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Old 11-29-2011
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ObGyn ObGyn Questions for November 29

1.A 55-year-old woman has a palpable 2 cm mass in her left breast. She had found the mass on self-examination, but she says that she had not done self-breast exam for at least six months before she did this one. Physical examination confirms the presence of the lesion, which is hard, movable, and not painful. A mammogram confirms the presence of an opacity in that area, but it does not have any of the radiological characteristics of a breast cancer. The radiologist also does a sonogram, and comes up with the same opinion, i.e., that neither study is suggestive for cancer. Fine needle aspirate is read as negative. Which of the following is the most appropriate next step in management?

A. Core biopsies of the mass

B. MRI of the breast

C. Reassurance

D. Repeat both imaging studies in six months

E. Repeat physical exam in six months

2.A 19-year-old woman comes to the office because of irregular vaginal spotting. She always has had normal periods that occur every 28 days and last 5 days, and so this is particularly concerning. She is sexually active with her boyfriend of 3 years and has been taking oral contraceptive pills that you prescribed 2 months ago. She has no known medical problems besides seasonal allergies and has never had any surgery. She takes the oral contraceptive pill daily and loratadine intermittently, but takes no other medications. She has no known drug allergies. Physical examination, including pelvic examination, is unremarkable. Urine hCG is negative. Which of the following is the most appropriate next step in management?

A. Explain that this is common and encourage pill continuation

B. Determine serum follicle stimulating hormone concentration

C. Determine serum thyroid stimulating hormone concentration

D. Send her for an endometrial biopsy

E. end her for a pelvic ultrasound

3. A 29-year-old woman comes to your office because she has been feeling depressed. She states that at times over the past several years she has regular occurrences of depression, anxiety, tearfulness, anger, and difficulty with work and social relationships. These occurrences have been increasing over the past several months. She doesn’t remember when her symptoms start or end. “It’s all a blur,” she says. She has had several urinary tract infections in her life, but otherwise has no medical problems. She takes no medications and has no drug allergies. Physical examination is normal. Which of the following is the most appropriate next step in caring for this patient?

A. Have her keep a symptom calendar

B. Schedule an MRI of the brain

C. Schedule a pelvic ultrasound

D. Start the patient on a benzodiazepine

E.Start the patient on a selective serotonin reuptake inhibitor
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Old 11-29-2011
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1.A. Core biopsies of the mass
2.A. Explain that this is common and encourage pill continuation
3.A. Have her keep a symptom calendar ????????????
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The correct answer is A. Only the pathologist can tell if a breast mass is benign or malignant, and an FNA provides limited opportunity to make that call. If this patient were 18 or 20 years old, we might be satisfied with all the negative information assembled so far, but at age 55, the possibility of breast cancer is too high to settle for anything less than biopsy. Cancers of the breast may not show any of the usual radiological signs of malignancy.
MRI (choice B) would be a very expensive way to end up with a mixed message at best. If it suggests malignancy, biopsy would follow, but if it did not, we would still want to get tissue.
Delaying the diagnosis, as suggested in choices C, D, and E, would be inappropriate management.
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The correct answer is A. Breakthrough bleeding is one of the most common reasons that adolescents stop taking the oral contraceptive pill (OCP). This is irregular spotting and bleeding that occurs during the first months of OCP use. Breakthrough bleeding often is caused by missed pills but also can occur in patients who take the pill every day, as the body adjusts to the OCP. Adolescents must be reassured that breakthrough bleeding is not harmful to their health, that it is most common in the first months of use, and that it usually resolves with a few months of OCP use.
Serum follicle stimulating hormone concentration (choice B) can be a useful test to determine ovarian reserve (e.g., in cases of infertility or menopause). It is not necessary, however, in this healthy 19-year-old with a history of normal periods.
Serum thyroid stimulating hormone concentration (choice C) is indicated in patients with irregular menstrual periods, as thyroid abnormalities can lead to menstrual dysfunction. This patient has a history of normal menstrual periods, however, and a much more likely cause for her irregular bleeding (i.e., breakthrough bleeding).
An endometrial biopsy (choice D) often is used in cases of irregular bleeding for patients at risk for endometrial cancer (e.g., postmenopausal patients). This young woman is at very low risk for endometrial cancer and endometrial biopsy carries risks for bleeding, infection, and perforation.
A pelvic ultrasound (choice E) would not be indicated in this patient, as there is no evidence of pelvic pathology on the physical examination, and intermittent vaginal spotting is a common complaint among young women starting the OCP.
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The correct answer is A. This patient presents with a constellation of symptoms including depression, anxiety, tearfulness, and anger. These symptoms interfere with her work and personal relationships. When these symptoms occur in an ovulating woman on a cyclic basis in the week before menses, with resolution in the first few days of the menses, the diagnosis of premenstrual dysphoric disorder may be given to the patient. The problem in diagnosing this patient is that it is not at all clear what the timing and pattern of her symptoms are. A woman who suffers from symptoms such as this on a constant basis with no relationship to the menstrual cycle does not have premenstrual dysphoric disorder. Also, a woman who has these symptoms but is not ovulating (e.g., a postmenopausal woman) does not have premenstrual dysphoric disorder. To correctly diagnose premenstrual dysphoric disorder, it is therefore essential to know the timing and pattern of the patient’s symptoms. Having the patient keep a calendar of symptoms is a useful tool to determine if there is a pattern related to the menstrual cycle. Trying to determine this pattern without a symptom calendar can be frustrating at best and impossible at worst, as the patient herself often cannot remember how she was feeling on a given day a month or two ago, or when exactly her menses started. Premenstrual dysphoric disorder can be diagnosed when the symptoms occur in the week before the start of the menses and resolve with the menses. This pattern should be documented by a symptom calendar over at least 2 months.
To schedule an MRI of the brain (choice B) would not be indicated at this point. This patient has symptoms that are consistent with premenstrual dysphoric disorder if, in fact, they are cyclically related to the menses. A symptom calendar, not a brain MRI, is what this patient requires.
To schedule a pelvic ultrasound (choice C) is not correct. This patient has no complaints of pelvic or abdominal pain or irregular menses and her physical examination is normal.
To start the patient on a benzodiazepine (choice D) would be incorrect. This patient has not been diagnosed yet. To start her on a medication without establishing a diagnosis would not be correct.
To start the patient on a selective serotonin reuptake inhibitor (SSRI) (choice E) would not be correct. Again, a diagnosis has not been established yet for this patient. If it is determined that she does have premenstrual dysphoric disorder, an SSRI is a good choice for first-line treatment.

Last edited by drnrpatel; 11-30-2011 at 06:24 AM.
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