1. A 28-year-old patient complains of infertility. The patient has been married for 4 years, has regular sexual life and does not use contraceptives but has never got pregnant. Examination revealed normal state of the genitals, tubal patency. Basal body temperature recorded over the course of 3 consecutive menstrual cycles appeared to have a single phase. What is the most likely cause of infertility?
2. A 28-year-old patient has been taken to a hospital for acute pain in the lower abdomen. There was a brief syncope. The delay ofmenstruation is 2 months. Objectively: the patient has pale skin, AP- 90/50 mm Hg, Ps- 110/min. Lower abdomen is extremely painful. Vaginal examination reveals uterus enlargement. There is positive Promtov’s sign. Right appendages are enlarged and very painful. Posterior vault hangs over. What is the most likely diagnosis?
3. A 58-year-old female patient came to the antenatal clinic complaining of bloody light red discharges from the genital tracts. Menopause is 12 years. Gynaecological examination revealed age involution of externalia and vagina; uterine cervix was unchanged, there were scant bloody discharges from uterine cervix, uterus was of normal size; uterine appendages were not palpable; parametria were free. What is the most likely diagnosis?
4. Full-term pregnancy. Body weight of the pregnant woman is 62 kg. The fetus has the longitudinal position, the fetal head is pressed against the pelvic inlet. Abdominal circumference is 100 cm. Fundal height is 35 cm. What is the approximate weight of the fetus?
5. A newborn’s head is of dolichocephalic shape, that is front to back elongated. Examination of the occipital region revealed a labour tumour located in the middle between the prefontanel and posterior fontanel. Specify the type of fetal presentation:
6. A 30-year-old multigravida has been in labour for 18 hours. 2 hours ago the pushing stage began. Fetal heart rate is clear, rhythmic, 136/min. Vaginal examination reveals the completecervical dilatation, the fetal head in the pelvic outlet plane. Sagittal suture in line with obstetric conjugate, the occipital fontanel is near the pubis. The patient has been diagnosed with primary uterine inertia. What is the further tactics of labour management?
7. During her first visit to the prenatal clinic a pregnant woman was referred to other doctors for mandatory consultation. The patient was referred to:
8. On the 2nd day of life a full term boy developed mild jaundice of skin and mucous membranes, the general condition of the child is normal. Blood test results: indirect hyperbilirubinemia 120 mmol/l. The child’s blood group is A(II) Rh(+), his mother’s blood group - B(III) Rh(+). What is the doctor’s tactics of choice?
9. A 28-year-old patient complains of profuse, painful and prolonged menstruation. Before and after the menstrual period there is spotting lasting for 4-6 days. Vaginal examination reveals that the uterus is enlarged corresponding to 5-6 weeks of pregnancy, has limited mobility, is painful. Appendages are not palpable. On the 15th day of the menstrual cycle, the uterus was of normal size, painless. On account of stated problems and objective examination the patient has been diagnosed with internal endometriosis. Which drug should be used for the effective treatment of this patient?
10. A 40 week pregnant secundipara is 28 years old. Contractions are very active. Retraction ring is at the level of navel, the uterus is hypertonic, in form of hourglass. On auscultation the fetal heart sounds are dull, heart rate is 100/min. AP of the parturient woman is 130/80 mm Hg. What is the most likely diagnosis?
11. A baby was born by a young smoker. The labour was complicated by uterine inertia, difficult delivery of the baby’s head and shoulders. The baby’s Apgar score was 4. Which of the following is a risk factor for a spinal cord injury?
12. A 37-year-old patient complains of acute pain in the region of genitals, swelling of the labia, pain when walking. Objectively: body temperature is 38, 7oC, Ps- 98/min. In the interior of the right labia there is a dense, painful tumour-like formation 5,0x4,5 cm large, the skin and mucous membrane of genitals is hyperemic, there are profuse foul smelling discharges. What is the most likely diagnosis?
13. A 10 week pregnant woman was admitted to a hospital for recurrent pain in the lower abdomen, bloody discharges from the genital tracts. The problems turned up after ARVI. The woman was registered for antenatal care. Speculum examination revealed cyanosis of vaginal mucosa, clean cervix, open cervical canal discharging blood and blood clots; the lower pole of the gestational sac was visible. What tactics should be chosen?
14. A multigravida at 39 weeks of gestation has been delivered to a hospital having a regular labour activity for 8 hours, the waters burst an hour ago. She complains of headache, seeing spots. AP is of 180/100mm Hg. Urine test results: protein - 3,3 g/l, hyaline cylinders. Fetal heart rate is 140/min, rhythmical. Vaginal examination reveals complete crevical dilatation, the fetal head is on the pelvic floor, sagittal suture is in line with obstetric conjugate, the occipital fontanel is under the pubis. What is the optimal tactics of labour management?
15. A patient complains of being unable to get pregnant for 5 years. A complete clinical examination gave the following results: hormonal function is not impaired, urogenital infection hasn’t been found, on hysterosalpingography both tubes were filled with the contrast medium up to the isthmic segment, abdominal contrast was not visualized. The patient’s husband is healthy. What tactics will be most effective?
16. A 22-year-old patient complains of amenorrhea for 8 months. Menarche occurred at the age of 12,5. Since the age of 18 the patient has a history of irregular menstruation. The patient is nulligravida. The mammary glands are developed properly, nipples discharge drops of milk when pressed. Gynecological study results: prolactin level is 2 times higher than normal. CT reveals a bulky formation with a diameter of 4 mm in the region of sella. What is the most likely diagnosis?
17. A 38-year-old female patient complains about hot flashes and feeling of intense heat arising up to 5 times a day, headaches in the occipital region along with high blood pressure, palpitations, dizziness, fatigue, irritability, memory impairment. 6 months ago the patient underwent extirpation of the uterus with its appendages. What is the most likely diagnosis?
18. 20 minutes after a normal delivery at 39 weeks a puerpera had a single temperature rise up to 38oC. Objectively: the uterus is dense, located between the navel and the pubis, painless. Lochia are bloody, of small amount. Breasts are moderately soft and painless. What is the optimal tactics?
19. A 55-year-old patient whose menstruation stopped 5 years ago complains of vaginal dryness, frequent and painful urination. Gynecologist revealed signs of atrophic colpitis. Urine analysis revealed no peculiarities. Which locally acting product will provide the proper therapeutic effect?
20. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left mammary gland. Body temperature is 38, 8oC, Ps- 94 bpm. The left mammary gland is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?
Explanation
Mastitis is inflammation of the breast tissue and can be broken down into lactational and non-lactational mastitis. Lactational mastitis is the most common form of mastitis. Lactational mastitis, also known as puerperal mastitis, is typically due to prolonged engorgement of milk ducts, with infectious components from the entry of bacteria through skin breaks. Patients can develop a focal area of erythema, pain, and swelling, and can have associated systemic symptoms, including fever. This occurs most commonly in the first six weeks of breastfeeding but can occur at any time during lactation, with most cases falling off after 3 months. Lactational mastitis is most commonly caused by bacteria that colonize the skin, with Staphylococcus aureus being the most common, in this case an antibiotic may be administered to fight the infection.
The first line of treatment is self-help remedies, such as ensuring that the breast is drained properly during feeds by breastfeeding regularly or expressing the milk. And after a feed, gently express any leftover milk.
Inhibition of lactation will complicate the condition. This is not a case of breast abscess. An abscess will be associated with pus discharge from the nipple, not drops of milk. Use a hot compress on the breast will not be enough to resolve the condition since there is a probability of an ongoing infection.
21. During self-examination a 22-year-old patient revealed a mammary tumour. Palpation revealed a firm, painless, mobile formation up to 2 cm, peripheral lymph nodes were not changed. USI results: in the superior external quadrant of the right mammary gland there was a big formation of increased echogenicity, sized 18x17 mm. The patient was provisionally diagnosed with fibroadenoma. What is a doctor’s further tactics?
Explanation
Fibroadenomas are typically present as firm, mobile, painless, and frequently multiple breast nodules. These tumors are common, benign breast tumors that usually affect women in second and third decades of life. Fibroadenomas are usually small and can be managed conservatively; however, a good percentage of these lesions will grow rapidly.
During pregnancy, fibroadenomas increase in size and may show lactational histologic changes. High concentrations of estrogen, progesterone, and prolactin promote the ductal growth and formation of tubuloalveolar structures. This may be a reason for the significant enlargement in this period.
Hence, it is recommended that it be removed prior to pregnancy.
22. A 49-year-old patient complains of itching, burning in the external genitals, frequent urination. The symptoms has been present for the last 7 months. The patient has irregular menstruation, once every 3-4 months. Over the last 2 years she presents with hot flashes, sweating, sleep disturbance. Examination revealed no pathological changes of the internal reproductive organs. Complete blood count and urinalysis showed no pathological changes. Vaginal smear contained 20-25 leukocytes in the field of vision, mixed flora. What is the most likely diagnosis?
23. 2 weeks after labour a parturient woman developed breast pain being observed for 3 days. Examination revealed body temperature at the rate of 39oC, chills, weakness, hyperaemia, enlargement, pain and deformity of the mammary gland. On palpation the infiltrate was found to have an area of softening and fluctuation. What is the most likely diagnosis?
Explanation
Mastitis is inflammation of the breast tissue and can be broken down into lactational and non-lactational mastitis. Lactational mastitis is the most common form of mastitis. Lactational mastitis, also known as puerperal mastitis, is typically due to prolonged engorgement of milk ducts, with infectious components from the entry of bacteria through skin breaks. Patients can develop a focal area of erythema, pain, and swelling, and can have associated systemic symptoms, including fever. This occurs most commonly in the first six weeks of breastfeeding but can occur at any time during lactation, with most cases falling off after 3 months. Lactational mastitis is most commonly caused by bacteria that colonize the skin, with Staphylococcus aureus being the most common. Risk factors for lactational mastitis include prior history of mastitis, nipple cracks and fissures, inadequate milk drainage, maternal stress, lack of sleep, tight-fitting bras, and use of antifungal nipple creams.
From the question stem, we can differentiate the different types of mastitis listed. On palpation, an INFILTRATE was found with an area of softening and fluctuation (PURULENT). We can boldly conclude it is purulent because lactational/puerperal mastitis is commonly caused by bacteria which will produce a purulent inflammation.
24. A puerpera breastfeeding for 1,5 weeks consulted a doctor about uniform breast engorgement. Breasts are painful. The body temperature is of 36, 6oC. Milk expressing is difficult. What is the most likely diagnosis?
25. Examination of a Rh-negative pregnant woman at 32 weeks of gestation revealed a four-time rise of Rh-antibody titer within 2 weeks, the titer was 1:64. In the first two pregnancies the patient had experienced antenatal fetal death due to hemolytic disease. What is the optimal tactics of pregnancy management?
Explanation
This question is talking about Rh incompatibility. This occurs when a Rhesus negative (Rh-) mother marries a Rh+ Man and they conceive a Rh+ child. Note: the mother must be Rh- and the child Rh+. The first child with Rh+ usually survives, but subsequently Rh+ fetus will be attacked by Rh antibodies in the mother which crosses the placenta to attack the fetal red blood cells causing hemolysis.
From the question, the patient already had 2 antenatal fetal deaths due to hemolytic disease. And in this pregnancy, it is observed that the Rh antibodies are beginning to rise (4 fold increase), therefore, another hemolytic disease is imminent.
The first Rh+ child usually survives because the mother is yet to develop the Rh antibodies. Usually, the Rh- mother will be exposed to these antibodies when the Rh+ antigens from the first child cross into her blood during delivery, or CS. In that case, the mother will develop Rh antibodies for any subsequent pregnancy that is Rh+.
Once this occurs, i.e. once a Rh- mother conceives a Rh+ child, she should receive RhoGAM at 28weeks of gestation and within 72hours after delivery. This will prevent the development of antibodies. However, if she did not receive the RhoGAM, she will develop the antibodies just as it is seen in this case and the best option is to deliver the fetus as soon as possible to prevent hemolytic reactions.
She’s already at 32weeks of gestation and if she took RhoGAM @28weeks, the antibodies will not rise. It’s medically wrong to leave the pregnancy till 37 weeks because there is a high chance the antibodies must have risen to a considerable level to cause massive hemolysis in the developing fetus before getting to 37 weeks of gestation. Ultrasound would not have any impact in this case.
There is no need waiting for another 2 weeks to screen for Rh antibodies. From the history, there are 2 confirmed cases of hemolytic disease in the past, she’s Rh- and the Rh antibodies are already increasing.
Anti-Rh immunoglobulin is effective when given to a Rh- mother @ 26-28 weeks of gestation and within 72hours after delivery of the first child that is Rh+.
The best management is to deliver the child while the fetus is still alive and hemolytic reaction is yet to start. At 32weeks, the mother should receive Corticosteroids to help the fetal lungs develop and deliver the fetus as soon as possible.
26. A 50-year-old female patient complains of aching pain in the lower abdomen. She has a history of normal menstrual cycle. At the age of 40, the patient underwent a surgery for gastric ulcer. Examination findings: abdomen is soft, in the hypogastrium there is a well-defined nodular tumor of limited mobility. Vaginal examination findings: the cervix is clean, of cylindrical shape. Body of the uterus cannot be palpated separately. On both sides of the uterus palpation reveals tight tumors with an uneven surface. The tumors are immobile andl fill the whole pelvic cavity. What is the most likely diagnosis?
27. A 21-year-old female patient consulted a gynecologist about itching, burning, watery vaginal discharges with a fish like smell. Speculum examination revealed that the cervical and vaginal mucosa was of a normal pink color. Vaginal examination revealed no alterations of the uterus and appendages. Gram stained smears included clue cells. What is the most likely pathology?
28. A 26-year-old secundipara at 40 weeks of gestation arrived at the maternity ward after the beginning of labor activity. 2 hours before, bursting of waters occurred. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height - 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4 cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in childbirth?
29. A 28-year-old female patient has been admitted to the gynecology department for abdominal pain, spotting before and after menstruation for 5 days. The disease is associated with the abortion which she had 2 years ago. Anti-inflammatory treatment had no effect. Bimanual examination findings: the uterus is enlarged, tight, painful, smooth. Hysteroscopy reveals dark red holes in the fundus with dark blood coming out of them. What diagnosis can be made on the grounds of these clinical presentations?
30. A woman at 30 weeks pregnant has had an attack of eclampsia at home. On admission to the maternity ward AP- 150/100 mm Hg. Predicted fetal weight is 1500 g. There is face and shin pastosity. Urine potein is 0, 66o/oo. Parturient canal is not ready for delivery. An intensive complex therapy has been started. What is the correct tactics of this case management?
31. A pregnant 26-year-old woman was admitted to a hospital for abdominal pain and bleeding from the genital tract. Bimanual examination revealed that uterus was the size of 9 weeks of pregnancy, the cervical canal let a finger through. Fetal tissues could be palpated in the orifice. There was moderate vaginal bleeding. What is the tactics of choice?
32. A 36-year-old female presented to a gynecological hospital with a significant bleeding from the genital tract and a 1-month delay of menstruation. Bimanual examination revealed soft barrel shaped cervix. Uterus was of normal size, somewhat softened. Appendages were unremarkable on both sides. Speculum examination revealed that the cervix was cyanotic, enlarged, with the the external orifice disclosed up to 0,5 cm. Urine hCG test was positive. What is the most likely diagnosis?
33. An 18-year-old girl complains of breast pain and engorgement, headaches, irritability, swelling of the lower extremities. These symptoms have been observed since menarche and occur 3-4 days before the regular menstruation. Gynecological examination revealed no pathology. Make a diagnosis:
34. A 25-year-old female presented to a women’s welfare clinic and reported the inability to get pregnant within 3 years of regular sexual activity. Examination revealed increased body weight, male pattern of pubic hair growth, excessive pilosis of thighs, dense enlarged ovaries, monophasic basal temperature. What is the most likely diagnosis?
Explanation
Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain male pattern pubic hair growth, excessive hair on the thighs etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation;
Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc. 35. A puerperant is 28 years old. It’s the 3rd day post-partum after a second, normal, term delivery. The body temperature is of 36, 8oC, Ps- 72/min, AP- 120/80 mm Hg. Mammary glands are moderately engorged, the nipples are clean. Abdomen is soft, painless. The fundus is 3 fingers’ breadth below the navel. Moderate bloody lochia are present. What diagnosis can be made?
Explanation
The postpartum physiological changes are those expected changes that occur to the woman's body after childbirth, in the postpartum period. These changes mark the beginning of the return of pre-pregnancy physiology and of breastfeeding.
Involution, a part of postpartum physiology, is the term given to the process of reproductive organs returning to their prepregnant state. Immediately following the delivery, the uterus, and the placental site contracts rapidly to prevent further blood loss.
After birth, the fundus of the uterus contracts downward into the pelvis one centimeter each day. After two weeks the uterus will have contracted and returned into the pelvis. Hence, the 3 finger’s breadth below the navel on the 3rd day postpartum.
The lochia is the vaginal discharge that originates from the uterus, cervix, and vagina. The lochia is initially red and consists of blood and fragments of decidua, endometrial tissues, and mucus and lasts 1 to 4 days. The lochia then changes color to yellowish or pale brown, lasting 5 to 9 days, and is composed mainly of blood, mucus, and leukocytes. Finally, the lochia is white and contains mostly mucus, lasting up to 10 to 14 days.
The lactogenesis or milk secretion starts the third or fourth day postpartum making the mammary glands engorged.
Subinvolution of the uterus is seen after childbirth, when the uterus does not return to its normal size. But a fundus 3 finger’s breadth below the navel on the 3rd day postpartum clearly indicates a physiologic process taking place.
36. A puerperant is 32 years old, it’s her first childbirth, term precipitate labor, the III period is unremarkable, the uterus is contracted, tight. Examination of the birth canal revealed a rupture in the left posterior vaginal wall that was closed with catgut. Two hours later, the patient complained of a feeling of pressure on the anus, pain in the perineum, minor vaginal discharges, edema of the vulva. These clinical presentations are indicative most likely of:
37. A 31-year-old female patient complains of infertility, amenorrhea for 2 years after the artificial abortion that was complicated by endometritis. Objectively: examination of the external genitalia revals no pathology, there is female pattern of hair distribution. According to the functional tests, the patient has biphasic ovulatory cycle. What form of infertility is the case?
38. A 19-year-old primiparous woman with a body weight of 54,5 kg gave birth at 38 weeks gestation to a full-term live girl after a normal vaginal delivery. The girl’s weight was 2180,0 g, body length - 48 cm. It is known from history that the woman has been a smoker for 8 years, and kept smoking during pregnancy. Pregnancy was complicated by moderate vomiting of pregnancy from 9 to 12 weeks pregnant, edemata of pregnancy from 32 to 38 weeks. What is the most likely cause of low birth weight?
39. A 23-year-old primigravida at 39 weeks gestation has been admitted to the maternity ward with irregular contractions. The intensity of uterine contractions is not changing, the intervals between them stay long. Bimanual examination reveals that the cervix is centered, soft, up to 1,5 cm long. There is no cervical dilatation. What diagnosis should be made?
Explanation
The Preliminary stage of labor is characterized by:
The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third combined. The first stage of labor has been divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase there is more progress in effacement ( stretching and thinning) of the cervix and little increase in descent. During the active phase and the transition phase there is more rapid dilation of the cervix and increased rate of descent of the presenting part.
The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The second stage takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.
The third stage of labor lasts from the birth of the fetus until the placenta is delivered. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born.The duration of the third stage may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits
The fourth stage of labor arbitrarily lasts approximately 2 hours after delivery of the placenta. It is the period of immediate recovery, when homeostasis is reestablished. It serves as an important period of observation for complications, such as abnormal bleeding.
Notice that this patient presents with irregular contraction and no cervical dilation.
40. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left breast. Body temperature is 38, 8oC, Ps- 94 bpm. The left breast is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?
41. During the breast self-exam a 37-year-old female patient revealed a lump in the lower inner quadrant of her left breast. Palpation confirms presence of a mobile well-defined neoplasm up to 2 cm large. Peripheral lymph nodes are not changed. What is the way of further management?
42. A 25-year-old female has a self-detected tumor in the upper outer quadrant of her right breast. On palpation there is a painless, firm, mobile lump up to 2 cm in diameter, peripheral lymph nodes are not changed. In the upper outer quadrant of the right breast ultrasound revealed a massive neoplasm with increased echogenicity sized 21x18 mm. What is the most likely diagnosis?
43. A 49-year-old female patient complains of itching, burning in the external genitals, frequent urination. The symptoms have been present for the last 7 months. The patient has irregular menstruation, once every 3-4 months. Over the last two years she has had hot flashes, sweating, sleep disturbance. Examination revealed no pathological changes of the internal reproductive organs. Complete blood count and urinalysis showed no pathological changes. Vaginal smear contained 20-25 leukocytes per HPF, mixed flora. What is the most likely diagnosis?
44. On admission a 35-year-old female reports acute abdominal pain, fever up to 38, 8oC, mucopurulent discharges. The pati-ment is nulliparous, has a history of 2 artificial abortions. The patient is unmarried, has sexual contacts. Gynecological examination reveals no uterus changes. Appendages are enlarged, bilaterally painful. There is profuse purulent vaginal discharge. What study is required to confirm the diagnosis?
45. A 20-year-old female consulted a gynecologist about not having menstrual period for 7 months. History abstracts: early childhood infections and frequent tonsillitis, menarche since 13 years, regular monthly menstrual cycle of 28 days, painless menstruation lasts 5-6 days. 7 months ago the patient had an emotional stress. Gynecological examination revealed no alterations in the uterus. What is the most likely diagnosis?
46. A 48-year-old female has been admitted to the gynecology department for pain in the lower right abdomen and low back pain, constipation. Bimanual examination findings: the uterus is immobile, the size of a 10-week pregnancy, has uneven surface. Aspirate from the uterine cavity contains atypical cells. What diagnosis can be made?
47. A 45-year-old woman came to the maternity clinic with complaints of periodical pains in her mammary glands that start 1 day before menstruation and stop after the menstruation begins. Palpation of the mammary glands detects diffuse nodes predominantly in the upper outer quadrants. What is the most likely diagnosis?
48. A 46-year-old woman came to the maternity clinic with complaints of moderate blood discharge from the vagina, which developed after the menstruation delay of 1.5 months. On vaginal examination: the cervix is clean; the uterus is not enlarged, mobile, painless; appendages without changes. Make the diagnosis:
49. A woman is 40 weeks pregnant. The fetus is in the longitudinal lie and cephalic presentation. Pelvic size: 26-29-31-20. Expected weight of the fetus is 4800 gram. The labor contractions has been lasting for 12 hours, within the last 2 hours they were extremely painful, the parturient woman is anxious. The waters broke 4 hours ago. On external examination the contraction ring is located 2 finger widths above the navel, Henkel-Vasten sign is positive. Fetal heart rate is 160/min., muffled. On internal examination the uterine cervix is fully open, the head is engaged and pressed to the entrance into the lesser pelvis. What is the most likely diagnosis?
50. A 17-year-old girl has made an appointment with the doctor. She plans to begin her sex life. No signs of gynecological pathology were detected. In the family history the patient’s grandmother had cervical cancer. The patient was consulted about the maintenance of her reproductive health. What recommendation will be the most helpful for prevention of invasive cervical cancer?
51. An infant has been born at the 41st week of gestation. The pregnancy was complicated with severe gestosis of the second semester. The weight of the baby is 2400 g, the height is 50 cm. Objectively: the skin is flabby, the layer of subcutaneous fat is thin, hypomyotonia, neonatal reflexes are weak. The internal organs are without pathologic changes. This newborn can be assessed as a:
52. The pregnancy is full term. The body weight of the parturient woman is 62 kg. Fetus is in a longitudinal lie, the head is engaged to the pelvic inlet. Belly circumference is 100 cm. Uterine fundus height is 35 cm. What body weight of the fetus can be expected?
53. A 22-year-old woman, gravida 1, para 0 arrived with complaints of sharply painful contractions that occur every 4-5 minutes and last for 25-30 seconds. Amniotic fluid did not burst. The fetus is in transverse lie, fetal heartbeats are not affected. Contraction ring is acutely painful, located obliquely at the umbilicus. What is the most likely diagnosis?
54. A 16-year-old girl has primary amenorrhea, no pubic hair growth, normally developed mammary glands; her genotype is 46 ХY; uterus and vagina are absent. What is your diagnosis?
55. 6 hours ago the waters of a 30-year-old gravida 1, para 0, burst; her preliminary period was pathologic and lasted for over 2 days; the term of pregnancy is 39 weeks. No labor activity is observed. Fetal head presents above the pelvic inlet. Fetal heartbeats are 142/min., clear and rhytmic. On vaginal examination the uterine cervix is not dilated. What further tactics should the doctor choose?
56. A newborn has Apgar score of 9. When should the infant be put to the breast?
57. A 23-year-old woman came the the gynecologist with complaints of blood smears from her genital tracts that have been observed for a long time. Her menstruation has been delayed for 8 weeks. Examination shows the uterine body to be enlarged up to 14 weeks of pregnancy. US detected a vesicular mole. What tactics should the doctor choose?
58. The gynecology unit received a patient with uterine bleeding that started 6 hours after induced abortion at the term of 11-12 weeks. Objectively the skin is pale, pulse is 100/min., blood pressure is 100/70 mm Hg. On vaginal examination the uterus is painless, its enlargement corresponds to the 10th week of pregnancy; uterine cervix is dilated enough to let in one finger, there are fragments of the fertilized ovum. What actions should be taken next:
59. A woman came to the general practitioner with complaints of fatigability, significant weight loss, weakness, and loss of appetite. She has been presenting with amenorrhea for the last 8 month. One year ago she gave birth to a live full-term child. Blood loss during delivery was 2 liters. The woman received blood transfusion and blood components. What is the most likely diagnosis?
60. A 22-year-old woman complains of itching and profuse discharge from her genital tracts. The condition developed 10 days ago after a sexual contact. Bacterioscopy of a discharge sample detected trichomonads. What drug should be prescribed for treatment in this case?
61. A multigravida on the 38th week of her pregnancy complains of increased BP up to 140/90 mm Hg, edema of the shins for 2 weeks. In the last month she gained 3.5 kg of weight. Urine analysis: protein - 0.033 g/L. Make the diagnosis:
Explanation
Preeclampsia, a pregnancy-specific condition in which hypertension develops after 20 weeks of gestation in a previously normotensive woman. It is characterized by hemoconcentration, hypertension, and proteinuria. The following are the differences between a mild and severe Preeclampsia:
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MIld Preeclampsia
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Severe Preeclampsia
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BP reading of 140/90 mm Hg twice, 4-6 hr apart
Proteinuria of 0.3 g/L in a 24 hr specimen or >0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart
Dependent edema, some puffiness of eyes, face, fingers; pulmonary edema absent
Output matching intake, ≥30 ml/hr or <650 ml/24 hr
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Rise to >160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest
Proteinuria of >0.5 g/L in 24 hr
Generalized edema, noticeable puffiness; eyes, face, fingers; pulmonary edema possibly present
<20 ml/hr or <400 ml to 500 ml/24 hr
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62. A 20-year-old woman, gravida 2, para 1 has been in labor for 4 hours. Her condition is satisfactory. Moderately painful contractions occur every 3 minutes and last for 35-40 seconds. The waters have not burst yet. The fetus is in longitudinal position. Fetal heartbeats are 136/min., clear and rhytmic. Major segment of the fetal head is engaged to the pelvic inlet. Vaginal examination shows smooth cervix of 6cm, amniotic sac is intact, sagittal suture is in the left oblique diameter, occipital fontanel is on the right near the symphysis pubis. What stage of the labor is it?
63. It is the 3rd day after the normal term labor; the infant is rooming-in with the mother and is on breastfeeding. Objectively: the mother’s general condition is satisfactory. Temperature is 36.4oC, heart rate is 80/min.,BP is 120/80 mm Hg. Mammary glands are soft and painless; lactation is moderate, unrestricted milk flow. The uterus is dense, the uterine fundus is located by 3 fingers width below the navel. Lochia are sanguinoserous, moderate in volume. Assess the dynamics of uterine involution:
64. A 30-year-old woman complains of milk discharge from her breasts and no menstruation for the last 5 months. One physiologic childbirth was 4 years ago. There are no maldevelopments of mammary glands. Bimanual examination revealed diminished uterus and normal sized ovaries. MRI-scan shows no brain pathologies. Thyroid stimulating hormone is within normal limits. Serum prolactin is high. What is the most likely diagnosis?
65. A 25-year-old woman during self-examination detected a tumor in the upper external quadrant of her right mammary gland. On palpation: painless, dense, mobile growth 2cm in diameter is detected in the mammary gland; no changes in the peripheral lymph nodes are observed. On US of the mammary glands: in the upper external quadrant of the right mammary gland there is a space-occupying lesion of increased echogenicity 21х18 mm in size. The most likely diagnosis is:
66. A 45-year-old woman underwent one year ago mastectomy followed by chemo and radiation therapy. She now complains of dyspnea at rest and temperature up to 37.2oC. Her general condition is severe acrocyanosis is observed. The right side of her chest practically does not participate in respiration. Percussion reveals a dull sound below the 3rd rib; auscultation detects acute weakening of the respiratory sounds. Pleural puncture on the right has yielded a large amount of hemorrhagic exudate. What complication has developed in the patient?
67. A 45-year-old woman came to the maternity clinic with complaints of periodical pains in her mammary glands that start 1 day before menstruation and stop after the menstruation begins. Palpation of the mammary glands detects diffuse nodes predominantly in the upper outer quadrants. What is the most likely diagnosis?
68. A woman complains of temperature increase up to 39oC, sharp pains in her lower abdomen, and sanguinopurulent discharge from her genital tracts. From her case history it is known that 6 days ago she underwent illegal abortion. Objectively her blood pressure is 100/60 mm Hg, pulse is 110/min. Abdominal rigidity, rebound tenderness (Bloomberg’s sign), and painful palpation of the lower abdomen are observed. On bimanual examination the uterus is enlarged up to 7 weeks of pregnancy, painful, and soft; posterior vaginal fornix overhangs. Make the diagnosis:
69. A 55-year-old woman came to a gynecologist with complaints of leukorrhea and bloody discharge from the vagina after 5 years of menopause. Anamnesis states no pregnancies. Bimanual examination: the uterus and uterine appendages are without changes. During diagnostic curettage of the uterine cavity the physician scraped off enchephaloid matter. What is the most likely diagnosis in this case?
70. A 24-year-old pregnant woman on her 37th week of pregnancy has been delivered to a maternity obstetric service with complaints of weak fetal movements. Fetal heartbeats are 95/min. On vaginal examination the uterine cervix is tilted backwards, 2 cm long, external orifice allows inserting a fingertip. Biophysical profile of the fetus equals 4 points. What tactics of pregnancy management should be chosen?
71. During regular preventive gynecological examination a 30-year-old woman was detected to have dark blue punctulated ”perforations” on the vaginal portion of the uterine cervix. The doctor suspects endometriosis of the vaginal portion of the uterine cervix. What investigation method would be most informative for diagnosis confirmation?
72. A postparturient woman, who has been breastfeeding for 3 weeks, made an appointment with the doctor. For the last 6 days she has been feeling unwell, complains of body temperature of 38-39oC, general weakness; within the last 2 days she developed pain and redness in the area of her right mammary gland. Examination revealed her mammary gland to be significantly enlarged and deformed; breast tissue fluctuations and lymphadenitis are observed. What type of mastitis is the most likely?
73. On the 9th day after childbirth the obstetric patient developed high fever up to 38oC. She complains of pain in the right mammary gland. The examination revealed the following: a sharply painful infiltrate can be palpated in the right mammary gland, the skin over the infiltrate is red, subareolar area and nipple are swollen and painful. What is your diagnosis?
74. A 32-year-old pregnant woman at the term of 5-6 weeks was vaccinated against influenza along with her whole family. At that time she was not aware of her pregnancy. The pregnancy is wanted. The woman needs an advice from the family doctor regarding the maintenance of her pregnancy, namely whether there is a risk of fetal malformations because of received vaccination. What advice should the doctor give in this case?
75. A 17-year-old girl has made an appointment with the doctor. She plans to begin her sex life. No signs of gynecological pathology were detected. In the family history there was a case of cervical cancer that occurred to the patient’s grandmother. The patient was consulted about the maintenance of her reproductive health. What recommendation will be the most helpful for prevention of invasive cervical cancer?
76. A 28-year-old woman has been delivered to a hospital with acute pain in the lower abdomen. There was a brief syncope. The delay of menstruation is 2 months. Objectively: the patient has pale skin, BP- 90/50 mmHg, Ps- 110/min. Lower abdomen is extremely painful. Vaginal examination reveals uterus enlargement. Promtov’s sign (pain during bimanual gynecological examination) is positive. Right uterine appendages are enlarged and very painful. Posterior vault hangs over. What is the most likely diagnosis?
77. A parturient woman complains of pain in her mammary gland. In the painful area there is an infiltration 3x4 cm in size with softened center. Body temperature is 38,5oC. What is the most likely diagnosis?
78. A 29-year-old woman came to a gynecologist with complaints of irritability, tearfulness, headache, nausea, occasional vomiting, pain in the heart area, tachycardia attacks, memory impairment, meteorism. These signs appear 6 days before menstruation and disappear the day before menstruation or during its first 2 days. On vaginal examination: the uterus and uterine appendages are without alterations. What diagnosis is the most likely?
79. A primigravida at the term of 20 weeks complains of pain in her lower abdomen, smearing blood-streaked discharge from the genital tracts. Uterine tone is increased, fetus is mobile. On vaginal examination: the uterus is enlarged according to the term, uterine cervix is shortened to 0,5 cm, external cervical orifice is open by 2 cm. What is the most likely diagnosis?
80. Vaginal examination reveals the head of the fetus, which fills the posterior surface of symphysis pubis and hollow of the sacrum. The lower edge of symphysis pubis, ischiadic spines, and sacrococcygeal joint can be palpated. Where in the lesser pelvis is the fetal head situated?
81. A 30-year-old multigravida has been in labour for 18 hours. 2 hours ago the pushing stage began. Fetal heart rate is clear, rhythmic, 136/min. Vaginal examination reveals complete cervical dilatation, the fetal head in the pelvic outlet plane. Sagittal suture is in line with obstetric conjugate, the occipital fontanel is near the pubis. The patient has been diagnosed with primary uterine inertia. What is the further tactics of labour management?
82. A 20-year-old woman on the 10th day after her discharge from the maternity ward developed fever up to 39oC and pain in her left mammary gland. On examination the mammary gland is enlarged, in its upper outer quadrant there is a hyperemic area. In this area a dense spot with blurred margins can be palpated. The patient presents with lactostasis and no fluctuation. Lymph nodes in the right axillary crease are enlarged and painful. Specify the correct diagnosis:
83. A 46-year-old woman came to a maternity clinic with complaints of moderate blood discharge from the vagina, which developed after the menstruation delay of 1,5 months. On vaginal examination: the cervix is clean; the uterus is not enlarged, mobile, painless; appendages without changes. Make the diagnosis:
84. A 30-year-old woman complains of amenorrhea that lasts for 2 years after she has given birth, loss of hair and body weight. The labor was complicated with hemorrhage caused by uterine hypotonia. Objectively the patient is of asthenic type, her external genitalia are hypoplastic, the uterine body is small in size and painless. No uterine appendages can be detected. What is the most likely diagnosis?
85. A 28-year-old woman complains of increased intervals between menstruations, up to 2 months, and hirsutism. Gynecological examination revealed the following: ovaries are enlarged, painless, and dense; no alterations of the uterus. US of the lesser pelvis: ovaries are 4-5 cm in diameter, with numerous enlarged follicles on the periphery. X-ray of the skull base: sellar region is widened. What is the most likely diagnosis?
86. A 37-year-old woman complains of acute pain in the genital area, swelling of the labia, pain when walking. Objectively: body temperature is 38,7oC, Ps- 98/min. In the interior of the right labia there is a dense, painful tumor-like formation 5,0x4,5 cm in size, the skin and mucous membrane of genitals are hyperemic, there is profuse foul-smelling discharge. What is the most likely diagnosis?
87. The left hand of a newborn is extended in all its joints, stretched along the torso, and pronated in the forearm. Active movements of the shoulder joint are retained. The hand is flattened, atrophied, cold to touch, hangs passively. Grasping and Babkin’s reflexes are absent at the affected side. Hemogram indicators are normal. Make the most likely diagnosis:
88. A 14-year-old girl has been delivered to a gynecological department with complaints of profuse blood discharge from her genital tract for 2 weeks. Anamnesis: menstruation since 13, irregular, painful, profuse; the last one was 2 months ago. Objectively: pale skin and mucosa, BP- 100/60 mm Hg, Hb- 108 g/l. The abdomen is soft and painless on palpation. Rectal examination revealed no pathologies of reproductive organs. What condition is it?
89. A man came to an urologist with complains of painful urination, discharge from urethra. The patient has been suffering from this condition for a week. Objectively: hyperemic urinary meatus, edema, purulent discharge. Microscopy of smears detected gram negative bacteria. Specify the diagnosis:
90. A 35-year-old woman has gained 20 kg weight within a year with the normal diet. She complains of chills, sleepiness, shortness of breath. The patient’s mother and sister are corpulent. Objectively: height - 160 cm, weight - 92 kg, BMI- 35,9. Obesity is uniform, there are no striae. The face is amimic. The skin is dry. The tongue is thickened. Heart sounds are muffled. HR- 56/min, BP- 140/100mm Hg. The patient has been suffering from amenorrhea for 5 months, has constipations. TSH- 28 mcIU/l (norm is 0,32-5). Craniogram shows no pathology. What is the etiology of obesity?
91. A multigravida at 39 weeks of gestation presenting with regular labour activity for 8 hours has been delivered to a hospital; the waters broke an hour ago. She complains of headache, seeing spots. BP is 180/100 mm Hg. Urine test results: protein - 3,3 g/l, hyaline cylinders. Fetal heart rate is 140/min, rhythmical. Vaginal examination reveals complete cervical dilatation, the fetal head is on the pelvic floor, sagittal suture is in line with obstetric conjugate, the occipital fontanel is under the pubis. What is the optimal tactics of labour management?
92. An 18-year-old woman complains of pain in her lower abdomen, profuse purulent discharge from the vagina, temperature rise up to 37,8oC. Anamnesis states that she had a random sexual contact the day before the signs appeared. She was diagnosed with acute bilateral adnexitis. On additional examination: leukocytes are present throughout all vision field, bacteria, diplococci with intracellular and extracellular position. What is the most likely agent in the given case?
93. A 6-year-old girl came to a general practitioner with her mother. The child complains of burning pain and itching in her external genitalia. The girl was taking antibiotics the day before due to her suffering from acute bronchitis. On examination: external genitalia are swollen, hyperemic, there is white deposit accumulated in the folds. The most likely disgnosis is:
94. A 22-year-old woman complains of amenorrhea for 8 months. Anamnesis states that menarche occured at the age of 12,5. Since the age of 18 the patient has a history of irregular menstruation. The patient is nulligravida. The mammary glands are developed properly, nipples discharge drops of milk when pressed. Hormone test: prolactin level is 2 times higher than normal. CT reveals a bulky formation with diameter of 4 mm in the region of sella. What is the most likely diagnosis?
95. A 14-year-old girl came to a general practitioner with complaints of weakness, loss of appetite, headache, rapid fatigability. Her last menstruation was profuse and lasted for 14 days after previous delay of 2 months. Objectively: the skin is pale, heart rate is 90/min., BP is 110/70 mm Hg, Hb is 88 g/l. Rectal examination: the uterus and its appendages are without changes, no discharge from the genital tracts. What complication occurred in the patient?
96. Examination of a Rh-negative pregnant woman at 32 weeks of gestation revealed a four-time rise of Rh-antibody titer within 2 last weeks; the titer is 1:64. The first two pregnancies resulted in antenatal fetal death due to hemolytic disease. What is the optimal tactics of pregnancy management?
97. A woman is on the 32nd week of her second pregnancy. She complains of fever, chills, nausea, vomiting, lumbar pain, and dysuria. Costovertebral angle tenderness is present on both sides. Urine analysis: pyuria, bacteriuria. Blood test: leukocytosis. What is the most likely diagnosis?
98. A pregnant woman is 28 years old. Anamnesis: accelerated labor complicated by the II degree cervical rupture. The following two pregnancies resulted in spontaneous abortions at the terms of 12 and 14 weeks. On mirror examination: the uterine cervix is scarred from previous ruptures at 9 and 3 hours, the cervical canal is gaping. On vaginal examination: the cervix is 2 cm long, the external orifice is open 1 cm wide, the internal orifice is half-open; the uterus is enlarged to the 12th week of pregnancy, soft, mobile, painless, the appendages are without changes. What diagnosis would you make?
99. A 26-year-old secundipara at 40 weeks of gestation arrived at a maternity ward after the beginning of labor activity. The bursting of waters occurred 2 hours prior. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height - 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4 cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in the childbirth?
100. A 26-year-old woman, who gave birth 7 months ago, has been suffering from nausea, morning sickness, somnolence for the last 2 weeks. The patient breasfeeds; no menstruation. She has been using no means of contraception. What method would be most efficient in clarification of the diagnosis?
101. A 30-year-old parturient woman was delivered to a maternity hospital with full-term pregnancy. She complains of severe lancinating pain in the uterus that started 1 hour ago, nausea, vomiting, cold sweat. Anamnesis states cesarean section 2 years ago. Uterine contractions stopped. Skin and mucous membranes are pale. Heart rate is 100/min., BP is 90/60 mm Hg. Uterus has no clear margins, is sharply painful. No heartbeat can be auscultated in the fetus. Moderate bloody discharge from the uterus can be observed. Uterus cervix is 4 cm open. Presenting part is not visible. The most likely diagnosis is:
102. A parturient woman is 23 years old. Internal obstetric examination shows the uterine cervix to be completely open. Fetal bladder is absent. Cephalic presentation is observed in the plane of the small pelvic outlet. Sagittal suture is at the longitudinal section of the small pelvic outlet, small fontanel is situated closer to the uterus. What cephalic position will the newborn have during birth in this case?
103. During the dynamic observation of a parturient woman in the second stage of labor it was registered that the fetal heart rate decreased to 90-100/min. and did not normalize after contractions. Vaginal examination revealed the complete cervical dilatation, the fetal head filling the entire posterior surface of the pubic symphysis and sacral hollow; the sagittal suture was in the anteroposterior diameter of the pelvic outlet, the posterior fontanelle was in front under the pubic arch. What plan for further labour management should be recommended?
104. A 27-year-old sexually active woman complains of numerous vesicles on the right sex lip, itch and burning. Eruptions regularly appear before menstruation and disappear 8-10 days later. What is the most likely diagnosis?
Explanation
Herpes simplex viruses are enveloped double stranded linear viruses. HSV-1 is also known as oral herpes ( gingivostomatitis, keratoconjunctivitis etc) while HSV-2 is known as genital or neonatal herpes. The clinical presentation of genital herpes include pain, itching, dysuria, vaginal and urethral discharge, tender lymphadenopathy, appearance of herpes vesicles on the external genitalia, labia majora, labia minora, vaginal vestibule - for women and glans penis, the prepuce, the shaft of the penis, and sometimes on the scrotum, thighs, and buttocks- for men.
Primary syphilis usually presents with a localized painless hard chancre on the genitals.
Cytomegalovirus is also known as human herpes virus-5, it is usually seen in immunocompromised patients and infected cells have characteristic ‘ owl's eye’ intranuclear inclusions. 105. A 35-year-old woman addressed a gynecological inpatient department with complaints of regular pains in her lower abdomen, which increase during menstruation, and dark-brown sticky discharge from the genital tracts. On bimanual examination: the uterine body is slightly enlarged, the appendages are not palpated. Mirror examination of the uterine cervix reveals bluish spots. What diagnosis is most likely?
106. A baby was born by a young smoker. The labour was complicated by uterine inertia, difficult delivery of the baby’s head and shoulders. The baby’s Apgar score was 4. Which of the following is a risk factor for a spinal cord injury?
107. A 25-year-old woman complains of menstruation retention lasting for 3 years. The patient explains it by a difficult childbirth complicated with profuse hemorrhage, weight loss, brittleness and loss of hair, loss of appetite, depression. Objective examination reveals no pathologic changes of uterus and uterine appendages. What pathogenesis is characteristic of this disorder?
108. A 26-year-old woman has attended maternity center complaining of her inability to become pregnant despite 3 years of regular sex life. Examination revealed the following: increased body weight; male-type pubic hair; excessive pilosis of thighs; ovaries are dense and enlarged; basal body temperature is monophasic. The most likely diagnosis is:
109. A woman addressed a gynecologist on the 20th day of puerperal period with complaints of pain in the left mammary gland, puruent discharge from the nipple. Objectively: Ps- 120/min., body temperature is 39oC. The left mammary gland is painful, larger than the right one, the skin there is hyperemic; in the upper quadrant there is an infiltrate 10x15cm in size with soft center. Blood test: ESR-50 mm/hour, leukocytes - 15, 0 · 109/l. What would be the treatment tactics?
110. A patient with fibromyoma of uterus sized up to 8-9 weeks of pregnancy consulted a gynaecologist about acute pain in the lower abdomen. Examination revealed pronounced positive symptoms of peritoneal irritation, high leukocytosis. Vaginal examination revealed that the uterus was enlarged corresponding to 9 weeks of pregnancy due to the fibromatous nodes, one of which was mobile and extremely painful. Appendages were not palpable. There were moderate mucous discharges. What is the optimal treatment tactics?
111. An 18-year-old woman complains of pains in her lower abdomen, purulent discharge from the vagina, temperature rise up to 37, 8oC. Anamnesis states that she had random sexual contact the day before the signs appeared. She was diagnosed with acute bilateral adnexitis. On additional examination: leukocytes in the all field of vision, bacteria, diplococci with intracellular and extracellular position. What agent is most likely in the given case?
112. During a regular check-up of a 50-year-old woman a tumor was detected in her right mammary gland. The tumor is 5 cm in diameter, dense, without clear margins. The skin over the tumor resembles lemon rind, the nipple is inverted. The lymph node can be palpated in the axillary region. What diagnosis is most likely?
113. A maternity patient breastfeeding for 1,5 weeks has attended a doctor. She considers the onset of her disease to be when proportional breast engorgement occurred. Mammary glands are painful. Body temperature is 36, 6oC. Expression of breast milk is hindered. The most likely diagnosis is:
114. 13 months after the first labor a 24-year-old patient complained of amenorrhea. Pregnancy ended in Caesarian section because of premature detachment of normally positioned placenta which resulted in blood loss at the rate of 2000 ml due to disturbance of blood clotting. Choose the most suitable investigation:
115. A 24-year-old primipara was hospitalised with complaints of discharge of the amniotic waters. The uterus is tonic on palpation. The position of the fetus is longitudinal, it is pressed with the head to pelvic outlet. Palpitation of the fetus is rhythmical, 140 bpm, auscultated on the left below the navel. Internal examination: cervix of the uterus is 2,5 cm long, dense, the external opening is closed, light amniotic waters are discharged. Point out the correct component of the diagnosis:
116. A primagravida with pregnancy of 37-38 weeks complains of headache, nausea, pain in epigastrium. Objectively: the skin is acyanotic. Face is hydropic, there is short fibrillar twitching of blepharons, muscles of the face and the inferior extremities. The stare is fixed. BP- 200/110 mm Hg; sphygmus is of 92 bpm, intense. Respiration rate is 32/min. Heart activity is rhythmical. Appreciable edemas of the inferior extremities are present. Urine is cloudy. What medication should be administered?
117. A 25-year-old female patient complains of marked weakness, sleepiness, blackouts, dizziness, taste disorder. The patient has a history of menorrhagia. Objectively: the patient has marked weakness, pale skin, cracks in the corners of her mouth, peeling nails, systolic apical murmur. Blood test results: RBC- 3, 4 · 1012/l, Hb- 70 g/l, colour index - 0,75, platelets - 140 · 109/l, WBC- 6, 2 · 109/l. What is the most likely diagnosis?
118. A 59-year-old female patient attended a maternity welfare clinic with complains of bloody discharge from the genital tracts. Postmenopause is 12 years. Vaginal examination revealed that external genital organs had signs of age involution, uterus cervix was not erosive, small amount of bloody discharge came from the cervical canal. Uterus is of normal size, uterine appendages are unpalpable. Fornices were deep and painless. What method should be applied for the diagnosis specification?
119. After examination a 46-year-old patient was diagnosed with left breast cancer T2N2M0, clinical group II-a. What will be the treatment plan for this patient?
120. A 28-year-old woman has bursting pain in the lower abdomen during menstruation; chocolate-like discharges from vagina are observed. It is known from the anamnesis that the patient suffers from chronic adnexitis. Bimanual examination revealed a tumour-like formation of heterogenous consistency 7х7 cm large to the left from the uterus. The formation is restrictedly movable, painful when moved. What is the most probable diagnosis?
121. A woman consulted a therapeutist about fatigability, significant weight loss, weakness, loss of appetite. She has been having amenorrhea for 8 months. A year ago she born a full-term child. Haemorrhage during labour made up 2 l. She got blood and blood substitute transfusions. What is the most probable diagnosis?
122. A 20-year-old parturient woman has the I labor stage. The pregnancy is full-term. Labors occur every 3 minutes and last for 55 seconds. Fetus presentation is polar, the head is pressed to the small pelvis entrance. Heart rate of the fetus is 150/min, distinct and rhythmic. Vagina examination: uterus cervix is smoothed out; mouth of the womb is 2 cm open; fetal bladder is intact; the head is presented over the I plane of small pelvis; moderate mucous-bloody discharge is observed. What phase of the I labor stage is it?
123. On the 10th day postpartum a puerperan woman complains of pain and heaviness in the left mammary gland. Body temperature is 38, 8oC, Ps- 94 bpm. The left mammary gland is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?
124. An Rh-negative woman with 32-week-long term of pregnancy has been examined. It was observed that Rh-antibodies titer had increased four times within the last 2 weeks and was 1:64. First two pregnancies ended in antenatal death of fetus caused by hemolytic disease. What tactics of pregnancy management should be chosen?
125. A 48-year-old patient was delivered to a hospital in-patient unit with uterine bleeding that occurred after the 2-week-long delay of menstruation. Anamnesis states single birth. Examination of the uterine cervix with mirrors revealed no pathologies. On bimanual examination: uterus is of normal size, painless, mobile; uterine appendages have no changes. Discharge is bloody and copious. What primary hemostatic measure should be taken in the given case?
126. A 30-year-old woman complains of irregular copious painful menstruations, pain irradiates to the rectum. Anamnesis states 10-year-long infertility. On bimanual examination: uterus is of normal size; uterine appendages on the both sides are corded, with rectricted mobility, painful; there are dense nodular painful growths detected in the posterior fornix. A doctor suspects endometriosis. What method allows to verify this diagnosis?
127. A 30-year-old woman complains of infertility during her 10-year-long married life. Menstruations occur since she was 14 and are irregular, with delays up to a month and longer. Body mass is excessive. Hirsutism is observed. On bimanual examination: uterine body is decreased in size; ovaries are increased in size, dense, painless, and mobile. The most likely diagnosis is:
128. A woman, primagravida, consults a gynecologist on 05.03.2012. A week ago she felt the fetus movements for the first time. Last menstruation was on 10.01.2012. When should she be given maternity leave?
129. A 28-year-old parturient complains about headache, vision impairment, psychic inhibition. Objectively: AP-200/110 mm Hg, evident edemata of legs and anterior abdominal wall. Fetus head is in the area of small pelvis. Fetal heartbeats is clear, rhythmic, 190/min. Internal examination revealed complete cervical dilatation, fetus head was in the area of small pelvis. What tactics of labor management should be chosen?
130. A secundipara has regular birth activity. Three years ago she had cesarean section for the reason of acute intrauterinen hypoxia. During parodynia she complains of extended pain in the area of postsurgical scar. Objectively: fetus pulse is rhythmic - 140 bpm. Vaginal examination shows 5 cm cervical dilatation. Fetal bladder is intact. What is the tactics of choice?
131. A 27-year-old woman presents at the maternity welfare centre because of infertility. She has had sexual life in marriage for 4 years, doesn’t use contraceptives. She hasn’t get pregnant. On examination: genital development is without pathology, uterine tubes are passable, basal (rectal) temperature is one-phase during last 3 menstrual cycles. What is the infertility cause?
132. A 25-year-old woman complains of profuse foamy vaginal discharges, foul, burning and itching in genitalia region. She has been ill for a week. Extramarital sexual life. On examination: hyperemia of vaginal mucous, bleeding on touching, foamy leucorrhea in the urethral area. What is the most probable diagnosis?
133. A 40 week pregnant secundipara is 28 years old. Contractions are very active. Retraction ring is at the level of navel, the uterus is hypertonic, in form of hourglass. On auscultation the fetal heart sounds are dull, heart rate is 100/min. AP of the parturient woman is 130/80 mm Hg. What is the most likely diagnosis?
134. A 25-year-old female patient complains about having amenorrhea for 3 years. She associates it with difficult labour complicated by massive hemorrhage. She also complains of loss of weight, hair fragility and loss, lack of appetite and depression. Objective examination reveals no pathological changes of uterus and its appendages. What is the desease pathogenesis?
135. A 28-year-old female patient complains of having haemorrhage from the genital tracts for 1 month. 6 months ago she had natural delivery and gave birth to a girl weighing 3100 g. Objectively: the uterus is enlarged to 9-10 weeks, mobile, painless, of heterogenous consistency. Examination reveals vaginal cyanosis, anaemia and body temperature rise up to 37, 8oC. There is a significant increase in hCG concentration in the urine. What is your provisional diagnosis?
136. During self-examination a 22-year-old patient revealed a mammary tumour. Palpation revealed a firm, painless, freely mobile formation up to 2 cm, peripheral lymph nodes were not changed. USI results: in the superior external quadrant of the right mammary gland there was a big formation of increased echogenicity, sized 18x17 mm. The patient was provisionally diagnosed with fibroadenoma. What is a doctor’s further tactics?
137. A 54-year-old female patient consulted a doctor about bloody discharges from the genital tracts after 2 years of amenorrhea. USI and bimanual examination revealed no genital pathology. What is the tactics of choice?
138. A 68-year-old patient consulted a doctor about a tumour in her left breast. Objectively: in the upper internal quadrant of the left breast there is a neoplasm up to 2,5 cm in diameter, dense, uneven, painless on palpation. Regional lymph nodes are not enlarged. What is the most likely diagnosis?
139. 10 minutes after delivery a woman discharged placenta with a tissue defect 5х6 cm large. Discharges from the genital tracts were profuse and bloody. Uterus tonus was low, fundus of uterus was located below the navel. Examination of genital tracts revealed that the uterine cervix, vaginal walls, perineum were intact. There was uterine bleeding with following blood coagulation. Your actions to stop the bleeding:
140. A 24-year-old female patient complains of acute pain in the lower abdomen that turned up after a physical stress. She presents with nausea, vomiting, dry mouth and body temperature 36, 6oC. She has a right ovarian cyst in history. Bimanual examination reveals that uterus is dense, painless, of normal size. The left fornix is deep, uterine appendages aren’t palpable, the right fornix is contracted. There is a painful formation on the right of uterus. It’s round, elastic and mobile. It is 7х8 cm large. In blood: leukocytosis with the left shit. What is the most likely diagnosis?
141. A parturient woman is 23 years old. Vaginal obstetric examination reveals full cervical dilatation. There is no fetal bladder. Fetal head is in the plane of pelvic outlet. Sagittal suture is in mesati pellic pelvis, anterior fontanel is closer to pubes. The fetal head diameter in such presentation will be:
142. A 26-year-old woman complains of having bloody discharges from the genitals for the last 14 days, abdominal pain, general fatiguability, weakness, weight loss, fever, chest pain, obstructed respiration. 5 weeks ago she underwent an induced abortion in the 6-7 week of gestation. Objectively: the patient is pale and inert. Bimanual examination revealed that the uterus was enlarged up to 8-9 weeks of gestation. In blood: Hb - 72 g/l. Urine test for chorionic gonadotropin gave the apparently positive result. What is the most likely diagnosis?
143. A 28-years-old woman complains of nausea and vomiting about 10 times per day. She has been found to have body weight loss and xerodermia. The pulse is 100 bpm. Body temperature is 37, 2oC. Diuresis is low. USI shows 5-6 weeks of pregnancy. What is the most likely diagnosis?
144. A full-term baby was born with body weight of 3200 g, body length of 50 cm, Apgar score - 8-10 points. What is the optimum time for the first breast-feeding?
145. A 22-year-old female patient complains of dull pain in her right iliac area that she has been experiencing for a week, morning sickness and gustatory change. She has a histrory of menstruation delay for 3 weeks. Objectively: AP-80/50 mm Hg, pulse is 78 bpm, body temperature is 37oC. Bimanual examination reveals that uterus is enlarged, soft, mobile and painless. Uterine appendages are palpable on the right, there is a dense, elastic and moderately painful formation 3x4 cm large. What is the most likely diagnosis?
146. A 32-year-old gravida complains of episodes of unconsciousness, spontaneous syncopes that are quickly over after a change of body position. A syncope can be accompanied by quickly elapsing bradycardia. There are no other complications of gestation. What is the most likely reason for such condition?
147. An ambulance delivered a 21-year-old woman to the gynaecological department with complaints of colicky abdominal pain and bloody discharges from the genital tracts. Bimanual examination revealed that uterus was soft, enlarged to the size of 6 weeks of gestation, a gestational sac was palpated in the cervical canal. Uterine appendages weren’t palpable. Fornices are free, deep and painless. Discharges from the genital tracts are bloody and profuse. What is the most likely diagnosis?
148. On the fifth day after a casual sexual contact a 25-year-old female patient consulted a doctor about purulent discharges from the genital tracts and itch. Vaginal examination showed that vaginal part of uterine cervix was hyperemic and edematic. There was an erosive area around the external orifice of uterus. There were mucopurulent profuse discharges from the cervical canal, uterine body and appendages exhibited no changes. Bacterioscopic examination revealed bean-shaped diplococci that became red after Gram’s staining. What is the most likely diagnosis?
149. A parturient woman is 25 years old, it is her second day of postpartum period. It was her first full-term uncomplicated labour. The lochia should be:
150. A pregnant woman was delivered to the gynecological unit with complaints of pain in the lower abdomen and insignificant bloody discharges from the genital tracts for 3 hours. Last menstruation was 3 months ago. Vaginal examination showed that body of womb was in the 10th week of gestation, a fingertip could be inserted into the external orifice of uterus, bloody discharges were insignificant. USI showed small vesicles in the uterine cavity. What is the most likely diagnosis?
151. A primigravida is 22 years old. She has Rh(-), her husband has Rh(+). Anti-bodies to Rh weren’t found at 32 weeks of pregnancy. Redetermination of antibodies to Rh didn’t reveal them at 35 weeks of pregnancy as well. How often should the antibodies be determined hereafter?
152. A 14-year-old girl complains of pain in vaginal area and lower abdomen that last for 3-4 days and have been observed for 3 months about the same time. Each time pain is getting worse. Objectively: mammary glands are developed, hairiness corresponds to the age. The virginal membrane is intact, cyanotic and protruded. She has never had menstruation. She has been diagnosed with primary amenorrhea. What is the reason of amenorrhea?
