Part 60

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

35) 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?

1) A healthy 25-year-old G1P0 at 40 weeks gestational age comes to your office to see you for a routine obstetric (OB) visit. The patient complains to you that on several occasions she has experienced dizziness, light-headedness, and feeling as if she is going to pass out when she lies down on her back to take a nap. What is the most appropriate plan of management for this patient?

2) A 22-year-old primigravida presents to your office for a routine OB visit at 34 weeks gestational age. She voices concern because she has noticed an increasing number of spidery veins appearing on her face, upper chest, and arms. She is upset with the unsightly appearance of these veins and wants to know what you recommend to get rid of them. Which of the following is the best advice to give this patient?

3) A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 hours. The patient also admits to bouts of nausea and emesis since eating a very spicy meal at a new Thai restaurant the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor who examines her pages you and reports that the patient has a low-grade fever of 37.7C (100F), with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds. She has no rebound tenderness. The patient has a WBC of 13,000, and electrolytes are normal. Which of the following is the most appropriate next step in the management of this patient?

4) A healthy 34-year-old G1P0 patient comes to see you in your office for a routine OB visit at 12 weeks gestational age. She tells you that she has stopped taking her prenatal vitamins with iron supplements because they make her sick and she has trouble remembering to take a pill every day. A review of her prenatal labs reveals that her hematocrit is 39%. Which of the following statements is the best way to counsel this patient?

5) A 14-year-old G1P0 girl who is 29 weeks’ pregnant with twins presents to the emergency department following a seizure. She was watching television and stood up to go to the bathroom when she “fell down and started shaking.” The patient has no history of seizures and is otherwise healthy. She missed her last obstetrician’s appointment, and her aunt states that her niece has had a lot of headaches and swelling over the past 2 days. On examination the patient is somnolent and difficult to arouse, and has edema of her hands and face. Her blood pressure is 205/120 mm Hg, pulse is 80/ min, and respiratory rate is 16/min. The fetal heart rate is 130/min. Which of the following is the most correct advice for the patient’s aunt?

6) A 19-year-old woman at 32 weeks’ gestation was the driver in a front-end motor vehicle crash. The air bags did not inflate, and the patient sustained blunt trauma to the abdomen. The patient is taken to a nearby emergency department in stable condition, where she notes a small amount of bright red blood on her underwear. Maternal vital signs are significant for a heart rate of 110/min and blood pressure of 110/55 mm Hg. What is most appropriate next step in management?

7) A 19-year-old G1P0 woman presents to the emergency department in active labor and delivers a full-term male infant. The infant appears healthy with the exception of jaundice (bilirubin 10 mg/dL [>95th percentile]). The mother does not speak English, but a cousin who does states that he has seen the mother taking pills prescribed by her doctor, although he does not know the reason she was taking medication. Based on the newborn’s jaundice, which drug was the mother most likely taking?

8) A 30-year-old obese G3P2 woman is in active labor at 41 weeks’ gestation. She has no significant past medical history, and had an uncomplicated pregnancy with appropriate prenatal evaluation. The patient ruptured membranes spontaneously 30 minutes ago. Contractions occur regularly every 2–3 minutes. Early decelerations are noted on the fetal heart rate monitor with each of the past five contractions. Which is the most appropriate next step in management?

9) A 25-year-old G2P1 woman who is 36 weeks pregnant presents to her obstetrician complaining of restlessness and weakness for the past month. She says her boyfriend recently left her and their 2-year-old son, and she feels overwhelmed with this pregnancy. She denies feeling depressed but does report that she has trouble sleeping. She had an upper respiratory infection last month, “caught from my son,” and states she still has a sore throat. Laboratory tests show: WBC count: 8000/mm3; Hemoglobin: 11.0 g/dL; Hematocrit: 40%, Platelet count: 250,000/mm3; Thyroid-stimulating hormone: 0.5μU/mL; Free thyroxine: 4.0 ng/dL. Which of the following is the best next step in management?

10) A 36-year-old G1P0 woman pregnant with twins presents to her obstetrician for her routine 32-week appointment. She has gained 5.4kg (12-lb) in the past 2 weeks. When questioned about her weight gain, she states she has had headaches and some blurred vision for the past 2 weeks, which she thinks is secondary to dehydration. To circumvent this, she has been drinking a lot of water, which she claims “is making me swell, even my hands.” She also has had some epigastric pain for the past 2 weeks, which she attributes to “all the water I’ve been drinking.” Her blood pressure is 142/90 mm Hg, pulse is 105/min, and respiratory rate is 18/min. Urinalysis reveals 1+ glycosuria and 4+ proteinuria. Which of the following is the best next step in management?

11) A 23-year-old woman develops painful vulvar vesicles that contain intranuclear inclusions on cytologic examination. She is 22 weeks’ pregnant. Which of the following statements about genital herpes is correct?

12) A 63-year-old woman has a 3-cm pruritic lesion on her right labia majora that she has noted for approximately 9 months. She has been treated with various topical creams and ointments for vulvar candidiasis without resolution of her symptoms or lesion. When you examine this woman, the lesion is still present. Which of the following is the most appropriate intervention?

13) A 35-year-old G3P3 woman has been experiencing bilateral breast pain for the past year. Breast examination and mammography are normal. Conservative measures have failed. Which of the following medications is most likely to bring relief?

14) In the evaluation of a 26-year-old patient with 4 months of secondary amenorrhea, you order serum prolactin and β-hCG assays. The β-hCG test is positive, and the prolactin level is 100 ng/mL (normal is <25 ng/mL in nonpregnant women in this assay). This patient requires which of the following?

15) A 23-year-old married woman consults you because she and her husband have never consummated their marriage because she has severe pain with attempts at vaginal penetration. Her pelvic examination is normal except for involuntary tightening of her vaginal muscles when you attempt to insert a speculum. Which of the following conditions would best be treated with the use of vaginal dilators?

16) A 32-year-old Hispanic woman presents to the emergency department complaining of heavy vaginal bleeding. Her temperature is 37 C (98.6 F), blood pressure is 80/50 mm Hg, pulse is 110/min, and respirations are 18/min. Her abdomen is soft, non-tender and non-distended. Her pelvic examination reveals approximately 200 mL of clotted blood in the vagina, an open cervical os with tissue protruding from it, and a 10-week-sized, non-tender uterus. Leukocyte count is 9000/mm3, hematocrit is 22%, and platelet count is 275,000/mm3. Quantitative hCG is 100,000mIU/L (normal: 5-200,000mIU/L). Pelvic ultrasound shows echogenic material within the uterine cavity consistent with blood or tissue, no adnexal masses, and no free fluid. No viable pregnancy is seen. Which of the following is the most appropriate next step in management?

17) A 25-year-old Caucasian woman, gravida 1, para 0, at 26 weeks' gestational age presents to her physician's office complaining of spotting from the vagina. She has no contractions and reports normal fetal movement. She denies any history of a bleeding disorder. Her temperature is 37.3 C (99.1 F), blood pressure is 100/60 mm Hg, pulse is 75/min, and respirations are 14/min. Her abdomen is gravid and benign, with a fundal height of 26 cm. A placenta previa is ruled out by ultrasound examination. Pelvic examination reveals some scant blood in the vagina, a closed os, and no uterine tenderness. Leukocyte count is 12,000/mm3, hematocrit is 33%, and platelet count is 140,000/mm3. Her blood type is A, Rh negative. Which of the following is the most appropriate pharmacotherapy?

18) A 29-year-old primigravid woman is admitted to the labor and delivery ward with strong contractions every 2 minutes and cervical change from 3 to 4 cm. Over the next 5 hours she progresses to full dilation. After 3 hours of pushing, the physician cuts a mediolateral episiotomy, and the woman delivers a 3770-g (8-lb, 4-oz) boy. Which of the following is the main advantage of a mediolateral episiotomy over a median (midline) episiotomy?

19) A 34-year-old woman, gravida 3, para 2, at 38 weeks gestation presents to the labor and delivery ward complaining of headache. She has no contractions. Her prenatal course was unremarkable until she noted the onset of swelling in her face, hands, and feet this week. Her obstetric history is significant for two normal spontaneous vaginal deliveries. She has no significant past medical or surgical history. Her temperature is 37 C (98.6 F), blood pressure is 160/92 mm Hg, pulse is 78/min, and respirations are 16/min. Examination reveals 3+ patellar reflexes bilaterally. A cervical examination reveals that her cervix is 3 cm dilated and 50% effaced and soft, and that the fetus is at 0 station and vertex. The fetal heart rate has a baseline of 140/min and is reactive. The results from a 24-hour urine collection show 5200 mg of protein (normal <300 mg/24 hours). The patient is given magnesium sulfate intravenously for seizure prophylaxis. Which of the following is the most appropriate next step in the management of this patient?

20) You have just performed diagnostic laparoscopy on a patient with chronic pelvic pain and dyspareunia. The patient had multiple implants of endometriosis on the uterosacral ligaments and ovaries and several on the rectosigmoid colon. At the time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces with the CO2 laser. But because of the extent of the patient’s disease, you recommend postoperative medical treatment. Which of the following medications is the best option for the treatment of this patient’s endometriosis?

21) You are treating a 31-year-old woman with danazol for endometriosis. You should warn the patient of potential side effects of prolonged treatment with the medication. When used in the treatment of endometriosis, which of the following changes should the patient expect?

22) A 30-year-old woman with a genetic disorder characterized by a deficiency of phenylalanine hydroxylase is planning a first pregnancy. Her physician explains the increased risk of mental retardation, as well congenital heart disease, in the infant. Which of the following should also be recommended?

23) A 22-year-old woman, gravida 2, para 1, comes to the physician for her first prenatal visit She had a previous full-term, normal vaginal delivery 2 years ago. She has no medical problems and has never had surgery. She takes no medications and has no known drug allergies. Pelvic examination reveals a mucopurulent cervical discharge, no cervical motion tenderness, and an 8-week-sized, non-tender uterus. A cervical swab is performed. Two days later, the laboratory calls to notify the physician that the patient is positive for Chlamydia trachomatis. Which of the following is the most appropriate pharmacotherapy?

24) A 39-year-old nulligravid woman comes to the physician because of a persistent vaginal itch, vaginal discharge, and dysuria. She has had these same symptoms several times over the past 2 years and each time has been diagnosed with Candida vulvovaginitis. On physical examination, she has a thick, white vaginal discharge and significant vulvar and vaginal erythema. A potassium hydroxide (KOH) smear shows pseudohyphae; the normal saline smear is negative. Which of the following is the most appropriate next step in management?

25) A 22-year-old nulliparous woman comes to the physician with lower abdominal pain, nausea, and vomiting. She is unable to keep anything down. She is sexually active and uses oral contraceptive pills. The patient's last menstrual period was 15 days ago. Her temperature is 39C (102.2F), blood pressure is 110/70 mm Hg, and pulse is 110/min. Physical examination shows dry mucous membranes, soft and symmetrical abdomen, and diffuse tenderness over the lower quadrants. External genitalia show no abnormalities; speculum examination shows purulent discharge from the cervical os. The uterus is normal in size but is tender to palpation and motion. The adnexae are markedly tender but no palpable mass is noted. Cervical cultures are pending. Urine pregnancy test is negative. Which of the following is the most appropriate next step in management of this patient?

26) A 25-year-old primigravid woman at 37 weeks gestation is brought to the emergency department because of severe uterine contractions and moderate vaginal bleeding. She has been followed for pre-eclampsia since her 32nd week of gestation. She is currently having intermittent bleeding. Ultrasonogram in the emergency department shows placental abruption and an intrauterine gestation consistent with dates. Placenta previa is ruled out. Her temperature is 37.0 C (98.7 F), blood pressure is 90/60 mmHg, pulse is 99/min and respirations are 20/min. Physical examination shows uterine tenderness and hyperactivity, increased uterine tone and vaginal bleeding. Her cervix is 1cm dilated and 10% effaced at the time of admission. Fetal heart tracing shows a rate of 110/min, a long-term variability of 4 cycles/min and a beat-to-beat variability of 20/min. Which of the following is the most appropriate next step in management?

27) A healthy 28-year-old woman comes to the physician for an annual physical examination. Her past medical history is unremarkable. Menses occur every 28 days and last 4-5 days. Her last menstrual period was 2 weeks ago. She became sexually active at age 18 and has had 3 sexual partners since then. The patient is in a relationship with her boyfriend of one year and uses oral contraceptives. She does not use tobacco, alcohol, or illicit drugs. Vital signs and general physical examination are within normal limits. Pelvic examination shows no cervical motion tenderness, adnexal masses, or cervical discharge. Pap smear is performed in the office. The results show adequate cellularity with transformation zone present and atypical squamous cells of undetermined significance. Which of the following is the most appropriate next step in management of this patient?

28) A 28-year-old G2, P1 woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020; Blood: ++; Glucose: negative; Ketones: negative; Protein: negative; Leukocyte esterase: negative; Nitrites: negative. What is the best next step in the management of this patient?

29) A 36-year-old woman comes to your office complaining of a 12-month history of inter-menstrual bleeding and heavy menses. She has had type-2 diabetes for the past 4-years, managed with glipizide and metformin. She has no family history of gynecological malignancies. She does not use tobacco or alcohol. Her temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg. Her BMI is 30 Kg/m2. Physical examination shows pale mucus membranes. Pelvic examination is within normal limits; no vaginal lesions are noted. Urine pregnancy test is negative. Her hemoglobin is 10.8 g/dl and platelet count is 223,000/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate next step in management?

30) A 34-year-old woman, gravida 4, para 3, at 32 weeks gestation is brought to the emergency department because of vaginal bleeding. 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 37.0C (98.7 F), 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 with fluids, but the bleeding continues. Which of the following is the most appropriate next step in management?

31) A 32-year-old multiparous African-American woman comes for her initial prenatal visit at 14 weeks' gestation. She complains of the recent appearance of facial hair and acne. The beta-HCG level is consistent with gestational age. Examination shows hirsutism. Ultrasonogram shows an intrauterine gestation consistent with dates and bilateral solid nodular masses in both ovaries. Which of the following is the most appropriate next step in management?

32) A 93-year-old woman is sent to your office from the nursing home for evaluation of vaginal bleeding. She is a poor historian and history is provided by her caregiver. Per her caregiver, she has a history of cerebrovascular accident with residual weakness, myocardial infarction, hypertension, type 2 diabetes mellitus and chronic renal insufficiency. She has been wheelchair-bound and living in the nursing home since her stroke five years ago. She takes multiple medications. Her temperature is 37.2C (98.9F), blood pressure is 176/76mmHg, pulse is 74/min and respirations are 14/min. She is awake, alert, and oriented to person, place and time. Physical examination reveals a friable, bleeding vaginal mass 3 cm in size, and a malodorous vaginal discharge. The remainder of the examination reveals left-sided spasticity and weakness. Biopsy of the mass reveals squamous cell carcinoma of the vagina, that does not extend to the pelvic wall. CT scan of the abdomen and pelvis shows no evidence of metastasis. You call the patient's daughter, who is the power of attorney, and she requests that you do the best you can. Which of the following is the most appropriate next step in management?

33) A 16-year-old teenage girl presents to your office with her mother complaining of primary amenorrhea. Her past medical history is not significant. Her family history is significant for hypothyroidism in her mother. Her vital signs are normal. Examination reveals absent breasts, as well as pubic and axillary hair. The uterus and gonads are visualized on ultrasound, and the FSH level is increased. Which of the following is the most appropriate next step in the management of this patient?

34) A 59-year-old patient with a 2-year history of metastatic breast cancer presents with the acute onset of severe low back pain. She underwent a radical mastectomy and lymphadenectomy 3 years ago. Four of seven nodes were positive at the time of her original diagnosis. One year ago she developed an asymptomatic metastasis to her right femur. On physical examination, she is in severe discomfort and finds movement extremely difficult. She has exquisite tenderness in the lumbar vertebral area, and any motion of her legs or lower back produces extreme pain. An emergent MRI reveals large lytic lesions in L3 and L4. Which of the following is the most appropriate next step in management?

35) A 22-year-old woman comes to the physician with her husband because of vaginal irritation and a malodorous vaginal discharge. Her symptoms started 4 days ago. She also notes pain with intercourse and dysuria. Pelvic examination reveals vaginal and cervical erythema and a copious greenish, frothy discharge. The pH of this discharge is 6.0. A wet preparation is done with normal saline, which shows numerous flagellated organisms that are slightly larger than the surrounding white blood cells. Which of the following is the most appropriate management?

36) A 24-year-old woman asks her physician about the possibility of genetic screening for BRCA1 mutations. Her mother died of breast carcinoma at age 44, and a sister had a diagnosis of in situ ductal carcinoma at age 38. Which of the following is the most appropriate advice to give this woman?

37) 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?

38) A 19-year-old woman presents to the physician's office for routine physical examination and Pap smear. She has no complaints. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no significant past medical history and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72mm Hg. Complete physical exam including pelvic examination is unremarkable. Cervical swab is sent for nucleic acid amplification of Chlamydia trachomatis and Neisseria gonorrhoeae. One week later, the nucleic acid amplification test returns positive for Chlamydia infection. The patient is still asymptomatic. What is the most appropriate next step in the management?

39) 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 (5.5lb). Further history or evaluation of the mother would most likely reveal which of the following?

40) A 30-year-old obese white female comes to the physician with a six months history of oligomenorrhea. She never had this problem before. She has no galactorrhea. She has gained significant weight over the past two years despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap smears since the age of 20; pap smears have shown no abnormalities. She takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid function tests are normal. Which of the following is the most appropriate next step in management?

41) A 36-year-old woman presents to your office for contraception. She has had three vaginal deliveries without complications. Her medical history is significant for hypertension, well-controlled with a diuretic, and a seizure disorder. Her last seizure was 12 years ago. Currently she does not take any antiepileptic medications. She also complains of stress-related headaches that are relieved with an over-the-counter pain medication. She denies any history of surgeries. She is divorced, smokes one pack of cigarettes per day, and has three to four alcoholic drinks per week. On examination, her vital signs include weight 90 kg, blood pressure 126/80 mmHg, pulse 68 beats per minute, respiratory rate 16 breaths per minute, and temperature 36.4C (97.6F). Her examination is normal except for some lower extremity nontender varicosities. She has taken birth control pills in the past and wants to restart them because they help with her cramps. Which of the following would contradict the use of combination oral contraceptive pills in this patient?

42) A 19-year-old primigravid woman at 12 weeks gestation comes to the physician for a routine prenatal visit. Her pregnancy has been uncomplicated to date, and her past medical history is unremarkable. Her medications include a multivitamin with iron and a folate supplement daily. She has no known drug allergies. Examination shows a uterus consistent in size with 12 weeks gestation. Clean-catch urine culture grows >100,000 colony-forming units/ml of Escherichia coli Sensitivity testing on the bacteria is pending. Which of the following is the most appropriate initial pharmacotherapy for this patient?

43) A 23-year-old primigravid woman comes to your office for her first prenatal visit. She is working as an aerobics instructor and is concerned about the effect her exercise schedule might have on the pregnancy. She teaches 30 minutes daily in the morning and does not feel fatigued. She does not use tobacco, alcohol or drugs. Vital signs are normal and physical examination is unremarkable. Which of the following is the best advice to give this patient?

44) A 25-year-old primigravid woman at 37 weeks gestation is brought to the emergency department because of severe uterine contractions and moderate vaginal bleeding. She has been followed for pre-eclampsia since her 32nd week of gestation. She is currently having intermittent bleeding. Ultrasonogram in the emergency department shows placental abruption and an intrauterine gestation consistent with dates. Placenta previa is ruled out. Her temperature is 37.0 C (98.7F), blood pressure is 90/60 mmHg, pulse is 99/min and respirations are 20/min. Physical examination shows uterine tenderness and hyperactivity, increased uterine tone and vaginal bleeding. Her cervix is 1em dilated and 10% effaced at the time of admission. Fetal heart tracing shows a rate of 110/min, a long-term variability of 4 cycles/min and a beat-to-beat variability of 20/min. Which of the following is the most appropriate next step in management

45) 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 the back. Her temperature is 37.0 C (98.7F), blood pressure is 110/76 mmHg, pulse is 84/min and respirations are 14/min. Physical examination shows a dilated cervix and products of conception are seen through it. Blood for grouping and typing is sent. The patient is treated appropriately, and all products of conception are evacuated. She is stabilized and transferred to the ward. Laboratory studies there show: Hematocrit: 33%; WBC: 6,000/mm3; Blood type: AB; Rh negative; Antibody titer: 1:4. Which of the following is the most appropriate next step in management?

46) A 7-year-old girl is seen in your office after her mother began to notice significant changes in her physical appearance. The mother says that she first noticed the development of her daughter's breasts, and she became more worried when her daughter developed both axillary and pubic hair. The patient's grandmother told the mother not to worry because two of the patient's aunts entered puberty at an early age. The patient has not had any behavioral changes or a decline in her school performance, and she denies headaches, visual changes, or vomiting. Physical examination reveals the presence of axillary hair, pubic hair at Tanner stage 3, and breast development at Tanner stage 4. The rest of the examination is unremarkable. GnRH stimulation test results in an increase of LH. Which of the following is the most appropriate management for this patient?

47) A 37-year-old woman comes to the physician because of intermenstrual bleeding and heavy menses. Her other medical problems include hypertension, type 2 diabetes, and hyperlipidemia. Her blood pressure is 144/86 mm Hg. Her BMI is 40 kg/m2. Physical examination shows no obvious abnormalities. Endometrial biopsy shows "complex hyperplasia without atypia." She has three young healthy children and does not want more children in the future. Which of the following is the most appropriate next step in management?

48) A 24-year-old woman, gravida 2, para 1, at 34 weeks' gestation comes for a routine prenatal visit. Her dates were confirmed by first trimester ultrasonogram. She has no painful uterine contractions. Her previous pregnancy was uncomplicated and ended with a normal vaginal delivery. Her vitals are stable and fetal heart tones are reassuring. Physical examination shows a closed cervix, vertex is palpable at the fundus, and the presenting part is not engaged. Which of the following is the appropriate next step in management?

49) A 24-year-old African American female presents in the 35th week of an uncomplicated pregnancy with numbness and burning in her right palm. She says the sensation is so uncomfortable that it frequently makes it difficult to sleep Which of the following is the best initial treatment for this patient?

50) A 19-year-old primigravid woman at 34 weeks' gestation presents for a routine prenatal visit. Her pregnancy has been uncomplicated to date. Her past medical history is unremarkable. She takes one multivitamin and one iron tablet daily. She has no known drug allergies. Physical examination shows a uterus consistent in size with 34 weeks gestational age. Routine clean-catch urine culture grows greater than 100,000 colonies/ml of Escherichia coli Which of the following is the most appropriate pharmacotherapy?

51) 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?

52) 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?

53) 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 37.7C (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?

54) 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?

55) 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?

56) 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?

57) 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?

58) 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?

59) 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?

60) 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?

61) 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?

62) 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?

63) 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?