Assignment 3

In this third assignment, you will begin by reading Abdominal Pain, Abnormal Bleeding, Normal Pregnancy, and Abnormal Pregnancy. After completing the reading, answer the questions listed below.

You can read the textbook off the computer screen, but many people find it easier to read a printed copy. To obtain a printed copy, click on the chapter, then print it

When you are ready to begin answering the test questions, call up an Answer Sheet by clicking here, then print the answer sheet.

After you have completed all six assignments and tests, mail them to the Naval School of Health Sciences.

If you need a more detailed explanation of the answer sheets, click here.

Test Questions

Learning Objective: Know how to treat abdominal pain in women when the diagnosis is unclear. Diagnose and initiate treatment of common gynecologic ailments causing abdominal or pelvic pain. Know the role of consultation, referral and medical evacuation in the diagnosis and treatment of abdominal pain in women.

In answering questions 3-1 through 3-7, select from column B the clinical characteristic associated with the disease described in column A. Some responses may be used once, more than once, or not at all.

A. Disease	B. Characteristic
3-1. Ovarian cyst	1. Unilateral (one-sided)abdominal pain
3-2. Mittelschmerz	2. Bilateral abdominal pain
3-3. Functional bowel syndrome	3. Abdominal pain moves from place to place
3-4. Gastroenteritis	4. Tender nodules in the Cul-de-sac
3-5. PID
3-6. IUD-associated PID
3-7. Endometriosis

3-8. Which of the following two statements is correct?

A. "In clinical gynecology, the diagnosis is often unclear."

B. "More important than knowing the correct diagnosis is doing the right thing for the patient."

1. Only "A" is true

2. Only "B" is true

3. Both are true

4. Neither are true

3-9. YN2 Lawrence is complaining of cramping pelvic pain of 3 days' duration. She states the last time she had sexual intercourse was more than 2 years ago and it would be impossible for her to be pregnant. Which of the following responses is the wisest?

1. Get a pregnancy test anyway.

2. Skip the pregnancy test but look for other problems.

3. Insist that she sign a statement certifying that she has not had sexual intercourse during the last 2 years and therefore couldn't possibly be pregnant.

4. Write a SF600 note indicating that because she hasn't had intercourse in the last 2 years, it is impossible for her to be pregnant.

3-10. Your ship is en route from Guam to the naval base in Yokosuka, Japan. It is 0930 and you are expected to dock in Yokosuka at 1030 tomorrow. LCDR Dewey reports to sick call complaining of slight vaginal bleeding and mild cramping. Her pregnancy test is positive. Her cervix is closed, but there is a small amount of bleeding from the cervix. The uterus is slightly enlarged and tender. Which of the following is the safest clinical response?

1. Arrange for helicopter MEDEVAC to the US Naval Hospital at Yokosuka.

2. Place her on bed rest and notify USNH Yokosuka of your situation and expected time of arrival.

3. Give her Ergotrate or Methergine.

4. Start IV antibiotics.

3-11. BM1 Perry complains of severe right lower quadrant pain for 12 hours. She is tender throughout the lower abdomen with rebound tenderness and some involuntary guarding. Her pregnancy test is negative. Her temperature is 103.4° You have just started her on IV antibiotics. You are on the USS Holland AS 32, a submarine tender with two physicians (Diving Officer and Medical Officer), 30 corpsmen (including an OR tech), and a small operating room which is currently used as an office for the Medical Officer. Your present position is off the western coast of Mexico, about 2 days' sailing from Acapulco and 7 days from Pearl Harbor, your destination. You should:

1. Restore the operating room to functional capacity and begin exploratory surgery as soon as possible.

2. Wait to see what BM1 Perry's clinical response to the antibiotics will be.

3. Call for MEDEVAC

4. Using battle lanterns over the Officer's Wardroom table, perform an emergency appendectomy after reading a book on how to do it.

3-12. Which of the following is true regarding endometriosis?

1. It may cause severe dysmenorrhea.

2. It may cause deep dyspareunia.

3. It may cause no symptoms at all.

4. All of the above

3-13. For women complaining of pelvic pain and a fever, antibiotics to cover PID is a wise precaution.

1. True

2. False

3-14. For women complaining of chronic pelvic pain and no fever, only give antibiotics in the presence of a positive culture.

1. True

2. False

3-15. Any woman complaining of pelvic pain should have a pregnancy test.

1. True

2. False

3-16. BCPs are a useful treatment for women complaining of intermittent, chronic pelvic pain.

1. True

2. False

3-17. Continuous BCPs (taken without the normal once a month break) are a safe and effective treatment for which of the following?

1. Mild endometriosis

2. Dysmenorrhea

3. Mittelschmerz

4. All of the above

3-18. Bed rest will usually prevent a miscarriage.

1. True

2. False

3-19. For a woman who is 28 weeks pregnant and bleeding, you should first perform a pelvic exam prior to calling the obstetrician so you will know whether the cervix is dilated or not.

1. True

2. False

3-20. Which of the following is NOT TRUE about ovarian cysts?

1. They usually require surgery to remove.

2. 3.0 cm cysts commonly form each month in normally-menstruating women.

3. They usually cause no trouble.

4. They occasionally cause trouble by causing pain.

3-21. Which of the following is NOT TRUE about women with torsion of an ovarian cyst?

1. They generally have severe, unilateral pelvic pain.

2. 95% of the time, the torsioned cyst will disappear without treatment, usually after the next menstrual flow.

3. They may develop severe metabolic acidosis.

4. They should be transported to a definitive care setting where surgery is available.

3-22. Which of the following medications is the single most effective medication used to treat dysmenorrhea?

1. Non-steroidal anti-inflammatory drugs

2. Oral contraceptive pills

3. Heparin

4. Antidepressants

3-23. Women with mittelschmerz usually alternate from the left side to the right side every other month.

1. True

2. False

3-24. Psychoactive drugs are advisable in most cases of functional bowel syndrome.

1. True

2. False

3-25. Some women with diverticular disease may have no symptoms; others may have moderate symptoms and other still may have severe, incapacitating symptoms.

1. True

2. False

In answering questions 3-26 through 3-30, select from column B the disease associated with the clinical characteristic described in column A. Some responses may be used once, more than once, or not at all.

A. Characteristic	B. Disease
3-26. Fever of 103.4°	1. Endometriosis
3-27. Steadily worsening dysmenorrhea	2. Mild PID
3-28. Mid-cycle pain	3. Moderate to severe PID
3-29. Requires IV antibiotics	4. Mittelschmerz
3-30. Is not associated with infertility

3-31. Elevated temperature (fever) is a consistent sign of appendicitis.

1. True

2. False

3-32. Progressive right lower quadrant abdominal pain with nausea and anorexia is the typical presentation of appendicitis in both men and women.

1. True

2. False

3-33. Acute degeneration of a uterine fibroid requires surgical therapy

1. True

2. False

3-34. The bladder is normally tender.

1. True

2. False

3-35. Cystitis can generally be treated with oral antibiotics, pushing fluids, and Pyridium.

1. True

2. False

3-36. Pyelonephritis is a serious medical condition requiring vigorous antibiotic therapy and brisk fluid intake.

1. True

2. False

Learning Objective: Know the difference between normal and abnormal bleeding. Know how to evaluate abnormal bleeding and initiate treatment. Know when to refer the patient for further evaluation and treatment not available in operational settings.

3-37. Which of the following may cause abnormal bleeding?

1. Pregnancy-related problems

2. Mechanical problems inside the uterus

3. Hormonal problems

4. All of the above.

3-38. What is required in the initial evaluation of abnormal bleeding?

1. Pregnancy test

2. Complete blood count

3. Pelvic examination

4. All of the above.

3-39. Which of the following is an example of a mechanical cause of abnormal bleeding?

1. Endometrial polyps

2. Ovulation

3. Anovulation

4. All of the above

3-40. Oral contraceptive pills are the principle means of therapy for abnormal bleeding due to hormonal causes.

1. True

2. False

3-41. If bed rest and oral contraceptive pills fails to bring the problem of abnormal bleeding to a successful resolution, the next step is surgery.

1. True

2. False

3-42. Iron supplementation (FeSO4 325 mg TID or its’ equivalent) is usually unnecessary in someone who is bleeding heavily.

1. True

2. False

3-43. In a woman who is 25 years old and who is bleeding heavily from the uterus, cancer of the uterus is a major concern.

1. True

2. False

3-44. Cancer of the vagina is ruled out with a normal Pap smear within the last year.

1. True

2. False

Learning Objective: Know how to diagnose pregnancy and establish gestational age. Know the basic elements of prenatal care, the physical limitations of pregnancy as they relate to work, exercise and disability. Understand and manage the common complaints of pregnancy. Know the precautions to be taken whenever a pregnant woman may be exposed to medications, thermal or barometric stresses and ionizing radiation. Recognize the signs of labor and have a plan for dealing with it.

3-45. What does MacDonald's Rule state?

1. The distance in cm from the pubic bone to the top of the uterus is roughly equal to the number of weeks gestation.

2. The distance in cm from the anterior iliac crest to the top of the uterus is roughly equal to the months of pregnancy.

3. Never mix plaids.

3-46. All of the following are common during pregnancy except one:

1. Carpal Tunnel Syndrome

2. Sciatica

3. Heartburn

4. Proteinuria

3-47. All of the following are considered safe to use during pregnancy except one:

1. Amoxicillin

2. Cephalosporins

3. Doxycycline

4. Erythromycin

3-48. Women who are pregnant may continue to safely dive, so long as:

1. The depths are restricted to less than 100 feet

2. The depths are restricted to less than 60 feet

3. The depths are restricted to 20 feet

4. There are no safe depths for a pregnant woman to dive.

3-49. Which of the following is not part of routine testing for pregnant women in the first trimester of pregnancy?

1. Hemoglobin

2. Glucose

3. Atypical antibody screen

4. VDRL

3-50. Which of the following sports may be safely continued during a normal pregnancy?

1. Downhill skiing

2. Horseback riding

3. Swimming

4. Snowmobile racing

3-51. The presence of ketones in the urine of a pregnant woman complaining of nausea and vomiting are reasonable grounds for IV hydration with crystalloid solutions.

1. True

2. False

In answering questions 3-52 through 3-62, select from column B the degree of safety with which medication described in column A may be used during pregnancy. Some responses may be used once, more than once, or not at all.

A. Medication	B. Relative Safety
3-52. Acetaminophen	1. Considered safe
3-53. Triprolidine	2. Considered unsafe
3-54. Penicillins	3. Considered safe only at certain times
3-55. Sulfa drugs
3-56. Metronidazole
3-57. Quinacrine
3-58. Chloroquine
3-59. Miconazole
3-60. Doxycycline
3-61. Aspirin
3-62. Xylocaine

3-63. Yellow fever immunization should not be given to pregnant women.

1. True

2. False

3-64. Tetanus toxoid should not be given to pregnant women.

1. True

2. False

3-65. Rubella immunization should not be given to pregnant women.

1. True

2. False

3-66. A cervical spine x-rays series performed on a pregnant woman, which delivers 3 millirads (0.003 Rad) to the pelvis would not be expected to cause any problems to the developing fetus.

1. True

2. False

3-67. Pregnant women should not work in front of a CRT because the electromagnetic radiation has been shown to be harmful to fetuses.

1. True

2. False

Learning Objective: Diagnose and initiate management of common pregnancy abnormalities, using non-surgical techniques when surgery is not available.

3-68. LT Isherwood is found collapsed in the Female Officer's Head. Her BP is 60/0, her pulse is 150 BPM and she is dyspneic. She has vaginal bleeding, a positive pregnancy test, distended abdomen and marked LLQ pelvic tenderness. Your ship is 2 days from Diego Garcia. Which of the following should you do?

1. Start 2 large-bore IVs and hydrate with crystalloid initially, in addition to giving oxygen.

2. Call for MEDEVAC.

3. Make plans for blood transfusion.

4. All of the above.

3-69. 2 days earlier, you saw LT Isherwood in Sick Call. At that time, she was complaining of intermittent LLQ pains, had a positive pregnancy test and was tender in the left adnexa. At that time, you encouraged her to try to get more rest and to see you next week. Which of the following do you wish you would have done?

1. Called for MEDEVAC 2 days ago.

2. Kept an IV in place and prepared for blood transfusion, if it became necessary.

3. Told her to have someone else teach the daily high-impact aerobic dance classes on the Helo Deck.

4. All of the above.

In answering questions 3-70 through 3-72, select from column B the treatment which is best for the condition described in column A. Some responses may be used once, more than once, or not at all.

A. Condition	B. Treatment
3-70. Septic abortion	1. Antibiotics and D&C
3-71. Threatened abortion	2. Observation
3-72. Ruptured ectopic pregnancy	3. Laparotomy
	4. Hyperthermia

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