A 32-year-old G2P2 woman presents 1 month post-intrauterine contraceptive device placement for follow-up position check. The patient states that she can no longer feel the strings from the device. She was told to check occasionally to make sure it stayed positioned properly. Upon vaginal exam, you confirm that the strings are no longer visible in the cervical os.

What is the most appropriate procedure to evaluate this patient?

A CT scan
B Laparoscopy
D Ultrasound
E X-ray
Click the card to flip 👆
1 / 30
Terms in this set (30)
A 32-year-old G2P2 woman presents 1 month post-intrauterine contraceptive device placement for follow-up position check. The patient states that she can no longer feel the strings from the device. She was told to check occasionally to make sure it stayed positioned properly. Upon vaginal exam, you confirm that the strings are no longer visible in the cervical os.

What is the most appropriate procedure to evaluate this patient?

A CT scan
B Laparoscopy
D Ultrasound
E X-ray

The fastest and best method to determine the location of an IUD is an ultrasound of the uterus. This can locate the IUD even if it has eroded through the lining of the uterus. This method is inexpensive, typically available in clinic, and does not expose the patient to radiation. If the IUD has perforated the uterus, then a laparoscopy may be necessary to remove the device. The other tests are not usually utilized in this situation.
Your patient is a 45-year-old woman concerned about the accelerated aging of her skin. 5 years ago, she underwent a total hysterectomy with oophorectomy. Since then, she gained about 20 pounds. She also has diabetes mellitus type II. On examination, you find a slightly overweight female (body mass index 26) with skin that has lost its elasticity and has reduced water-holding capacity, increased pigmentation, and decreased vascularity.

What are her symptoms signs of?

A Elevated testosterone
B Decreased testosterone
C Elevated estrogen
D Decreased estrogen
E Insulin resistance

Lower levels of estrogen are associated with skin aging, most probably because of telomeres shortening. The effects of reduced estrogen levels cause loss of elasticity, reduced water holding capacity, thickness, increased pigmentation, decreased vascularity in the skin, and facial hair. Some of those signs are found in your patient.

Your patient has no ovaria, and testosterone is primarily secreted in the ovaries (small amounts are also secreted by the adrenal glands). Too much testosterone will cause excessive oiliness and acne rather than accelerated aging of the skin.

Testosterone levels in this woman are decreased after the removal of the uterus and ovaries. Symptoms related to her skin are not characteristics of decreased testosterone levels. More often in decreased testosterone there will be a loss of muscle strength and mass, accumulation of fat, especially around the abdomen, osteoporosis, vaginal dryness, etc.

High levels of estrogen can be found in women who are pregnant, extremely overweight, have diabetes, or have liver disease. They are sometimes associated with acne, red flushed appearance, spider nevi, etc. Skin changes in this patient cannot be attributed to high estrogen.

Insulin resistance is a condition when insulin becomes less effective at lowering blood sugars. It can lead to weight gain and estrogen hyperproduction, resulting in skin changes attributable to high estrogen levels (acne, red flushed appearance, spider nevi, etc). Skin changes in this patient cannot be attributed to the high estrogen.
A 40-year-old woman presents to the emergency department with unremitting left flank pain. She denies dysuria or fever. Upon interview of the patient, she also noted that her urine output has decreased over the last few days. As you observe the patient, she is writhing on the gurney and unable to find a comfortable position. On further inquiry, the patient states that she has been trying to lose weight by increasing protein in her diet, exercising, and decreasing her normal fluid intake. On urinalysis, red blood cells are noted.

What is the most likely diagnosis?

A Acute renal failure
B Nephrolithiasis
C Cystitis
D Chronic renal failure
E Nephritic syndrome

The clinical picture is suggestive of nephrolithiasis (renal stones). Most patients with renal stones present with flank pain and hematuria. There are numerous causes of renal stones, but dehydration favors stones formation and a high protein diet can predispose a patient to stone formation.

Acute renal failure can be associated with renal stones. Renal stones are categorized as a post-renal cause of acute renal failure; however, with acute renal failure, a rapid rise in BUN and creatinine would be seen on serum chemistries, which is not seen in this patient.

Cystitis, or bladder infection or inflammation, would present with suprapubic pain, dysuria, nocturia, odd or foul smell to urine, an increase in urinary frequency, and no fever. On urinalysis, a cloudy appearance and white blood cells would be seen. These symptoms are not present in this patient.

Chronic renal failure is most commonly caused by untreated or poorly-controlled diabetes mellitus, and untreated or poorly-controlled hypertension. There is no indication of untreated or poorly-controlled diabetes mellitus and untreated or poorly-controlled hypertension in this patient.

Nephritic syndrome is characterized by proteinuria, hematuria, azotemia, red blood cell casts, oliguria, and hypertension.
A mother brings her 16-year-old son to your medical office for a comprehensive history and physical examination. She tells you she is concerned about his immature physical development and insecure behavior. She thinks these characteristics are markedly different from her other children. His IQ is 70, and he is in special education for a language-based learning disability. On physical examination, he is tall and thin; he has sparse body hair and a high-pitched voice. Heart, lungs, abdomen, and neurologic exam are unremarkable. Pertinent positive findings include disproportionately long arms and legs, gynecomastia, as well as small testes and phallus.

What is the most likely diagnosis?

A Fragile X syndrome
B Klinefelter syndrome (XXY)
C Turner syndrome (XO)
D Triple X syndrome (XXX)
E XYY syndrome (XYY)

The combination of hypogonadism, long extremities, decreased intelligence, and behavioral problems makes Klinefelter syndrome (also referred to as XXY syndrome, 47,XXY, and Klinefelter's syndrome) the most likely diagnosis. The original syndrome, as described by Dr. Klinefelter, consisted of gynecomastia, testicular atrophy, and infertility. Intelligence profiles can range from specific learning disabilities (language learning or reading impairment most common) to frank mental retardation/intelligence disability (MR/ID). The only constant feature of the syndrome is testicular atrophy with resulting azoospermia and infertility. The atrophy of the testis is the result of fibrosis, which begins to appear in childhood and progresses until all the seminiferous tubules are replaced by fibrous tissue. In males presenting with gynecomastia, MR/ID, and eunuchoidism (i.e., loss of male secondary sexual characteristics, small penis, loss of body hair, and a high-pitched voice), Klinefelter syndrome should be at the top of the list in the differential diagnosis.

Most patients with Klinefelter's syndrome have 47 chromosomes instead of the normal 46 chromosome karyotype. The extra chromosome is an X chromosome, making the sex chromosome constitution XXY instead of XY. Klinefelter's syndrome is one of the most common chromosome abnormalities seen in males and occurs in 1 in 300 of the male population. Patients with this syndrome show that the Y chromosome is strongly sex-determining; thus, a patient who has an XXY chromosome constitution may have the appearance of a normal male, with infertility being the only incapacity, while the loss of a Y chromosome leads to the development of a bodily form that is essentially feminine.

Fragile X syndrome is incorrect, as it is characterized by prominent jaw, large ears with soft cartilage, and macroorchidism in pubertal male patients.

Turner syndrome (XO) is incorrect, as it is a genetic condition of females patients; it is usually characterized by a short stature, increased distance between the nipples, low hairline, low set ears, a webbed neck, amenorrhea, and sterility.

Triple X syndrome (XXX) is incorrect. This condition only occurs in female patients.

XYY syndrome (XYY) is incorrect. In this condition, IQ is normal, and there is normal sexual development as well as normal fertility.
A 28-year-old pregnant woman at 18-weeks gestation presents because she has been exposed to fifth disease. The patient is currently asymptomatic. What can you tell her about human parvovirus B19 and pregnancy?

A Less than 25% of adults are immune to this virus, and she should be treated with immunoglobulin
B Parvovirus B19 has not been associated with any fetal effects
C If she develops an infection, she will need to be followed with serial fetal ultrasounds
D The virus is spread by fecal-oral transmission, and she should wash her hands very carefully
E The risk of fetal loss in an infected mother is between 45-55%

Fifth disease is caused by human parvovirus B19, which is a DNA virus. Fifth disease, also called erythema infectiosum, is usually a mild exanthem of childhood, but infection of a pregnant woman can have severe fetal complications

Fetal (transplacental) infection with parvovirus B19 can result in a variety of fetal complications, including fetal loss, especially if the infection is between gestational weeks 10 and 20. A common complication includes fetal hydrops; it is caused by damage to fetal hematopoietic tissue, and it causes severe anemia and a resultant congestive heart failure. The virus can also cause a fetal viral myocarditis, which further worsens cardiac function and fetal hydrops. More rarely, first trimester infections with parvovirus B19 can cause teratogenic effects, including multiorgan abnormalities.

Between 30-60% of adults are immune to parvovirus B19, as evidenced by the presence of IgG to B19 in their serum; therefore, most pregnant patients are probably immune to this virus. However, if a pregnant patient develops a rash or aplastic crisis that may be consistent with fifth disease, then igG and IgM serologies for parvovirus should be drawn to evaluate for acute infection.

If parvovirus B19 infection is diagnosed in a pregnant patient, then her physician may choose to follow her with serial fetal ultrasounds to evaluate for the development of fetal hydrops. In some cases, fetal umbilical cordocentesis has been used to detect fetal infection.

In children, fifth disease is characterized by a classic "slapped-cheek" facial erythema; it is associated with fever and often GI or other systemic symptoms. Adult patients will demonstrate a rash. The rash may be reticular, morbilliform, or even purpuric. Adult patients often have fever, lymphadenopathy, and/or arthritis. Parvovirus B19 is also associated with an acute transient aplastic crisis.

Unfortunately, fifth disease is infectious for days before the onset of the rash; thus, many obstetrical patients may be exposed, particularly if they work closely with children. The virus is spread by aerosolized respiratory droplets, and it has an incubation period of 4 to 14 days.
A 24-year-old man presents with fever and 1-week history of a transient maculopapular rash. His serum creatinine and blood urea nitrogen (BUN) are elevated. The urinalysis is significant for hematuria, pyuria, white blood cell casts, and eosinophiluria.

What is the most likely diagnosis?

A Acute tubular necrosis
B Diabetic nephropathy
C Hypertensive nephrosclerosis
D Interstitial nephritis
E Lupus nephritis

The clinical picture includes fever, recent etiological exposure (e.g., drugs, infection), and maculopapular rash; coupled with with serum and urinalysis findings of elevated creatine, elevated BUN, hematuria, pyuria, white blood cells casts, and eosinopiluria, the picture is suggestive of interstitial nephritis. Interstitial nephritis typically occurs following medication administration, but can also occur in response to viruses or bacterial infections. It is an allergic reaction of the kidney that results in fevers, rash, arthralgias, hematuria, and eosinophilia.

In acute tubular necrosis, the BUN and creatinine are elevated, but the urinalysis may show a brown color. On microscopic examination, muddy brown casts (pigmented granular casts), epithelial cell casts, and renal tubular cells would be seen, which is not the case in this patient.

There is no history of diabetes or hypertension in this patient; therefore, diabetic nephropathy and hypertensive nephrosclerosis are ruled out.

Lupus nephritis is a complication of systemic lupus erythematosus. It is an autoimmune inflammatory disorder that affects many organs. About 85% of patients are women. On urinalysis, hematuria and/or proteinuria are common findings.
A 16-year-old sexually active girl is seen for a 2-month history of amenorrhea. She denies having unprotected sex, but always relies upon her partner to use a condom. She has vomited in the early morning twice in the past week. She has also had vaginal spotting for 3 days, accompanied by cramping lower abdominal pain that became sharp. Onset of menses was at 12 years, with normal, regular periods since then. There is no history of sexually transmitted disease. Physical examination revealed normal vital signs. Slight right and left lower quadrant abdominal tenderness without guarding and rebound was present. The cervix was closed. No blood was seen in the vaginal vault. The uterus was not palpable. Serum β-HCG: 5,200 mIU/ml. Vaginal spotting has increased, and abdominal pain has become more frequent. Repeat examination 3 days after the initial visit is unchanged. The uterus is still not palpable. Repeat serum β-HCG is 6,800 mIU/ml. Transvaginal ultrasound failed to reveal an intrauterine pregnancy or gestational sac.

What is the most likely diagnosis?

A Cervical ectopic pregnancy
B Choriocarcinoma
C Pseudocyesis
D Tubal ectopic pregnancy
E Very early intrauterine gestation

The absence of fetal pole or gestational sac in the uterus with elevated serum β-HCG indicates an ectopic pregnancy, of which a tubal ectopic is the most common. The full triad of abdominal/pelvic pain, amenorrhea and irregular vaginal bleeding is present in only one-half of patients. Abdominal/pelvic pain may be unilateral or bilateral, usually worse on the affected side.

Cervical ectopic pregnancies are rare.

Serum β-HCG is not adequately elevated to suggest choriocarcinoma.

Serum β-HCG is not elevated in pseudocyesis (false pregnancy), a condition in which the female patient truly believes she is pregnant and may exhibit signs and symptoms of true pregnancy such as amenorrhea, hyperemesis, breast swelling and tenderness, weight gain, abdominal tenderness, and even quickening.

Transvaginal ultrasound failed to reveal even a fetal pole or gestational sac in the uterus, which should be detected by 36 to 40 days.
A 25-year-old woman is on a 2-week honeymoon trip with her new husband. At the end of the first week she experiences a burning sensation on micturition and finds herself going to the bathroom every 15-20 minutes. As the day progresses, she notices an ache in the lower abdominal area and seeks treatment at an urgent care center nearby. She has no fever, nausea, or diarrhea. On exam, her vitals are normal, and other than mild lower abdominal tenderness, there are no physical findings of significance. Baseline labs show serum: Hb 13g/dl, WBC 6500/uL, platelets 340000/ul; urine: WBC 12 and RBC 2.

In all likelihood, this patient has which one of the following?

A Acute pyelonephritis
B Acute cystitis
C Acute gastroenteritis
D Acute left sided salpingitis
E Acute diverticulitis

The symptoms of high fever with chills, nausea, vomiting, and back pain with tenderness in the renal angle are classic for pyelonephritis. It is a common condition in young women. The common organisms are gram negative, for example E.coli, klebsiella, proteus, enterobacter, and pseudomonas. Gram positive bacteria, like staphylococcus aureus and enterococcus fecalis, may also be seen. The usual mode of infection is ascent from the lower urinary tract, except for staphylococcus aureus, which is hematogenously spread. Leukocytosis with a left shift and abnormal urine with pyuria and bacteriuria confirm the condition. Absence of pyuria should be an indication to look for an alternative diagnosis. Hematuria may also be present. Blood and urine cultures should be done. Imaging may be needed in complicated cases, in which scenario an ultrasound may reveal hydronephrosis due to obstruction from a calculus or other causes. It is generally recommended that all males with acute pyelonephritis undergo imaging with ultrasound or CT scan, since such an infection is usually associated with an anatomical abnormality like enlarged prostate, etc. A long urethra and absence of organisms residing in vagina makes it unusual for men to have a urinary infection with a normal anatomy. Treatment should be started empirically without waiting for culture results, since they are usually not available immediately, and as they become available, antibiotics may be changed accordingly. Urine gram stain, which is available right away, may be a useful tool to direct antibiotic treatment. Indications for hospitalization include vomiting, pregnancy, HIV disease, diabetes, impending septic shock with unstable vitals, and other comorbidities like renal failure, post transplant, etc. It should be treated with oral fluoroquinolone or trimethoprim-sulfamethoxazole for mild to moderate disease and IV ceftriaxone or a fluoroquinolone for hospitalized patients, to be substituted with oral antibiotics after improvement in symptoms. Total duration of antibiotics should be 10-14 days. Prognosis is usually good if diagnosis is prompt, treatment appropriate, and complications absent.
Acute cystitis is a milder disease, which is more common in women than men due to a short urethra and proximity to vagina with its abundance of micro-organisms. About 50-60% adult women have had a urinary tract infection in their lives at some point. 10% postmenopausal women also have been found to get these infections. Coitus seems to be a predisposing factor, and symptoms quite often arise after sexual intercourse (honeymoon cystitis). The offending organisms include gram negative bacteria, such as E.coli, in 80-85% cases in women; it is also common in men. Most of the other cases in women are due to staphylococcus saprophyticus, though this is uncommon in case of males. This is a coagulase negative staphylococcus, which is normally considered benign but is actually a true urinary pathogen and should not be ignored. Rarely, klebsiella, proteus, enterococci, etc. may be isolated. Symptoms include low grade fever, dysuria, urgency, increased frequency of urination, and suprapubic abdominal pain. Occasionally women may have gross hematuria. There is suprapubic tenderness on examination without costovertebral angle tenderness. Urinalysis shows pyuria, bacteriuria, and hematuria. Hematuria is absent in female patients with urethritis and vaginitis, which can cause similar symptoms and can be used to differentiate the conditions. Urine culture is usually positive for the causative organism. Treatment is based on culture reports. Uncomplicated cystitis in women can be treated with a 3-day course of trimethoprim-sulfamethoxazole, trimethoprim alone, fluoroquinolone, or cephalexin. A 7-day course of nitrofurantoin is also adequate. Men should be evaluated for underlying conditions since uncomplicated cystitis is uncommon in males. A 7-day course is recommended even for uncomplicated cases in men.

Acute gastroenteritis, or food poisoning, has a similar picture but without costovertebral angle tenderness. Diffuse abdominal pain and watery diarrhea are the predominant symptoms. Fever may be low grade or high grade. UA is usually normal.

Acute salpingitis, or pelvic inflammatory disease, is characterized by lower abdominal pain and tenderness, abnormal vaginal discharge and/or bleeding, dyspareunia with adnexal tenderness, and cervical motion tenderness on a pelvic examination. An acute episode may present with high fever and chills, profuse vaginal discharge, and severe lower abdominal pain. Leukocytosis is found in less than 50% patients; UA is mostly normal, and culture of the vaginal fluid should be done. Treatment is with broad spectrum antibiotics.

Acute diverticulitis is usually left sided and manifested by left lower quadrant abdominal pain and tenderness with diarrhea and occasionally low grade fever without chills. Leukocytosis may be present with sterile pyuria sometimes. The patient does not have back pain or costovertebral angle tenderness and seems well hydrated. Treatment is with ciprofloxacin and metronidazole for 7-10 days.
An 18-year-old male high school baseball player has been hospitalized with a severe throat infection, fever, and possible pneumonia. He had been taking a number of antibiotics, and his physician noted lower extremity edema and an elevated blood pressure. Ten days after being discharged, he began to note blood in his urine. You order a urinalysis, and the dipstick results are positive for blood and protein. Microscopic results are positive for RBCs and RBC casts.

What is the most likely diagnosis?

A Chronic renal failure
B Nephrolithiasis
C Cystitis
D Glomerulonephritis
E Nephrotic syndrome

The clinical picture is suggestive of glomerulonephritis. Signs and symptoms of glomerulonephritis include hematuria, proteinuria, edema, and hypertension, usually occurring 7 to 10 days after the onset of acute pharyngitis.

Chronic renal failure is most commonly caused by untreated or poorly-controlled diabetes mellitus, and untreated or poorly-controlled hypertension. There is no indication of untreated or poorly controlled diabetes mellitus, or untreated or poorly-controlled hypertension in this patient.

Nephrolithiasis, or kidney stones, would present with severe flank pain, hematuria, and oliguria. There is no indication of flank pain or oliguria in this patient.

Cystitis, or bladder infection or inflammation, would present with suprapubic pain, dysuria, nocturia, odd- or foul-smelling urine, an increase in urinary frequency, and no fever. On urinalysis, a cloudy appearance and white blood cells would be seen on microscopic examination. These symptoms are not present in this patient.

Nephrotic syndrome presents with massive proteinuria (> 3.0 grams per 24-hour urine), hypoalbuminemia, peripheral edema, and hyperlipidemia. Oval fat bodies may be seen on urinalysis. These symptoms, with the exception of edema, are not present in this patient.
A 52-year-old nulliparous woman presents with dyspareunia, persistent mucoid vaginal discharge, and soreness of the vaginal introitus. She has had several miscarriages, and she was told that they happened because her uterus is T-shaped. She is in a stable relationship with 1 man, has never had a sexually transmitted disease, and has no other complaints. On examination, her vaginal discharge is white and odorless; 2 bright red, fragile, hyperemic, superficial lesions are detected on the vaginal wall. The surrounding tissue initially appears normal, but fails to stain with Schiller's iodine. Biopsy of both lesions and the surrounding tissue reveals vaginal adenosis. A colposcopy, surgical excision, and cauterization of the lesion is planned.

What other management step should be undertaken?

A Dilation and curettage
B Human papilloma virus (HPV) vaccine
C Breast cancer screen
D Metronidazole treatment
E Triple screen test

The correct response is a breast cancer screen.

Being 52 years old and having vaginal adenomatosis, structural malformation of the reproductive tract, and problems with her pregnancies, this patient most probably was exposed to DES (diethylstilbestrol). In the 1950s and early 1960s, DES was prescribed for early pregnancy bleeding. The exposure to DES in utero before 18 weeks of pregnancy interferes with the growth and development of the uterus, cervix, vagina, and fallopian tubes, but many women are not aware of having been exposed. Exposure also raises the risk of otherwise rare, clear cell adenocarcinoma of the vagina and cervix. Patients may have an ectopic pregnancy, premature birth, infertility, or other pregnancy complications. They need a yearly exam (colposcopy and cytology), even after a hysterectomy or menopause.

DES exposure in utero also is associated with an increased risk of breast cancer. Over age 40, the risk of breast cancer is 2 times higher than in unexposed women; after age 50, the risk is even higher. Women who took DES during pregnancy also have an increased risk of breast cancer. Both groups (mothers and daughters) should be screened by mammography.

Dilation and curettage (D & C) is a diagnostic gynecological procedure, commonly performed to resolve cases of abnormal uterine bleeding or as a method of abortion.

The human papilloma virus (HPV) vaccine does not treat HPV or cervical cancer; it prevents infection with certain species of human papilloma virus associated with the development of cervical cancer, genital warts, and some less common cancers. It is recommended for female patients who are 9 - 26 years of age, girls and boys age 11 and 12 years, and those 13 - 21 years of age who have not been previously immunized. Men who are 22 - 26 years of age may be vaccinated; men in this age group who have sex with men should receive the vaccine.

Metronidazole is an antibiotic, amebicide, and antiprotozoal given for symptomatic (and often asymptomatic) trichomoniasis, as well as other inflammatory processes (i.e., endometritis, endomyometritis, tubo-ovarian abscess) and infections caused by succeptible organisms. Trichomoniasis will present with copious green, frothy vaginal discharge. Diagnosis can be made via a wet mount ('corkscrew' motility of the organisms) or via overnight culture (sensitivity of 75 - 95%). Rapid antigen testing, transcription-mediated amplification, and PCR have even greater sensitivity, but are not in widespread use.

The triple screen test is performed in the 2nd trimester of pregnancy to estimate a risk of chromosomal abnormalities and neural tube defects. It detects serum levels of alpha-fetoprotein, estriol, and beta-hCG in maternal serum.