A 28-year-old G2P2 woman returns today for follow up on her abnormal Pap test which reveals atypical squamous cells of undetermined significance (ASCUS).
... [Show More] Reflex HPV testing is positive for high risk type. She has never had a prior abnormal Pap test, and has been following the recommended screening guidelines. She is asymptomatic. Her pelvic exam reveals a normal cervix with a small amount of cervical mucous. What is the next best step in the management of this patient?
A. Routine screening
B. Repeat Pap test in one year
C. Repeat HPV testing in one year
D. Repeat co-testing with Pap and HPV in one year
E. Colposcopy - Answer- E. Colposcopy is indicated for all abnormal Pap test results including ASCUS Pap test when HPV is positive. Reflex HPV testing for high-risk DNA types should be performed in patients with ASCUS. If negative, then co-testing with cytology and HPV can be repeated in three years. Repeat cytology in one year is also an acceptable option for ASCUS if HPV testing cannot be done. http://www.asccp.org/Portals/9/docs/ASCCP%20Updated%20Guidelines%20Algorithms%206.3.13.pdf
A 17-year-old G0 high school student is brought in by her mother for her first gynecologic examination. She began her menses at age 12 and has had regular periods for the past three years. Her last menstrual period was one week ago. For privacy, you ask to examine the patient without her mother. Further history is obtained in the examination room. She admits that she has been sexually active with her boyfriend for the past three years. She uses condoms occasionally and is fearful about possible pregnancy. She requests that her mother not be informed about her sexual activity. On physical examination, she is anxious, but normally developed. Her pelvic examination reveals no vulvar lesions, minimal non-malodorous discharge, and a nulliparous appearing cervix. The bimanual examination reveals a normal size uterus, and her adnexa are non-tender and not enlarged. Urine pregnancy test is negative. In addition to discussing contraception. What is the next best step in the management of this patient?
A. Obtain a serum Beta-hCG level
B. Obtain a Pap test
C. Obtain DNA probes for gonorrhea and chlamydia
D. Initiate treatment with doxycycline and ceftriaxone
E. Order a pelvic - Answer- C. Counseling about and screening for sexually transmitted infections is the best next step. This patient does not require treatment due to a lack of diagnostic criteria. A serum Beta-hCG is not indicated in the setting of normal menstrual cycles with last menstrual period a week ago and a negative urine pregnancy test. Guidelines for initiation of cervical cancer screening is recommended at age 21 regardless of coitarche. A pelvic ultrasound would not be indicated at this time especially since the pregnancy test is negative and given her lack of menstrual or pelvic symptoms.
A 68-year-old G2P2 woman who has recently moved in with her daughter (a long-standing patient of yours) comes in for a health maintenance examination. A vaginal hysterectomy was done in her fifties for uterine prolapse. She is not sure if her ovaries were removed. She has never had an abnormal mammogram or Pap test and has had yearly exams. She stopped hormone replacement therapy 10 years ago. She was recently widowed after being married for 50 years. She does not smoke or drink. Her diabetes is well-controlled with Metformin; she takes a daily baby aspirin and is on a lipid-lowering agent. On examination, she is a thin elderly woman with a dowager's hump. Her breast exam is unremarkable. Her lower genital tract is notable for atrophy. No masses are noted on bimanual and recto-vaginal exam. A fecal occult blood test is negative. Which of the following tests is not necessary?
A. Bone density
B. Colonoscopy
C. Pap test
D. Mammogram
E. Annual bimanual and recto-vaginal exam - Answer- C. Pap test screening is not indicated in patients who have had a hysterectomy, unless it was done for cervical cancer or a high-grade cervical dyspalsia. Patients with a uterus can discontinue cervical cancer screening between the ages of 65-70 if they have had three consecutive negative smears or two negative consecutive cotesting in the last 10 years and no history of high-grade cervical intraepithelial neoplasia or cancer. Patients still need yearly bimanual and rectovaginal exam. Mammograms are done annually, as breast cancer increases with age. Colon cancer screening is recommended at age fifty. The patient has an exaggerated thoracic spine curvature, termed a dowager's hump, likely secondary to thoracic compression fractures secondary to osteoporosis. If this is confirmed on a bone density test, she may benefit from the addition of bisphosphonates
A 32-year-old G2P2 woman presents for a health maintenance examination. She is in good health and has no concerns. She does not have a history of abnormal Pap test and her last one was three years ago. Her examination is normal including her pelvic exam. A Pap test is performed and returns as normal with HPV negative. What is the most appropriate screening recommendation for cervical cancer in this patient?
A. Pap test and HPV testing in one year
B. Pap test and HPV testing in three years
C. Pap test and HPV testing in five years
D. HPV testing alone in one year
E. HPV testing alone in three years - Answer- C. According to the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) guidelines for the Prevention and Early Detection of Cervical Cancer, women ages 30 to 65 years should be screened with cytology and HPV testing (''co-testing'') every five years (preferred) or cytology alone every three years (acceptable). Screening by HPV testing alone is not recommended for most clinical settings and there is insufficient evidence to change screening intervals in this age group following a history of negative screens.
A 28-year-old G0 woman has a pap test which is reported as high-grade squamous intraepithelial lesion (HSIL). She is currently sexually active. She has had six sexual partners and has been in a monogamous relationship with her fiancé for the last year. What is the next most appropriate next step in the management of this patient?
A. Colposcopy
B. Cryotherapy
C. Reflex HPV testing
D. Repeat Pap test in one month
E. Repeat Pap test in six months - Answer- A. The American Society for Colposcopy and Cervical Pathology guidelines recommend immediate LEEP or colposcopy for women with HSIL cytology test results. A diagnostic excisional procedure is recommended for women with HSIL cytology test results when the colposcopic examination is inadequate. Unlike a LEEP, cryotherapy is inadequate as this procedure does not provide a tissue specimen. Repeat cytology testing alone or reflex HPV testing is unacceptable. For women not managed with immediate excision, colposcopy is recommended regardless of HPV result obtained at co-testing.
A 19-year-old G0 woman presents with lower abdominal cramping. The pain started with her menses and has persisted, despite resolution of the bleeding. She thinks she may have a fever, but has not taken her temperature. No urinary frequency or dysuria are present. Her bowel habits are regular. She denies vomiting, but has mild nausea. A yellow blood-tinged vaginal discharge preceded her menses. No pruritus or odor was noted. She is sexually active, uses oral contraceptives and states that her partner does not like condoms. On examination: temperature is 100.2°F (37.9°C); pulse 90; blood pressure 110/60. She is well-developed and nourished and in mild distress. No flank pain is elicited. Her abdomen has normal bowel sounds, but is very tender with guarding in the lower quadrants. No rebound is present. Pelvic examination reveals a moderate amount of thick yellow discharge. The cervix is friable with yellow mucoid discharge at the os. Cervical motion tenderness is present. Uterus and the adnexa are tender without masses. Urine dip is negative for nitrates. Urine pregnancy test is negative. What is the most likely diagnosis?
A. Vulvovaginal candidiasis
B. Acute salpingitis
C. Trichomonas vaginitis
D. Cervicitis
E. Bacterial vaginosis - Answer- B. This patient has findings suggestive of acute salpingitis (pelvic inflammatory disease) including lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, and vaginal discharge. Mucopurulent cervicitis with exacerbation in the symptoms during and after menstruation is classically gonorrhea. Chlamydia is frequently associated with gonorrhea and also causes cervicitis and pelvic inflammatory disease. Cervicitis alone would not explain this patient's constellation of findings. Trichomonas may cause a yellow frothy discharge, and Candida may cause a thick white cottage cheese-like discharge, but neither would cause fever and abdominal pain.
A 39-year-old G0 woman presents to the clinic reporting non-tender spots on her vulva for about a week. No pruritus or pain is present. She also notes a brownish rash on the palms of her hands. She admits to IV drug abuse. She was diagnosed as HIV-positive two years ago, but has not been compliant with suggested treatment. On examination, three elevated plaques with rolled edges are noted on the vulva. They are non-tender. A brown macular rash is noted on the palms of her hands and the soles of her feet. What is the most appropriate next step in the management of this patient?
A. Obtain a treponemal-specific test
B. Biopsy of the lesion
C. Colposcopic evaluation of the vulvar lesions
D. Culture the base of the lesion
E. Initiate empiric treatment with doxycycline and ceftriaxone - Answer- A. The diagnosis of syphilis is often established by serologic testing. Non-treponemal tests (VDRL or RPR) are non-specific. In this patient with high suspicion for syphilis, specific testing with treponemal antibody can confirm infection. The classic coiled spirochete is easily seen with dark-field microscopy but availability is limited. A characteristic finding is a macular rash on the palms and soles that are often described as copper penny lesions. Colposcopy would not be diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic. Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly would not be the most expedient way to make the diagnosis. Penicillin G is the preferred drug for treating all stages of syphilis.
A 24-year-old G0 woman presents with multiple painful ulcers involving the vulva. The sores were initially fluid filled, but are now open, weeping and crusted. She reports a fever and is having difficulty voiding due to pain. She uses a vaginal ring for contraception. She has multiple sexual partners and uses condoms for vaginal intercourse. She is distraught that she may have a sexually transmitted infection. She is healthy and does not smoke or use drugs. On physical exam, she is in obvious distress. Temperature is 100.2°F (37.9°C); pulse 100. Examination of the genital tract is limited due to her discomfort. Multiple ulcers and erosions of variable size are localized to the perineum, labia minora and vestibule. Swelling is diffuse. The lesions are eroded, some with a purulent eschar. There is exquisite tenderness to touch. What further testing should be offered to this patient?
A. RPR (rapid plasma regain)
B. HIV
C. Herpes culture
D. DNA probe for gonorrhea and chlamydia
E. All of the above - Answer- E. This patient has classic primary herpes with painful genital ulcerations, fever and dysuria. Given the presence of one sexually transmitted infection, screening should be offered for other STIs. Resolution of the acute episode is required before a speculum can be inserted to allow endocervical sampling for gonorrhea and chlamydia. If it was a high-risk exposure, prophylactic empiric treatment could be offered to cover gonorrhea and chlamydia. The patient should be counseled that primary herpes can be acquired despite condoms and even by oral-genital inoculation. Hepatitis B vaccination should be offered to protect her against any future exposures. She should be encouraged to discuss her diagnosis with all sexual partners and to continue to reliably use latex condoms.
A 38-year-old G0 woman comes to the office because she noted a persistent yellow, frothy discharge associated with mild external vulvar irritation. She denies any odor. She tried over the counter anti-fungal medication without success. The discharge has been present for over three months, gradually increasing in amount. Douching has resulted in temporary relief, but the symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix. A sample of the discharge is examined under the microscope. What is the most likely finding?
A. Strong amine fishy odor when KOH applied to sample
B. Marked polymorphonuclear cells with multi-nucleate giant cells
C. Motile ovoid protozoa with flagella
D. Budding yeast and pseudo-hyphae
E. Clue cells - Answer- C. This patient most likely has trichomoniasis. The erythematous patches on the cervix are characteristic of "strawberry cervicitis." Trichomonads are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide must be examined immediately. The discharge is mixed with saline and placed on the slide with a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green vaginal discharge. Clue cells are seen on a saline wet mount in women who have bacterial vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation may be herpes.
A 23-year-old G0 woman reports having a solitary, painful vulvar lesion that has been present for three days. This lesion has occurred twice in the past. She states that herpes culture was done by her doctor during her last outbreak and was negative. She is getting frustrated in that she does not know her diagnosis. She has no significant previous medical history. She uses oral contraceptives and condoms. She has had four sexual partners in her lifetime. On physical examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. How do you explain the negative culture?
A. Cultures were taken too early
B. Oral contraceptives affect the growth of the virus
C. The cultures were refrigerated prior to transport to the lab
D. Herpes cultures have a 10-20% false negative rate
E. The herpes virus cannot be recovered with recurrent infections - Answer- D. Culture is the gold standard in the diagnosis of herpes. They are highly specific, yet sensitivity is limited. It is best to culture the lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The herpes virus can theoretically be isolated from both primary and recurrent infections. This patient very likely presented too late in the course for a useful culture. Oral contraceptives do not affect the growth of viruses. While serum antibody screening can be performed, it indicates lifetime exposure and would not answer the question as to the etiology of the specific lesion. Alternatively, DNA studies such as the polymerase chain reaction can be done, if available.
A 27-year-old G1P0 woman at 34 weeks gestation is brought in by ambulance after a motor vehicle accident. Although restrained in the car with a safety belt, she suffers a significant head laceration. When she arrives in the emergency department, her initial trauma survey is completed. On her secondary survey, there is bright red blood coming from the vagina. Her abdomen is noted to be tense. Subsequent documentation of the fetal heart tones reveals fetal tachycardia. Abruption is suspected and the patient is rushed to the operating room for an emergent Cesarean section. After delivery, the nurse notes that an informed surgical consent was never signed. Which of the following is true?
A. Informed consent is valid if the doctor-patient discussion occurred soon after the patient received intravenous morphine for pain relief
B. Informed consent is unnecessary in an emergency situation if a delay in treatment would risk the patient's health/life
C. Informed consent is only required for invasive procedures
D. Informed consent would not have been valid anyway because the patient sustained a head laceration
E. In an emergency situation, informed consent documents can be signed after the procedure is over and the patient is stable - Answer- B. Informed consent needs to be obtained for all procedures while patient is fully alert and has not received any narcotics or other medications that may affect her decision-making. The only exception is in true emergency situations that would risk the patient's life. Obtaining informed consent does not necessarily protect the provider from lawsuits and should never be signed after a procedure is already completed.
A 36-year-old G3P2 woman presents in active labor at full term with a known placenta previa. She reports brisk vaginal bleeding. Evaluation shows that fetus and patient are currently hemodynamically stable. She has had two normal vaginal deliveries in the past. She declines your recommendation to undergo Cesarean section. Which of the following is not advisable during your initial management of this patient?
A. Soliciting her reasons for not undergoing a Cesarean section
B. Obtaining hospital Ethics Committee recommendation
C. Proceeding with an emergency [Show Less]