Obgyn Shelf Review PDF

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obgyn shelf study guide...

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When you review questions that have appeared on previous shelf exams, think of each as a type of question. From each stem, the question might be what is the diagnosis, how do you make the diagnosis (lab, etc), what is the next step in management or treatment, what are risk factors for the diagnosis, etc. Shelf exams like to test common things, but also uncommon things that shouldn’t be missed by any type of doctor, like cancers for example. So they stress recognizing risk factors for cancers or signs/symptoms of potentially serious conditions. Here are some questions that students have recalled from recent exams. Don’t focus on the particular question, focus on the theme. This first set is from one student and one shelf. This can given you an idea of common areas of focus. Most shelf exams are similar in focus: 

3-4 questions on postmenopausal bleeding, asking about next step in management. 

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Several questions on choosing appropriate antibiotics for UTI, urethritis, PID, endometritis. One asked for best prophylactic Ab for UTIs with bactrim allergy (macrobid). Also, 3 or 4 on what pathogen is responsible for different infections 

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Virtually every test you will take in the future will ask you to work through anemia. Understand how to use the MCV and other common labs, inheritance patterns of genetic causes of anemias, etc.

2 or 3 precocious puberty, choosing lab test and management 

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These types of questions are high yield. Know the presentation of the infection, the common organisms, the microscopic description of the bug, and the antibiotic. All of these are on the Charts on the website.

Microcytic anemia and you had to decide if it was iron def, thalassemia, or phys anemia of pregnancy. 

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Know risk factors; always diagnosis (e.g. endometrial biopsy) before treatment

Examiners love this. Its unusual but tests your knowledge of the basic sciences. Remember the paradoxical action of Lupron in this case.

Several postpartum fever questions, mostly after CD 

A lot of times there are 8-10 questions about post-op fever, either post-gyn or post-CD, SVD. Make sure you know the differential and

presentation, including atelectasis, UTI, wound infections/abscesses, pelvic/abd abscesses, endomyometritis, mastitis, DVT, septic pelvic thrombophlebitis, etc. 

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3-4 primary amenorrhea, one was androgen insensitivity, one was Turner's, but the only physical finding it gave was "increased cubitus valgus" and she was short, answer was to karyotype 2 secondary amenorrhea- one excess exercise/low BMI, one was premature ovarian failure and choosing lab test to confirm (FSH) 

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Hypoestrogenic hyperprolactinemia in a young woman- choose treatment 

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Google partograms and understand that they may show you the course of a labor based on one of these charts. Then you’ll have to identify common arrest disorders (arrest of dilation, descent, etc.). Arrest of dilation is no change for four hours in active labor (beyond 6 cm) with adequate contractions. You need all three to diagnosis. If it’s earlier in labor and/or contractions aren’t adequate, then they want you to augment (amniotomy, pitocin).

1 preschool teacher in 2nd or 3rd trimester with hydrops, I think it was parvo 

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The Shelf so far hasn’t focussed on management of tracings or the categories, but on the pathophysiology of patterns (lates, variables, tachycardia, earlies, etc)

1 arrest of dilation, had to determine from labor curve 

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Don’t forget to image head before proceeding with treatment

2 strips, one was fetal tachycardia, the other showed early's during labor and asked for appropriate management 

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Test writers also love amenorrhea. Remember the four categories of amenorrhea: 1) (-breasts, +uterus) is usually Turners; 2) (+breasts. -uterus) is usually Androgen Insensitivity or MRKH syndrome; 3) (-breasts, -uterus) is usually 17, 20 Desmolase deficiency; 4) (+breasts, +uterus) overlaps with causes of 2nd amenorrhea but includes things like imperforate hymen on the test

The differential of immune and nonimmune hydrops is popular. TORCH infections, Rh disease, parvo etc are all highly tested.

Effect of uncontrolled maternal hypertension on placenta

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Effect of hyperemesis on fetus 

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You don’t get a lot of it on the rotation, but breast stuff is high yield. Know screening guidelines. Understand the triple test (this will help you get most questions right). If the stem says mass or lump, you have to have a biospy and imaging; don’t be reassured just by reassuring imaging. Have to biospy. In general, if cancer is in your differential, do a biopsy. Period.

STDs- 7 or 8 total. Definately 1 (but maybe 2?) disseminated gonococcal infection, 1 primary HSV, 1 described condyloma accuminata and you chose pathogen, 1 trich (ID pathogen) 

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Fertility is a highly tested area too for at least a few questions. So are hysterosalpingograms. Google HSGs with different things. This one is an intracavitary fibroid. Watch the video about mullerian abnormalities too. They may show HSGs of these. Anything that makes the cavity smaller (like a unicornuate uterus) increases the risk of preterm labor. Anything that makes the cavity have less surface area (like fibroids or a septum) makes the risk of miscarriage higher). For infertility think about: male factor (sperm analysis), ovulatory (test LH surge, basal body temp, midluteal progesterone; tx with clomiphene or letrazole); tubal factor (history of PID or endometriosis, do an HSG; if blocked do IVF); cervical factor (history of LEEP or something; do an IUI). Also some unusual genetic stuff like Kallman’s is often tested.

Breast stuff- differentiating galactocele from abscess, when to start mammogram with fam h/o early breast ca. 

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Are none. The problems with hyperemesis are maternal. They just want to make sure you know that.

3-4 infertility. One had image of HSG with round light 1 cm spot on uterus and asked what the pt is at increased risk for during pregnancy 

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Risk factors for growth restriction (Htn, vascular dz) and growth acceleration (DM) are popular and the sequelae from both.

So these are highly tested; all of them are fair game. Again memorize the Charts. Know the typical presentation, the bug, the screening AND confirmatory tests, the treatment, the treatment in pregnancy; the effects of the infection on pregnancy or fetus.

2 vulvar lesions, one asked about next step (I'm pretty sure it was biopsy), one was diagnosis and I think it was HSV

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2 nephrolithiasis questions 

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So test writers love using tumor markers to make a vignette and then you have to identify the tumor. These are on the Charts. So for example, estrogenic symptoms with a mass is probably a granulosa cell tumors. These markers are high yeld.

I don't remember how it was set up, but for one question you had to know that fetal factors cause symmetric IUGR 

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These are a type of question again; common complications of pregnancy and common causes of pelvic pain are high yield

Few on ovarian tumors, one was rapid virilization in 34 y/o woman with 8 cm adnexal mass, one with super elevated b-hCG 

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Here again, if malignancy is in the differential, the next step is biopsy. Know common vulvar presentations, like lichen scl. Condyloma (in a woman under 50) doesn’t include cancer in the diff dx, so no need to biopsy; lichen scl does include cancer, so you have to biopsy. The Charts are good for these too.

Symmetric and asymmetric IUGR is def something to understand. Symmetric is genetic/chromosomal stuff and TORCH stuff; asymmetric is related to placental problems/HTN.

One I struggled with was young G3P2 with 20 yr h/o well controlled Type 1 DM at 8 weeks gestation, HbA1c of 6.5%. Then there were 2 sentences explaining she had 2 previous uncomplicated pregnancies, normal vaginal deliveries and normal birth weights. It asked what would be the appropriate test to perform in the 1st trimester. Options were antiphospholipid antibody screening, dexamethasone suppression test, 24 urine collection for creatinine clearance, total iron binding capacity, or free T4 level. 

Remember to anticipate the complications of different medical issues on the pregnancy and change screenings etc to anticipate this. A diabetic is at increased risk for preeclampsia and also is likely to already have proteinuria, so a baseline urine will help to manage her later. This is a type of question. Apply this to other medical complications too.

Here are some questions from another student: 

after c-section, low BP, pericardial friction rub, pulmonary hypertension, firm uterus,what does she have? CHF, pneumonia, pylo, uterine atony, PE

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not an emergency, baby was transverse positions- c-section or turn fetus to breech position and deliver 

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risk factors for diabetes, preeclampsia, preterm labor, pprom 

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Again remember the Triple Test. Do a biopsy. Avoid aspirations on solid masses. Excisional biopsy are usually for things that are at high risk for malignancy or a failed core or aspiration biopsy. She also needs imaging at some point. But always biospy masses.

breast feeding mother has a breast that is tender, no mass, skin is red upper outer quadrant- mastitis, cancer 

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Chorio is on almost every test. Lots of ways to ask the question. Not sure about the bleeding mother question, but might be abruption. Abruption is not a reason to do a c-section, but fetal distress is. Most women with abruption deliver vaginally.

a 45 y/o with a mobile, nontender breast mass, cyclic growth, what do u do? Aspiration biopsy, excision biopsy 

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Pap smear stuff is easy. First pap at 21, then every 3 years. After 30, can do every 5 with HPV cotesting. If ASCUS, get an HPV. If ASCUS and HPV negative, treat it like a normal pap. If ASCUS HPV pos or worse (LSIL, HSIL, ASC-H), do a colpo (there are exceptions but not important for the shelf). If the Colpo is normal or CIN1, do another pap in a year and get two normals in a row then resume regular screening. If CIN2 or CIN3, do a LEEP or CKC (do a CKC if the lesion extends up into the cervix)

baby tachycardic, mother bleeding at 38wks with 50% effacement and 4 cm dilated, what is wrong?- placenta abruption, chorio, long list baby tachycardic, mother with fever, clear fluid leakage- same list as #5 

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Tests love risk factors

an abnormal pap and then two normal pap, when should she get a pap? In three years, once year 

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Neither is option is right. Turn the baby to cephalic and deliver. If it won’t turn do a section.

Sounds like mastitis to me; remember Dicloxacillin is the drug of choice.

lot of questions on women with c-sections and fever two days after

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infertility, had gotten sperm analysis, had 28 day cycle, in the past had 18 partners but monogamous now, what next? FSH, prolactin, LH, TSH, HSG, testosterone, or laparoscopy 

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Well a really big anterior fibroid might sit on the bladder and cause a sensation to void, but don’t bite for that. Common things are common and 3 cm is not big. This is just detrusor instability.

bulge in vagina, had a hysterectomy, no anterior or posterior wall problems- enterocele 

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Recognize common causes of female pelvic pain. This is endometriosis. We diagnosis with biopsy at laparoscopy but you can also try to treat empirically and see if she improves before running to surgery.

urge incontinence, had a 3 cm fibroid in uterus, why is she having this problem? Detrusor instability or fibroid 

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Remember what I said above. She sounds ovulatory and the sperm analysis is normal. The stem is implying that she might have had chlamydia or something. HSG will test tubes.

woman comes in with pelvic pain, dyspareunia, dysmenorrhea, nodularity in posterior fornix, no masses felt on exam, what next? Laparoscopy, CT 

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Talked about this above

Urogyn isn’t heavily tested but not the vignettes for different types of incontinence and the treatments and recognize symptoms and types of prolapse. They still use the terms enterocele, cystocele, and rectocele.

amenorrhea, pubic and axillary hair, no breast, no uterus- androgen insensitivity, mullerian agenesis , 17 hydroxylase deficiency, agonadism 

Remember what I said before. This is Type 3 above, so its an enzyme problem, in this case 17-hydrox.

Another student with our back and forth about questions she found difficult: 

Heavier periods in perimenopausal pt. U/S shows smooth concave intrauterine mass infiltrating myometrium; it’s heterogeneous. Her uterus is slightly enlarged. Most like dx? I was between adenomyosis (but don't remember much about it) vs. endometrial cancer; another option was fibroid.

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Normal-weight girl, stressful job, secondary amenorrhea, next best test: measure PRL & TSH, or Estrogen & progesterone? Other options included head/pelvic CT… 

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I would give no meds here. If the vignette presents thyroid storm then beta blockade/ptu might be useful. But this sounds like just do the D&C. (Molar pregnancies are heavily tested; love the snowstorm US and the basic science implications)

recurrent variable decels + brady after ROM: do amnio-infusion? Cervical exam? Cesarean? 

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Well none of these. The HCG is the best of those three for sure. She might be pregnant and you would want to exclude pregnancy before doing something like an HSG or hysteroscopy.

Molar pregnancy (HTN ~150/100, snowstorm on US, etc). Anxious pt. Give any meds before D&C? Options: no meds; labetalol; carbamazepine; PTU 

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PRL and TSH. Obviously first best test was an pregnancy test. A progesterone by itself is not really useful and neither is an estrogen by itself but an estrogen plus FSH might be.

Secondary amenorrhea in 22yo for 6 years (has end-stage renal dz). Sexually active, uses condoms consistently. Normal pelvic exam. Next best test for amenorrhea workup: HSG, hysteroscopy, or B-hCG? 

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Most likely is fibroid. Need to exclude cancer with biopsy. Adenomyosis is a possibility. But this sounds like a submucosal fibroid. Here are some pictures: http://www.advancedfertility.com/uterinefibroid.htm

Well they want you to think of cord prolapse here. She needs a cesarean but you need to do a cervical exam first to confirm and then elevate the fetal head off of the prolapsed cord (what’s the next best step questions frustrate students because all of the answers might be appropriate, but just imagine being there in front of the patient and put the steps in order).

G2P0010 (prev stillbirth at 37 wk) starts itching at 35wk. What test: Skin bx? Liver bx? Alk-phos? Serum bile acids? 

Serum bile acids. Generalized itching is possibly intrahepatic cholestasis of pregnancy. It is associated with a roughly five times risk of fetal death and has a genetic predisposition giving you a

recurrence risk (rare dz but they don’t want you to ignore potentially bad things with benign presentations). 

Pelvic infection 2 weeks after IUD insertion… see fever, copious yellow discharge from cervix. Tx w/ abx… and also remove IUD, or leave it there? 

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Dull, constant pelvic pain. Tender on bimanual exam, not much discharge. Chlamydia or gonorrhea? 

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Well vulvar itching is not usually due to vaginal atrophy, not trich. A fishy smelling, copious gray discharge of course sounds like BV. However there are no clue cells and that shouldn’t matter with the slide. Due to the rise in pH with vulvovaginal atrophy, women do sometimes report a discharge and the buzzword is grey. Yellow and green are the buzzwords for BV and trich. So I would have picked atrophy. Here is an article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800285/pdf/mayocli nproc_85_1_012.pdf

Described intrauterine fetal demise (no FM for 24h, no heart tones, 3rd trimester). Confirm by amniocentesis, or u/s? 

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Wouldn't think this was either. If they wanted you to think PID then chlamydia is most common, but there’s not enough info here to discriminate.

Vulvar burning/itching in older pt, answer choices for etiology included both trichomoniasis and vaginal atrophy. Copious grey discharge, fishysmelling, otherwise normal exam. Wet mounts showed WBC's but no clue cells or organisms. One question said the wet mount had dried up before it was viewed... so could that one still have had trichomonas on it, just not visualized? 

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Leave it there is the current thinking. Treat only. Remove if she fails treatment.

Confirm by US. No way to confirm death with amniocentesis, but obviously can with US. Sometimes an amnio is done after an IUFD to harvest amniocytes for genetic testing prior to induction of labor.

Mastitis not responsive to dicloxacillin, what is the bug: candida? Klebsiella? E. coli? GBS? MRSA? I should've said MRSA but forgot that dicloxacillin doesn't cover it :(

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There were some easier ones at least e.g. on PCOS, contraception, postop infections, postpartum hemorrhage, cancer screening/prevention... A question asked whether 37 weeks was preterm! 

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A lot of the questions are very easy. Don’t question your answer just because it was easy; there’s no trick to them. They are on a bell-shaped curve of difficulty.

I had 5-7 questions dealing with urinary incontinence. The question stem would always give a post void volume (it would not give a normal range and we were expected to know what volume is normal) and we would need to recognize the significance of it, in addition to other typical stress/ urge sx. 

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Yes probably MRSA but yeast mastitis is a common problem. However, yeast doesn’t present with fever or the systemic flu like symptoms, so it depends on how they worded it.

A lot of students are thrown off by not understanding post-void residuals. They are reporting the PVR because it is appropriate to check it with virtually every presentation of incontinence. They aren’t trying to trick you.

Another question that was interesting read something like this. 12 yo has not had menses in 6 months. She plays softball in the spring and has phys ed class twice a week. Menses occurred at 11, and then gave vitals. What is the diagnosis? Most of us put either reassurance or athletic amenorrhea. I put reassurance. 

Not sure what the question was here but reassurance and no work up is appropriate. Also commonly tested is a young girl whose mom brings in for a breast lump. Its a breast bud and reassurance is the answer. Don’t biopsy an 11 year old’s breast even if mom did have breast cancer.

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Make sure you understand what is being asked. For example, a UTI in a newly sexually active girl. What is the most common bug? E. coli (you were thinking saprophyticus; that’s more likely in that group ...