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Old 11-28-2011
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ObGyn ObGyn Questions for November 28

1.A 27-year-old woman, gravida 3, para 0 (termination of pregnancy ´ 3) comes to your office for an annual examination. Over the past year she has been in good health except for recurrent upper respiratory tract infections. She smokes ½ pack of cigarettes per day. She has tried to stop smoking three times but is not ready to try again to stop now. She takes a combined oral contraceptive pill (OCP) with 35 μg of estrogen in it. She takes no other medications and has no known drug allergies. Physical examination, including breast and pelvic exams, is significant for intermittent wheezes on chest auscultation. Regarding her birth control choice, which of the following is the most appropriate counseling?

A. Change to a combined OCP with 50-μg estrogen
B. Continue on the present OCP
C. Stop the OCP immediately
D. Stop the OCP over the next 2 years
E. Take a daily baby aspirin with the OCP

2. An 18-year-old woman comes to your office because of abdominal pain. She states that the pain started yesterday afternoon and has been worsening. The pain is in the right lower quadrant and does not radiate. She rates it a 7 on a scale of 1 to 10. She has had some nausea but no vomiting. Nothing seems to improve or worsen the pain. She has a history of hypothyroidism for which she takes thyroid hormone replacement, and no other medical problems. She has never had surgery. She is allergic to penicillin. Physical examination is significant for right lower quadrant tenderness. Bimanual examination reveals right adnexal tenderness. Which of the following is the most appropriate next step in the diagnostic workup of this patient?


A.Abdominal computed tomography (CT)

B. Abdominal x-ray

C. Appendiceal ultrasound

D. Pelvic ultrasound

E. Urine human chorionic gonadotropin (hCG)

3.A 17-year-old married girl comes to see you, complaining of “feeling tired all the time,” vomiting in the morning, and weight gain. Examination shows signs of pregnancy that is confirmed by laboratory studies. When informed of this, the girl is visibly distraught. “How could this happen?” she says, “I’ve been on the pill!” Mentioning that she and her husband live with her parents, she declares that she wants an immediate abortion. Which of the following is the best reply?



A. “Certainly, let’s schedule you for the procedure right now.”

B. “Have you considered discussing this with your husband first?”

C. “I want you to take time to think about things before you do anything rash.”

D. “Maybe you should talk this over with your parents before proceeding.”

E.“That’s one option, but I’d like to talk with you a bit before we schedule anything.
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bebix (11-28-2011), drnirajmavani (11-28-2011), pass7 (11-28-2011)



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Old 11-28-2011
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1. C
2. E
3. E
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Old 11-28-2011
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1.B. Continue on the present OCP
2.E. Urine human chorionic gonadotropin (hCG)
3.E.“That’s one option, but I’d like to talk with you a bit before we schedule anything.
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Quote:
Originally Posted by bebix View Post
1.B. Continue on the present OCP
2.E. Urine human chorionic gonadotropin (hCG)
3.E.“That’s one option, but I’d like to talk with you a bit before we schedule anything.

1. answer is B. since her age is < 35 years
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Old 11-28-2011
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C. Stop the OCP immediately(just guessing)as ocps r contraindicated in smokers
E. Urine human chorionic gonadotropin (hCG)
E.“That’s one option, but I’d like to talk with you a bit before we schedule anything.
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Old 11-28-2011
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1). B
2). E
3). E
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Old 11-28-2011
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1. C
2. E
3. E
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Old 11-29-2011
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The correct answer is B. Smoking continues to be a major problem in the United States and represents the number-one preventable cause of morbidity and mortality in women in the United States. Early formulations of the combined OCP were with 50 μg or more of estrogen. Many studies from the 1960s through 1980s demonstrated a strong association between the use of the OCP by smokers and myocardial infarction. This association was strongest for smokers greater than 35 years of age. Newer formulations of the pill use 35 μg of estrogen or less. Recent large studies have shown no association between the use of the OCP with 35 μg of estrogen or less and myocardial infarction or stroke in smokers or nonsmokers regardless of age. However, these studies contained few smokers greater than 35 year of age on the combined OCP because most physicians will not prescribe the OCP to women in this category. Therefore, current recommendations continue to be that smokers older than 35 years should not use the combined OCP. This patient, however, is a 27-year-old woman and she is taking a combined OCP with 35 μg of estrogen. She should be allowed to continue on her current OCP and she should be strongly encouraged to quit smoking.
Advising her to change to a combined OCP with 50 μg of estrogen (choice A) would absolutely be incorrect. She is happy with her current pill. Older formulations of the OCP contained 50 μg of estrogen, and these pills were associated with higher risks of MI and stroke.
Counseling her that she should stop the OCP immediately (choice C) is not correct. The OCP is not contraindicated for smokers younger than 35 years of age. She should continue to take the OCP but should aggressively try to quit smoking.
Telling her to stop the OCP over the next 2 years (choice D) would not be correct. The focus with this patient should not be on stopping the OCP but rather on her quitting smoking.
Advising her to take a daily baby aspirin with the OCP (choice E) is not correct. Daily baby aspirin is not currently recommended for a 27-year-old woman, such as this patient.
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The correct answer is E. Ectopic pregnancy must be a primary consideration in the evaluation of any woman of childbearing age with abdominal pain or vaginal bleeding. Ectopic pregnancy is a leading cause of maternal morbidity and mortality and much of the problem stems from a delay in diagnosis and treatment. For any young woman who presents with abdominal pain or vaginal bleeding, an initial step in the workup therefore should be a pregnancy test. Current urine pregnancy tests are sensitive and suitable for use to determine if a patient is pregnant. If the patient is found not to be pregnant, then ectopic pregnancy can safely be removed from the differential diagnosis and further evaluation and treatment can proceed. If the patient is found to be pregnant a serum quantitative hCG level may be obtained to establish a level of the hormone and to guide further management. The patient should be questioned regarding sexual intercourse and date of the last menstrual period. A history of no recent sexual intercourse or a normal last menstrual period, however, does not obviate the need for a pregnancy test. Sexual histories are notoriously inaccurate as is the recall of the last menstrual period. Furthermore, patients can have bleeding from an ectopic pregnancy that they mistake for a menstrual cycle. The initial step in the evaluation of abdominal pain in this young woman thus should be a urine pregnancy test.
Abdominal computed tomography (CT) (choice A) is a helpful diagnostic tool for the evaluation of abdominal pain. It can identify appendicitis, diverticulitis, bowel obstruction, and numerous other intraabdominal conditions. In the pregnant patient with abdominal pain, however, pelvic ultrasound is the more appropriate initial radiologic study.
Abdominal x-ray (choice B) does not provide as comprehensive an evaluation of the abdomen and pelvis as does abdominal-pelvic CT or pelvic ultrasound. It would not be, therefore, the most appropriate next step.
Appendiceal ultrasound (choice C) can be used to evaluate a patient for appendicitis. The first step in diagnosing a young woman with abdominal pain, however, is to determine whether or not she is pregnant.
Pelvic ultrasound (choice D) is a useful tool for evaluating the uterus and adnexal structures in a young woman. Before performing the ultrasound it is helpful to know whether or not the patient is pregnant. In a nonpregnant female with significant abdominal pain, many physicians would opt for abdominal-pelvic CT as the initial radiologic study rather than pelvic ultrasound.
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The correct answer is E. The physician’s duty is to lay out all options so the patient can make an informed choice. In this case the patient leaps to the abortion option. The physician is not to encourage or discourage her choice, but must be sure that she has full information before proceeding. The issue here is not simply abortion, but the process by which informed consent is achieved.
“Certainly, let’s schedule you for the procedure right now,” (choice A) is premature. Before the patient understands all available options, any convergence on one option is premature.
Her husband’s consent is not required, although encouraging her to discuss this sensitive decision with him is good practice (choice B). The options should be laid out for the woman first, however.
Simply asking her to think (choice C) does not provide her with the options she needs to make her choice.
Because the girl is married, she is emancipated and should be treated as a full adult; parental consent is not needed (choice D).
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