OB/GYN: ACOG OBSTETRICS UPDATED
ACTUAL Questions and CORRECT
Answers
A 28-year-old G2P2 woman returns today for follow up on her abnormal pap smear which
reveals atypical squamous cells of undetermined significance (ASCUS). Reflex HPV testing is
positive for high risk type. She has never had a prior abnormal pap smear, and has been
following the recommended screening guidelines. She is asymptomatic. Her pelvic exam reveals
a normal cervix with a small amount of cervical mucous. What is the next best step in the
management of this patient?
A. Routine screening
B. Repeat Pap smear in one year
C. Repeat HPV testing in one year
D. Repeat co-testing with Pap and HPV in one year
E. Colposcopy - CORRECT ANSWER -E
A 17-year-old G0 high school student is brought in by her mother for her first gynecologic
examination. She began her menses at age 12 and has had regular periods for the past three
years. Her last menstrual period was one week ago. For privacy, you ask to examine the patient
without her mother. Further history is obtained in the examination room. She admits that she has
been sexually active with her boyfriend for the past three years. She uses condoms occasionally
and is fearful about possible pregnancy. She requests that her mother not be informed about her
sexual activity. On physical examination, she is anxious, but normally developed. Her pelvic
examination reveals no vulvar lesions, minimal non-malodorous discharge, and a nulliparous
appearing cervix. The bimanual examination reveals a normal size uterus, and her adnexa are
non-tender and not enlarged. Urine pregnancy test is negative. In addition to discussing -
CORRECT ANSWER -D
A 25-year-old G0 woman is scheduled to discuss her recent abnormal Pap smear which showed
atypical squamous cells of undetermined significance (ASCUS). She has had one Pap smear at
age 22 which was normal. Her only significant gynecologic history is genital warts that have not
responded to treatment with local application of trichloroacetic acid. She has had eight sexual
partners. She uses condoms and oral contraceptives. She has smoked a pack a day for the past
two years. Which of the following is the most appropriate next step in the management of this
patient?
,A. HPV typing
B. Repeat Pap smear in three years
C. Cone biopsy
D. Cryotherapy
E. Loop Electrosurgical Excision Procedure (LEEP) - CORRECT ANSWER - A. HPV
typing
A 39-year-old G0 woman presents to the clinic reporting non-tender spots on her vulva for about
a week. No pruritus or pain is present. She also notes a brownish rash on the palms of her hands.
She admits to IV drug abuse. She was diagnosed as HIV-positive two years ago, but has not been
compliant with suggested treatment. On examination, three elevated plaques with rolled edges
are noted on the vulva. They are non-tender. A brown macular rash is noted on the palms of her
hands and the soles of her feet. What is the most appropriate next step in the management of this
patient?
A. Obtain a treponemal-specific test
B. Biopsy of the lesion
C. Colposcopic evaluation of the vulvar lesions
D. Culture the base of the lesion
E. Initiate empiric treatment with doxycycline and ceftriaxone - CORRECT ANSWER -
A. The diagnosis of syphilis is often established by serologic testing. Non-treponemal tests
(VDRL or RPR) are non-specific. In this patient with high suspicion for syphilis, specific testing
with treponemal antibody can confirm infection. The classic coiled spirochete is easily seen with
dark-field microscopy but availability is limited. A characteristic finding is a macular rash on the
palms and soles that are often described as copper penny lesions. Colposcopy would not be
diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic.
Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly
would not be the most expedient way to make the diagnosis. Penicillin G is the preferred drug for
treating all stages of syphilis.
A 24-year-old G0 woman presents with multiple painful ulcers involving the vulva. The sores
initially were fluid filled, but are now open, weeping and crusted. She reports a fever and is
having difficulty voiding due to pain. She uses a vaginal ring for contraception. She has multiple
sexual partners and uses condoms for vaginal intercourse. She is distraught that she may have a
sexually transmitted infection. She is healthy and does not smoke or use drugs. On physical
exam, she is in obvious distress. Temperature is 100.2°F (37.9°C), pulse 100. Examination of the
genital tract is limited due to her discomfort. Multiple ulcers and erosions of variable size are
,localized to the perineum, labia minora and vestibule. Swelling is diffuse. The lesions are eroded,
some with a purulent eschar. There is exquisite tenderness to touch. What further testing should
be offered to this patient?
A. RPR (rapid plasma regain)
B. HIV - CORRECT ANSWER - E. This patient has classic primary herpes with painful
genital ulcerations, fever and dysuria. Given the presence of one sexually transmitted infection,
screening should be offered for other STIs. Resolution of the acute episode is required before a
speculum can be inserted to allow endocervical sampling for gonorrhea and chlamydia. If it was
a high-risk exposure, prophylactic empiric treatment could be offered to cover gonorrhea and
chlamydia. The patient should be counseled that primary herpes can be acquired despite
condoms and even by oral-genital inoculation. Hepatitis B vaccination should be offered to
protect her against any future exposures. She should be encouraged to discuss her diagnosis with
all sexual partners and to continue to reliably use latex condoms.
A 38-year-old G0 woman comes to the office because she noted a persistent yellow, frothy
discharge associated with mild external vulvar irritation. She denies any odor. She tried over the
counter anti-fungal medication without success. The discharge has been present for over three
months, gradually increasing in amount. Douching has resulted in temporary relief, but the
symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious
yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix.
A sample of the discharge is examined under the microscope. What is the most likely finding?
A. Strong amine fishy odor when KOH applied to sample
B. Marked polymorphonuclear cells with multi-nucleate giant cells
C. Motile ovoid protozoa with flagella
D. Budding yeast and pseudo-hyphae
E. Clue cells - CORRECT ANSWER - C. This patient most likely has trichomoniasis. The
erythematous patches on the cervix are characteristic of "strawberry cervicitis." Trichomonads
are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide
must be examined immediately. The discharge is mixed with saline and placed on the slide with
a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green
vaginal discharge. Clue cells are seen on a saline wet mount in women who have bacterial
vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges
of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial
vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which
results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation
may be herpes.
, A 23-year-old G0 woman reports having a solitary, painful vulvar lesion that has been present
for three days. This lesion has occurred twice in the past. She states that herpes culture was done
by her doctor during her last outbreak and was negative. She is getting frustrated in that she does
not know her diagnosis. She has no significant previous medical history. She uses oral
contraceptives and condoms. She has had four sexual partners in her lifetime. On physical
examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior
fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. How do you
explain the negative culture?
A. Cultures were taken too early
B. Oral contraceptives affect the growth of the virus
C. The cultures were refrigerated prior to transport to the lab
D. Herpes cultures have a 10-20% false negative rate
E. The herpes virus cannot b - CORRECT ANSWER - D. Culture is the gold standard in
the diagnosis of herpes. They are highly specific, yet sensitivity is limited. It is best to culture the
lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The
herpes virus can theoretically be isolated from both primary and recurrent infections. This patient
very likely presented too late in the course for a useful culture. Oral contraceptives do not affect
the growth of viruses. While serum antibody screening can be performed, it indicates lifetime
exposure and would not answer the question as to the etiology of the specific lesion.
Alternatively, DNA studies such as the polymerase chain reaction can be done, if available.
A 27-year-old G1 at 12 weeks gestation presents for first prenatal care visit. She is previously
healthy and takes no medications. An ultrasound is performed and a viable pregnancy is
confirmed. At the end of the visit, the patient discusses with you her desire to have a Cesarean
section for delivery, as she does not wish to go through the pain of labor. Her husband, an
orthopedic surgeon, expresses concerns as they desire to have at least three children and he is
worried about potential complications with repeated Cesarean sections. What is the most
appropriate next step in the counseling of this patient?
a.Agree with her decision after proper counseling and perform a Cesarean section at 39 weeks
gestation
b.Agree with her decision after proper counseling and perform a Cesarean section at 41 weeks
gestation if she has not gone into labor by then
c.Advise her that it is not possible to plan a Cesarean section for del - CORRECT
ANSWER - A. Elective cesarean section on demand has been getting more popular among
women for a variety of reasons. Although, it might sound unreasonable to undergo a Cesarean
section for being afraid of pain, the patient has the right to request it and the physician's duty is
to make sure she understands all the risks and potential complications associated with such a
ACTUAL Questions and CORRECT
Answers
A 28-year-old G2P2 woman returns today for follow up on her abnormal pap smear which
reveals atypical squamous cells of undetermined significance (ASCUS). Reflex HPV testing is
positive for high risk type. She has never had a prior abnormal pap smear, and has been
following the recommended screening guidelines. She is asymptomatic. Her pelvic exam reveals
a normal cervix with a small amount of cervical mucous. What is the next best step in the
management of this patient?
A. Routine screening
B. Repeat Pap smear in one year
C. Repeat HPV testing in one year
D. Repeat co-testing with Pap and HPV in one year
E. Colposcopy - CORRECT ANSWER -E
A 17-year-old G0 high school student is brought in by her mother for her first gynecologic
examination. She began her menses at age 12 and has had regular periods for the past three
years. Her last menstrual period was one week ago. For privacy, you ask to examine the patient
without her mother. Further history is obtained in the examination room. She admits that she has
been sexually active with her boyfriend for the past three years. She uses condoms occasionally
and is fearful about possible pregnancy. She requests that her mother not be informed about her
sexual activity. On physical examination, she is anxious, but normally developed. Her pelvic
examination reveals no vulvar lesions, minimal non-malodorous discharge, and a nulliparous
appearing cervix. The bimanual examination reveals a normal size uterus, and her adnexa are
non-tender and not enlarged. Urine pregnancy test is negative. In addition to discussing -
CORRECT ANSWER -D
A 25-year-old G0 woman is scheduled to discuss her recent abnormal Pap smear which showed
atypical squamous cells of undetermined significance (ASCUS). She has had one Pap smear at
age 22 which was normal. Her only significant gynecologic history is genital warts that have not
responded to treatment with local application of trichloroacetic acid. She has had eight sexual
partners. She uses condoms and oral contraceptives. She has smoked a pack a day for the past
two years. Which of the following is the most appropriate next step in the management of this
patient?
,A. HPV typing
B. Repeat Pap smear in three years
C. Cone biopsy
D. Cryotherapy
E. Loop Electrosurgical Excision Procedure (LEEP) - CORRECT ANSWER - A. HPV
typing
A 39-year-old G0 woman presents to the clinic reporting non-tender spots on her vulva for about
a week. No pruritus or pain is present. She also notes a brownish rash on the palms of her hands.
She admits to IV drug abuse. She was diagnosed as HIV-positive two years ago, but has not been
compliant with suggested treatment. On examination, three elevated plaques with rolled edges
are noted on the vulva. They are non-tender. A brown macular rash is noted on the palms of her
hands and the soles of her feet. What is the most appropriate next step in the management of this
patient?
A. Obtain a treponemal-specific test
B. Biopsy of the lesion
C. Colposcopic evaluation of the vulvar lesions
D. Culture the base of the lesion
E. Initiate empiric treatment with doxycycline and ceftriaxone - CORRECT ANSWER -
A. The diagnosis of syphilis is often established by serologic testing. Non-treponemal tests
(VDRL or RPR) are non-specific. In this patient with high suspicion for syphilis, specific testing
with treponemal antibody can confirm infection. The classic coiled spirochete is easily seen with
dark-field microscopy but availability is limited. A characteristic finding is a macular rash on the
palms and soles that are often described as copper penny lesions. Colposcopy would not be
diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic.
Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly
would not be the most expedient way to make the diagnosis. Penicillin G is the preferred drug for
treating all stages of syphilis.
A 24-year-old G0 woman presents with multiple painful ulcers involving the vulva. The sores
initially were fluid filled, but are now open, weeping and crusted. She reports a fever and is
having difficulty voiding due to pain. She uses a vaginal ring for contraception. She has multiple
sexual partners and uses condoms for vaginal intercourse. She is distraught that she may have a
sexually transmitted infection. She is healthy and does not smoke or use drugs. On physical
exam, she is in obvious distress. Temperature is 100.2°F (37.9°C), pulse 100. Examination of the
genital tract is limited due to her discomfort. Multiple ulcers and erosions of variable size are
,localized to the perineum, labia minora and vestibule. Swelling is diffuse. The lesions are eroded,
some with a purulent eschar. There is exquisite tenderness to touch. What further testing should
be offered to this patient?
A. RPR (rapid plasma regain)
B. HIV - CORRECT ANSWER - E. This patient has classic primary herpes with painful
genital ulcerations, fever and dysuria. Given the presence of one sexually transmitted infection,
screening should be offered for other STIs. Resolution of the acute episode is required before a
speculum can be inserted to allow endocervical sampling for gonorrhea and chlamydia. If it was
a high-risk exposure, prophylactic empiric treatment could be offered to cover gonorrhea and
chlamydia. The patient should be counseled that primary herpes can be acquired despite
condoms and even by oral-genital inoculation. Hepatitis B vaccination should be offered to
protect her against any future exposures. She should be encouraged to discuss her diagnosis with
all sexual partners and to continue to reliably use latex condoms.
A 38-year-old G0 woman comes to the office because she noted a persistent yellow, frothy
discharge associated with mild external vulvar irritation. She denies any odor. She tried over the
counter anti-fungal medication without success. The discharge has been present for over three
months, gradually increasing in amount. Douching has resulted in temporary relief, but the
symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious
yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix.
A sample of the discharge is examined under the microscope. What is the most likely finding?
A. Strong amine fishy odor when KOH applied to sample
B. Marked polymorphonuclear cells with multi-nucleate giant cells
C. Motile ovoid protozoa with flagella
D. Budding yeast and pseudo-hyphae
E. Clue cells - CORRECT ANSWER - C. This patient most likely has trichomoniasis. The
erythematous patches on the cervix are characteristic of "strawberry cervicitis." Trichomonads
are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide
must be examined immediately. The discharge is mixed with saline and placed on the slide with
a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green
vaginal discharge. Clue cells are seen on a saline wet mount in women who have bacterial
vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges
of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial
vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which
results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation
may be herpes.
, A 23-year-old G0 woman reports having a solitary, painful vulvar lesion that has been present
for three days. This lesion has occurred twice in the past. She states that herpes culture was done
by her doctor during her last outbreak and was negative. She is getting frustrated in that she does
not know her diagnosis. She has no significant previous medical history. She uses oral
contraceptives and condoms. She has had four sexual partners in her lifetime. On physical
examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior
fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. How do you
explain the negative culture?
A. Cultures were taken too early
B. Oral contraceptives affect the growth of the virus
C. The cultures were refrigerated prior to transport to the lab
D. Herpes cultures have a 10-20% false negative rate
E. The herpes virus cannot b - CORRECT ANSWER - D. Culture is the gold standard in
the diagnosis of herpes. They are highly specific, yet sensitivity is limited. It is best to culture the
lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The
herpes virus can theoretically be isolated from both primary and recurrent infections. This patient
very likely presented too late in the course for a useful culture. Oral contraceptives do not affect
the growth of viruses. While serum antibody screening can be performed, it indicates lifetime
exposure and would not answer the question as to the etiology of the specific lesion.
Alternatively, DNA studies such as the polymerase chain reaction can be done, if available.
A 27-year-old G1 at 12 weeks gestation presents for first prenatal care visit. She is previously
healthy and takes no medications. An ultrasound is performed and a viable pregnancy is
confirmed. At the end of the visit, the patient discusses with you her desire to have a Cesarean
section for delivery, as she does not wish to go through the pain of labor. Her husband, an
orthopedic surgeon, expresses concerns as they desire to have at least three children and he is
worried about potential complications with repeated Cesarean sections. What is the most
appropriate next step in the counseling of this patient?
a.Agree with her decision after proper counseling and perform a Cesarean section at 39 weeks
gestation
b.Agree with her decision after proper counseling and perform a Cesarean section at 41 weeks
gestation if she has not gone into labor by then
c.Advise her that it is not possible to plan a Cesarean section for del - CORRECT
ANSWER - A. Elective cesarean section on demand has been getting more popular among
women for a variety of reasons. Although, it might sound unreasonable to undergo a Cesarean
section for being afraid of pain, the patient has the right to request it and the physician's duty is
to make sure she understands all the risks and potential complications associated with such a
