Form 0990 Y4R - SBMA

Appendix I:
SBMA Written Exams and Case Studies for
Fourth-Year Resident Physicians

Form Approved OMB no. 0990-xxxx (Exp. Date XX/XX/XX11)

SBMA Written Exams and Case Studies for
Fourth-Year Resident Physicians

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Written Evaluation

OBGYN RY4

Critical Thinking

1) Significant physical support of the perineum comes from diaphragms which include all of the following muscles EXCEPT

1. coccygeus

2. iliococcygeus

3. ischiocavernosus

4. deep transverse perineal

2) Ovarian vessels are found in which of the following ligaments?

1. broad

2. round

3. uterosacral

4. infundibulopelvic

3) The uterine artery is a main branch of which of the following arteries?

1. aorta

2. internal iliac artery

3. external iliac artery

4. common iliac artery

Urogynecology

4) What are the therapeutic mainstays for treatment of detrusor instability?

1. anticholinergic drug therapy

2. behavioral modification

3. surgery

4. a and b

5) The maximal normal straining angle by convention on Q-tip test is

1. 30 degrees

2. 45 degrees

3. 20 degrees

4. 35 degrees

6) The muscle strengthened by routine Kegel exercises is

1. obturator internus

2. piriformis

3. ileococcygeus

4. pubococcygeus

7) To prevent vaginal vault prolapse after the performance of a vaginal hysterectomy for uterine prolapse, the surgeon should

1. secure the vaginal angle to the ipsilateral cardinal ligament

2. perform a Kelly plication

3. obliterate the cul-de-sac of Douglas

4. perform a posterior colpoperineorrhaphy

8) At the completion of a total vaginal hysterectomy with repair of enterocele, cystocele, and rectocele for uterine prolapse, the MOST desired anatomic outcome is

1. the vagina is shortened and narrowed to one finger in depth and diameter

2. the upper one third of the vagina is parallel to the floor when the patient is standing

3. the apex of the posterior suture line points toward the sacral promontory

4. the perineal body is shortened as much as possible

9) Which of the following statements regarding a McCall culdoplasty is TRUE?

1. enterocele repair is rarely necessary at the time of surgery for total procidentia

2. the procedure results in narrowing of the levator hiatus

3. the internal McCall suture should include the pararectal fascia on both sides and the posterior vaginal wall

4. the McCall sutures should be tied after the performance of the anterior colporrhaphy

10) Which of the following statements regarding the goals of surgical correction of uterine prolapse is FALSE?

1. the length of the uterosacral and cardinal ligaments should be maintained

2. the cul-de-sac of Douglas should be obliterated

3. the upper vagina should be restored over the levator plate

4. the endopelvic fascial attachments of the vagina should be reconstructed

11) In most patients, pelvic organ prolapse can be best managed via which approach?

1. vaginal

2. abdominal

3. laparoscopic

4. combined approach

12) A 39-year-old gravida 4 para 4 presents complaining of a “bulge” in her vagina. When ring forceps are placed against the anterior vaginal wall and directed laterally and posteriorly toward the ischial spines, the defect is corrected. Which of the following is the most likely defect(s)?

1. transverse defect alone

2. midline defect alone

3. paravaginal defect alone

4. paravaginal and midline defect

13) On a vaginal reconstruction of an anterior defect, where is the first suture usually placed?

1. close to the posterior surface of the pubic bone

2. about halfway between the urethrovesical junction and the urethral meatus

3. just through the vaginal epithelium near the lateral edge of the pubocervical fascia

4. into the tendinous arch and obturator fascia anterior to the ischial spine

14) During a difficult dissection of the bladder at the time of hysterectomy in a woman with two previous cesarean sections, which of the following has NOT been recommended as a way to decrease the risk of bladder injury?

1. careful blunt dissection to isolate the bladder

2. use of a two-way indwelling catheter

3. an extraperitoneal cystotomy

4. retrograde filling of the bladder

15) After a prolonged labor and difficult forceps delivery you are asked to consult on a 26-year-old woman who is otherwise in good health. On examination, she has a 1-cm vesicovaginal fistula in the anterior, upper one third of the vaginal wall with associated edema. The best chance of a successful repair is with

1. immediate vesicovaginal fistula repair

2. high-dose oral steroids for 2 days and then fistula repair

3. wait 4 weeks, then repair

4. wait 3 to 6 months, then repair

16) The anal canal and lower rectum are under both voluntary and involuntary mechanisms. Which of the following structures is under voluntary control?

1. internal anal sphincter

2. inner rectal mucosa

3. mucosal glands in the distal rectum

4. medial portion of the puborectalis muscle

17) In addition to the history and physical examination, what tools should be used in aiding the diagnosis of anal incontinence?

1. abdominal x-ray film (KUB)

2. CT scan

3. ultrasound

4. stool cultures

Reproductive Endocrinology

18) Which of the following is commonly associated with mullerian duct deformities?

1. cardiac anomalies

2. renal anomalies

3. gastrointestinal tract anomalies

4. limb anomalies

19) A transverse vaginal septum and vaginal agenesis are thought to result from which of the following?

1. defective canalization of the vagina

2. lack of fusion of the mullerian ducts

3. unilateral mullerian duct atresia

4. regional ischemia due to anomalous vascular supply

20) Vaginal atresia is seen in which of the following disorders?

1. androgen insensitivity syndrome

2. Asherman syndrome

3. congenital adrenal hyperplasia

4. 5alpha-reductase deficiency

21) Uterine anomalies are associated with what reproductive problems?

1. abnormal fetal lie

2. preterm delivery

3. recurrent miscarriage

4. all of the above

22) The differential diagnosis of dysfunctional uterine bleeding (DUB) in the perimenarchal girl includes

1. anovulation

2. pregnancy

3. coagulopathies

4. all of the above

23) In the treatment of childhood vulvovaginitis, the most effective is generally

1. application of topical corticosteroids

2. application of topical antibiotics

3. use of oral broad-spectrum antibiotics

4. improvement in local perineal hygiene

24) Examination of a 3-year-old reveals labial adhesions. The child is able to void without difficulty. One should initially recommend

1. topical estrogen

2. surgical separation

3. manual separation in the clinic

4. no treatment

25) In newborns with either male external genitalia and bilateral cryptorchidism or completely ambiguous external genitalia, what diagnosis should be immediately ruled out?

1. congenital adrenal hyperplasia

2. 5alpha-reductase deficiency

3. Gonadal dysgenesis

4. Maternal androgen-secreting tumor

26) Which of the following is NOT characteristic of female pseudohermaphroditism?

1. mullerian-inhibiting substance is not produced

2. the fetus is exposed to excess androgen

3. the karyotype is 46, XX

4. a testis is present on one side

27) Which of the following is NOT characteristic of androgen insensitivity syndrome?

1. female phenotype

2. short, blind-ending vagina

3. no uterus or fallopian tubes

4. ovarian remnants on one side

28) By which of the following mechanisms can endometriosis affect fertility?

1. local inflammatory response within the pelvis

2. anatomic distortion of the pelvic organs

3. diminished oocyte pickup

4. all of the above

29) Choose the INCORRECT statement regarding treatment of endometriosis

1. progestins inhibit pituitary LH release and suppress ovarian production of estrogen to promote secretory changes in the glandular epithelium

2. danazol has direct androgenic action on endometrial implants antagonistic to endometriosis

3. oral contraceptive pills can induce a “pseudo-pregnancy” state that improves symptoms of endometriosis

4. GnRH agonists function to upregulate the pituitary-ovarian axis over time, which decreases symptoms of endometriosis

30) Which of the following can be used to treat dysfunctional uterine bleeding (DUB)?

1. progestin-impregnated IUD

2. combination oral contraceptive pills

3. nonsteroidal anti-inflammatory medications

4. all of the above

31) Choose the INCORRECT statement

1. in cases of postmenopausal bleeding, endometrial thickness less than 4 mm on transvaginal ultrasound may be used to exclude endometrial cancer

2. sampling of the endometrium may be performed with either a silastic curette or dilation and curettage

3. when unopposed estrogen is used in postmenopausal patients with an intact uterus, endometrial hyperplasia develops in 50% of patients

4. endometrial sampling in postmenopausal patients may be complicated by cervical stenosis

32) Dysfunctional uterine bleeding is defined as

1. menstruation beyond the age of 50

2. failure to menstruate because of anatomic obstruction

3. irregular menstruation without anatomic lesions of the uterus

4. failure to menstruate within 6 months of a previous menstrual cycle

33) Which of the following distinguishes secondary from primary amenorrhea?

1. absence of anatomic defects

2. history of prior menses

3. chance of future fertility

4. follicle-stimulating hormone (FSH) levels

34) An 18-year-old G0P0 patient complains of cyclic, sharp, crampy, lower abdominal pain that begins on the day of her menstrual flow and lasts for 2 to 3 days. Periods are regular and heavy, with clots. She has been attempting pregnancy for the past year. Pelvic examination is normal. Which of the following is the most likely diagnosis for this patient?

1. primary dysmenorrhea

2. adenomyosis

3. uterine myomas

4. endometriosis

35) An 18-year-old G0P0 patient complains of cyclic, sharp, crampy, lower abdominal pain that begins on the day of her menstrual flow and lasts for 2 to 3 days. Periods are regular and heavy, with clots. She has been attempting pregnancy for the past year. Pelvic examination is normal. The most appropriate therapy for this patient would be

1. low-dose, monophasic oral contraceptive pills

2. an acetaminophen/codeine combination

3. a nonsteroidal anti-inflammatory agent

4. an injectable progestin contraceptive agent

36) Which of the following statements is LEAST descriptive of premenstrual syndrome (PMS)?

1. it occurs in a regular, cyclical relationship to the luteal phase of the menstrual cycle

2. it can resemble certain psychiatric conditions

3. its onset may occur in a woman’s fourth decade of life

4. the severity tends to increase over time

37) Which of the following is most likely to help a patient’s PMS symptoms?

1. Transdermal estrogen

2. Vaginal progesterone

3. Combined oral contraceptives

4. Oral medroxyprogesterone acetate

38) The treatment for androgen-excess disorders is directed at

1. suppression of source of androgen

2. stimulation of production of feminizing hormones

3. induction of estrogen receptors

4. reduction of hair growth

39) Hirsutism is most frequently associated with

1. temporal balding

2. development of acne

3. enlargement of the clitoris

4. remodeling of the limb-shoulder girdle

40) Which of the following is inconsistent with the diagnosis of polycystic ovarian disease?

1. oliomenorrhea

2. anovulation

3. acne

4. virilization

41) Successful treatment of polycystic ovarian syndrome with oral contraceptives should result in

1. increased luteinizing hormone production

2. increased production of androstenedione

3. increased production of testosterone

4. decreased incidence of endometrial hyperplasia

42) Increased facial hair in menopausal women results from

1. increased testosterone production

2. increased dihydrotestosterone production

3. increased dehydroepiandrosterone sulfate production

4. reduced sex hormone-binding-globulin

43) Which of the following is NOT a risk factor for osteoporosis?

1. reduced height for weight

2. family history of osteoporosis

3. late menopause

4. low calcium intake

44) Which of the following is a known risk of unopposed estrogen therapy?

1. endometrial hyperplasia

2. leiomyoma uteri

3. endocervical adenocarcinoma

4. squamous cell carcinoma of the cervix

45) Infertility is defined as a couple’s failure to conceive following unprotected sexual intercourse for

1. 6 months

2. 1 year

3. 2 years

4. 3 years

46) The generation time of sperm is approximately

1. 33 days

2. 53 days

3. 73 days

4. 113 days

47) Which of the following statements about clomiphene citrate is correct?

1. it acts by stimulating estrogen production and binding

2. it should be administered in conjunction with progesterone

3. it results in an increase in the release of follicle-stimulating hormone from the pituitary

4. dosage should not exceed 50 mg/day

Gynecology

48) Which of the following best describes a “clue cell”?

1. clumped white blood cells

2. immature vaginal epithelial cells

3. keratinized vaginal epithelial cells with adherent white blood cells

4. vaginal epithelial cells with adherent bacteria

49) Which of the following characterizes vaginal trichomoniasis?

1. cervical ectropion

2. vaginal dryness

3. motile protozoa on microscopic examination

4. white discharge

50) In a patient with recurrent yeast infections, what concurrent disease should be suspected?

1. systemic lupus erythematosus

2. diabetes mellitus

3. syphilis

4. Cushing syndrome

51) What types of cells are characteristic of atrophic vaginitis?

1. columnar cells

2. parabasal cells

3. ciliated cells

4. white blood cells

52) Which of the following is the LEAST accurate statement about vulvar vestibulitis?

1. vulvar vestibulitis involves the vestibular glands located just inside the vaginal introitus near the hymenal ring

2. patients often report a progressive worsening of the condition

3. light touch of a moistened cotton tip applicator to the proper anatomic areas will duplicate the pain of the complaint

4. treatment with hydrocortisone ointments and topical Xylocaine jelly is uniformly successful

53) Lichen sclerosis is characterized by which of the following statements?

1. the lesion is unlikely to totally resolve, requiring intermittent treatment for an indefinite period

2. the lesion is likely to be premalignant

3. the vulva is only rarely termed “onion-skinned” in appearance

4. there is obviously hyperkeratotic skin with secondary excoriation

54) Determinants of healthy sexuality include

1. one’s overall health status

2. one’s general perception of well-being

3. the quality of an individual’s previous sexual experiences

4. all of the above

55) The persistent or recurrent deficiency or absence of sexual fantasies, thoughts, and/or desire for or receptivity to sexual activity is

1. hypoactive sexual desire disorder

2. female sexual arousal disorder

3. female orgasmic disorder

4. female pain disorder

56) What is the etiology of soft chancres?

1. Treponema pallidum

2. Haemophilus ducreyi

3. Trichomonas vaginalis

4. Calymmatobacterium granulomatis

57) Choose the INCORRECT statement

1. adnexal torsion is a common gynecologic surgical emergency with a prevalence of 5%

2. the classic presentation for adnexal torsion includes acute onset of abdominal pain with clinical evidence of peritonitis and an adnexal mass

3. torsion is more likely to occur during ovulation

4. unwinding the involved adnexa to observe for tissue reperfusion and viability is safe

58) In describing the clinical features of leiomyomata, it is important to remember that

1. most leiomyomata are asymptomatic and may not require any treatment

2. if the uterine size is believed to be greater than 12 weeks size, a hysterectomy is recommended

3. most women will have an increase in symptomatology after menopause

59) A 28-year-old woman, gravida 2, has a routine obstetrical ultrasound at 18 weeks gestation and a 3.5-cm smooth walled cyst is noted in the right ovary. The best plan of management would be

1. ultrasound guided needle aspiration of the cyst with cytologic examination of the fluid

2. repeat ultrasound in 6 weeks

3. exploratory laparotomy with right oophorectomy

4. plan for cesarean delivery with right ovarian cystectomy at that time

60) Choose the INCORRECT answer

1. pelvic adhesions are a common cause of chronic pelvic pain

2. site of pelvic adhesions does not correlate with site of pelvic pain

3. intensity of pelvic pain is unrelated to the extent of adhesions present

4. adhesions are anatomically stable a few months after surgery or infection

61) The term “chronic pelvic pain” is applied to pain that has been present for

1. three consecutive menstrual periods

2. at least 6 months

3. three or more of a woman’s first six menstrual cycles

4. more than 21 days in a given month

62) Which of the following would NOT contribute to a diagnosis of irritable bowel syndrome?

1. pain relieved by defecation

2. change in the frequency of bowel movements

3. change in appetite

4. change in the form of stool

63) A 30-year-old patient with a family history of breast cancer undergoes a needle aspiration of a cystic breast mass. The fluid obtained is clear. Your next step in the management of this patient would be to

1. send the fluid for cytology

2. obtain a mammogram

3. check the site for recurrence of the mass

4. perform a needle biopsy of the cyst wall

64) Fibroadenomas occur in about what percent of all women?

1. 1 to 2%

2. 10 to 20%

3. 30 to 40%

4. 50 to 60

65) What is the most common benign breast condition?

1. ductal ectasia

2. fibroadenoma

3. fibrocystic change

4. intraductal papilloma

66) What is the most common form of breast cancer?

1. cystosarcoma phylloides

2. infiltrating intraductal carcinoma

3. noninfiltrating intraductal carcinoma

4. lobular carcinoma

67) Compared with detection of breast cancer by self-examination, breast cancer is detectable by mammography

1. significantly earlier

2. at about the same time

3. significantly later

68) Breast pain is a presenting symptom in approximately what percent of patients with breast cancer?

1. 10%

2. 50%

3. 70%

4. 90%

Obstetrics

69) Which of the following hemodynamic values remains unchanged in pregnancy?

1. systemic vascular resistance

2. pulmonary vascular resistance

3. colloid osmotic pressure

4. pulmonary capillary wedge pressure

70) Which of the following levels increases markedly during pregnancy?

1. thyroid-binding globulin (TBG)

2. thyrotropin-releasing hormone (TRH)

3. thyrotropin

4. none of the above

71) At what gestational age does the fetal kidney begin producing urine?

1. 8 weeks

2. 12 weeks

3. 16 weeks

4. 20 weeks

72) What is the most common etiology of congenital hypothyroidism?

1. idiopathic

2. thyroid agenesis

3. therapeutic radioiodine

4. transient hypothyroidism

73) Which of the following fetal activities is monitored during a contraction stress test?

1. breathing

2. eye movements

3. heart rate

4. body movements

74) Which of the following is NOT a fetal biophysical variable used in the biophysical profile?

1. heart rate

2. breathing

3. contractions

4. body movement

75) What is the primary treatment approach for thyrotoxicosis during pregnancy?

1. medical

2. surgical

3. combination of medical and surgical

4. no treatment necessary

76) What is the most common histological diagnosis of thyroid nodules biopsied during pregnancy?

1. carcinoma

2. cystic degeneration

3. granulomatous disease

4. nodular hyperplasia

77) Which of the following is the pathophysiology of type 2 diabetes?

1. absence of the islet cells

2. destruction of the islet cells

3. insulin resistance in target tissues

4. develops ketoacidosis if untreated

78) How is gestational diabetes diagnosed?

1. 1-hour value after a 50-g glucose load exceeds 140 mg/dL

2. elevated fasting value after a 100-g glucose load

3. elevated 1-hour value after a 100-g glucose load

4. two abnormal values after a 100-g glucose load

79) When can a pregnant woman be discharged home on oral antibiotics following parenteral antibiotic therapy for pyelonephritis?

1. when she is no longer symptomatic

2. when she becomes afebrile

3. when 10 full days of inpatient therapy is complete

4. when pyuria resolves

80) Which of the following is an associated fetal risk with cytomegalovirus infection?

1. diabetes

2. cataracts

3. spastic paralysis

4. deafness

81) Which of the following is associated with malarial infections in pregnancy?

1. fetal hydrops

2. preterm labor

3. congenital blindness

4. congenital cardiac defects

82) What are the classical morphological features of iron-deficiency anemia?

1. hyperchromia, macrocytosis

2. hypochromia, microcytosis

3. macrocytosis, teardrop cells

4. spherocytosis, red cell fragments

83) Which of the following characterizes B-thalassemias?

1. impaired production of beta-globin chains

2. increased destruction of erythrocytes containing hemoglobin F

3. increased production of alpha-globin chains

4. decreased production of hemoglobin F

84) When is heart failure and cardiac-related maternal death most common?

1. first trimester

2. second trimester

3. third trimester

4. peripartum

85) Which of the following is the preferred mode of delivery in a woman with a cyanotic heart lesion?

1. vaginal delivery with spinal analgesia

2. vaginal delivery with epidural analgesia

3. elective cesarean delivery with epidural analgesia

4. elective cesarean delivery with general anesthesia

86) Which of the following perinatal complications is associated with bacterial pneumonia?

1. fetal growth retardation

2. preterm labor

3. persistent fetal circulation

4. cerebral palsy

87) What is the first-line therapy for mild asthma?

1. antibiotics

2. Beta-adrenergic agonists

3. methylxanthines

4. cromolyn sodium

88) What is the etiology of reflux esophagitis in pregnancy?

1. constriction of upper esophageal sphincter

2. relaxation of upper esophageal sphincter

3. constriction of lower esophageal sphincter

4. relaxation of lower esophageal sphincter

89) What is the most common cause of bowel obstruction in pregnancy?

1. infection

2. adhesions

3. cancer

4. mechanical compression from the uterus

90) Epileptic pregnant women are at increased risk for which of the following?

1. cesarean delivery

2. placental abruption

3. first-trimester abortion

4. none of the above

91) Which of the following should be supplemented during pregnancy, particularly if a woman is taking anticonvulsants?

1. zinc

2. cobalt

3. folic acid

4. pyridoxine

92) Which location of leiomyomata is most associated with spontaneous abortion?

1. subserosal

2. submucosal

3. intramural

4. pedunculated

93) The characteristic history of incompetent cervix includes

1. pain but no bleeding

2. no pain or bleeding

3. bleeding but no pain

4. both pain and bleeding

94) Which of the following is the least likely cause for a second-trimester spontaneous abortion?

1. abnormal placentation

2. chromosomal abnormality

3. maternal systemic disease

4. uterine anomaly

95) What is the incidence of twinning after clomiphene citrate induction of ovulation?

1. 1 in 3 pregnancies

2. 1 in 12 pregnancies

3. 1 in 90 pregnancies

4. 1 in 250 pregnancies

96) Twinning within 3 days of fertilization will likely result in what organization of the fetal membranes?

1. conjoined twins

2. monoamniotic/monochorionic

3. diamniotic/dichorionic

4. diamniotic/monochorionic

97) Which of the following conditions is NOT associated with postterm pregnancy?

1. meconium passage

2. shoulder dystocia

3. placental dysfunction

4. maternal hypertension

98) A normal pregnancy is defined to last from about 38 weeks to how many weeks?

1. 40

2. 41

3. 42

4. 43

99) The most common situation that can be confused at term with premature rupture of membranes is

1. bloody show

2. passage of cervical mucus

3. intermittent urinary leakage

4. yeast vaginitis

100) Which of the following factors should be considered in developing a management plan for a patient with premature rupture of the membranes?

1. the gestational age at the time of rupture

2. the presence of uterine contractions

3. the amount of amniotic fluid around the fetus

4. all of the above

101) Which of the following statements about isoimmunization is INCORRECT?

1. It involves the development of fetal antibodies in response to maternal red blood cells

2. The antibodies involved in isoimmunization cross the placental barrier

3. The ability of the fetus to produce red blood cells can to some degree counter the isoimmunization process

4. The father must be Rh+ and the mother Rh- for Rh isoimmunization to occur

102) When is administration of RhoGAM appropriate for an Rh- patient?

1. after an ectopic pregnancy

2. after a spontaneous abortion

3. after an elective abortion

4. in all of the above circumstances

103) What is the average weight of the fetus at 32 gestational weeks?

1. 1200 g

2. 1500 g

3. 1800 g

4. 2000 g

104) Which of the following are recognized signs and symptoms associated with preterm labor?

1. low, dull backache

2. pelvic pressure

3. change in vaginal discharge

4. all of the above

105) Which of the following are factors associated with preterm birth?

1. placental abnormalities

2. uterine distortion

3. excessive uterine enlargement

4. all of the above

106) The intrauterine growth restriction often associated with hypertensive disease in pregnancy is most likely related to

1. chronic uteroplacental insufficiency

2. congenital anomalies of the fetus

3. anomalies of placental structure

4. placental abruption

107) Asymmetrical IUGR is associated with

1. equal decrease in the size of structures

2. congenital anomalies

3. hypertension

4. early intrauterine infection

108) What is the most likely diagnosis of a patient who presents with hypertension in the twelfth week of pregnancy?

1. preeclampsia

2. eclampsia

3. chronic hypertension

4. hyperthyroidism

109) Which of the following is the mechanism of action of hydralazine?

1. direct peripheral vasodilation

2. direct vasodilation, cardiac effects

3. decreased plasma volume and cardiac output

4. false neurotransmission, central nervous system effects

110) Which of the following is the mechanism of action of nifedipine?

1. calcium channel blocker

2. Beta-adrenergic blocker

3. alpha- and Beta-adrenergic blockers

4. direct vasodilation, cardiac effects

111) Which of the following is NOT a component of the Bishop score?

1. parity

2. dilation

3. effacement

4. station

112) What is the mean half-life of oxytocin?

1. 5 minutes

2. 10 minutes

3. 20 minutes

4. 30 minutes

113) When does the onset of the analgesia effect of morphine given intravenously occur?

1. less than 5 minutes

2. 20 minutes

3. 45 minutes

4. 60 minutes

114) What is the etiology of spinal headaches?

1. puncture of meninges followed by leaking fluid

2. hypotension after spinal block

3. vasodilation of cerebral vessels

4. drug-induced hormonal changes

115) Which vitamin is not found in human breast milk?

1. A

2. D

3. C

4. K

116) Mastitis followed by breast abscess is most frequently caused by

1. Pneumococcus

2. Escherichia coli

3. Streptococcus pyogenes

4. Staphylococcus aureus

Oncology

117) In a classic type III radical hysterectomy, the uterine artery is ligated at which point?

1. its origin from the hypogastric artery

2. where it crosses over the ureter

3. 1 cm lateral to the uterus

4. As it enters the parametrial “web”

118) The most common late sequela of radical hysterectomy and pelvic lymphadenectomy is

1. vesicovaginal fistula

2. numbness of the medial thigh

3. leg edema

4. bladder dysfunction

119) You may consider omitting lymphadenectomy as part of the staging procedure for squamous cell vulvar carcinoma when

1. lesion 1.5 cm diameter, less than 5 mm invasion

2. unilateral lesion, less than 5 mm invasion

3. any location, less than 1 mm invasion

4. unilateral lesion 1.3 cm diameter, 3 mm invasion

120) What is the single most effective method of reducing groin wound breakdown?

1. prophylactic antibiotics

2. ligation of draining lymphatics

3. prophylactic suction drainage

4. separate groin incisions

121) Lymphatic drainage from the cervix empties mainly into which group of nodes?

1. iliac

2. inguinal

3. hypogastric

4. internal iliac

122) Initial workup of a 40-year-old woman with a Pap showing atypical glandular cells should include all of the following EXCEPT

1. colposcopy

2. endocervical curettage

3. pelvic ultrasound

4. endometrial biopsy

123) A patient with a Grade I endometrial adenocarcinoma undergoes an exploratory laparotomy, TAH-BSO, and pelvic washings. Which of the following prognostic factors would mandate pelvic and paraaortic lymphadenectomy?

1. lymph-vascular space invasion

2. invasion of the myometrium to the outer 1/3

3. history of tamoxifen use

4. patient age

124) You are consulted intraoperatively by a colleague who has a 33-year-old G2P0A2 patient diagnosed with endometrioid borderline tumor of the right ovary. The tumor appears to be confined to that ovary that was 20 cm in diameter and was removed intact. The patient strongly desires to maintain her fertility. Which of the following treatments would you recommend?

1. unilateral salpingo-oophorectomy with surgical staging

2. unilateral salpingo-oophorectomy of the opposite ovary

3. bilateral salpingo-oophorectomy without hysterectomy, with the possibility of donor oocyte pregnancy remaining

4. TAH-BSO with surgical staging

125) The stages of grief include

1. denial

2. guilt

3. depression

4. all of the above

126) Which of the following statements regarding early feeding in patients who have undergone a bowel anastomosis is true?

1. the rate of ileus is significantly higher in patients who are fed before passing flatus

2. the rate of anastomotic complications is significantly decreased by delaying feeding

3. return of bowel function generally occurs at the same rate regardless of early or delayed feeding

4. early feeding decreases the probable length of hospital stay

127) Which of the following is a common reason for bowel obstruction?

1. adhesions

2. hernias

3. malignancies

4. all of the above

128) A 34-year-old patient undergoes a TAH-BSO for leiomyomata. During the surgery the small bowel sustains a thermal injury requiring resection of 4 cm of small bowel. The remaining bowel appears healthy. Which of the following types of anastomosis should probably NOT be used because of the higher potential for excessive luminal narrowing?

1. end-to-end hand-sewn anastomosis

2. side-to-side hand-sewn anastomosis

3. end-to-end staple anastomosis

4. side-to-side staple anastomosis (functional end-to-end anastomosis)

Examinee__________________________________

Abnormal Uterine Bleeding Case Study

Mrs. C. is a 36 year old morbidly obese gravida0 who presents to OPD complaining of a history of menometrorrhagia with menses every 2-3 months since onset of menarche at age 14. She also complains of recent exacerbation of hirsutism. She has never used hormonal contraception, has no known medical problems or medication use. Her exam is normal.

What particular aspects of Mrs. C.’s physical examination will help you make a diagnosis & why?

What screening procedures / laboratory tests will you include in your assessment of Mrs. C & why?

Lab results: HgB 11.5, Urine pregnancy test – negative, TSH & prolactin – normal, Endometrial Biopsy – disorderly proliferative phase, no hyperplasia or malignancy

Based on these findings, what is Mrs. C.’s diagnosis & why?

Based on your diagnosis, what is your plan of care for Mrs. C & why?

Examinee__________________________________

Shock Case Study

Mrs. A. is 20 years old. She gave birth to a full-term newborn 2 hours ago at home. Her birth attendant was a local traditional birth attendant, who has brought Mrs. A. to the health center because she has been bleeding heavily since childbirth. The duration of labor was 12 hours, the birth was normal & the placenta was delivered 20 minutes after the birth of the newborn.

What will you include in your initial assessment of Mrs. A & why?

What particular aspects of Mrs. A.’s physical examination will help you make a diagnosis or identify her diagnosis & why?

What screening procedures / laboratory tests will you include in your assessment of Mrs. A & why?

You have completed your rapid assessment of Mrs. A & your main findings include the following:

Pulse rate 108 beats/minute BP 80/60 RR 22 breaths/minute Temp 36.8C

She is pale & sweating

Uterus is soft & does not contract with fundal massage. She has heavy, bright red vaginal bleeding

The TBA says she thinks the placenta & membranes were complete

Based on these findings, what is Mrs. A.’s diagnosis & why?

Based on your diagnosis, what is your plan of care for Mrs. A & why?

Some placental tissue has been removed from Mrs. A’s uterus. 15 minutes after initiation of treatment, however, she continues to have heavy vaginal bleeding. Her bedside clotting test is 5 minutes. Her pulse is 100 beats/minute & BP 80/60 mmHg.

Based on these findings, what is your continuing plan of care for Mrs. A & why?

What are 2 examples of surgical treatment that may be performed?

Examinee__________________________________

Vaginal Bleeding in Early Pregnancy Case Study # 2

Mrs. B. is a 20 year old Para 2 who came to the health center 2 days ago complaining of irregular vaginal bleeding & abdominal & pelvic pain. Symptoms of early pregnancy were detected & confirmed with a pregnancy test. Mrs. B. was advised to avoid strenuous activity & sexual intercourse & return immediately if her symptoms persisted. Mrs. B. returns to the health center today & reports that irregular vaginal bleeding has continued & she now has acute abdominal pain that started 2 hours ago.

What will you include in your initial assessment of Mrs. B. & why?

What particular aspects of Mrs. B.’s physical examination will help you make a diagnosis & why?

What screening procedures / laboratory tests will you include in your assessment of Mrs. B & why?

You have completed your assessment of Mrs. B, & your main findings include the following:

Mrs. B.’s temperature is 36.8 degrees C, her pulse rate is 130 beats per minute & weak, her blood pressure is 85/60 & her respirations are 20 per minute. Her skin is pale & sweaty. Mrs. B. has acute abdominal & pelvic pain, her abdomen is tense & she has rebound tenderness. She has light vaginal bleeding. On vaginal exam, the cervix is found to be closed & cervical motion tenderness is present. The 6 week size uterus is softer than normal.

Based on these findings, what is Mrs. B.’s diagnosis & why?

Based on your diagnosis, what is your plan of care for Mrs. B & why?

Mrs. B’s postoperative course was without complications and notable for patient tolerating oral intake, having minimal complaints of abdominal pain, ambulating well & spontaneously voiding. She is now ready to be discharged: however, her hemoglobin is 9g/dL. She has indicated that she would like to become pregnant again, but not for at least a year.

Based on these findings, what is your continuing plan of care for Mrs. B. & why?

Examinee__________________________________

Shoulder Dystocia Case Study

Mrs. A. is a 35 year old gravida 7, para 6. She was admitted to RBH in active labor at 10:00 pm. Labor has progressed well, as indicated on her partograph. It is now 4:00 am & the fetal head has just delivered & remains tightly applied to the vulva.

What will you include in your initial assessment of Mrs. A & why?

Immediate assessment of the situation reveals the following:

The chin retracts & depresses the perineum

Traction on the head fails to delivery the shoulder, which is caught behind the symphysis pubis.

Based on these findings, what is Mrs. A.’s diagnosis & why?

Based on your diagnosis, what is your plan of care for Mrs. A & why?

No further progress has been made

Based on these findings, what is your continuing plan of care for Mrs. A & why?

Examinee__________________________________

Partograph Case Study # 2

Record all information on the partograph

Mrs. B was admitted at 10:00 on September 4, 2006.

Membranes intact

Gravida 1, Para 0

Medical Record number 1443

The fetal head is 5/5 palpable above the symphysis pubis

The cervix is 4cm dilated

There are 2 contractions in 10 minutes, each lasting less than 20 seconds

FH 140

Membranes intact

Blood pressure 100/70

Temperature 36.2

Pulse 80 per minute

Urine output 400mL: negative protein & acetone

What is your diagnosis? ___________________________________________

What action will you take? _________________________________________

10:30 FH 140, Contractions 2/10 each 15 sec, pulse 90

11:00 FH 136, Contractions 2/10 each 15 sec, pulse 88, membranes intact

11:30 FH 140, Contractions 2/10 each 20 sec, pulse 84

12:00 FH 136, Contractions 2/10 each 15 sec, pulse 88, Temp 36.2

The fetal head is 5/5 palpable above the symphysis pubis

The cervix is 4cm dilated, membranes intact

What is your diagnosis? ___________________________________________

What action will you take? _________________________________________

12:30 FH 136, Contractions 1/10 each 15 sec, pulse 90

13:00 FH 140, Contractions 1/10 each 15 sec, pulse 88

13:30 FH 130, Contractions 1/10 each 20 sec, pulse 88

14:00 FH 140, Contractions 2/10 each 20 sec, pulse 90, temp 36.8, blood pressure 100/70

The fetal head is 5/5 palpable above the symphysis pubis

Urine output is 300 mL, negative protein & acetone

What is your diagnosis? ___________________________________________

What action will you take? _________________________________________

The cervix is 4cm dilated, sutures apposed

Labor augmentation with oxytocin 2.5 units in 500 mL IV fluid at 10 drops per minute (dpm) is started

14:30 FH 140, Contractions 2/10 each 30 sec, pulse 88, infusion increased to 20 dpm

15:00 FH 140, Contractions 3/10 each 30 sec, pulse 90, infusion increased to 30 dpm

15:30 FH 140, Contractions 3/10 each 30 sec, pulse 88, infusion increased to 40 dpm

16:00 FH 144, Contractions 3/10 each 30 sec, pulse 92, fetal head is 2/5 palpable above the symphysis pubis, cervix is 6cm dilated, sutures apposed, infusion increased to 50 dpm

16:30 FH 140, Contractions 3/10 each 45 sec, pulse 90

What action will you take? _________________________________________

17:00 FH 138, Pulse 92, Contractions 2/10 each 40 sec, maintain at 50 dpm

17:30 FH 140, Pulse 94, Contractions 3/10 each 45 sec, maintain at 50 dpm

18:00 FH 140, Pulse 96, Contractions 4/10 each 50 sec, maintain at 50 dpm

18:30 FH 144, Pulse 94, Contractions 4/10 each 50 sec, maintain at 50 dpm

19:00 FH 144, Pulse 90, Contractions 4/10 each 50 sec, fetal head is 0/5 palpable above the symphysis pubis, the cervix is fully dilated

19:30 FH 142, Pulse 100, Contractions 4/10 each 50 sec

20:00 FH 146, Pulse 110, Contractions 4/10 each 50 sec

20:10 Spontaneous delivery of a live male infant, Wt 2.654kg

How long was the active phase of the first stage of labor?

How long was the second stage of labor?

Why was labor augmented?

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