Pediatric Examination and Board Review (122 page)

SELECT THE ONE BEST ANSWER

1.
Which of the following statements concerning the prevalence of dysmenorrhea is not accurate?

(A) dysmenorrhea affects up to 72% of 17-year-old girls

(B) in 10% of adolescents, dysmenorrhea may be severe enough to be incapacitating for 1-3 days a month

(C) 40% of adolescent patients with dysmenorrhea have associated organic pathology

(D) dysmenorrhea is the greatest single cause of lost school hours among adolescent girls

(E) the prevalence of dysmenorrhea doubles between SMR 3 and 5

2.
All of the following elements of the clinical history are helpful in differentiating primary from secondary dysmenorrhea except

(A) acute versus gradual onset

(B) cyclic nature of symptoms

(C) associated clinical manifestations

(D) duration of pain

(E) severity of pain

3.
Which among the following are factors involved in the pathogenesis of primary dysmenorrhea?

(A) elevation of myometrial resting tone

(B) increased frequency of myometrial contractions

(C) increased contractile myometrial pressures above the normal range (>120 mm Hg)

(D) dysrhythmic uterine contractions

(E) all of the above

4.
Which of the following statements concerning the role of prostaglandins in primary dysmenorrhea is not true?

(A) prostaglandin F
₂
α causes myometrial contractions, vasoconstriction, and ischemia

(B) prostaglandins are synthesized in the endometrial tissue

(C) anovulatory cycles are associated with lower prostaglandin levels and rarely are associated with dysmenorrhea

(D) prostaglandin inhibitors increase dysmenorrhea

(E) patients with dysmenorrhea have higher levels of prostaglandin levels in the endometrium

5.
Which of the following items would be relevant in the clinical evaluation of dysmenorrhea?

(A) age at menarche

(B) menstrual pattern

(C) response to analgesics

(D) vaginal discharge

(E) all of the above

6.
Regarding the value of the pelvic examination in the evaluation of dysmenorrhea, all of the following statements are true except

(A) a pelvic examination is helpful in the diagnosis of endometriosis, polyps, uterine, and cervical abnormalities

(B) a pelvic ultrasound is sometimes needed to rule out pelvic pathology in virginal patients

(C) a pelvic examination is not needed in virginal patients with a history suggestive of primary dysmenorrhea who respond to prostaglandin inhibitors

(D) a pelvic examination is needed in all patients to rule out secondary dysmenorrhea

(E) a pelvic examination is mandatory in cases of acute and subacute pelvic pain

7.
Which of the following conditions should be considered in the differential diagnosis of secondary dysmenorrhea?

(A) endometriosis

(B) congenital obstruction of the outflow tract

(C) pelvic inflammatory disease

(D) ovarian cysts

(E) all of the above

8.
All of the following are helpful in the treatment of primary dysmenorrhea except

(A) ibuprofen or naproxen sodium

(B) acetaminophen

(C) aspirin

(D) mefenamic acid

(E) continuous hormonal therapy

9.
When using nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with primary dysmenorrhea, what are the most common pitfalls leading to failure to achieve adequate symptom relief?

(A) starting medication several hours after the pain started

(B) poor compliance because of side effects

(C) failing to offer a loading dose

(D) taking the medication at 12-hour intervals

(E) A and C

10.
All of the following statements are true regarding the role of oral contraceptives in the treatment of primary dysmenorrhea in adolescents except

(A) combined oral contraceptives provide relief in 70% of patients with primary dysmenorrhea

(B) oral contraceptives are beneficial in primary dysmenorrhea as a result of inhibition of ovulation, endometrial hypoplasia, and reduction of menstrual flow

(C) in patients with primary dysmenorrhea but no need for birth control, “the pill” can be prescribed for 3-6 months, discontinued, and then reinstituted if a trial of NSAIDs fails to provide relief

(D) patients with severe dysmenorrhea who fail to respond to continued use of oral contraceptives should be reevaluated for organic pathology

(E) all of the above statements are true

11.
Which of the following is not a typical symptom or sign of endometriosis in adolescents?

(A) cyclic, severe dysmenorrhea

(B) vaginal discharge

(C) abnormal uterine bleeding

(D) dyspareunia

(E) pain on defecation

12.
What is the most common gynecologic cause of acute pain leading to hospitalization in women of reproductive age in the United States?

(A) adnexal torsion

(B) ovarian cysts

(C) endometriosis

(D) ectopic pregnancy

(E) pelvic inflammatory disease

13.
Which of the following gastrointestinal conditions should be included in the differential diagnosis of acute pelvic pain in teens?

(A) appendicitis

(B) intestinal obstruction

(C) constipation

(D) inflammatory bowel disease

(E) all of the above

14.
Regarding the evaluation of acute pelvic pain in adolescents, which of the following statement is not true?

(A) a normal pelvic ultrasound excludes endometriosis and pelvic inflammatory disease (PID)

(B) a psychosocial history might reveal contributing factors such as stress or a history of sexual or physical abuse

(C) the initial laboratory workup should include a CBC with differential, sedimentation rate, C-reactive protein (CRP), urinalysis and urine culture, cervical culture, pregnancy test, and a stool guaiac test

(D) an elevated leukocyte count reflects inflammation, ischemia, or infection and may indicate ovarian torsion

(E) bone and joint inflammations and infections may present as acute pelvic pain

15.
Which of the following statements apply to the evaluation of chronic pelvic pain?

(A) a normal pelvic examination and normal ultrasound are predictive of a normal laparoscopy 50% of the time

(B) the predictive value of an abnormal pelvic ultrasound is 92%

(C) the most common laparoscopic finding in adolescents with chronic pelvic pain is endometriosis

(D) no obvious cause of chronic pelvic pain is found on laparoscopy in 25% of patients

(E) all of the above

16.
If her dysmenorrhea were severe enough to merit long-term use of combined oral contraceptives, which of the following conditions would you need to exclude before prescribing them?

(A) ovarian cyst

(B) endometriosis

(C) family history of breast cancer

(D) varicose veins

(E) diastolic blood pressure higher than 100 mm Hg

ANSWERS

1.
(C)
In adolescent girls, dysmenorrhea is the most common gynecologic complaint. By definition, primary dysmenorrhea refers to pain associated with menstrual flow in the absence of organic pelvic pathology. Secondary dysmenorrhea indicates menstrual pain secondary to organic disease, such as ovarian cysts, adhesions, endometriosis, or PID. Primary dysmenorrhea is very common in adolescents and rarely has its onset after age 20 years. It is associated with ovulatory cycles, and therefore it typically develops approximately 2 years after menarche, once normal ovulation becomes established. Secondary dysmenorrhea may occur at any age. In adolescence, however, primary dysmenorrhea is by far the most common cause of painful menses.

2.
(E)
Primary dysmenorrhea usually has a gradual onset as opposed to the acute onset of most menstrual pain associated with pelvic pathology. The cyclic nature of the bleeding and cramping helps differentiate primary from secondary dysmenorrhea because in the latter there is often irregular intermenstrual bleeding. The duration of pain is an important clinical feature, lasting 1-2 days in primary dysmenorrhea (usually starting right before the period), whereas in secondary dysmenorrhea, prolonged intermenstrual pain, worsening during periods, is the rule. Nausea, vomiting, fatigue, headache, irritability, diarrhea, and backache are common in primary dysmenorrhea. In secondary dysmenorrhea there is often a history of an STD, severe abdominal pain, and dyspareunia.

3.
(E)
All the above myometrial factors play a role in the pathogenesis of dysmenorrhea.

4.
(D)
Exogenous injections of prostaglandins induce dysmenorrhea while prostaglandin inhibitors decrease menstrual pain.

5.
(E)
When evaluating an adolescent for dysmenorrhea, it is important to determine the age at menarche because primary dysmenorrhea usually starts a year after menarche (most commonly at ages 14-16 years) and peaks around 17-18 years. After the age of 20 years, new-onset dysmenorrhea is usually secondary to pelvic pathology. Other relevant questions include the date of the last menstrual period, the onset of pain, and characteristics of the pain such as location, radiation, duration, severity, and degree of functional impairment. A sexual history should be elicited, asking about condom use, contraception, number of sexual partners, exposure to STDs, dyspareunia, and vaginal discharge. Response to prostaglandin inhibitors is important to distinguish primary from secondary dysmenorrhea and to select appropriate further management.

6.
(D)
A pelvic examination is helpful in the diagnosis of organic pathologies underlying secondary dysmenorrhea. It is mandatory in cases of acute and subacute pelvic pain. Adolescent girls without a history of sexual activity and with a clinical picture consistent with primary dysmenorrhea responsive to prostaglandin inhibitors will not need a pelvic examination. Occasionally, however, a pelvic ultrasound may be needed in such patients if symptoms persist.

7.
(E)
The following conditions should be considered in the differential diagnosis of secondary dysmenorrhea: endometriosis, PID, pelvic abscess, ovarian cysts, neoplasias, adhesions, congenital obstruction of the outflow tract (cervical stenosis), and complications of pregnancy such as ectopic pregnancy or miscarriage.