Question 1

A 53-year-old woman comes to the office for a routine follow-up visit.  She has seen the physician for menopausal symptoms for the past 2 years and started medication for worsening hot flashes 6 months ago.  She says, "I'm doing pretty well; that medication you gave me seems to have helped my hot flashes somewhat.  My sleep isn't great, but it's not that different from usual.  At least I'm not waking up 3 times a night anymore."  Her medical problems include hypertension and chronic insomnia.  Medications include enalapril and venlafaxine that was started at her last visit to target vasomotor symptoms.  The patient drinks a glass of wine each day and does not use tobacco.  She works as a librarian and is married to her second husband.  She exercises regularly and enjoys socializing with her friends when she has the opportunity.  When the physician inquires about her home life, she says her marriage is "fine" although she wishes that she and her husband had more time for each other and were more intimate.  She says, "Actually, I am a little upset with my husband.  He comes home from work exhausted and just wants to watch television.  He doesn't understand the changes I'm going through.  He doesn't seem interested in anything, including me!" 
Which of the following questions would be most helpful to address the patient's concerns?
A)Are you concerned that your husband might be depressed?
B)Can you tell me more about your sex life?
C)Can you tell me more about your sleep difficulties?
D)How has your mood been lately?
E)Would you consider a referral for couple's therapy to address your difficulties?

Accepted Answer

Explanation: This postmenopausal patient reports that her physical symptoms have improved (venlafaxine appears to have improved her vasomotor symptoms and sleep to some extent) but describes intimacy problems with her husband. Taking a sexual history should be considered part of a routine medical examination, and physicians should seek to normalize sexual health concerns. Patients have varying degrees of comfort discussing sexual issues and may be reluctant to bring up these topics. The physician should facilitate the discussion with a sensitive, nonjudgmental, and open-ended approach. An open-ended question such as "Can you tell me more about your sex life?" is effective in initiating the discussion. (Choice A) Although the patient's comments raise concern about her husband's mental health, focusing on her own concerns should take priority. (Choice C) This patient has a history of chronic insomnia that was likely exacerbated by nighttime awakenings due to menopausal hot flashes. However, treating her vasomotor symptoms with venlafaxine has improved her sleep, which is now close to her baseline. Obtaining further history about lack of intimacy with her husband, which is the main cause of her current distress, is the priority. (Choice D) Although assessing a patient's mood is useful, this patient is not currently experiencing depression and appears to be functioning well (eg, working, exercising, socializing). Exploring her concerns about her relationship is more important. (Choice E) Although this couple may benefit from therapy, the physician should first obtain additional information about the patient's concerns regarding intimacy. If a sexual problem is identified, it may need to be addressed medically. Educational objective: Sexual history should be obtained routinely in health visits. Physicians should normalize sexual health concerns and provide patients with the opportunity to openly discuss these issues. References: General practitioners' procedures for sexual history taking and treating sexual dysfunction in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/24261826) Standard operating procedures for taking a sexual history. (http://www.ncbi.nlm.nih.gov/pubmed/22970717)

Question 2

A 23-year-old woman comes to the office with worsening fever, chills, and lower abdominal pain for 3 days.  The patient has been taking nonsteroidal anti-inflammatories for pain relief.  She also has increasing malodorous vaginal discharge.  The patient has a history of 2 episodes of pelvic inflammatory disease that required hospitalization and intravenous antibiotic treatment.  She has smoked a pack of cigarettes daily for 7 years and consumes 1 or 2 beers daily.  The patient has had 6 sexual partners over the last 6 months.  She had an intrauterine device (IUD) placed a year ago and inconsistently uses barrier contraception.  The patient has no known drug allergies.  Temperature is 38.3 C (100.9 F), blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are 20/min.  Weight is 60 kg (132.3 lb) and height is 157.5 cm (5 ft 2 in).  Examination shows a soft, nondistended abdomen with mild rigidity and rebound tenderness in the lower abdomen; bowel sounds are present.  There is no hepatosplenomegaly.  No lesions are present on the vulva or vagina.  Pelvic examination reveals cervical motion and bilateral adnexal tenderness as well as purulent discharge from the cervical os.  The IUD strings are visible at the external cervical os.  Laboratory results are as follows:  Urinalysis shows 50+/hpf of WBCs.  Urine pregnancy test is negative.  Nucleic acid amplification testing is positive for Neisseria gonorrhoeae.  Pelvic ultrasound reveals a dilated fallopian tube filled with debris.  Which of the following is the strongest risk factor for this patient's condition?
A)Age <25
B)Inconsistent use of barrier contraception
C)Intrauterine contraceptive device
D)Multiple sexual partners
E)Previous episodes of pelvic inflammatory disease

Accepted Answer

Explanation: 11ec2b69_c147_5300_8f63_db20004a69ee_MD0005_00 This patient's fever, abdominal pain, purulent cervical discharge, and cervical motion tenderness are the classic presentation of pelvic inflammatory disease (PID). Gonococcal cervicitis predisposes the upper reproductive tract (eg, uterus, fallopian tube) to the polymicrobial infection of PID. Acute complications of PID include tubo-ovarian abscess, pyosalpinx, and perihepatitis (eg, Fitz-Hugh-Curtis syndrome). Long-term complications include infertility and increased risk of ectopic pregnancy due to fallopian tube damage. Risk factors for PID include multiple sexual partners, age 15-25, previous episodes of PID, inconsistent use of barrier contraception, and a partner with a sexually transmitted infection. Studies show that among all PID risk factors, having multiple sexual partners is associated with the highest increase (4.6- to 20-fold) in risk for PID occurrence. (Choice A) Being age 15-25 is a risk factor for PID due to the frequency of Chlamydia trachomatis and Neisseria gonorrhoeae infection in this age group. However, being age 15-25 is associated with less risk than a history of having multiple sexual partners. (Choice B) Use of barrier contraception, particularly condoms, helps prevent PID. Inconsistent use of condoms approximately doubles the risk of PID; having multiple sexual partners increases the risk by 4.6- to 20-fold. Therefore, a woman not using condoms with a single sexual partner is less likely to have PID than a woman using condoms with multiple sexual partners. (Choice C) There is minimal increase in the risk of PID with the use of an intrauterine device (IUD); this risk is typically limited to the first few weeks after insertion. (Choice E) Women with previous episodes of PID have a 2.3-fold increase in the risk for recurrent infection. Educational objective: Having multiple sexual partners is associated with the highest increase in risk for pelvic inflammatory disease (PID). Other risk factors include being age 15-25, previously having PID, inconsistently using barrier contraception, and having a partner with a sexually transmitted infection. References: Which sexually active young female students are most at risk of pelvic inflammatory disease? A prospective study. (http://www.ncbi.nlm.nih.gov/pubmed/26082320) Prevalence of pelvic inflammatory disease in sexually experienced women of reproductive age - United States, 2013-2014. (http://www.ncbi.nlm.nih.gov/pubmed/28125569)

Question 3

A 27-year-old woman, gravida 0 para 0, comes to the office with her husband for an infertility evaluation. The patient discontinued her combination oral contraceptive pills 14 months ago, and the couple has been trying to conceive since that time. The patient was initially placed on oral contraceptives at age 19 for dysmenorrhea. Her menstrual periods occur every 27 days; she has 3 days of light bleeding with painful cramping moderately controlled with aspirin, acetaminophen, and heating pads. For the last 8 months, the couple has had intercourse at least every other day from day 9 to day 16 of the patient's cycle. The patient has no chronic medical conditions and has had no surgery. She takes a daily prenatal vitamin. The patient has no history of abnormal Pap tests or sexually transmitted infections. She does not use tobacco, alcohol, or illicit drugs. Her husband is age 34 and has no children from previous relationships. He has no chronic medical conditions or previous surgery. He reports normal pubertal development. The patient's blood pressure is 120/70 mm Hg and pulse is 76/min. Height is 157.5 cm (5 ft 2 in) and BMI is 24 kg/m². Pelvic examination reveals a well-rugated vagina, a small anteverted uterus, and no adnexal masses. Physical examination of the husband shows normal secondary sexual characteristics and bilaterally descended testes. Which of the following is the most appropriate response to this couple's inability to conceive? A)Difficulty conceiving after long-term oral contraceptive use is common; no further testing is indicated now. B)Evaluation of mid-luteal serum progesterone would be the best first step. C)The inability to conceive after 14 months is abnormal; the first evaluation should be a semen analysis. D)The infertility is due to a possible chromosomal abnormality; I recommend a karyotype analysis. E)The infertility is due to endometriosis; I recommend a diagnostic laparoscopy as the initial step.

Accepted Answer

Explanation: Infertility is defined as a couple's inability to conceive after >12 months of appropriately timed intercourse without contraception. For women age >35, evaluation occurs after >6 months of infertility. Male factor infertility is a common cause of infertility; the most common etiologies are testicular or genetic defects (eg, Klinefelter syndrome, varicocele) that result in changes in sperm quality and function. A semen analysis, a noninvasive, low-cost test, is the gold standard in evaluation of the male partner and is the first step in an infertility evaluation. Sperm volume, pH, concentration, motility, and morphology are assessed; if abnormal, infertility can be treated with intrauterine insemination or in-vitro fertilization. (Choice A) For most women, ovulation and fertility return within a month of discontinuing oral contraceptives. Patients unable to conceive for >12 months require investigation, regardless of prior methods of contraception. (Choice B) A history of regular menses suggests ovulation, and mid-luteal serum progesterone to confirm ovulation is not indicated. (Choice D) Chromosomal abnormalities may be suspected in cases of recurrent pregnancy loss (>3 spontaneous abortions) or cases of abnormal semen analysis (eg, azoospermia, oligospermia). Klinefelter syndrome (47, XXY) is the most common chromosomal cause of male infertility; typical examination findings include gynecomastia and cryptorchidism, not seen in this case. Klinefelter syndrome (Choice E) Laparoscopy is indicated if endometriosis (eg, chronic pelvic pain, immobile uterus, pelvic nodularity) is suspected, as resection improves pregnancy rates. However, it is not a first-line procedure for infertility, particularly in patients without findings suggestive of pelvic pathology. Educational objective: Infertility is defined as a couple's inability to conceive after >12 months of appropriately timed, unprotected intercourse. Initial evaluation includes a semen analysis, a noninvasive, low-cost test to detect male factor infertility. References: Trends of male factor infertility, an important cause of infertility: A review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/26752853)

Question 4

A 14-year-old girl is brought to the office by her mother due to "not yet reaching puberty."  The mother reports that her daughter started to have breast development and wear a bra about 2 years ago.  However, the patient has not had a growth spurt or reached menarche.  Her mother is worried because the girl's 2 older sisters had their first menstrual periods at age 11 and are both over 172.7 cm (5 ft 8 in) tall.  The mother states, "Nobody else in our family has been a 'late bloomer'."  The patient has had increasing facial acne over the last year for which she uses an over-the-counter topical cream.  She has no chronic medical conditions and has had no previous surgeries.  The patient was born at term and met all developmental milestones.  She recently started high school and is a member of the cheerleading squad.  The patient is not sexually active and does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 110/60 mm Hg and pulse is 68/min.  Weight and height are at the 25th and 55th percentiles, respectively.  Breast development is sexual maturity rating stage 3.  The external genitalia are normal and pubic hair is Tanner stage 2.  Skin examination reveals mild comedonal acne on the nose and forehead.  Which of the following is the best next step in management of this patient?
A)Bone age test
B)FSH level
C)Karyotype analysis
D)Pelvic ultrasound
E)Reassurance and observation

Accepted Answer

Explanation: Puberty is the process of achieving sexual maturity as a result of increasing levels of sex hormones. The hypothalamic-pituitary-ovarian axis is typically activated in early adolescence, causing a pulsatile secretion of hypothalamic GnRH to stimulate the release of FSH and LH and activate the ovaries to produce estrogen. This leads to a sequence of events beginning with breast development (thelarche) in girls age 8-12 and culminating in the onset of menses (menarche) 2-2.5 years later. hypothalamic-pituitary-ovarian axis The timing of menarche varies, but it is normal if menses occur by age 15 in girls with secondary sexual characteristics. This patient is age 14 with normal pubertal progression, including breast and pubic hair development. The mild facial acne is a sign of normal adrenarche that occurs during puberty. In addition, this patient has normal stature; growth spurts typically occur shortly before the onset of menses. Given these findings, reassurance and observation are indicated. However, this patient requires reevaluation if menarche does not occur by age 15. (Choice A) Constitutional delay of puberty, characterized by a delayed bone age, may be considered in girls age >12 with short stature and no breast development (first sign of puberty). This patient has a normal height and breast development; therefore, a bone age is not indicated. (Choices B and D) Pelvic ultrasound and a FSH level are ordered to evaluate for primary amenorrhea, the lack of menses at age >15 with secondary sexual characteristics (eg, breast development) or age >13 with no secondary sexual characteristics. (Choice C) Karyotype analysis is indicated to evaluate for Turner syndrome. Patients can present with primary amenorrhea; however, they typically have concomitant short stature (<3rd percentile) and little to no breast development. Educational objective: Puberty in girls typically begins with breast development and pubic hair growth, followed by menarche about 2-2.5 years later. A lack of menses at age <15 is normal if secondary sexual characteristics are present; reassurance and observation are indicated. References: Normal and abnormal puberty. (http://www.ncbi.nlm.nih.gov/pubmed/25905253)

Question 5

A 34-year-old woman comes to the emergency department due to a 12-hour history of sudden-onset, upper abdominal pain. She describes the pain as intense, constant, and radiating to the back. The pain is relieved by leaning forward and worsens with eating. The patient also reports nausea and has vomited several times. She has no previous episodes of abdominal pain, fever, chills, weight loss, fatigue, or night sweats. The patient has no known medical conditions and takes no prescription or over-the-counter medications. She does not use alcohol, tobacco, or illicit drugs. Her last menstrual period was 2 weeks ago and was normal. The patient is sexually active with a male partner and uses condoms. Temperature is 36.7 C (98.1 F), blood pressure is 134/72 mm Hg, pulse is 72/min, and respirations are 14/min. BMI is 24 kg/m². Physical examination shows moist mucous membranes and anicteric sclera. Lung fields are clear, and S1 and S2 are normal. The abdomen is soft and tender in the upper abdomen but without rebound, involuntary guarding, or rigidity. Bowel sounds are normal. Neither hepatomegaly nor splenomegaly is present. Bimanual examination reveals no adnexal masses or tenderness. Neurologic examination is within normal limits. Which of the following is the most appropriate immediate next step for establishing the diagnosis in this patient? A)Contrast-enhanced CT scan of the abdomen only B)Serum blood tests and contrast-enhanced CT scan of the abdomen C)Serum blood tests only D)Upper gastrointestinal endoscopy E)X-ray of the abdomen

Accepted Answer

Explanation: 11ec2b69_c14b_bfd9_8f63_5ffb3ed11f5c_MD0005_00 This patient most likely has acute pancreatitis (AP) presenting with acute, severe epigastric pain radiating to the back and associated with nausea and vomiting. The diagnosis of AP requires 2 of 3 criteria: Acute onset of persistent, severe epigastric pain Elevation of serum lipase or amylase ≥3 times the upper limit of normal (lipase is more specific) Characteristic findings of pancreatitis on abdominal imaging (contrast-enhanced CT scan, MRI) In patients with typical abdominal pain, laboratory analysis (ie, serum lipase) is sufficient to confirm the diagnosis of AP. Establishing the diagnosis with laboratory markers is preferred over imaging due to lower cost, faster result time, and lack of exposure to ionizing radiation. In addition, CT scan has low sensitivity in the first 72 hours of presentation. It is generally reserved for cases of diagnostic uncertainty and would be performed in this patient only if laboratory analysis is unrevealing (eg, normal lipase and/or amylase) (Choices A and B). (Choice D) Endoscopy is generally not helpful in AP. Although endoscopy with retrograde cholangiopancreatography (ERCP) may be used to remove a common bile duct stone in patients with gallstone-induced AP, ERCP is associated with significant risk and should not be used as the initial diagnostic test. (Choice E) An x-ray can help diagnose a perforated peptic ulcer, which typically presents with signs of peritonitis (eg, involuntary guarding, rebound tenderness, rigidity), which are not present in this patient. X-ray is neither sensitive nor specific for AP. Educational objective: The diagnosis of acute pancreatitis can be made when serum lipase (or amylase) levels are ≥3 times the upper limit of normal in the setting of characteristic epigastric abdominal pain. Advanced abdominal imaging (eg, CT scan) should be reserved for cases of diagnostic uncertainty. References: Acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25368923) Early phase of acute pancreatitis: assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/25133018) Clinical guideline: management of gastroparesis. (http://www.ncbi.nlm.nih.gov/pubmed/23147521)

Question 6

A 69-year-old woman, gravida 5 para 5, comes to the office for leakage of urine. The patient reports that her urine "leaks all the time" and that she is "afraid to leave the house because I constantly smell like urine." She is also "exhausted from waking up every hour to go to the bathroom." Since menopause at age 53, the patient has had occasional leakage of urine after sneezing, but her symptoms have worsened over the last few months. She has type 2 diabetes mellitus and is on an insulin regimen. The patient recently moved to be closer to her grandchildren; since moving, she has been diagnosed with allergic rhinitis and started on a daily antihistamine. She has had no previous surgery. The patient's pregnancies all resulted in spontaneous vaginal deliveries; the largest infant was 4.6 kg (10.2 lb). She does not use tobacco, alcohol, or illicit drugs. The patient does aqua-aerobic exercises at the senior center 5 times a week. Blood pressure is 120/80 mm Hg and pulse is 70/min. BMI is 25 kg/m². Abdominal examination shows no tenderness or masses. Speculum examination shows a pale vagina but no evidence of pelvic organ prolapse. Bimanual examination shows a small, mobile, nontender uterus and no adnexal masses. Urine dribbling is noted on examination, but no leakage occurs when the patient is asked to cough. There is decreased sensation to pinprick testing over the perineum. Which of the following is the most likely diagnosis in this patient? A)Genitourinary syndrome of menopause B)Intrinsic sphincter deficiency C)Overflow incontinence D)Urethral hypermobility E)Urgency incontinence

Accepted Answer

Explanation: 11ec2b69_c149_00b2_8f63_b7af8976dd3f_MD0005_00 Overflow incontinence occurs due to incomplete bladder emptying that is the result of decreased detrusor muscle contractility and/or bladder outlet obstruction. Urine accumulates, distends the bladder, and increases the intravesicular pressure. Whenever the intravesicular pressure is greater than the urethral closing pressure, urine dribbles out. Therefore, patients with overflow incontinence commonly experience constant urinary leakage, nocturia, and a weak urinary stream. Typical examination findings include decreased perineal sensation (eg, neuropathy) and a large post-void residual urine volume (>150 mL). Overflow incontinence is often associated with neuropathy (eg, poorly controlled diabetes mellitus, spinal injury, multiple sclerosis). Patients with an underlying neuropathy can develop overflow incontinence when additional risk factors (eg, antihistamines) result in exacerbation of symptoms (as in this patient). Treatment includes correction of any underlying etiology and intermittent self-catheterization. (Choice A) Genitourinary syndrome of menopause can cause urinary symptoms due to vulvovaginal atrophy; however, it typically presents with an associated dyspareunia, vulvar irritation, and pelvic organ prolapse, which are not seen in this patient. (Choices B and D) Intrinsic sphincter deficiency and urethral hypermobility are associated with stress urinary incontinence - involuntary leakage of urine that occurs with increased intraabdominal pressure (eg, coughing, sneezing, Valsalva). Patients with stress urinary incontinence typically have a positive bladder stress test (leakage of urine with coughing during examination), which is not seen in this patient. (Choice E) Urgency incontinence (also known as overactive bladder) typically presents with a sudden, overwhelming urge to void followed by an involuntary loss of urine. Educational objective: Overflow incontinence presents as a constant dribbling of urine and is due to bladder distension from incomplete emptying. Typical examination findings include signs of neuropathy and an increased post-void residual urine volume (>150 mL). Treatment involves intermittent self-catheterization and correction of the underlying etiology. References: Diagnosis of urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/23668444)

Question 7

A 53-year-old man comes to the emergency department due to sudden onset of nausea, vomiting, and severe epigastric pain radiating to the back.  He has no constipation, diarrhea, or black stools.  His medical history includes epilepsy, hypertension, and depression.  The patient was recently treated for cellulitis.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.8 C (100 F), blood pressure is 130/80 mm Hg, pulse is 118/min, and respirations are 20/min.  The abdomen is tender in the epigastric region.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's symptoms?
A)Amlodipine
B)Cephalexin
C)Chlorthalidone
D)Fluoxetine
E)Metoprolol

Accepted Answer

Explanation: 11ec2b69_c14b_4aa7_8f63_5f332e01034d_MD0005_00 Drug-induced pancreatitis (DIP) accounts for approximately 1% of cases of pancreatitis. Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) and most loop diuretics (eg, furosemide) belong to the sulfonamide class of drugs and have been associated with DIP. These drugs likely cause DIP through several pathophysiologic mechanisms, which include hypersensitivity to the sulfonamide molecule, ischemia due to decreased intravascular blood volume, and increased viscosity of pancreatic secretions. Numerous other medications have been associated with DIP and act through the same or other pathophysiologic mechanisms (eg, toxicity from metabolites, intravascular thrombosis). Diagnosing DIP can be difficult and requires careful consideration of the patient's medication history. Although the rates of DIP for any specific medication are low, certain medications are more strongly associated with the disease. Given the wide range of medications involved, physicians should be aware of a number of common groups of patients who are at higher risk for DIP. These include patients with the following: Heart failure or hypertension (ACE inhibitors, angiotension II receptor blockers, diuretics) Autoimmune disease (azathioprine, mesalamine, corticosteroids) Chronic pain (acetaminophen, opiates, nonsteroidal anti-inflammatory drugs) Seizure disorder (valproic acid, carbamazepine) HIV (lamivudine, didanosine, trimethoprim-sulfamethoxazole) (Choices A, B, D, and E) Although ACE inhibitors and angiotensin II receptor blockers have been consistently implicated in DIP, calcium-channel blockers and beta blockers have not been identified as significant causes. Likewise, many antibiotics, including metronidazole, tetracyclines, and isoniazid, have been associated with DIP, but cephalexin has not. In addition, among the selective-serotonin reuptake inhibitors, sertraline has been reported to cause DIP, but there are no reports for fluoxetine. Educational objective: Drug-induced pancreatitis is an uncommon but important cause of pancreatitis, and many medications have been associated with the disease. Diuretics (eg, hydrochlorothiazide, chlorthalidone, furosemide) are particularly important drugs that have been implicated in this disease. References: Drug-induced pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/22314811) Drug-induced acute pancreatitis: an evidence-based review. (http://www.ncbi.nlm.nih.gov/pubmed/17395548)

Question 8

A 63-year-old woman, gravida 3 para 3, comes to the office for urinary incontinence. The patient has been experiencing involuntary leakage of urine that occurs after a strong sensation "that I really have to go." After the sensation occurs, "I can never get to the bathroom in time." The patient reports that her symptoms started over 2 years ago. The leakage was initially occasional but now occurs 2 or 3 times a day and soaks an entire pad. The patient's symptoms occur randomly and she now avoids leaving the house. She has hypertension controlled on an ACE inhibitor. She has had no surgery. The patient's deliveries were all vaginal; her Pap tests have been normal. She drinks 8 ounces of water 3 or 4 times a day but limits water intake in the evening; on weekends she drinks a cup of caffeinated coffee with breakfast. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 72/min. BMI is 23 kg/m². Speculum examination shows a pale vagina without rugae. Bimanual examination reveals a small, mobile uterus and no adnexal masses. No leakage of urine occurs when the patient coughs with a full bladder. After voiding, the patient is catheterized and 30 mL of urine are drained from the bladder. Urinalysis is within normal limits. The patient returns to the office 10 weeks later for follow-up. She reports no response to the initial therapy. Repeat urinalysis is normal. Which of the following is the best next step in management of this patient? A)Collect a urine sample for culture and cytology B)Prescribe a course of terazosin C)Prescribe a course of tolterodine D)Recommend a urethral sling procedure E)Recommend intermittent self-catheterization

Accepted Answer

Explanation: 11ec2b69_c14a_1223_8f63_cf14be7dfb5c_MD0005_00 Patients who have no improvement in their urgency incontinence symptoms despite lifestyle modifications (eg, bladder training) may benefit from the addition of an antimuscarinic medication such as tolterodine, solifenacin, or oxybutynin. Antimuscarinic medications improve bladder capacity and inhibit detrusor muscle contraction during bladder filling by blocking acetylcholine release in the bladder. The anticholinergic properties of these medications frequently result in side effects (eg, dry mouth, constipation, drowsiness, blurry vision) that may limit their usefulness. To minimize these side effects, antimuscarinics are initiated at the lowest dose and titrated up as tolerated. Patients with persistent incontinence symptoms despite the use of antimuscarinic medication can be considered for botulinum toxin injections or percutaneous tibial nerve stimulation. (Choice A) Urinary tract infections are a reversible cause of urinary incontinence, and a urine culture is indicated in patients with a urinalysis suggestive of infection. Urine cytology evaluates for bladder cancer and is indicated for patients with hematuria on urinalysis. This patient had 2 normal urinalyses; therefore, neither a urine culture nor a cytologic evaluation is indicated. (Choice B) Terazosin, an alpha-1 antagonist, is indicated in the treatment of benign prostatic hypertrophy, which can present with urgency incontinence or, in men, with poor bladder emptying. (Choice D) A urethral sling procedure is indicated for patients with stress urinary incontinence who have failed conservative management (eg, weight loss, dietary modification, pessary). Urethral sling procedures do not alter detrusor overactivity and are not indicated in the management of urgency incontinence. (Choice E) Intermittent self-catheterization is indicated in the management of patients with overflow incontinence. These patients have an increased post-void residual volume (>150 mL) and constant urinary dribbling that occurs due to bladder over-distension from incomplete emptying (not seen in this patient). Educational objective: Patients with urgency incontinence who fail bladder training with timed voids are treated with antimuscarinic medications such as oxybutynin and tolterodine. Patients with persistent symptoms can be considered for botulinum toxin injections or percutaneous tibial nerve stimulation. References: Modifiers of response to treatment with Fesoterodine for urgency-predominant urinary incontinence in a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/28118174)

Question 9

A 33-year-old woman comes to the office to discuss contraception options. The patient and her boyfriend have been using condoms and the "morning-after pill" occasionally to prevent pregnancy. She most recently used an emergency contraceptive a week ago. The patient used combined oral contraceptives in her early 20s and would like to restart them. Her medical conditions include occasional headaches, which she describes as a throbbing pain on the right side of her face preceded by "flickering zigzags" in her peripheral vision. During the headache, she has light sensitivity and facial numbness. The patient has had no previous surgeries. Her menses are regular; her last menstrual period was 3 weeks ago. The patient's mother was diagnosed with epithelial ovarian cancer at age 59 and is undergoing chemotherapy. Her maternal grandmother also had ovarian cancer and died at age 56. The patient smokes half a pack of cigarettes a week but does not use alcohol or illicit drugs. She has no known medication allergies. Blood pressure is 130/80 mm Hg and pulse is 76/min. BMI is 33 kg/m². Physical examination is normal. Which of the following is a contraindication to the use of combined hormonal contraceptives in this patient? A)Blood pressure B)Family history of ovarian cancer C)History of headaches D)Recent emergency contraception use E)Tobacco use

Accepted Answer

Explanation: 11ec2b69_c142_e629_8f63_d115d95f4128_MD0005_00 Combined hormonal contraceptives include estrogen/progestin pills, a transdermal patch, and a vaginal ring. Estrogen alters hemostasis and increases the risk of thrombosis. Therefore, estrogen-containing medications have more contraindications than progestin-containing contraceptives (eg, implant, injection, intrauterine device) or the copper intrauterine device. Combined hormonal contraceptives are contraindicated in patients with risk factors for thromboembolic disease (eg, history of thromboembolism, prolonged immobilization). Because of an association with ischemic stroke and cardiovascular events, estrogen-containing contraceptives are also contraindicated for patients with additional risk factors (eg, hypertension 160/100 mm Hg, heavy smokers age 35, migraines with aura, diabetes mellitus with end-organ damage). Migraines typically present as unilateral or bilateral throbbing headaches accompanied by nausea and light/sound sensitivity. Aura refers to focal neurologic symptoms, most commonly visual (eg, flickering lights). Patients who have migraines with auras have a slightly increased risk of ischemic stroke compared with the general population. Although this patient previously used combined oral contraceptives without complications, she is at risk for stroke and cannot use estrogen-containing contraception. (Choice A) Blood pressure >160/100 mm Hg is an absolute contraindication to combined hormonal contraception use due to the risk of myocardial infarction and stroke. This patient's blood pressure is 130/80 mm Hg. (Choice B) Combination oral contraceptives decrease the risk of ovarian and endometrial cancer. They are not contraindicated in patients with a family history of ovarian cancer. (Choice D) Oral emergency contraception (eg, ulipristal, levonorgestrel) prevents pregnancy by interrupting ovulation. Recent use is not a contraindication to the initiation of a new contraception method. (Choice E) Women age >35 with heavy tobacco use (>15 cigarettes a day) are at high risk of adverse events with combined hormonal contraceptive use. This patient is not a heavy smoker and does not meet the age criterion. Educational objective: Migraine headache with aura is an absolute contraindication to combined hormonal contraceptives at any age due to the increased risk of ischemic stroke. Other absolute contraindications include blood pressure >160/100 mm Hg and women age >35 who smoke >15 cigarettes per day. References: Migraine as a risk factor for young patients with ischemic stroke: a case-control study. (http://www.ncbi.nlm.nih.gov/pubmed/28083761) Selected practice recommendations for contraceptive use. (http://www.ncbi.nlm.nih.gov/pubmed/28080000) U.S. medical eligibility criteria for contraceptive use, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/27467196)

Question 10

A 16-year-old girl comes to the office with her mother for a contraception consultation. The patient recently became sexually active with her boyfriend of 6 months, and they use condoms for contraception. She has regular monthly menses, with 4 days of vaginal bleeding. On the first day of her menstrual period she often has heavier bleeding and mild cramping relieved by nonsteroidal anti-inflammatory drugs. Her last menstrual period was 2 weeks ago. The patient has no chronic medical conditions or previous surgeries. Family history is significant for osteoporosis in her maternal grandmother and an aunt, but is otherwise noncontributory. She does not use tobacco, alcohol, or illicit drugs. She has no known drug allergies. Blood pressure is 118/68 mm Hg and pulse is 72/min. BMI is 23 kg/m². Physical examination is unremarkable. Urine pregnancy test is negative. Chlamydia and gonorrhea nucleic acid amplification testing are collected. The patient asks about the side effects of different contraception methods. Which of the following is the most appropriate response to the patient? A)Combined oral contraceptive pills can cause irregular or breakthrough bleeding. B)Combined oral contraceptive pills can cause weight gain. C)Copper and progestin intrauterine devices are not recommended for nulliparous women. D)Depot medroxyprogesterone acetate decreases bone density; it is not recommended for adolescents. E)Hormonal contraception can impair fertility in the long term when started during adolescence.

Accepted Answer

Explanation: 11ec2b69_c143_5b5a_8f63_17a940e6d790_MD0005_00 Combined estrogen/progestin contraception is a common contraceptive method used by adolescents. Contraception is achieved due to the action of progestin, which suppresses GnRH pulses, thereby reducing FSH and LH secretion and inhibiting ovulation. Breakthrough bleeding is a common side effect, particularly with low-dose and continuous pills, and can lead to discontinuation of oral contraceptive use. Breakthrough bleeding occurs due to a thin, atrophic endometrium that sheds erratically when oral contraceptives do not contain enough estrogen. Breakthrough bleeding may be treated by prescribing a contraceptive pill with higher estrogen dose to thicken and stabilize the endometrium. Even if irregular bleeding occurs, combined oral contraceptives are still effective in preventing pregnancy and should be continued on schedule. Other common side effects of combined oral contraceptives include breast tenderness, nausea, headaches, and moodiness; these are most common at the time of initiation. Noncontraceptive benefits include treatment of dysmenorrhea and abnormal uterine bleeding (eg, anovulation, leiomyoma), reduction of acne and hirsutism (eg, polycystic ovary syndrome), and decrease in ovarian and endometrial cancer risk. (Choice B) Weight gain does not occur with combined oral contraceptive use; however, bloating is a common side effect. (Choice C) Copper and progestin intrauterine devices are long-acting, reversible contraceptive methods and are first-line contraception for adolescents due to ease of use and effectiveness after placement. Nulliparity is not a contraindication to use. (Choice D) Depot medroxyprogesterone acetate is a safe method of contraception and can temporarily decrease bone mineral density during use. This bone density loss is reversible and not associated with an increased risk of future osteoporosis. (Choice E) Combined hormonal contraceptives prevent pregnancy by suppressing ovulation. Ovulation resumes within 30 days of discontinuation of combined hormonal contraceptives, but may take up to 12 months with depot medroxyprogesterone acetate. There is no long-term effect on fertility with either of these methods. Educational objective: Unscheduled bleeding is the most common side effect of the combined oral contraceptive pill and occurs due to a thin atrophic unstable endometrium that sheds erratically. Oral contraceptives do not cause weight gain or impaired fertility. References: Committee opinion no 699: adolescent pregnancy, contraception, and sexual activity. (http://www.ncbi.nlm.nih.gov/pubmed/28426620) Committee opinion no. 602: depot medroxyprogesterone acetate and bone effects. (http://www.ncbi.nlm.nih.gov/pubmed/24848921) Treatment of unscheduled bleeding in women using extended- or continuous-use combined hormonal contraception: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23044386)

Question 11

A 63-year-old woman, gravida 3 para 3, comes to the office for urinary incontinence. The patient has been experiencing involuntary leakage of urine that occurs after a strong sensation "that I really have to go." After the sensation occurs, "I can never get to the bathroom in time." The patient reports that her symptoms started over 2 years ago. The leakage was initially occasional but now occurs 2 or 3 times a day and soaks an entire pad. The patient's symptoms occur randomly and she now avoids leaving the house. She has hypertension controlled on an ACE inhibitor. She has had no surgery. The patient's deliveries were all vaginal; her Pap tests have been normal. She drinks 8 ounces of water 3 or 4 times a day but limits water intake in the evening; on weekends she drinks a cup of caffeinated coffee with breakfast. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 72/min. BMI is 23 kg/m². Speculum examination shows a pale vagina without rugae. Bimanual examination reveals a small, mobile uterus and no adnexal masses. No leakage of urine occurs when the patient coughs with a full bladder. After voiding, the patient is catheterized and 30 mL of urine are drained from the bladder. Urinalysis is within normal limits. Which of the following is the best next step in management of this patient? A)Prescribe duloxetine therapy B)Prescribe oral hormone replacement therapy C)Recommend a pessary placement D)Recommend bladder training with timed voids E)Recommend greater fluid restriction

Accepted Answer

Explanation: This patient presents with urgency incontinence - involuntary urine leakage - that occurs after a strong urge to urinate. Due to the rapidity of the subsequent leakage, patients are unable to get to the bathroom in time. Other presenting symptoms include increased urinary frequency, nocturia, and small-volume voids. Diuretic use often exacerbates symptoms. Urgency incontinence is caused by bladder detrusor muscle overactivity, leading to an involuntary intense contraction that causes leakage. Although the detrusor overactivity is typically idiopathic, it can be caused by neurologic disease (eg, multiple sclerosis) or bladder abnormalities. Risk factors for urgency incontinence include increasing age, stroke, depression, diabetes mellitus, obesity, caffeine intake, and tobacco abuse. Management of urgency incontinence typically begins with timed voids and bladder training. With bladder training, the patient determines a baseline voiding interval and gradually increases the time between voids, eventually voiding every 3-4 hours. Other initial measures include weight loss, smoking cessation, and avoidance of caffeine and alcohol. (Choices A and C) A pessary and duloxetine, a serotonin-norepinephrine reuptake inhibitor, are indicated for the treatment of stress incontinence, which presents with leakage precipitated by increased intraabdominal pressure (eg, cough, Valsalva). Patients with stress urinary incontinence typically have a positive bladder stress test (ie, leakage of urine with cough on examination). (Choice B) Vulvovaginal atrophy can cause urinary incontinence; vaginal estrogen cream is indicated in incontinence treatment if vaginal atrophy is a contributing factor. Oral hormone replacement therapy is not indicated in the treatment of incontinence. (Choice E) Women with incontinence who drink >1.9 L (64 oz) of fluid daily should decrease their fluid intake. Fluid restriction to amounts less than this can cause dehydration. Educational objective: Urgency incontinence, the involuntary loss of urine that is associated with a sudden intense urge to urinate, is caused by detrusor muscle overactivity. Initial management includes bladder training with timed voids, weight loss, smoking cessation, and avoidance of caffeine and alcohol. References: Medical management of urinary incontinence in women. (http://www.ncbi.nlm.nih.gov/pubmed/28198687)

Question 12

A 31-year-old woman, gravida 5 para 3, comes to the office to discuss contraception methods. The patient has 3 children delivered vaginally at term and 2 elective first-trimester pregnancy terminations. Her last delivery was a year ago and she does not currently use contraception. She has just finished breastfeeding. The patient is worried about unintended pregnancy and says that she has completed childbearing. She has no history of thromboembolism, migraines, or liver disease. Her regular monthly menses typically have 4-5 days of moderate bleeding. The last menstrual period was a week ago. Her last Pap test was a year ago, and all testing has been normal. The patient had acute cervicitis at age 19 with negative sexually transmitted infection screening since then. Her maternal aunt was diagnosed with breast cancer at age 54 and died from complications of pulmonary embolism. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 128/70 mm Hg and pulse is 70/min. BMI is 27 kg/m². Physical examination is normal. Which of the following is the best contraception option for this patient? A)Combination oral contraception B)Condom with spermicide C)Depo-medroxyprogesterone acetate injection D)Hormonal contraceptive patch E)Progestin subdermal implant

Accepted Answer

Explanation: 11ec2b69_c142_49e8_8f63_656451edf8e8_MD0005_00 The effectiveness of contraception is categorized by perfect use and typical use. Perfect use refers to contraceptive use in a research setting ensuring patients' consistent and correct use. Typical use of contraception refers to efficacy rates that occur due to patient error and inconsistent administration in the general population. Methods that rely on the user for proper and consistent administration have a discrepancy between perfect and typical use, with higher rates of pregnancy with typical use. The progestin subdermal implant, which is long-acting and reversible, is the most effective contraceptive method with a >99% efficacy rate with typical use. The progestin subdermal implant has a high pregnancy prevention rate because once inserted it is effective for 3 years and is not user dependent. It is even more effective than the intrauterine device (0.2%-0.8% failure rate) and female sterilization (0.5% failure rate). Contraception is achieved by progesterone-induced changes that result in cervical mucus thickening and decreased tubal motility, which inhibit sperm migration. In addition, progestin causes ovulation suppression via decreased FSH and LH secretion. Side effects include unscheduled bleeding (most common), weight gain, and headache. A contraindication to use is progesterone receptor-positive breast cancer. Ovulation and fertility return within a month after removal. progestin subdermal implant intrauterine device (Choices A and D) Combination oral contraceptives and the hormonal contraceptive patch are less efficacious (91%) than the progestin implant. (Choice B) Male condoms protect against sexually transmitted infections but are only 82% effective in preventing pregnancy with typical use. The addition of spermicide can cause genital irritation and increase HIV transmission rates. (Choice C) Depo-medroxyprogesterone acetate injection has a mechanism of action similar to that of the progestin implant, but it requires an injection every 90 days and is less efficacious (94%). Educational objective: The progestin subdermal implant, which is long-acting and reversible, is the most effective contraceptive, with a >99% efficacy rate with typical use. References: U.S. selected practice recommendations for contraceptive use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition. (http://www.ncbi.nlm.nih.gov/pubmed/23784109) Efficacy and safety of long-acting reversible contraception. (http://www.ncbi.nlm.nih.gov/pubmed/21668037)

Question 13

53-year-old woman comes to the office for a routine follow-up visit.  She has seen the physician for menopausal symptoms for the past 2 years and started medication for worsening hot flashes 6 months ago.  She says, "I'm doing pretty well; that medication you gave me seems to have helped my hot flashes somewhat.  My sleep isn't great, but it's not that different from usual.  At least I'm not waking up 3 times a night anymore."  Her medical problems include hypertension and chronic insomnia.  Medications include enalapril and venlafaxine that was started at her last visit to target vasomotor symptoms.  The patient drinks a glass of wine each day and does not use tobacco.  She works as a librarian and is married to her second husband.  She exercises regularly and enjoys socializing with her friends when she has the opportunity.  When the physician inquires about her home life, she says her marriage is "fine" although she wishes that she and her husband had more time for each other and were more intimate.  She says, "Actually, I am a little upset with my husband.  He comes home from work exhausted and just wants to watch television.  He doesn't understand the changes I'm going through.  He doesn't seem interested in anything, including me!" The patient continues, "I guess it shouldn't matter to me as much anymore, but my sex life has been frustrating for the past 2 years.  My husband and I are never in the mood at the same time; when we are, well, let's just say we're not 18 anymore!  Although I wish our sex life was better, sometimes I feel like giving up because it's just not that pleasurable.  It's become easier not to try."  Which of the following is the most likely explanation of this patient's sexual dysfunction?
A)Age-related change in libido
B)Antidepressant sexual adverse effects
C)Husband's sexual dysfunction
D)Performance anxiety
E)Vaginal atrophy

Accepted Answer

Explanation: The physician's open-ended approach has enabled the patient to express frustration with her sex life and concerns that sexual activity is no longer "pleasurable." There are multiple possibilities to consider, including relationship problems with her husband, possible sexual dysfunction in the husband, menopause-related changes (eg, sexual interest, arousal, vaginal atrophy), and antidepressant adverse effects. Although all areas should be explored when taking a comprehensive sexual history, the priority should be determining if the patient's menopausal symptoms are causing her difficulty. Specifically, all postmenopausal women should be asked about vaginal dryness and dyspareunia. Although there is evidence that selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (eg, venlafaxine) relieve vasomotor symptoms, low-dose vaginal estrogen therapy may also be necessary to treat vaginal atrophy. (Choice A) Although some postmenopausal women experience decreased libido, this patient still has interest but describes sex as no longer pleasurable. Vaginal dryness should be considered first. (Choice B) Antidepressant-induced sexual dysfunction could be a contributing factor as SSRIs and SNRIs are associated with decreased libido and anorgasmia in women. However, the patient reports that her sexual problems have been going on for 2 years and she has taken venlafaxine for only the past 6 months. (Choice C) Although the husband may have sexual dysfunction that could contribute to the patient's difficulty, her lack of enjoyment coincides with menopause, when vaginal atrophy is common, making this the more likely diagnosis. (Choice D) There is no history to suggest this woman was anxious about her sexual performance prior to the onset of menopause. It is more likely that vaginal dryness and lack of enjoyment have led her to avoid sex. Educational objective: A comprehensive evaluation of sexual dysfunction requires assessing physiological, psychological, and relationship factors. Postmenopausal women should be specifically assessed for vaginal dryness and dyspareunia. References: Relationship between changes in vulvar-vaginal atrophy and changes in sexual functioning. (http://www.ncbi.nlm.nih.gov/pubmed/28539177) Current management strategies of the postmenopausal patient with sexual health problems. (http://www.ncbi.nlm.nih.gov/pubmed/17394596)

Question 14

A 52-year-old woman, gravida 3 para 3, comes to the office with irregular vaginal bleeding for the past 8 months. She has had vaginal bleeding for the last 10 days, with passage of large clots on the first 2 days. Today, she has minimal spotting. Previously, menses were regular and occurred every 30 days with 4 days of bleeding. She also has frequent hot flashes, difficulty sleeping, and occasional headaches. The patient was diagnosed with type 2 diabetes mellitus 16 years ago and has good blood glucose control with insulin therapy. She had a tubal ligation after her last pregnancy. The patient's last Pap test was 2 years ago, and there is no history of abnormal results. She has not been sexually active for several years. Family history is significant for breast cancer in her maternal aunt at age 72 but is otherwise noncontributory. She does not use tobacco and has no drug allergies. Blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 16/min. BMI is 35 kg/m². Pelvic examination shows a small amount of dark red blood in the vaginal vault and a multiparous cervix without any visible lesions. On bimanual examination, there is a small, mobile, anteverted uterus with no cervical motion tenderness. There are no adnexal masses. Hemoglobin is 12 g/dL. The patient asks for an explanation of her symptoms and what should be done for evaluation. Which of the following is the most appropriate response? A)Symptoms are consistent with menopausal transition; no further evaluation is indicated B)Symptoms are consistent with menopausal transition; systemic hormone replacement therapy is indicated C)Symptoms are suggestive of menopausal transition; however, further evaluation for coagulation factor deficiencies is indicated D)Symptoms are suggestive of menopausal transition; however, further evaluation with an endometrial biopsy is indicated E)Symptoms are suggestive of menopausal transition; measurement of serum FSH is required for confirmation

Accepted Answer

Explanation: 11ec2b69_c146_ddce_8f63_3f180e2e1f1c_MD0005_00 Menopause is the permanent cessation of menses due to the loss of ovarian function. The median age of menopause is 51 and the diagnosis is made after >1 year of amenorrhea. Most women experience symptoms of menopause (eg, hot flashes, irregular menses, sleeping difficulties) over several years prior to the cessation of menses. Anovulatory bleeding (eg, heavy, irregular menses) occurs due to oocyte depletion and decreased progesterone secretion. However, the endometrium may continue to proliferate due to unopposed estrogen secretion and progress into endometrial hyperplasia or cancer. Because the risk of endometrial hyperplasia and cancer increases with age and long periods of anovulation, women age >45 with anovulatory bleeding are evaluated for malignancy with an endometrial biopsy. endometrial biopsy (Choice A) This patient's symptoms may be due to menopausal transition. However, she has several risk factors for endometrial hyperplasia and cancer (eg, obesity, age >45, anovulation, diabetes mellitus) and requires evaluation with an endometrial biopsy. (Choice B) After endometrial hyperplasia and cancer are ruled out, treatment of anovulatory bleeding can be offered in the absence of contraindications. Treatment options for anovulatory bleeding include low-dose oral contraceptives, cyclic progestins, or a levonorgestrel-containing intrauterine device, all of which provide endometrial protection. (Choice C) Coagulopathies typically present as heavy, regular menstrual periods rather than anovulatory bleeding. In addition, inherited coagulopathies (eg, von Willebrand disease) typically present in adolescence. Therefore, coagulation factor studies are not indicated for this patient. (Choice E) Menopause is a clinical diagnosis and an FSH level is not required. Educational objective: The menopausal transition is characterized by anovulatory bleeding, hot flashes, and sleeping difficulties prior to the cessation of menses. An endometrial biopsy is indicated in women age >45 with anovulatory bleeding to evaluate for endometrial hyperplasia or cancer. References: Incidence of endometrial hyperplasia. (http://www.ncbi.nlm.nih.gov/pubmed/19393600) Obesity and endometrial hyperplasia and cancer in premenopausal women: A systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/26829507)

Question 15

A 16-year-old girl comes to the office with a breast lump that she discovered 2 days ago while applying lotion.  Menarche was at age 12 and menstrual periods are regular, occurring approximately every 30 days.  Her last menstrual period was about 1 month ago.  The patient has a history of atopic dermatitis that typically flares during the summer and with exercise.  She also has asthma for which she takes albuterol as needed.  She takes no other medications and has no allergies.  Her immunizations are up to date.  The patient drinks alcohol and smokes marijuana 2-3 times per week.  She does not use tobacco or other drugs.  Her maternal aunt is in remission after metastatic breast cancer, which was diagnosed at age 55.  Physical examination shows a rubbery, 4-cm mass in the superior outer quadrant of the left breast.  Which of the following findings is most likely to be expected in this patient?
A)Axillary lymphadenopathy
B)Decrease in mass size after menses
C)Eczematous lesions on areola
D)Similar mass in the opposite breast
E)Symptom resolution with needle aspiration

Accepted Answer

Explanation: 11ec2b69_c145_a54d_8f63_152d2810f891_MD0005_00 Fibroadenoma is the most common cause of a palpable breast mass in adolescents. Characteristic physical findings include a single, rubbery, mobile, well-circumscribed mass in the upper outer breast quadrant. Due to hormonal fluctuation, many patients may experience tenderness a few days prior to menstruation. Tenderness as well as size may improve after menses. After observing the suspected fibroadenoma over 1 or 2 menstrual cycles, most adolescent patients can be reassured that the benign mass will regress spontaneously over time. Patients who are non-adolescents or have persistent lesions may require an ultrasound, which would reveal a solid, well-circumscribed, avascular mass. (Choice A) Axillary lymphadenopathy may accompany breast malignancy or infection. Malignancy in a young woman with a mobile breast mass is highly unlikely. Infection is also unlikely without fever, erythema, or significant pain. (Choice C) Eczema (atopic dermatitis) in children and adults typically causes scaly, erythematous, pruritic rashes on flexural surfaces (eg, antecubital fossa). Eczema involving the nipple and areola is rare and should be a red flag for Paget disease of the breast, which typically also produces pruritis and nipple flattening/retraction. (Choice D) Fibrocystic breast changes are common and typically present as palpable clusters of small masses or areas of thickening that are similar in both breasts. The associated breast pain is bilateral and generalized, with an increase in pain prior to menstrual onset. In contrast, fibroadenomas are typically solitary and unilateral, rather than multiple and bilateral. (Choice E) Resolution of a simple breast cyst is expected after needle aspiration. A simple breast cyst may present as a tender, solitary mass; however, the peak incidence is at age 35-50. It is much less common than fibroadenoma or fibrocystic breast changes in adolescents. Educational objective: An adolescent with a single, rubbery, mobile breast mass most likely has a fibroadenoma. Breast tenderness preceding menses typically improves after the menstrual period has ended. References: Pediatric and adolescent breast masses: A review of pathophysiology, imaging, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/23345385) Diagnosis and management of fibroadenomas in the adolescent breast. (http://www.ncbi.nlm.nih.gov/pubmed/24872735) Breast diseases in adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/22846531)

Question 16

A 28-year-old woman comes to the office with 2 days of vaginal spotting.  The patient has no fever, chills, nausea, vomiting, or cramping.  Her last menstrual period was 6 weeks ago, and she had a positive home pregnancy test yesterday.  The patient has no chronic medical conditions or previous surgeries.  She is sexually active with a new male partner and uses condoms for contraception.  The patient previously used a copper intrauterine device for contraception but had it removed due to increased pain and heavy menstrual bleeding.  Recent nucleic acid amplification testing for chlamydia and gonorrhea was negative.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 108/68 mm Hg, and pulse is 81/min.  The abdomen is soft and nontender with no guarding or rebound.  Pelvic examination reveals dark red blood in the posterior vaginal fornix and a closed cervix.  On bimanual examination, there is mild left adnexal tenderness with fullness but no cervical motion tenderness.  The uterus is small and nontender.  Quantitative β-hCG is 3,700 IU/L.  Transvaginal ultrasound reveals a 4.6-cm left adnexal complex mass and a thickened endometrium.  Which of the following is the most likely diagnosis in this patient?
A)Corpus luteum cyst
B)Early pregnancy of unknown location
C)Ectopic pregnancy
D)Implantation bleeding
E)Threatened abortion

Accepted Answer

Explanation: 11ec2b69_c145_090c_8f63_b755d1b7421b_MD0005_00 This patient has first-trimester vaginal bleeding and a positive pregnancy test, concerning for an ectopic pregnancy. Patients with a suspected ectopic pregnancy undergo evaluation with pelvic ultrasound and a β-hCG level. An early intrauterine pregnancy can be visualized by ultrasound when the β-hCG level is above the discriminatory zone (>3,500 IU/L). This patient has a level above the discriminatory zone and an ultrasound revealing an empty uterus and a complex adnexal mass, which are diagnostic of an ectopic pregnancy. Symptoms of an ectopic pregnancy typically occur 6-8 weeks after the last menstrual period. In addition to vaginal bleeding, lower abdominal pain and amenorrhea may occur. The most common location for ectopic pregnancy is the ampulla of the fallopian tube; other implantation sites include the ovary, abdomen, and cornual region of the uterus. Risk factors include prior ectopic pregnancy, history of pelvic surgery, tobacco use, pelvic inflammatory disease, infertility, and in vitro fertilization. ampulla of the fallopian tube Treatment is with either medical (eg, methotrexate) or surgical management, depending on the patient's hemodynamic status and contraindications to methotrexate. (Choice A) The corpus luteum, a physiologic ovarian cyst, develops after ovulation and produces progesterone to maintain the pregnancy until the placenta develops. The cyst appears as an adnexal mass on ultrasound; however, an associated intrauterine pregnancy is also seen on ultrasound. (Choice B) An early pregnancy of undetermined location occurs when a pregnancy cannot be visualized on ultrasound at a β-hCG level below the discriminatory zone (≤3,500 IU/L); it can be either ectopic or intrauterine. In stable patients, the β-hCG level is repeated every 48 hours to determine whether the increase is consistent with a normal pregnancy (≥35% rise every 48 hours). Ultrasound is repeated until β-hCG is >3,500 IU/L and an intrauterine pregnancy is visualized. (Choice D) Implantation bleeding may occur approximately 2 weeks after fertilization (or 4 weeks after the last menstrual period) as the fertilized egg attaches to the endometrium. Bleeding is scant and painless. The absence of an intrauterine gestation on ultrasound makes this diagnosis unlikely. (Choice E) A threatened abortion presents with vaginal bleeding, a closed cervix, and an intrauterine pregnancy with normal fetal cardiac activity. threatened abortion Educational objective: An ectopic pregnancy can present with first-trimester vaginal bleeding, a positive pregnancy test, and a complex adnexal mass without evidence of an intrauterine pregnancy. References: Ultrasound evaluation of first trimester complications of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27720100) Suspected ectopic pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/16449130)

Question 17

A 34-year-old woman comes to the office for treatment of infertility. The patient has been trying to become pregnant with her current partner for the past year but has not yet conceived. Since menarche, she has had irregular menses, occurring every 3-6 months, with 7-14 days of bleeding. The patient's last menstrual period was 2 months ago. Over the last 6 months, she has tried to lose weight with exercise and diet but has been unsuccessful. The patient has no chronic medical conditions or prior surgeries. She takes a daily prenatal vitamin and has no medication allergies. The patient does not use tobacco, alcohol, or illicit drugs. BMI is 33 kg/m². On skin examination, there is moderate acne on the chest and back and terminal hairs on the upper lip. Pelvic examination shows a nulliparous cervix, a normal uterus, and bilateral enlarged ovaries. The remainder of the physical examination is unremarkable. Hysterosalpingography reveals a normal uterine cavity with bilateral tubal patency, and her partner's semen analysis is normal. A urine pregnancy test is negative. Which of the following is the best treatment option for this patient's infertility? A)Letrozole B)Leuprolide C)Metformin D)Progesterone E)Spironolactone

Accepted Answer

Explanation: 11ec2b69_c147_ef41_8f63_d9adb820d289_MD0005_00 This patient with irregular menses and signs of hyperandrogenism (eg, acne, hirsutism) likely has polycystic ovary syndrome (PCOS), a common cause of infertility due to chronic anovulation. Ovulation induction agents (eg, letrozole, clomiphene) can treat anovulatory fertility by increasing gonadotropin levels (ie, FSH, LH), which stimulates ovulation. Letrozole and clomiphene stimulate gonadotropin release via the manipulation of different targets on the hypothalamic-pituitary-ovarian (HPO) axis: Letrozole acts on the ovaries. Ovarian theca cells produce androgens, which are converted to estrogen by the enzyme aromatase within ovarian granulosa cells. Patients with PCOS typically have increased ovarian androgen production, which leads to increased ovarian estrogen production and the inhibition of GnRH, FSH, and LH release due to negative feedback on the HPO axis. Letrozole inhibits aromatase, thereby inhibiting conversion of androgen to estrogen at the ovary. This decrease in estrogen provides feedback to the hypothalamus to increase GnRH secretion, which increases pituitary FSH release and stimulates ovulation. Clomiphene acts on the hypothalamus. It depletes hypothalamic estrogen receptors, leading the hypothalamus to perceive low estrogen levels. Without negative feedback from estrogen, the hypothalamus increases GnRH release, which increases FSH and LH levels and induces ovulation. (Choice B) Leuprolide is a GnRH agonist that causes decreased pulsatile GnRH release. The result is decreased FSH, LH, and estrogen levels (ie, hypogonadotropic hypogonadal state), which would worsen rather than improve infertility. (Choice C) Metformin can be used in patients with PCOS who have insulin resistance (eg, impaired glucose tolerance); however, it is not used for anovulatory infertility due to lower pregnancy and live-birth rates compared to letrozole and clomiphene. (Choice D) Progesterone is secreted by the corpus luteum during the luteal phase of the menstrual cycle (ie, following ovulation) to prepare the endometrium for possible pregnancy implantation. Although cyclic progesterone withdrawal can be used in anovulatory patients for endometrial protection (ie, prevention of hyperplasia/cancer), it does not treat infertility. (Choice E) Spironolactone blocks peripheral androgen receptors and can be used to treat hyperandrogenic symptoms (eg, acne, hirsutism) associated with PCOS. However, spironolactone does not enhance fertility and is not recommended in patients desiring pregnancy because of the risk for fetal abnormalities. Educational objective: Polycystic ovary syndrome (PCOS) causes infertility due to chronic anovulation. Affected patients can be treated with letrozole, an aromatase inhibitor that inhibits ovarian estrogen production to stimulate gonadotropin release and induce ovulation.

Question 18

A 15-year-old girl is brought to the office by her mother to discuss contraception. The patient recently became sexually active with her boyfriend of a year and uses condoms most of the time. She revealed to her mother that she has been sexually active, and they decided that she needs a reliable form of contraception. The patient reports no vaginal spotting or abnormal vaginal discharge. She has no chronic medical conditions or previous surgeries. She started menstruating at age 12; menses occur every 29 days and consist of 2-3 days of light bleeding and no cramping. Family history is noncontributory. The patient takes no medications and does not use tobacco, alcohol, or illicit drugs. She does well in school and is a member of the debate team. Blood pressure is 120/80 mm Hg and pulse is 68/min. BMI is 23 kg/m². The rest of the physical examination is unremarkable. Sexually transmitted infection screening is performed. Urine pregnancy test is negative. In addition to condom use, which of the following is the best contraception option for this patient? A)Contraceptive patch B)Copper-containing intrauterine device C)Depot medroxyprogesterone D)Oral contraceptives E)Vaginal spermicide

Accepted Answer

Explanation: 11ec2b69_c141_d4b7_8f63_edf8bd98a41c_MD0005_00 Most adolescent pregnancies are unintended as few adolescents use effective contraception regularly. Barriers to contraception use in adolescents include poor access, prohibitive cost, misconceptions about the risk of pregnancy, concerns about confidentiality, and miseducation about contraception side effects. Because barrier methods (eg, condoms) are the only type of contraception that prevents sexually transmitted infections, all patients should be advised to use them. However, because condoms are associated with a significant failure rate, an additional contraceptive method is indicated to further decrease the risk of pregnancy. Long-acting reversible contraception (LARC) is the first-line contraceptive method for adolescents given its efficacy (>99%), safety, high rate of satisfaction, long duration of use, and quick return to fertility on discontinuation. LARCs include intrauterine devices (IUDs) and contraceptive implants. The copper-containing IUD is effective for up to 10 years, the progestin-releasing IUD for 5 years, and the subdermal implant for 3 years; however, all can be removed earlier. The progestin-releasing IUD is recommended for patients with heavy menstrual bleeding and dysmenorrhea. The copper-containing IUD is recommended for patients who have light menstrual periods, desire long-term contraception, and wish to avoid hormonal contraception. Contraindications to IUD insertion include uterine anomalies and active pelvic infection. Nulliparity is not a contraindication to IUD use. copper-containing IUD (Choices A and D) Neither the contraceptive patch nor oral contraceptives are as effective as LARCs (91% vs. 99%), even with ideal use. Method failure is commonly due to improper use or missed doses. (Choice C) Depot medroxyprogesterone, an intramuscular injection given every 3 months, has a lower efficacy rate (94%) than a LARC. In addition, the need for serial injections decreases the likelihood of long-term continuation. (Choice E) Spermicides immobilize sperm by damaging cell membranes. Their effectiveness is low when used alone (eg, 80% failure rate); therefore, spermicides should be used with cervical caps or diaphragms. In addition, spermicides may cause damage to genital epithelium and increase susceptibility to sexually transmitted infections. Educational objective: Long-acting reversible contraceptives (eg, intrauterine devices, subdermal implants) are first-line contraceptive methods for adolescents. They are safe, are effective, and result in a high rate of satisfaction, a long duration of use, and a quick return to fertility on discontinuation. References: Contraception for adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/25266430) Long-acting reversible contraception: an essential guide for pediatric primary care providers. (http://www.ncbi.nlm.nih.gov/pubmed/28292451)

Question 19

A 32-year-old woman telephones the office due to continued vaginal discharge and vulvar pruritus.  She first noticed the presence of a white, malodorous vaginal discharge a week ago.  The patient began using an over-the-counter antifungal cream at that time.  A few times last year she had similar symptoms that resolved with the same medication.  The patient was diagnosed with type 1 diabetes mellitus 20 years ago.  She has had no surgeries.  The patient has no medication allergies and does not use tobacco, alcohol, or illicit drugs.  Family history is noncontributory.  She is sexually active and uses a levonorgestrel-releasing intrauterine device for contraception.  The patient is concerned about the ongoing symptoms and asks for a recommendation of a more effective treatment.  Which of the following is the most appropriate response?
A)Obtain a more detailed sexual history
B)Prescribe a single dose of oral fluconazole
C)Recommend removal of the intrauterine device
D)Review blood sugar control over the past month
E)Schedule an appointment in the office for an examination

Accepted Answer

Explanation: 11ec2b69_c14a_8754_8f63_972a6215c7e5_MD0005_00 The typical features of vaginitis (ie, discharge, pruritus, odor) are common and nonspecific, and often lead to incorrect self-diagnosis and over-the-counter treatment. Etiologies include infections of the vulva, vagina, and cervix. Noninfectious causes are chemicals, irritants, hormonal disorders, and (rarely) some systemic disorders. The most common infections are bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. History alone is not reliable and should be confirmed in the office by a pelvic examination and wet mount microscopy or nucleic acid amplification testing to avoid misdiagnosis and inappropriate treatment. (Choice A) A detailed sexual history can provide further evidence of a specific infection, but laboratory evidence is required for appropriate therapy. (Choice B) Prescribing fluconazole is inappropriate in the absence of a specific diagnosis. (Choice C) Intrauterine devices do not increase the risk of vaginitis, and treatment of pelvic infections does not require their removal. (Choice D) Tight blood sugar control is important to prevent recurrences of vulvovaginal candidiasis; however, it does not replace microscopy for diagnostic confirmation. Educational objective: Clinical features of vaginitis are common, nonspecific, and can lead to incorrect self-diagnosis. The diagnosis should always be confirmed by wet mount microscopy or nucleic acid amplification testing to avoid inappropriate treatment. References: Vaginitis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/21084788)

Question 20

A 2-year-old girl is brought to the office for evaluation of persistent watery diarrhea.  Five days ago, the patient began having watery diarrhea and vomiting multiple times throughout the day.  The vomiting resolved within 24 hours, but the patient has since refused to eat her normal meals because of nausea, preferring to drink apple and pear juice throughout the day.  She has had large, watery stools 4 or 5 times a day with no visible blood and she passes gas frequently, but she has no diarrhea overnight.  The patient takes no medications and has no allergies.  Immunizations are up to date.  Family history is significant for celiac disease in her mother and maternal grandmother.  Temperature is 36.7 C (98 F), blood pressure is 100/70 mm Hg, and pulse is 120/min.  Height is 85 cm (33.5 in, 50th percentile) and weight is 10.8 kg (23.8 lb, 40th percentile), down 1 kg (2.2 lb) from her well-child visit a month ago.  The lips appear dry but the oral mucosa is moist and has no oral lesions.  Auscultation reveals hyperactive bowel sounds.  The abdomen is mildly tender to palpation in all quadrants, but there is no rebound or guarding.  Skin examination shows perianal erythema and irritation but no jaundice or other abnormalities.  Capillary refill is brisk.  Which of the following is the best next step in management of this patient?
A)Begin empiric antibiotic therapy
B)Evaluate stool for protein and fat malabsorption
C)Order tissue transglutaminase IgA
D)Provide reassurance with no additional intervention
E)Recommend discontinuing fruit juice consumption

Accepted Answer

Explanation: 11ec2b69_c14a_d575_8f63_6ba1ba42bca6_MD0005_00 This patient with emesis, watery diarrhea, abdominal tenderness, and hyperactive bowel sounds most likely has viral gastroenteritis. Symptoms can be exacerbated by fruit juice, as seen in this patient. Excessive consumption of juice high in fructose (eg, apple juice) or sorbitol increases osmotic load and leads to fructose malabsorption in the small intestine. In addition, a mild, transient lactase deficiency with dairy intake can result from gastroenteritis due to inflammation and damage to the intestinal epithelium. Fluid repletion is the first-line treatment for viral gastroenteritis. This child has signs of mild dehydration (ie, dry lips, normal vital signs, brisk capillary refill) and is able to tolerate oral intake. Therefore, oral rehydration with a hypo-osmolar solution containing electrolytes and small amounts of glucose is the best rehydration option for her. Hydration with water alone, however, could result in dangerous hypoglycemia or hyponatremia. An age-appropriate diet can be resumed as tolerated; however, fruit juice should be avoided until symptoms resolve. (Choice A) Antibiotics may be prescribed for severe or prolonged bacterial gastroenteritis (eg, Campylobacter, Shigella) with high fevers, blood in the stool, and intense abdominal pain, findings not seen in this patient. (Choice B) Fat and protein malabsorption (eg, cystic fibrosis) typically presents with failure to thrive and chronic steatorrhea rather than acute watery diarrhea. (Choice C) Tissue transglutaminase IgA is elevated in celiac disease, which presents as chronic diarrhea, abdominal distension, and failure to thrive. This patient's normal growth percentiles and acute onset of symptoms are not characteristic. (Choice D) Although viral gastroenteritis is generally self-limited, this child's diarrhea is exacerbated by excessive fruit juice consumption during the daytime; discontinuing juice may help her symptoms. Educational objective: Viral gastroenteritis commonly causes acute watery diarrhea in children, and excessive fruit juice consumption may exacerbate symptoms. Treatment involves oral rehydration therapy and avoidance of fruit juice during illness. References: Recent advances of oral rehydration therapy (ORT). (http://www.ncbi.nlm.nih.gov/pubmed/21468201) Fruit juice in infants, children, and adolescents: current recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/28562300)

Exam 2: Foundations of Independent Practice