Family Medicine (AAFP Questions) with accurate answers. Graded A+ 2022/2023

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Family Medicine (AAFP Questions) with accurate answers. Graded A+ 2022/2023 MCC of HTN in children < 6 yrs - ✔✔renal parenchymal dz (urinalysis, urine culture, and renal ultrasonography shoul... d be ordered for all children presenting with hypertension) TZDs should not be used in patients - ✔✔with New York Heart Association class III or IV heart failure next step in management if patient is already on maximum therapy for CHF? - ✔✔cardiac resynchronization therapy (look for bundle branch block and EF less than or equal to 30%) what dietary recommendation has been shown to decrease the rate of a sudden death due to cardiovascular disease? - ✔✔Increased intake of omega-3 fax chest radiograph shows widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement -> Dx? Management? - ✔✔dissecting aortic aneurysm Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. initial medical management aortic dissections confined to the descending aorta? - ✔✔reduce the systolic blood pressure to 100-120 mmHg or to the lowest level tolerated (use beta blockers such as propranolol or labetalol to get the heart rate below 60 beats per minute, if systolic blood pressure remains over 100 mmHg, IV nitroprusside should be added... but must have beta-blockade before her nitroprusside because of vasodilation from nitroprusside will induce reflex activation of the sympathetic nervous system,, causing increased ventricular contraction and increased shear stress on the aorta) If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of intravenous ___ - ✔✔verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may be necessary. electrical cardioversion may be necessary if these measures fail to terminate the tachycardia arrhythmia (also remember to treat contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances). monotherapy for hypertension and African American patients is more likely to consist of ___ - ✔✔diuretics for calcium channel blockers (rather than 8 a blockers or ACE inhibitors; it has been suggested that hypertension and African American does not as angiotensin II dependent as it appears to be in Caucasians) carvedilol and metoprolol are metabolized by the __ - ✔✔liver enoxaparin isn't metabolized by the ___ - ✔✔kidneys ( requires dosage adjustment in renal disease) inpatient with MI, new left bundle branch block suggests ___ What is indicated in this situation? - ✔✔Occlusion of LAD, placing a significant portion of LV in jeopardy Thrombolytic therapy (this would be harmful in a patient with ischemia but no infarction-they will show ST segment depression only) isolated systolic hypertension in the elderly responds best to ___ - ✔✔diuretics (and beta blockers to a lesser extent) thiazide diuretics can improve osteoporosis 31 yo F pt found to have thrombus in axillosubclavian vein (only activity she recalls is digging strenuously to plant a garden the prior day) -> what is Dx? - ✔✔a compressive anomaly in the thoracic outlet (these are usually bilateral so there is similar risk on the other side) For patients with a first episode of unprovoked deep venous thrombosis, evidence supports treatment with ___ - ✔✔warfarin for at least 3 months profuse perspiration with feeding and a 6 month old suggests? - ✔✔CHF you diagnose a patient with aortic stenosis view only complains of dyspnea on exertion (denies chest pain and syncope), echo shows transvalvular gradient of 55 mmHg and a calculated valve area of 0.6 cm^2 -> Management? - ✔✔Valve replacement (patients with symptomatic aortic stenosis had dismal prognosis without treatment, prompt correction of mechanical obstruction with aortic valve replacement is indicated) Contraindications to beta-blocker use include...? - ✔✔hemodynamic instability, heart block, bradycardia, and severe asthma. Beta-blockers may be tried in patients with mild asthma or COPD as long as they are monitored for potential exacerbations. how are patients who are capable of moderate activity (greater than 4 METs) without cardiac symptoms cleared for surgery? - ✔✔A resting 12-lead EKG is recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease. No stress testing or coronary angiography for elective minor or intermediate-risk operations (even if pt had prior cardiac hx but is now asymptomatic). a patient in her third trimester has 2+ pitting edema bilaterally, blood pressure is 118/78 -> management of edema? - ✔✔leg swelling requires no further evaluation what can be used for cardiac prophylaxis both before and after her surgery in patients with known cardiac disease or cardiac risk factors? - ✔✔Beta blockers best initial approach for atrial fibrillation - ✔✔ventricular RATE control with calcium channel blocker or beta blocker (digoxin is less effective for rate control and should be reserved as an add-on for patients not controlled with the beta blocker or calcium channel blocker, or for patients with significant LV systolic dysfunction) and anti-coagulation with warfarin cilostazol (useful for treatment of intermittent claudication) should be avoided in patient's with? - ✔✔CHF patients with long QT syndrome that had sudden arrhythmia death syndrome usually have? - ✔✔torsades de pointes or V. fib Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors such as - ✔✔unstable coronary syndrome (acute or recent myocardial infarction, unstable angina), decompensated congestive heart failure, significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease. Intermediate clinical predictors of increased perioperative cardiovascular risk for elderly patients include - ✔✔mild angina, previous myocardial infarction, compensated congestive heart failure, diabetes mellitus, and renal insufficiency. Minor clinical predictors of increased perioperative cardiovascular risk for elderly patients include - ✔✔advanced age, an abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled hypertension. Subclinical hypothyroidism (TSH >10 µU/mL) is likely to progress to overt hypothyroidism, and is associated with increased ___ - ✔✔LDL cholesterol. Subclinical hyperthyroidism (TSH <0.1 µU/mL) is associated with the development of ___ - ✔✔atrial fibrillation, decreased bone density, and cardiac dysfunction. ___ therapy can elevate calcium levels by elevating parathyroid hormone secretion from the parathyroid gland. This duplicates the laboratory findings seen with mild primary hyperparathyroidism. - ✔✔Lithium A patient with a recurrent kidney stone and an elevated serum calcium level most likely has ___ - ✔✔hyperparathyroidism (Elevated PTH is caused by a single parathyroid adenoma in approximately 80% of cases.) When evaluating a patient with a solitary thyroid nodule, red flags indicating possible thyroid cancer include - ✔✔male gender; age <20 years or >65 years; rapid growth of the nodule; symptoms of local invasion such as dysphagia, neck pain, and hoarseness; a history of head or neck radiation; a family history of thyroid cancer; a hard, fixed nodule >4 cm; and cervical lymphadenopathy. ___, even if well controlled, disqualifies a driver for commercial interstate driving - ✔✔Insulin-dependent diabetes ___ may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. - ✔✔Volvulus The classic finding on abdominal plain films for volvulus is ___ - ✔✔the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. ___ is the most common congenital abnormality of the small intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa. Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis. - ✔✔Meckels diverticulum Eradication of ___ significantly reduces the risk of ulcer recurrence and rebleeding in patients with duodenal ulcer, and reduces the risk of peptic ulcer development in patients on chronic NSAID therapy. - ✔✔Helicobacter pylori (Eradication has minimal or no effect on the symptoms of nonulcer dyspepsia and gastroesophageal reflux disease) Although H. pylori infection is associated with gastric cancer, have trials shown that eradication of H. pylori purely to prevent gastric cancer is beneficial? - ✔✔No What organisms are resistant to chlorine and are important causes of gastroenteritis from drinking water? - ✔✔Cryptosporidium oocysts, Giardia cysts, Entamoeba histolytica and hepatitis A virus A vaccinated person has been exposed to a known Hep B positive individual. What should be done? - ✔✔The exposed person should be tested for hepatitis B antibodies; if antibody levels are inadequate (<10 IU/L by radioimmunoassay, negative by enzyme immunoassay) HBIG should be administered immediately, as well as a hepatitis B vaccine booster dose. Alpha-fetoprotein is a marker for ___ - ✔✔hepatocellular carcinoma and nonseminomatous germ cell tumor, and is elevated in 80% of hepatocellular carcinomas. CA-125 is a marker for ___ - ✔✔ovarian cancer (Although it is elevated in 85% of ovarian cancers, it is elevated in only 50% of early-stage ovarian cancers) Carcinoembryonic antigen (CEA) is a marker for) ___ - ✔✔colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Cancer antigen 27.29 (CA 27-29) is a tumor marker for ___ - ✔✔breast cancer What is MCC of bacterial diarrhea in US? - ✔✔Campylobacter ___ is a dome shaped lesion that has a central plug, grows rapidly and may heal within 6 months to a year. - ✔✔Keratoacanthoma (Squamous cell carcinoma may appear grossly and histologically similar to keratoacanthoma but does not heal spontaneously). The pain from infiltration of local anesthetics can be decreased by - ✔✔using a warm solution, using small needles, and performing the infiltration slowly.It is also helpful to add sodium bicarbonate to neutralize the anesthetic since they are shipped at an acidic pH to prolong shelf life. An exception to this tip is bupivicaine (Marciane, Sensorcaine) as it will precipitate in the presence of sodium bicarbonate. Cause of cutaneous larva migrans? - ✔✔Ancylostoma species (dog or cat hookworm) Chronic paronychia is a common condition in workers whose ___ Treatment? - ✔✔hands are exposed to chemical irritants or are wet for long periods of time. strong topical corticosteroids over several weeks can greatly reduce the inflammation, allowing the nail folds to return to normal and helping the cuticles recover their natural barrier to infection ___ yields the best results in the treatment of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy. - ✔✔Excision of the lateral nail plate with lateral matricectomy. (Antibiotic therapy and cotton-wick elevation are acceptable for very mildly inflamed ingrown toenails.) The most common infection transmitted person-to-person in wrestlers is ___ - ✔✔herpes gladiatorum caused by the herpes simplex virus. Keratinized plugs? - ✔✔molluscum contagiosum Osteoporotic bone loss can be caused or accelerated by prolonged use of what medications? - ✔✔Anticonvulsants such as phenytoin increase the hepatic metabolism of vitamin D, thereby reducing intestinal calcium absorption. Other medications that adversely affect bone mineral density include glucocorticoids, cyclosporine, phenobarbital, and heparin. (Thiazide diuretics reduce urinary calcium loss and are believed to preserve bone density with long-term use.) A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure. Which one of the following would be the most appropriate next step? - ✔✔This is developmental dysplasia of the hip. Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip (ie refer to ortho). Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. ___ is a disease of the middle-aged and elderly. Discomfort is common in the neck, shoulders, and hip girdle areas. There is an absence of objective joint swelling, and findings tend to be symmetric. Characteristically, the erythrocyte sedimentation rate and C-reactive protein levels are significantly elevated; however, these tests are nonspecific. Occasionally there are mild elevations of liver enzymes, but muscle enzymes, including creatine kinase, are not elevated in this disorder. - ✔✔Polymyalgia rheumatica The current Dietary Reference Intake recommendation for vitamin D is ___ for all women between the ages of 9 and 50 years; pregnancy or lactation does not affect the recommendation. The DRI __ daily for women age 51-70 and ___ daily for women over the age of 70. - ✔✔200 IU/day doubles to 400 IU, triples to 600 IU (The maximum daily oral intake of vitamin D thought to be safe is 2000 IU/day for all females over the age of 12 months.) Is there a linear correlation between bone mineral density and fracture risk? - ✔✔No. Bone architecture may be changed by bisphosphonate therapy, which may result in a decreased fracture risk, despite minimal change in T-score. Pts should be encouraged to continue bisphosphonate tx despite minimal T-score change if they have not had a fracture. Proximal muscle involvement and elevation of serum muscle enzymes such as creatine kinase and aldolase suggests a diagnosis of ___. ___ are the accepted treatment of choice. - ✔✔Inflammatory myopathy (polymyositis/dermatomyositis) group. Corticosteroids You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with the cosmetic appearance and possible future disability, and request that she be treated. You recommend ___? - ✔✔Observation There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8-10 years of age who still have cosmetically unacceptable, dysfunctional gaits. A ___ will reduce both pain and disability in patients with osteoarthritis of the knee. - ✔✔therapeutic exercise program The most serious complication of a slipped capital femoral epiphysis is ___ - ✔✔avascular necrosis The three most common knee conditions in children and adolescents are - ✔✔patellar subluxation, tibial apophysitis, and patellar tendinitis. Analgesic that is contraindicated in seizure disorders - ✔✔tramadol ___ syncope is a strong diagnostic consideration for episodes of syncope associated with a characteristic precipitating factor. The event can be duplicated with ___, demonstrating hypotension and bradycardia. - ✔✔Reflex tilt testing Does postoperative depression increase the risk for subsequent cardiovascular events? - ✔✔yes The only modality of complementary and alternative medicine that has been shown to have a therapeutic effect on migraines is ___ ___ is used to treat cluster HA's - ✔✔biofeedback oxygen The clinical presentation consisting of parkinsonian symptoms (rigidity, tremor), fluctuating levels of alertness and cognitive abilities, and behavior sometimes mimicking acute delirium suggests ___. On pathologic examination, ___ bodies (seen in the substantia nigra in patients with Parkinson's disease) are present diffusely in the cortex. - ✔✔Lewy body dementia (Significant visual hallucinations are common, and delusions and auditory hallucinations are seen to a lesser degree.) Lewy A 75-year-old male has not seen a physician in 25 years and presents with advanced Parkinson's disease. The best initial treatment would be ___ - ✔✔carbidopa/levidopa (While anticholinergics such as benztropine and amantadine may provide some improvement of symptoms, these effects wane within a few months. Such medications are not a good option in this patient with advanced disease. Dopamine agonists provide some improvement in motor complications, but are mainly used to delay the introduction of levodopa in younger patients, to avoid levodopa-related adverse reactions.) What medications should be avoided in the treatment and prophylaxis of migraine during early pregnancy? - ✔✔Ergotamines should be avoided as they are uterotonic and have abortifacient properties. They have also been associated with case reports of fetal birth defects. Triptans have the potential to cause vasoconstriction of the placental and uterine vessels and should be used only if the benefit clearly outweighs the harm. What side effect induced by traditional neuroleptic agents responds to treatment with beta-blockers? - ✔✔Akithesia (motor restlessness & inability to sit still) Most s/e's of neuroleptics can be tx'ed w/ anticholinergics (as can akithesia, but it also responds to BB's) MCC of fainting? - ✔✔vasovagal syncope A post-traumatic air-fluid level in the sphenoid sinus is associated with ___ - ✔✔basilar skull fractures (This finding is frequently noted on cervical spine films.) What are the contraindications of thrombolytic therapy? - ✔✔Contraindications include blood glucose levels <50 mg/dL or >400 mg/dL, resolving transient ischemic attack, and hemorrhage visible on a CT scan. Why should meperidine be avoided in the elderly? - ✔✔it's metabolite can accumulate and cause seizures. n a child, what is most likely to improve adherence to a chronic medication regimen? - ✔✔Adding a favorite flavor to bitter liquid medications What is the only consistent t risk factor for being a victim of domestic abuse? - ✔✔gender (females) Many older or less-educated Mexican-Americans consider direct eye contact to be - ✔✔disrespectful (Because a physician is held in high regard, these patients will often either look down or look at another, more equal person in the room while being interviewed) Patients at the end of life have five main areas of concern: - ✔✔control of pain and other symptoms; avoiding a prolongation of the dying process; having a sense of control; relieving burdens on family and loved ones; and strengthening relationships with family and friends. What sleep problem in children is most likely to occur during the second half of the night? - ✔✔Nightmares occur in the second half of the night, when rapid eye movement (REM) sleep is most prominent. Parasomnias, including sleepwalking, confusional arousal, and sleep terrors, are disorders of arousal from non-REM (NREM) sleep. These are more common in children than adults because children spend more time in deep NREM sleep. Such disorders usually occur within 1-2 hours after sleep onset, and coincide with the transition from the first period of slow-wave sleep. There are no absolute contraindications to electroconvulsive therapy (ECT), but more complications are seen in patients with... - ✔✔a history of recent cerebral hemorrhage, stroke, or increased intracranial pressure A 79-year-old male has psychosis secondary to dementia associated with Parkinson's disease. After exhausting all other options you decide to prescribe an antipsychotic agent. What is the best antipsychotic to use in this case? - ✔✔Quetiapine is an atypical antipsychotic that has no clinically significant effect on the dopamine D2 receptor, which is responsible for the parkinsonian side effects of antipsychotic medications. Because of this, it is considered the antipsychotic of choice in patients with dementia associated with Parkinson's disease, although its use has not been studied extensively in this clinical situation. A 16-year-old male is brought to your office by his mother for "stomachaches." On review of systems, he also complains of headaches, occasional bedwetting, and trouble sleeping. His examination is within normal limits. His mother says that he is often in the nurse's office at school, and doesn't seem to have any friends. After some questions from you, he admits to being called names and teased at school. Which one of the following would be most appropriate? - ✔✔This is bullying. Check w/ school counselor to see if the school has a process for dealing with bullying and supporting victims. Compared to children with attention-deficit/hyperactivity disorder (ADHD), adults with ADHD tend to be less ___ - ✔✔impulsive (impulsivity decreases with age, but inattention does not) What psychotropic medication is contraindicated in breast-feeding mothers? - ✔✔Lithium (Breastfed infants of women taking lithium can have blood lithium concentrations that are 30%-50% of therapeutic levels.) What antipsychotics are associated with hyperglycemia? - ✔✔olanzapine and clozapine are associated w/ hyperglycemia and the development of DM2. If the patient remains in distress, mood should be evaluated. If it waxes and wanes with time and if self-esteem is normal, this is likely preparatory grief. The patient may have fleeting thoughts of suicide and likely will express worry about separation from loved ones. This usually responds to counseling. In patients with anhedonia, persistent dysphoria, disturbed self-image, hopelessness, poor sense of self-worth, rumination about death and suicide, or an active desire for early death, depression is the problem. For patients who are expected to live only a few days, ___ should be used. For those who are expected to survive longer, ___ are a good choice - ✔✔psychostimulants such as methylphenidate, SSRIs Which SSRI is associated with the fewest drug interactions? - ✔✔Like all drugs, SSRIs have significant side effects, including inhibition of the cytochrome P-450 system. However, citalopram is least likely to inhibit this system, making it a preferred SSRI for patients taking multiple medications for other illnesses. The patient exhibits signs of a moderate bleeding diathesis. Her prothrombin time (PT) elevation, without evidence of hepatocellular damage or hepatic dysfunction, is highly suspicious for ___ ingestion. The normalization of the PT under observation in a hospital setting is consistent with this suspicion. - ✔✔warfarin ___ is the most common cause of acute vaginitis, accounting for up to 50% of cases in some populations. It is usually caused by a shift in normal vaginal flora. - ✔✔Bacterial vaginosis (BV) (BV is considerably more common as a cause of vaginal discharge than C. albicans and T. vaginalis.) What fetal ultrasound measurements gives the most accurate estimate of gestational age in the first trimester (up to 14 weeks)? - ✔✔Crown-rump length (In the second trimester, biparietal diameter and femur length are used. During the third trimester, biparietal diameter, abdominal circumference, and femur length are best for estimating gestational age.) A 20-year-old female long-distance runner presents with a 3-month history of amenorrhea. A pregnancy test is negative, and other blood work is normal. She has no other medical problems and takes no medications. With respect to her amenorrhea, you advise her - ✔✔increase her calorie intake Amenorrhea is an indicator of inadequate calorie intake, which may be related to either reduced food consumption or increased energy use. This is not a normal response to training, and may be the first indication of a potential developing problem. A 4-year-old white female is brought to your office by her mother, who reports that the child recently developed a foul-smelling vaginal discharge. After an appropriate history and general examination, you determine that a genital examination is necessary. What position is most likely to allow for visualization of the child's vagina and cervix without instrumentation? - ✔✔The knee-chest position on an examination table In the 2001 Bethesda System, atypical squamous cells of unknown significance (ASCUS) was replaced by ___ - ✔✔atypical squamous cells (ASC). ___ has proven to be the most reliable clinical symptom of uterine rupture. - ✔✔Fetal distress The "classic" signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone or cessation of uterine contractions are not reliable and are often absent. Recommended management strategies for women with ASC-US include repeat cytology at 4-6 months, immediate colposcopy, and reflex DNA testing for oncogenic HPV types. Should two repeat cytologic examinations at 4- to 6-month intervals prove negative, the patient can ___ Should any repeat examination detect ASC-US or more significant cytology, ___ is indicated. - ✔✔safely return to routine cytologic screenings. colposcopy What finding is most sensitive for the diagnosis of bacterial vaginosis? - ✔✔the pH of the discharge (clue cells are most specific) What is required before Rx'ing OCPs to a teen who has recently become sexually active? - ✔✔BP and pregnancy test (no further workup is necessary unless indicated by the hx) The probability of pregnancy after unprotected intercourse is the highest at which time? - ✔✔1 day before ovulation There is a 30% probability of pregnancy resulting from unprotected intercourse 1 or 2 days before ovulation, 15% 3 days before, 12% the day of ovulation, and essentially 0% 1-2 days after ovulation Is PCOS a risk factor for endometrial cancer? - ✔✔Yes (Patients with persistent hyperestrogenic states are at heightened risk for the development of endometrial cancer. The chronic anovulation and consequent hyperstimulation of the endometrium seen with polycystic ovary syndrome predispose women to endometrial hyperplasia and carcinoma.) The Centers for Disease Control and Prevention (CDC) recommends antenatal screening for group B streptococcal disease by obtaining cultures from the ___ at ___ weeks' gestation - ✔✔rectum and vaginal introitus, 35-37 The gastrointestinal tract is the most likely reservoir of group B Streptococcus with secondary spread to the genital tract. Cultures from the vaginal introitus and the rectum are the most sensitive for detecting colonization. No speculum examination is necessary. The closest time to delivery that cultures can be performed and allow time for results to be available is 35-37 weeks' gestation. Culture-positive women are then treated during labor. A 31-year-old married white female complains of vaginal discharge, odor, and itching. Speculum examination reveals a homogeneous yellow discharge, vulvar and vaginal erythema, and a "strawberry" cervix. The most likely diagnosis is: - ✔✔Trichomonal vaginitis usually causes a yellowish discharge which sometimes has a frothy appearance. Colpitis macularis (strawberry cervix) is often present. A 27-year-old white female sees you for the first time for a routine evaluation. A Papanicolaou test reveals atypical glandular cells of undetermined significance (AGUS). What is most commonly found in this situation? - ✔✔Cervical intraepithelial neoplasia is the most common histologic diagnosis found in patients evaluated for AGUS. Clinical practice guidelines recommend that all patients with atypical glandular cells of undetermined significance (AGUS) be evaluated by colposcopy and endocervical curettage; endometrial sampling is recommended in women 35 years of age or older, and in those with AGUS favoring neoplasia or suggesting an endometrial source. An 18-year-old white female presents with small, localized warts on the vulva and lower vaginal mucosa. She wants to avoid injections and surgical treatment if possible. What is an acceptable topical agent for treating these vaginal lesions? - ✔✔Trichloroacetic acid is acceptable for use on vaginal mucosa. It is also acceptable for use when pregnancy is a possibility. Professional application is necessary. Podofilox and podophyllin in alcohol are not safe for use on mucosa. Imiquimod cream is also not approved for mucosal use. Interferon requires injection. The ___ maneuver by itself (maximal flexion and abduction of the maternal hips) relieves the impaction of the anterior shoulder against the maternal symphysis in a large percentage of cases, especially when combined with suprapubic pressure. - ✔✔McRoberts The classic clinical presentation of ___ is painless, bright red vaginal bleeding. This diagnosis must be considered in all patients beyond ___ weeks' gestation who present with bleeding. - ✔✔placenta previa 24 When should female diaphragms used for contraception be refitted? When should diaphragms be removed? - ✔✔After 15 lb weight gain or pelvic surgery 6-24 hrs after intercourse During a routine physical examination of a 35-year-old Asian female, you note a right adnexal fullness. She has had no symptoms of pain or bloating and has been menstruating normally. Her menses occur approximately every 30 days and her next period is expected to occur in 1 week. Pelvic ultrasonography reveals a thin-walled simple cyst 5 cm in diameter. No other abnormalities are seen in the pelvic structures. What is the best course of action? - ✔✔Repeat ultrasonography in 2-3 months to confirm resolution of the cyst Adnexal masses in women under 45 years of age are benign in 80%-85% of cases. The specific findings of this case also strongly suggest a benign etiology, namely a thin-walled, simple cyst, a lesion that is less than 8 cm in size, and a patient of relatively young age. No aggressive means are indicated in these situations unless there are significant clinical symptoms such as pain, abdominal pressure, urinary symptoms, or gastrointestinal symptoms. Most experts currently recommend a conservative approach with repeat ultrasonography in at least 2 months, during which time the vast majority of benign cysts resolve spontaneously. You note fetal bradycardia in a VBAC mother, what are you thinking? - ✔✔uterine rupture A 12-year-old Hispanic female is brought to your office because of the recent onset of a white vaginal discharge. She is otherwise asymptomatic and has never menstruated. She denies sexual activity and a general examination reveals no abnormalities. You note the presence of breast buds and scant pubic hair. Microscopic examination of the vaginal discharge shows sheets of vaginal epithelial cells. Which is the likely diagnosis? - ✔✔his child is entering puberty. In the 6- to 12-month period before menarche, girls often develop a physiologic vaginal discharge secondary to the increase in circulating estrogens. The gray-white discharge is non-irritating. When physiologic discharge is examined with the microscope, sheets of vaginal epithelial cells are seen. A patient at 40 weeks' gestation has had a fundal height 3-4 cm greater than expected relative to dates for the last several visits. Ultrasonography 2 days ago showed a fetus in the vertex position with an estimated fetal weight of 4200 g (9 lb 4oz). On examination today the patient's cervix is closed, long, posterior, and firm, with the vertex at -2 station. Her pregnancy has been otherwise uncomplicated. Appropriate management at this point would be: - ✔✔Scheduling a routine prenatal visit in 1 week Fetal macrosomia at term is defined by various authorities as birth weight above 4000-4500 g. Ultrasonography, unfortunately, does not provide a particularly accurate estimate of fetal weight for large fetuses. The risk of difficult vaginal delivery and shoulder dystocia does increase with birth weight above 4000-4500 g. This has led to attempts to prevent shoulder dystocia and possible birth injury by either performing an elective cesarean section or inducing labor when the fetus is estimated to be macrosomic. However, no studies have shown a benefit to either intervention in otherwise uncomplicated pregnancies. Suspected macrosomia on its own is no longer considered an indication for induction or cesarean section. However, should this patient not spontaneously go into labor she will soon need to be managed as a post-dates pregnancy and thus a return visit should be scheduled in a week. What is black cohosh? - ✔✔Black cohosh is an herbal preparation widely used in the treatment of menopausal symptoms and menstrual dysfunction. Studies have demonstrated that this botanic medicine appears to be effective in alleviating menopausal symptoms. It has not been proven effective in randomized controlled trials and should not be used to prevent osteoporosis. Questions as to its stimulating effect on endometrial tissue are as yet unanswered. [Show More]

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