When you review questions that have appeared on previous shelf exams, think of each as a type of question. From each stem, the question might be what is the diagnosis, how do you make the diagnosis (lab, etc), what is the next step in management or treatment, what are risk factors for the diagnosis, etc. Shelf exams like to test common things, but also uncommon things that shouldn’t be missed by any type of doctor, like cancers for example. So they stress recognizing risk factors for cancers or signs/symptoms of potentially serious conditions.
Here are some questions that students have recalled from recent exams. Don’t focus on the particular question, focus on the theme. This first set is from one student and one shelf. This can given you an idea of common areas of focus. Most shelf exams are similar in focus:
- 3-4 questions on postmenopausal bleeding, asking about next step in management.
- Know risk factors; always diagnosis (e.g. endometrial biopsy) before treatment
- Several questions on choosing appropriate antibiotics for UTI, urethritis, PID, endometritis. One asked for best prophylactic Ab for UTIs with bactrim allergy (macrobid). Also, 3 or 4 on what pathogen is responsible for different infections
- These types of questions are high yield. Know the presentation of the infection, the common organisms, the microscopic description of the bug, and the antibiotic. All of these are on the Charts on the website.
- Microcytic anemia and you had to decide if it was iron def, thalassemia, or phys anemia of pregnancy.
- Virtually every test you will take in the future will ask you to work through anemia. Understand how to use the MCV and other common labs, inheritance patterns of genetic causes of anemias, etc.
- 2 or 3 precocious puberty, choosing lab test and management
- Examiners love this. Its unusual but tests your knowledge of the basic sciences. Remember the paradoxical action of Lupron in this case.
- Several postpartum fever questions, mostly after CD
- A lot of times there are 8-10 questions about post-op fever, either post-gyn or post-CD, SVD. Make sure you know the differential and presentation, including atelectasis, UTI, wound infections/abscesses, pelvic/abd abscesses, endomyometritis, mastitis, DVT, septic pelvic thrombophlebitis, etc.
- 3-4 primary amenorrhea, one was androgen insensitivity, one was Turner's, but the only physical finding it gave was "increased cubitus valgus" and she was short, answer was to karyotype
- 2 secondary amenorrhea- one excess exercise/low BMI, one was premature ovarian failure and choosing lab test to confirm (FSH)
- Test writers also love amenorrhea. Remember the four categories of amenorrhea: 1) (-breasts, +uterus) is usually Turners; 2) (+breasts. -uterus) is usually Androgen Insensitivity or MRKH syndrome; 3) (-breasts, -uterus) is usually 17, 20 Desmolase deficiency; 4) (+breasts, +uterus) overlaps with causes of 2nd amenorrhea but includes things like imperforate hymen on the test
- Hypoestrogenic hyperprolactinemia in a young woman- choose treatment
- Don’t forget to image head before proceeding with treatment
- 2 strips, one was fetal tachycardia, the other showed early's during labor and asked for appropriate management
- The Shelf so far hasn’t focussed on management of tracings or the categories, but on the pathophysiology of patterns (lates, variables, tachycardia, earlies, etc)
- 1 arrest of dilation, had to determine from labor curve
- Google partograms and understand that they may show you the course of a labor based on one of these charts. Then you’ll have to identify common arrest disorders (arrest of dilation, descent, etc.). Arrest of dilation is no change for four hours in active labor (beyond 6 cm) with adequate contractions. You need all three to diagnosis. If it’s earlier in labor and/or contractions aren’t adequate, then they want you to augment (amniotomy, pitocin).
- 1 preschool teacher in 2nd or 3rd trimester with hydrops, I think it was parvo
- The differential of immune and nonimmune hydrops is popular. TORCH infections, Rh disease, parvo etc are all highly tested.
- Effect of uncontrolled maternal hypertension on placenta
- Risk factors for growth restriction (Htn, vascular dz) and growth acceleration (DM) are popular and the sequelae from both.
- Effect of hyperemesis on fetus
- Are none. The problems with hyperemesis are maternal. They just want to make sure you know that.
- 3-4 infertility. One had image of HSG with round light 1 cm spot on uterus and asked what the pt is at increased risk for during pregnancy
- Fertility is a highly tested area too for at least a few questions. So are hysterosalpingograms. Google HSGs with different things. This one is an intracavitary fibroid. Watch the video about mullerian abnormalities too. They may show HSGs of these. Anything that makes the cavity smaller (like a unicornuate uterus) increases the risk of preterm labor. Anything that makes the cavity have less surface area (like fibroids or a septum) makes the risk of miscarriage higher). For infertility think about: male factor (sperm analysis), ovulatory (test LH surge, basal body temp, midluteal progesterone; tx with clomiphene or letrazole); tubal factor (history of PID or endometriosis, do an HSG; if blocked do IVF); cervical factor (history of LEEP or something; do an IUI). Also some unusual genetic stuff like Kallman’s is often tested.
- Breast stuff- differentiating galactocele from abscess, when to start mammogram with fam h/o early breast ca.
- You don’t get a lot of it on the rotation, but breast stuff is high yield. Know screening guidelines. Understand the triple test (this will help you get most questions right). If the stem says mass or lump, you have to have a biospy and imaging; don’t be reassured just by reassuring imaging. Have to biospy. In general, if cancer is in your differential, do a biopsy. Period.
- STDs- 7 or 8 total. Definately 1 (but maybe 2?) disseminated gonococcal infection, 1 primary HSV, 1 described condyloma accuminata and you chose pathogen, 1 trich (ID pathogen)
- So these are highly tested; all of them are fair game. Again memorize the Charts. Know the typical presentation, the bug, the screening AND confirmatory tests, the treatment, the treatment in pregnancy; the effects of the infection on pregnancy or fetus.
- 2 vulvar lesions, one asked about next step (I'm pretty sure it was biopsy), one was diagnosis and I think it was HSV
- Here again, if malignancy is in the differential, the next step is biopsy. Know common vulvar presentations, like lichen scl. Condyloma (in a woman under 50) doesn’t include cancer in the diff dx, so no need to biopsy; lichen scl does include cancer, so you have to biopsy. The Charts are good for these too.
- 2 nephrolithiasis questions
- These are a type of question again; common complications of pregnancy and common causes of pelvic pain are high yield
- Few on ovarian tumors, one was rapid virilization in 34 y/o woman with 8 cm adnexal mass, one with super elevated b-hCG
- So test writers love using tumor markers to make a vignette and then you have to identify the tumor. These are on the Charts. So for example, estrogenic symptoms with a mass is probably a granulosa cell tumors. These markers are high yeld.
- I don't remember how it was set up, but for one question you had to know that fetal factors cause symmetric IUGR
- Symmetric and asymmetric IUGR is def something to understand. Symmetric is genetic/chromosomal stuff and TORCH stuff; asymmetric is related to placental problems/HTN.
- One I struggled with was young G3P2 with 20 yr h/o well controlled Type 1 DM at 8 weeks gestation, HbA1c of 6.5%. Then there were 2 sentences explaining she had 2 previous uncomplicated pregnancies, normal vaginal deliveries and normal birth weights. It asked what would be the appropriate test to perform in the 1st trimester. Options were antiphospholipid antibody screening, dexamethasone suppression test, 24 urine collection for creatinine clearance, total iron binding capacity, or free T4 level.
- Remember to anticipate the complications of different medical issues on the pregnancy and change screenings etc to anticipate this. A diabetic is at increased risk for preeclampsia and also is likely to already have proteinuria, so a baseline urine will help to manage her later. This is a type of question. Apply this to other medical complications too.
Here are some questions from another student:
- after c-section, low BP, pericardial friction rub, pulmonary hypertension, firm uterus,what does she have? CHF, pneumonia, pylo, uterine atony, PE
- not an emergency, baby was transverse positions- c-section or turn fetus to breech position and deliver
- Neither is option is right. Turn the baby to cephalic and deliver. If it won’t turn do a section.
- risk factors for diabetes, preeclampsia, preterm labor, pprom
- an abnormal pap and then two normal pap, when should she get a pap? In three years, once year
- Pap smear stuff is easy. First pap at 21, then every 3 years. After 30, can do every 5 with HPV cotesting. If ASCUS, get an HPV. If ASCUS and HPV negative, treat it like a normal pap. If ASCUS HPV pos or worse (LSIL, HSIL, ASC-H), do a colpo (there are exceptions but not important for the shelf). If the Colpo is normal or CIN1, do another pap in a year and get two normals in a row then resume regular screening. If CIN2 or CIN3, do a LEEP or CKC (do a CKC if the lesion extends up into the cervix)
- baby tachycardic, mother bleeding at 38wks with 50% effacement and 4 cm dilated, what is wrong?- placenta abruption, chorio, long list
- baby tachycardic, mother with fever, clear fluid leakage- same list as #5
- Chorio is on almost every test. Lots of ways to ask the question. Not sure about the bleeding mother question, but might be abruption. Abruption is not a reason to do a c-section, but fetal distress is. Most women with abruption deliver vaginally.
- a 45 y/o with a mobile, nontender breast mass, cyclic growth, what do u do? Aspiration biopsy, excision biopsy
- Again remember the Triple Test. Do a biopsy. Avoid aspirations on solid masses. Excisional biopsy are usually for things that are at high risk for malignancy or a failed core or aspiration biopsy. She also needs imaging at some point. But always biospy masses.
- breast feeding mother has a breast that is tender, no mass, skin is red upper outer quadrant- mastitis, cancer
- Sounds like mastitis to me; remember Dicloxacillin is the drug of choice.
- lot of questions on women with c-sections and fever two days after
- infertility, had gotten sperm analysis, had 28 day cycle, in the past had 18 partners but monogamous now, what next? FSH, prolactin, LH, TSH, HSG, testosterone, or laparoscopy
- Remember what I said above. She sounds ovulatory and the sperm analysis is normal. The stem is implying that she might have had chlamydia or something. HSG will test tubes.
- woman comes in with pelvic pain, dyspareunia, dysmenorrhea, nodularity in posterior fornix, no masses felt on exam, what next? Laparoscopy, CT
- Recognize common causes of female pelvic pain. This is endometriosis. We diagnosis with biopsy at laparoscopy but you can also try to treat empirically and see if she improves before running to surgery.
- urge incontinence, had a 3 cm fibroid in uterus, why is she having this problem? Detrusor instability or fibroid
- Well a really big anterior fibroid might sit on the bladder and cause a sensation to void, but don’t bite for that. Common things are common and 3 cm is not big. This is just detrusor instability.
- bulge in vagina, had a hysterectomy, no anterior or posterior wall problems- enterocele
- Urogyn isn’t heavily tested but not the vignettes for different types of incontinence and the treatments and recognize symptoms and types of prolapse. They still use the terms enterocele, cystocele, and rectocele.
- amenorrhea, pubic and axillary hair, no breast, no uterus- androgen insensitivity, mullerian agenesis , 17 hydroxylase deficiency, agonadism
- Remember what I said before. This is Type 3 above, so its an enzyme problem, in this case 17-hydrox.
Another student with our back and forth about questions she found difficult:
- Heavier periods in perimenopausal pt. U/S shows smooth concave intrauterine mass infiltrating myometrium; it’s heterogeneous. Her uterus is slightly enlarged. Most like dx? I was between adenomyosis (but don't remember much about it) vs. endometrial cancer; another option was fibroid.
- Most likely is fibroid. Need to exclude cancer with biopsy. Adenomyosis is a possibility. But this sounds like a submucosal fibroid. Here are some pictures: http://www.advancedfertility.com/uterinefibroid.htm
- Normal-weight girl, stressful job, secondary amenorrhea, next best test: measure PRL & TSH, or Estrogen & progesterone? Other options included head/pelvic CT…
- PRL and TSH. Obviously first best test was an pregnancy test. A progesterone by itself is not really useful and neither is an estrogen by itself but an estrogen plus FSH might be.
- Secondary amenorrhea in 22yo for 6 years (has end-stage renal dz). Sexually active, uses condoms consistently. Normal pelvic exam. Next best test for amenorrhea workup: HSG, hysteroscopy, or B-hCG?
- Well none of these. The HCG is the best of those three for sure. She might be pregnant and you would want to exclude pregnancy before doing something like an HSG or hysteroscopy.
- Molar pregnancy (HTN ~150/100, snowstorm on US, etc). Anxious pt. Give any meds before D&C? Options: no meds; labetalol; carbamazepine; PTU
- I would give no meds here. If the vignette presents thyroid storm then beta blockade/ptu might be useful. But this sounds like just do the D&C. (Molar pregnancies are heavily tested; love the snowstorm US and the basic science implications)
- recurrent variable decels + brady after ROM: do amnio-infusion? Cervical exam? Cesarean?
- Well they want you to think of cord prolapse here. She needs a cesarean but you need to do a cervical exam first to confirm and then elevate the fetal head off of the prolapsed cord (what’s the next best step questions frustrate students because all of the answers might be appropriate, but just imagine being there in front of the patient and put the steps in order).
- G2P0010 (prev stillbirth at 37 wk) starts itching at 35wk. What test: Skin bx? Liver bx? Alk-phos? Serum bile acids?
- Serum bile acids. Generalized itching is possibly intrahepatic cholestasis of pregnancy. It is associated with a roughly five times risk of fetal death and has a genetic predisposition giving you a recurrence risk (rare dz but they don’t want you to ignore potentially bad things with benign presentations).
- Pelvic infection 2 weeks after IUD insertion… see fever, copious yellow discharge from cervix. Tx w/ abx… and also remove IUD, or leave it there?
- Leave it there is the current thinking. Treat only. Remove if she fails treatment.
- Dull, constant pelvic pain. Tender on bimanual exam, not much discharge. Chlamydia or gonorrhea?
- Wouldn't think this was either. If they wanted you to think PID then chlamydia is most common, but there’s not enough info here to discriminate.
- Vulvar burning/itching in older pt, answer choices for etiology included both trichomoniasis and vaginal atrophy. Copious grey discharge, fishy-smelling, otherwise normal exam. Wet mounts showed WBC's but no clue cells or organisms. One question said the wet mount had dried up before it was viewed... so could that one still have had trichomonas on it, just not visualized?
- Well vulvar itching is not usually due to vaginal atrophy, not trich. A fishy smelling, copious gray discharge of course sounds like BV. However there are no clue cells and that shouldn’t matter with the slide. Due to the rise in pH with vulvovaginal atrophy, women do sometimes report a discharge and the buzzword is grey. Yellow and green are the buzzwords for BV and trich. So I would have picked atrophy. Here is an article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800285/pdf/mayoclinproc_85_1_012.pdf
- Described intrauterine fetal demise (no FM for 24h, no heart tones, 3rd trimester). Confirm by amniocentesis, or u/s?
- Confirm by US. No way to confirm death with amniocentesis, but obviously can with US. Sometimes an amnio is done after an IUFD to harvest amniocytes for genetic testing prior to induction of labor.
- Mastitis not responsive to dicloxacillin, what is the bug: candida? Klebsiella? E. coli? GBS? MRSA? I should've said MRSA but forgot that dicloxacillin doesn't cover it :(
- Yes probably MRSA but yeast mastitis is a common problem. However, yeast doesn’t present with fever or the systemic flu like symptoms, so it depends on how they worded it.
- There were some easier ones at least e.g. on PCOS, contraception, post-op infections, postpartum hemorrhage, cancer screening/prevention... A question asked whether 37 weeks was preterm!
- A lot of the questions are very easy. Don’t question your answer just because it was easy; there’s no trick to them. They are on a bell-shaped curve of difficulty.
- I had 5-7 questions dealing with urinary incontinence. The question stem would always give a post void volume (it would not give a normal range and we were expected to know what volume is normal) and we would need to recognize the significance of it, in addition to other typical stress/ urge sx.
- A lot of students are thrown off by not understanding post-void residuals. They are reporting the PVR because it is appropriate to check it with virtually every presentation of incontinence. They aren’t trying to trick you.
- Another question that was interesting read something like this. 12 yo has not had menses in 6 months. She plays softball in the spring and has phys ed class twice a week. Menses occurred at 11, and then gave vitals. What is the diagnosis? Most of us put either reassurance or athletic amenorrhea. I put reassurance.
- Not sure what the question was here but reassurance and no work up is appropriate. Also commonly tested is a young girl whose mom brings in for a breast lump. Its a breast bud and reassurance is the answer. Don’t biopsy an 11 year old’s breast even if mom did have breast cancer.
Other things that confuse students:
- Make sure you understand what is being asked. For example, a UTI in a newly sexually active girl. What is the most common bug? E. coli (you were thinking saprophyticus; that’s more likely in that group ut E. coli is still the most common). Or a woman has a pelvic abscess after a c-section, what bugs should you focus treatment on? The answers is broad spectrum against a polymicrobial infection; the most likely bug might be bacteroides but you won’t just treat that.
- An elderly woman breaks a bone in a car accident; later she has a spiculated mass on mammogram. What’s the most likely diagnosis? Fat necrosis. Are we going to rule out cancer? Absolutely. The next step in management is still biopsy. The most likely cause of postmenopausal bleeding is not endometrial cancer; not even close. But the next step in management is still going to be to rule out cancer.
- A pregnant woman presents with classic symptoms of appendicitis; what do you do next? This is one of the most misunderstood questions ever. The answer is not surgery. It is never is for women; that’s the answer for men. So you have to image. The imaging modality of choice is CT (maybe MRI but the shelf doesn’t usually give that). The radiation exposure is not an issue. US is NEVER the correct answer in pregnant women.
- In general don’t waste time studying things that have wide variation in practice. The test writers know that your school may do things different than the next so they don’t ask questions about it. For example, don’t worry about medicines used in pregnancy unless they are specifically contraindicated and associated with a classic birth defect (like lithium or coumadin). Do know what common first line treatments for things are (like Vit b6/doxalymine for nausea in pregnancy). But don’t worry about whether fentanyl or stadol is better in pregnancy (fentanyl) or labetalol of aldomet (both are widely used). Know that some medicines may cause a particular side effect (like a pseudosinusoidal fetal tracing due to stadol or ringing in the ears or a metallic taste in the mouth from an intravenous injection of lidocaine [that should have been intrathecal with regional anesthesia]).
- Here a bit longer list of stuff than is on the Charts:
fetal renal tubular dysplasia and neonatal renal failure, oligohydramnios, intrauterine IUGR, lack of cranial ossification
FAS (growth restriction before and after birth, mental retardation, midfacial hypoplasia, renal and cardiac defects). Consumption of >6 drinks a day associated with 40% risk of FAS
neural tube defects, fingernail hypoplasia, microcephaly, developmental delay, IUGR
bowel atresias; congenital malformations of the heart, limbs, face, and GU tract; microcephaly; IUGR; cerebral infarctions
clear cell adenocarcinoma of the vagina or cervix, vaginal adenosis, abnormalities of the cervix and uterus or testes, possible infertility
increased spontaneous abortion rate; stillbirths
congenital heart disease (Ebstein's Anomaly)
increased spontaneous abortion rate
Organic Mercury (from Whole Foods)
cerebral atrophy, microcephaly, mental retardation, spasticity, seizures, blindness
IUGR, mental retardation, microcephaly, dysmorphic craniofacial features, cardiac defects, fingernail hypoplasia
microcephaly, mental retardation. Medical diagnostic radiation deliverying < 0.05 Gy to the fetus has no risk
Streptomycin and kanamycin
hearing loss; CN 8 dmg
permanent yellow-brown discoloration of deciduous teeth; hypoplasia of tooth enamel
bilateral limb deficiencies, anotia and microtia, cardiac and GI anomalies
Trimethadione and paramethadione
cleft lip or palate, cardiac defects, mricrocephaly, mental retardation
neural tube defects (spina bifida), minor craniofacial defects
Vitamin A and derivatives
increased spontaneous abortion rate, microtia, thymic agenesis, cardiovascular defects, craniofacial dysmorphism, micropththalmia, cleft lip or palate, mental retardation
nasal hypoplasia and stippled bone epiphyses, developmental delay, IUGR, ophthalmologic abnormalities
- Know in general terms when extra fetal testing is indicated and what is normal and abnormal in terms of results. For example, BPPs or NST are indicated for women with high risk hypertension or medicine-requiring diabetes or a history of growth restriction etc. Know that an abnormal test requires action but the specifics are complicated and controversial so you won’t be asked to manage per se except that a person with abnormal testing at term should be delivered. The test will more focus on potential causes of abnormalities than treatment; for example, oligohydramnios due to rupture membranes or uteroplacental insufficiency, or polyhydramnios due to diabetes or esophageal atresia; or variable decels due to cord compression or prolapse, etc.
- Again, the test writers avoid controversy. Tocolytics for example won’t be tested because there is no scientific evidence supporting their use and many schools don’t expose their students to them except to say that they don’t use them. But betamethasone for women at risk of delivery before 34 weeks is not controversial or GBS screening and treatment is universal. Those things should be done at every school and are fair game for testing.
- The test will expect that you know normal physiologic changes/adaptations during pregnancy and not over work-up common problems of pregnancy, like GERD or edema. The physiologic changes of pregnancy on the obgynstudent.com website is sufficient.
- You never need to know specific doses of medicines and things like that, just know what medicine to use. For example, you should know that a particular patient needs insulin but the type of insulin and the way it is dosed is so widely variable among physicians that a student would never be asked to offer a right answer.
- Know where some labs are different in pregnancy, again mostly what’s on obgynstudent.com. You need to know the general trends of an ABG for example because they might ask you to answer a physiologic question of pregnancy based on that. And for all of your future testing life, know how to basically interpet ABGs. Know that anemia is mostly normal and pregnancy and why, for example, so that you don’t waste resources working up a pregnant woman with a Hg of 10.3.
- Know the average weight gains and caloric increases of pregnancy and the major dietary contraindications like large mercury containing fish, etc. Other common pregnancy counseling issues are good to know, but remember many are controversial. Much of what is told to pregnant women is not evidence based. The test IS evidence based. The thing you learned in the book is the right answer even if you saw something different on the rotation.
- Know the general overview of Urogyn and REI. Understand the basics (almost at a medical literacy level) of what they things are they do, like urodynamics testing or a TOT, or IVF, IUI, etc. But you don’t need to know gory details about how to do a stim cycle. You do need to recognize complications you might see if you worked in the ER, like ovarian hyperstimulation syndrome or obstructive uropathy after surgery.
- We don’t have a very diverse patient population here, but the test will certainly expect you to recognize and treat things like sickle cell crisis in pregnancy. That is not that uncommon of a problem. Also we don’t see a lot of infectious diseases, but certainly syphilis and HIV in pregnancy you should have an a basic work-up and treatment understanding of.
- We also see a ton of substance abuse here but that too is skewed. It won’t be heavily tested but knowing the effects of various drugs of abuse on a pregnancy is still fair game. Most psych stuff that is tested revolves around postpartum blues/depression/psychosis etc.