An asymptomatic 24-year-old white female comes to your office for a refill of oral contraceptive pills. A speculum examination is normal with the exception of a slightly friable, well-demarcated, 1.4-cm raised lesion involving a portion of the cervix. All previous Papanicolaou (Pap) tests have been normal and she has no history of abnormal bleeding or leukorrhea.
Which one of the following would be most appropriate at this point?
Correct Answer C:
The finding of a red, raised, friable lesion on the cervix, or a well-demarcated cervical lesion, mandates a biopsy to exclude cervical carcinoma, and treatment for chronic cervicitis should not be started until the biopsy results are available. A Papanicolaou test by itself is insufficient if there is a grossly visible lesion, as false-negatives occur in 10% 50% of tests.
Colposcopy-directed biopsy is usually diagnostic. If not, cone biopsy is required. A cone biopsy may be done if the abnormal tissue cannot be seen with colposcopy but was found in cells collected from a biopsy of the cervical canal, or the abnormal tissue seen with colposcopy extends high into the cervical canal.
At the time of physical examination, detection of a lower-abdominal tumor in a 7-year-old girl is best accomplished by palpation of the abdomen coupled with:
Correct Answer A:
In a virginal 7-year-old, the best way to examine a lower abdominal process is with a rectal examination, not with a vaginal exam. Rectal exam will be able to detect most pelvic and lower abdominal masses.
B. Vaginal exam in a 7-year-old should be avoided.
C. See answer to B.
D. A lower abdominal may be missed by percussion, unless it is large enough to have a significant portion within the abdominal cavity.
A 21-year-old patient comes to you for a pelvic examination and contraceptive counseling. She tells you she has never had intercourse and fears her vagina may be too small, even though she has used tampons for 3 years. You reassure her that her examination is normal.
Which of the following approaches is the next step?
During intercourse, the vagina can significantly expand and elongate. After surgical reconstruction of the vagina or with creation of a neovagina, intercourse is the best technique to maintain normal caliber and size of the vagina when compared with dilators.
A. Dilation of the hymen is unnecessary.
B. With the normal exam, explanation of the normal physiology of the female sexual response is the appropriate next step.
D. No surgical procedures are indicated.
E. See above explanation.
An 18-year-old pregnant woman presents to the clinic for a routine checkup. She is at the 5th week of gestation. Except for morning nausea, she denies any problems with her pregnancy so far. The patient is allergic to penicillin. Physical exam is unremarkable and appropriate for gestational age. Routine screening lab tests were ordered. VDRL screening returned positive and was confirmed by the FTA-ABS test.
Which of the following is considered the best management of this patient?
Correct Answer D:
Penicillin is the treatment of choice for treating syphilis. For treatment of syphilis during pregnancy, no proven alternatives to penicillin exist. Treatment guidelines recommend desensitization in penicillin-allergic pregnant women (choice D), followed by treatment with penicillin. Syphilis in pregnancy is associated with mental retardation, stillbirth and sudden infant death syndrome; therefore it should be treated promptly.
→ Data are insufficient to recommend ceftriaxone (choice A) for treatment of maternal infection and prevention of congenital syphilis.
→ Erythromycin (choice C) and azithromycin should not be used, because neither reliably cures maternal infection or treats an infected fetus.
→ Tetracycline (choice E) and doxycycline (choice B) are contraindicated in pregnancy and ceftriaxone is much less effective than penicillin.
The most common cause of abnormal vaginal discharge in a sexually active 19-year-old female is:
Correct Answer E:
Bacterial vaginosis is the most common cause of acute vaginitis, accounting for up to 50% of cases in some populations. It is usually caused by a shift in normal vaginal flora. Mixed vaginal flora is considerably more common as a cause of vaginal discharge than C. albicans and T. vaginalis.
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