905-1031 genicology tiya 3

905. A 23-year-old woman presents for evaluation of infertility. For the past 12 months she has been having sexual intercourse without contraception but has not been able to conceive. Her history is significant for irregular periods for the past 2 years. She reports exercising intensely six days per week and acknowledges having a lot of stress at work. She smokes one pack of cigarettes daily. On physical examination, her vital signs are within normal limits. Her BMI is 18 kg/m2. Urine pregnancy test is negative. Laboratory studies show: Serum FSH: low Serum LH: low Serum prolactin: normal Serum TSH: normal Which of the following therapies would be most helpful for this patient's infertility?

906. After reading an article titled: "The Risk of Cancer in Patients with Diethylstilbestrol (DES) Exposed Mothers", a 23-year old female comes to your office with her mother for assessment of possible risks. Her mother had been given DES while pregnant. Which of the following cancers is this patient most at risk of developing?

907. A 28-year-old male comes for evaluation of infertility. He has been healthy and otherwise has no complaints. He says the he eats a high protein diet and exercises daily in order to be muscular. He weighs 85 kg (187 1 b) and is 175cm (70 in) tall. His temperature is 37.2 C (98.9 F), and his blood pressure is 130/82 mmHg. Physical examination shows small testes. The remainder of the examination is unremarkable. Initial laboratory studies show: Hemoglobin: 16.0 g/L Platelets: 200,000/mm3 Leukocyte count: 4,500/mm3 Serum creatinine: 1.4 mg/dl Serum LH: low Serum testosterone: low Which of the following is the most likely cause of his infertility?

908. A 26-year-old G1P 1woman requests contraception after delivering a healthy baby three weeks ago. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

909. A 24-year-old primigravid woman at 35 weeks gestation comes to the emergency department with uterine contractions. She started these contractions six hours earlier, and they have not increased in intensity since then. The contractions started in the lower abdomen and are irregular. Her pregnancy has been uncomplicated. Her prenatal course, prenatal tests and fetal growth have been normal. She has no history of trauma. She does not use tobacco, alcohol or drugs. Vital signs are normal. Examination shows a firm, posterior and closed cervix. Ultrasonogram in the emergency department shows a gestational age of 35-weeks and the fetus in the vertex presentation. Fetal heart tones are heard. She feels better after mild sedation. Which of the following is the most appropriate next step in management?

910. A 23-year-old primigravid female at 38 weeks' gestation was admitted to the delivery room for management of labor. She was in active labor for 4-hours during which her cervical dilation progressed from 3cm to 8cm, and descent progressed from - 1 to +1 station. Examination 6-hours later showed the same degree of dilation and descent. The fetal head is in the Left Occipita Anterior (LOA) position. An external tocometer is placed and reveals contractions 3 min apart, lasting 50 seconds each. Internal pelvic assessment shows prominent ischial spines. FetaI heart monitoring shows a baseline of 140 bpm with frequent accelerations. Prenatal ultrasound at 37-weeks showed a fetus of average size. Which of the following is the most appropriate next step in management?

911. A 21-year-old gravida 1, para 0 woman comes to the office for a routine prenatal visit at 26 weeks gestation. She has no complaints. She has no significant past medical history. She does not use tobacco, alcohol, or drugs. She takes prenatal vitamins regularly, and has no known drug allergies. Her vital signs are within normal limits. Examination shows a uterine size appropriate for gestational age, and fetal heart tones are heard. One hour 50gram oral glucose tolerance test shows a blood glucose level of 120 mg/dl. Urine culture grew 105 colony forming units/ml of E.coli. This patient is at greatest risk for which of the following complications?

912. A 16-year-old female comes to the emergency department because of heavy vaginal bleeding. She has no pain. Since menarche, menses have been irregular. She has a steady boyfriend and uses condoms for contraception. She has no other medical problems. She does not use alcohol, tobacco, or drugs. Her temperature is 37C (99F), blood pressure is 11 0/60 mm Hg, pulse is 90/min, and respirations are 16/min. Physical examination shows active vaginal bleeding. Pregnancy test is negative. Coagulation studies are within normal limits. Ultrasound shows no abnormalities. Her hemoglobin is 9.8 g/dl and hematocrit is 29%. Which of the following is the most appropriate next step in management?

913. A 32-year-old woman comes to your office for re-evaluation of her birth control method. She wants her intrauterine device (IUD) removed because it is causing her pelvic pain. She wants to be placed on oral contraceptive pills (OCPs). She has had hypertension for the past five years controlled with hydrochlorothiazide and atenolol. She has a family history of diabetes mellitus and ovarian carcinoma. Her body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. If she starts taking oral contraceptive pills, which of the following statement is most correct?

914. A 30-year-old female comes to your office for her first prenatal visit. She has been married for 3-years and has been trying to conceive for the past year. She had been unsuccessful; however, she now has a 2-month history of amenorrhea. She has been experiencing morning sickness and has had abdominal distension and breast fullness over the past two weeks. She states that her home urine pregnancy test is positive. She seems happy and excited about this long awaited pregnancy. She has no previous medical problems. She has been taking prenatal vitamins for the past 3 weeks after she first missed her period. Physical examination shows a tympanic abdomen. Ultrasonogram shows a normal endometrial stripe. Pregnancy testing in the office is negative. Which of the following is the most likely diagnosis?

915. A 24-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to you for a routine prenatal visit. She has had mild constipation. She has had no nausea, vomiting, fever, burning urination, back pain, or other complaints. She has no history of urinary tract infections. She takes iron and folic acid supplements. She does not use tobacco, alcohol, or drugs. She is afebrile; her blood pressure is 124/74 mm Hg and pulse is 78/min. Examination shows a uterus consistent in size with a 16-week gestation. Physical examination shows no abnormalities. Urinalysis is within normal limits. A routine clean-catch urine culture grows greater than 100,000 colonies/ml of Escherichia coli. Which of the following is the most appropriate next step in management?

916. A 14-year-old female is brought to the physician's office for evaluation of excessive menstrual bleeding. She experienced menarche at age 13, and since then her menses have been irregular and unpredictable. Her last menstrual period was 6 weeks ago and for the past week she has been having heavy menstrual bleeding. She has never been sexually active. Vital signs are stable. Her external genitalia are normal. She refused pelvic examination, and a pregnancy test is negative. Which of the following is the most likely cause of her symptoms?

917. A 65-year-old woman is found to have osteoporosis on DEXA scan. She underwent right knee surgery five years ago and developed post-operative deep venous thrombosis, for which she was treated with 6 months of warfarin therapy. She also has severe gastroesophageal reflux disease and takes lansoprazole daily. Her mother died of breast cancer, her maternal aunt has endometrial cancer, and her paternal aunt has a history of ovarian cancer. She does not want to use bisphosphonates because of her reflux symptoms, and would like to consider raloxifene. Which of the following is a contraindication to raloxifene in this patient?

918. A 37-year-old obese, hypertensive female comes to the physician because of intermenstrual bleeding and heavy menses. Endometrial biopsy shows "complex hyperplasia without atypia." She has two young healthy children and does not want more children in the future. W hich of the following is the most appropriate next step in management?

919. A 25-year-old female presents to the physician's office for evaluation of infertility. Her menstrual periods are regular. She has mild chronic pelvic pain. Her husband's semen analysis is within normal limits. She has no history of sexually transmitted diseases in the past. Her temperature is 37.2 C (98.9 F), and her blood pressure is 120/72 mmHg. Physical examination shows a normal sized uterus and enlarged left adnexae. Ultrasonography shows a homogeneous mass on the left ovary, but is otherwise normal. Which of the following is the most likely diagnosis?

920. 27-year-old nulliparous woman presents to your office complaining of a 7-week history of amenorrhea with a negative urine pregnancy test. Upon further questioning, she says that she feels fine and does not have any symptoms. She has a steady boyfriend and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any medications beside vitamin supplements to help her in her workout. She is a senior college student and works as a secretary in a law firm. On physical examination, there is no hirsutism or galactorrhea. The rest of the examination reveals nothing abnormal. Her BMI is 28 kg/m2. Initial work-up reveals the following: Serum TSH 2.5 mU/mL (N= 0.5-5.0) Prolactin 10 ng/ml (< 20 ng/ml) According to these findings, which of the following is the most appropriate next step in the management of this patient?

921. A 32-year-old, gravida 3, para 2 woman at 35 weeks gestation comes to the hospital because of regular and painful uterine contractions occurring every 5 - 6 minutes. She also has continuous leakage of clear fluid from her vagina that started 10 hours earlier. She has chronic hypertension and was prescribed methyldopa throughout pregnancy but has been noncompliant. She also has a history of drug abuse and has missed two previous antenatal appointments. Her temperature is 37.0C (98.7F), blood pressure is 160/100 mmHg, pulse is 80/min and respirations are 16/min. Sterile speculum examination shows pooling of amniotic fluid in the vagina; the cervix is 80% effaced and 3cm dilated. Ultrasound shows a small for gestational age fetus in the vertex presentation with a decreased amniotic fluid index. Fetal heart monitoring shows repetitive late decelerations. Uterine contractions are now occurring every 4 minutes. Which of the following is the most appropriate next step in management?

922. A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?

923. A 30-year-old woman in her second pregnancy presents to your office at 36 weeks gestation complaining of dull, low back pain. The pain is minimal in the morning, but increases at the end of the day. She also noticed ankle edema that appears at the end of the day. Her past medical history is insignificant. Her temperature is 36.7C (98F), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min. Urinalysis is normal. Which of the following is the most likely cause of this patient's complaints?

A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of gushing bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0 C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. She is anxious and concerned about her baby. Which of the following is the most appropriate next step in management?

924. A 24-year-old female comes to the physician because of increasing facial acne and recent menstrual irregularities. She has no significant past medical history and she takes no medications. She does not use tobacco, alcohol or drugs. She weighs 170lb (77 Kg) and is 62 in (155cm) tall. Physical examination shows moderate acne on her face and prominent hair on the upper lip. For which of the following conditions is she at greater risk than the general population?

925. A 22-year-old woman presents to office with a 3-week history of scant vaginal discharge. She has no other complaints. She is sexually active and uses oral contraceptives. She has regular 26-day menstrual cycles and her last menstrual period was ten days ago. She does not smoke or consume alcohol. Her temperature is 36.7C (98 F), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 14/min. On examination, the abdomen is non-tender. Yellow mucopurulent discharge is seen at the cervical os. Which of the following organisms is the most probable cause of this patient's problem?

926. A 24-year-old female and her husband come to the physician's office for evaluation of infertility. They have not been able to conceive after 12 months of frequent intercourse without contraception. She has no other medical problems and takes no medication. Physical examination shows an obese woman with excess thick hair over her chin and along the linea alba of the lower abdomen. There is no increase in muscles mass. When asked about the excess hair, she states that she has had it for a long time. Serum testosterone levels are elevated. Which of the following is the most likely cause of her infertility?

927. A 41-year-old woman, gravida 3, para 3, comes to the physician because of a 2-year history of dysmenorrhea and menorrhagia that has been increasing in intensity. She has no dyspareunia or any other symptoms. She has a history of chronic hypertension. She had a cesarean section in her 3rd pregnancy followed by surgical sterilization. Vital signs are normal. Bimanual examination shows a symmetrically enlarged and tender uterus with soft consistency and free adnexae. Which of the following is the most likely diagnosis?

928. A 23-year-old woman who is 10 weeks pregnant with her first pregnancy is referred to you for smoking cessation. She has been smoking since the age of 21 and has never tried to quit. However, now that she is pregnant she would really like to quit. She has no symptoms of depression. Her past medical history is significant for asthma. She uses an inhaler occasionally for her asthma and takes no other medications. She has never had surgery and has no known drug allergies. Physical examination is normal for a patient at 10 weeks’ gestation. Which of the following is the most appropriate management for this patient?

929. A 42-year-old woman with hypertension and a past history of an ectopic pregnancy 18 years earlier comes to your office and reports one episode of unprotected sexual intercourse 6 days ago. Her last menstrual period was normal and occurred 2 weeks earlier. She is concerned about unintended pregnancy and asks you about the “Morning After” pill. She reports no other complaints, has been healthy recently, and her hypertension has been well controlled. She has smoked one pack of cigarettes per day for the past 20 years. Which of the following factors in this patient would be a relative contraindication to prescribing hormonal emergency contraception?

930. A 29-year-old woman, gravida 2, para 1, at 33 weeks’ gestation is referred to your office because of a possible herpes outbreak. She developed a painful vesicular rash a few days ago in her genital area. She has never before had any similar symptoms. She has no other medical problems, takes no medications, and has no known drug allergies. Examination reveals numerous erythematous vesicles and ulcerations. Testing of the lesion demonstrates herpes simplex virus infection and serologic testing reveals that it is a primary outbreak for the patient. Which of the following is the most appropriate management of this patient?

931. A 35-year-old woman with type 2 diabetes comes to your office seeking pregnancy advice. Although she is not currently pregnant and has never been pregnant, she and her spouse, are planning to have their first child. She has previously managed her diabetes with diet and exercise. Approximately 4 months ago, however, you started her on metformin, as her fasting blood glucose levels were consistently elevated. Her hemoglobin A1c level at that time was 9%. She has no specific complaints today and her physical examination is unremarkable. A hemoglobin A1c level drawn 1 week before today’s visit is 6.2%. She would like to know which, if any, diabetic medications she can take during her pregnancy. Which of the following is the most appropriate pharmacologic monotherapy for her?

932. A 42-year-old woman comes to your office for an annual examination. She states that she has been feeling good over the past year. She exercises three times a week and watches her diet. She has no medical problems. She had an appendectomy at the age of 25, and no other surgeries. She uses a 35μg combined oral contraceptive pill (OCP) daily, and takes no other medications. She has been on “the pill” for birth control for the past 10 years and is happy with it. She has no known drug allergies. Physical examination, including breast and pelvic exams, is normal. She wants to know if she can continue to take the oral contraceptive pill. Which of the following is the most appropriate advice to give her?

933. A 24-year-old woman comes to your office with vaginal spotting 2 weeks after a missed menstrual period. Her past medical history is significant for pelvic inflammatory disease. She has never had surgery. She takes no medications and is allergic to penicillin. Examination demonstrates scant blood in the vaginal vault and minimal right adnexal tenderness. Laboratory evaluation reveals a beta-hCG value of 1600 mIU/mL. Blood type is O positive. Hematocrit is 39%. Pelvic ultrasound demonstrates nothing in the uterus and a right adnexal mass consistent with ectopic pregnancy. The decision is made to proceed with intramuscular methotrexate for medical treatment of the ectopic pregnancy. Which of the following is the most likely side effect from this treatment?

934. 22-year-old woman comes to the physician for an annual examination. She has normal periods every month and has no complaints. She has no medical problems but does smoke one pack of cigarettes per day. She has intercourse with more than one partner. Examination is unremarkable, including a normal pelvic examination. A Papanicolaou smear shows a high-grade squamous intraepithelial lesion. Which of the following is the most appropriate next step in management?

935. A 4-year-old girl is brought to the physician by her mother because of a bloody, greenish, malodorous vaginal discharge. The discharge was first noted 3 days ago and has worsened since then. The girl has no other symptoms. The mother reports no concerns regarding abuse of the child. Examination is attempted but impossible because of the child's absolute refusal to be examined. Several efforts at persuasion are made but are unsuccessful. Which of the following is the most appropriate next step in management?

936. A 38-year-old woman, gravida 3, para 2, at 32 weeks' gestation comes to the physician because of bleeding from the vagina. She states that this morning she passed 2 quarter-sized clots of blood from her vagina. Otherwise, she states that she is feeling well. The baby has been moving normally and she has had no contractions or gush of fluid from the vagina. Her obstetrical history is significant for 2 low-transverse cesarean deliveries for non-reassuring fetal heart rate tracings. An ultrasound is performed that demonstrates a complete placenta previa. For which of the following conditions is this patient at highest risk?

937. 22-year-old G3P0030 obese female comes to your office for a routine gynecologic examination. She is single, but is currently sexually active. She has a history of five sexual partners in the past, and became sexually active at age 15. She has had three first-trimester voluntary pregnancy terminations. She uses Depo-Provera for birth control, and reports occasionally using condoms as well. She has a history of genital warts, but denies any prior history of abnormal Pap smears. The patient denies use of any illicit drugs, but admits to smoking about one pack of cigarettes a day. Her physical examination is normal. However, 3 weeks later you receive the results of her Pap smear, which shows a high-grade squamous intraepithelial lesion (HGSIL). Which of the following factors in this patient’s history does not increase her risk for cervical dysplasia?

938. A 22-year-old woman presents for her first Pap smear. She has been sexually active with only one boyfriend since age 19. Her physical examination is completely normal. However, 2 weeks later her Pap smear results return showing HGSIL. There were no endocervical cells seen on the smear. Which of the following is the most appropriate next step in the management of this patient?

939. A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your colposcopic impression is of acetowhite changes suggestive of human papilloma virus infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which of the following is the most appropriate next step in the management of this patient?

940. A 55-year-old postmenopausal female presents to her gynecologist for a routine examination. She denies any use of hormone replacement therapy and does not report any menopausal symptoms. She denies the occurrence of any abnormal vaginal bleeding. She has no history of any abnormal Pap smears and has been married for 30 years to the same partner. She is currently sexually active with her husband on a regular basis. Two weeks after her examination, her Pap smear comes back as atypical glandular cells of undetermined significance (AGUS). Which of the following is the most appropriate next step in the management of this patient?

941. A 24-year-old G0 presents to your office complaining of vulvar discomfort. More specifically, she has been experiencing intense burning and pain with intercourse. The discomfort occurs at the vaginal introitus primarily with penile insertion into the vagina. The patient also experiences the same pain with tampon insertion and when the speculum is inserted during a gynecologic examination. The problem has become so severe that she can no longer have sex, which is causing problems in her marriage. She is otherwise healthy and denies any medical problems. She is experiencing regular menses and denies any dysmenorrhea. On physical examination, the region of the vulva around the vaginal vestibule has several punctate, erythematous areas of epithelium measuring 3 to 8 mm in diameter. Most of the lesions are located on the skin between the two Bartholin glands. Each inflamed lesion is tender to touch with a cotton swab. Which of the following is the most likely diagnosis?

942. After making a diagnosis in the patient in question 319, you recommended that she wear loose clothing and cotton underwear and to stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved. Which of the following treatment options is the best next step in treating this patient’s problem?

943. A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. Which of the following is the most likely diagnosis?

944. A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. In the patient described in the question above, which of the following is the best treatment?

945. A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency room complaining of a 24-hour history of increasing pelvic pain. This morning she experienced chills and a fever, although she did not take her temperature. She reports no changes in her urine or bowel habits. She has had no nausea or vomiting. She is hungry. She denies any medical problems. Her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses and denies dysmenorrhea. She is currently sexually active. She has a new sexual partner and had sexual intercourse with him just prior to her last menstrual period. She denies a history of any abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is completely normal. WBC is 18,000. Temperature is 38.8C (102F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished. Which of the following is the most likely diagnosis?

946. A 32-year-old women presents to the emergency room complaining of severe lower abdominal pain. She says she was diagnosed with pelvic inflammatory disease by her gynecologist last month, but did not take the medicine that she was prescribed because it made her throw up. She has had fevers on and off for the past 2 weeks. In the emergency room, the patient has a temperature of 38.3C (101F). Her abdomen is diffusely tender, but more so in the lower quadrants. She has diminished bowel sounds. On bimanual pelvic examination, bilateral adnexal masses are palpated. The patient is sent to the ultrasound department, and a transvaginal pelvic ultrasound demonstrates bilateral tubo-ovarian abscesses. Which of the following is the most appropriate next step in the management of this patient?

947. A 36-year-old woman presents to the emergency room complaining of pelvic pain, fever, and vaginal discharge. She has had nausea and vomiting and cannot tolerate liquids at the time of her initial evaluation. The emergency room physician diagnoses her with pelvic inflammatory disease and asks you to admit her for treatment. Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?

948. A 43-year-old G2P2 comes to your office complaining of an intermittent right nipple discharge that is bloody. She reports that the discharge is spontaneous and not associated with any nipple pruritus, burning, or discomfort. On physical examination, you do not detect any dominant breast masses or adenopathy. There are no skin changes noted. Which of the following conditions is the most likely cause of this patient’s problem?

949. A 20-year-old G0, LMP 1 week ago, presents to your gynecology clinic complaining of a mass in her left breast that she discovered during routine breast self-examination in the shower. When you perform a breast examination on her, you palpate a 2-cm firm, nontender mass in the upper inner quadrant of the left breast that is smooth, well-circumscribed, and mobile. You do not detect any skin changes, nipple discharge, or axillary lymphadenopathy. Which of the following is the most likely diagnosis?

950. You have a 32-year-old G1P0 patient who has undergone a routine obstetrical ultrasound screening at 20 weeks of gestation. The patient phones you immediately following the ultrasound because during the procedure the ultrasonographer commented that she noted several small fibroid tumors in the patient’s uterus. As this is the patient’s first pregnancy, she is concerned regarding the possible effects that the fibroid tumors may have on the outcome of her pregnancy. As her obstetrician, which of the following should you tell her?

951. A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and denies any alcohol or drug use. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for moderate dysplasia. She has had three cesarean sections and a tubal ligation. On physical examination, her uterus is 12 weeks in size and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative. Which of the following is the most reasonable next step in the evaluation of this patient?

952. A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An endometrial sampling done in the office shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound done at the hospital demonstrates multiple, large uterine fibroids. Which of the following is the best treatment option for this patient?

953. You see five postmenopausal patients in the clinic. Each patient has one of the conditions listed, and each patient wishes to begin hormone replacement therapy today. Which one of the following patients would you start on therapy at the time of this visit?

954. A mother brings her 12-year-old daughter in to your office for consultation. She is concerned because most of the other girls in her daughter’s class have already started their period. She thinks her daughter hasn’t shown any evidence of going into puberty yet. Knowing the usual first sign of the onset of puberty, you should ask the mother which of the following questions? a. Has her daughter had any acne?

955. A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. Which of the following is the most common cause of this condition in girls?

956. A 55-year-old woman presents to your office for consultation regarding her symptoms of menopause. She stopped having periods 8 months ago and is having severe hot flushes. The hot flushes are causing her considerable stress. What should you tell her regarding the psychological symptoms of the climacteric?

957. A 58-year-old Caucasian woman comes in to your office for advice regarding her risk factors for developing osteoporosis. She is 5ft 1 in tall and weighs 195 lb. She stopped having periods at age 49. She is healthy but smokes one pack of cigarettes per day. She does not take any medications. She has never taken hormone replacement for menopause. Her mother died at age 71 after she suffered a spontaneous hip fracture. Which of the following will have the least effect on this patient’s risk for developing osteoporosis?

958. A mother brings her 14-year-old daughter in to the office for consultation. The mother says her daughter should have started her period by now. She is also concerned that she is shorter than her friends. On physical examination, the girl is 4ft 10 in tall. She shows evidence of breast development at Tanner stage 2. She has no axillary or pubic hair. You reassure the mother that her daughter seems to be developing normally. Educating the mother and daughter, your best advice is to tell them which of the following?

959. An 18-year-old consults you for evaluation of disabling pain with her menstrual periods. The pain has been present since menarche and is accompanied by nausea and headache. History is otherwise unremarkable, and pelvic examination is normal. You diagnose primary dysmenorrhea and recommend initial treatment with which of the following?

960. An 18-year-old patient presents to you for evaluation because she has not yet started her period. On physical examination, she is 5ft 7 in tall. She has minimal breast development and no axillary or pubic hair. On pelvic examination, she has a normally developed vagina. A cervix is visible. The uterus is palpable, as are normal ovaries. Which of the following is the best next step in the evaluation of this patient?

961. A 7-year-old girl is brought in to see you by her mother because the girl has developed breasts and has a few pubic hairs starting to show up. Which of the following is the best treatment for the girl’s condition?

962. A mother brings her daughter in to see you for consultation. The daughter is 17 years old and has not started her period. She is 4ft 10 in tall. She has no breast budding. On pelvic examination, she has no pubic hair. By digital examination, the patient has a cervix and uterus. The ovaries are not palpable. As part of the workup, serum FSH and LH levels are drawn and both are high. Which of the following is the most likely reason for delayed puberty and sexual infantilism in this patient?

963. While evaluating a 30-year-old woman for infertility, you diagnose a bicornuate uterus. You explain that additional testing is necessary because of the woman’s increased risk of congenital anomalies in which organ system?

964. 30-year-old female comes to the office complaining of vaginal discharge, dyspareunia and vulvar pruritus. She has a history of hypothyroidism and takes thyroid replacement therapy. She uses tobacco and alcohol every day. On examination, you notice a thin, grayish vaginal discharge and erythema and edema of the vulva and vaginal mucosa. The pH of the discharge is 6.0 and wet-mount examination reveals pear-shaped motile organisms. First line treatment is prescribed for both the patient and her partner. The patient must avoid which of the following during the treatment period?

965. A 30-year-old female comes to your office for her first prenatal visit. She has been married for 3-years and has been trying to conceive for the past year. She had been unsuccessful; however, she now has a 2-month history of amenorrhea. She has been experiencing morning sickness and has had abdominal distension and breast fullness over the past two weeks. She states that her home urine pregnancy test is positive. She seems happy and excited about this long awaited pregnancy. She has no previous medical problems. She has been taking prenatal vitamins for the past 3 weeks after she first missed her period. Physical examination shows a tympanic abdomen. Ultrasonogram shows a normal endometrial stripe. Pregnancy testing in the office is negative. Which of the following is the most likely diagnosis?

966. A 15-year-old girl is being evaluated for primary amenorrhea. She has no other symptoms. She has not been sexually active. She has no other medical problems and does not take any medication. Her family history is unremarkable. On examination, you note fully developed breasts and absent axillary and pubic hair. External genitalia have a normal appearance, but the vagina is abnormally short and blind ended. Initial work-up reveals no uterus on ultrasound, a testosterone level of 400 ng/dl (Normal is 20-80 for a female), and a 46 XY karyotype. Which of the following events is most likely to have caused the absence of in utero development of the internal reproductive organs?

967. A 30-year-old female delivers a term male infant with signs of thyrotoxicosis. Prior to the pregnancy, she was surgically treated for Graves’ disease and was prescribed hormone replacement therapy in the form of levothyroxine 0.25 mg daily. Levothyroxine was maintained during pregnancy and thyroid hormone levels were monitored and maintained within the reference range. Which of the following is the most likely cause of the neonate's condition?

968. A 25-year-old woman presents to the physician's office for evaluation of foul-smelling vaginal discharge. She has been sexually active with a new partner for the past month. Physical examination reveals a thin, whitish-gray vaginal discharge. There is no discharge from the cervical os, and there is no adnexal or cervical motion tenderness. The remainder of the examination is normal. The pH of the vaginal fluid is 5.0. When KOH is added to vaginal discharge on a slide, an amine-like ("fishy") odor is perceived. A wet mount of the fluid reveals many epithelial cells with adherent bacteria. No polymorphonuclear cells are seen.

969. A 25-year-old nulligravid woman comes to the physician because of chronic pelvic and low sacral back pain for several months. The pain is usually worse premenstrually. She tried over the counter anti-inflammatory medications but had little relief. She has been in a monogamous relationship with her boyfriend for the past 4 years. She has no fever or abnormal vaginal discharge. Her temperature is 37.2° C (98.9° F), and blood pressure is 120/78 mm Hg. Physical examination shows tender posterior vaginal fornix and pain upon uterine motion. Complete blood count is normal. Pelvic ultrasonogram is normal. Urine pregnancy test is negative. Which of the following is most appropriate diagnostic test in her management?

970. A 24-year-old woman comes to the physician for her third prenatal check-up at 12 weeks gestation. She has been feeling well for the last 4 weeks because she no longer has nausea and vomiting. She had a small dark brown discharge 4 weeks ago, but it stopped spontaneously. Physical examination shows the cervix is closed and fetal heart tones are not heard. Real-time ultrasonogram shows a collapsed gestational sac with absent fetal heart motion. Urine pregnancy test is positive. Which of the following is the most likely diagnosis?

971. A 19-year-old woman comes to the physician for a routine physical examination. She has no complaints. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no significant past medical history and takes no other medications. She has no known drug allergies. Her temperature is 37.2° C (98.9° F) and blood pressure is 120/72 mm Hg. Complete physical examination, including pelvic examination, is unremarkable. A cervical swab is sent for nucleic acid amplification of Chlamydia trachomatis and Neisseria gonorrhoeae. The nucleic acid amplification test returns positive for chlamydia infection and negative for gonorrhea. The patient is still asymptomatic. Which of the following is the most appropriate next step in management?

972. A 28-year-old woman, gravida 3, para 2, at 35 weeks gestation is rushed to the emergency department because of vaginal bleeding. She was sleeping when she first noticed the bleeding. She has had no uterine contractions. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 14th week of gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. Her previous pregnancies were uncomplicated. Her temperature is 37.0°C (98.7°F), blood pressure is 90/60 mmHg, pulse is 11 6/min and respirations are 16/min. Physical examination shows cold extremities and bright red vaginal bleeding. Which of the following is the most appropriate next step in management?

973. A 23-year-old G1POfemale presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepithelial lesions (HSIL) is seen at cytology. A test for HPV discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no site of abnormalities. At this time the next best step is:

974. A 25-year-old primiparous woman comes to your office 12 weeks after vaginal delivery of a healthy female baby. She has not had a menstrual period since delivery. She is nursing, and is using barrier methods for contraception. Examination shows no abnormalities. Which of the following is the most likely mechanism for this patient's amenorrhea?

975. A 20-year-old G0 and her partner, a 20-year-old man, present for counseling for sexual dysfunction. Prior to their relationship, neither had been sexually active. Both deny any medical problems. In medical experience, which type of male or female sexual dysfunction has the lowest cure rate?

976. A 28-year-old G3P3 presents to your office for contraceptive counseling. She denies any medical problems or sexually transmitted diseases. You counsel her on the risks and benefits of all contraceptive methods. Which of the following is the most common form of contraception used by reproductive-age women in the United States?

977. A 20-year-old woman presents to your office for her well-woman examination. She has recently become sexually active and desires an effective contraceptive method. She has no medical problems, but family history is significant for breast cancer in a maternal aunt at the age of 42. She is worried about getting cancer from taking birth control pills. You discuss with her the risks and benefits of contraceptive pills. You tell her that which of the following neoplasms has been associated with the use of oral contraceptives?

978. A 39-year-old G3P3 presents for her postpartum examination and desires a long-term contraceptive method, but is unsure if she wants sterilization. She has been happily married for 15 years and denies any sexually transmitted diseases. Her past medical history is significant for mild hypertension, for which she takes a low-dose diuretic. She is considering an intrauterine device and wants to know how it works. Which of the following is the best explanation for the mechanism of the action of the intrauterine device (IUD)?

979. A 21-year-old G0 presents to your office because her menses is 2 weeks late. She states that she is taking her birth control pills correctly; she may have missed a day at the beginning of the pack, but took it as soon at she remembered. She denies any medical problems, but 3 or 4 weeks ago she had a “viral stomach flu” and missed 2 days of work for nausea, vomiting, and diarrhea. Her cycles are usually regular even without contraceptive pills. She has been on the pill for 5 years and recently developed some midcycle bleeding, which usually lasts about 2 days. She has been sexually active with the same partner for the past 3 months and has a history of chlamydia 3 years ago. She has had a total of 10 sexual partners. A urine pregnancy test is positive. Which of the following is the major cause of unplanned pregnancies in women using oral contraceptives?

980. A 25-year-old G2 P1 woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul-smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?

981. A 14-year-old girl is brought to the physician's office because of irregular menstrual periods. She had her menarche at age 13, and since then her periods have been irregular with the cycles varying from 3 to 6 weeks. She has no other symptoms. Physical examination is unremarkable. She has age appropriate secondary sexual characteristics. A urine pregnancy test is negative. Serum prolactin and thyroid stimulating hormone levels are normal. Administration of micronized oral progesterone results in withdrawal bleeding in 3 days. Which of the following most likely explains her irregular periods?

982. A 15-year-old girl is being evaluated for primary amenorrhea. She is otherwise healthy and has no previous medical problems. Vital signs are within normal limits. Physical examination reveals normal breast development, normal pubic and axillary hair, and a blind vagina; the uterus and adnexae could not be appreciated. Pelvic ultrasonography reveals 2 ovaries and no uterus is seen. The karyotype is 46 XX. Which of the following is the most likely diagnosis?

983. A 20-year-old woman presents with complaints of vaginal discharge and vulvar pruritus. She has no other medical problems. Physical examination reveals a thin, malodorous vaginal discharge and erythema of the vulva and vaginal mucosa. No other exam abnormalities are noted. Wet-mount preparation of the discharge shows motile pear-shaped organisms. Which of the following management options is most appropriate?

984. A 28-year-old woman comes to the physician's office at 30 weeks gestation because she has not felt her baby's movements for the past week. Fetal heart tones are not heard by Doppler. An ultrasound shows an absence of fetal cardiac activity. Fetal demise is diagnosed. She underwent a cesarean section for her previous delivery to avoid a post-term pregnancy. She has no other medical problems. Vital signs are normal and physical examination shows no abnormalities. Her cervix is 3 cm dilated and 70 percent effaced. Laboratory studies show a platelet count of 230,000/mm and a fibrinogen level of 480 mg/dl (normal:150-450mg/dl). Both the patient and her husband are shocked after hearing the news of fetal demise. Which of the following is the most appropriate next step in management?

985. An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old G5P4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. Which of the following is the most appropriate course of action?

986. A 34-year-old G1P1 with a history of pulmonary embolism presents to your office to discuss contraception. Her cycles are regular. She has a history of pelvic inflammatory disease last year, for which she was hospitalized. She has currently been sexually active with the same partner for the past year. She wants to use condoms and a spermicide. You counsel her on the risks and benefits. Which of the following statements is true regarding spermicides found in vaginal foams, creams, and suppositories?

987. A 32-year-old woman presents to your office for her well-woman examination. She is also worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners and achieved orgasm with them. She is taking a combined oral contraceptive pill for birth control and an antihypertensive medication for chronic hypertension. She has also been on fluoxetine for depression for the past 2 years. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago. Which of the following is the most likely cause of her sexual dysfunction?

988. A 20-year-old woman presents to your office for a well-woman examination. She has been sexually active with one male partner for the past year. She has not achieved orgasm with her partner. On further questioning, she has never achieved orgasm with other partners or with masturbation or the use of a vibrator. Which of the following statements is true regarding her condition?

989. A 23-year-old woman presents to your office with the complaint of a red splotchy rash on her chest that occurs during intercourse. It is nonpuritic and painless. She states that it usually resolves within a few minutes to a few hours after intercourse. Which of the following is the most likely cause of the rash?

990. A 19-year-old woman presents for voluntary termination of pregnancy 6 weeks after her expected (missed) menses. She previously had regular menses every 28 days. Pregnancy is confirmed by β-human chorionic gonadotropin (β-hCG), and ultrasound confirms expected gestational age. Which of the following techniques for termination of pregnancy would be safe and effective in this patient at this time?

991. A 48-year-old woman presents to your office with the complaint of vaginal dryness during intercourse. She denies any medical problems or prior surgeries and does not take any medications. She still has regular menstrual cycles every 28 days. She denies any sexually transmitted diseases. She describes her sexual relationship with her husband as satisfying. Her physical examination is normal. Components of the natural lubrication produced by the female during sexual arousal and intercourse include which of the following?

992. A 62-year-old woman presents for annual examination. Her last spontaneous menstrual period was 9 years ago, and she has been reluctant to use postmenopausal hormone replacement because of a strong family history of breast cancer. She now complains of diminished interest in sexual activity. Which of the following is the most likely cause of her complaint?

993. A 28-year-old primigravid woman comes to the physician for a follow-up prenatal visit. According to prenatal records, ultrasound at 16 weeks gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She is now at 40 weeks gestation. Examination shows a fundal height consistent with dates and the cervix is not favorable. Fetal heart tracing is reassuring. She wishes to continue the pregnancy for two more weeks rather than undergoing induction. She should be closely monitored for which of the following?

994. A 25-year-old woman, gravida 2, para 1, at 32 weeks gestation is brought to the emergency department because of acute onset severe uterine contractions and moderate vaginal bleeding. Her first pregnancy was uncomplicated. She has a history of cocaine addiction. Ultrasonogram performed at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her temperature is 37.0° C (98.7° F), blood pressure is 130/80 mmHg, pulse is 90/min and respirations are 15/min. Physical examination shows uterine tenderness, hyperactivity, and increased uterine tone. Fetal heart tracing shows 140/min with good long-term and beat-to-beat variability. Which of the following is the most likely diagnosis?

995. A 34-year-old sexually active female comes to your office because of urinary frequency and dysuria for two days. She has had two such episodes in the past, each treated with oral antibiotics. Physical examination reveals suprapubic tenderness and her urinalysis is positive for nitrite, leukocyte esterase, many WBC, and a moderate amount of bacteria. Which of the following is the most common reason for the higher incidence of urinary tract infections in females than in males?

996. A 35-year-old female complains of nipple discharge. The discharge is from both breasts, brown in color and occurs intermittently. She has two children who are 5 and 8 years old. She has not been recently pregnant. Her last menstrual period was one week ago. She describes no other symptoms. Examination shows normal breasts without palpable lumps or nipple abnormalities. Brownish discharge is expressed from the nipples, and it is guaiac negative. Which of the following is the most appropriate next step in management?

997. A 27-year-old female comes to the physician's office for evaluation of infertility. She has not been able to conceive for 12 months despite frequent intercourse. Her menses started at age 12 and have always been irregular. She uses over the counter acne medications. She is also obese and has been unsuccessful with weight loss. Physical examination shows an obese woman with sparse hair over the upper lip. There is no galactorrhea, thyromegaly or clitoromegaly. Which of the following is the most appropriate therapy for this patient's infertility?

998. A 20-year-old, gravida 1, para 0, at 10 weeks gestation is brought to the emergency department because of moderate vaginal bleeding. She has a colicky suprapubic pain radiating to the back and denies the passage of tissue through her introitus. She does not use tobacco, alcohol or drugs. She has no history of trauma or serious illness. Her temperature is 37.0° C (98.7° F), blood pressure is 100/65 mm of Hg, pulse is 90/min and respirations are 17/min. Physical examination shows a dilated cervix and the products of conception can be seen through it. Her blood type is AB Rh negative and her antibody titer is 1:2. Ultrasonogram shows a ruptured gestational sac with no fetal heart motion. Which of the following is the most appropriate next step in management?

999. 28-year-old, G2 P1 woman presented to the hospital at 34-weeks gestation because of midepigastric and right upper quadrant pain associated with nausea and vomiting. She has been closely followed for mild hypertension and mild proteinuria (300 mg/24hr) on an outpatient basis since the 28th week of gestation. Her previous pregnancy was without incident. Her temperature is 37.2° C (98.9° F), blood pressure is 160/94 mmHg and pulse is 80/min. Physical examination shows epigastric and right upper quadrant tenderness; her bowel sounds are slightly reduced. The extremities have 2+ edema. Fetal heart sounds are audible on Doppler. Laboratory studies show: Hb: 8.2g/dl Platelets: 96,000/mm3 Prothrombin time: 12.4 sec Partial thromboplastin time: 23.6 sec Serum creatinine: 1.1 mg/dl Total bilirubin: 2.6 mg/dl Direct bilirubin: 0.8 mg/dl Alkaline phosphatase: 120 U/L Aspartate aminotransferase: 308 U/L Alanine aminotransferase: 265 U/L Lipase: 53 U/L Peripheral blood smear shows numerous red blood cell fragments. Which of the following is the most likely diagnosis?

1000. A 21-year-old gravida 1, para 0 woman comes to the office for a routine prenatal visit at 26 weeks gestation. She has no complaints. She has no significant past medical history. She does not use tobacco, alcohol, or drugs. She takes prenatal vitamins regularly, and has no known drug allergies. Her vital signs are within normal limits. Examination shows a uterine size appropriate for gestational age, and fetal heart tones are heard. One hour 50gram oral glucose tolerance test shows a blood glucose level of 120 mg/dl. Urine culture grew 105 colony forming units/mL of E coli. This patient is at greatest risk for which of the following complications?

1000. A 21-year-old gravida 1, para 0 woman comes to the office for a routine prenatal visit at 26 weeks gestation. She has no complaints. She has no significant past medical history. She does not use tobacco, alcohol, or drugs. She takes prenatal vitamins regularly, and has no known drug allergies. Her vital signs are within normal limits. Examination shows a uterine size appropriate for gestational age, and fetal heart tones are heard. One hour 50gram oral glucose tolerance test shows a blood glucose level of 120 mg/dl. Urine culture grew 105 colony forming units/mL of E coli. This patient is at greatest risk for which of the following complications?

1001. A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0° C (98.7° F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. Nonstress test is performed, and the strip is reactive and reassuring. Which of the following is the most appropriate next step in management?

1002. A wealthy American executive donates five million dollars for the prevention of intrauterine growth restriction in the local county. Spending this money on which of the following programs would prevent the greatest number of cases of fetal growth restriction (FGR) in the population?

1003. A 26-year-old woman, gravida 3, para 2, comes to the physician for the first time for a prenatal checkup. She changed her physician and in the interim has missed two prenatal checkups. She states that she is at 7months gestation. According to her prenatal records and an ultrasound performed at 16 weeks gestation, she is now at 30 weeks, but her fundal height is only 26 cm (10.2 inches). Fetal heart tones are heard by Doppler. Blood pressure is 140/90 mm Hg. You suspect fetal growth restriction (FGR) and order a repeat ultrasonogram. Which of the following is the single most useful parameter for predicting fetal weight by ultrasonogram in suspected FGR?

1004. 24-year-old primigravid woman comes to the physician because of recent onset amenorrhea. Her last menstrual period was 7 weeks ago, and she has had nausea for the past 2 weeks. A urine pregnancy test is positive. She is being evaluated for dysphagia, and one-week ago she had a barium swallow examination. She is concerned for the baby because of her recent exposure to radiation. Which of the following is the most appropriate next step in management?

1005. A 50-year-old woman presents to your office complaining of severe insomnia, hot flashes, and mood swings. She also states that her mother had a hip fracture at 65 years of age. She is afraid of developing osteoporosis and having a similar incident. Her last menstrual period was six months ago. Her past medical history is significant for hypothyroidism diagnosed seven years ago. She takes L-thyroxine and the dose of the hormone has been stable for the last several years. Her blood pressure is 120/70 mmHg and her heart rate is 75/min. Serum TSH level is normal. You consider estrogen replacement therapy for this patient. Which of the following is most likely concerning estrogen replacement therapy in this patient?

1006. A 31-year-old woman comes to the physician because she has not had a menstrual period for 7 months. She previously had normal cycles. She also states that over the past year she has felt increasingly weak and tired. She notes that she always feels cold and that her hair has been thinning over the course of the year. She also complains of constipation, weight gain, and depression. Her temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 56/minute, and respirations are 10/minute. Examination is significant for brittle hair and delayed deep tendon reflexes. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is 20 μU/mL. Prolactin is normal. Which of the following is the most likely cause of this patient's amenorrhea?

1007. A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?

1008. 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient?

1009. A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management?

1010. 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered "unacceptable," so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?

1011. A 68-year-old woman comes to the physician because of a painful lump in her vagina. She states that the lump has been there for a few months, but has recently begun to cause her pain. She has hypertension, for which she takes a diuretic, but no other medical problems. Examination shows a 4 cm cystic mass near the patient's introitus by the right labia. The mass is mildly tender. The remainder of the pelvic examination is normal. Which of the following is the most appropriate next step in management?

1012. A 28-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management?

1013. A 17-year-old female comes to the physician because she has not yet had a menstrual period. She also complains of a lack of breast development. Past medical history is significant for anosmia and color blindness. Past surgical history is significant for a cleft palate that was repaired in childhood. She takes no medications and has no allergies to medications. Examination is significant for absent breast development, and a hypoestrogenic vulva and vagina. Urine hCG is negative. Which of the following is the most likely diagnosis?

1014. A 21-year-old woman, gravida 2, para 1, at 28 weeks' gestation comes to the physician because of spotting after intercourse and a foul-smelling vaginal discharge. Her prenatal course has, up to now, been uncomplicated, and she has no medical problems. Speculum examination shows inflammation of the cervix with a mucopurulent cervical discharge. A gonorrhea and Chlamydia test is performed which comes back positive for chlamydia. Which of the following is the most appropriate pharmacotherapy?

1015. A 38-year-old woman comes to the physician because of burning with urination. She states that the burning started about 2 days ago and has been growing worse since. She has no frequency or urgency. She had one episode of pyelonephritis in the past but no other medical problems. On examination there is no costovertebral angle or abdominal tenderness. The examination is significant for a thick, white vaginal discharge with erythema and excoriations of the labia. Urinalysis is negative. KOH/Normal saline smear demonstrates pseudohyphae. Which of the following is the most likely diagnosis?

1016. A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?

1017. A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward with a gush of blood, abdominal pain, and irregular, painful contractions. Her prenatal course was significant for her being Rh negative and antibody negative. Her temperature is 37 C (98.6 F), pulse is 110/minute, blood pressure is 110/70 mm Hg, and respirations are 12/minute. Abdominal examination shows a tender abdomen and cervical examination shows the cervix to be closed and long with a significant amount of blood in the vagina. The fetal heart rate is in the 170s with moderate to severe variable decelerations with contractions. The diagnosis of placental abruption is made and an emergent cesarean delivery is performed. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?

1018. A 32-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?

1019. A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient?

1020. A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child has delayed physical development. In particular, the mother is concerned because her daughter has not yet had a menstrual period. The daughter began developing breasts at age 10, but has not had her first period. The daughter has no medical problems and takes no medications. Examination shows developing breasts and normal external female genitalia. Which of the following is the most appropriate response to the mother?

1021. A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?1021. A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?1021. A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?1021. A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?1021. A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?1021. A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?

1022. A 25-year-old woman, gravida 2, para 2, comes to the physician to discuss birth control options. She and her partner have tried to use condoms; however, they find it difficult to use them consistently and she would like to try another form of contraception. She has no medical problems, takes no medications, and has no family history of cancer. Her examination is within normal limits. After a discussion with the physician, she chooses to take the oral contraceptive pill (OCP). She stays on the pill for the next three years. She now has most significantly decreased her risk of developing which of the following malignancies?

1023. A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?

1024. A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?

1025. A 25-year-old woman comes to the physician because of pain and burning with urination. She states that the symptoms started two days ago and have worsened since. She has no fever or chills and has never had these symptoms before. She has hypothyroidism for which she takes thyroid hormone replacement. Otherwise she has no medical problems. Her temperature is 37 C (98.6 F). Examination is unremarkable including a normal pelvic examination. A KOH and normal saline "wet prep" is performed on her vaginal discharge and is negative. Urinalysis reveals numerous white blood cells. Which of the following is the most likely pathogen?

1026. A 33-year-old woman comes to the physician because she has not had a menstrual period for 8 months. She had menarche at the age of 12 and, after a few years of irregular menses, has since had normal monthly menses. She has no medical problems and takes no medications. Examination reveals a normal-appearing female with no abnormalities noted. Urine human chorionic gonadotropin (hCG) is negative. Serum thyroid stimulating hormone (TSH) and prolactin are also normal. The patient is given a 10-day course of medroxyprogesterone acetate. Upon completing the 10 days, she has a heavy menstrual period. This patient's withdrawal bleeding in response to the progesterone provides good evidence for which of the following?

1027. A 41-year-old woman, gravida 4, para 3, at term is admitted to the labor and delivery ward with regular contractions every 2 minutes. Examination shows that her membranes are grossly ruptured and that her cervix is 5 cm dilated. Over the following 3 hours, she progresses to full dilation and +2 station. A fetal bradycardia develops, and the decision is made to proceed with vacuum-assisted vaginal delivery. A 7 pound, 8ounce boy is delivered. APGAR scores are 8 at 1 minute and 9 at 5 minutes. Which of the following best represents an advantage of vacuum extraction over the forceps for expediting delivery?

1028. A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?

1029. A 22-year-old woman, gravida 3, para 2, at 22 weeks' gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient?

1030. A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad "flu" with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?

1031. A 34-year-old primigravid woman at 30 weeks' gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patient is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?