Gyneco 141-280GM

141. A 22-year-old woman is being followed by her family physician during her first pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse for the past 15 weeks. Her first prenatal exam was at 12 weeks' gestation, at which time her HIV, chlamydia, gonorrhea, Rh(D)-antibody, and urine cultures were negative. Her blood type is A negative. She does not know who the father of the child is but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?

142. A 28-year-old woman presents to her obstetrician for her first prenatal visit. She is at 8 weeks' gestation as determined by her last menstrual period. She has no medical problems and takes no medications. She does not smoke cigarettes and stopped drinking alcohol when she decided to become pregnant. She has no history of illicit drug use and has never been diagnosed with a sexually transmitted disease. She has been in a monogamous relationship with her husband for the past one year. Her family history is unremarkable. Her BMI is 23 kg/m2. Her physical examination, including vital signs, is within normal limits. Which of the following preventive measures is warranted at this visit?

143. 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?

144. 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 W BC, 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?

145. A 16-year-old girl is brought to your office by her mother for evaluation of primary amenorrhea. Her older sister had her first period at age 13. Vitals signs are within normal limits. Physical examination shows absence of breast development and external genitalia at Tanner stage 1. Examination shows no other abnormalities. Which of the following is the most appropriate next step in management?

146. You are asked to consult on a 31-year-old woman who is at 26 weeks’ gestation and who has had fever for 2 days. She states that she starting feeling fevers and chills approximately 3 days ago. These symptoms have worsened since that time and she has also experienced myalgias, back pain, malaise, and upper respiratory complaints. She was initially diagnosed with the flu, but her condition seems to be worsening. Her prenatal course has been otherwise uncomplicated. She has no past medical or surgical history. Her past obstetric history is significant for a normal spontaneous vaginal delivery 3 years ago. She takes no medications and is allergic to sulfa drugs. Her physical examination is significant for a temperature of 38.3 C (101.0 F) and mild abdominal tenderness. Her urine culture is negative. Her obstetrician performed an amniocentesis yesterday that demonstrated gram-positive rods. Which of the following is the most likely causative organism?

147. A 31-year-old woman comes to the clinic for a preoperative evaluation. She is undergoing an infertility workup and a laparoscopy is planned. She and her husband have been trying to have a child for the last 5 years, but have not had any success. Over that time period, this woman has suffered three miscarriages. Her past medical history is remarkable for anemia, a history of depression, and a deep venous thrombus suffered during her first pregnancy. Her review of systems reveals diffuse arthralgias, but is otherwise unremarkable. She is currently not taking any medications, though she does report having a drug reaction to prenatal vitamins. Early in pregnancy, she had a red facial rash across her face that spared her nasolabial folds. Physical examination today is unremarkable. Laboratory studies, with the exception of a prothrombin time elevated to two times greater than normal, are unremarkable. Which of the following studies will most likely explain this patient’s laboratory abnormality?

148. A 30-year old woman has irregular menses. She reports that her last menstrual period (LMP) was 8 weeks ago. She has been experiencing vaginal spotting and left lower quadrant pain. She is afebrile. She has a normal size uterus and mild tenderness in the right lower quadrant with no rebound tenderness. A human chorionic gonadotropin (hCG) beta-subunit level of 1400 mIU/ml is reported in her records from an obstetrics visit 2 days ago. Which of the following is the appropriate management?

149. You are asked to consult on a 23-year-old woman who is 18hours status-post cesarean delivery. She presented 20 hours ago, at 32 weeks’ gestation, with vaginal bleeding and contractions and a nonreassuring fetal heart rate tracing. She was rushed to the operating room for an emergent cesarean delivery. The placenta had a large retroplacental clot. The infant is in the neonatal intensive care unit. On examination, the patient has a temperature of 37.7 C (99.9 F), blood pressure of 110/60 mm Hg, pulse of 124/min, and respirations of 14/min. The patient has bleeding from her abdominal incision and her intravenous sites. Laboratory studies show: Hematocrit: 18% Leuckocytes: 16,000/mm3 Platelets: 62,000/mm3 Prothrombin time: 60sec Partial thromboplastin time: 100sec Appropriate management includes which of the following?

150. A 27-year-old woman, gravida 3, para 0 (termination of pregnancy ´ 3) comes to your office for an annual examination. Over the past year she has been in good health except for recurrent upper respiratory tract infections. She smokes ½ pack of cigarettes per day. She has tried to stop smoking three times but is not ready to try again to stop now. She takes a combined oral contraceptive pill (OCP) with 35μg of estrogen in it. She takes no other medications and has no known drug allergies. Physical examination, including breast and pelvic exams, is significant for intermittent wheezes on chest auscultation. Regarding her birth control choice, which of the following is the most appropriate counseling?

151. A 20-year-old female comes to the physician because she has never had a period. She has no medical problems, has never had surgery, and takes no medications. Examination shows that she is a tall female with long extremities. She has normal size breasts, although the areolas are pale. She has little axillary hair. Pelvic examination is significant for scant pubic hair and a short, blind-ended vaginal pouch. Which of the following is the most appropriate next step in the management of this patient?

152. A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen?

153. A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since the age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with multiple partners and intermittently uses condoms. She has no medical problems and takes no medications. Her examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of endocervical cells. It is otherwise within normal limits. Which of the following is the most appropriate next step in management?

154. A 24-year-old woman comes to the physician because of right lower quadrant abdominal pain. She has had the pain off and on for the past month, but it is now increasing. She has no other symptoms and no medical problems. Examination reveals a mildly tender, right adnexal mass. Pelvic ultrasound shows a 7 cm right adnexal complex cyst. Urine hCG is negative. The patient is taken to the operating room for laparotomy and right ovarian cystectomy. Microscopically the cyst has cartilage, adipose tissue, intestinal glands, hair, and a calcification that appears to be a tooth. There is also a large amount of thyroid tissue. Which of the following is the most likely diagnosis?

155. A 60-year-old woman comes to the physician for an annual examination. She has no complaints. She had her last menstrual period at age 55 and has had no vaginal bleeding since. She has no medical problems and has never had surgery. She takes no medications and has no allergies to medications. The physical examination is unremarkable. She is concerned about cancer and wants to know which type is the major cause of cancer death in women. Which of the following is the correct response?

156. A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate next step in management?

157. A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response?

158. A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. Coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management?

159. A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy?

160. A 64-year-old woman undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine prolapse. On postoperative day 1, a complete blood count shows the following: Leukocytes.......5500/mm3 Hematocrit.......36% Platelets...........245,000/mm3 By postoperative day 2, the patient is alert and able to ambulate without difficulty. She has no complaints. She has not taken in nutrition orally but is receiving IV fluids. She is voiding without difficulty and has passed flatus. Her temperature is 37 C (98.6 F), blood pressure is 124/72 mm Hg, pulse is 86/min, and respirations are 12/min. Examination shows her abdomen to be soft, nontender, and non-distended. The incision is clean, dry, and intact. The rest of the examination is unremarkable. Which of the following is a reason for keeping this patient hospitalized for a longer period of time?

161. A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient?

162. A 43-year-old primigravid woman at 10 weeks' gestation comes to the physician for a prenatal visit. She is feeling well except for some occasional nausea. She has had no bleeding from the vagina, abdominal pain, dysuria, frequency, or urgency. She has asthma for which she occasionally uses an inhaler. Examination is normal for a woman at 10 weeks gestation. Urine dipstick is positive for nitrites and leukocyte esterase and a urine culture shows 50,000 colony forming units per milliliter of Escherichia coli. Which of the following is the most appropriate next step in management?

163. A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response?

164. A 36-year-old primigravid woman at 36 weeks' gestation comes to the physician for a prenatal visit. She is experiencing good fetal movement and has had no loss of fluid, bleeding from the vagina, or contractions. She has no complaints. Her past medical history is significant for mitral stenosis, which she developed after an episode of rheumatic fever as a child. She also has asthma for which she uses an albuterol inhaler daily. She has herpes outbreaks approximately once a year. At her last visit she was found to be positive for Group B Streptococcus colonization. For which of the following disease processes would this patient benefit by having a forceps-assisted vaginal delivery at the time of delivery?

165. A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management?

166. A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis?

167. During a routine return OB visit, an 18-year-old G1P0 patient at 23 weeks gestational age undergoes a urinalysis. The dipstick done by the nurse indicates the presence of trace glucosuria. All other parameters of the urine test are normal. Which of the following is the most likely etiology of the increased sugar detected in the urine?

168. A 29-year-old G1P0 patient at 24 weeks gestational age presents to your office complaining of some shortness of breath that is more intense with exertion. She has no significant past medical history and is not on any medication. The patient denies any chest pain. She is concerned because she has always been very athletic and cannot maintain the same degree of exercise that she was accustomed to prior to becoming pregnant. On physical examination, her pulse is 72 beats per minute. Her blood pressure is 90/50 mm Hg. Cardiac examination is normal. The lungs are clear to auscultation and percussion. Which of the following is the most appropriate next step to pursue in the workup of this patient?

169. The shortest distance between the sacral promontory and the symphysis pubis is called which of the following?

170. A patient presents in labor at term. Clinical pelvimetry is performed. She has an oval-shaped pelvis with the anteroposterior diameter at the pelvic inlet greater than the transverse diameter. The baby is occiput posterior. The patient most likely has what kind of pelvis?

171. On pelvic examination of a patient in labor at 34 weeks, the patient is noted to be 6 cm dilated, completely effaced with the fetal nose and mouth palpable. The chin is pointing toward the maternal left hip. This is an example of which of the following?

172. 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 (155 cm) 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?

173. A 54-year-old female comes to the physician because of involuntary loss of urine. She states "Doc, whenever I laugh, cough, or sneeze, I am unable to hold my urine. I am afraid to leave the house." She has no involuntary loss of urine while sleeping. She had a hysterectomy four years ago. She has had no trauma to her head or back. She has no other medical problems and takes no medications. Physical examination shows a relaxed anterior vaginal wall. Neurological examination shows no abnormalities. A cotton-tipped swab test reveals a urethral straining angle of 45 degrees when intra-abdominal pressure is increased. Urinalysis shows no abnormalities. Which of the following is most beneficial long-term management for this patient?

174. A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis is insignificant and her blood pressure has ranged from 95 to110 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this patient?

175. A 27-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding and cramping lower abdominal pain. She continues to have cramping in the ER. Her temperature is 37.0° C (98.7° F), blood pressure is 100/76 mmHg, pulse is 84/min and respirations are 14/min. Physical examination shov1s an effaced and dilated cervix. Gestational tissue is visualized through the internal cervical os. Bimanual examination shows the uterus is soft and enlarged, and vaginal bleeding is seen. Which of the following is the most likely diagnosis?

176. A 24-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the physician complaining of aching and swelling in both legs. The aching of her legs is worst at night. She has no shortness of breath or chest pain. She has no past medical history. Her temperature is 36.9° C (98.2° F), blood pressure is 110/70 mmHg, and pulse is 78/min. Physical examination shows symmetrical pitting edema of both calves with no tenderness of either calf. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

177. A 28-year-old woman, gravida 2, para 0, aborta 1, at 30 weeks' gestation comes to the physician because of a decrease in fetal movements. She has felt no fetal movements the past 18-hours. Her prenatal course, prenatal tests, and fetal growth have been normal up to this point. Triple test was performed at 14-weeks and showed no abnormalities. Her first pregnancy was terminated because her fetus was diagnosed with Down's syndrome. She does not use tobacco, alcohol, or drugs. Fetal heart tones are heard by Doppler. Non-stress test is non-reactive; therefore, biophysical profile is performed and shows a score of 8. Which of the following is the most appropriate next step in management?

178. A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding. She has colicky pain in the suprapubic region radiating to her back. Her temperature is 37.0° C (98.7° F), blood pressure is 110/76 mm Hg, pulse is 84/min, and respirations are 14/min. Physical examination shows a dilated cervix and the products of conception are seen through it. Blood is sent to the laboratory for type and antibody screen. The patient is treated with dilation and curettage and all products of conception are evacuated. She is stabilized and transferred to the ward. Her laboratory results are as follows: Hematocrit: 32% Leukocyte count: 8,000 cells/μL Blood type: AB; Rh-negative Anti-Rh antibody titer: 1:4 Which of the following is the most appropriate next step in management?

179. A 30-year-old G2P2 woman comes to the physician with fatigue, mood swings, irritability, breast tenderness, abdominal bloating, and headaches that occur monthly. The symptoms are worse just before her menses and resolve by the third day of her menstrual cycle. The symptoms interfere with her daily activities, including her proficiency at work. The patient's only current medication is a multivitamin. She uses spermicidal foam and condoms for birth control. Her menses are regular. Her sister was diagnosed with hypothyroidism and takes levothyroxine. Examination shows no abnormalities. Which of the following is the most likely cause of her symptoms?

180. A 29-year-old woman presents for a routine prenatal visit She is 24 weeks pregnant by last menstrual period and ultrasound. She does not have any medical problems and does not take any medications. She does not use tobacco, alcohol or illicit drugs. She works as a financial advisor in a local firm. She and her husband have been monogamous since getting married 5 years ago. Vital signs are normal. Physical examination shows no abnormalities. At the end of the visit she tells you that her newborn niece recently had a group B streptococcal infection and she is afraid that her child might develop the same. Which of the following is the most appropriate response?

181. A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucus and a clear cervical secretion, which when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?

182. 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 37.0° C (98.7° F), 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 3 cm 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?

183. The labor nurse calls you in your office regarding your patient who is 30 weeks pregnant and complaining of decreased fetal movement. The fetus is known to have a ventricular septal defect of the heart. The nurse has performed a nonstress test on the fetus. No contractions are seen. She thinks the tracing shows either a sinusoidal or saltatory fetal heart rate (FHR) pattern. Without actually reviewing the FHR tracing what can you tell the nurse?

184. You are counseling a 24-year-old woman who is a G2P1 at 36 weeks gestation. She delivered her first baby at 41 weeks gestation by cesarean section as a result of fetal distress that occurred during an induction of labor for mild preeclampsia. She would like to know if she can have a trial of labor with this pregnancy. Which of the following is the best response to this patient?

185. A 32-year-old poorly controlled diabetic G2P1 is undergoing amniocentesis at 38 weeks for fetal lung maturity prior to having a repeat cesarean section. Which of the following laboratory tests results on the amniotic fluid would best indicate that the fetal lungs are mature?

186. A 24-year-old woman with chronic hypothyroidism presents to her gynecologist for her annual examination. She recently got married, and she and her husband would like to conceive. Her hypothyroidism is well controlled and stable on thyroxine, and she has no other medical conditions. She is healthy and does not smoke or drink alcohol. She would like to know if she should keep taking her thyroxine. Which of the following is the best advice to give this patient?

187. A 32-year-old G3P3 woman is postoperative day 5 after an emergent cesarean section due to fetal distress. The patient progressed rapidly through passive labor without incident, but after her membranes were ruptured manually, a fetal scalp probe was placed in the active phase secondary to several runs of mid-late decelerations. Cesarean section was ultimately performed after 2 hours of active labor secondary to fetal distress. The patient presents now with a fever to 38.7°C (101.7°F) and uterine tenderness. Laboratory tests reveal a WBC count of 14,000/mm³, with 70% neutrophils and 4% bands. Which of the following is the most appropriate treatment?

188. A 32-year-old G3P3 woman presents to her obstetrician for help conceiving. She states her menstrual cycles have not been regular since the birth of her third child 3 years ago. Furthermore, although she readily became pregnant with her other three children, she has failed to become pregnant despite trying over the past 2 years. She has no significant past medical history and takes only prenatal vitamins. Although she says she has not been ill lately, she reports feeling “tired and cold all the time.” She also reports she has had trouble sleeping over the past several months. Her physical examination is normal. Laboratory tests show: WBC count: 9000/mm³ Hemoglobin: 8.0 g/dL Platelet count: 300,000/mm³ Hematocrit: 40% Thyroid-stimulating hormone level: 0.5μU/mL Free thyroxine: 2.0 ng/dL Luteinizing hormone: 0.5 mU/mL Follicle-stimulating hormone: 0.5 mU/mL Which of the following will this woman likely need to take to conceive?

189. At a follow-up routine prenatal visit, the uterine fundus of a healthy 23-year-old pregnant woman is palpated halfway between her symphysis pubis and umbilicus. Which of the following is the most appropriate test to order at this stage of her pregnancy?

190. A 64-year-old woman undergoes left radical mastectomy for breast cancer. A 4-cm infiltrating ductal carcinoma is found on pathologic examination. Four of 20 axillary lymph nodes are positive for malignancy. Neoplastic cells are immunoreactive for estrogen and progesterone receptors. No evidence of metastatic disease is found on bone scanning with 99mTc-labeled phosphate or chest x-ray films. The patient receives appropriate radiation therapy and multidrug chemotherapy. Which of the following is the most appropriate adjunctive therapy in this setting?

191. A 23-year-old gravida 3, para 2 is admitted to the hospital at 31 weeks' gestation with painful uterine contractions. Her cervix is initially 3 cm dilated. Magnesium sulfate is started. Over the next 5 hours she progresses to full dilation. After a 1-hour second stage, she delivers a 2013-g (4-lb, 7-oz) newborn. In the neonatal intensive care unit, the infant develops respiratory distress and pneumonia. Over the following days the infant develops septicemia. Preliminary blood cultures demonstrate gram-positive cocci in chains. Treatment with which of the following would most likely have prevented this neonatal outcome?

192. A 32-year-old Caucasian primigravida presents to your office in her 30'" week of pregnancy. On review of systems, she complains of leg swelling and occasional heartburn. She denies abdominal pain or vaginal discharge. She eats a balanced diet and takes folic acid supplements. Her blood pressure is 165/100 mmHg and her heart rate is 90/min. Which of the following additional findings is most likely in this patient?

193. A 25-year-old woman in her 15th week of pregnancy presents with uterine bleeding and passage of a small amount of watery fluid and tissue. She is found to have a uterus that is much larger than estimated by her gestational dates. Her uterus is found to be filled with cystic, avascular, grapelike structures that do not penetrate the uterine wall. No fetal parts are found. Immunostaining for p57 was negative in the cytotrophoblasts and villi mesenchyme. Which of the following is the best diagnosis?

194. A healthy, 32-year-old, primigravid woman at 12 weeks of gestation comes to the physician for a routine prenatal visit. She has no complaints. She does not use tobacco or alcohol. She has blood group O, Rh(O)+, and her husband has blood group AB, Rh(O)+. She is concerned about the risk of alloimmunization because her mother had that problem during her second pregnancy. Although the child will have a different blood group from the patient, alloimmunization is of little concern due to which of the following?

195. A 76-year-old woman presents with complaints of severe vulvar itching for the past six months. She has tried over-the-counter topical lubricants without relief. Physical examination reveals numerous vulvar excoriations. The vulvar skin is thin, dry and white in color. The labia minora are difficult to visualize. Which of the following is the most appropriate next step in management?

196. A 32-year-old woman, gravida 3, para 2, at 30 weeks’ gestation comes to the hospital because of new onset painful, regular uterine contractions that began 5 hours ago. Her pregnancy has been uncomplicated. Her second pregnancy was complicated by preterm labor at 28 weeks’ gestation. She has no discharge, leakage of fluid or bleeding from the vagina; she has no dysuria or urgency. Her temperature is 37.0° C (98.7° F), blood pressure is 125/70 mmHg, pulse is 80/min and respirations are 18/min. Pelvic examination shows a soft, partially effaced and posterior cervix dilated to 2 cm. A Nitrazine test is negative. Non-stress test shows a reassuring fetal heart pattern and uterine contractions occurring every 7 minutes. Which of the following is the most appropriate next step in management?

197. A 20-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling in her hands and ankles. She has no headache, visual disturbances or epigastric pain. She has no previous medical problems. She does not use tobacco, alcohol or illicit drugs. Her previous prenatal check-up at 28-weeks gestation was normal. Her medical records show no preexisting hypertension or proteinuria. Her blood pressure is 156/100 mmHg, and after 15 minutes of lateral rest, a repeat reading is 154/98mmHg. Physical examination shows 2+ pitting edema in both legs and hands. Deep tendon reflexes are normal. Fundoscopic examination shows no abnormalities. FetaI heart tones are audible by Doppler. Laboratory studies show: Hb: 13.0 g/dl Hct: 50% Platelets: 300,000/mm3 Creatinine: 1.1 mg/dl Urinalysis shows 1+ proteinuria, which is new. Which of the following is the most likely diagnosis?

198. A 17-year-old female comes to the physician's office for a routine physical examination. She has no complaints and has no previous medical problems. She has been having sex since the age of 14 and has had 3 sexual partners so far. Vital signs are stable and physical examination is unremarkable. Pap smear is performed and the report came back as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepithelial lesion). Which of the following is the most appropriate next step in management?

199. A 27-year-old primigravid woman at 28 weeks gestation comes to the physician's office because she has not felt any fetal movements for the past 48 hours. Her pregnancy thus far has been uncomplicated. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She has no history of trauma. She has no history of serious illness. Review of systems reveals no abnormalities. She does not use tobacco, alcohol or drugs. Fetal heart tones are not heard by Doppler. Vital signs are normal. Which of the following is the most appropriate next step in management?

200. A 22-year-old woman presents with complaints of vaginal discharge and severe vulvar pruritus. She is otherwise healthy. Physical examination reveals a thin, malodorous vaginal discharge and marked vulvar and vaginal erythema. The pH of the vaginal discharge is 5.5. Microscopic examination of the discharge is most likely to reveal which of the following:

201. 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?

202. A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit. 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?

203. A 24-year-old woman presents to your office with a self-palpated breast lump. She discovered the mass 2 days ago while taking a shower and noted that it is mildly tender. Her menstrual periods are regular, occurring every 26 days. Her last menstrual period (LMP) was 3 weeks ago. Her past medical history is insignificant. She has no family history of breast cancer. Physical examination reveals a lump in the superior outer quadrant of the right breast without palpable lymphadenopathy. Which of the following is the most reasonable next step in the management of this patient?

204. A 76-year-old woman presents with complaints of severe vulvar itching for the past six months. She has tried over-the-counter topical lubricants without relief. Physical examination reveals numerous vulvar excoriations. The vulvar skin is thin, dry and white in color. The labia minora are difficult to visualize. Which of the following is the most appropriate next step in management?

205. A 30-year-old G2 P 1woman at 38 weeks gestation presents to the hospital complaining of regular and painful uterine contractions that started two hours earlier. Pelvic examination reveals bulging membranes, and her cervix is 50% effaced and dilated to 3 cm. Her pregnancy was complicated by first trimester hemorrhage of unknown cause. Her past medical history is unremarkable. After placing a fetal heart monitor and an external tocometer on the patient, you note 3 separate 15 beat/min decreases in the fetal heart rate not coinciding with uterine contractions, each lasting for 25 seconds. Which of the following is the most appropriate next step in the management of this patient?

206. 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 46XX. Which of the following is the most likely diagnosis?

207. A 24-year-old woman delivered a healthy baby by vaginal delivery at 36 weeks gestation. She had a prolonged premature rupture of the membranes, and mid forceps application was required during delivery. On the second postpartum day she complained of fever and chills. She cannot breast-feed because her "nipples are tender". Her temperature is 38.5C (101.3F), blood pressure is 120/55 mmHg and pulse is 92/min. Bimanual examination shows tender uterus and foul-smelling lochia. Her nipples are cracked but without surrounding erythema or warmth. Physical examination otherwise shows no abnormalities. Which of the following is the most likely diagnosis?

208. 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?

209. A 26-year-old G1 P1 woman requests contraception after delivering a healthy baby three weeks ago. She is breastfeeding the child and plans to continue for at least six months. 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?

210. A 20-year-old, G1 PO, woman at 35 weeks gestation comes to the hospital because of regular uterine contractions. She noticed a passage of clear fluid per vagina for the past 24 hours. She has no other symptoms. Her pregnancy thus far has been uncomplicated. Her temperature is 38.2° C (100.7° F), blood pressure is 120/68 mmHg, pulse is 110/min and respirations are 17/min. Speculum examination shows a closed cervix and clear fluid pooling in the vaginal fornix. The pH of the fluid is 7.5. Fetal heart monitoring shows a rate of 165/min and uterine contractions occurring every 3-4 minutes. Initial laboratory studies show: Hemoglobin: 10.2 g/L Platelets: 198,000/mm3 Leukocyte count: 18,500/mm3 Neutrophils: 86% Lymphocytes: 14% Which of the following is the most likely diagnosis?

211. 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?

212. A 37-year-old woman comes to the physician for evaluation of infertility. She and her 39-year-old husband have not been able to conceive after 13 months of unprotected and frequent intercourse. She has 28-day regular menstrual cycles. The patient had a pregnancy with her husband at age 31. She has no other genitourinary complaints such as menorrhagia, dyspareunia or pelvic pain. She has no previous history of sexually transmitted diseases or abdominal surgery. The patient does not use tobacco, alcohol, or illicit drugs. She is an aerobics instructor and teaches 230-minute classes daily. Her blood pressure is 130/80 mm Hg and pulse is 84/min. Her body mass index is 23 kg/m2. Complete physical examination is unremarkable. Which of the following is the most likely cause of her condition?

213. A 24-year-old, gravida 0, para 0 woman comes to the physician because of an 8-week history of amenorrhea. She is sexually active and uses oral contraceptive pills for contraception. Her only other complaints are moderate fatigue and a decline in mood. She denies headaches, visual disturbances, and gastrointestinal symptoms. She has no other medical problems. She socially drinks alcohol and does not use tobacco or illicit drugs. She denies stress at home or work. She walks 1-2 miles every day. Her BMI is 24 kg/m2. Visual field test is within normal limits. Examination shows no hirsutism. Breast examination reveals a white, milky secretion upon expression of both nipples. Pelvic examination reveals a uterus of normal size. Initial investigations reveal a negative serum β-human chorionic gonadotropin (hCG) level. According to these findings, which of the following is the most appropriate next step in management?

214. A 22-year-old woman (G2POA1) is being followed by her family physician for pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse during her pregnancy. Her first prenatal exam at 12 weeks' gestation showed a negative HIV, Chlamydia, gonorrhea, and urine cultures. Her blood type is A negative and Rh (D) negative. She has not communicated with the father of the child during the pregnancy but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?

215. A 29-year-old woman presents for her first prenatal visit. She is 10 weeks pregnant as determined by her last menstrual period. She does not have any medical problems and does not take any medications. She is devoutly religious and has been in a monogamous relationship with her husband since getting married 5 years ago. They live in a house built in 1983 where she works as a homemaker. Her husband is an accountant. She does not smoke cigarettes or drink alcohol. Her physical exam is within normal limits. Which of the following screening tests is indicated at this time

216. A 17-year-old teenage girl presents to your office with a 10-month history of lower abdominal pain that radiates to the upper thighs and back. The pain is colicky in nature and usually starts a few hours prior to menses, lasting 3-4 days. Menses have occurred at regular 28-day intervals over the past 2 years. She has no inter-menstrual bleeding. She became sexually active 6-months ago and does not use contraception. Physical examination shows healthy external genitalia and well-developed secondary sexual characteristics; the uterus is normal in size and freely mobile. Examination shows no other abnormalities. Which of the following is the most likely cause of her pelvic pathology?

217. A 30-year-old woman, gravida 2, para 1, at 37 weeks gestation is brought to the emergency department because of acute onset intense uterine contractions and vaginal bleeding. She has been followed closely for pre-eclampsia since her 32nd week of gestation. Her temperature is 37.0 C (98.7F), blood pressure is 140/86mmHg, pulse is 92/min and respirations are 18/min. Physical examination shows uterine tenderness and hyperactivity and moderate vaginal bleeding. Pelvic examination shows an effaced and 3cm dilated cervix. Ultrasonography shows a fundic placenta and a fetus in the cephalic position. Fetal heart tracing shows 140/min with good long-term and beat-to-beat variability. After initial resuscitation the bleeding is stopped Which of the following is the most appropriate next step in management?

218. A wealthy 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?

219. A 20-year-old, G1PO, woman at 35 weeks gestation comes to the hospital because of regular uterine contractions and passage of clear fluid per vagina. She has no other symptoms. Her pregnancy thus far has been uncomplicated. Her temperature is 38.2 C (100.7 F), blood pressure is 120/68 mmHg, pulse is 110/min and respirations are 17/min. Speculum examination shows a closed cervix and clear fluid pooling in the vaginal fornix. The pH of the fluid is 7.5. Fetal heart monitoring shows a rate of 165/min and uterine contractions occurring every 3-4 minutes. Initial laboratory studies show: Hemoglobin 10.2 g/L Platelets 198,000/mm3 Leukocyte count 18,500/mm3 Neutrophils 86% Lymphocytes 14% Which of the following is the most likely diagnosis?

220. A 30-year-old African-American woman with type- 1 diabetes and hypertension comes to the physician's office after obtaining a positive result from a home pregnancy test. She takes insulin and enalapril. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (99.0F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination is unremarkable. Her BUN is 18 mg/dl and creatinine is 1.4 mg/dl. A repeat β-HCG test performed in the office confirms pregnancy. Which of the following is the most appropriate next step in management?

221. An 81-year-old woman presents to your office complaining that her uterus fell out 2 months ago. She has multiple medical problems, including chronic hypertension, congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair because of her health problems. Her fallen uterus causes significant pain. On physical examination, the patient is frail and requires assistance with getting on the examination table. She has complete procidentia of the uterus. Which of the following is the most appropriate next step in the management of this patient?

222. A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension, and history of myocardial infarction requiring angioplasty presents to your office for evaluation of something hanging out of her vagina. She had a hysterectomy for benign indications at age 48. For the past few months, she has been experiencing the sensation of pelvic pressure. Last month she felt a bulge at the vaginal opening. Two weeks ago something fell out of the vagina. On pelvic examination, the patient has total eversion of the vagina. There is a superficial ulceration at the vaginal apex. Which of the following is the best next step in the management of this patient?

223. A 40-year-old G3P3 comes to your office for a routine annual GYN examination. She tells you that she gets up several times during the night to void. On further questioning, she admits to you that during the day she sometimes gets the urge to void, but sometimes cannot quite make it to the bathroom. She attributes this to getting older and is not extremely concerned, although she often wears a pad when she goes out in case she loses some urine. This patient is very healthy otherwise and does not take any medication on a regular basis. She still has regular, monthly menstrual periods. She has had three normal spontaneous vaginal deliveries of infants weighing between 7 and 8 lb. An office dipstick of her urine does not indicate any blood, bacteria, WBCs, or protein. Her urine culture is negative. Based on her office presentation and history, which of the following is the most likely diagnosis?

224. A 38-year-old woman presents to your office complaining of urinary incontinence. Her symptoms are suggestive of urge incontinence. She admits to drinking several large glasses of iced tea and water on a daily basis because her mother always told her to drink lots of liquids to lower her risk of bladder infections. Urinalysis and urine culture are negative. After confirming the diagnosis with physical examination and office cystometrics, which of the following treatments should you recommend to the patient as the next step in the management of her problem?

225. A 45-year-old woman with previously documented urge incontinence continues to be symptomatic after following your advice for conservative self-treatment. Which of the following is the best next step in management?

226. An 18-year-old G0 comes to see you complaining of a 3-day history of urinary frequency, urgency, and dysuria. She panicked this morning when she noticed the presence of bright red blood in her urine. She also reports some midline lower abdominal discomfort. She had intercourse for the first time 5 days ago and reports that she used condoms. On physical examination, there are no lacerations of the external genitalia, there is no discharge from the cervix or in the vagina, and the cervix appears normal. Bimanual examination is normal except for mild suprapubic tenderness. There is no flank tenderness, and the patient’s temperature is normal. Which of the following is the most likely diagnosis?

227. A 28-year-old woman presents to your office with symptoms of a urinary tract infection. This is her second infection in 2 months. You treated the last infection with Bactrim DS for 3 days. Her symptoms never really improved. Now she has worsening lower abdominal discomfort, dysuria, and frequency. She has had no fever or flank pain. Physical examination shows only mild suprapubic tenderness. Which of the following is the best next step in the evaluation of this patient?

228. A 17-year-old teenage girl presents to your office with a 10-month history of lower abdominal pain that radiates to the upper thighs and back. The pain is colicky in nature and usually starts a few hours prior to menses, lasting 3-4 days. Menses have occurred at regular 28-day intervals over the past 2 years. She has no inter-menstrual bleeding. She became sexually active 6-months ago and does not use contraception. Physical examination shows healthy external genitalia and well-developed secondary sexual characteristics; the uterus is normal in size and freely mobile. Examination shows no other abnormalities. Which of the following is the most likely cause of her pelvic pathology?

229. A 23-year-old G3POA2 female presents to your clinic at an estimated 12 weeks of gestational age. She is a new patient and has come to your clinic to seek an elective abortion. She has had two elective abortions in the past because of unplanned pregnancy. She has no past medical history and takes no medications. Her physical examination is within normal limits and a limited ultrasound examination was able to detect fetal heart tones. You and your partners have a strict policy against performing abortions because some members of the group object to the procedure. You decide it would be best to stick to this policy; however, the patient becomes angry and tells you that she will sue you if you do not perform the procedure. What is the best response to this patient?

230. A 24-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the physician complaining of aching and swelling in both legs. The aching of her legs is worst at night. She has no shortness of breath or chest pain. She has no past medical history. Her temperature is 36.9 C (98.2F), blood pressure is 11 0/70 mm Hg, and pulse is 78/min. Physical examination shows symmetrical pitting edema of both calves with no tenderness of either calf. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

231. 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?

232. 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 37.0C (98.7F), 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?

233. You have diagnosed a healthy, sexually active 24-year-old female patient with an uncomplicated acute urinary tract infection. Which of the following is the likely organism responsible for this patient’s infection?

234. A 32-year-old woman presents to your office with dysuria, urinary frequency, and urinary urgency for 24 hours. She is healthy but is allergic to sulfa drugs. Urinalysis shows large blood, leukocytes, and nitrites in her urine. Which of the following medications is the best to treat this patient’s condition?

235. You are seeing a patient in the emergency room who complains of fever, chills, flank pain, and blood in her urine. She has had severe nausea and started vomiting after the fever developed. She was diagnosed with a urinary tract infection 3 days ago by her primary care physician. The patient never took the antibiotics that she was prescribed because her symptoms improved after she started drinking cranberry juice. The patient has a temperature of 38.8C (102F). She has severe right-sided CVA tenderness. She has severe suprapubic tenderness. Her clean-catch urinalysis shows a large amount of ketones, RBCs, WBCs, bacteria, and squamous cells. Which of the following is the most appropriate next step in the management of this patient?

236. A 22-year-old woman has been seeing you for treatment of recurrent urinary tract infections over the past 6 months. She married 6 months ago and became sexually active at that time. She seems to become symptomatic shortly after having sexual intercourse. Which of the following is the most appropriate recommendation for this patient to help her with her problem?

237. A 23-year-old G1PO female presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepitheliallesions (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:

238. A 28-year-old G3P2 woman at 32 weeks gestation comes to the physician because she has felt only 2 or 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. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard by Doppler. Which of the following is the most appropriate next step in management of this patient?

239. An 18-year-old woman comes to your office because of abdominal pain. She states that the pain started yesterday afternoon and has been worsening. The pain is in the right lower quadrant and does not radiate. She rates it a 7 on a scale of 1 to 10. She has had some nausea but no vomiting. Nothing seems to improve or worsen the pain. She has a history of hypothyroidism for which she takes thyroid hormone replacement, and no other medical problems. She has never had surgery. She is allergic to penicillin. Physical examination is significant for right lower quadrant tenderness. Bimanual examination reveals right adnexal tenderness. Which of the following is the most appropriate next step in the diagnostic workup of this patient?

240. A 17-year-old married girl comes to see you, complaining of “feeling tired all the time,” vomiting in the morning, and weight gain. Examination shows signs of pregnancy that is confirmed by laboratory studies. When informed of this, the girl is visibly distraught. “How could this happen?” she says, “I’ve been on the pill!” Mentioning that she and her husband live with her parents, she declares that she wants an immediate abortion. Which of the following is the best reply?

241. A 32-year-old woman comes to the physician because of amenorrhea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy?

242. A 32-year-old woman, gravida 3, para 2, at 14 weeks' gestation comes to the physician for a prenatal visit. She has some mild nausea, but otherwise no complaints. She has no significant medical problems and has never had surgery. She takes no medications and has no known drug allergies. She is concerned for two reasons. First, the "flu season" is coming, and she seems to get sick every year. Second, a child at her son's daycare center recently broke out with welts and was sent home. Which of the following vaccinations should this patient most likely be given?

243. A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management?

244. 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 7 months 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 26cm (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?

245. 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 37.0C (98.7F), 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?

246. A 25-year-old G1PO woman at 39 weeks gestation by last menstrual period confirmed by first trimester ultrasound presents to the hospital with complaints of vulvar pain and a "bump" on her vulva. On examination you see clear vesicles and inguinal adenopathy. No cervical or vaginal lesions are present. She is 2cm dilated, 50% effaced and at-2 station. Fetal heart rate and contraction monitoring is started. She is contracting regularly. No abnormalities are seen. Which of the following is the most effective intervention to reduce neonatal morbidity in this patient?

247. A 54-year-old female comes to the physician because of involuntary loss of urine. She states "Doc, whenever I laugh, cough, or sneeze, I am unable to hold my urine. I am afraid to leave the house." She has no involuntary loss of urine while sleeping. She had a hysterectomy four years ago. She has had no trauma to her head or back. She has no other medical problems and takes no medications. Physical examination shows a relaxed anterior vaginal wall. Neurological examination shows no abnormalities. A cotton-tipped swab test reveals a urethral straining angle of 45 degrees when intra-abdominal pressure is increased. Urinalysis shows no abnormalities. Which of the following is most beneficial long-term management for this patient?

248. 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 37° C (99° F), blood pressure is 110/60 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?

249. A 45-year-old woman presents to her physician's office complaining of night sweats and insomnia. She states that for the past month she has woken up completely soaked with perspiration on several occasions. She has had irregular menstrual periods for the past six months. She consumes one ounce of alcohol nightly before going to the bed, and quit smoking 5 years ago. She has a history of hypertension controlled with hydrochlorothiazide. She denies illicit drug use. Her temperature is 36.7° C (98° F), blood pressure is 140/90 mmHg, pulse is 80/min, and respirations are 14/min. Physical examination shows no abnormalities. Which of the following is the best next step in management?

250. A 25-year-old woman is referred to the physician for lactation suppression after the death of her 1-month-old infant from severe sepsis. She is very depressed and complains of breast fullness and tenderness. Examination shows both breasts are warm, firm and tender to palpation. Prenatal records show no abnormalities except mild varicosities. Which of the following is the most appropriate next step in management?

251. A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. This pregnancy has been uncomplicated thus far. She is known to be D (-) while her husband is D (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-D immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-D 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?

252. 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 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?

253. A 32-year-old woman who is one week postpartum presents with dull pain in her left leg for the past three days. She denies any history of trauma, fever or chills. Her pregnancy and delivery were uncomplicated, and her past medical history is unremarkable. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/76 mm Hg. Physical examination reveals a swollen, tender, and mildly erythematous left leg. Doppler ultrasonogram reveals a thrombus in the superficial femoral vein of the left leg. Which of the following is the most appropriate next step in management?

254. A 47-year-old woman presents to your office with complaints of lower abdominal pain, nocturia, urinary urgency and frequency relieved with urination. She states the symptoms have been worsening this past month and she recently experienced dyspareunia. She is sexually active with her husband, but this is causing her a great amount of pain. She has four children and had uncomplicated pregnancies. She denies fevers or chills. On examination, she has diffuse lower abdominal pain with no rebound or guarding. Her external genitalia appear normal. On bimanual examination, palpation of the anterior vaginal wall elicits extreme pain. No cervical motion tenderness is present. No other abnormalities are noted. A urinalysis is negative. The most likely diagnosis is:

255. A previously healthy 50-year-old gravida 5, para 4, Caucasian woman comes to the physician complaining of passing small amounts of urine while sneezing or coughing for the past five months. She denies any episodes of weakness, numbness or fecal incontinence. There is no history of dysuria, increased frequency of urination, or hematuria. Her symptoms are progressively getting worse. Her other medical problems include diabetes mellitus-type 2 diagnosed 3 years ago, treated with glyburide 2.5mg/day. She does not use tobacco, alcohol, or drugs, and has no known drug allergies. She mentions that she is an avid jogger, but her problem causes her significant embarrassment. She now has to wear absorbent pads while jogging. Her vital signs are within normal limits. On examination, the abdomen is soft. Neurological examination is within normal limits. Pelvic examination shows a cystocele. The patient's labs reveal: Urine Specific gravity: 1.020 Blood: negative Glucose: negative Leukocyte esterase: negative Nitrites: negative WBC: 5-10/hpf Bacteria: none Random blood sugar is 120 mg/dl. Which of the following is the most likely cause of her symptoms?

256. A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis is insignificant and her blood pressure has ranged from 95 to11 0 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this patient?

257. A 26-year-old woman comes to the physician for a routine annual visit. She has no complaints. She has no significant previous medical problems. She has been sexually active since the age of 19 with the same partner. They married 4 years ago. She has never had any sexually transmitted diseases. She had her last Pap smear 4 years ago and was within normal limits. She does not use tobacco, alcohol or illicit drugs. Pelvic examination shows no abnormalities. A repeat Pap smear now shows atypical squamous cells of undetermined significance (ASC-US). Which of the following is the most appropriate next step in management?

258. A 20-year old GOPO woman presents to the emergency room with complaints of vaginal bleeding and right lower quadrant pain. Her last menstrual period was approximately 5 weeks ago. She is sexually active and uses condoms occasionally. Her temperature is 37.2° C (98.9° F), blood pressure is 120/74 mm Hg, pulse is 80/min and respirations are 14/min. Examination shows mild right lower quadrant tenderness, but no rebound or guarding. There is no active vaginal bleeding and the cervical os is closed. Her initial hemoglobin is 11.0 g/dl. She is Rh positive and a quantitative β-HCG is 1000 mIU/mL. A vaginal ultrasound is done and no intrauterine or extrauterine pregnancy can be seen. Which of the following is next best step in management?

259. A 26-year-old G1P0 patient at 34 weeks gestation is being evaluated with Doppler ultrasound studies of the fetal umbilical arteries. The patient is a healthy smoker. Her fetus has shown evidence of intrauterine growth restriction (IUGR) on previous ultrasound examinations. The Doppler studies currently show that the systolic to diastolic ratio (S/D) in the umbilical arteries is much higher than it was on her last ultrasound 3 weeks ago and there is now reverse diastolic flow. Which of the following is correct information to share with the patient?

260. A 17-year-old primipara at 41 weeks wants an immediate cesarean section. She is being followed with biophysical profile (BPP) testing. Which of the following is correct information to share with the patient?

261. A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time?

262. A patient presents for her first initial OB visit after performing a home pregnancy test and gives a last menstrual period of about 8 weeks ago. She says she is not entirely sure of her dates, however, because she has a long history of irregular menses. Which of the following is the most accurate way of dating the pregnancy?

263. A healthy 20-year-old G1P0 presents for her first OB visit at 10 weeks gestational age. She denies any significant medical history both personally and in her family. Which of the following tests is not part of the recommended first trimester blood testing for this patient?

264. Your patient is a healthy 28-year-old G2P1001 at 20 weeks gestational age. Two years ago, she vaginally delivered at term a healthy baby boy weighing 6 lb 8 oz. This pregnancy, she had a prepregnancy weight of 130 lb. She is 5ft 4 in tall. She now weighs 140 lb and is extremely nervous that she is gaining too much weight. She is worried that the baby will be too big and require her to have a cesarean section. What is the best counsel for this patient?

265. A healthy 31-year-old G3P2002 patient presents to the obstetrician’s office at 34 weeks gestational age for a routine return visit. She has had an uneventful pregnancy to date. Her baseline blood pressures were 100 to 110/60 to70, and she has gained a total of 20 lb so far. During the visit, the patient complains of bilateral pedal edema that sometimes causes her feet to ache at the end of the day. Her urine dip indicates trace protein, and her blood pressure in the office is currently 115/75. She denies any other symptoms or complaints. On physical examination, there is pitting edema of both legs without any calf tenderness. Which of the following is the most appropriate response to the patient’s concern?

266. 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 3 cm dilated. Amniotomy is performed. Immediately after the rupture of membranes, the baseline fetal heart rate increases to 160 beats/min and then drops to 70 beats/min with repetitive late decelerations. There is severe acute 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?

267. A 25-year-old woman delivered a baby boy at 38 weeks gestation. The newborn has a small body size with microcephaly, hypoplasia of the distal phalanges of the fingers and toes, excess hair and a cleft palate. He weighs 2.5kg (5.51b). Further history or evaluation of the mother would most likely reveal which of the following:

268. A 35-year-old African-American marathon runner presents to the gynecologist complaining of secondary amenorrhea that developed three months ago. Her cycles are normally 28 days long, and her menses last three to five days with moderate flow. One year ago, the woman adopted a vigorous exercise regimen that lasted between three and five hours every day. Since then, her BMI has declined from 23.4 to 16.5 Kg/m2. She has been winning many local races and is considering increasing the difficulty of her exercise regimen, but would like to address the issue of her amenorrhea first. Physical examination reveals a thin woman with well-defined musculature but is otherwise unremarkable. Pregnancy test is negative. What is the most likely etiology of her amenorrhea?

269. A 19-year-old woman with a history of bipolar disorder and psychosis comes to the physician requesting a pregnancy test. Her last menstrual period was 2 months ago. Her menses usually occur every 30 days. She is sexually active with one partner and occasionally uses condoms. She is concerned because she has gained 3 kg (6 lb) in the past 3 months. She also complains of breast tenderness and milky-white discharge from both nipples. She denies headaches, nausea, vomiting, diarrhea, and fever. Her vital signs are within normal limits. Physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is most likely to be responsible for this patient's symptoms?

270. A 62-year-old postmenopausal woman was found to have right adnexal enlargement on pelvic examination 2 weeks ago. Transabdominal and transvaginal ultrasounds revealed a 5 cm, unilocular, right ovarian mass with regular borders. There is no ascites. The patient went through menopause at age 52. She has had no postmenopausal spotting. There is no family history of ovarian or breast cancer. Her latest mammogram 2 months ago showed no abnormalities. Which of the following is the most appropriate course of action?

271. A 26-year-old graduate student presents at her husband's urging, complaining of severe pain during sexual intercourse. She says that she was a virgin when she married her husband two years ago, and that she has been experiencing severe "genital pain" during sex since then. As a result, she avoids sexual intimacy with her husband, which is placing a strain upon their marriage. She also complains of intense pain with her menses and when passing stool. She admits to sporadic pelvic pain that waxes and wanes with no discernible trigger. What would be the most appropriate treatment given this woman's condition?

272. 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 (98.4° F), 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?

273. A 19-year-old woman comes to the emergency department because of a 2-day history of fever, shaking chills and lower abdominal pain. She had an abortion at an outside clinic 3 days ago. Her temperature is 39.8°C(103.7° F), blood pressure is 100/65mmHg, pulse is 114/min and respirations are 26/min. Physical examination shows mild rigidity and guarding. Fundal height is at 12 weeks gestation, the adnexae are free and no mass is noted. Bimanual examination shows uterine tenderness with purulent, offensive vaginal discharge coming out of a dilated cervical os. Which of the following is the most appropriate sequence in management?

274. A 30-year-old woman comes to the physician because of a 10-month history of dysmenorrhea associated with a dull pelvic sensation. She has heavy periods but denies inter-menstrual bleeding. She is sexually active with her husband and does not use contraception because they have been trying to become pregnant for one year. She has no pain during intercourse. Physical examination shows normal external genitalia and an enlarged uterus, but is otherwise normal. Which of the following is the most likely diagnosis?

275. 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?

276. A 28-year-old woman is admitted for delivery. She began experiencing regular, painful uterine contractions three hours ago and her water broke en route to the hospital. The cervix is 5 cm dilated and 80% effaced. The fetal presentation is vertex and the baby's head is at -1 station. After placing a fetal heart monitor and external tocometer, repetitive decreases in fetal heart rate are noted which begin at the same time as the contractions and end before the contractions have ceased. Which of the following is most likely responsible for the fetal heart pattern?

277. A 24-year-old primigravid woman at 28 weeks gestation comes to the physician because she has not felt her baby's movements for the past two weeks. Fetal heart tones are not heard by Doppler. Ultrasonogram shows absence of fetal cardiac activity. Fetal demise is diagnosed. Laboratory studies show: Serum fibrinogen level: 250 mg/dl (normal is 150 - 450 mg/dl) Platelets: 130,000/mm3 Prothrombin time: 15 sec Partial thromboplastin time: 33sec There are no signs of active bleeding. Which of the following is the most appropriate next step in management?

278. A 37-year-old G4 P3 woman delivered a 4,100gram (9.02lbs) infant by spontaneous vaginal delivery one hour ago. This pregnancy has been complicated by gestational diabetes for which she is being treated with insulin. The patient is currently on magnesium sulfate for elevated blood pressures and proteinuria. You are called to evaluate her because she began to have very heavy vaginal bleeding and is feeling lightheaded. Her blood pressure is 90/60 mmHg and pulse is 98/min. On physical examination you see heavy vaginal bleeding and numerous blood clots. Her cervix is closed and the uterus can be palpated 3cm above the umbilicus. The uterus feels boggy. The next best step in management is:

279. A seven-year-old girl is brought to the physician's office because of a sudden onset of growth spurt, pubic hair development, and breast enlargement. Her family history is not significant. She has no other medical problems. On examination, there is no hirsutism or acne. Her weight is 70th percentile and her height is 98th percentile. Examination showed a pelvic mass. Pelvic ultrasonogram showed a right ovarian mass. Initial evaluation showed elevated estrogen levels Which of the following is the most likely diagnosis?

280. A 26-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling of her hands and feet. Her previous prenatal check-up was normal. Blood pressure is 150/95 mmHg, and five minutes later following lateral rest her blood pressure is 140/95 mmHg. Physical examination shows 2+ pitting edema of the legs and a macular eruption on the cheekbones. Optic fundi show no abnormalities. Laboratory studies are as follows: Urinalysis: 4+ protein, RBC casts Urine protein: 8 g/24hr Uric acid: 5 mg/dl BUN: 28 mg/dl Serum creatinine: 2.1 mg/dl Serum electrolytes, liver function tests and coagulation studies are within normal limits. A serum antinuclear antibody (ANA) test is positive in high titers Which of the following is the most likely diagnosis?