Questions
DIRECTIONS (Questions 1 through 18): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.
1. A mother brings her 4-year-old daughter in for complaints of itching “down there” and staining on the underwear. Which of the following conditions is the most likely cause of vulvovaginal symptoms in children?
(A) foreign body (B) lichen sclerosis (C) nonspecific
(D) physiologic leukorrhea (E) trauma
2. A 6-year-old girl is referred by her pediatrician for a friable mass in the genital region. You suspect a urethral prolapse. Which of the following is the most common symptom of urethral prolapse in the prepubertal, unestroge-nized girl?
(A) dysuria (B) hematuria
(C) painless genital bleeding (D) urinary frequency
(E) urinary retention
3. A mother has brought in her 8-year-old daughter because of the development of breasts over the past year. They are now to the size that she is requiring a bra and is being teased by the other children.
Premature thelarche differs from true precocious puberty in that premature thelarche is associated with which of the following?
(A) axillary hair development (B) isolated breast development (C) pubic hair development (D) spontaneous ovulations (E) voice changes
4. A 14-year-old girl is brought into the office by her mother because of a concern of a lack of menarche.
Her mother is worried that something is wrong since she has not started menstruating. Based on a complete history and limited physical and thorough application of a knowledge of normal pubarche changes, you may be able to calm the mother. Which of the following occurs earliest in preadolescent girls entering puberty?
(A) axillary hair growth (B) breast development
(C) menarche
(D) peak growth velocity (E) pubic hair growth
5. A 16-year-old girl is seen in the emergency department for evaluation of nausea and vomiting. Her vital signs are blood pressure, 80/40 mm kg; pulse, 130 bpm; and temperature, 102.2°F. Physical
examination shows conjunctivitis, oropharyngeal hyperemia, and a sunburn-like macular rash over the face, proximal extremities, and trunk. Palpation of the extremities elicits muscle tenderness. Pelvic examination is normal, and a bloody tampon is present in the vagina. Which of the following is the most likely diagnosis?
(A) erysipelas
(B) human immunodeficiency virus (HIV) (C) Kawasaki disease
(D) syphilis
(E) toxic shock syndrome (TSS)
6. A 14-year-old girl has a chronic cough with copious expectoration. A biopsy of the respiratory mucosa shows ciliated epithelium devoid of dynein arms. Which of the following conditions is most likely to occur in later life?
(A) abnormal vaginal bleeding (B) chronic diarrhea
(C) infertility (D) pelvic pain
(E) urinary incontinence
Questions 7 and 8 apply to the following patient:
An 8-year-old girl is brought in by the mother after finding her crying and having bloody underwear. She will not tell her mother what happened. On examination, there are injuries consistent with vaginal penetration. You advise the mother that it is very important to allow the authorities to speak with the daughter about what happened.
7. What is the percentage of sexually abused children who know their assailant?
(A) 15 (B) 35 (C) 55 (D) 75 (E) 95
8. Which of the following is the most commonly reported form of incest?
(A) brother-sister (B) father-daughter (C) father-son (D) mother-son
(E) stepfather-daughter
Questions 9 and 10 apply to the following patient:
A father brings his 9-year-old daughter to the office after he picked her up for his joint custody visit. He and his ex-wife have been in a long drawn-out custody battle. His daughter told him that her mom’s new boyfriend was touching and poking her “down there” last night while mom was shopping.
9. When childhood sexual assault is suspected within the past 72 hours, which of the following should be the next action of the physician?
(A) bring family members together for an interview (B) contact mental health workers
(C) notify the police
(D) perform a complete physical examination (E) report the incident to Child Protective Services
10. Which of the following is a legal but not a medical responsibility of the physician caring for an alleged sexual assault victim?
(A) collecting samples of hair and vaginal secretions, and microscopic evaluation of motile sperm (B) obtaining a complete gynecologic history
(C) obtaining informed consent from patient
(D) offering postcoital hormonal prophylaxis to prevent pregnancy if reproductive age (E) providing counseling and emotional support
11. Which of the following legal theories describes the failure of a physician to disclose the risks of a procedure?
(A) abandonment (B) breach of duty (C) informed consent (D) intentional tort (E) lack of diligence
12. Professional liability insurance that protects against claims made during the policy period, regardless of when the suit is filed, is which of the following?
(A) claims-made policy (B) occurrence policy (C) tail policy
(D) nose policy
(E) time-limited policy
13. An 8-year-old girl is brought to your office soon after suffering a fall on her brother’s bicycle. Her mother reports that the girl’s foot slipped off the bicycle pedal, which resulted in the girl falling on the center bar of the bicycle. The girl complains of sharp pain between her legs. There has been no
obvious bleeding and no other injuries are apparent. The girl is in moderate distress with a pulse of 110 bpm, blood pressure of 118/68 mm Hg, and respirations of 28/min. Physical examination is normal with the exception of inspection of the vulva where a 6-cm tender bluish mass is present in the area of the right labia majora. No further examination is possible because of the girl’s discomfort. Which management is most directly related to an uncomplicated outcome?
(A) topical application of ice (B) use of prophylactic antibiotics (C) bed rest for the next 24 hours
(D) examination under anesthesia
(E) surgical evacuation of the hematoma
14. Which legal document sets out a patient’s wishes regarding her future health status, including end-of- life issues?
(A) living will (B) proxy directive (C) advanced directive (D) informed consent
(E) durable power of attorney
15. What is a common emotional sequella of rape?
(A) mania (B) depression (C) rage
(D) bipolar disorders (E) panic attacks
16. A 6-year-old girl is seen for a 10-day history of intense vulvar itching leading to excoriation. The vulva are noted to be diffusely inflamed. What is the most likely cause for these symptoms?
(A) Candida albicans infection (B) foreign body
(C) sexual assault
(D) Enterobius vermicularis (E) atrophic vulvitis
17. Which of the following sales activities would be considered unethical in medical practice?
(A) sale of a pessary fitted in the office
(B) sale of prescription medications to be taken at home (C) sale of cookies for a local charity
(D) sale of annual flu vaccine given in the office (E) brokered sale of a vacation home to patient
18. A patient presents for her new obstetrical visit. During her history, she reports that she is a Jehovah’s Witness and will not accept any blood products. You counsel her regarding risks and benefits of
receiving blood in case she experiences a massive hemorrhage. She listens to you politely, asks some appropriate questions, and then states she will not accept any blood products and would prefer to die than receive a transfusion. You must either refer the patient or honor this request as an example of which of the following ethical principles?
(A) justice (B) beneficence (C) autonomy
(D) nonmalfeasance
(E) religious independence
Answers and Explanations
1. (C) Nonspecific vulvovaginitis (NSV) accounts for 25% to 75% of vulvovaginal symptoms in children.
The predominant vaginal organism cultured in NSV is E. coli. Although vaginal colonization with E.
coli occurs in asymptomatic girls, half of 3- to 10-year-old girls with NSV have this organism present in the vagina. Foreign bodies can cause a profuse, foul odor discharge but this is a less likely cause.
Physiologic discharge is very uncommon a few months after delivery (due to maternal estrogen) and prior to onset of puberty. Trauma such as straddle injuries or sexual abuse is uncommon but needs to be included in the differential.
2. (C) Girls with urethral prolapse typically experience painless genital bleeding. This symptom can be precipitated by straining or constipation. Urinary frequency and retention can also be seen
occasionally. Dysuria and hematuria occur only with significant irritation and inflammation.
Conservative management with estrogen cream and sitz baths is appropriate with surgical intervention only in extreme cases.
3. (B) Premature thelarche is the spontaneous development of breast tissue as an isolated event without other pubertal changes. It is caused by presence of estrogen only and not the normal cascade of pubertal events and may represent estrogen-secreting tumor such as a granulosa cell tumor. Premature onset of puberty involves activation of the full pubertal cascade that includes androgenic as well as estrogenic effects such as pubic hair along with breast development.
4. (B) Pubertal changes are marked by various stages of sexual and somatic development. A growth spurt, but not peak growth velocity, generally precedes the more readily identifiable sexual changes of
puberty. Breast development or thelarche is the first sexual sign of puberty in the female, usually occurring between 9 and 11 years of age. Breast development is complete within 3.5 years after onset.
Adrenarche is the onset of sexual hair growth. Pubic hair growth occurs between 11 and 12 years of age, while axillary hair growth occurs later. Menarche is the final stage of puberty and occurs after 12 years of age. Thus if the patient has breast and pubic hair but only recently, she is likely having a slightly delayed but normal timing of her puberty. If none of these changes are occurring then she may be experiencing a delayed puberty or some difficulty.
5. (E) TSS has an incidence of only about 1–2 per 100,000 menstruating women annually. It was originally associated with one brand of super-absorbent tampon (Rely) but the incidence has been dramatically reduced since the removal of that tampon from the market in 1980. (The last active surveillance for TSS was in 1987.) TSS still occurs occasionally with the use of diaphragms, vaginal sponges, cervical caps, and postoperative wound infections. Symptoms of TSS occur during
menstruation and include sudden high fever, flulike symptoms (sore throat, headache, diarrhea), erythroderma, signs of multisystemic failure, and hypotension. TSS is usually associated with vaginal strains of S. aureus producing an exfoliative exotoxin (toxic shock syndrome toxin [TSST-1]).
Adolescent females are at greatest risk for TSS because they have not yet developed immunity against TSST-1. Treatment of TSS includes aggressive supportive therapy (e.g., hydration, transfusion,
replacement of coagulation factors, and use of vasoactive agents) and antistaphylococcal antibiotic therapy. Mechanical ventilation and hemodialysis may be required to treat adult respiratory distress syndrome and renal failure. Risk for recurrence of TSS is 30% and may be reduced by intermittent use
of tampons during menses or by not using tampons.
6. (C) Immobile cilia syndrome, or Kartagener syndrome, refers to the congenital absence of dynein arms in ciliated epithelium. Abnormalities of microtubular structure may coexist. Patients with Kartagener syndrome have chronic cough, sinusitis, bronchiectasis, and airway obstruction. The diagnosis is usually made by microscopic examination of the respiratory mucosa. Immobile cilia may coexist in the fallopian tube epithelium and may increase the risk of infertility in some individuals.
7. (D) About 75% of sexually abused children know their assailant. At least one-half of these cases involve another family member.
8. (B) Incest refers to a sexual relationship between people who are related and cannot legally marry. The most commonly reported form of incest involves the father and his own daughter (75% of reported cases). Brother-sister incest may actually be the most common form of incest but is not reported often.
A sexual relationship between a stepfather and child or between a mother’s boyfriend and child is called “functional parent incest” because the individuals are not related.
9. (D) Any child in whom sexual assault is suspected within the past 72 hours should be examined immediately to document physical findings corroborating the assault. Since the child of an incestuous relationship may not disclose the full history in the presence of the involved family member, the parents and child should be interviewed separately. When sexual assault is suspected weeks to months earlier, the child can be examined after the interviewing process is completed. In many locations, suspected sexual assault at any age requires police notification and when a minor is involved, child protective service must also be contacted, although these notifications should be secondary to the immediate evaluation and care of the patient.
10. (A) It is important to distinguish legal from medical responsibilities in the care of an alleged sexual assault victim. The collection of hair and vaginal secretions for the microscopic evaluation of motile sperm and semen is a legal responsibility to provide evidence to the authorities for the sake of
documentation. All of the other answers provided represent medical responsibilities to the patient.
11. (B) The doctrine of informed consent states that a patient having an unfavorable result from a procedure may seek recovery for failure of the physician to properly disclose the risks of the
procedure. This disclosure as a part of the informed consent process is his legal duties to the patient.
Recovery is not sought for medical negligence or fault. To avoid lawsuits claiming lack of informed consent, the physician should provide complete, understandable information regarding treatment, document informed discussions about the treatment, and personally obtain written consent from the patient after answering any questions and the likely benefit of the treatment. If the risk of a treatment has a realistic incidence of occurrence, it must be disclosed along with alternative treatments and their pros/cons.
12. (B) An occurrence policy protects against claims made during the policy period, regardless of when the suit is filed. This form of insurance is expensive for obstetric coverage. A claims-made policy protects against claims made during the life of the policy. It does not provide coverage if the policy is discontinued and the physician is subsequently sued for an event occurring when the policy was in effect. (For such coverage, an additional tail policy can be purchased when the claims-made policy is discontinued.)
13. (A) The first and most effective therapy for this type of vulvar injury is the application of ice. This reduces the pain and produces local vasospasm that reduces further growth of the hematoma. Unless there is evidence of continued growth of the hematoma or a suggestion of other associated trauma, examination under anesthesia or surgical exploration is both unnecessary and potentially harmful.
Based on the history provided, there is little to suggest internal injuries that would warrant an
examination under anesthesia. Surgical exploration is associated with an increased risk of infection and is associated with technical difficulties of finding the source of bleeding and securing hemostasis in the loose areolar tissues of the vulva. Unless the skin has been broken, there is no indication for antibiotic use. While vulvar hematomas are painful, ice and analgesics are generally sufficient to allow relatively normal activity. Normal activity neither exacerbates a stable hematoma nor hastens its resolution. Most patients can be allowed to increase their activity as tolerated, and bed rest is not indicated.
14. (C) An advance directive is the formal mechanism by which a patient may express here values regarding her future health status, including end-of-life issues. This directive may take the form of a living will, a proxy directive, or a durable power of attorney that designates someone else to be able to act in her stead if she were unable to do so by her self. Informed consent refers to process involving all the elements of information and ability that go into the patient’s decisions regarding a proposed
treatment, rather than a physical document.
15. (B) A well-defined rape trauma syndrome including isolation, depression, anxiety, somatic symptoms, suicide attempts, and posttraumatic stress disorder has been well described. There are three sequences in reaction to rape: a short-term, an intermediate, and a long-term reaction. A range of traumatic
symptoms, such as somatic complaints, characterizes the short-term reaction; sleep disturbance and nightmares, fear, suspiciousness, anxiety, major depression, and impairment in social functioning are also common. Symptoms generally remain relatively stable for 2 or 3 months. Three months to 12 months after assault (intermediate phase) the diffuse anxiety usually becomes rape specific. Women then experience depression and social and sexual dysfunction. The long-term reaction, 1 year following the assault, involves anger, hy-pervigilance to danger, sexual dysfunction, and diminished capacity to enjoy life. Some of these symptoms may last for years or a lifetime. More than half of rape victims show some level of rape trauma.
16. (A) While the lower estrogen levels of childhood result in a relative atrophy of the vulva and vagina, infections with monilial species are still common and present in the same way as in reproductive women. Intravaginal foreign bodies in children more commonly present with a yellow, malodorous discharge or painless bleeding. Pin worms (Enterobius vermicularis) cause perineal itching
predominately at night and will be easily differentiated from a monilial infection by inspection and microscopic examination of a vaginal specimen. Suspicion of sexual assault should also be a part of any presenting complaint when there is a discrepancy between the presenting complaint and the physical findings.
17. (B) Under most circumstances, the sale of products by physicians violates several generally accepted principles of medical ethics. First, and most important, the practice of physician sales to patients
creates a potential conflict of interest with the physician’s fiduciary responsibility to put the interests of patients above their own. When a product or device is only available by prescription and must be used or administered in the physician’s office, it is acceptable to sell the item at cost, plus any associated overhead cost associated with having it available. This can also apply to devices, such as pessaries, that may not be readily available in the patient’s community. Inexpensive items for the benefit of
community organizations (such as Girl Scout cookies) are acceptable as long as the products are sold without pressure, and the physician does not derive a profit from such sales. Sale of products that clearly are external to the patient-physician relationship, would be considered appropriate, especially if brokered by a third party.
18. The principle of autonomy includes the ability of the patient, after being given the pros and cons of a procedure (or lack of it), to make a decision that she feels is best for her. In the case of Jehovah’s Witnesses, this can pose a problem for some providers but they must acknowledge the patient’s
autonomy and ability to make an informed decision that we may not agree with. Beneficence means to do good. Although some may feel that to give blood is consistent with this principle, the patient’s autonomy trumps it. Nonmaleficence is to do no harm, but a JW feels that to receive blood is having a harm done to her. Justice is complex and one might try to argue that allowing her to die if a major hemorrhage occurs thus leaving the newborn without a mother. Again autonomy trumps. There is no unique ethical principle of religious freedom.
CHAPTER 26