Question of the Week # 454

Your patient presents at 33 weeks gestation. She is a 27 year old gravida 2 para 1 female with a previous pregnancy complicated by pre-eclampsia, with a vaginal delivery of a healthy infant at 37 weeks. Her current pregnancy has been uncomplicated, but today she is experiencing abdominal pain and uterine contractions that began 5 hours prior to presentation. She states that she has had some fluid leaking from her vagina since the previous evening, but denies vaginal bleeding, trauma, urinary urgency or frequency.

Her temperature is 101.6 degrees Fahrenheit. Blood pressure is 98/60, heart rate is 100/minute, with respirations of 18/minutes. On pelvic examination, she has clear fluid in the posterior fornix, which causes nitrazine paper to turn blue in color. She is dilated to 4 centimeters and her cervix is 60% effaced. Her uterus is diffusely tender on examination and the fetal heart rate is 175 beats per minute, with frequent accelerations. Maternal white blood cell count is 13,000/mm3.

What is the next step in the management of this patient?

A. Initiation of ciprofloxacin

B. Urine culture

C. Initiation of ampicillin and gentamycin

D. Cesarean delivery

E. Induction of labor.

Question of the Week # 392

392)  A 28 year old woman presents with a history of amenorrhea of about 6 month duration. She does not have any breast discharge, visual deficits or headaches. Her home pregnancy test was negative a week ago. Her past medical history is significant for three missed abortions for which she underwent dilatation and curettage. On examination, her vitals are stable. Body mass index is about 22 . Breast examination is normal with out any discharge.  Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  A trial of medroxyprogesterone and a later trial of estrogen-progesterone combination fails to induce bleeding. Which of the following is the most appropriate next step?

A) Anti-phospholipid Antibodies

B) Hysteroscopy

C) Dehydro-epiandrosterone level

D) Pituitary MRI

E) Ultrasound of Ovaries

Question of the Week # 391

391)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. This patient is at increased risk for which of the following conditions?

A) Visual Deficits

B) Endometrial Cancer

C) Osteoporosis

D) Pituitary Necrosis

E) Vertebral Compression Fractures

Question of the Week # 390

390)  A 28 year old woman has had amenorrhea for the past 4 months. She reports having regular menstrual cycles prior to these episodes. She is sexually active and a home pregnancy test was negative on two occasions over the last one week. She denies any excessive stress or physical activity. She has had headaches almost daily over the past three months. She denies any visual deficits. Her past medical history is significant for schizophrenia for which she is using risperdal for several years with good control of her disease. On examination, her vitals are stable. Body mass index is about 28 . There is milky discharge on breast examination. Pelvic exam is normal. Serum pregnancy test is negative. A serum prolactin level is 30mcg/ml (5 to 20 mcg/L). A serum Thyroid Stimulating Hormone and Follicle Stimulating Hormone level are within normal limit. An MRI of the brain reveals 10 cm lobulated mass in the anterior skull base. Which of the following is the initial step in evaluating this patient?

A) Repeat Prolactin after Serum Dilution

B) Discontinue Risperdal

C) Trans-Sphenoidal Resection of the Tumor

D) Pituitary Irradiation

E) Bromocriptine

Question of the Week # 389

389)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. Which of the following explains her amenorrhea?

A) Past use of Oral Contraceptive Pills

B) Uterine Adhesions

C) Hypothalamic amenorrhea

D) Polycystic Ovarian Syndrome

E) Premature Ovarian Failire

Question of the Week # 370

370)  A 47  year old woman presents to your office with complaints of change in her menstrual cycles. Lately, she has had very irregular periods and sometimes, they have been heavy. She reports her cycles have been irregular for past 8 months. Her most recent period was two weeks ago and was much heavier than usual. She also has started experiencing hot flashes. She is not on oral contraceptive pills. She does not smoke or use alcohol. She has no other past medical problems and otherwise, feels healthy. Her family history is unremarkable. Physical examination including pelvic examination is unremarkable. A urine pregnancy test and Thyroid stimulating hormone are within normal limits. Urinalysis is normal. Which of the following is the most appropriate initial step in management?

A) Reassure that she is menopausal transition and observe

B) Obtain Serum FSH level

C) Start Oral Contraceptive Pills

D) Endometrial Biopsy

E) Oral Progestin

Question of the Week # 369

369)  A 56 year old post-menopausal woman presents to your office for evaluation of occasional vaginal spotting for past two weeks. She has not had a menstrual period for the past five years.  She  has never taken hormone replacement therapy.  She denies any fever or dysuria. She is sexually active and enjoys it. Her bleeding is unrelated to sexual activity. She has no other past medical problems and otherwise, feels healthy. Physical examination is unremarkable. A transvaginal ultrasound reveals endometrial stripe thickness of 3mm. She is reassured and sent home. Two months later she is re-evaluated in your office for persistent vaginal spotting that has not resolved. She has seen another primary care physician a week ago for a second opinion because she was concerned. He repeated a transvaginal ultrasound which showed endometrial stripe thickness unchanged at 3 mm.  Which of the following is the most appropriate management recommendation?

A) A trial of vaginal estrogen

B) Reassure and Observe

C) Vaginal pH testing

D) Oral Progestin Trial

E) Endometrial Biopsy

Question of the Week # 368

368)  A 58 year old post-menopausal woman presents to your office with intermittent vaginal bleeding for the past 1 month. She has not had a menstrual period for the past six years.  She  has never taken hormone replacement therapy. She reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. A transvaginal ultrasound reveals endometrial stripe thickness of 2mm. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 367

367)  A 62 year old woman presents to your office with complaints of vaginal spotting for the past three months. Occasionally, she also had vaginal bleeding. She is concerned with this new development because she has not has not had a menstrual period for the past  ten years. She  has never taken hormone replacement therapy. She also reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 366

366)  A 59 year old woman is evaluated in your office for vaginal bleeding. The patient has not had a menstrual period for the past eight years. She  has never taken hormone replacement therapy. Over the past 6 months she has had several episodes of spotting. The bleeding is more pronounced after sexual activity. Physical examination including pelvic examination is unremarkable. Which of the following is the most common cause of post-menopausal bleeding?

A) Endometrial Carcinoma

B) Endometrial Hyperplasia

C) Cervical polyps

D) Vaginal Atrophy

E) Fibroids

Question of the Week # 365

365)  A 26 year old woman presents to the outpatient gynecology clinic with complaints of for intermittent vaginal bleeding. She has started Combination oral contraceptive pills 3 months ago. Initially, she had spotting in the first month after starting OC pills however, she now has frank bleeding for past 4 weeks. Her scheduled menstrual period usually, occurs during the pill free period of the month.  She denies any dysuria , fever, vaginal discharge or post-coital bleeding. She smoked about 1 pack per day for the past eight years. She denies alcohol or drug use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative. Which of the following is the first step in managing this patient’s intermenstrual bleeding?

A) Observation

B) Smoking Cessation

C) Pelvic ultrasound

D) Increase Estrogen component of the pill

E) Change the progesterone component to Levonorgestrel

Question of the Week # 364

364)  A 28 year old woman seeks your advice regarding an effective contraception method. She is sexually active with her long term boy-friend. He has been using condoms however, he prefers not to use them on a regular basis . She tells you that she does not want to consider an Intra-Uterine Device Her past medical history is significant for Gastro-esophageal reflux disease and well- controlled Epilepsy. Her medications include omeprazole and carbamazepine.  She does not smoke. On examination, she is age appropriate with normal vitals. Physical examination including pelvic examination is normal. Which of the following contraceptive methods is most appropriate for this patient?

A) Continuous Combination Oral Contraceptive Pills

B) Cyclical Combination Oral Contraceptive Pills

C) Diaphragm with Spermicides

D) Estrogen-Progesterone vaginal ring ( Nuva-Ring)

E) Depot Medroxy Progesterone

Question of the Week # 363

363)  A 25 year old woman presents to your office with complaints of inter-menstrual vaginal bleeding  for the past one month. She is sexually active. She never used barrier methods for contraception but she has been on cyclical combination oral contraceptive pills ( Ethinyl estradiol + Levonorgestrol) for the past 3 months. She denies any fever or vaginal discharge or dysuria or pain. Her menstrual periods occur as scheduled every month during the pill free period however, she also has been experiencing inter-menstrual bleeding only for the past one month and sometimes, more after sexual activity. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. She denies smoking , alcohol or drug use. Upon physical examination, she is afebrile. There is no obvious vaginal discharge. When gentle endocervical swabbing is attempted, bleeding from endocervix is noted. On bimanual examination, she has no adnexal tenderness. A urine pregnancy test is negative. Which of the following is the most appropriate first management option?

A) Reassure that this is OC Pill related bleeding and will abate.

B) Test for N. gonorrhoeae and C. trachomatis

C) Increase the dose of Ethinyl Estradiol

D) Empiric antibiotic therapy for Gonorrhea and Chlamydia

E) Discontinue OC pills

Question of the Week # 362

362)  A 26 year old woman presents to your office with complaints of intermittent vaginal bleeding  after she started using oral contraceptive pills 1 month ago. She uses continuous oral contraceptive pill combination of ethinyl estradiol and norethindrone. She reports her bleeding is troublesome and interferes with activity. Because of the bleeding, she is considering discontinuing the oral pills but her partner does not want to use barrier methods of contraception. She is distressed and seeks some remedy to address this issue. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. Her bleeding is unrelated to sexual activity and is not associated with pain. She denies any dysuria, fever or vaginal discharge. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Observation

B) Stop the pills for 3 days and then resume at least 21 days

C) Pelvic ultrasound

D) Discontinue Oral Contraceptive pills

E) Vaginal fluid Nucleic Acid Test for Chlamydia Trachomatis

Question of the Week # 361

361)  A 22 year old woman is seen in the outpatient clinic for intermittent vaginal bleeding. For the past two months, she has had spotting and occasionally, frank bleeding  even before her scheduled menstrual period. It is unrelated to sexual activity and is not associated with pain. She denies any dysuria or fever.  She is sexually active with her fiancee and she reports taking cyclical combined oral contraceptive pills ( OC pills) for the past 2 months. She has been following the exact directions regarding the use of oral contraceptive pills and her scheduled period occurs during the contraceptive free interval however, this unscheduled spotting and bleeding is bothering her. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Pelvic ultrasound

B) Reassure and counsel on consistent OC pill use

C) Increase estrogen component of the pills

D) Switch to continuous combined OC pill regimen

E) Discontinue Oral Contraceptive pills

Question of the Week # 360

360)  A 30 year old woman presents to your office accompanied by her husband. She is concerned about her inability to conceive despite having regular intercourse for the past six months.  Her menstrual cycles have always been regular and she has not been using oral contraceptives for the past 10 months. She denies any cold or heat intolerance. She has no other complaints. She does not smoke or drink alcohol. On examination, she is age-appropriate. Pelvic examination is benign. A urine pregnancy test is negative. You counsel the couple and  advise them on continuing regular sexual intercourse. Which of the following is the most appropriate next step?

A) Semen analysis

B) Re-evaluate in 6 months

C) Obtain luteal-phase progesterone level

D) Serum FSH level

E) Hysterosalpingography

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