ovum (incomplete) resulting in 69 chromosomes (incomplete). They typically present with vaginal bleeding, nausea, and vomiting in the first trimester, and uterine size out of proportion to expected gestational age. Pelvic inflammatory disease (Choice E) typically presents with fever, mucopurulent cervical discharge, and cervical or adnexal tenderness. Adnexal tenderness may be present in cases of tuba-ovarian abscess. Educational Objective: Ectopic pregnancy is an abnormal extrauterine pregnancy (eg, in the fallopian tube, cervix, ovary, or peritoneum) occurring in an anatomic location that cannot support a pregnancy. It commonly presents with vaginal bleeding, abdominopelvic pain, absence of a fetal pole within the endometrial cavity on ultrasonography, and abnormally low serum ~-hCG concentrations, which in a normal pregnancy should double approximately every 48 hours. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 4 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 4. A healthy 32-year-old primigravid woman at 8 weeks' gestation comes for her first prenatal visit. She has achondroplasia. She does not use tobacco , alcohol , or drugs. She works as a chef 10 to 12 hours daily. She is 107 cm (3 ft 6 in) tall and weighs 36 kg (80 lb). Her pulse is 72/min , and blood pressure is 106/60 mm Hg. Examination shows a uterus consistent in size with an 8-week gestation. Examination of the pelvis shows a conjugate diameter of 7 cm , intraspinous diameter of 5 cm , and intertuberous diameter of 5 cm. Ultrasonography shows a fetus at 9 weeks' gestation. Her hemoglobin concentration is 9.9 g/dl. Urinalysis shows trace protein. This patient is at greatest risk for which of the following ? A) Cesarean delivery B) Fetal achondroplasia C) Preeclampsia D) Renal failure E) Uterine rupture Correct Answer: A. Achondroplasia is an autosomal dominant disorder of abnormal long bone growth, with minimal effect on the cranium, as a result of a mutation in fibroblast growth factor receptor 3 (FGFR3). It is the most common cause of dwarfism. Because the disease is autosomal dominant, this patient's fetus has a 50% chance of developing achondroplasia with associated macrocephaly. The normal measurements of an adult female pelvis are 10 to 12 cm conjugate diameter, 9.5 to 11.5 cm intraspinous diameter, and 10 to 12 cm intertuberous diameter, making this patient's pelvis much smaller than would be needed for the successful passage of the fetus through the pelvic inlet and outlet during a vaginal delivery (cephalopelvic disproportion). Achondroplasia, thus, increases the chances for fetal arrest of descent during labor, whether her child has achondroplasia or not, which places the patient at greatest risk for requiring a cesarean delivery. Incorrect Answers: B, C, D, and E. Fetal achondroplasia (Choice B) carries a 50% likelihood given the autosomal dominant inheritance of the disease. However, given the patient's small pelvic size, cesarean delivery will likely be necessary regardless of the presence of fetal achondroplasia. Preeclampsia (Choice C) presents with hypertension, edema, and proteinuria, typically after 20 weeks of gestation. Achondroplasia does not increase the risk for preeclampsia. Renal failure (Choice D) presents with symptoms of uremia (eg, fatigue, nausea, pruritus, altered mental status), hyperkalemia, and hypervolemia. It is not a typical complication of pregnancy in a patient with achondroplasia. Uterine rupture (Choice E) occurs when the muscular wall of the uterus tears and presents with severe abdominal pain, hemodynamic instability, and loss of fetal station. Risk factors include previous cesarean delivery, multiparity, and induction of labor but does not include achondroplasia. Educational Objective: Achondroplasia is an autosomal dominant disorder of abnormal long bone growth. Pregnant patients with achondroplasia frequently require cesarean delivery because of their small pelvic size, resulting in severe cephalopelvic disproportion. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 5 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 5. A 47-year-old nulligravid woman comes to the physician because of two episodes of heavy vaginal bleeding during the past 3 months. Menarche was at the age of 11 years , and she has four to six menstrual periods each year with moderate flow. She has type 2 diabetes mellitus treated with glyburide and hypertension treated with hydrochlorothiazide. She has never received hormone therapy. She is 163 cm (5 ft 4 in) tall and weighs 79 kg (174 lb); BMI is 30 kg/m 2 Her temperature is 37°C (98.6°F), pulse is 88/min , respirations are 22/min , and blood pressure is 150/88 mm Hg. Pelvic examination shows a small amount of blood at the cervical os. Which of the following is the strongest risk factor for endometrial cancer in this patient? A) Chronic anovulation B) Diabetes mellitus C) Early menarche D) Hypertension E) Nulliparity Correct Answer: A. Risk factors for endometrial cancer include chronically increased estrogen concentrations, unopposed estrogen therapy, chronic anovulation, obesity, estrogen-secreting tumors, and endometrial hyperplasia. Exogenous sources of estrogen include systemic estrogen therapy and tamoxifen. Endogenous sources of increased estrogen include chronic anovulation, obesity, and estrogen-secreting tumors (eg, granulosa cell tumors). Chronic anovulation is the strongest risk factor for endometrial cancer in this patient, as she presents with a history of irregular menses for decades, which would indicate a prolonged history of anovulation. Anovulation results in the abnormal increased production of estrogen, as progesterone is primarily produced by the corpus luteum after ovulation. The patient's chronic anovulation has likely resulted in persistent, abnormal endometrial turnover, in which chronic estrogen production, unopposed by progesterone, has caused proliferation of the endometrium. This results in endometrial hyperplasia, which places the patient at a higher risk for the development of endometrial carcinoma. Incorrect Answers: B, C, D, and E. Obesity and insulin resistance have been shown to increase the risk for endometrial carcinoma because of the increased conversion of androstenedione to estrone and androgens to estradiol in adipose tissue, resulting in high concentrations of endogenous estrogen. However, diabetes mellitus (Choice B) itself is not a direct risk factor for endometrial carcinoma. Early menarche (Choice C) and late menopause can be associated with an increased risk for endometrial carcinoma. The association between early menarche and endometrial carcinoma is not as strong as chronic anovulation, which directly results in chronic unopposed estrogen production and endometrial hyperplasia. Hypertension (Choice D) has not been shown to independently increase the risk for endometrial carcinoma. Comorbid factors, such as obesity, likely account for this increased risk. Nulliparity (Choice E) has been shown to also increase the risk for endometrial cancer because of the lack of a gestational period, which typically serves as an extended time period without cyclic endometrial proliferation and menstruation. The more menstrual cycles a patient has experienced in life, the higher the risk for endometrial cancer. Educational Objective: Risk factors for endometrial cancer include chronically increased estrogen concentrations, unopposed estrogen therapy, chronic anovulation, obesity, estrogen-secreting tumors, and endometrial hyperplasia. Chronic anovulation results in abnormal endometrial turnover, in which chronic increased estrogen production, unopposed by progesterone, causes increased proliferation of the endometrium, leading to endometrial hyperplasia and increasing the risk for endometrial carcinoma. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 6 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 6. A 32-year-old woman , gravida 3, para 3, comes for a routine health maintenance examination. She has used a copper-containing IUD for contraception for 2 years. Examination shows an enlarged uterus and a visible IUD string. Pelvic ultrasonography shows the IUD to be near the fundus adjacent to a 4-cm intramural leiomyoma uteri; the endometrial cavity is normal in size. Which of the following is the most appropriate next step in management? A) Leave the IUD in i:>lace, but inform the patient that the leiomyoma may cause heavier menses B) Remove the IUD, and recommend another contraceptive method C) Remove the IUD, and recommend removal of the leiomyoma D) Replace the IUD with an IUD of a different shape E) Reposition the IUD farther from the leiomyoma to maintain the effectiveness of the IUD Correct Answer: A. Leiomyomata uteri, also known as uterine fibroids, are benign neoplasms of uterine myometrial smooth muscle and a common tumor in women. They most commonly present with vaginal bleeding, pelvic pain, and miscarriage or infertility that can sometimes be asymptomatic. Physical examination will disclose an enlarged, irregularly shaped uterus. Subserosal fibroids are the most common and can alter the exterior diameter of the uterus. Intramural fibroids are located within the wall of the myometrium, and submucosal fibroids extend into the uterine cavity, abutting the endometrium, and altering its shape. They are all typically well- visualized on pelvic ultrasonography. They are estrogen-responsive and increase in size with pregnancy and decrease in size with menopause. Treatment options for symptomatic fibroids include nonsteroidal anti- inflammatory drugs (NSAIDs), combined oral contraceptives, gonadotropin-releasing hormone agonists, and surgical options such as myomectomy or hysterectomy. In this particular case, as this patient's fibroid is asymptomatic and there are no alterations made to the shape of the endometrial cavity, it is appropriate to leave the IUD in place for long-term pregnancy prevention but to inform the patient that the leiomyoma may cause heavier menses. Incorrect Answers: B, C, D, and E. Remove the IUD, and recommend another contraceptive method (Choice B) is not necessary at this time, as this patient's IUD is positioned appropriately in the endometrial cavity and not altered in shape by the fibroid. Its efficacy is not affected by the presence of the leiomyoma. Remove the IUD, and recommend removal of the leiomyoma (Choice C) is not the most appropriate next step in management, as this patient is asymptomatic and removal of neither the IUD nor the leiomyoma is necessary at this time. Replace the IUD with an IUD of a different shape (Choice D) is not the most appropriate next step in management, as the T-shape of the copper IUD is unaltered by the presence of the intramural fibroid. It is unlikely to be expelled or ineffective, and replacement would be unnecessary. Reposition the IUD farther from the leiomyoma to maintain the effectiveness of the IUD (Choice E) is not necessary, as the T-shape of the copper IUD is unaltered by the presence of the intramural fibroid, and thus, its effectiveness is unlikely to be altered. Educational Objective: Leiomyomata uteri, or benign tumors of the uterine myometrial smooth muscle, can present as subserosal, intramural, or submucosal myometrial masses. Intrauterine device efficacy is not affected by the presence of fibroids in the absence of endometrial cavity alteration. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 7 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 7. A 27-year-old woman , gravida 3, para 3, comes to the physician because of tenderness of the left breast for 2 days. She has been breast-feeding for 2 weeks. Her temperature is 38.4°C (101.1°F). Examination of the breast shows an erythematous, hard, tender upper outer quadrant. The nipple has fissures. Which of the following is the most appropriate pharmacotherapy? A) Ampicillin B) Dicloxacillin C) Erythromycin D) Tetracycline E) Trimethoprim-sulfamethoxazole Correct Answer: B. Mastitis refers to cellulitis of the breast, usually because of bacterial introduction from microtrauma during breastfeeding at the nipple. It presents with unilateral erythematous, indurated, edematous, warm, tender breast tissue, and is frequently associated with fever. It is treated with continuation of breastfeeding and oral antibiotics. Mastitis is most associated with Staphylococcus aureus, or less commonly Streptococcus pyogenes (group A) and Streptococcus agalactiae (group B), Haemophilus influenzae, and Escherichia coli. Effective antibiotics include dicloxacillin or cephalexin. Dicloxacillin is commonly chosen as a result of its efficacy against ~-lactamase-producing bacteria such as S. aureus. It is also safe for use in breastfeeding, as there are no demonstrated adverse effects to the neonate and it only passes into breast milk to a small extent. If mastitis continues untreated, it may progress to a breast abscess. Incorrect Answers: A, C, D, and E. Ampicillin (Choice A) would not be as ideal a choice because of resistance. ~-lactamase-producing bacteria hydrolyze the ~-lactam ring of the antibiotic and are thus resistant to earlier generation penicillins and aminopenicillins such as ampicillin. Erythromycin (Choice C) and other macrolides are effective against common pathogens causing atypical pneumoniae (eg, Mycoplasma species and Legionella species) and Streptococcus but are less effective against S. aureus. Tetracyclines (Choice D) are effective against common pathogens causing atypical pneumoniae, Borrelia burgdorferi, and offer some coverage against S. aureus. However, tetracyclines are associated with tooth and bone malformations in children and should not be administered as they are excreted into breast milk. Trimethoprim-sulfamethoxazole (Choice E) could be appropriate if methicillin-resistant S. aureus (MRSA) infection was suspected. However, most mastitis is to the result of methicillin-sensitive S. aureus (MSSA). Educational Objective: Mastitis refers to cellulitis of the breast tissue, usually because of bacterial introduction at the nipple, and presents with unilateral erythematous, indurated, edematous, warm, tender breast tissue, and fever. It is typically caused by methicillin-sensitive S. aureus (MSSA) and treatment is with continued breastfeeding and dicloxacillin. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 8 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 8. A 25-year-old nulligravid woman comes to the physician with her husband for counseling prior to conception. They are planning to start a family next year and would like to know their risk for having a child with Tay-Sachs disease. She is French-Canadian and has some distant cousins who died during early childhood. Her husband is Jewish but not of Ashkenazi descent. He has no known relatives with Tay-Sachs disease. Examination of the patient shows no abnormalities. Which of the following is the most appropriate next step to determine the risk for Tay-Sachs disease in this patient's future children? A) Testing of the husband first; if positive, no further testing is indicated B) Testing of the wife first; if negative, no further testing is indicated C) Testing of the wife first; if positive, no further testing is indicated D) No testing is indicated Correct Answer: B. Tay-Sachs disease is an autosomal recessive lysosomal storage disease for which preconception testing is recommended for patients from high-risk populations. If testing of the high-risk patient is negative, no testing of the spouse is indicated since the child would have no chance of developing Tay-Sachs disease due its autosomal recessive inheritance pattern. High-risk populations include the Ashkenazi Jewish, French- Canadians, Pennsylvania Dutch, and Cajun populations. Since this patient is French-Canadian, she should be tested first. In Tay-Sachs disease, a genetic mutation causing a deficiency of the hexosaminidase A (Hex A) enzyme leads to accumulation of the cell membrane glycolipid GM2 ganglioside within neuronal lysosomes. A negative DNA test indicates a wild-type allele for the Hex A enzyme, which will produce enough Hex A enzyme to degrade the GM2 ganglioside. Tay-Sachs disease presents with normal motor development in the first few months of life followed by progressive loss of motor skills, muscle spasticity, macrocephaly (as a result of accumulation of GM2 ganglioside in the brain), and a characteristic cherry red macular spot. Ultimately, blindness, seizures, and fatal aspiration pneumonia (as a result of pharyngeal muscle weakness) result and typically limit life expectancy to between 2 to 5 years. Incorrect Answers: A, C, and D. In the case of a positive test of either the husband or wife (Choices A and C), testing of the other spouse would be indicated to determine whether the child has a chance of inheriting this autosomal recessive disease. The wife should be tested first given her risk factors for carrying the Tay-Sachs genetic mutation. No testing is indicated (Choice D) if neither the husband nor wife are from high-risk populations nor demonstrate a family history of the disease. The wife is from a French-Canadian background and has a family history of premature childhood death, which are two definitive reasons to undergo preconception testing. Educational Objective: Tay-Sachs disease is an autosomal recessive lysosomal storage disease that leads to progressive neurodegeneration starting in the first few months of life and a characteristic cherry red macular spot. Preconception testing is recommended for patients from high-risk populations, such as Ashkenazi Jewish and French-Canadian populations or patients with a family history of the disease. If the high-risk parent tests negative, no additional testing is needed. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 9 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 9. A 16-year-old girl comes alone to the physician requesting advice regarding contraception. She states that she is planning to become sexually active for the first time with her boyfriend , and she requests an oral contraceptive. She has no history of serious illness and takes no medications. Menses occur at regular 28-day intervals. Physical examination shows no abnormalities. In addition to counseling about sexually transmitted disease prevention, which of the following is the most appropriate next step in management? A) Provide information on contraception only B) Schedule a follow-up visit with a parent C) Perform testing for Chlamydia trachomatis and Neisseria gonorrhoeae D) Have the patient return after her menstrual cycle for a pelvic examination E) Prescribe a low-dose oral contraceptive Correct Answer: E. The landmark United States Supreme Court case Carey vs. Population Services International (1977) affirmed the rights of minors to access contraceptive services. Most states do not require parental consent in order for minors to be prescribed contraceptives by a physician or to purchase them. In the case of this teenage patient who is requesting oral contraceptives, it is most appropriate for the physician to provide information and counseling on contraception and to provide a prescription. A variety of contraceptive methods are appropriate, including oral or injectable hormonal contraceptives or intrauterine or subdermal implant devices. Incorrect Answers: A, B, C, and D. Providing information on contraception only (Choice A) is inappropriate and will lead to an unnecessary risk for unintended pregnancy. Schedule a follow-up visit with a parent (Choice B) is not necessary in most states and will lead to an unnecessary risk for the patient being lost to follow-up, with an associated risk for unintended pregnancy. Performance of testing for Chlamydia trachomatis and Neisseria gonorrhoeae (Choice C) is unnecessary in this patient who is asymptomatic and who is not currently sexually active. While teenagers are at increased risk for sexually transmitted infections, including C. trachomatis and N. gonorrhoeae, screening for these infections is not necessary prior to initiation of oral contraceptives. Teenage patients who are starting contraceptive methods should be counseled that these methods do not prevent sexually transmitted infections. Having the patient return after her menstrual cycle for a pelvic examination (Choice D) is unnecessary and subjects the patient to an invasive examination. Pelvic examination is needed prior to insertion of an intrauterine device but is not needed when starting oral contraceptives. Educational Objective: Minors have the right to access contraceptive services. Most states do not require parental notification or consent prior to initiation of contraception. Teenage patients seeking contraception should receive appropriate information and counseling but should also receive a prescription for contraception. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 10 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 10. A 27-year-old woman , gravida 2, para 2, comes to the physician for advice regarding contraception. She is sexually active with two male partners and does not use contraception. She does not want to become pregnant now. She had a deep venous thrombosis during her second pregnancy, and she is not certain if she would like to have more children in the future. Three months ago, she was treated for Chlamydia trachomatis infection. She currently takes no medications and reports that she has had difficulty remembering to take daily medications in the past. Her blood pressure is 110/70 mm Hg. Physical examination, including pelvic examination , shows no abnormalities. In addition to advising the patient to use condoms, which of the following is the most appropriate recommendation regarding contraception? A) Vaginal contraceptive ring B) Depot medroxy~rogesterone C) Laparoscopic tubal ligation D) Oral contraceptive E) Placement of an IUD Correct Answer: B. Depot medroxyprogesterone is an intramuscular or subcutaneous progestin that persists for 14 weeks. It is a hormonal contraceptive and prevents pregnancy (96% effective) by causing a sustained release of progestin, which prevents ovulation and causes thickening of the cervical mucus and thinning of the endometrial layer by inhibiting gonadotropin-releasing hormone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estrogen production. It is often used as a method of contraception for patients that have a contraindication to estrogen therapy (eg, history of deep venous thrombosis), particularly if a patient is nonadherent to daily medication, as progestin pills require a strict daily schedule to be effective. Contraindications include hypertension, diabetes, ischemic heart disease, unexplained vaginal bleeding, and chronic corticosteroid use. Complications include a delayed return to fertility, decreased bone mineral density, and increased risk for diabetes. Incorrect Answers: A, C, D, and E. Vaginal contraceptive rings (Choice A) are combined hormonal contraceptives that contain estrogen and progesterone to prevent pregnancy. They are less effective than depot medroxyprogesterone in preventing pregnancy (91 % versus 96%), require replacement monthly, and are contraindicated in patients with a history of deep venous thrombosis. Laparoscopic tubal ligation (Choice C) is the surgical ligation of the fallopian tubes, which prevents pregnancy with almost 100% efficacy by preventing ovum from traveling to the uterus to be fertilized by a sperm. It is difficult to reverse, so is an inappropriate choice in this patient who may want further children in the future. Oral contraceptives (Choice D) are combined hormonal contraceptives that contain estrogen and progesterone to prevent pregnancy. When taken as directed, they are approximately 92% effective but must be taken at a similar time daily. They are contraindicated in patients with a history of deep venous thrombosis. Placement of an IUD (Choice E), whether copper or progestin-containing, alters the uterine environment to make it unfavorable for implantation of an embryo. They are extremely effective at preventing pregnancy, and last for 3 to 10 years. However, they are relatively contraindicated in a patient with a history of recent genital tract infection or at risk for sexually transmitted infections. Educational Objective: Depot medroxyprogesterone is an effective form of birth control that is given every 14 weeks and can be utilized in patients at risk for complications from estrogen therapy. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section: Item 11 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 11. A 52-year-old nulligravid woman comes to the physician for a routine health maintenance examination. She feels well and has no history of serious illness. Menses occur at regular 30-day intervals. She has received all appropriate childhood immunizations but none since that time. She has never been sexually active but plans on becoming sexually active with her boyfriend soon. Physical examination shows no abnormalities. Prior to discussing contraceptive options with this patient, which of the following is the most appropriate vaccine to administer at this time? A) Hepatitis A B) Human papillomavirus C) Influenza virus D) Meningococcal E) Varicella Correct Answer: C. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends a yearly influenza vaccination for patients older than 6 months of age. The influenza vaccine is available in inactivated, recombinant, and live-attenuated forms. The only absolute contraindication to receiving a vaccination is a history of Guillain-Barre syndrome within 6 weeks of a previous dose of influenza vaccine. The live-attenuated vaccine should not be used in patients who are immunocompromised (eg, HIV, immunosuppressant medications, asplenia), pregnant, or that have a cochlear implant. Seasonal influenza is responsible for a high rate of morbidity and mortality because of its complications of pneumonia with acute respiratory distress syndrome, myositis, and myocarditis, as well as multisystem organ failure. Annual vaccination is required as a result of the high rate of mutation of the influenza virus, which results in a decreased host immunity. Incorrect Answers: A, B, D, and E. Hepatitis A (Choice A) vaccination is recommended for patients who are immunosuppressed (eg, chronic liver disease, HIV), traveling to countries with endemic hepatitis A, use intravenous drugs, work in a healthcare setting, or are men who have sex with other men. Human papillomavirus (HPV) (Choice B) vaccination is recommended for all patients aged 9 to 26 years and is occasionally administered to patients up to 45 years old. It is an important vaccination for the prevention of infection with high risk HPV strains 16, 18, 31, and 33, which can cause cervical, vulvar, penile, and anal squamous cell cancer. Meningococcal (Choice D) vaccination is recommended for patients living in shared housing (eg, college dorms, military barracks), those with asplenia, and those traveling to countries with epidemic meningococcal disease (eg, Sub-Saharan Africa). Varicella (Choice E) vaccination is recommended for patients that lack immunity to varicella (eg, were born after 1980 and did not have chickenpox as a child). As this patient is 52 years old, a varicella vaccination would not be recommended. Educational Objective: Annual influenza vaccinations are recommended for all patients older than 6 months. The only absolute contraindication to receiving the influenza vaccine is a history of Guillain-Barre syndrome within 6 weeks of a previous dose of influenza vaccine. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 12 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 12. An 18-year-old primigravid woman at 18 weeks' gestation comes for her second prenatal visit. Abdominal examination shows a uterus that measures 23 cm above the pubic symphysis. She has gained 4.5 kg (10 lb) since her last visit 4 weeks ago. Her blood pressure is 120/72 mm Hg. Fetal heart tones are 160/min. Urine dipstick is negative for protein and trace positive for glucose. Which of the following is the most appropriate next step in management? A) Schedule an appointment in 1 week B) Nutritional counseling C) Measurement of serum estriol concentration D) Glucose tolerance test E) UltrasonograEJhy for dating Correct Answer: E. Fundal height is often used to estimate gestational age. The distance in centimeters between the pubic symphysis and top of the uterine fundus approximates the gestational age in weeks. Typically, gestational age is calculated from the last menstrual period. When there is a discrepancy between these two measurements, the most appropriate next step in management is ultrasonography to assess the gestational age of the fetus through objective parameters for accurate dating. Measurements of fetal crown-rump length, biparietal diameter, femur length, and abdominal circumference can be used to accurately date a pregnancy. Ultrasonography-guided gestational age measurements are the most accurate during the first trimester. Ultrasonography can also determine other causes for a fundal height larger than expected, including multiple gestations, hydatidiform moles, and fetal macrosomia. Incorrect Answers: A, B, C, and D. Scheduling an appointment in 1 week (Choice A) would not be appropriate, as there is uncertainty about the gestational age of the fetus given the differences in calculated gestational age and fundal height. Weekly appointments are common after 36 weeks' gestation or earlier if any pregnancy-related complications occur (eg, preeclampsia). Nutritional counseling (Choice B) is not necessary, as this patient is gaining the appropriate amount of weight for her pregnancy. A typical weight gain for a patient with a normal BMI is 11.3 to 15.9 kg (25 to 35 lb) over the course of the gestation. Measurement of serum estriol concentration (Choice C) is used as part of the quad screen, along with a-fetoprotein, ~-human chorionic gonadotropin, and inhibin A, to determine the likelihood of genetic disorders of the fetus. It is commonly measured at 15 to 22 weeks, based on maternal preferences. However, it is more important to determine an accurate gestational date with ultrasonography, as the quad screen reference ranges depend on gestational age. Glucose tolerance test (Choice D) is typically completed at 24 to 28 weeks' gestation to screen for gestational diabetes. This patient is only 18 weeks based on the last menstrual period or 23 weeks based on fundal height, making either scenario too early for a glucose tolerance test. Educational Objective: Ultrasonography is the most appropriate next step in management when there is a discrepancy between the fundal height and calculated gestational age based on the patient's last menstrual period. It can provide accurate dating based on objective fetal parameters and assess for multiple gestations, hydatidiform moles, and macrosomia. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 13 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 13. A 32-year-old woman , gravida 3, para 2, delivers a full-term , 4082-g (9-lb) newborn vaginally. The pregnancy was uncomplicated. Despite receiving oxytocin therapy in the recovery room , she has excessive vaginal bleeding and a boggy uterus. The bleeding continues after uterine massage. Which of the following is the most appropriate next step in management? A) Measurement of plasma fibrinogen concentration , prothrombin time , partial thromboplastin time , and factor VIII B) Ergonovine therapy C) Endometrial curettage D) Uterine artery embolization E) Exploratory laparotomy Correct Answer: B. Uterine atony typically presents with postpartum hemorrhage and a boggy uterus on physical examination, as in this patient. Initial management involves intravenous fluid administration, uterine massage, and oxytocin infusion and evaluation for other causes of postpartum hemorrhage (eg, cervical laceration). If uterine atony persists despite these interventions, carboprost tromethamine, a prostaglandin, or methylergonovine (methergine), an ergot alkaloid, can be administered. Carboprost is contraindicated in asthmatic patients as it may induce bronchospasm, whereas ergonovine therapy is contraindicated in patients with a history of hypertension and coronary or cerebral artery disease. Ergonovine works directly on the uterine smooth muscle, inducing increased uterine tone through sustained tetanic contraction, which reduces blood loss and is an effective treatment for postpartum uterine atony. It can potentially cause arterial vasospasm, which may result in deleterious side effects in patients with a history of arterial disease (eg, coronary artery or cerebrovascular disease). Further interventions to manage the hemorrhage associated with uterine atony include a tamponade balloon, blood transfusions, uterine or hypogastric artery embolization, or hysterectomy. Risk factors for uterine atony include macrosomia, multiple gestations, prolonged labor, uterine infection, and spinal anesthesia. Incorrect Answers: A, C, D, and E. Measurement of plasma fibrinogen concentration, prothrombin time, partial thromboplastin time, and factor VI II (Choice A) may be an appropriate choice to rule out bleeding diatheses and determine the necessity for the administration of blood products. However, it is more important to try to stop the bleeding as quickly as possible, and these labs will take time to process. Endometrial curettage (Choice C) is useful in treating heaving or abnormal uterine bleeding that does not respond to other interventions, as well as for removing fetal tissue or retained products of conception. However, it does not play a role in the management of uterine atony. Uterine artery embolization (Choice D) and exploratory laparotomy (Choice E) for hysterectomy may be necessary if the bleeding remains uncontrolled despite optimal medical management. As there are still medical options to try, such as ergonovine therapy, these invasive options are not the most appropriate next step in management. Educational Objective: Uterine atony presents with postpartum hemorrhage and a boggy uterus on physical examination. Initial management includes uterine massage and oxytocin, followed by ergonovine therapy (contraindicated in patients with a history of hypertension, coronary artery disease and cerebrovascular disease) and carboprost tromethamine therapy (contraindicated in patients with asthma). r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 14 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 14. A 27-year-old woman , gravida 2, para 1, at 31 weeks' gestation has had constant moderate pain in the right flank for 12 hours. Her temperature is 38.6°C (101.4°F). A catheterized urine specimen shows 15-20 RBC/hpf and 30-40 WBC/hpf. Ultrasonography of the kidneys shows no abnormalities. The ureters are markedly dilated , the right more than the left. Which of the following is the most likely diagnosis? A) Bilateral ureteral obstruction B) Hemorrhagic cystitis C) Pyelonephritis D) Renal vein thrombosis E) Ureteral calculus Correct Answer: C. Fever, chills, and flank pain are classic findings in the diagnosis of pyelonephritis, an infection of the kidney that commonly results from retrograde spread of a urinary tract infection. Urinary tract infections are much more common in women because of the shorter urethra and favorable regional environment for bacterial growth. If untreated, bacteria can travel up the ureter to infect the kidney, resulting in pyelonephritis. Pyelonephritis typically presents with dysuria, flank pain, and associated systemic symptoms such as fever, rigors, nausea, vomiting, myalgias, arthralgias, and fatigue. On examination, patients with pyelonephritis typically demonstrate high fevers, tachycardia, leukocytosis, and costovertebral angle tenderness. Urinalysis in pyelonephritis often shows >10 WBC/hpf and may also demonstrate red blood cells as evidence of mucosal inflammation and white blood cell casts. Bacteria are generally seen on microscopy, with Gram-negative rods being the most common pathogen. Pregnant patients are at higher risk for urinary tract infections including pyelonephritis as a result of stagnation of urine from progesterone-induced decreased ureteral tone and motility, and mechanical compression of the ureters at the pelvic brim, bladder, and ureteral orifices by the gravid uterus. Incorrect Answers: A, B, D, and E. The gravid uterus can cause mechanical compression of the ureters at the pelvic brim, the bladder, and ureteral orifices, which can result in bilateral ureteral obstruction (Choice A). However, obstruction by itself would not cause fever, hematuria, or pyuria unless complicated by pyelonephritis. Hemorrhagic cystitis (Choice B) may present with hematuria and pyuria in the context of a lower urinary tract infection. Lower urinary tract infection symptoms include dysuria, frequency, urgency, incontinence, and suprapubic pain. Systemic symptoms such as fever, chills, nausea, and vomiting are less likely, and vital signs are generally within normal limits. Renal vein thrombosis (Choice D) may occur in patients with underlying thrombophilia and can present with flank pain, hematuria, acute kidney injury, or may be asymptomatic. It would not cause fever or dysuria. Ureteral calculus (Choice E) typically presents with colicky, unilateral flank pain radiating to the groin, and with gross or microscopic hematuria. The common types of urinary tract calculi are calcium oxalate or phosphate, ammonium magnesium phosphate, uric acid, and cystine. On urinalysis, RBCs without casts are common. It would not cause fever, dysuria, or pyuria unless there was a concomitant infection. Educational Objective: Pyelonephritis typically presents with fevers, nausea, vomiting, and flank pain with associated costovertebral angle tenderness on physical examination. This most commonly occurs from ascending urinary tract infections. Pregnant patients are at higher risk for pyelonephritis as a result of stagnation of urine from progesterone-induced decreased ureteral tone and motility, and mechanical compression of the ureters at the pelvic brim, bladder, and ureteral orifices by the gravid uterus. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 15 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 15. An otherwise healthy 22-year-old woman comes to the physician 4 months after noticing a painless lump in her right breast during breast self-examination. She notes that the lump has increased in size. She feels well. Menses occur at regular 28-day intervals. Her last menstrual period was 2 weeks ago. She takes no medications. Vital signs are within normal limits. There is no lymphadenopathy. Examination of the right breast shows a raised area in the upper outer quadrant; there are no skin changes. A 4-cm, firm , smooth, mobile mass is palpated in the upper outer quadrant of the right breast. Examination of the left breast shows no abnormalities. Which of the following is the most likely diagnosis? A) Abscess B) Fat necrosis C) Fibroadenoma D) Fibrocystic changes of the breast E) Galactocele F) lntraductal papilloma G) Lipoma H) Mammary ductal ectasia I) Mastitis Correct Answer: C. Fibroadenomas are benign breast masses composed of epithelial and fibroblastic stromal tissue. Fibroadenomas are the most common breast tumor of young women. They present in women between the ages of 25 and 40 as a painless, mobile breast lump. They are typically small (less than 3 cm in diameter), mobile, and have a rubbery consistency. Diagnosis may be facilitated with ultrasonography or mammography. Definitive diagnosis requires biopsy, which discloses a well-circumscribed mass composed of hypercellular stromal cells with a bland, uniform appearance without atypia, as well as epithelial cells. Fibroadenomas usually decrease in size over time and have little malignant potential. Treatment is with regular observation. Incorrect Answers: A, B, D, E, F, G, H, and I. Abscess (Choice A) is often a complication of mastitis. Breast abscesses commonly occur in breastfeeding women, and present with a localized region of indurated, fluctuant, erythematous, tender tissue. Fat necrosis (Choice B) is often detected in the breast as a palpable nodularity in an area of previous trauma. On imaging, peripheral calcifications are often seen. Fibrocystic changes of the breast (Choice D) are a benign and cyclic etiology of breast pain that presents with focal masses or nodules. Fibrocystic changes occur most commonly in premenopausal women over the age of 35. Patients may present with various sites of breast pain and lumps, which may be bilateral. Galactocele (Choice E) defines a retained collection of breast milk and presents as a painless breast lump typically following the cessation of lactation. They generally self-resolve. lntraductal papilloma (Choice F) is the most common cause of unilateral bloody nipple discharge. It is a benign tumor originating from the walls of lactiferous ducts and can be solitary or multiple. Lipoma (Choice G) describes a benign neoplasia of adipocytes, and generally presents as a solitary, painless, soft, mobile, subcutaneous mass, often on the torso. Mammary ductal ectasia (Choice H) often occurs in perimenopausal women and is a widening of the lactiferous ducts, often near the nipple. Ectatic ducts are often asymptomatic until they become blocked, at which time they may become nodular or painful. Mastitis (Choice I) presents with erythema and induration of the breast in an area of tender, warm skin. It classically occurs in breastfeeding mothers because of nipple trauma leading to inoculation from cutaneous or oral flora. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 15 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment ~ -.. A) Abscess B) Fat necrosis C Fibroadenoma D) Fibrocystic changes of the breast E) Galactocele F) lntraductal papilloma G) Lipoma H) Mammary ductal ectasia I) Mastitis Correct Answer: C. Fibroadenomas are benign breast masses composed of epithelial and fibroblastic stromal tissue. Fibroadenomas are the most common breast tumor of young women. They present in women between the ages of 25 and 40 as a painless, mobile breast lump. They are typically small (less than 3 cm in diameter), mobile, and have a rubbery consistency. Diagnosis may be facilitated with ultrasonography or mammography. Definitive diagnosis requires biopsy, which discloses a well-circumscribed mass composed of hypercellular stromal cells with a bland, uniform appearance without atypia, as well as epithelial cells. Fibroadenomas usually decrease in size over time and have little malignant potential. Treatment is with regular observation. Incorrect Answers: A, B, D, E, F, G, H, and I. Abscess (Choice A) is often a complication of mastitis. Breast abscesses commonly occur in breastfeeding women, and present with a localized region of indurated, fluctuant, erythematous, tender tissue. Fat necrosis (Choice B) is often detected in the breast as a palpable nodularity in an area of previous trauma. On imaging, peripheral calcifications are often seen. Fibrocystic changes of the breast (Choice D) are a benign and cyclic etiology of breast pain that presents with focal masses or nodules. Fibrocystic changes occur most commonly in premenopausal women over the age of 35. Patients may present with various sites of breast pain and lumps, which may be bilateral. Galactocele (Choice E) defines a retained collection of breast milk and presents as a painless breast lump typically following the cessation of lactation. They generally self-resolve. lntraductal papilloma (Choice F) is the most common cause of unilateral bloody nipple discharge. It is a benign tumor originating from the walls of lactiferous ducts and can be solitary or multiple. Lipoma (Choice G) describes a benign neoplasia of adipocytes, and generally presents as a solitary, painless, soft, mobile, subcutaneous mass, often on the torso. Mammary ductal ectasia (Choice H) often occurs in perimenopausal women and is a widening of the lactiferous ducts, often near the nipple. Ectatic ducts are often asymptomatic until they become blocked, at which time they may become nodular or painful. Mastitis (Choice I) presents with erythema and induration of the breast in an area of tender, warm skin. It classically occurs in breastfeeding mothers because of nipple trauma leading to inoculation from cutaneous or oral flora. Educational Objective: Fibroadenomas are the most common breast mass in young women and are benign masses composed of epithelial and fibroblastic stromal tissue. They are small, mobile, and have a rubbery consistency. Diagnosis is confirmed with biopsy, after which fibroadenomas can be followed with routine observation. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 16 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 16. A 32-year-old woman , gravida 3, para 2, at 34 weeks' gestation comes to the physician for a routine prenatal visit. She reports that, 1 week ago, she had malaise for 2 days followed by a bright rash over her cheeks that resolved within 3 days. A rash has now developed on her arms and legs. Her temperature is 37.2°C (99°F), and pulse is 90/min. Examination shows a marble-appearing rash over the upper and lower extremities. The lungs are clear to auscultation. The abdomen is soft. Fundal height is 35 cm. The fetal heart rate is 160/min. Which of the following is the most likely causal organism? A) Cytomegalovirus B) Herpes simplex virus 1 C) Human papillomavirus D) Parvovirus E) Rubella CorrectAnswer: D. Parvovirus B19, in the context of an acquired infection while pregnant, is typically a mild viral syndrome that may include a rash, fever, chills, headache, myalgias, arthralgias, nausea, vomiting, abdominal cramping, diarrhea, or mild respiratory symptoms. The rash seen in adult parvovirus B19 infection is variable in distribution, less likely to demonstrate the characteristic red-cheeked appearance as in children, and may not be present at all. It is generally self-resolving and seldom carries a significant burden of morbidity in otherwise healthy persons. There may be consequences of maternal parvovirus B 19 infections for the developing fetus, however, especially if the infection is acquired in the second or third trimester. Parvovirus B19 has a tropism for bone marrow and infects erythroid progenitor cells, which can cause fetal anemia. Fetal anemia may present as fetal tachycardia, high-output heart failure, hydrops fetal is, and death. Parvovirus is also a potential cause of fetal myocarditis. Incorrect Answers: A, B, C, and E. Cytomegalovirus (CMV) (Choice A) can often be asymptomatic or cause a short febrile, flu-like illness, but it does not commonly present with rash. Fetal infection with CMV is associated with intrauterine growth restriction, hepatosplenomegaly, petechiae, jaundice, thrombocytopenia, microcephaly, and chorioretinitis. Herpes simplex virus 1 (HSV1) (Choice B) is characterized by tender vesicles followed by ulceration and crusting, most commonly around the mouth but can also cause genital lesions. A fetal infection with HSV1 can cause localized lesions of the skin, eyes, and mouth, along with the potential for disseminated disease, such as encephalitis or multiorgan dysfunction. Human papillomavirus (HPV) (Choice C) infection is usually asymptomatic, but chronic infections, particularly with high-risk strains 16, 18, 31, and 33, can lead to the development of cervical, vulvar, penile, or anal cancer. It does not typically present with a skin rash. Rubella (Choice E) infection can be asymptomatic or present with an erythematous rash, arthralgias, and fever. Fetal infection presents with sensorineural deafness, neurodevelopmental delay, congenital cardiac defects, microcephaly, and extramedullary hematopoiesis. Educational Objective: Parvovirus B19 presents in an adult as a mild viral syndrome that may include a rash, fever, chills, headache, myalgias, arthralgias, nausea, vomiting, abdominal cramping, diarrhea, or mild respiratory symptoms. In pregnant patients, it can cause hydrops fetal is of the fetus secondary to fetal anemia and high-output cardiac failure, especially when the infection occurs in the second or third trimester. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 17 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 17. During a routine health maintenance examination , an asymptomatic 65-year-old woman is found to have a second-degree cystocele , a first-degree rectocele , and a first-degree uterovaginal prolapse. The right ovary is palpable but less than 5 cm in diameter; the left ovary cannot be palpated. Which of the following findings is of most concern requiring further evaluation? A) Cystocele B) Nonpalpable left ovary C) Pali:Jable right ovary D) Rectocele E) Uterovaginal prolapse Correct Answer: C. In postmenopausal women, a palpable ovary raises concern for an ovarian malignancy. In postmenopausal women, 30% of ovarian masses are malignant. Any incidental ovarian enlargement or cyst in a woman over the age of 50 years should be investigated for malignancy with imaging and potential biopsy. If discovered early, an ovarian malignancy can present as a mass on pelvic examination or imaging, though ovarian cancer classically presents late in the course and is often metastatic and invasive at the time of discovery. Presenting features are often nonspecific, and may include weight loss, abdominal discomfort or distention, ascites, and gastrointestinal symptoms including early satiety, bloating, nausea, cramping, and bowel obstruction. Bowel obstruction can occur because of locally invasive disease or because of peritoneal carcinomatosis, which is a common presenting diagnosis. Ovarian cancer is potentially hereditary, with an increased frequency of cases seen in women with mutations in BRCA 1/2 and Lynch syndrome. Treatment includes surgical resection and debulking plus chemotherapy. Early diagnosis and treatment are key to maximize survival. Incorrect Answers: A, B, D, and E. Pelvic organ prolapse, which includes cystocele (Choice A), rectocele (Choice D), and uterovaginal prolapse (Choice E), is a relatively common condition in older women. Cystocele refers to prolapse of the urinary bladder into the anterior wall of the vagina. Uterovaginal prolapse refers to the prolapse of the uterus and vagina through the vaginal opening. Rectocele refers to the rectum prolapsing into the posterior wall of the vagina. These presentations are related to weakening of the pelvic floor musculature. Risk factors include multiparity, older age, obesity, hysterectomy, and chronic constipation. Symptomatic prolapse can be managed with pelvic floor exercises, pessary placement, or surgical repair. Nonpalpable ovaries (Choice B) are typical for postmenopausal women. Ovarian volume usually decreases after menopause. Educational Objective: In postmenopausal women, a palpable ovary raises concern for an ovarian malignancy. If discovered early, an ovarian malignancy can present as a mass on pelvic examination or imaging, though ovarian cancer classically presents late in the course with weight loss, abdominal discomfort, or gastrointestinal symptoms and is often metastatic and invasive at the time of discovery. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 18 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 18. A 22-year-old primigravid woman at 27 weeks' gestation is brought to the emergency department because of a 2-day history of moderate back pain , fever, and nausea. Pregnancy has been complicated by a positive urine culture for Streptococcus aga/actiae (group B) infection at 8 weeks' gestation that resolved with ampicillin therapy; and iron deficiency anemia with a hemoglobin concentration of 9.9 g/dl. She has not adhered to her medication regimen of iron supplementation and a prenatal vitamin. She appears moderately anxious. Her temperature is 38.4°C (101.1°F), respirations are 22/min , and blood pressure is 140/90 mm Hg. Abdominal examination shows mild tenderness to palpation in the right upper quadrant and right costovertebral angle tenderness. The uterus is soft and nontender. Fundal height is 26 cm. The baseline fetal heart rate is 180/min with decreased variability. Contractions occur every 10 to 15 minutes and last 20 seconds. Pelvic examination shows clear mucoid discharge from the cervical os. The cervix is not dilated or effaced. Her hemoglobin concentration is 9.7 g/dl. Which of the following is the most likely cause of the fetal tachycardia? A) Fetal anemia B) Fetal dehydration C) Maternal anemia D) Maternal anxiety E) Maternal fever Correct Answer: E. Maternal fever can cause fetal tachycardia, which is defined as a heart rate greater than 160/min. Other causes of fetal tachycardia include hypoxia, fetal anemia, intra-amniotic infection, and maternal medications. Conversely, bradycardia is defined by a heart rate less than 110/min and can be caused by congenital heart malformations, as well as hypoxia, fetal distress, and maternal hypotension. Decreased variability can be caused by fetal hypoxia, the administration of opioids or magnesium, and a fetal sleep cycle, but it is nonspecific. Given this patient's presentation, it is most likely that the fetal tachycardia is secondary to maternal fever in the setting of likely pyelonephritis. There are no signs of significant fetal anemia or hypoxia. Incorrect Answers: A, B, C, and D. Fetal anemia (Choice A) can present with tachycardia but is also likely to be associated with ascites, pericardia! fluid, and pleural effusions, as well as an increased middle cerebral artery peak systolic velocity. It is a less likely cause of fetal tachycardia in this case. Fetal dehydration (Choice B) is uncommon and unlikely in the absence of signs of maternal dehydration. It could potentially cause fetal tachycardia but is an unlikely cause of fetal tachycardia in this case. Maternal anemia (Choice C) is common, especially given the physiologic adaptations to pregnancy such as increased plasma volume, in addition to an increased risk for iron deficiency. Severe maternal anemia can cause premature birth and low birth weight but does not typically cause fetal tachycardia. Maternal anxiety (Choice D) can cause fetal tachycardia if severe, because of a release of catecholamines that can cross the placenta. However, this patient is only experiencing moderate anxiety, and her high fever is a more likely cause of the fetal tachycardia. Educational Objective: Causes of fetal tachycardia, or a heart rate greater than 160/min, include maternal fever, fetal hypoxia, fetal anemia, intra-amniotic infection, and maternal medications. In the setting of a maternal infection, fetal tachycardia is most likely secondary to maternal fever. r " , ~ r-- r , Previous Next Score Report Lab Values Calculator Help Pause Exam Section : Item 19 of 50 National Board of Medical Examiners Mark Obstetrics and Gynecology Self-Assessment 'I 19. A previously healthy 42-year-old woman , gravida 2, para 2, comes to the physician because of an 8-month history of severe pelvic pain and heavy bleeding during her menstrual periods. Menses occur at regular 28-day intervals and last 6 days. The pain begins 2 days before the onset of menses and lasts for 4 days; treatment with ibuprofen does not control the pain. She takes no other medications. She has had two cesarean deliveries; delivery of her second child was complicated by deep venous thrombosis. She and her husband do not want to have any more children , and he is planning on undergoing vasectomy. Physical examination of the patient, including pelvic examination, shows no abnormalities. Pelvic ultrasonography shows a normal uterus. Which of the following is the most appropriate next step in management? A) Combination oral contraceptive therapy B) Placement of a copper IUD C) Endometrial ablation D) Dilatation and curettage E) Uterine artery embolization Correct Answer: C. Abnormal uterine bleeding refers to irregular menstrual bleeding that may be abnormal in quality, duration, or timing. It may be caused by structural abnormalities such as cervical or endometrial polyps, adenomyosis, endometrial hyperplasia, malignancy, inflammation or infection of the genital tract, coagulopathy, ovulatory dysfunction, endocrine dysfunction (eg, thyroid disorders, prolactin, androgens), iatrogenic, or may be idiopathic. Abnormal uterine bleeding may be treated medically or surgically. Medical approaches to abnormal uterine bleeding include estrogen-progestin contraceptives or levonorgestrel intrauterine devices; both decrease the amount of vaginal bleeding during menses and provide contraception. For patients who are unable to take combination oral contraceptives, do not desire future pregnancy, or fail medical management, endometrial ablation is an option for the treatment of heavy uterine bleeding. It is contraindicated in patients who desire future pregnancy or those with endometrial hyperplasia or cancer. Endometrial ablation involves the resection and destruction of the endometrial lining of the uterus. Incorrect Answers: A, B, D, and E. Combination oral contraceptive therapy (Choice A) may be used to treat heavy menstrual bleeding; however, it would be contraindicated in the patient because of a history of deep venous thrombosis. Besides history of thromboembolism, other contraindications to estrogen-progestin contraceptives include migraines, smoking, breast malignancy, hypertension, and a history of coronary artery disease, congestive heart failure, or cerebrovascular disease. Placement of a copper IUD (Choice B) would not decrease heavy menstrual bleeding as the copper IUD contains no hormones that decrease endometrial proliferation. Copper IUDs may cause irregular vaginal bleeding, increased