# Answer Notes

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Answers

1. D

2. C - Regardless of what her symptoms are or what the actual diagnosis is, pregnancy MUST be ruled out and therefore C is the correct answer. Q: Shouldn’t it
be urine hCG? A: Either can be used to diagnose pregnancy. Since urine isn't an option pick the one that is.

3. B - Previous macrosomic infant is risk for development of gestation DM. In these patients we check glucose at first antenatal visit.

4. B - Confirm syphilis infection with either screening test when one test shows positive result.

5. B - One of the main risk factor for endometrial carcinoma is OBESITY especially in postmenopausal. This is mainly because of the peripheral conversion of
androgens into estrogens and aromatization of androstenedione into estrone. This will lead to chronic stimulation of the endometrium by the estrogen without
the balancing effect of progesterone (just like the effect of anovulation on the endometrium).

6. C - Pelvic organ prolapse centrally = enterocele.

7. C - Rh negative with antibody also negative that means C is the answer, daycare is clue to Parvovirus B19.

8. A - Cervical cancer screening recommended twice in the first year after diagnosis of HIV and then annually if results are normal (UTD).

9. A - Fetal bradycardia - pelvic exam to palpate cord prolapse.

10. B - She can use Lamotrigine for seizures.

11. B - Müllerian duct is responsible for the formation of 1. Uterus, 2. Fallopian tubes, and 3. Upper portion of the vagina. In müllerian duct agenesis the ovaries
are completely fine and present, therefore a person with müllerian duct agenesis should present as amenorrhea with fully developed secondary sexual
characteristics (indicator of functional ovaries). But in this patient, her secondary sexual characteristics are not fully developed (breast) therefore this patient is
most likely an XY with decreased testosterone sensitivity which has led to the prominence of the estrogen and the formation of a rudimentary vagina (they
usually have testes as well, but the testes should be removed to avoid malignancy). Q: But she has no uterus; why this is not D? A: In müllerian agenesis,
secondary sexual characteristics (axillary or pubic hair) are normal.

12. B - There are several things to look for that are dichorionic in nature or at least lend to it more like being dichorionic: >2mm dividing membrane, two
genders, two placentas, twin peak (lambda sign). This one has 2 so it’s very likely dichorionic.

More: So apparently, thanks to Google, I found out that the thickness is the only way to differentiate monochorionic from dichorionic. The first trimester is the
best time to evaluate the chorionicity and amnionicity of twin gestations. Look at the difference in the thickness in these two images:

A. Sonogram in a 10-week monochorionic-diamniotic gestation. A thin dividing membrane (arrow) from the two apposed amniotic sacs is seen.

B. Sonogram from a 7-week dichorionic-diamniotic gestation. Both amnions (arrows) surrounding the developing embryos are well seen in this diamniotic twin
pregnancy. Dichorionicity is confirmed by the thick intertwin membrane.
A. B.

13. E

14. E - Endometriosis, laparoscopy needed to confirm the diagnosis.

15. D - Patients with a positive TST or IGRA must undergo clinical evaluation to rule out active tuberculosis; this includes evaluation for symptoms (e.g. fever,
cough, weight loss) and radiographic examination of the chest (with appropriate shielding), regardless of gestational age (UTD).

16. J - Amniotic fluid embolism syndrome happens either during the labor and delivery or in the immediate postpartum. In UTD they say that it rarely has been
reported as late as 48 hours after a C-section. For this patient it has been 72 hours. Another clue is that amniotic fluid embolism presents with DIC. Q: Her fibrin
split product is normal - it rules out PE. It has to be amniotic fluid embolism? A: Fibrin split products not as relevant as D-dimer for PE. Q: What about bilateral
wheezing? Lungs should be clear? A: Her bilateral wheezing is probably due to the cor pulmonale. Note: no explanation why she is acidotic. She should have a
respiratory alkalosis. Possibly a mistake.

17. E - Her chronic HTN leads to less than optimal placental blood vessels leading to uteroplacental insufficiency which leads to fetal growth restriction.

18. C - One important clue here is the "prolonged" labor in the very first line, which places her at greatest risk for endometritis. Diffuse cramping of lower
abdomen + tenderness and rigidity on examination + fever + leukocytosis - all these are very typical for the diagnosis of postpartum endometritis. RBCs in the
urine in the presence urinary catheter is suggestive of traumatic catheterization finding upon insertion (not significant to the given stem just a DISTRACTOR).
RBCs in the urine is often a distractor in surgical questions.

19. F - She is a smoker and >35, both of which are contraindications for OCPs.

20. A - Hypogonadotropic hypogonadism due to extreme exercise.

21. E - Most common cause of abnormal uterine bleeding in young children. Runny nose is a distractor.
22. A - Urinary urgency + nocturia = urge incontinence (mainly secondary to detrusor instability). Detrusor instability may be caused by stones, infection, or in
this case, a mass, where the bladder lining is irritated and produces a contraction. Incontinence in this patient is an indirect complication of the fibroid, not
direct. 80% of women will have fibroids by 60, so when you see a 3 cm fibroid it shouldn't be the first think you suspect. If it had been 13 cm then yes, but 3 cm
seen on US tells you nothings because it's small and US cannot differentiate between fibroid location.

23. D

24. A - Here the best option is to administer the second dose of Betamethasone (which should be given in two doses within 24 hours)

In case of this option has not been listed, CHECK the gestational age (whether less than 34 weeks or more). This patient in this given scenario is 28 week
gestation, presenting with preterm premature rupture of membrane (PPROM). As per UWorld recommendation, we should evaluate first for signs of infections
or fetal compromise.

If these were POSITIVE: start with antibiotics + corticosteroids + MgSO4 (if less than 32 weeks) + delivery

If signs were NEGATIVE: start with antibiotics + corticosteroids + fetal surveillance.

26. C - 5-alpha reductase deficiency. No conversion of testosterone to dihydrotestosterone, which is in charge of development of external male genitalia. They
are raised as girls but in puberty due to increase in testosterone they acquire male characteristics. More: 5-alpha reductase converts testosterone to
dihydrotestosterone. The latter is the most potent form, which is in charge of development of external male genitalia, male baldness, and enlargement of the
prostate. Deficiency of this enzyme prenatally results in hypospadias and ambiguous genitalia.

27. D - SCC of cervix associated with benign retroperitoneal fibrosis and hydrouretere (terible triad of advanced cervical cancer is sciatic back pain, leg sweling,
and hydroureter).

28. C - HPV 6 and 11: genital warts. Exposure to lower grade HPV strains likely coincided with exposure to the higher grade strains that gave her the LSIL. More:
Genital warts commonly manifest as flesh-colored, painless, cauliflower-like lesions (condyloma acuminata), but may also manifest as smooth, dome-shaped
papules (papular warts), flat crusty papules resembling seborrheic keratosis (keratotic warts), or macular or slightly raised flat-topped papules.

29. A - Give GBS prophylaxis if unknown status, premature, or delivery >18 hrs after RoM.

30. F - Acanthosis nigricans (“velvety pigmented skin”) is associated with insulin resistance.

31. C - Maternal fever causes fetal tachycardia.

32. D - No fluid seen on US. Note: Explanation unsatisfactory.

33. A - Asherman Syndrome from the D&C.

34. E - In vulvar squamous cell carcinoma, most patients present with a unifocal vulvar plaque, ulcer, or mass (fleshy, nodular, or warty) on the labia majora; the
labia minora, perineum, clitoris, and mons are less frequently involved. In lichen sclerosis the patient presents with a whitish plaque.

35. C - Cervical stenosis and/or insufficiency from LEEP x2.

36. C - Endometrial hyperplasia, treat with cycle progestin therapy to shed the endometrium.

37. D - Diabetics are at risk for polyhydramnios. Q: Even when the blood sugar is control? A: HbA1c would reflect her glycemic state for longer period. Q: How to
rule out error in gestational age? A: Because 1st trimester ultrasound estimates gestational age accurately and she started receiving prenatal care since 7 weeks
so dating error is unlikely.

38. A - Smoking is a risk factor for IUGR and due to decreased fundal height, do a NST. A fetal fibronectin is done at <34 weeks of gestation together with cervical
length measurement.

39. A - CAH leading to virilization, not AIS because AIS is XY and option D is a normal process of X inactivation in females.

40. C - Chancroid due to H. ducreyi.

41. D
Screening men: The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men 35 years and older for lipid disorders (A), men 20 to 35
years of age for lipid disorders if they are at increased risk of coronary heart disease (CHD) (B).

Screening women at increased risk: The USPSTF strongly recommends screening women 45 years and older for lipid disorders if they are at increased risk of
CHD (A), women 20 to 45 years of age for lipid disorders if they are at increased risk of CHD (B).

Screening young men and all women not at increased risk: The USPSTF makes no recommendation for or against routine screening for lipid disorders in men 20
to 35 years of age, or in women 20 years and older who are not at increased risk of CHD (C).

42. G - She is sexually active with no other screening indications.

43. A - Patient had miscarriage but is stable, thus hCG needs to be followed until it is undetectable.

44. F - Pulmonary hypoplasia due to early gestational age and polyhydramnios.

45. A - Severe presentation of (fever, nausea) is among indications for hospitalization for PID.

46. D - She likely has trichomoniasis. Absences from school are supposed to be a clue to sexual activity. More: Ectropion occurs when eversion of the endocervix
exposes columnar epithelium to the vaginal milieu. It is common in adolescents. After adolescence, it may be observed in women who are pregnant or taking
estrogen-progestin contraceptives or who had a cervical laceration during labor and delivery.

47. B - 1.) Hysterosalpingogram is far less invasive than surgery; 2.) We know she's ovulating because she has regular cycles, no ovulation = CL = no progesterone
= no progesterone withdrawal = no period. Therefore we know she has estrogen, we know she's ovulating, we know the sperm is good to go, now we just need
to know if there is an anatomic abnormality and given a history of multiple partners the best test to evaluate = HSP.

48. B - Hypochromic (low MCH), microcytic anemia, normal HbA % = IDA.

49. D - Ultrasound is needed, but what's interesting is gestational age is for sure accurate as it is not going off of LMP since she has already experienced
menopause. She was implanted with a viable fertilized egg at a known date, so ultrasound is used to evaluate why the fundal height is not matching up with her
gestational age (e.g. multiple gestations).

50. J - A differential diagnosis for postpartum fever includes pulmonary or amniotic fluid embolism (dyspnea, tachycardia, V/Q mismatch), UTI/pyelonephritis
(abnormal urinalysis, flank pain, CVA tenderness), endometritis (tender uterus), wound infection (wound indurated and erythematous), septic pelvic
thrombophlebitis (diagnosis of exclusion – all other causes eliminated and unresponsive to antibiotics). Nothing fits her symptoms here besides a wound
infection. She definitely has some sort of infection based on her fever and CBC. If her wound were “clean and dry”, then you would default to septic pelvic
thrombophlebitis, which requires antibiotics and anticoagulants.