A 27-year-old woman presented with a malodorous discharge in the vagina which started a week earlier. On examination, Whiff's test is positive and the gram stain shows the presence of clue cells. This infection is commonly treated with which of the following?
Q2
A female presents with postcoital bleeding. Which of the following is the most appropriate investigation?
Q3
Which of the following is a tumor marker associated with ovarian solid-cystic masses?
Q4
A 45-year-old woman presents with a history of cervical erosion and spotting for the past 2 months. What is the next best step?
Q5
A 25-year-old pregnant woman, at 18 weeks of gestation, undergoes a routine ultrasound scan. The ultrasound images provided show below. Based on the imaging findings, what is the most likely diagnosis?
Q6
A 28-year-old married woman is anxious about conception and presents with complaints of profuse vaginal discharge. She has no history of itching. It has been 12 days since her last menstrual period (LMP). What is the most likely cause of her symptoms?
Q7
A 25-year-old woman presents with intense vaginal pruritus and pain for the past week. She says the pain is worse when she urinates. Her last menstrual period was 4 weeks ago. She is sexually active, has a single partner, and uses condoms infrequently. She denies any recent history of fevers, chills, abdominal or flank pain, or menstrual irregularities. Her past medical history is significant for systemic lupus erythematosus (SLE), diagnosed 5 years ago and managed medically. Her current medications include prednisone and oral contraceptives. The patient is afebrile and her vital signs are within normal limits. Physical examination is significant for a small amount of discharge from the vagina, along with severe inflammation and scarring. The discharge is thick, white, and has the consistency of cottage cheese. The vaginal pH is 4.1. The microscopic examination of potassium hydroxide (KOH) mount of the vaginal discharge reveals pseudohyphae. A urine pregnancy test is negative. Which of the following would be the most appropriate treatment for this patient’s condition?
Q8
A 35-year-old G0P1 female presents to her OB/GYN after 17 weeks gestation. A quad screen is performed revealing the following results: elevated inhibin and beta HCG, decreased aFP and estriol. An ultrasound was performed demonstrating increased nuchal translucency. When the fetus is born, what may be some common characteristics of the newborn if amniocentesis confirms the quad test results?
Q9
A 31-year-old G3P0020 presents to her physician for a prenatal visit at 12 weeks gestation. She does not smoke cigarettes and stopped drinking alcohol once she was diagnosed with pregnancy at 10 weeks gestation. An ultrasound examination showed the following:
Ultrasound finding Measured Normal value (age-specified)
Heart rate 148/min 137–150/min
Crown-rump length 44 mm 45–52 mm
Nasal bone visualized visualized
Nuchal translucency 3.3 mm < 2.5 mm
Which of the following statements regarding the presented patient is correct?
Q10
A 45-year-old primigravida woman at 13-weeks' gestation is scheduled for a prenatal evaluation. This is her first appointment, though she has known she is pregnant for several weeks. A quad screening is performed with the mother's blood and reveals the following:
AFP (alpha-fetoprotein) Decreased
hCG (human chorionic gonadotropin) Elevated
Estriol Decreased
Inhibin Elevated
Ultrasound evaluation of the fetus reveals increased nuchal translucency. Which mechanism of the following mechanisms is most likely to have caused the fetus’s condition?
Screening tests US Medical PG Practice Questions and MCQs
Question 1: A 27-year-old woman presented with a malodorous discharge in the vagina which started a week earlier. On examination, Whiff's test is positive and the gram stain shows the presence of clue cells. This infection is commonly treated with which of the following?
A. Metronidazole (Correct Answer)
B. Azithromycin
C. Nystatin pessary
D. Tetracycline
Explanation: ***Metronidazole***
- This patient's symptoms (malodorous vaginal discharge, positive **Whiff test**, and presence of **clue cells** on Gram stain) are classic findings for **bacterial vaginosis (BV)**.
- **Metronidazole** is the first-line and most effective antibiotic for treating bacterial vaginosis, as it targets the anaerobic bacteria overgrowing in the vagina.
*Azithromycin*
- **Azithromycin** is primarily used to treat infections like **chlamydia**, gonorrhea, or some respiratory tract infections.
- It is **not effective** against the anaerobic bacteria responsible for bacterial vaginosis.
*Nystatin pessary*
- **Nystatin** is an **antifungal medication** specifically used to treat **vulvovaginal candidiasis (yeast infection)**.
- The patient's presentation (malodorous discharge, positive Whiff test, clue cells) does not align with a yeast infection, making nystatin ineffective.
*Tetracycline*
- **Tetracycline** is a broad-spectrum antibiotic, but it is **not the preferred treatment** for bacterial vaginosis.
- Its use is often associated with a higher risk of side effects and is typically reserved for other bacterial infections like **chlamydia**, acne, or Rocky Mountain spotted fever.
Question 2: A female presents with postcoital bleeding. Which of the following is the most appropriate investigation?
A. Pap smear, HCV DNA, electrophoresis
B. Liquid-based cytology, cervical biopsy
C. Cervical biopsy, HBV DNA
D. Pap smear, HPV DNA testing (Correct Answer)
Explanation: **Pap smear, HPV DNA testing**
- **Postcoital bleeding** is a classic symptom of **cervical cancer**, which can be identified by a **Pap smear** to detect abnormal cervical cells.
- **HPV DNA testing** is essential as persistent infection with high-risk human papillomavirus (HPV) genotypes is the primary cause of cervical cancer.
*Pap smear, HCV DNA, electrophoresis*
- While a **Pap smear** is appropriate for cervical cytology, **HCV DNA testing** is for Hepatitis C virus infection and is not routinely indicated for postcoital bleeding.
- **Electrophoresis** is used to analyze proteins (e.g., hemoglobinopathies) and has no direct role in evaluating postcoital bleeding or cervical pathology.
*Liquid-based cytology, cervical biopsy*
- **Liquid-based cytology** is a method of preparing a Pap smear, but it's not a standalone investigation.
- A **cervical biopsy** is a more invasive procedure done *after* initial screening (like Pap smear with HPV testing) suggests abnormalities, not as a primary first-line investigation for postcoital bleeding unless there are visible lesions.
*Cervical biopsy, HBV DNA*
- A **cervical biopsy** is typically performed following an abnormal **Pap smear** or colposcopy findings, not as the initial diagnostic step for postcoital bleeding.
- **HBV DNA testing** is for Hepatitis B virus infection and is irrelevant to the workup of postcoital bleeding.
Question 3: Which of the following is a tumor marker associated with ovarian solid-cystic masses?
A. CEA
B. HCG
C. HER2/neu
D. AFP (Correct Answer)
Explanation: ***AFP (Alpha-fetoprotein)***
- **AFP** is a reliable tumor marker for differentiating **germ cell tumors**, especially **yolk sac tumors**, which often present as an ovarian solid-cystic mass.
- Elevated **AFP** levels help in diagnosis, monitoring treatment response, and detecting recurrence of these specific ovarian malignancies.
*CEA (Carcinoembryonic antigen)*
- **CEA** is primarily associated with **gastrointestinal cancers**, such as colorectal cancer, and is less specific for ovarian masses.
- While it can be elevated in some mucinous ovarian carcinomas, it's not the most specific marker for a general solid-cystic ovarian mass.
*HCG (Human chorionic gonadotropin)*
- **HCG** is a key marker for **gestational trophoblastic disease** and some **germ cell tumors**, such as choriocarcinoma.
- It is not typically elevated in most common solid-cystic ovarian masses, especially those of epithelial origin.
*HER2/neu (Human Epidermal growth factor Receptor 2)*
- **HER2/neu** is primarily associated with **breast cancer** and some gastric cancers, playing a role in targeted therapy.
- It is not a standard tumor marker for the general evaluation or diagnosis of ovarian solid-cystic masses.
Question 4: A 45-year-old woman presents with a history of cervical erosion and spotting for the past 2 months. What is the next best step?
A. LBC + HPV (Correct Answer)
B. Pap smear + HSV
C. Pap smear + HBV
D. LBC + HSV
Explanation: ***LBC + HPV***
- Cervical erosion and spotting are concerning for **cervical intraepithelial neoplasia (CIN)** or **cervical cancer**, making **Liquid-Based Cytology (LBC)** the appropriate screening method.
- **Human Papillomavirus (HPV) testing** is crucial as persistent high-risk HPV infection is the primary cause of cervical cancer and helps in risk stratification and management.
*Pap smear + HSV*
- A **routine Pap smear** (conventional cytology) is less sensitive than LBC for detecting abnormal cervical cells and is generally being phased out by LBC.
- **Herpes Simplex Virus (HSV)** causes genital herpes and is not directly associated with cervical cancer, thus testing for it in this context is not the most appropriate immediate next step.
*Pap smear + HBV*
- As mentioned, a **routine Pap smear** is not the preferred method for cervical cancer screening compared to LBC.
- **Hepatitis B Virus (HBV)** causes liver disease and is entirely unrelated to cervical pathology; therefore, testing for it would be irrelevant to the patient's symptoms.
*LBC + HSV*
- While **LBC** is the correct advanced cytology method, adding **HSV testing** is not indicated as HSV does not cause cervical cancer or intraepithelial lesions that present with cervical erosion and spotting.
- Focus should be on identifying potential malignancy or pre-malignant changes with HPV co-testing, not sexually transmitted infections unrelated to cancer risk.
Question 5: A 25-year-old pregnant woman, at 18 weeks of gestation, undergoes a routine ultrasound scan. The ultrasound images provided show below. Based on the imaging findings, what is the most likely diagnosis?
A. Spina bifida (Correct Answer)
B. Anencephaly
C. Encephalocele
D. Holoprosencephaly
E. Iniencephaly
Explanation: ***Spina bifida***
- The ultrasound image shows a **defect in the posterior elements of the fetal spine**, with characteristic splaying or widening of the vertebral arches.
- This is a **neural tube defect** resulting from incomplete closure of the spinal column during embryonic development.
- Associated findings on prenatal ultrasound may include the **"lemon sign"** (scalloping of frontal bones) and **"banana sign"** (abnormal cerebellar shape).
- Spina bifida is typically detected on **second-trimester anatomy scan** (18-20 weeks).
*Anencephaly*
- This condition involves the **absence of a major portion of the brain, skull, and scalp** due to failure of anterior neural tube closure.
- On ultrasound, anencephaly presents with **absent calvarium above the orbits** and absent cerebral hemispheres, which is distinctly different from a spinal defect.
- This would be a **cranial abnormality**, not a spinal column defect.
*Encephalocele*
- An **encephalocele** is a protrusion of brain tissue and meninges through a defect in the skull, most commonly at the **occipital region**.
- On ultrasound, this appears as a **cranial mass** extending beyond the skull contour, not a spinal defect.
*Holoprosencephaly*
- This condition results from **failure of forebrain (prosencephalon) to divide properly** into two hemispheres.
- Ultrasound findings include **single ventricle**, fused thalami, and absent midline structures, often with associated **facial anomalies**.
- The imaging would show **brain abnormalities**, not spinal column defects.
*Iniencephaly*
- This is a rare **neural tube defect** characterized by extreme retroflexion of the head with severe spinal defects in the cervical and thoracic regions.
- On ultrasound, iniencephaly shows the fetal head in extreme **hyperextension** with the face looking upward, creating a characteristic "stargazing" appearance.
- This differs from the typical spinal defect pattern seen in spina bifida.
Question 6: A 28-year-old married woman is anxious about conception and presents with complaints of profuse vaginal discharge. She has no history of itching. It has been 12 days since her last menstrual period (LMP). What is the most likely cause of her symptoms?
A. Candida
B. Trichomonas
C. Physiological (Correct Answer)
D. Bacterial vaginosis
Explanation: ***Physiological***
- **Physiological vaginal discharge** at mid-cycle (12 days post-LMP) is common and normal, often becoming profuse, clear, and elastic, indicating **ovulation**.
- The absence of **itching** or other bothersome symptoms supports a non-pathological cause, especially given her anxiety about conception.
*Candida*
- **Candidal infections** typically present with a **thick, white, curdy discharge** and are characteristically associated with intense **itching**, which is absent in this case.
- The discharge is usually not described as profuse or clear.
*Trichomonas*
- **Trichomoniasis** is associated with a **frothy, greenish-yellow discharge** and often causes **vaginal itching**, **burning**, and a **foul odor**, none of which are described.
- While discharge can be profuse, the clinical picture does not align with Trichomonas.
*Bacterial vaginosis*
- **Bacterial vaginosis** typically presents with a **thin, grayish-white discharge** and a characteristic **"fishy" odor**, especially after intercourse.
- **Itching** is less common than with Candida, but the discharge characteristics and the timing relative to ovulation do not fit this diagnosis.
Question 7: A 25-year-old woman presents with intense vaginal pruritus and pain for the past week. She says the pain is worse when she urinates. Her last menstrual period was 4 weeks ago. She is sexually active, has a single partner, and uses condoms infrequently. She denies any recent history of fevers, chills, abdominal or flank pain, or menstrual irregularities. Her past medical history is significant for systemic lupus erythematosus (SLE), diagnosed 5 years ago and managed medically. Her current medications include prednisone and oral contraceptives. The patient is afebrile and her vital signs are within normal limits. Physical examination is significant for a small amount of discharge from the vagina, along with severe inflammation and scarring. The discharge is thick, white, and has the consistency of cottage cheese. The vaginal pH is 4.1. The microscopic examination of potassium hydroxide (KOH) mount of the vaginal discharge reveals pseudohyphae. A urine pregnancy test is negative. Which of the following would be the most appropriate treatment for this patient’s condition?
A. A single dose of azithromycin
B. Oral fluconazole for the patient alone (Correct Answer)
C. Oral metronidazole for the patient and her sexual partner
D. Oral fluconazole for the patient and her sexual partner
E. Topical antifungal cream for the patient alone
Explanation: ***Oral fluconazole for the patient alone***
- The presence of **intense vaginal pruritus and pain**, **thick, white, cottage cheese-like discharge**, a **vaginal pH of 4.1**, and **pseudohyphae on KOH mount** are classic findings for **vulvovaginal candidiasis (VVC)**, also known as a yeast infection.
- Oral fluconazole is an effective systemic antifungal treatment for VVC. Since VVC is generally not sexually transmitted, treating the partner is typically not necessary.
*A single dose of azithromycin*
- **Azithromycin** is an antibiotic primarily used to treat bacterial infections like **Chlamydia trachomatis**, which would present with different symptoms such as mucopurulent discharge and dysuria, but not typically the profound pruritus or characteristic discharge described.
- It would be ineffective against a fungal infection and could disrupt the normal vaginal flora, potentially worsening VVC.
*Oral metronidazole for the patient and her sexual partner*
- **Metronidazole** is an antibiotic used to treat **bacterial vaginosis** (typically pH > 4.5, thin grey discharge, positive whiff test) or **trichomoniasis** (foamy yellow-green discharge, high pH).
- Treating the partner for VVC is generally unnecessary, and metronidazole is not effective against fungal infections.
*Oral fluconazole for the patient and her sexual partner*
- While oral fluconazole is appropriate for the patient, **VVC is not considered a sexually transmitted infection**, so routine treatment of the sexual partner is not recommended unless the partner is symptomatic with balanitis.
- There is no indication that the partner has symptoms of a fungal infection, making partner treatment unnecessary.
*Topical antifungal cream for the patient alone*
- Topical antifungal creams (e.g., miconazole, clotrimazole) are effective for **uncomplicated VVC**.
- However, given the **"intense vaginal pruritus and pain," "severe inflammation and scarring,"** and the patient's history of **SLE managed with prednisone** (which can predispose to more severe or recurrent infections), a systemic treatment like oral fluconazole may be more appropriate for a potentially complicated or severe case, offering faster relief and better penetration.
Question 8: A 35-year-old G0P1 female presents to her OB/GYN after 17 weeks gestation. A quad screen is performed revealing the following results: elevated inhibin and beta HCG, decreased aFP and estriol. An ultrasound was performed demonstrating increased nuchal translucency. When the fetus is born, what may be some common characteristics of the newborn if amniocentesis confirms the quad test results?
A. Microphthalmia, microcephaly, cleft lip/palate, holoprosencephaly, and polydactyly
B. Epicanthal folds, high-pitched crying/mewing, and microcephaly
C. Epicanthal folds, macroglossia, flat profile, depressed nasal bridge, and simian palmar crease (Correct Answer)
D. Elfin facies, low nasal bridge, and extreme friendliness with strangers
E. Rocker-bottom feet, micrognathia, clenched hands with overlapping fingers, and prominent occiput
Explanation: ***Epicanthal folds, macroglossia, flat profile, depressed nasal bridge, and simian palmar crease***
- The quad screen results (**elevated inhibin and beta HCG, decreased aFP and estriol**) and **increased nuchal translucency** are classical findings suggestive of **Down syndrome (Trisomy 21)**.
- The listed characteristics are all common clinical features observed in newborns with **Down syndrome**, including distinctive facial features and a single palmar crease.
*Microphthalmia, microcephaly, cleft lip/palate, holoprosencephaly, and polydactyly*
- These features are indicative of **Patau syndrome (Trisomy 13)**. The quad screen findings for Patau syndrome would typically show **decreased beta-hCG** and **decreased PAPP-A**, which do not match the patient's results.
- While nuchal translucency can be increased in Trisomy 13, the specific quad screen pattern points away from this diagnosis.
*Epicanthal folds, high-pitched crying/mewing, and microcephaly*
- The **high-pitched crying (cat-like cry)** is a hallmark feature of **Cri-du-chat syndrome (5p deletion)**, which is associated with microcephaly.
- Quad screen abnormalities are not reliably associated with Cri-du-chat syndrome, and it's a chromosomal deletion, not a trisomy, which is implied by the quad screen pattern.
*Elfin facies, low nasal bridge, and extreme friendliness with strangers*
- These are characteristic features of **Williams syndrome (deletion on chromosome 7 impacting elastin gene)**.
- Williams syndrome is a microdeletion syndrome not typically detected by quad screening, and the presented quad screen results are not consistent with this condition.
*Rocker-bottom feet, micrognathia, clenched hands with overlapping fingers, and prominent occiput*
- These features are classic physical findings associated with **Edwards syndrome (Trisomy 18)**.
- The quad screen for Edwards syndrome would show **decreased beta-hCG**, **decreased AFP**, and **decreased unconjugated estriol**, which is different from the patient's elevated inhibin and beta HCG.
Question 9: A 31-year-old G3P0020 presents to her physician for a prenatal visit at 12 weeks gestation. She does not smoke cigarettes and stopped drinking alcohol once she was diagnosed with pregnancy at 10 weeks gestation. An ultrasound examination showed the following:
Ultrasound finding Measured Normal value (age-specified)
Heart rate 148/min 137–150/min
Crown-rump length 44 mm 45–52 mm
Nasal bone visualized visualized
Nuchal translucency 3.3 mm < 2.5 mm
Which of the following statements regarding the presented patient is correct?
A. To increase the diagnostic accuracy of this result, the levels of serum alpha-fetoprotein, hCG, and unconjugated estriol should be determined.
B. At this gestational age, nuchal translucency has low diagnostic value.
C. Pathology other than Down syndrome should be suspected because of the presence of a nasal bone.
D. To increase the diagnostic accuracy of this result, the levels of free beta-hCG and pregnancy-associated plasma protein A (PAPP-A) should be determined. (Correct Answer)
E. The observed ultrasound image is caused by the problems with the embryonic kidneys.
Explanation: ***To increase the diagnostic accuracy of this result, the levels of free beta-hCG and pregnancy-associated plasma protein A (PAPP-A) should be determined.***
- An elevated **nuchal translucency** at 12 weeks gestation is a soft marker for aneuploidy, particularly Down syndrome, making further biochemical screening appropriate.
- Combining **free beta-hCG** and **PAPP-A** with nuchal translucency (first-trimester screening) significantly improves the detection rate for chromosomal abnormalities like trisomy 21.
*To increase the diagnostic accuracy of this result, the levels of serum alpha-fetoprotein, hCG, and unconjugated estriol should be determined.*
- **Alpha-fetoprotein (AFP)**, **hCG**, and **unconjugated estriol** are components of the second-trimester triple or quad screen, typically performed between 15-20 weeks, not 12 weeks.
- Performing these markers at 12 weeks would yield less accurate results for genetic screening and is not the standard approach for first-trimester risk assessment.
*At this gestational age, nuchal translucency has low diagnostic value.*
- **Nuchal translucency (NT)** is highly valuable and diagnostically significant *between 11 weeks 2 days and 13 weeks 6 days gestation*, or when the crown-rump length (CRL) is 45-84 mm.
- The measurement presented (3.3 mm) is **elevated (>2.5 mm)** for this gestational age, indicating increased risk and requiring further evaluation.
*Pathology other than Down syndrome should be suspected because of the presence of a nasal bone.*
- While the **presence of a nasal bone** can be a reassuring sign, it does not rule out Down syndrome, especially with a significantly elevated nuchal translucency (3.3 mm).
- The combination of a thickened NT and a present nasal bone still warrants further investigation, as **nasal bone hypoplasia/absence** is a stronger, but not exclusive, marker for Down syndrome.
*The observed ultrasound image is caused by the problems with the embryonic kidneys.*
- **Nuchal translucency** is a collection of fluid under the skin in the fetal neck, and while multiple abnormalities can cause it, kidney problems are not a direct or primary cause.
- Abnormally increased **NT** is associated with chromosomal abnormalities (e.g., trisomy 21, 18, 13), cardiac defects, and other genetic syndromes, not typically isolated embryonic kidney pathology at this stage.
Question 10: A 45-year-old primigravida woman at 13-weeks' gestation is scheduled for a prenatal evaluation. This is her first appointment, though she has known she is pregnant for several weeks. A quad screening is performed with the mother's blood and reveals the following:
AFP (alpha-fetoprotein) Decreased
hCG (human chorionic gonadotropin) Elevated
Estriol Decreased
Inhibin Elevated
Ultrasound evaluation of the fetus reveals increased nuchal translucency. Which mechanism of the following mechanisms is most likely to have caused the fetus’s condition?
A. Nucleotide excision repair defect
B. Mismatch repair
C. Mosaicism
D. Robertsonian translocation
E. Nondisjunction (Correct Answer)
Explanation: ***Nondisjunction***
- The quad screen results (**decreased AFP**, **elevated hCG**, **decreased estriol**, **elevated inhibin**) combined with **increased nuchal translucency** are highly suggestive of **Trisomy 21 (Down syndrome)**.
- **Nondisjunction** is the most common mechanism leading to trisomies, such as Trisomy 21, where homologous chromosomes fail to separate during meiosis I or sister chromatids fail to separate during meiosis II.
*Nucleotide excision repair defect*
- This mechanism is associated with conditions like **xeroderma pigmentosum**, characterized by extreme sensitivity to UV light and increased risk of skin cancer.
- It does not explain the quad screen findings or increased nuchal translucency indicative of a chromosomal aneuploidy.
*Mismatch repair*
- Defects in **mismatch repair** are linked to conditions like **Lynch syndrome**, which predisposes individuals to various cancers, particularly colorectal cancer.
- This mechanism is not related to the genesis of chromosomal abnormalities like Trisomy 21.
*Mosaicism*
- **Mosaicism** occurs when an individual has at least two genetically distinct cell lines originating from a single zygote, meaning some cells have Trisomy 21 and others do not.
- While it can result in Down syndrome, **nondisjunction** is the primary event that leads to the initial trisomy in the majority of cases, and mosaicism is considered a less common cause or a secondary event.
*Robertsonian translocation*
- A **Robertsonian translocation** involves the fusion of two acrocentric chromosomes, which can lead to Trisomy 21 if an individual inherits an extra copy of chromosome 21 in addition to the translocated chromosome.
- While it accounts for a minority of Down syndrome cases (about 4%), **nondisjunction** is the most frequent cause, responsible for approximately 95% of cases.
