Part 55

91) A 30-year-old G3P3 is postoperative day 4 after a repeat cesarean delivery. During the surgery she received 2 units of packed red blood cells for a hemorrhage related to uterine atony. She is to be discharged home today. She complains of some yellowish drainage from her incision and redness that just started earlier in the day. She states that she feels feverish. She is breast-feeding. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. Her vital signs are temperature 37.8C (100.1F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Breast, lung, and cardiac examinations are normal. Her midline vertical skin incision is erythematous and has a foul-smelling purulent discharge from the lower segment of the wound. It is tender to touch. The uterine fundus is not tender. Which of the following is not a risk factor for her condition?

92) A 44-year-old G6P3215 presents for her well-woman examination. She tells you that all of her deliveries were vaginal and that her largest child weighed 2900 g at birth. How many full-term pregnancies did this patient have?

93) A 30-year-woman presents to your office with the fear of developing ovarian cancer. Her 70-year-old grandmother recently died from ovarian cancer. You discuss with her the risks factors and prevention for ovarian cancer. Which of the following can decrease a woman’s risk of ovarian cancer?

94) Which of the following statements is true regarding contraception?

95) A 31-year-old primigravida develops gestational diabetes mellitus and is managed appropriately during pregnancy. She asks you about the consequences of gestational diabetes to her and her fetus. Which one of the following statements is correct?

96) A 23-year-old G1P0010 woman complains of severe dysmenorrhea (i.e., pain with menses). She misses work for the first 3 days of her menstrual cycle almost every month and states that this has been a problem for about 3 years, now getting worse. She is not currently sexually active and is not using any hormonal contraception. She complains of occasional deep abdominal pain after bowel movements. Subsequent laparoscopic evaluation reveals endometriosis. Which of the following is a true statement regarding this condition?

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

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

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

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

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

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

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

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

105) 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 170 lb (77 Kg) and is 62 in (155cm) tall. Physical examination shows moderate acne on her face and prominent hair on the upper lip. For which of the following conditions is she at greater risk than the general population?

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

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

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

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

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

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

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

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

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

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

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

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

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

1) A 16-year-old girl presents to the emergency department complaining of fever, chills, abdominal pain, and vaginal bleeding. She gives a history of unprotected sexual activity with her 17-year-old boyfriend over the past several months. Her last menstrual period was 8 weeks ago. She reports having a dilatation and curettage procedure at an unlicensed abortion clinic recently to try to abort the pregnancy. Her temperature is 38.7C (101.7F), heart rate is 120/min, and blood pressure is 100/70 mmHg. Pelvic examination reveals cervical motion tenderness, tissue in the internal os, and foul-smelling vaginal discharge. Urine is positive for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

2) A 19-year-old G0 woman presents to her family physician complaining of dysmenorrhea for the past year. She reports severe right-sided pain that coincides with days 1–5 of her menstrual cycle. Her menses occur regularly every 28 days, and she requires three to four pads per day for the first 2 days of her bleeding and one to two pads per day for the remainder. She has never had surgery. She is not sexually active and does not smoke. Her last menstrual period was 1 week ago. Her temperature is 36.7C (98.1F), blood pressure is 121/74 mmHg, heart rate is 80/min, and respiratory rate is 14/min. Physical examination reveals a thin, healthy-appearing young woman. Pelvic examination reveals a normal sized uterus and no cervical motion tenderness. Which of the following is the most likely diagnosis?

3) After an appropriate diagnostic evaluation, a 59-year-old woman with postmenopausal bleeding had a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). The pathologic diagnosis is adenocarcinoma of the endometrium. An endometrial adenocarcinoma that is confined to the uterus and extends more than 50% through the myometrium is at which stage?

4) A 39-year-old woman at 16 weeks’ gestation complains of headaches, blurred vision, and epigastric pain. Her blood pressure is now 156/104 mmHg. Her uterine fundus is palpable 22 cm above her symphysis pubis. Fetal heart tones could not be heard with a handheld Doppler. She has 3+proteinuria. Which of the following is the most likely diagnosis?

5) A 39-year-old G3P3 complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Results of endometrial biopsy are normal. Which of the following is the most likely diagnosis?

6) A 28-year-old G3P0 has a history of severe menstrual cramps, prolonged, heavy periods, chronic pelvic pain, and painful intercourse. All of her pregnancies were spontaneous abortions in the first trimester. A hysterosalpingogram (HSG) she just had as part of the evaluation for recurrent abortion showed a large uterine septum. You have recommended surgical repair of the uterus. Of the patient’s symptoms, which is most likely to be corrected by resection of the uterine septum?

7) A 22-year-old woman presents with mouth sores, sore throat, vaginal discharge, fever, and myalgia. She has no other medical problems. She takes oral contraceptive pills. She is in a monogamous relationship and states that her partner occasionally uses barrier contraception. Physical examination reveals a temperature of 38.3 C (101 F), cervical and inguinal lymphadenopathy, exudative pharyngitis, and multiple ulcers on the oral mucosa, the labia, and cervix. The vaginal discharge is profuse, and Gram stain indicates many neutrophils. Which of the following is the most likely diagnosis?

8) A 14-year-old Caucasian female presents to clinic for a routine check-up. She complains that her menstrual cycles are irregular and that her menses last seven to ten days. She underwent menarche one year ago and her last menstrual period was two weeks ago. She eats a balanced diet and works out in a gym on weekends. Her past medical history is insignificant and her BMI is 25 kg/m2. Which of the following is the most likely cause of this patient's complaints?

9) A 32-year-old female with a history of amenorrhea develops white nipple discharge. She eats a balanced diet and exercises regularly. She is not sexually active. Her family history is significant for her mother dying of breast cancer at age 50. The most likely diagnosis in this patient is:

10) A 37-year-old female presents to your clinic complaining of lower abdominal discomfort. On bimanual examination the uterus is enlarged. Biopsy reveals normal appearing endometrial glands within the myometrium. The most likely diagnosis is:

11) A 75-year-old woman presents with a pruritic vulvar lesion. Physical examination reveals an irregular white, rough area involving her vulva. Biopsies from this area reveal a combination of squamous hyperplasia of the epidermis (acanthosis) with hyperkeratosis and mild dermal inflammation. No atrophy or dysplasia of the epidermis is seen. What is the best diagnosis?

12) A 65-year-old woman presents with a pruritic red, crusted, sharply demarcated map-like lesion involving a large portion of her labia majora. Histologic sections from this lesion reveal individual anaplastic tumor cells infiltrating the epidermis. Distinctive clear spaces are noted between these anaplastic cells and the surrounding normal epithelial cells. These malignant cells stain positively for mucin and negatively with S100. Which of the following is the most likely diagnosis?

13) A 39-year-old woman presents with severe menorrhagia and colicky dysmenorrhea. A hysterectomy including resection of the fallopian tubes and ovaries is performed. Examination by the pathologist finds a right adnexal cyst measuring approximately 2.3 cm in diameter and filled with clotted blood. Microscopic examination reveals the presence in the wall of the cyst of endometrial glands, stroma, and hemosiderin pigment. What is the best diagnosis?

14) A 23-year-old woman presents with urinary frequency and abnormal uterine bleeding. A careful medical history finds that her abnormal menstrual bleeding is characterized by excessive bleeding at irregular intervals. A pelvic examination finds a single mass in the anterior wall of the uterus, this being confirmed by ultrasonography. Which one of the following clinical terms best describes the abnormal uterine bleeding in this woman?

15) A 25-year-old woman presents with lower abdominal pain, fever, and a vaginal discharge. Pelvic examination reveals bilateral adnexal (ovarian) tenderness and pain when the cervix is manipulated. Cultures taken from the vaginal discharge grow Neisseria gonorrhoeae. Which of the following is the most likely cause of this patient’s adnexal pain?

16) A 28-year-old primigravid woman at 34 weeks gestation is brought to the emergency department following a motor vehicle accident. She had intense abdominal pain and became agitated and restless in the ambulance. She has mild vaginal bleeding and diffuse abdominal pain. She is on continuous fetal heart monitoring. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her blood pressure is 110/60mmHg, pulse is 110/min and respirations are 32/min. Physical examination shows hyperventilation, cold extremities and a distended abdomen with irregular contours. Fetal heart monitoring shows repetitive late decelerations and a long-term variability of 2 cycles/min. Which of the following is the most likely diagnosis?

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

18) A 32-year-old woman, gravida 3, para 2, at 38 weeks gestation is admitted to the hospital for labor pains. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. In her second pregnancy, she had to undergo cesarean section. The woman is admitted to the delivery room and fetal heart and uterine contraction monitoring is started. Her blood pressure is 100/60mmHg, pulse is 115/min and respirations are 26/min. Pelvic examination shows the cervix is 60% effaced and 6cm dilated. Uterine contractions are regular and occurring every 4 minutes. Fetal heart tracing shows no abnormalities. Suddenly, the patient starts complaining of an intense lower abdominal pain. She is restless and vaginal bleeding is noted. Fetal heart monitoring shows variable decelerations, and the fetus has shifted to the ‘-2' station from '0' station Which of the following is the most likely diagnosis?

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

20) During the evaluation of infertility in a 25-year-old female, a hysterosalpingogram showed evidence of Asherman syndrome. Which one of the following symptoms would you expect this patient to have?

21) A 29-year-old woman presents with complaints of a vaginal discharge. She has had two sexual partners over the past 4 weeks, and she reports that she uses oral contraceptives and that her partners were not using condoms. Examination shows she is afebrile, with no lymphadenopathy. Pelvic examination shows no ulcers, but a thick white discharge is noted at the cervical os on speculum examination. A Gram stain of the discharge reveals gram negative diplococci. A sample of the discharge is also sent out for culture. The patient is appropriately treated and returns unhappily 3 weeks later with identical symptoms. A Gram stain of the discharge is again done, and this time reveals no organisms. Which of the following is the most likely cause of her symptoms?

22) An 18-year-old woman presents with amenorrhea and is found to have normal secondary sex characteristics and normal-appearing external genitalia. Her first menstrual period was at age 13, and her cycle has been unremarkable until now. She states that her last menstrual period was 8 weeks prior to this visit. A urine test for hCG is positive. Which of the following is the most likely diagnosis?

23) A 24-year-old woman delivers a normal 8-lb baby boy at 40 weeks of gestation. She has no history of drug abuse, and her pregnancy was unre-markable. Examination had revealed the placenta to be located normally, but following delivery the woman fails to deliver the placenta and subsequently develops massive postpartum hemorrhage and shock. Emergency surgery is performed to stop the bleeding. Which of the following is the most likely cause of her postpartum bleeding?

24) A 26-year-old woman develops acute lower abdominal pain and vaginal bleeding. While in the bathroom she passes a cast of tissue composed of clot material and then collapses. She is brought to the hospital, where a physical examination reveals a soft, tender mass in right adnexa and pouch of Douglas. Histologic examination of the tissue passed in the bathroom reveals blood clots and decidualized tissue. No chorionic villi or trophoblastic tissue are present. Which of the following conditions is most likely present in this individual?

25) 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 mmHg and urinalysis reveals slight proteinuria. Which of the following is the most likely diagnosis?

26) 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?

27) 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?

28) 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?

29) 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?

30) 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?

31) 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?

32) 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?

33) 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?

34) 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?

35) 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?

36) 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?

37) 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 shows 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?