You are asked to evaluate a 6-year-old girl who has fallen off her brother’s bicycle and is complaining of severe vulvar pain. The girl will not permit anyone to touch her vulva. However, on inspection, the upper labia majus is blue and there is vaginal bleeding.
What is the next step in managing her injury?
Correct Answer A:
In a young child, if the straddle injury is nonpenetrating and associated with a non-expanding small vulvar hematoma, then ice packs and conservative therapy are preferred. In the presence of vaginal bleeding, an examination under anesthesia is required. The depth of many lacerations is greater than initially suspected and can involve neighboring organs and structures. Although a fall is the usual cause of a straddle injury in a young child, sexual abuse must always be considered in the differential diagnosis.
B. Having anyone, including the patient’s mother, attempting to restrain the girl while she is being examined will often result in an unsatisfactory exam as well as emotional trauma.
C. See answer to B.
D. With the presence of vaginal bleeding, penetrating trauma must be ruled out.
E. If peritoneal contents are seen spilling into the vagina during the exam under anesthesia, then a laparotomy may be necessary.
A 32-year-old Asian female presents to your office for a 6-month follow up for hypothyroidism. She informs you that she is about 8 weeks pregnant. She currently takes levothyroxine (Synthroid), 100 µg daily.
Which one of the following changes should be made to her medication regimen?
Correct Answer B:
Women with hypothyroidism who become pregnant usually require an increase of up to 40% in their thyroid maintenance dose. This adjustment must be made early in pregnancy because normal fetal brain development in the first 12 weeks of gestation depends upon maternal thyroxine as its source of thyroid hormone. There is strong circumstantial evidence that a deficiency of maternal T4 in the first trimester is associated with lower IQs in the offspring.
Concurrent iron supplementation will interfere with T4 absorption and should be given at separate times.
Of the following, which one has the greatest effect on the relative risk of developing endometrial carcinoma?
Correct Answer E:
The factor associated with the greatest relative risk for endometrial carcinoma is polycystic ovary syndrome, which has a relative risk of 75. The use of long-term high doses of postmenopausal estrogen carries an estimated risk of 10-20. Living in North America or Europe also has an estimated risk of 10-20.
A lower relative risk is associated with nulliparity, obesity, infertility, late menopause, older age, and white race. The relative risk associated with these factors falls into the range of 2-5. Early menarche, higher education or income levels, menstrual irregularities, and a history of diabetes, hypertension, gall bladder disease, or thyroid disease have a relative risk of around 1.5-2.0.
A postmenopausal woman comes to your office for advice because her best friend has been diagnosed with endometrial cancer. The patient is concerned that she too may develop the disease. You tell her that risk factors associated with endometrial cancer include the following, except:
Correct Answer C:
DES (diethylstilbestrol, a synthetic estrogen) exposure is associated with adenosis and clear cell adenocarcinoma of the vagina and cervix. If a patient is nulliparous, obese, and reaches menopause at age 52 or later, there appears to be a 5 fold increase in the risk of endometrial cancer over the patient who does not fulfill these criteria. Also upper body fat localization, which is related to lower serum hormone-bound globulin and higher endogenous production of non-protein bound estradiol, is a risk factor for endometrial cancer.
A. Increased relative risk for developing endometrial adenocarcinoma.
B. Increased relative risk for developing endometrial adenocarcinoma.
D. Increased relative risk for developing endometrial adenocarcinoma due to an increase in the circulating levels of estrogens (peripheral conversion of androgens to estrogens by the adipose tissue).
E. Increased relative risk for developing endometrial adenocarcinoma due to the long exposure to unopposed estrogen.
You are asked to consult on a young woman with a preexisting cardiac defect. She wants to become pregnant in the near future and seeks advice about what risks to her health that this will create.
You tell that the highest maternal mortality rates are associated with which of the following cardiac defects:
Eisenmenger’s syndrome is one where there is communication between the systemic and pulmonary system, along with increased pulmonary vascular resistance, either to systemic level or above systemic level (right to left shunt). A would-be mother must be informed that to become pregnant would incur a 50% risk of dying. Even if she survives, fetal mortality approaches 50% as well.
→ Severe symptomatic aortic stenosis has a mortality in pregnancy of about 20%. Prevention of reduction in preload is necessary in all obstructive cardiac lesions. Balloon valvuloplasty can be done in pregnancy.
→ Due to the increased blood volume and cardiac output in pregnancy, mitral stenosis can lead to severe pulmonary edema. Balloon valvuloplasty can be done in pregnancy.
→ Ebstein anomaly is a malformation of the tricuspid valve. It is usually not associated with maternal mortality.
→ Atrial-septal defects rarely cause complications in pregnancy, labor, or delivery.
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