Gyneco_USMLE 833-932

833. A Caucasian couple presents to your office for infertility evaluation. They are unable to conceive after 14 months of unprotected sex. The woman is 23 years of age. Her menstrual periods are regular, occurring every 26 days. She denies perimenstrual pain or pelvic discomfort. Her last menstrual period was six days ago. Her past medical history is insignificant, and bimanual examination is normal. The man is 27 years old. He is not taking any medications. Physical examination, including external genitals, is normal. What is the best next step in the management of this couple?

834. A nurse called to report a low grade temperature in a 20-year-old woman who delivered a healthy baby 12 hours earlier. She had a normal vaginal delivery, and the placenta was delivered spontaneously. She had shaking chills during and ten minutes following the delivery. She continues to have bloody vaginal discharge. Her temperature is 38.0C (1004F), blood pressure is 120/80 mmHg, pulse is 76/min and respirations are 14/min. Pelvic examination shows bloody discharge along with small blood clots on the introitus and vaginal walls. Her uterus is soft and non-tender. Laboratory studies show a WBC of 11,000/mm3 with 78% neutrophils. Which of the following is the most appropriate next step in management?

835. A healthy 32-year-old primigravid woman at 12 weeks' gestation comes for a routine prenatal visit. She has no complaints. She does not smoke or consume alcohol. She has blood group 0, Rh+ and her husband has blood group AB, Rh+. She is concerned about the risk of alloimmunization because her mother had that problem during her second pregnancy. You respond that although the child will have a blood group different from hers, alloimmunization is of little concern because:

836. A 37-year-old pregnant woman has a genetic amniocentesis at 16 weeks’ gestation. A concurrent ultrasound shows normal fetal anatomy. Her prenatal course has been unremarkable. Her prenatal laboratory tests include a B-negative blood type, a negative rubella antibody titer, a negative hepatitis B surface antigen, and a hematocrit of 31%. Which of the following is the most appropriate management for this woman?

837. A 19-year-old primigravida at term has been completely dilated for 21/2 hours. The vertex is at 2 to 3 station, and the position is occiput posterior. She complains of exhaustion and is unable to push effectively to expel the fetus. She has an anthropoid pelvis. Which of the following is the most appropriate management to deliver the fetus?

838. A pregnant woman has been taking phenytoin (Dilantin) for a seizure disorder. She is concerned that the drug will cause fetal abnormalities. Which of the following defects is the most common anomaly associated with phenytoin?

839. A 39-year-old woman known to have fibrocystic disease of the breast complains of persistent fullness and pain in both breasts. Which of the following drugs will be most effective in relieving her symptoms?

840. A couple consults you because each has neurofibromatosis and wish to know what their reproductive possibilities are. You should tell them which of the following?

841. A 26-year-old woman complains of a vaginal discharge causing burning and itching of the perineum. The pH of the discharge is 4.5. Which of the following is the most likely cause of her discharge?

842. A 45-year-old woman has bilateral breast pain that is most severe premenstrually. On palpation, there is excessive nodularity, tenderness, and cystic areas that diminish in size after menses. Which of the following is the most likely diagnosis?

843. Which feature of fibrocystic disease of the breast is associated with the greatest risk of developing breast cancer?

844. A 35-year-old woman at 30 weeks’ gestation discovers a lump in her left breast. Examination reveals a 2–3 cm, firm nodule in the upper outer quadrant. Which of the following is the most appropriate next step in the management of this patient?

845. A 1-cm carcinoma of the breast is diagnosed by an excisional biopsy in a 36-year-old woman at 14 weeks’ gestation. The axillary nodes are negative. Which of the following is the best management of this patient?

846. 19-year-old woman, gravida 1, para 1, is immediately status post a normal spontaneous vaginal delivery and normal third stage when she develops brisk bright red bleeding from the vagina. Her prenatal course was unremarkable. She has asthma, which worsened during the pregnancy. Ten years ago, she had a tonsillectomy. She takes a steroid and albuterol inhaler. She has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 115/min, and respirations are 16/min. Her abdomen is soft and non-tender. Her uterus is soft and "boggy" to palpation. Pelvic examination reveals no evidence of a laceration. Which of the following treatments should be avoided in managing this patient's postpartum hemorrhage?

847. A 36-year-old woman, gravida 3, para 3, is 2 days status post cesarean section for dystocia when she begins wandering the hallways of the hospital at 2 AM. She is extremely confused and thinks that she is at the police station. She states that she cannot sleep, feels very anxious, and wants to hurt her baby. Her prenatal course was unremarkable. She has no medical problems and had never had surgery. She has been taking Tylenol with codeine postpartum for incisional pain. Which of the following is the most appropriate next step in the management?

848. A 19-year-old nulligravid woman at 38 weeks' gestation comes to her physician because she has passed bloody mucus discharge. Her prenatal course was unremarkable including a normal 19-week ultrasound. On speculum examination, there are no vaginal or cervical lesions. On vaginal examination, the cervix is 2 cm dilated and 100% effaced, and the fetus is at +1 station. The fetal heart rate has a baseline of 140 and is reactive. She has painful contractions every 2 minutes. One hour later the patient's cervix is 3 cm dilated, and a small amount of bloody mucus is noted on the examining glove. Which of the following is the most likely diagnosis?

849. A 23-year-old woman, gravida 2, para 1 at 26 weeks' gestation, comes to the physician because of fevers and pain in the middle of the back on the right side. Her fevers started 2 days ago, and the back pain began yesterday. Her temperature is 38.3 C (101 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 16/min. She has left costovertebral angle tenderness. Her abdomen is benign and gravid. Her laboratory values show leukocytes of 18,000/mm3. Urinalysis reveals white blood cells that are too numerous to count per high powered field. Which of the following is the most appropriate pharmacotherapy for this patient?

850. A 42-year-old woman, gravida 4, para 3, at 38 weeks' gestation, comes to the labor and delivery ward complaining of contractions. She has had type 1 diabetes since the age of 20. She has a history of syphilis that was adequately treated 4 years ago. She took insulin and prenatal vitamins throughout the pregnancy. Otherwise, her prenatal course was unremarkable, including normal screening. Her blood pressure is 140/90 mm Hg. Her cervix is 4 cm dilated and 100% effaced. She is admitted. Which of the following IV medications will this patient likely require during labor and delivery to prevent neonatal complications?

851. A 22-year-old female comes to the physician complaining of pain during sexual activity. She is unable to have intercourse because her vagina becomes tense, resulting in intense pain upon penetration. She is living with her boyfriend and this is her first sexual relationship. She now avoids intercourse because of her fear of the pain. She has no history of serious illness. Speculum examination is not possible due to tense perineal musculature. Which of the following is the most appropriate next step in management?

852. A 19-year-old college student presents to her primary care physician for emergency contraception. She had unprotected sexual intercourse 48-hours ago while on a trip to Mexico with her boyfriend. She wants to prevent pregnancy. Her last menstrual period was 18-days ago. She has no previous medical problems. Family history is significant for migraines in her mother. She does not use tobacco, alcohol or drugs. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

853. A 28-year-old woman at 30 weeks gestation comes to the physician because of 2 days of a near absence of fetal movements. This is only her second prenatal visit because she has skipped many appointments. She has a medical history significant for chronic hepatitis C infection and a MRSA skin abscess that was drained. She smokes cigarettes and uses heroin, cocaine and alcohol. She says that she is trying hard to be sober. Her temperature is 37.0C (98.7F), blood pressure is 138/85 mm Hg and pulse is 80/min. Physical examination shows a fundal height of 26cm (10.2in). Fetal heart tones are heard by Doppler. Nonstress test (NST) shows no accelerations. After vibroacoustic stimulation, NST is still not reactive so a biophysical profile is ordered and shows a score of 2. Her lab work showed the following: Complete blood count Hemoglobin: 8.0 g/L MCV: 105fl Platelets: 120,000/mm3 Leukocyte count: 3,500/mm3 Which of the following is the most appropriate next step in management?

854. A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. She is known to be 0 (-) while her husband is 0 (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-0 immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-0 antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?

855. A 34-year-old woman, gravida 4, para 3, at 32 weeks gestation is brought to the emergency department because of vaginal bleeding. She has had no uterine contractions or abdominal pain. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation consistent with dates. Her temperature is 37.0 C (98.7F), blood pressure is 90/70 mm of Hg, pulse is 98/min and respirations are 18/min. Physical examination shows continuous bright red vaginal bleeding. Ultrasonogram in the emergency department shows complete placenta previa. Fetal heart tracing shows repetitive late decelerations. The patient's vital signs are stabilized, but the bleeding continues. Which of the following is the most appropriate next step in management?

856. A 24-year-old woman, G1P 1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

857. A 26-year-old woman, gravida 2, para 2, complains of loss of small amounts of urine immediately after a spontaneous vaginal delivery. She received epidural anesthesia during labor and delivery because of severe pain. She has no fever, dysuria, urgency, or hematuria. She has no other medical problems, takes no medication except prenatal vitamins, and has no known drug allergies. Her vital signs are normal. Examination shows a soft, non-tender abdomen. Pelvic examination is normal. The patient voids 30-40ml of urine each time; her postvoid residual volume is 400 mi. The patient's labs reveal: Urine: Specific gravity: 1.020 Blood: trace Glucose: negative Leukocyte esterase: negative Nitrites: negative WBC: 1-2/hpf RBC: 3-4/hpf Which of the following is the most appropriate treatment for her incontinence?

858. A 75-year-old woman comes to the physician complaining of vulvar itch that has been worsening for the past 2 years. She has had no bleeding from the vagina since she underwent menopause at the age of 52. She smokes five cigarettes per day. On physical examination she has a raised, pigmented lesion on the right labia majora. The rest of her physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

859. A 33-year-old, white woman, gravida 3, para 2, at 37 weeks' gestation comes to the emergency department because of painful uterine contractions and heavy vaginal bleeding that started after she used intranasal cocaine. The patient's prenatal course was significant because she conceived while on the oral contraceptive pill, she occasionally used cocaine and heroin during the pregnancy, and she was found to be positive for group B Streptococcus colonization at 35 weeks. Fetal monitoring is not reassuring. The patient undergoes cesarean section, at which the uterus has a bluish hue. On inspection, the placenta is noted to have an adherent, retroplacental clot on 50% of its surface. Which of the following is the most likely initiating factor for this patient's presentation?

860. A 22-year-old primigravid woman at 32 weeks' gestation comes to the emergency department because of heavy vaginal bleeding and abdominal pain. Her prenatal course was unremarkable, including a normal 20- week ultrasound. Physical examination demonstrates a contracted uterus with hypertonus. A large "gush" of blood occurs during the cervical examination, which demonstrates a long and closed cervix. The fetal heart rate tracing shows severe late decelerations. Which of the following is the most appropriate next step in management?

861. A premenopausal, 48-year-old woman undergoes a routine mammographic screening. Physical examination is normal. Mammography identifies a suspicious focus with clustered micro-calcifications located deeply in the lateral upper quadrant of the right breast. No abnormality can be detected in this area on breast examination. Which of the following is the most appropriate next step in diagnosis?

862. A 64-year-old woman comes to the physician because she is "leaking" urine. She states that, over the past 3 years, she has had incontinence several times daily. She describes these episodes as small squirts of urine that come out whenever she laughs, coughs, sneezes, or engages in physical activity. Physical examination shows mild uterine prolapse and a moderate cystocele. Urine culture is negative. Postvoid residual is 25 ml (normal <50 mL) Cystometrogram is normal. Which of the following is the most likely diagnosis?

863. A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

864. A 21-year-old woman presents with left lower quadrant pain. An anterior 7-cm firm adnexal cyst is palpated. Ultrasound confirms a complex left adnexal mass with solid components that appear to contain bone and teeth. What percentage of these tumors are bilateral?

865. A 54-year-old woman undergoes a laparotomy because of a pelvic mass. At exploratory laparotomy, a unilateral ovarian neoplasm is discovered that is accompanied by a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. Which of the following is the most appropriate intraoperative course of action?

866. A 58-year-old woman is seen for evaluation of a swelling in her right vulva. She has also noted pain in this area when walking and during coitus. At the time of pelvic examination, a mildly tender, fluctuant mass is noted just outside the introitus in the right vulva in the region of the Bartholin gland. Which of the following is the most appropriate treatment?

867. A 51-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Intravenous pyelography (IVP) and sigmoidoscopy are negative, but a computed tomography (CT) scan of the abdomen and pelvis shows grossly enlarged pelvic and periaortic nodes. This patient is classified at which of the following stages?

868. A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. How should you classify or stage this patient’s disease?

869. A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. The patient above now asks you for your advice on how to treat her cervical disease. Your best recommendation is for the patient to undergo which of the following

870. A woman is found to have a unilateral invasive vulvar carcinoma that is 2 cm in diameter but not associated with evidence of lymph node spread. Initial management should consist of which of the following?

871. A patient is receiving external beam radiation for treatment of metastatic endometrial cancer. The treatment field includes the entire pelvis. Which of the following tissues within this radiation field is the most radiosensitive?

872. An intravenous pyelogram (IVP) shows hydronephrosis in the workup of a patient with cervical cancer otherwise confined to a cervix of normal size. This indicates which one of the following stages?

873. A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?

874. Stage Ib cervical cancer is diagnosed in a young woman who wishes to retain her ability to have sexual intercourse. Your consultant has therefore recommended a radical hysterectomy. Assuming that the cancer is confined to the cervix and that intraoperative biopsies are negative, which of the following structures would not be removed during the radical hysterectomy?

875. A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?

876. A 70-year-old woman presents for evaluation of a pruritic lesion on the vulva. Examination shows a white, friable lesion on the right labia majora that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the lesion confirms squamous cell carcinoma. In this patient, lymphatic drainage characteristically would be first to which of the following nodes?

877. A 17-year-old girl is seen by her primary care physician for the evaluation of left lower quadrant pain. The physician felt a pelvic mass on physical examination and ordered a pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the ultrasound. Which of the following is the most common ovarian tumor in this type of patient?

878. A 41-year-old woman undergoes exploratory laparotomy for a persistent adnexal mass. Frozen section diagnosis is serous carcinoma. Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in this malignancy?

879. A postmenopausal woman presents with pruritic white lesions on the vulva. Punch biopsy of a representative area is obtained. Which of the following histologic findings is consistent with the diagnosis of lichen sclerosus?

880. A 21-year-old woman returns to your office for evaluation of an abnormal Pap smear. The Pap smear showed a squamous abnormality suggestive of a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy confirms the presence of a cervical lesion consistent with severe cervical dysplasia (CIN III). Which of the following human papilloma virus (HPV) types is most often associated with this type of lesion?

881. A 20-year-old woman presents complaining of bumps around her vaginal opening. The bumps have been there for several months and are getting bigger. Her boyfriend has the same type of bumps on his penis. On physical examination the patient has multiple 2- to 10-mm lesions around her introitus consistent with condyloma. Her cervix has no gross lesions. A Pap smear is done. One week later, the Pap smear returns showing atypical squamous cells of undetermined significance (ASCUS). Reflex HPV typing showed no high-risk HPV. Which of the following viral types is most likely responsible for the patient’s condyloma?

882. A patient is diagnosed with carcinoma of the breast. Which of the following is the most important prognostic factor in the treatment of this disease?

883. A 25-year-old woman presents to you for routine well-woman examination. She has had two normal vaginal deliveries and is healthy. She smokes one pack of cigarettes per day. She has no gynecologic complaints. Her last menstrual period was 3 weeks ago. During the pelvic examination, you notice that her left ovary is enlarged to 5 cm in diameter. Which of the following is the best recommendation to this patient?

884. A 23-year-old woman presents to your office complaining of growths around her vaginal opening. Recently, the growths have been itching and bleeding. On physical examination she has several broad-based lesions measuring 2 to 4 cm in diameter along the posterior fourchette. Although there is no active bleeding, the largest lesion appears to have been bleeding recently. Which of the following is the best way to treat this patient?

885. At the time of annual examination, a patient expresses concern regarding possible exposure to sexually transmitted diseases. During your pelvic examination, a single, indurated, nontender ulcer is noted on the vulva. Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody (FTA) tests are positive. Without treatment, the next stage of this disease is clinically characterized by which of the following?

886. A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV). The diagnosis can be established by which of the following?

887. One day after a casual sexual encounter with a bisexual man recently diagnosed as antibody-positive for human immunodeficiency virus (HIV), a patient is concerned about whether she may have become infected. A negative antibody titer is obtained. To test for seroconversion, when is the earliest you should reschedule repeat antibody testing after the sexual encounter?

888. A 38-year-old woman, gravida 2, para 1, at 10 weeks gestation comes to the physician's office for prenatal counseling of genetic disorders. She has a healthy 3-year-old child. Given her age, she is worried about the risk of Down syndrome, and if her baby test is positive for Down syndrome she would like to terminate the pregnancy. Ultrasonogram shows increased fetal nuchal fold lucency. Which of the following is the most appropriate next step in management?

889. 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?

890. A 7-year-old girl is brought to your office by her parents after they noticed the development of axillary and pubic hair 3 months ago. The girl has also experienced a significant growth spurt over the past year. There has been no change in her behavior or school performance. The girl denies headaches, vomiting or visual disturbances. Her personal and family medical histories are unremarkable. On examination, you note the presence of axillary hair, pubic hair at Tanner stage 2, and breast development at Tanner stage 3. Abdominal, genital and neurologic examinations reveal nothing abnormal. Her bone age is more than two standard deviations above normal. Serum FSH and LH levels are elevated. MRI of the brain is normal. Which of the following is the most likely cause of her symptoms?

891. A 57-year-old woman comes to the physician's office for evaluation of vaginal dryness, burning and dyspareunia. She also has dysuria and increased urinary frequency. The symptoms have been present for several months but have intensified recently. She has tried over-the-counter lubricants with little relief. Her last menstrual period was seven years ago. She takes hydrochlorothiazide for hypertension and pravastatin for hypercholesterolemia. Physical examination shows scarce pubic hair and reduced elasticity and turgor of the vulvar skin. Pale, dry and smooth vaginal epithelium is noted. Urine dipstick is normal. Which of the following is the most appropriate next step in management?

892. A 16-year-old girl presents for evaluation of acne, which has been getting progressively worse over the past 2 weeks. Her medical history is significant for systemic lupus erythematosus (SLE) for which she has been taking prednisone for a recent exacerbation. Hydroxychloroquine is her only other medicine. She does not use tobacco, alcohol or drugs and her menstrual cycle is regular. On physical examination, her blood pressure is 110/76 mmHg and her pulse is 72/min. Her BMI is 22 kg/m2. Distributed over the face, arms and trunk are monomorphous erythematous papules. There are no open or closed comedones. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of her acne?

893. A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit, for the first time. According to her history, she is at 18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is the most appropriate next step in management?

894. A 15-year-old girl is brought to the physician by her mother because she has not begun menstruating. She is otherwise healthy and has no medical problems. Vitals signs are within normal limits. Physical examination shows absence of breast development and no pubic hair is seen. Examination shows no other abnormalities. Ultrasound confirms the presence of a uterus. Which of the following is the most appropriate next step in management?

895. A 24-year-old woman, G1 P1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

896. A 22-year-old, gravida 1, para 0, at 13 weeks gestation is brought to the emergency department because of vaginal discharge and lower abdominal discomfort. She has had no passage of tissue from her vagina. She does not use tobacco, alcohol or drugs. She has no history of trauma. Her temperature is 37.0°C (98.7°F), blood pressure is 128/80 mmHg, pulse is 76/min and respirations are 14/min. Physical examination shows a closed cervix, a slightly tender uterus with a size consistent with gestational age, free adnexa and scant bright red bleeding from the introitus. Ultrasonogram in the emergency department shows normal fetal heart motion. She is anxious and concerned about her baby. Which of the following is the most likely diagnosis?

897. A 28-year-old woman at 39 weeks gestation is admitted to the hospital. She has regular uterine contractions. Her blood pressure is 120/70mmHg, pulse is 80/min and respirations are 18/min. Fetal heart monitoring is placed and shows a baseline rate of 130 beats/min, without any associated abnormalities. Pelvic examination shows the cervix is 50% effaced and 3cm dilated. Amniotomy is performed and a bloody show is noted. Immediately after the rupture of membranes, the baseline fetal heart rate increases to 160 beats/min and then drops to 70beats/min. As labor progresses, repetitive late decelerations are noted, as well as an increase in vaginal bleeding. Repeat vital signs of the patient shows a blood pressure of 130/70mmHg, pulse of 80/min and respirations of 18/min. Which of the following is the most likely cause of the current condition?

898. A 28-year-old woman, gravida 3, para 2, at 28 weeks gestation comes to the physician because she has only felt 2-3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. She does not use tobacco, alcohol or drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard. Which of the following is the next most appropriate step in management?

899. A 20-year-old woman, gravida 1, para 0, at 36 weeks gestation comes to the physician because of diffuse headache, blurry vision and epigastric pain. She has no previous history of hypertension, renal disease or neurologic disease. Her mother has a history of migraine headaches. Her temperature is 37.2 C (98.9 F), blood pressure is 200/126 mmHg and pulse is 80/min. Physical examination shows bilateral lower extremity edema. Deep tendon reflexes are exaggerated. Laboratory studies show: Blood urea nitrogen (BUN) 23 mg/dl Serum creatinine 1.6 mg/dl Blood glucose 98 mg/dl Urinalysis: Protein: 4+ Blood: negative Glucose: negative WBC: 1-2/hpf RBC: 1-2/hpf Casts: none Fetal heart tones are heard by Doppler. While evaluating her, she suddenly develops generalized tonic-clonic convulsions. Which of the following is the most accurate diagnosis of this new event?

900. A 29-year-old woman, gravida 3, para 2, at 35 weeks gestation is brought to the emergency department because of vaginal bleeding. She has had no uterine contractions. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation consistent with dates. Four years ago, she had a low transverse cesarean section in her second pregnancy. Physical examination shows bright red vaginal bleeding. Her temperature is 37.0 C (98.7 F), blood pressure is 100/70 mm Hg, pulse is 90/min and respirations are 16/min. Fetal heart monitoring is reassuring. Which of the following is the most likely diagnosis?

901. A 27-year-old woman, gravida 2, para 1, at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7F), blood pressure is 11 0/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?

902. A 23-year-old woman, gravida 2, para 1, at 38 weeks' gestation was admitted to the delivery room for management of labor. On admission 6-hours ago, the patient was in the active phase of labor and the cervix was 4cm dilated. She was then placed under external tocometer and epidural anesthesia. Contractions were regular, occurring 2-3 minutes apart and lasting 40-60 seconds. She progressed well to 7cm. However, she has remained at 7cm the past 4-hours. The fetus is in the Left Occipita Anterior (LOA) position and at +1 station. Internal pelvic assessment shows prominent ischial spines. Electronic fetal heart monitoring shows 140 bpm with normal beat-to-beat and long term variability. Prenatal ultrasound at 37-weeks showed no abnormalities. Which of the following is the most likely cause of this patient's anomaly of labor?

903. A 24-year-old woman, gravida 2, para 1, at 36 weeks' gestation is brought to the emergency department after passing out. She is drowsy and moaning, complaining of abdominal pain. Her husband accompanies her. He states that she has not experienced any trauma, but that she experienced the sudden onset of severe abdominal pain before she passed out. She has no significant past medical history. Her pregnancy has been uncomplicated thus far. She does not use tobacco, alcohol, or drugs. She takes supplemental vitamins, but no other medications. Her temperature is 36.9 C (98.4F), blood pressure is 90/60 mm of Hg, and pulse is 130/min. Physical examination shows a cold and diaphoretic female. Examination shows a uterus consistent in size with a 36-week gestation; the cervical os is closed and no vaginal bleeding is noted. Which of the following is the most likely diagnosis?

904. A 24-year-old woman presents for her first prenatal visit at 12 weeks gestation. She was diagnosed with HIV two years ago, and her most recent CD4 count three months ago was 600cells/mm3. She does not use tobacco, alcohol, or illicit drugs. Physical examination is within normal limits. Which of the following is the single most important intervention for reducing maternal-fetal transmission of HIV infection?

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?

923' )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?