Question 1

A 34-year-old woman, gravida 2 para 1, at 30 weeks gestation comes to the emergency department due to a severe, unilateral headache.  The patient has a history of migraine headaches, and earlier today she developed a severe, throbbing headache on the right side of the head.  She drank a can of caffeinated soda and tried to rest in a dark room, but the headache has not improved.  The patient has had no nausea, vomiting, or changes in vision.  She has no other chronic medical conditions, takes no daily medications, and has no known drug allergies.  Temperature is 37.2 C (99 F), blood pressure is 126/82 mm Hg, and pulse is 92/min.  Fetal heart rate is 150/min.  Neurologic examination is normal.  The remainder of the physical examination is unremarkable.  Urine dipstick is negative for protein.  Which of the following is the most appropriate initial pharmacotherapy for this patient?

Accepted Answer

Explanation: 11ec25c8_d981_5027_bc81_55349b96ba91_MD0003_00 During pregnancy, headaches are common and typically benign. Headaches with atypical features (eg, altered mental status, neurologic deficits) or in patients ≥20 weeks gestation require evaluation to exclude other etiologies, such as preeclampsia or cerebral venous thrombosis, due to risk of adverse maternal (eg, stroke, disseminated intravascular coagulation) and fetal (eg, growth restriction, demise) outcomes. This patient has a throbbing, unilateral headache without changes in vision, consistent with a typical migraine without aura. Management of migraines in pregnancy is complicated due to limited therapeutic options. Acetaminophen is the preferred first-line option; patients also typically benefit from caffeine and limiting exposure to light and sound (eg, resting in a dark room). In patients who do not improve with acetaminophen alone, a low-potency opioid (eg, acetaminophen-codeine), antiemetics (eg, promethazine), or caffeine/butalbital may be beneficial. More potent opioids (eg, oxycodone) are typically not used due to their tendency to worsen gastrointestinal symptoms (eg, constipation, nausea) during pregnancy; however, they can be considered if all other options fail to improve symptoms (Choice E). Parenteral antiemetics (eg, metoclopramide) are used acutely and are effective monotherapy. (Choice B) Ergotamine is an effective migraine medication but is contraindicated in pregnancy due to risk of hypertonic uterine contractions and vasoconstriction, which can lead to adverse obstetric outcomes (eg, preterm labor, fetal growth restriction). Triptans (eg, sumatriptan) are also typically avoided in pregnancy due to risk of uteroplacental vasoconstriction, increased uterotonic activity, preterm delivery, and low birth weight. (Choice C) Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) can be used for headaches refractory to acetaminophen, but they are typically avoided in the first and third trimesters due to the risk of fetal complications (eg, spontaneous abortion, premature ductus arteriosus closure, oligohydramnios, renal dysfunction). (Choice D) Magnesium sulfate is used for seizure prophylaxis in patients with preeclampsia with severe features (eg, new-onset hypertension at ≥20 weeks gestation with headache or vision changes). This patient is normotensive and has no proteinuria, making this diagnosis unlikely. Magnesium sulfate for migraine treatment has more limited efficacy. Educational objective: Acetaminophen is the first-line treatment option for migraines during pregnancy. Second- and third-line options include addition of opioids (eg, acetaminophen-codeine), antiemetics, and nonsteroidal anti-inflammatory drugs (in the second trimester only). References: Headache and pregnancy: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/29052046) Acute migraine headache: treatment strategies. (http://www.ncbi.nlm.nih.gov/pubmed/29671521)

Question 2

A 31-year-old woman at 12 weeks gestation comes to the office for recurrent headaches.  The patient has a history of episodic migraines that typically resolve with nonsteroidal anti-inflammatory drugs; but since becoming pregnant, the headaches have become more severe and frequent.  Over the past month, the patient has had 5 migraine headaches with associated nausea and vomiting that required treatment in the emergency department.  In addition, she has had to go to a dark room and rest for a few hours before recovering.  The patient has no other chronic medical conditions and her only other medication is a daily prenatal vitamin.  Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, and pulse is 76/min.  Fetal heart rate is 160/min.  Cranial nerves are intact.  Deep tendon reflexes are 2+.  Strength and sensation are normal in all extremities.  Which of the following is the most appropriate preventive therapy for this patient?

Accepted Answer

11ec25c8_d97f_f095_bc81_d34a61354e87_MD0003_00 Migraine headaches are common in women of childbearing age (eg, 20-40) possibly due to cyclic increases and decreases in estrogen and progesterone. Migraines typically improve during pregnancy due to loss of these cyclic changes, but some women have worsening symptoms, likely due to an increase in other migraine risk factors (eg, sleep disturbance, physical exertion, emotional stress) that occur during pregnancy. This patient has frequent migraines (eg, ≥4 headaches per month) with significant impairment (eg, multiple emergency department visits) and would benefit from preventive therapy, which can decrease migraine frequency and severity. There are multiple preventive therapy options and the choice of medication should be based on patient comorbidities and medication risk profile, particularly during pregnancy due to potential fetal risks (eg, fetal anomalies, growth restriction). First-line prevention during pregnancy is with beta blockers such as propranolol or metoprolol, which have the best fetal safety profile. Calcium channel blockers (eg, verapamil) are also effective and safe in pregnancy. However, prolonged beta blocker use can potentially cause growth restriction (likely due to decreased placental perfusion from low blood pressure); therefore, patients should be initiated on the lowest effective dose and require frequent monitoring. (Choice A) Doxylamine, a first generation antihistamine, often in combination with pyridoxine, is used as a preventive antiemetic (eg, hyperemesis) in pregnancy. It is not used for migraine prophylaxis. (Choices B and E) Ergotamines and triptans (eg, sumatriptan) can be used to abort an acute migraine but are not typically used for migraine prevention. In addition, these medications are not used in pregnancy due to risks of fetal anomalies (ergotamine), growth restriction (triptans), and preterm labor (both). (Choice D) Sertraline is safe for use in pregnancy to treat depression and anxiety. Unlike tricyclic antidepressants and venlafaxine, which are used for migraine prevention in nonpregnant patients, sertraline does not prevent migraines. (Choice F) Topiramate is effective for migraine prevention but avoided in pregnancy due to risk of fetal abnormalities (eg, cleft palate, low birth weight). Educational objective: Preventive migraine therapy may benefit patients with severe migraine headaches (eg, ≥4 times per month, significant impairment). During pregnancy, first-line prevention is with beta blockers (eg, propranolol, metoprolol). References: Preventive treatment in migraine and the new US guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23717045) Current prophylactic medications for migraine and their potential mechanisms of action. (http://www.ncbi.nlm.nih.gov/pubmed/29671241)

Question 3

A 29-year-old woman, gravida 1 para 1, is evaluated in the emergency department for a headache.  Three days ago, she had an uncomplicated vaginal delivery with neuraxial anesthesia.  This morning, the patient developed an occipital headache that has not improved with acetaminophen.  The headache has become progressively worse, and the patient cannot sit without becoming nauseated and vomiting.  The patient has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 162/96 mm Hg, pulse is 98/min, and respirations are 18/min.  On examination, heart sounds are normal with no rubs or murmurs, and the lungs are clear to auscultation.  Cranial nerves are intact and deep tendon reflexes are 3+.  There is 5/5 strength in the right lower extremity and 3/5 strength in the left.  Which of the following is the best next step in management of this patient?

Accepted Answer

11ec25c8_d986_0b20_bc81_efc9877e5030_MD0003_00 This postpartum patient with worsening headache and severe hypertension (eg, systolic ≥160 or diastolic ≥110 mm Hg) has preeclampsia with severe features, which can present up to 6 weeks after delivery. The most common presenting symptom is a severe headache in the bilateral occipital or frontal regions that does not improve with acetaminophen or nonsteroidal anti-inflammatory drugs. Patients with preeclampsia are at increased risk of hemorrhagic and ischemic stroke due to acute elevations in cerebral perfusion pressure and vessel rupture (hemorrhagic), as well as preeclampsia-mediated vascular endothelial damage and microthrombi formation (ischemic). To decrease this risk, preeclamptic patients with severe-range blood pressures require aggressive antihypertensive therapy (eg, labetalol, nifedipine) and magnesium sulfate, which helps prevent eclamptic seizures that can worsen stroke symptoms. Most preeclamptic patients do not require imaging; however, in those with focal neurologic deficits, such as this patient with asymmetric motor deficits (strength right > left), CT scan of the head should be performed to evaluate for possible stroke and help guide management. (Choices A and E) Oxygen administration is used to alleviate cluster headaches, which typically present with a short-lived, unilateral, orbital headache with autonomic symptoms (eg, ptosis, lacrimation). Triptans (eg, sumatriptan) are used to treat migraines, which can present as occipital headaches with nausea, vomiting, and occasionally motor aura (eg, hemiplegic migraine). However, CT scan should be performed in this patient prior to attempting symptomatic therapy in order to exclude life-threatening causes of neurologic deficit. (Choice C) An epidural blood patch is used to treat postdural puncture headaches, which can occur after neuraxial anesthesia and may present as an occipital headache that worsens with sitting or standing due to cerebrospinal fluid (CSF) leakage. However, this type of headache is not associated with hypertension or focal neurologic deficits. (Choice D) Lumbar puncture can evaluate for CSF infection (eg, meningitis, encephalitis), which may present with headache after neuraxial anesthesia. This patient is afebrile, making this diagnosis less likely. In addition, lumbar puncture is usually performed after CT scan to exclude a brain mass because there is a risk of herniation with mass effect. Educational objective: Preeclampsia can present up to 6 weeks postpartum with headache and hypertension. Patients with preeclampsia are at increased risk of stroke, and those with focal neurologic deficits should be evaluated with CT scan of the head. References: Preeclampsia: association with posterior reversible encephalopathy syndrome and stroke. (http://www.ncbi.nlm.nih.gov/pubmed/29438078) Cerebrovascular complications in pregnancy and puerperium. (http://www.ncbi.nlm.nih.gov/pubmed/24431615)

Question 4

A 39-year-old woman comes to the office due to worsening urinary symptoms for the past several weeks.  The patient has increasingly had sudden, intermittent urges to urinate followed by small-volume urine.  On several occasions, she has had difficulty reaching the bathroom in time and has involuntarily leaked a small amount of urine.  The patient reports no fever, dysuria, hematuria, abdominal pain, or abnormal vaginal discharge.  She was diagnosed with multiple sclerosis 3 years ago after an episode of gait unsteadiness.  Since then, she has had several acute exacerbations, most recently 2 months ago, which were treated with glucocorticoids.  Her other medical conditions include hypertension and glucocorticoid-induced hyperglycemia.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Physical examination shows hyperreflexia of the lower extremities and mild intention tremor.  The remainder of the examination shows no abnormalities.  Urine dipstick is negative for leukocyte esterase and nitrite but positive for glucose.  Postvoid bladder scan reveals a contracted, small bladder.  Which of the following is the most likely cause of this patient's urinary symptoms?

Accepted Answer

11ec25c8_d982_afba_bc81_5fd89ad1a398_MD0003_00 This patient with multiple sclerosis (MS) has developed urgency incontinence (also known as overactive bladder), which is the sudden-onset urge to void followed by an involuntary leakage of urine. Sclerotic plaques of MS in the cerebral cortex can impair the upper motor neurons that exert inhibitory control of spinal neurons (eg, descending corticospinal tracts). This results in lower motor neuron overactivity, leading to spasticity, which can manifest as gait disturbances and hyperreflexia, as seen in this patient. Similarly, cerebral cortex MS plaques can impair upper motor neurons that inhibit the micturition reflex. This can lead to increased involuntary (ie, spastic) contractions and overactivity of the detrusor muscle, resulting in a small, contracted bladder (as seen in this patient's bladder scan). These bladder spasms do not allow adequate time between the sensation to void and the loss of urine, which can be worsened in patients with gait abnormalities that limit their ability to quickly reach a bathroom. Treatment options of urgency incontinence include antimuscarinics (eg, oxybutynin) and β-3 receptor agonists (eg, mirabegron). (Choices A and C) Demyelination of the sacral spinal cord (ie, cauda equina) can lead to impairment of the lower motor neuron input to the bladder, resulting in detrusor underactivity. Either detrusor underactivity or obstruction of the bladder outlet can lead to urinary retention and overflow incontinence. However, these patients would have a distended bladder and a large (>150 mL) postvoid residual urine volume. (Choice B) Hyperglycemia can lead to polyuria due to glucosuria-induced osmotic diuresis, which can cause overflow incontinence. However, in contrast to this patient, patients with overflow incontinence typically have a constant dribbling of urine and a distended bladder with large postvoid residuals. (Choice E) Weakness of pelvic floor muscles can lead to urethral hypermobility, which causes stress urinary incontinence, characterized by urine leakage with increased intraabdominal pressure (eg, Valsalva, cough, sneeze). This patient's sudden urge to urinate and inability to reach the bathroom are more consistent with urge incontinence. Educational objective: Patients with multiple sclerosis can develop urgency incontinence due to loss of cortical (ie, upper motor neuron) inhibition of detrusor contraction.

Question 5

A 36-year-old primigravid woman at 34 weeks gestation arrives at the emergency department after being found unresponsive on the floor by her husband.  She was found unconscious about 30 minutes ago and became gradually responsive over a few minutes.  The husband reports the patient has had increasing nausea and vomiting over the past few hours and a severe frontal headache.  Currently she has no symptoms other than the headache.  Medical history is significant for migraines, and the patient takes no daily medications.  Temperature is 36.7 C (98.1 F), blood pressure is 138/98 mm Hg, pulse is 78/min, and respirations are 20/min.  Cranial nerves are intact, and the neck is supple.  Funduscopic examination is normal.  The lungs are clear to auscultation bilaterally.  Cardiac examination demonstrates normal heart sounds.  The abdomen is nontender, and the uterine fundus measures 34 weeks gestation.  There is minimal pretibial edema, and deep tendon reflexes are 3+.  Motor examination is normal.  Laboratory results are as follows:  Urine drug screen is negative.  CT scan of the head reveals bilateral frontal lobe edema but no mass lesions or bleeding.  Which of the following is the best next step in management of this patient?

Accepted Answer

11ec25c8_d981_ec69_bc81_1f84c4b60bcb_MD0003_00 This pregnant patient was found unconscious and gradually became more responsive, suggestive of a postictal state. Given her hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg in pregnancy) and headache, consistent with preeclampsia with severe features, this presentation is most consistent with eclamptic seizure. Patients with preeclampsia are at risk for developing generalized tonic-clonic seizures (eclampsia) due to preeclampsia-induced cerebrovascular dysfunction (eg, vasospasm with subsequent brain ischemia). Although eclampsia classically presents with seizure activity, many patients are found in the postictal state because eclamptic seizures are usually brief (<1 minute), as in this patient. The postictal confusion and unresponsiveness typically resolve in 10-20 minutes, but patients continue to have signs of preeclampsia with severe features, such as severe headache, nausea, vomiting, hyperreflexia, and elevated creatinine levels. Eclampsia is usually a clinical diagnosis. However, CT scan of the head is performed in patients with atypical or prolonged symptoms and usually reveals bilateral frontal or occipital lobe edema, as seen in this patient. Because eclamptic seizures can cause brain injury and increased risk for stroke, eclampsia requires emergency treatment with magnesium sulfate infusion to prevent seizure recurrence. Fetal delivery is required for definitive cure. (Choice A) CT venography can diagnose cerebral venous thrombosis (CVT), which may present with severe headache and seizure. However, CVT typically causes papilledema and focal neurologic deficits, which are not seen in this patient. (Choice B) Lumbar puncture can diagnose CNS infection, idiopathic intracranial hypertension, or subarachnoid hemorrhage (particularly when CT scan of the head appears benign). However, these diagnoses are unlikely in this patient with no fever, nuchal rigidity, or signs of elevated intracranial pressure (eg, no papilledema on funduscopic examination). (Choice D) Triptan abortive therapy can treat migraines but is not used during pregnancy due to risks of fetal growth restriction and preterm labor. In addition, migraines typically cause unilateral (not bilateral) throbbing pain; however, loss of consciousness, hyperreflexia, and frontal lobe edema are not usually present. (Choice E) Video EEG may be used to diagnose patients with suspected psychogenic nonepileptic seizures; however, this management is inappropriate and potentially life-threatening in this patient with an emergent, medical cause of seizure. Educational objective: Eclampsia, generalized tonic-clonic seizures, can develop in patients with preeclampsia with severe features (eg, hypertension with elevated creatinine). Patients may present in a postictal state with persistent headache and hyperreflexia. Treatment is with magnesium sulfate infusion. References: Magnesium sulfate treatment for the prevention of eclampsia: a brief review. (http://www.ncbi.nlm.nih.gov/pubmed/19211496)

Question 6

A 58-year-old woman, gravida 2 para 2, comes to the office for evaluation of increased urinary frequency and painful urination. The patient developed these symptoms 2 days ago, and they did not improve despite increasing fluid intake and voiding regularly. She has had 2 other episodes of acute simple cystitis in the past 8 months, which resolved with antibiotics. The patient underwent menopause at age 53 and has had no episodes of postmenopausal bleeding. BMI is 28 kg/m². Vital signs are normal. Physical examination shows mild suprapubic tenderness and no costovertebral tenderness. Pelvic examination shows thin vulvar tissue but no excoriations or lesions. Urinalysis is positive for leukocyte esterase and nitrites. The patient is prescribed a course of antibiotics and is asymptomatic a week later. Which of the following is the best next step in management of this patient's symptoms?

Accepted Answer

Explanation: 11ec25c8_d97e_42e2_bc81_7b6308b24785_MD0003_00 This patient has recurrent urinary tract infections (UTI), defined as ≥3 episodes in a year (or ≥2 episodes in 6 months) of simple cystitis (eg, leukocyte esterase and nitrites on urinalysis with no costovertebral tenderness). Women are at increased risk for cystitis due to the proximity of the urethra to the vagina and rectum. In postmenopausal women, the risk increases further due to estrogen deficiency, which causes: vulvovaginal atrophy (eg, thin vulvar tissue). decreased bulk and elasticity of the bladder trigone and urethra, resulting in an increased risk for ascending infection. decreased vaginal lactobacilli levels and an elevated vaginal pH, leading to an increased rate of vaginal Escherichia coli colonization. Therefore, in addition to behavioral changes (eg, increased fluid intake), treatment of postmenopausal women with recurrent UTI is with topical vaginal estrogen. Topical estrogen can improve genitourinary atrophy and prevent future UTI episodes. In addition to vaginal estrogen, antibiotic prophylaxis (daily or postcoital) can be considered. (Choices A and E) Cystoscopy and urine cytology can evaluate for bladder cancer, which may present with recurrent UTIs; however, bladder cancer is typically associated with gross hematuria or red blood cells on urinalysis, which are not seen in this patient. In addition, she has no significant risk factors (eg, tobacco use, prior pelvic radiation). (Choice B) Daily probiotic consumption has not been shown to increase vaginal Lactobacillus colonization or decrease the risk of recurrent cystitis. (Choice C) Pelvic ultrasonography may be indicated in patients with abnormal uterine bleeding (eg, postmenopausal bleeding) or a pelvic mass; it is not used to evaluate recurrent cystitis. (Choice D) Topical corticosteroids can treat vulvar lichen planus and lichen sclerosus, which may present in postmenopausal patients with dyspareunia and atrophic vulvar tissue. However, patients typically have visible lesions (ie, plaques) or excoriations due to vulvar pruritus, which are not seen in this patient. lichen planus Educational objective: Recurrent urinary tract infections (≥3 episodes in a year or ≥2 episodes in 6 months) commonly occur in postmenopausal patients due to estrogen deficiency, which causes vulvovaginal atrophy, decreased bulk and elasticity of the bladder trigone and urethra, and increased vaginal pH. Treatment is with vaginal estrogen. References: Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/27472999)

Question 7

A 28-year-old woman, gravida 3 para 2, at 30 weeks gestation is brought to the emergency department due to vaginal bleeding after a motor vehicle collision.  The patient was restrained by a lap and shoulder belt, but the steering wheel struck her abdomen.  Her underwear and pants are soaked with blood, and she states that she is "not sure if my water broke."  Blood pressure is 90/60 mm Hg, pulse is 136/min, respirations are 22/min, and pulse oximetry is 98% on room air.  Physical examination shows an alert but anxious-appearing woman with abdominal tenderness and cool extremities.  On speculum examination, 100 mL of blood is evacuated from the vagina, and minimal active bleeding from the cervix is observed.  Blood type is O, Rh positive.  Fetal heart monitoring shows a baseline of 140/min with minimal to moderate variability; there are no late or variable decelerations.  Tocometry reveals uterine contractions every 3 minutes.  Intravenous fluids are started.  Which of the following is the best next step in management of this patient?

Accepted Answer

11ec25c8_d985_6edf_bc81_09b0fd17b1bb_MD0003_00 This pregnant patient with abdominal pain, contractions, and vaginal bleeding following blunt abdominal trauma (eg, motor vehicle collision) likely has abruptio placentae (ie, placental abruption). Due to the volume of blood supplied to the uterus, abruptio placentae can cause hypovolemic shock from hemorrhage (ie, hemorrhagic shock), as seen in this patient with hypotension, tachycardia, and cool extremities. Management of the trauma patient with hemorrhagic shock requires rapid resuscitation with replacement of intravascular volume, transitioning from crystalloid to blood products as soon as possible. In addition, pregnant patients are placed in a left lateral decubitus position (if the spine is stable) to displace the uterus off the aortocaval vessels and maximize cardiac output. If hemorrhage or hemodynamic instability continues despite initial resuscitation efforts, massive transfusion protocol (MTP) should be activated. MTP is the administration of packed red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio to avoid coagulopathy from dilution of platelets and clotting factors. (Choice A) Emergency cesarean delivery after maternal trauma may be indicated for imminent fetal compromise (ie, category 3 tracing). This patient has a category 2 tracing (due to minimal variability) but otherwise the fetal heart rate is normal with no variable or late decelerations; therefore, she does not require emergency delivery. (Choice B) A fetal biophysical profile evaluates for fetal acidosis and may be indicated for fetal heart rate tracings without accelerations. However, maternal stabilization is the priority over further fetal evaluation in this patient. (Choice C) Kleihauer-Betke testing measures the amount of fetal blood mixed into maternal circulation following trauma, which helps guide anti-D immunoglobulin dosing in Rh-negative patients (ie, to prevent Rh-alloimmunization). Rh-positive patients (such as this one) are not at risk for Rh-alloimmunization, and testing does not change management. Kleihauer-Betke testing Rh-alloimmunization (Choice E) Vasopressor therapy (eg, norepinephrine) is contraindicated in the setting of isolated hemorrhagic shock because peripheral vascular tone is already increased to compensate for decreased blood volume. In addition, vasopressor use can decrease uterine blood flow and therefore impair fetal oxygenation. Educational objective: Blunt abdominal trauma (eg, motor vehicle collision) in pregnancy can cause severe maternal bleeding and hemorrhagic shock (eg, abruptio placentae). Trauma patients with hemorrhagic shock require replacement of intravascular volume, transitioning from crystalloid to blood product resuscitation as soon as possible. References: Trauma in pregnancy: assessment, management, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/25403036) Optimal fluid therapy for traumatic hemorrhagic shock. (http://www.ncbi.nlm.nih.gov/pubmed/27894494)

Question 8

A 67-year-old woman, gravida 1 para 1, comes to the office for a routine health examination. The patient feels well. Her last menstrual period was at age 53 with no bleeding since. Pap test and human papillomavirus (HPV) cotesting were negative 2 years ago at age 65. All prior Pap tests were normal. The patient is sexually active in a monogamous relationship with her husband of 42 years. She has no medical conditions. The patient had an ovarian cystectomy via laparotomy at age 37 for a benign cystic teratoma. She takes no medications and does not use tobacco, alcohol, or illicit drugs. There is no family history of cancer. BMI is 25 kg/m². Pelvic examination shows a normal cervix without lesions; a smooth, anteverted, mobile uterus; and no adnexal masses. Screening mammography was normal 6 months ago, and screening colonoscopy was normal 2 years ago. Which of the following is the most appropriate recommendation for cervical cancer screening in this patient?

Accepted Answer

11ec25c8_d988_ca45_bc81_4dfa1e40a376_MD0003_00 The progression from persistent human papillomavirus (HPV) infection to invasive cervical carcinoma takes many years. Screening for cervical cancer with Pap tests is performed to detect lesions (eg, low-grade squamous intraepithelial lesions) in earlier, more treatable stages. Risk factors for cervical cancer include tobacco use, oral contraceptive use, early onset of sexual activity, sexually transmitted infections, and high-risk sexual activity, all of which are associated with persistent HPV infection. Normal Pap tests exclude persistent HPV infection, and patients with adequate screening by age 65 are at low risk of developing cervical cancer. In such patients, Pap tests may be stopped. If a patient has a history of cervical intraepithelial neoplasia 2 or higher on histology, screening continues for another 20 years after detection (past age 65 if indicated). Terminating Pap tests at age 65 may not be appropriate for women with cervical cancer risk factors (eg, immunosuppression, high-risk sexual activity, tobacco use, diethylstilbestrol exposure). (Choices A, C, D, and E) Pap tests without HPV cotesting are repeated every 3 years beginning at age 21. At age 30, either Pap tests with HPV cotesting or primary HPV testing alone may be done and repeated every 5 years if negative. Regardless of screening interval, Pap testing ends at age 65; therefore, this patient requires no screening. Educational objective: Pap testing may be discontinued in patients age 65 who have had adequate Pap testing without prior high-grade cervical lesions or cervical cancer risk factors (eg, tobacco use, immunocompromised status). References: Cancer screening in the older patient. (http://www.ncbi.nlm.nih.gov/pubmed/19119555) Cervical cancer screening in average-risk women: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. (http://www.ncbi.nlm.nih.gov/pubmed/25928075)

Question 9

A 17-year-old primigravida at 29 weeks gestation comes to the clinic due to headaches. For the last 2 weeks, she has had an intermittent throbbing pain in the left frontal region when she wakes up. The pain is sometimes accompanied by a rhythmic pulsating sound. Acetaminophen provides minimal improvement. The patient has had no fever, right upper quadrant pain, contractions, or vaginal bleeding. She recalls no trauma and has no chronic medical conditions. Prepregnancy BMI is 31 kg/m², and the patient has gained 20 kg (44 lb) so far. Temperature is 37.1 C (98.8 F), blood pressure is 136/76 mm Hg, pulse is 80/min, and respirations are 18/min. Fetal heart rate is 160/min. There is no neck stiffness. Visual field testing is normal. Funduscopic examination shows bilateral optic disc edema. Bilateral deep tendon reflexes are 2+. The remainder of the neurologic examination is unremarkable. Urinalysis has trace protein. Which of the following is the best next step in evaluation of this patient?

Accepted Answer

11ec25c8_d97e_df23_bc81_4d6ff2189930_MD0003_00 This patient has headaches and optic disc edema most likely due to idiopathic intracranial hypertension (IIH), a disorder in which increased intracranial pressure (ICP) occurs without a secondary cause. IIH is most common in obese (BMI ≥30 kg/m²) women of childbearing age, and although pregnancy by itself is not a risk factor, excessive weight gain (as in this patient) can exacerbate the disorder. ² Patients typically have positional headaches that are worse when lying flat, which increases ICP, and improve with sitting, which decreases ICP. Pulsatile tinnitus (due to increased vascular pulsations) and blurry vision (due to increased pressure on the optic nerves) also commonly occur. On physical examination, increased ICP can manifest as optic disc edema (ie, papilledema), abducens nerve (CN VI) palsy (lateral rectus palsy), and/or visual field deficits. Diagnosis is with neuroimaging followed by lumbar puncture, which reveals an elevated opening pressure (>250 mm H₂O). MRI of the brain, often with MR venography to rule out cerebral vein thrombosis, is the preferred imaging modality and avoids fetal radiation exposure. MRI is performed before lumbar puncture to exclude other causes of elevated ICP (eg, space-occupying mass) that would increase the risk of cerebral herniation (Choice B). (Choice A) A 24-hour urine collection can be used to diagnose preeclampsia (systolic blood pressure ≥140 or diastolic ≥90 mm Hg), which can cause headache and blurry vision in pregnant women. However, this patient's blood pressure is <140/90 mm Hg, and her trace urine protein is a normal pregnancy finding. (Choice D) Polysomnography can be used to diagnose obstructive sleep apnea (OSA), which is more common during pregnancy and in patients with obesity or rapid weight gain. OSA may be associated with morning headaches but not tinnitus or papilledema, making this diagnosis unlikely. (Choice E) Tonometry is used to evaluate for increased intraocular pressure, which can cause severe eye pain and headache if pressure changes acutely (eg, angle-closure glaucoma). In contrast, eye findings associated with IIH (eg, papilledema) are due to increased intracranial, not intraocular, pressure; therefore, tonometry is not used for evaluation. Educational objective: Idiopathic intracranial hypertension is most common in obese women of childbearing age and can present with positional headaches, pulsatile tinnitus, and papilledema. Diagnosis is with MRI of the brain followed by lumbar puncture. References: Idiopathic intracranial hypertension (pseudotumor cerebri): recognition, treatment, and ongoing management. (http://www.ncbi.nlm.nih.gov/pubmed/23136035) Idiopathic intracranial hypertension and pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/23563883)

Question 10

A 20-year-old woman, gravida 1 para 0, at 36 weeks gestation is brought to the emergency department by her mother due to a seizure.  The patient was sitting outside when she suddenly had a 2-minute seizure with loss of urinary continence.  She is still confused when she arrives in the emergency department.  Her mother reports that the patient has had increasing anxiety and has been acting out for the past several days.  Her only surgery was a splenectomy after a motor vehicle collision last year.  Temperature is 37.7 C (99.9 F), blood pressure is 158/98 mm Hg, and pulse is 120/min.  The patient is agitated and diaphoretic.  The pupils are dilated bilaterally.  The cranial nerves are intact.  The neck is supple and nontender.  Cardiopulmonary examination is normal.  The abdomen is gravid without rebound or guarding, and the uterus is nontender.  There is 2+ pitting pedal edema bilaterally.  Sensation and strength are normal in the bilateral upper and lower extremities.  Laboratory results are as follows:  CT scan of the head is normal.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

This patient at 36 weeks gestation likely had a generalized tonic-clonic seizure. New-onset seizures in pregnancy can be due to either pregnancy-specific (eg, eclampsia) or nonobstetric (eg, meningitis, intracranial bleeding) conditions. The most common cause of seizures in pregnant and postpartum women is eclampsia, which is classically associated with preeclampsia (ie, new-onset hypertension at ≥20 weeks gestation with proteinuria and/or signs of end-organ damage). Although this patient has hypertension, her additional findings of agitation, dilated pupils, hyponatremia, normal head CT scan (vs white matter edema seen in eclampsia), and absence of proteinuria suggest another etiology (Choice B). This patient's seizure is likely due to amphetamine intoxication. Amphetamines cause overstimulation of alpha-adrenergic receptors, causing tachycardia, hypertension, and occasionally hyperthermia. Patients may also have diaphoresis and minimally reactive, dilated pupils. Severe intoxication can cause electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity. Amphetamine intoxication is confirmed with urine drug testing. Distinguishing between eclampsia and other causes of seizure is essential because it may determine whether or not there is a need for emergency delivery. (Choice C) Heat stroke can cause altered mental status and electrolyte abnormalities. However, patients have an elevated temperature (>40 C [104 F]) often associated with hemodynamic instability (eg, hypotension). (Choice D) Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy that can cause seizures (ie, eclampsia). In contrast, this patient's hematocrit level is normal (ie, no hemolysis), and patients with HELLP syndrome typically have platelet counts <100,000/mm³. (Choice E) Pneumococcal meningitis can cause seizures and altered mental status in patients with prior splenectomy. However, patients typically have high fever and nuchal rigidity, making this diagnosis less likely. Educational objective: Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure (due to hyponatremia). References: Stimulant use in pregnancy: an under-recognized epidemic among pregnant women. (http://www.ncbi.nlm.nih.gov/pubmed/30601144)

Question 11

A 70-year-old woman comes to the office for worsening constipation. The patient has chronic constipation for which she takes over-the-counter fiber supplements and stool softeners; however, for the past 3 months, the patient has had to push 2 fingers into her vagina to defecate. She has had increased bloating but no nausea, diarrhea, or abdominal pain. The patient has 1 son. Medical history includes hypothyroidism and type 2 diabetes mellitus for which she takes levothyroxine and metformin. A colonoscopy last year was normal. BMI is 32 kg/m². Vital signs are normal. The abdomen is soft and nontender with normoactive bowel sounds. On rectal examination, the resting sphincter tone is normal and there are no palpable masses. With Valsalva maneuver, the posterior vaginal wall extends outside the hymenal ring. There is no fecal incontinence with Valsalva maneuver. Anocutaneous reflex is intact bilaterally. TSH is 3.9 mU/L and serum hemoglobin A1c is 7.5%. Fecal occult blood testing is negative. Which of the following is the most likely underlying cause of this patient's presentation?

Accepted Answer

11ec25c8_d97d_a6a1_bc81_bdb5c4576f86_MD0003_00 This patient's chronic constipation is caused by pelvic organ prolapse, the herniation of pelvic organs (eg, bladder, rectum) into the vaginal wall due to levator ani muscle complex damage. The levator ani muscle complex forms most of the pelvic floor and functions to hold the pelvic organs in a stable position. When this complex is damaged, such as with increased intraabdominal pressure (eg, pregnancy, obesity) or obstetric trauma (eg, forceps-assisted vaginal delivery), there is increased pelvic floor laxity, resulting in decreased pelvic organ support. The decreased pelvic floor support causes an anatomic change to normal pelvic organ positions; for the rectum, this leads to a change in rectal angle during defecation, which can cause incomplete defecation and constipation. With accumulation of fecal material, the rectum expands and herniates through the rectovaginal septum, causing prolapse of the rectum into the posterior vaginal wall (ie, rectocele). The prolapse is exacerbated by Valsalva maneuvers (eg, vaginal bulge extending past the hymen while straining), which cause further difficulty with defecation. Therefore, some patients apply digital pressure against the prolapse (ie, splinting) to help improve bowel movements. Treatment is with pelvic floor muscle exercises, vaginal pessary placement, or possible surgical correction. (Choice A) Diabetic autonomic neuropathy can occasionally cause constipation but is more commonly associated with gastroparesis and chronic diarrhea (usually due to decreased rectal sphincter tone). This patient has a normal rectal sphincter tone, making this diagnosis unlikely. (Choice B) External anal sphincter dysfunction can occur with prior perineal laceration, a common complication of vaginal delivery. In contrast to this patient, those with external anal sphincter dysfunction typically have decreased sphincter tone and anal incontinence (ie, involuntary loss of flatus or fecal material). perineal laceration (Choice D) Fiber supplementation is used to help treat constipation, and overuse can cause abdominal bloating and flatulence but typically not worsening constipation. (Choice E) Hypothyroidism can cause chronic constipation; however, this patient's TSH level is normal, making subtherapeutic levothyroxine dosing an unlikely cause of this patient's symptoms. Educational objective: Pelvic organ prolapse, the herniation of pelvic organs (eg, rectum) into the vagina, occurs due to damage to the levator ani muscle complex. Patients with prolapse of the posterior vaginal wall (ie, rectocele) classically have chronic constipation and a vaginal bulge. References: Functional disorders: rectocele. (http://www.ncbi.nlm.nih.gov/pubmed/28144214)

Question 12

A 31-year-old woman, gravida 1 para 0, at 32 weeks gestation comes to the office for a routine prenatal visit. The patient reports normal fetal movements and has had no abdominal pain or vaginal bleeding. Over the past 2 weeks, she has had intermittent uncomfortable sensations in her legs, especially at bedtime and when she sits for prolonged durations like watching a movie. The patient reports no leg pain or pins and needles sensation, and the symptoms improve once she gets up and moves around. Her husband states that she frequently gets in and out of bed. Medical history is significant for depression and anxiety during adolescence after her parents' divorce. Vital signs are within normal limits. Prepregnancy BMI was 30 kg/m², and she has gained 6.8 kg (15 lb) during this pregnancy. Physical examination shows trace lower extremity edema, but no other abnormalities are present. Which of the following is the most likely cause of this patient's current symptoms?

Accepted Answer

11ec25c8_d980_b3e6_bc81_65ded2e87364_MD0003_00 This pregnant patient with an uncomfortable feeling in her legs temporarily alleviated by movement most likely has restless legs syndrome (RLS), a neurologic condition common in pregnancy that can interfere with duration and quality of sleep. RLS is characterized by dysesthesia (eg, crawling and itching feelings) and an irresistible urge to move the legs when at rest. Symptoms occur primarily in the evenings and at night; they are partially relieved by movement and recur when movement ceases. Symptoms of RLS that appear during pregnancy typically worsen throughout gestation and improve or resolve after delivery. However, women who have RLS symptoms during pregnancy are at increased risk of developing primary (idiopathic) RLS in the future. As in other patients with RLS, serum iron studies should be obtained. Patients with iron deficiency, or even low-normal ferritin levels (≤75 µg/L), should take supplemental iron, which often improves symptoms. Improvement in sleep hygiene and gentle exercise should also be recommended as well as reassurance of the likely temporary nature of symptoms. Other agents typically used in RLS (eg, dopamine agonists, alpha-2-delta calcium channel ligand) should be avoided in pregnancy. (Choice A) Compressive neuropathy (eg, meralgia paresthetica, sciatica) is also common in pregnancy. Although compressive neuropathy can present with abnormal sensations, neuropathic pain is typically described as burning or shock-like rather than the vague discomfort seen in RLS. Unlike RLS, compressive neuropathy is typically associated with numbness and may be accompanied by motor weakness. In addition, pain due to compressive neuropathy would not immediately be relieved with movement. (Choice B) Positional leg discomfort is very common in pregnancy. It is relieved with position change but does not require continuous movement to maintain the relief. It is also not associated with specific times (eg, evenings, bedtime). (Choice C) Leg cramps are also common in pregnancy and can interfere with sleep. However, they present with sudden, painful tightness of the calf muscles with obvious hardening of the muscle. In addition, relief typically requires stretching of the specific muscle affected rather than continuous movement. (Choice D) Patients with RLS often have comorbid psychiatric disorders that can interfere with sleep. However, anxiety disorders do not cause leg discomfort relieved by walking. Educational objective: Restless legs syndrome can occur during pregnancy and is characterized by an urge to move the legs accompanied by dysesthesia that is worsened by inactivity and improved with movement. Symptoms are worse in the evening or at night and may impair sleep.

Question 13

A 42-year-old woman comes to the emergency department for severe lower abdominal pain.  The pain started several hours ago and has progressively worsened.  She has associated nausea and vomiting but no fever, diarrhea, or abnormal vaginal discharge.  The patient was diagnosed with adenomyosis last month due to increasingly heavy menses and dysmenorrhea and is currently taking tranexamic acid as needed.  Her menses started yesterday, but she reports that the pain is more severe than usual and radiates to the left lower quadrant.  Temperature is 37.8 C (100 F), blood pressure is 110/74 mm Hg, and pulse is 110/min.  The abdomen is soft with normoactive bowel sounds, and there is voluntary guarding in the left lower quadrant.  On pelvic examination, the uterus is globular and boggy, and there is dark red blood with small clots in the vagina.  The left adnexa is tender on bimanual examination, and there are no palpable adnexal masses.  Urine pregnancy testing is negative.  Hemoglobin is 11 g/dL.  Which of the following is the best next step in management of this patient?

Accepted Answer

11ec25c8_d983_4bfb_bc81_7f1b71f736f0_MD0003_00 This patient has adenomyosis, a common cause of pelvic pain in women age >40 that typically presents with heavy menstrual bleeding and a tender, globular uterus (as seen in this patient). However, adenomyosis typically causes chronic, dull, midline pelvic pain; therefore, this patient's sudden change in pain severity and acute onset of symptoms are concerning for another acute gynecologic condition. adenomyosis This patient's sudden-onset unilateral pelvic pain accompanied by nausea/vomiting is most likely due to ovarian torsion, which represents partial or complete rotation of the ovary around the infundibulopelvic (IP) ligament. The IP ligament contains the ovarian vessels; rotation acutely interrupts ovarian blood flow, causing acute-onset pain. As ovarian ischemia progresses, patients may develop radiating pain, ovarian edema (eg, adnexal tenderness or fullness, with or without a palpable mass), and peritonitis (eg, rebound/guarding, fever). Ovarian torsion is a gynecologic emergency that is clinically diagnosed in patients with classic symptoms. Although a Doppler ultrasound revealing decreased or absent ovarian blood flow can support the diagnosis, normal findings do not exclude torsion. Because of the risk of tissue necrosis and loss of ovarian function (eg, infertility, menopause), ovarian torsion requires urgent diagnostic laparoscopy to manually untwist the adnexa and restore blood flow. (Choices A and F) Tranexamic acid (an antifibrinolytic agent) and oral contraceptives can be used to decrease heavy menstrual bleeding due to adenomyosis. This patient's new pain symptoms are inconsistent with adenomyosis and require additional evaluation. In addition, discontinuation of tranexamic acid may increase this patient's menstrual bleeding. (Choice B) Conservative management (eg, observation with serial abdominal examinations) is appropriate for patients with self-limiting, nonurgent causes of pelvic pain (eg, ruptured simple ovarian cyst). This patient has severe pain and guarding consistent with an acute abdomen and requires immediate surgery. (Choices D and E) Endometrial ablation (ie, cauterization of the uterine lining) and uterine artery embolization can be used to treat heavy vaginal bleeding. This patient's bleeding is normal (dark red blood with small clots), and her hemoglobin is appropriate; therefore, these procedures are not indicated at this time. Educational objective: Ovarian torsion, or rotation of the ovary around the infundibulopelvic ligament, classically presents with nausea/vomiting; new-onset, severe unilateral pelvic pain; and adnexal tenderness. Ovarian torsion is a gynecologic emergency and requires diagnostic laparoscopy. References: Adnexal torsion. (http://www.ncbi.nlm.nih.gov/pubmed/29941434) Accuracy of pelvic ultrasound in diagnosing adnexal torsion. (http://www.ncbi.nlm.nih.gov/pubmed/31354994)

Question 14

A 29-year-old woman comes to the emergency department due to vaginal spotting and discharge.  She had a positive pregnancy test last week after missing her last menstrual period and estimates that she is at 5 weeks gestation.  The patient has had increased vaginal discharge for the past 2 days but no pelvic pain or cramping.  Today, she started having vaginal spotting, which prompted her to come to the emergency department.  The patient had a spontaneous abortion 3 years ago that was treated with medication, but she has no chronic medical conditions.  Temperature is 37.6 C (99.7 F), blood pressure is 100/60 mm Hg, and pulse is 90/min.  The abdomen is soft, nontender, and without rebound or guarding.  The cervix appears closed and without lesions, and there is bloody, yellow mucus at the external cervical os.  The remainder of the physical examination is normal.  Quantitative β-hCG level is 5,200 IU/L and blood type is O, Rh positive.  Ultrasound shows an intrauterine fetal pole with a positive fetal heartbeat.  Which of the following is the best next step in management of this patient?

Accepted Answer

11ec25c8_d984_ab8e_bc81_c536de3c432c_MD0003_00 This patient at 5 weeks gestation has first-trimester bleeding. A common cause is spontaneous abortion (particularly in patients with a prior spontaneous abortion), but there are many other etiologies of first-trimester bleeding that range from benign (eg, cervical polyp) to life threatening (eg, ectopic pregnancy, septic abortion). Therefore, initial evaluation is with speculum examination to determine the source of bleeding and with pelvic ultrasound to determine pregnancy location. This patient's nontender abdomen, closed cervix, and viable intrauterine pregnancy on ultrasound indicate that a spontaneous abortion is unlikely to be the cause of her bleeding. In this patient, the vaginal spotting with associated mucopurulent endocervical discharge (eg, bloody, yellow mucus at the external os) is classic for acute cervicitis, which is cervical inflammation and friability typically caused by a sexually transmitted infection (eg, gonorrhea, chlamydia). Acute cervicitis is diagnosed clinically and requires empiric antibiotic therapy. Nonpregnant patients are typically treated with ceftriaxone and doxycycline; however, because doxycycline is a potential teratogen, pregnant patients are treated with ceftriaxone and azithromycin. Because untreated, undertreated, or recurrent infection can ascend to the uterus and increase the risk of obstetric (eg, spontaneous abortion, preterm prelabor rupture of membranes) and neonatal (eg, conjunctivitis) complications, pregnant patients also require a test of cure after treatment. friability (Choice A) Anti-D immune globulin administration is administered to Rh-negative women after pregnancy-related bleeding (eg, spontaneous abortion, ectopic pregnancy) due to the risk of fetomaternal hemorrhage and possible Rh alloimmunization that can lead to hemolytic disease of the newborn in future pregnancies. This patient is Rh positive. (Choice B) Cervical biopsy is indicated in patients with suspected cervical cancer, which can cause vaginal spotting and mucopurulent discharge (particularly when there is associated tissue necrosis); however, patients typically have a visible cervical lesion, which is not seen in this patient. (Choices D, E, and F) Patients with spontaneous abortion can be treated with either medical (eg, mifepristone, misoprostol) or surgical (eg, suction curettage) management based on patient preference and hemodynamic status. Suction curettage is also indicated in patients with a septic abortion, which can present with mucopurulent cervical discharge; however, this diagnosis is unlikely in this patient with no other signs of infection (eg, afebrile, soft and nontender abdomen). Educational objective: Acute cervicitis can present with first-trimester bleeding and mucopurulent endocervical discharge. Pregnant patients with acute cervicitis require empiric treatment with ceftriaxone and azithromycin followed by a test of cure. References: Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296) Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815)

Question 15

A 25-year-old woman, gravida 1 para 0, at 29 weeks gestation comes to the emergency department due to a headache.  The patient has a history of migraines but has not had one during the pregnancy until today.  She has no other chronic medical conditions.  This morning, the patient woke with a left-sided frontal headache and blurry vision in the left eye.  She took a dose of acetaminophen, but the headache did not improve and now is in the bilateral frontal region.  The patient has no sick contacts but has had increased stress at work and is working longer hours.  Her caffeine consumption has increased to 2-3 cups of coffee a day.  Blood pressure is 156/92 mm Hg and pulse is 84/min.  Fetal heart rate is 155/min.  Repeat blood pressure a few hours later is 150/94 mm Hg.  Cranial nerves are intact.  There is no nuchal rigidity.  The abdomen is soft, gravid, and nontender.  Deep tendon reflexes are normal.  The remainder of the examination is unremarkable.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

11ec25c8_d97f_7b64_bc81_af55fd5b0536_MD0003_00 Headaches are common in pregnancy, particularly in patients with a history of headaches outside of pregnancy. Most cases of headache are benign, but women at ≥20 weeks gestation or with atypical headache symptoms require evaluation for preeclampsia. Although this patient has a history of migraines, which can present with unilateral, frontal pain and visual aura (eg, seeing bright shapes, vision loss), another etiology for her headache should be suspected because pregnant patients usually have either resolution (as in this patient) or increasing severity of migraines, not a sporadic pattern (Choice C). In addition, this patient's new-onset hypertension (ie, systolic blood pressure ≥140 or diastolic ≥90 mm Hg) at ≥20 weeks gestation plus headache with vision changes (eg, blurry vision, scotoma) are consistent with preeclampsia with severe features (eg, preeclampsia with visual or cerebral symptoms, indicating CNS dysfunction). Preeclampsia causes headaches due to high blood pressure, which creates acute elevations in cerebral perfusion pressure and dysregulated cerebral blood flow. Patients often describe preeclampsia headaches as "the worst of my life," and these headaches are typically refractory to acetaminophen or nonsteroidal anti-inflammatory drugs. Patients with preeclampsia, especially those with severe features, are at increased risk for seizure and stroke; therefore, management includes magnesium sulfate and blood pressure control (eg, labetalol, nifedipine). (Choice A) Increased caffeine consumption can cause mild hypertension and tachycardia; caffeine withdrawal can cause headaches. However, neither caffeine use nor withdrawal results in vision changes, making this diagnosis unlikely. (Choice B) Cluster headaches typically present with unilateral orbital or temporal pain with associated autonomic symptoms (eg, ptosis, miosis, lacrimation). Blurry vision is uncommon, and patients typically have relatively quick resolution of symptoms (<3 hr), making this diagnosis unlikely. (Choice E) Tension-type headaches are often worsened by stress and typically present with bilateral, band-like pain; however, they do not cause visual changes. Educational objective: Preeclampsia with severe features commonly presents in women at ≥20 weeks gestation with new-onset hypertension (ie, systolic blood pressure ≥140 or diastolic ≥90 mm Hg) and headache with vision changes (eg, blurry vision). References: Preeclampsia: association with posterior reversible encephalopathy syndrome and stroke. (http://www.ncbi.nlm.nih.gov/pubmed/29438078)

Question 16

A 45-year-old woman comes to the office for evaluation of irregular menstrual bleeding. For the past 8 months, the patient has had some intermenstrual spotting. The bleeding initially occurred for 1-2 days between menstrual cycles but now has become progressively prolonged and heavy, and she now bleeds almost daily. The patient previously used a progestin-releasing intrauterine device for contraception, but had it removed 2 years ago when her husband had a vasectomy. She takes no daily medications and does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 38 kg/m². Bimanual examination shows no abnormalities. On speculum examination, dark-red blood is seen at the cervical os. There are no cervical or vaginal lesions. An endometrial biopsy reveals endometrial hyperplasia. Which of the following is the most likely cause of this patient's condition?

Accepted Answer

11ec25c8_d989_3f76_bc81_d96d9dfd8b70_MD0003_00 This patient has abnormal uterine bleeding (eg, intermenstrual bleeding, daily bleeding); women age ≥45 with abnormal uterine bleeding require an endometrial biopsy. This patient's endometrial biopsy shows endometrial hyperplasia, a precursor to endometrial cancer. Major risk factors for endometrial hyperplasia/cancer include obesity and chronic anovulation (eg, polycystic ovary syndrome), as seen in this patient. Obese women have increased estrogen levels because of the increased peripheral conversion and aromatization of androgens to estrone in adipose tissue. The increased unopposed estrogen levels cause and compound chronic anovulation, which results in continued stimulation of the endometrium. The endometrial lining continues to proliferate and becomes increasingly disordered, resulting in hyperplasia. (Choice A) Chronic endometritis, a polymicrobial infection within the endometrial cavity, can cause intermenstrual bleeding due to sloughing of infected tissue. It does not affect ovulation; therefore, it does not increase the risk of endometrial hyperplasia. (Choice B) Progesterone, provided by either endogenous (eg, ovulation) or exogenous (eg, progestin-releasing intrauterine device) sources, decreases endometrial proliferation and promotes endometrial differentiation. Therefore, it is protective against endometrial hyperplasia/cancer and can be used in treatment of select cases of endometrial hyperplasia. (Choices C and E) Uterine leiomyomata (ie, proliferative myocytes that distort the uterine cavity) and adenomyosis (ie, myometrial invasion of endometrial glands) typically cause heavy, regular bleeding because they increase the surface of the endometrial cavity. They do not increase the thickness of the endometrial lining; therefore, neither increases the risk of endometrial hyperplasia. Uterine leiomyomata (Choice D) Endometriosis (ie, ectopic implantation of endometrial glands) typically causes heavy, painful menses (rather than abnormal bleeding) due to inflamed endometrial tissue on the peritoneum. Women with this condition have a slightly increased risk of epithelial ovarian cancer; however, endometriosis does not increase the risk of endometrial hyperplasia. Educational objective: Endometrial hyperplasia, a precursor to endometrial cancer, occurs due to unregulated endometrium proliferation. Obesity is a major risk factor for endometrial hyperplasia because adipose tissue increases peripheral conversion of androgens to estrone, thereby increasing estrogen levels and causing unopposed uterine estrogen exposure. References: Evaluation and management of abnormal uterine bleeding in premenopausal women. (http://www.ncbi.nlm.nih.gov/pubmed/22230306) The percentages of endometrial hyperplasia and endometrial cancer among polycystic ovary syndrome (PCOS) patients presenting with abnormal menstrual pattern. (http://www.ncbi.nlm.nih.gov/pubmed/24765893) Cancer risk and PCOS. (http://www.ncbi.nlm.nih.gov/pubmed/23624028)

Question 17

An 18-year-old, nulliparous woman comes to the office with lower abdominal pain, nausea, and vomiting for the past day.  She has been unable to tolerate food or water for the past 8 hours.  The patient is sexually active and uses oral contraceptive pills.  She has had 3 lifetime sexual partners.  Her last menstrual period was 15 days ago.  The patient has no medication allergies.  Temperature is 39 C (102.2 F), blood pressure is 100/70 mm Hg, and pulse is 110/min.  Physical examination reveals dry mucous membranes and delayed capillary refill.  The abdomen has diffuse tenderness over the lower quadrants.  The external genitalia have no abnormalities; speculum examination shows purulent discharge from the cervical os.  The uterus is small, anteverted, and tender to palpation and motion.  The adnexa are markedly tender bilaterally, with no palpable masses.  Cervical nucleic acid amplification testing is pending.  Urine pregnancy test is negative.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec25c8_d983_e83d_bc81_5579cec3c768_MD0003_00 This patient has fever, lower abdominal pain, purulent cervical discharge, and cervical motion and adnexal tenderness, findings consistent with pelvic inflammatory disease (PID). PID is typically preceded by cervicitis due to Neisseria gonorrhoeae or Chlamydia trachomatis infection, which disrupts the barrier to the upper genital tract (eg, uterus, fallopian tubes), allowing a polymicrobial infection to develop in a normally sterile area. PID is treated with empiric, broad-spectrum antibiotics. The decision to treat either with inpatient or outpatient antibiotic therapy depends on several factors, including the following: Severity of presentation: Patients with high fever, severe pain, dehydration (eg, dry mucous membranes, delayed capillary refill), and inability to tolerate oral antibiotics (eg, nausea/vomiting) require inpatient treatment. In contrast, patients with a mild presentation (eg, no nausea/vomiting, pain manageable with over-the-counter medication) can be treated as an outpatient (Choices C, D, and E). Failure of outpatient therapy and/or presence of complications: PID can cause the formation of a tuboovarian abscess (eg, persistent fever, adnexal mass), perihepatitis (eg, new-onset pain in the right upper quadrant), or sepsis, all of which require inpatient treatment. Patient compliance: Inpatient treatment may benefit patients at risk for nonadherence to outpatient treatment (eg, adolescents). Therefore, this patient requires hospitalization, fluid resuscitation, and intravenous antibiotic therapy because she cannot tolerate food or water. A common regimen is an intravenous cephalosporin (eg, cefoxitin) plus oral doxycycline, which may require concomitant administration of an intravenous anti-nausea medication. Cephalosporins provide coverage for gram-negative bacilli (eg, Escherichia coli). Doxycycline treats gram-positive (eg, Streptococcus), gram-negative (eg, N gonorrhoeae), and atypical organisms (eg, C trachomatis, Mycoplasma). Metronidazole is added for additional anaerobic coverage when PID is complicated by a tuboovarian abscess. (Choice A) PID is typically polymicrobial and delayed treatment can increase the risk of severe and long-term complications (eg, perihepatitis, infertility). Therefore, both hospitalization and immediate broad-spectrum antibiotic treatment are required while nucleic acid amplification tests results are pending. Educational objective: Pelvic inflammatory disease may present with fever; diffuse lower abdominal pain; mucopurulent cervical discharge; and cervical motion, uterine, or adnexal tenderness. Indications for inpatient treatment with intravenous antibiotics include high fever, inability to tolerate oral antibiotics, and risk of nonadherence to outpatient treatment. References: Clinician perspectives on management of adolescents with pelvic inflammatory disease using standardized patient scenarios. (http://www.ncbi.nlm.nih.gov/pubmed/23680907) Pelvic inflammatory disease: diagnosis, management, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/31524362)

Question 18

A 36-year-old primigravida at 26 weeks gestation comes to the office for evaluation of painful urination.  She has had urinary frequency since her first month of pregnancy, but a week ago she developed dysuria.  The patient has also had chills and fatigue for the past 2 days.  She has intermittent, nonpainful contractions but no vaginal bleeding or leakage of fluid.  Fetal movement is normal.  Three years ago, the patient was treated for pyelonephritis.  She has no chronic medical conditions and has had no surgeries.  Temperature is 100.4 F (38 C), blood pressure is 110/60 mm Hg, and pulse is 110/min.  Fundal height is 26 cm and fetal heart tones are 170/min.  There is tenderness over the right costovertebral angle.  The uterus is nontender and the cervix is closed.  Urinalysis is positive for leukocyte esterase and blood; a urine culture is collected.  Which of the following is the best next step in management of this patient?

Accepted Answer

11ec25c8_d986_a761_bc81_9fa5c3077b3e_MD0003_00 This patient has acute pyelonephritis, an upper urinary tract infection. Pyelonephritis is more common in pregnancy, likely due to the increased risk of recurrent, asymptomatic bacteriuria and physiologic maternal immunosuppression. In addition, progesterone-induced ureteral dilation, ureteral valve laxity, and bladder compression from the gravid uterus may facilitate bacterial ascent from the lower urinary tract. Patients with pyelonephritis can have preceding symptoms of cystitis (eg, dysuria) followed by fever, chills, maternal and fetal tachycardia, and costovertebral angle tenderness. Diagnosis is confirmed with urinalysis (eg, leukocyte esterase, blood), as in this patient. Pregnant patients with pyelonephritis are at high risk for severe maternal (eg, sepsis, acute respiratory distress syndrome, preterm labor) and fetal (eg, preterm birth) complications. Therefore, these patients require inpatient admission and empiric intravenous antibiotics (eg, ceftriaxone) while urine culture results are pending. Once patients remain afebrile for 24-48 hours and have symptomatic improvement, they may be transitioned to oral antibiotics (Choice C). (Choices A and D) Renal imaging (eg, CT scan of the abdomen and pelvis, renal ultrasound) is not required to diagnose acute pyelonephritis. However, if this patient does not improve within 48-72 hours of intravenous antibiotics, a renal ultrasound would be recommended to evaluate for renal abscess or nephrolithiasis. (Choice E) A voiding cystourethrogram assesses for vesicoureteral reflux, which can be a normal finding in pregnancy due to progesterone-induced relaxation of the ureteral valves. Therefore, this test is not indicated. Educational objective: Acute pyelonephritis in pregnancy typically presents with fever, maternal and fetal tachycardia, and costovertebral angle tenderness. Due to the high risk of severe maternal and fetal complications (eg, sepsis, preterm delivery), management is with inpatient admission and empiric intravenous antibiotics (eg, ceftriaxone). References: Medical and infectious complications associated with pyelonephritis among pregnant women at delivery. (http://www.ncbi.nlm.nih.gov/pubmed/24194632) Pyelonephritis in pregnancy: an update on treatment options for optimal outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/20731473)

Question 19

A 20-year-old woman comes to the office for a refill of oral contraceptives.  She is in a monogamous relationship that began 6 months ago and uses condoms as back-up contraception.  The patient became sexually active at age 14 and has had 5 lifetime partners.  Her last menstrual period was 2 weeks ago.  She has regular menses lasting 4-5 days every 28 days.  The patient has not received the human papillomavirus (HPV) vaccination series and has never had a Pap test.  Three months ago, she had negative screening for sexually transmitted infection.  The patient has no chronic medical conditions and has had no prior surgery.  She smokes cigarettes socially but does not use alcohol or illicit drugs.  Vital signs are normal.  Physical examination shows normal external genitalia without any lesions.  Which of the following is recommended for this patient?

Accepted Answer

11ec25c8_d988_5514_bc81_c134a6fda1d4_MD0003_00 Human papillomavirus (HPV) is the most common sexually transmitted infection and has been linked to multiple diseases, including condylomata acuminata (ie, anogenital warts) as well as vulvar, vaginal, anal, oropharyngeal, and cervical cancer. Persistent HPV infection (particularly with types 16 and 18) results in cellular dysplasia because the incorporation of viral DNA increases prooncogenic protein expression and inhibits normal cellular regulation. cellular dysplasia The HPV vaccination induces an antibody response that decreases the risk of both HPV infection and subsequent related diseases. Routine administration of the vaccine series is indicated for female and male patients age 11 to 26, but vaccination may be given from age 9 to 45. Catch-up vaccination should be offered for patients who are either unvaccinated or did not complete the series (Choice E). (Choice A) Previous or current HPV infection is not a contraindication to HPV vaccination because vaccination provides protection against other HPV types that the patient may encounter with future sexual activity. (Choices C and D) Pap testing begins at age 21 in immunocompetent patients regardless of age of onset of sexual activity or number of sexual partners. Although most young (age <30) women become infected with HPV shortly after the onset of sexual activity, the infection typically clears and does not progress to cervical dysplasia or cancer. Therefore, routine HPV testing is not indicated in this population because it would increase the rate of unnecessary cervical procedures (eg, conization) and thereby increase the risk of pregnancy complications (eg, cervical insufficiency). Educational objective: Human papillomavirus (HPV) vaccination is recommended to prevent HPV-related disease; it is typically administered to those age 11-26 but can be given from age 9 to 45. Cervical cancer screening with Pap testing begins at age 21 in immunocompetent patients regardless of age of onset of sexual activity. References: Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. (http://www.ncbi.nlm.nih.gov/pubmed/31415491) Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/31255301)

Question 20

A 26-year-old woman comes to the emergency department due to a bump on her vaginal introitus.  The patient first noticed the mass 2 days ago, but it has increased in size and now causes discomfort when she walks or exercises.  She had unprotected sex with a new partner 6 weeks ago and has had 10 lifetime partners.  The patient had an abnormal Pap test last year but had a normal colposcopy.  She smokes a half pack of cigarettes daily but does not use alcohol or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 80/min.  On pelvic examination, the pubic hair is shaved.  There is a 4-cm, mobile, soft, nontender cystic mass behind the right posterior labium majus that extends into the vagina.  The remainder of the examination is normal.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

11ec25c8_d987_b8d3_bc81_3587068d0d09_MD0003_00 This patient has a Bartholin duct cyst, which occurs due to blockage of the Bartholin gland duct. The Bartholin glands are located bilaterally at the posterior vaginal introitus and have ducts that drain into the vulvar vestibule at the 4 and 8 o'clock positions to provide vulvovaginal lubrication. The Bartholin glands are not palpable unless ductal blockage occurs, resulting in mucoid fluid buildup and cyst formation. Women with small Bartholin duct cysts are often asymptomatic and may be diagnosed incidentally on routine examination. In contrast, larger cysts (as seen in this patient) cause increased tissue tension and friction, resulting in vaginal pressure and discomfort with sexual activity, walking, or sitting (all of which apply direct pressure on the vulva and cyst). On pelvic examination, a soft, mobile, nontender, cystic mass is palpated behind the posterior labium majus with possible extension into the vagina. Asymptomatic cysts can be managed expectantly; symptomatic cysts require incision and drainage with possible Word catheter placement. Word catheter placement (Choice B) A Bartholin gland abscess can develop from an infected cyst; however, patients have additional findings of localized erythema and induration and a tender, fluctuant mass (not seen in this patient). (Choice C) Condylomata acuminata appear as groups of smooth papules or sessile, verrucous growths typically caused by human papillomavirus types 6 and 11. Condylomata acuminata (Choice D) Condylomata lata-a feature of secondary syphilis-are gray-white, raised lesions affecting mucous membranes (eg, mouth, perineum); there is no associated cyst formation. (Choice E) Epidermal inclusion cysts appear as raised, mobile, flesh-colored nodules sometimes associated with a central punctum. (Choice F) Hidradenitis suppurativa creates inflamed, purulent nodules in intertriginous areas (eg, axilla, inguinal region) that cause draining sinuses and scarring; disease is typically multifocal and painful. (Choice G) Lymphogranuloma venereum presents as small, painless papules or pustules that ulcerate. Advanced stages develop painful, swollen lymph nodes that coalesce to form buboes, which may rupture. Educational objective: Large, symptomatic Bartholin duct cysts can present with vaginal discomfort and pressure with sexual activity, walking, or sitting. Physical examination reveals a soft, mobile, nontender mass located behind the posterior labium majus with possible extension into the vagina. Treatment of symptomatic Bartholin duct cysts is with incision and drainage. References: Clinical pathology of Bartholin's glands: a review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/26195958) Lesions of the Bartholin gland: a review. (http://www.ncbi.nlm.nih.gov/pubmed/24914884) Management of Bartholin's cyst and abscess using the Word catheter: implementation, recurrence rates and costs. (http://www.ncbi.nlm.nih.gov/pubmed/25963974)

Exam 5: Obstetrics & Gynecology