1. A 28 year old woman presents to your clinic with oligomenorrhea, severe menstrual cramping (dysmenorrhea), and increased menstrual flow when her periods do occur. She took high doses of naproxen (Aleve®) for the pain, which was moderately effective. There is no family history of similar symptoms, and she had no vaginal bleeding except during her periods. There is no fever, weight loss, nausea or vomiting, or vaginal discharge. Abdominal and pelvic ultrasounds are normal except for a small simple cystic area in the left ovary. The most likely diagnosis is [1]:

   A. Uterine Fibroids (Leiomyomas)
   B. Endometriosis
   C. Pelvic Inflammatory Disease
   D. Endometritis
   E. Ruptured Ovarian Cyst

2. The appropriate diagnostic proceedure for this patient (assuming no contraindications to any of the listed proceedures) is [2]:

   A. Exploratory Laparotomy
   B. Computerized Tomography with Intravenous and Oral Contrast (CT Scan)
   C. Magnetic Resonance Imaging (MRI) Scan
   D. Exploratory Laparoscopy
   E. Nuclear Medicine Scan

3. Which of the following is NOT a therapy for improvement of infertility in these patients [3] ?

   A. Surgical Correction
   B. Synthetic Progestins
   C. GnRH (Gonadotropin Releasing Hormone) Agonists
   D. Progesterones
   E. Laparoscopic Cauterization

4. Hydrops Fetalis is usually caused by Rh incompatibility between the mother (Rh negative) and the fetus (Rh positive). Which of the following is NOT a common component of the syndrome of Hydrops Fetalis (Rh Disease) in the fetus [4] ?

   A. Neonatal Parenchymal Hepatitis
   B. High Output Congestive Heart Failure
   C. Hemolysis and Hemolytic Anemia
   D. Subcutaneous Edema and Ascites
   E. Neonatal Jaundice

5. Which of the following is NOT required for the development of Rh related Hydrops Fetalis [5] ?

   A. Two exposures of the mother to fetal Rh Antigens
   B. Father is Rh Positive
   C. Mother must produced IgG anti-Rh Antibodies
   D. Fetal Hemolytic Anemia is central to the development of heart failure
   E. Mother must have carried at least one fetus full term

6. A 22 year Grava 3 Para 2 woman presents to your clinic with a thick greenish vaginal discharge for four days along with itching. In addition, she has a low grade fever and mild abdominal pain, which she describes as cramping. She has a history of gonorrhea two years ago treated with ceftriaxone injection. There are no chills, nausea or vomiting, sore throat, arthritis, dysuria, hematuria, kidney pain or abnormal menstruation. A pelvic examination reveals a mild greenish discharge and diffuse cervical motion tenderness. Microscopic examination of the discharge reveals white blood cells and squamous cells (both normal appearing) and flagellated (motile) microorganisms. The discharge is most likely caused by [6]:

   A. Trichomonas Infection
   B. Gardnerella Infection
   C. Streptococcal Infection
   D. Gonorrheal Infection
   E. Candida Infection

7. The patient (and her partner) are treated with the appropriate antibiotic. The patient returns 10 days later with increasing pelvic pain and a clear to white discharge. You review culture results from her previous visit and find that all cultures were negative except for the organism found in Question 6. Her temperature is 100.2° by mouth and she reports a chill the previous evening. Sexual intercourse is painful and there is mild dysuria. Her partner is asymptomatic. A repeat pelvic examination reveals left sided adnexal tenderness. Microscopic examination of the vaginal discharge shows only white blood cells. The most likely diagnosis is [7]:

   A. Gonorheal Infection
   B. Group B Streptococcal Infection
   C. Chlamydial Infection
   D. Escherichia coli Infection
   E. Ruptured Ectopic Pregnancy

8. The patient is treated with intramuscular and oral antibiotics. There is initially improvement, but she returns to clinic 5 days later with increasing abdominal pain, fever to 102.4° by mouth, rigors, nausea and vomiting. The white blood cell count is 15,600/µl with 10% immature neutrophil (band) forms. The most appropriate course of action is [8]:

   A. Admission, IV fluids, pan-culture, fever control, await culture results
   B. Admission, IV fluids, pan-culture, pregnancy test, IV antibiotics, pelvic ultrasound
   C. Admission, IV fluids, pan-culture, pregnancy test, IV antibiotics
   D. Admission, IV fluids, pan-culture, IV antibiotics, pelvic ultrasound
   E. Admission, IV fluids, pan-culture, IV antibiotics, exploratory laparoscopy

9. Which of the following is NOT a complication of the above episode [9] ?

   A. Infertility
   B. Increased risk of tubal pregnancy
   C. Tubo-Ovarian Abscess
   D. Endometriosis
   E. Inflammatory Arthritis

10. Which of the following is safe during pregnancy [10] ?
A. Anti-convulsants (eg. Phenytoin)
B. Aminoglycoside Antibiotics
C. ACE inhibitors
D. Tetracyclines
E. Erythromycin

Answers

1. B
2. D
3. C
4. A (Hepatitis due to severe neonatal heart failure is late stage and very rare.)
5. E (Previous abortion, elective or spontaneous, can sensitize mother to fetal blood cells.)
6. A (Flagellated protozoans, sometimes causing a greenish discharge.)
7. C
8. B (This is most likely pelvic inflammatory disease; ultrasound to rule out abscess.)
9. D
10. E