Gyneco USMLE 101-200

A 26-year-old woman comes to the physician for follow-up after a recent spontaneous abortion at 14 weeks gestation. She had one other spontaneous first trimester abortion two years ago. She has no other medical problems and does not use tobacco, alcohol or drugs. Review of systems reveals photosensitivity and occasional hematuria. On examination, you observe a bilateral malar rash. What is the most likely pathophysiology for her abortions?

A 29-year-old woman, gravida 2, para 0, comes for a routine prenatal visit. According to her history, she is at 16-weeks gestation. She had a first trimester miscarriage during her previous pregnancy. She does not take any vitamin supplementation. Vital signs are stable and physical examination is unremarkable. Initial laboratory studies show increased maternal serum alpha-fetoprotein (MSAFP) levels. Which of the following is the most likely cause of the abnormal laboratory finding?

A 26-year-old woman in the third trimester of her first pregnancy develops persistent headaches and swelling of her legs and face. Early during her pregnancy, a physical examination was unremarkable; however, now her blood pressure is 170/105 mm Hg and urinalysis reveals slight proteinuria. Which of the following is the most likely diagnosis?

A 22-year-old nulliparous woman has recently become sexually active. She consults you because of painful coitus, with the pain located at the vaginal introitus. It is accompanied by painful involuntary contraction of the pelvic muscles. Other than confirmation of these findings, the pelvic examination is normal. Which of the following is the most common cause of this condition?

.A 39-year-old patient is contemplating discontinuing birth control pills in order to conceive. She is concerned about her fertility at this age, and inquires about when she can anticipate resumption of normal menses. You counsel her that by 3 months after discontinuation of birth control pills, what proportion of patients will resume normal menses?

106.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 mm Hg, 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?

107.A 30-year-old woman presents for a physical examination for work. She denies any medical problems or surgeries in the past. She has had no pregnancies. She is sexually active and has been using oral contraceptive pills for the past 6 years. She denies any allergies to medications. On examination, her weight is 62 kg, blood pressure 120/78 mm Hg, pulse 76 beats per minute, respiratory rate 15 breaths per minute, temperature 36.8C (98.4F). Her physical examination is normal. Laboratory evaluation is also done. Which direct effect of birth control pills could be noted in the laboratory results?

108.A 32-year-old woman presents to your office to discuss contraception. She has recently stopped breast-feeding her 8-month-old son and wants to stop her progestin-only pill because her cycles are irregular on it. You recommend a combination pill to help regulate her cycle. You also mention that with estrogen added, the contraceptive efficacy is also higher. In combination birth control pills, which of the following is the primary contraceptive effect of the estrogenic component?

109.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?

110.A 27-year-old woman comes to the physician for preconception counseling. She takes no medication. Her menses are regular, are moderate in amount, and last 5-6 days. Her diet is well balanced. Her grandparents are from Greece. Her husband's family is also of Mediterranean ancestry. Her mother and sister have been diagnosed with anemia, but she does not know the types. The presence of thalassemia anemia in her family is suspected. Which of the following is the most appropriate initial screening test?

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

112.A 22-year-old woman comes to your office at 10 weeks gestation for her first prenatal visit. Her obstetrical history is significant for a spontaneous abortion at 12 weeks gestation one year ago. She states that her mother has hypothyroidism, and she asks you to order thyroid function tests for her. She denies any symptoms, and her physical examination is unremarkable. Ultrasound reveals an intrauterine gestation with normal fetal cardiac activity. Which of the following results is most likely to be expected in this patient?

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

114.A 22-year-old woman presents to your office for her well-woman examination and contraception. She has no medical problems or prior surgeries. She does not smoke or drink. Her vital signs and physical examination are normal. You explain the risks and benefits of combination oral contraceptive pills to the patient. She wants to know how they will keep her from getting pregnant. Which of the following mechanisms best explains the contraceptive effect of birth control pills that contain both synthetic estrogen and progestin?

115.A 45-year-old white female has undergone a right mastectomy for a node-negative, estrogen and progesterone receptor-positive tumor. She is scheduled to begin adjuvant therapy with tamoxifen. Her menstrual cycles are regular and her last menstrual period was 15 days ago. She has many concerns about tamoxifen therapy and would like to know its risks and benefits. Which of the following is she at risk for?

116.A 25-year-old woman at 28 weeks gestation comes to the ER because of strong, regular and painful uterine contractions that started 4 hours earlier with the passage of clear fluid from her vagina. She denies any vaginal bleeding. She has had no prenatal care. Vital signs are normal. A sterile speculum examination shows pooling of amniotic fluid within the vagina, and a cervix that is 4 cm dilated and 80% effaced. Ultrasonogram in the emergency department shows an amniotic fluid index of 4 and bilateral renal agenesis in the fetus. Which of the following is the most appropriate next step in management?

117.A 25-year-old G2 P 1woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul-smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?

118.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. 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?

119.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?

120.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 11 0/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?

121.A 27-year old woman comes to the physician for evaluation of infertility. She and her 31-year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. She has regular 28-day menstrual cycles and during the menstrual cycles she develops mild pelvic pain and bilateral breast tenderness. She has no pain during sexual intercourse. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination is completely unremarkable. Which of the following could most likely be abnormal in this patient?

122.A 22-year-old woman comes to your office at 10 weeks gestation for her first prenatal visit. Her obstetrical history is significant for a spontaneous abortion at 12 weeks gestation one year ago. She states that her mother has hypothyroidism, and she asks you to order thyroid function tests for her. She denies any symptoms, and her physical examination is unremarkable. Ultrasound reveals an intrauterine gestation with normal fetal cardiac activity. Which of the following results is most likely to be expected in this patient?

123.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?

124.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?

125.A 38-year-old Caucasian female presents to the office complaining of lethargy, weight gain and fatigue. She denies headaches, pruritus or urine discoloration. She just gave birth 2 months ago via vaginal delivery; her baby is in good health and receives formula nutrition. Her delivery was complicated by vaginal bleeding that required blood transfusion, and postpartum endometritis that rapidly responded to antibiotics. She has not had any menstrual periods following delivery. Physical examination shows sparse pubic hair, dry skin and delayed tendon reflexes. Urinalysis shows no glucose or ketones. Which of the following is most likely to be responsible for this patient's condition?

126.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?

127.A 24-year-old gravida 2, para 1, African American woman at 12 weeks gestation comes for her first prenatal visit. Except for early morning mild headaches and nausea she has no other symptoms. Physical examination shows mild bilateral ankle edema. Blood pressure is measured twice 15 minutes apart and is 150/96 mmHg on both occasions. Blood is drawn for laboratory tests and the patient is sent home with a follow-up appointment 3 days later. She returns 3 days later and repeat blood pressure is the same. Laboratory studies show: Urinalysis: Protein: negative Blood: negative Glucose: negative Ketones: negative Leukocyte esterase: negative Nitrites: negative WBC:1-2/hpf RBC: 1-2/hpf Chemistry panel Serum sodium: 150 mEq/L Serum potassium: 2.5 mEq/L Chloride: 100 mEq/L Bicarbonate: 23 mEq/L Blood urea nitrogen (BUN): 14 mg/dL Serum creatinine: 0.8 mg/dL Ultrasonogram reveals intrauterine gestation consistent with dates; no abnormalities noted. Which of the following is the most likely diagnosis?

128. An 18-year-old woman arrives in your clinic with primary amenorrhea, sexual infantilism, and clitoromegaly. She has a history of ambiguous external genitalia noted at birth. Reviewing her records, you see that laparotomy performed at 17 months of age revealed normal internal female genitalia and ovarian biopsy performed at that time revealed normal-appearing primordial follicles. Laboratory studies today reveal a normal female karyotype and high serum testosterone and androstenedione concentrations. Estradiol and estrone are undetectable in the serum. Serum FSH and LH concentrations are high. Pelvic imaging shows multiple ovarian cysts. What is the most likely diagnosis?

129.A 32-year-old woman, gravida 1, is in active labor. Lumbar epidural anesthesia is being used for pain control. She is having contractions every two to three minutes. The cervix is 4 cm dilated. Fetal heart rate is reassuring. Her blood pressure is 90/55 mmHg and heart rate is 120/min. What is the most probable cause of her hypotension?

130.A 29-year-old woman, gravida 2, para 1, at 37 weeks gestation was admitted to the hospital. Her previous pregnancy was uncomplicated and she delivered a 3,500 g (7.7lb) baby vaginally. The current pregnancy demonstrated a breech presentation at 30 weeks gestation. A repeat ultrasonogram now shows persistent frank breech presentation with an estimated fetal weight of 2,800 g (6 lb). No fetal or uterine abnormalities are noted. She has intact membranes. Examination shows a closed cervix. Fetal heart monitoring is reassuring. Which of the following is the most appropriate next step in management?

131.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?

132.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?

133.A 27-year-old female at 30 weeks gestation complains of difficulty hearing, especially on the right side. She denies any ear pain or discharge. Her pregnancy was complicated by acute pyelonephritis at 22 weeks gestation, which was treated with antibiotics. She does not smoke or consume alcohol, and she eats a balanced diet. She has no preexisting medical problems and takes no medications aside from a multivitamin. Her blood pressure is 160/100 mmHg and heart rate is 75/min. Cardiac and pulmonary examinations are unremarkable. No focal abnormalities are found on neurologic examination. When a tuning fork is placed on the right mastoid process, she appreciates the tone louder than when it is held near the external auditory meatus. Audiometry shows right low-frequency hearing loss. Which of the following is the most likely cause of this patient's complaints?

134.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?

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

136.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?

137.Five patients present for contraceptive counseling, each requesting that an IUD be inserted. Which of the following is a recognized contraindication to the insertion of an IUD?

138.A 30-year-old woman presents to your office for her well-woman examination and contraception. She has two prior vaginal deliveries without any complications. Her medical and surgical histories are negative. Her family history is significant for coronary heart disease in her father and breast cancer in her mother diagnosed at the age of 62 years. In addition to effective contraception, health benefits for women taking oral combination contraceptives include which of the following?

139.A couple presents to your office to discuss permanent sterilization. They have three children and are sure they do not want any more. You discuss the risk and benefits of surgical sterilization. Which of the following statements is true regarding surgical sterilizations?

140.A couple presents to your office to discuss sterilization. They are very happy with their four children and do not want any more. You discuss with them the pros and cons of both female and male sterilization. The 34-yearold male undergoes a vasectomy. Which of the following is the most frequent immediate complication of this procedure?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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: