Endometriosis surgical management — MCQs

A 32-year-old woman visits her family physician for a routine health check-up. During the consult, she complains about recent-onset constipation, painful defecation, and occasional pain with micturition for the past few months. Her menstrual cycles have always been regular with moderate pelvic pain during menses, which is relieved with pain medication. However, in the last 6 months, she has noticed that her menses are “heavier” with severe lower abdominal cramps that linger for 4–5 days after the last day of menstruation. She and her husband are trying to conceive a second child, but lately, she has been unable to have sexual intercourse due to pain during sexual intercourse. During the physical examination, she has tenderness in the lower abdomen with no palpable mass. Pelvic examination reveals a left-deviated tender cervix, a tender retroverted uterus, and a left adnexal mass. During the rectovaginal examination, nodules are noted. What is the most likely diagnosis for this patient?

A 31-year-old female presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to the three months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are currently trying to have children. What is the next best step?

A 19-year-old woman presents to her gynecologist for evaluation of amenorrhea and occasional dull right-sided lower abdominal pain that radiates to the rectum. She had menarche at 11 years of age and had regular 28-day cycles by 13 years of age. She developed menstrual cycle irregularity approximately 2 years ago and has not had a menses for 6 months. She is not sexually active. She does not take any medications. Her weight is 94 kg (207.2 lb) and her height is 166 cm (5.4 ft). Her vital signs are within normal limits. The physical examination shows a normal hair growth pattern. No hair loss or acne are noted. There is black discoloration of the skin in the axillae and posterior neck. Palpation of the abdomen reveals slight tenderness in the right lower quadrant, but no masses are appreciated. The gynecologic examination reveals no abnormalities. The hymen is intact. The rectal examination reveals a non-tender, mobile, right-sided adnexal mass. Which of the following management plans would be best for this patient?

A 36-year-old African American G1P0010 presents to her gynecologist for an annual visit. She has a medical history of hypertension, for which she takes hydrochlorothiazide. The patient’s mother had breast cancer at age 68, and her sister has endometriosis. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min. Her BMI is 32.4 kg/m^2. Pelvic exam reveals a nontender, 16-week sized uterus with an irregular contour. A transvaginal ultrasound is performed and demonstrates a submucosal leiomyoma. This patient is at most increased risk of which of the following complications?

A 66-year-old woman presents to her primary care physician for a wellness exam. She noticed mild spotting a few days prior to presentation. Her last menstrual period was when she was 53 years of age, and she denies any trauma to the area. She is sexually active with one male partner and does not use condoms. Medical history is significant for type II diabetes mellitus and hypertension. She is currently taking metformin and lisinopril. Her last pap smear was normal. She is 5 ft 5 in (165.1 cm), weighs 185 lbs (84 kg), and BMI is 30.8 kg/m2. Her blood pressure is 115/70 mmHg, pulse is 85/min, and respirations are 15/min. Pelvic examination demonstrates a normal sized uterus with no adnexal masses. There are no vulvar, vaginal, or cervical lesions. Stool testing for blood is negative and an endometrial biopsy is performed, which demonstrates simple endometrial hyperplasia without atypia. Which of the following is the best next step in management?

A 25-year-old nulliparous woman presents to her gynecologist complaining of recurrent menstrual pain. She reports a 4-month history of pelvic pain that occurs during her periods. It is more severe than her typical menstrual cramps and sometimes occurs when she is not on her period. She also complains of pain during intercourse. Her periods occur every 28-30 days. Her past medical history is notable for kyphoscoliosis requiring spinal fusion and severe acne rosacea. She takes tretinoin and has a copper intra-uterine device. Her family history is notable for ovarian cancer in her mother and endometrial cancer in her paternal grandmother. Her temperature is 99°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 90/min, and respirations are 16/min. On exam, she appears healthy and is in no acute distress. A bimanual examination demonstrates a normal sized uterus and a tender right adnexal mass. Her intrauterine device is well-positioned. What is the underlying cause of this patient's condition?

A previously healthy 25-year-old woman is brought to the emergency department because of a 1-hour history of sudden severe lower abdominal pain. The pain started shortly after having sexual intercourse. The pain is worse with movement and urination. The patient had several urinary tract infections as a child. She is sexually active with her boyfriend and uses condoms inconsistently. She cannot remember when her last menstrual period was. She appears uncomfortable and pale. Her temperature is 37.5°C (99.5°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. Abdominal examination shows a palpable, tender right adnexal mass. Her hemoglobin concentration is 10 g/dL and her hematocrit is 30%. A urine pregnancy test is negative. Pelvic ultrasound shows a 5 x 3-cm right ovarian sac-like structure with surrounding echogenic fluid around the structure and the uterus. Which of the following is the most appropriate management for this patient's condition?

A 31 year-old-man presents to an urgent care clinic with symptoms of lower abdominal pain, bloating, bloody diarrhea, and fullness, all of which have become more frequent over the last 3 months. Rectal examination reveals a small amount of bright red blood. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Colonoscopy is performed, showing extensive mucosal erythema, induration, and pseudopolyps extending from the rectum to the splenic flexure. Given the following options, what is the most appropriate treatment to induce remission in this patient?

An 8-year-old boy and his 26-year-old babysitter are brought into the emergency department with severe injuries caused by a motor vehicle accident. The child is wheeled to the pediatric intensive care unit with a severe injury to his right arm, as well as other external and internal injuries. He is hemorrhaging and found to be hemodynamically unstable. He subsequently requires transfusion and surgery, and he is currently unconscious. The pediatric trauma surgeon evaluates the child’s arm and realizes it will need to be amputated at the elbow. Which of the following is the most appropriate course of action to take with regards to the amputation?

A 34-year-old woman is brought into the emergency department by emergency medical services after an electrical fire in her apartment. She is coughing with an O2 saturation of 98%, on 2L of nasal cannula. The patient's physical exam is significant for a burn on her right forearm that appears to be dry, white, and leathery in texture. Her pulses and sensations are intact in all extremities. The patient's vitals are HR 110, BP 110/80, T 99.2, RR 20. She has no evidence of soot in her mouth and admits to leaving the room as soon as the fire started. Which of the following is the best treatment for this patient?