516-1031 obstrestic tiya

35-year-old G1 PO woman at 35 weeks gestation by last menstrual period and confirmed by a first trimester ultrasound comes to the hospital because of leakage of fluid one hour ago. She received her prenatal care at an outside hospital and the records are not available. She reports no other complications with this pregnancy thus far. She reports no medical problems, takes no daily medications other than a prenatal vitamin, and has no allergies to medications. She is examined and preterm premature rupture of membranes is confirmed by a positive nitrazine test, positive pooling test, and a positive ferning test. She is 2 cm dilated, 50% effaced, and at -2 station. She is admitted to the hospital. Transabdominal ultrasound confirms that the fetus is in a vertex presentation, and the amniotic fluid index is decreased at 3 cm. Fetal heart rate and contraction monitoring is started, and occasional uterine contractions are noted on the monitor. Which of the following is the most appropriate next step in management?

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

A 30-year-old G2 P1 woman at 38 weeks gestation comes to the hospital because of regular and painful uterine contractions that started two hours ago. Pelvic examination reveals bulging membranes, and her cervix is 50% effaced and dilated to 3 cm. Her pregnancy was complicated by first trimester hemorrhage of unknown cause. Her past medical history is unremarkable. Upon observing the fetal heart rate monitor and an external tocometer for 20 minutes, you note 6 contractions. You also note 4 separate 15 - 20 beat/min decreases in the fetal heart rate with every contraction. The depth and duration of decelerations vary with successive uterine contractions. Which of the following is the most appropriate next step in the management of this patient?

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

A 22-year-old professional tennis player presents to your office with a 5-month history of amenorrhea. She describes an intense schedule of regular exercise, and says that she eats a balanced diet but avoids fatty foods. She does not smoke or consume alcohol. Her mother suffers from long-standing hypertension. The patient's BMI is 22.5 kg/mm2. Pregnancy test is negative. The patient is at greatest risk for which of the following?

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

A 25-year-old G1 PO woman at 39 weeks gestation by last menstrual period confirmed by first trimester ultrasound presents to the hospital with complaints of vulvar pain and a "bump" on her vulva. On examination you see clear vesicles and inguinal adenopathy. No cervical or vaginal lesions are present. She is 2 cm dilated, 50% effaced and at -2 station. Fetal heart rate and contraction monitoring is started. She is contracting regularly. No abnormalities are seen. Which of the following is the most effective intervention to reduce neonatal morbidity in this patient?

A 24-year-old woman, gravida 2, para 2, comes to the physician for a yearly physical and birth control counseling. She is currently using the rhythm method of birth control, but has heard that this method has a high failure rate and would like to try a different method. Several of her friends use the intrauterine device (IUD), and she is wondering whether she could also use this method. Past medical history is significant for eczema. Past surgical history is significant for a right ovarian cystectomy 2 years ago. Past gynecologic history is significant for multiple episodes of Chlamydia cervicitis and two episodes of pelvic inflammatory disease (PID), the most recent episode occurring 1 year ago. She takes acetaminophen for occasional tension headaches. She is allergic to penicillin. She smokes onehalf pack of cigarettes per day. Physical examination is unremarkable. Which of the following would be the best recommendation for this patient regarding her birth control method?

A 26-year-old woman, gravida 2, para 1 at 28 weeks' gestation, comes to the physician for a follow-up ultrasound after a previous ultrasound demonstrated a marginal placenta previa. The present ultrasound shows complete resolution of the marginal previa, but the fetus is noted to be in breech presentation. The patient has otherwise had an unremarkable prenatal course. She has no medical problems and has never had surgery. She takes prenatal vitamins and is allergic to sulfa drugs. Assuming that the fetus stays in breech presentation, when should an external cephalic version be attempted?

A 27-year-old woman, gravida 2, para 1, at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0° C (98.7° F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?

A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea. She says that it all started two months ago and progressively worsened. She is sexually active and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the following: Serum pregnancy test: Negative Free T4: 2.5 μg/dl (N= 5-12) Serum TSH: 11 .0 μU/ml (N= 0.5-5.0) Prolactin: 30 ng/ml (< 20 ng/ml) Antimicrosomal antibodies: Positive of the following, which represents the association between hypothyroidism and hyperprolactinemia in the above patient?

A 25-year-old female presents to the office for a prenatal visit. She is gravida 3, para 0, ab 2. Her first abortion was an elective abortion at 18 weeks gestation. Her second abortion was a spontaneous abortion at 17 weeks gestation. She has had a cervical loop electrosurgical excision(LEEP) procedure, 8 months ago, for severe cervical dysplasia. Her LMP was 16 weeks ago. She does not use tobacco, alcohol or illicit drugs. She has had an uneventful pregnancy thus far and denies any concerns at this visit. Her temperature is 98.6° F (37° C), blood pressure is 100/64, heart rate is 72/minute and respirations are 17/minute. Her uterine fundus measures 14.5 cm and is consistent with a 15-16 weeks gestation. The fetal heart rate is 140/minute. This patient is at greatest risk for which of the following complications?

A 22-year-old woman presents to office with a 3-week history of scant vaginal discharge. She has no other complaints. She is sexually active and uses oral contraceptives. She has regular 26-day menstrual cycles and her last menstrual period was ten days ago. She does not smoke or consume alcohol. Her temperature is 36.7° C (98° F), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 14/min. On examination, the abdomen is nontender. Yellow mucopurulent discharge is seen at the cervical os. Which of the following organisms is the most probable cause of this patient's problem?

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

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

A 36-year-old woman, gravida 3, para 2, comes to the physician for a prenatal checkup. According to her last menstrual period and an ultrasonography performed at 16 weeks gestation, she is at 30 weeks gestation. She missed two antenatal appointments. She does not use tobacco, alcohol, or drugs. Examination shows a fundal height of 26 cm (9.8 in). Fetal heart tones are heard by Doppler. Repeat ultrasound shows a fetal biparietal diameter consistent with 30 weeks and an abdominal circumference below the 10th percentile. Which of the following could most likely be responsible for the observed fetal findings?

A 19-year-old primigravid woman at 34 weeks gestation comes to the physician because of diffuse headache, right upper quadrant pain and visual disturbances. During her last visit two weeks ago she was found to have an elevated blood pressure and 1+ proteinuria. She was advised to follow-up closely and sent home on bed rest. Her blood pressure today is 176/120 mm Hg and pulse is 86/min. Physical examination shows 2+ pitting edema in both legs and right upper quadrant tenderness. Fetal heart tones are audible by Doppler. Urinalysis shows 3+ proteinuria. Serum aspartate aminotransferase (AST) is 88 U/L and alanine aminotransferase (ALT) is 80 U/L. Serum creatinine now is 1.4 mg/dl. Which of the following is the most likely cause of her right upper quadrant pain?

A 26-year-old woman presents to her physician because of pain in her breast. She gave birth 3 months ago and is breast-feeding. Soon after she began lactating she developed cracks in the nipples, and for the past 5 days her left breast has become progressively more tender. On physical examination, her affected breast is red, hot, swollen, and painful to palpation. Her temperature is 38.3 C (101 F), and her white cell count is 13,000/mm3. Which of the following is the most likely diagnosis?

A 32-year-old G3P2 woman at 38 weeks gestation is admitted to the hospital for labor pains. Her prenatal course, prenatal tests, and fetal growth have been normal. Ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. In her second pregnancy, she underwent a cesarean section. The woman is admitted to the delivery room and fetal heart and uterine contraction monitoring is started. Her blood pressure is 100/60 mm Hg, pulse is 115/min, and respirations are 26/min. Pelvic examination shows that the cervix is 60% effaced and 6 cm dilated. Uterine contractions are regular and occur every 4 minutes. Fetal heart tracing shows no abnormalities. The patient suddenly complains of intense lower abdominal pain. She is restless and vaginal bleeding is noted. Fetal heart monitoring shows repetitive variable decelerations, and the fetus has shifted from 0 to -2 station. Which of the following is the most likely diagnosis?

A 36-year-old woman, gravida 2, para 1, at 16 weeks' gestation undergoes amniocentesis for evaluation of Down syndrome. She has no past medical history. Immediately after the procedure she becomes breathless, cyanotic and loses consciousness. Minutes later, she experiences a generalized tonic-clonic seizure. A generalized purpuric rash is noted. Her blood pressure is 90/50 mm Hg, pulse is 110/min, and respirations are 26/min. Oxygen saturation is 75% on 100% facemask. Which of the following is the most appropriate next step in management?

536. A 16-year-old female presents to the ER complaining of left lower quadrant abdominal pain that started suddenly 24 hours ago. The pain does not radiate and is 5/10 in severity. She denies having fevers, vomiting, dysuria, diarrhea or vaginal bleeding. Her last menstrual period was two weeks ago. She takes no medications. On physical examination, her temperature is 37.2° C (98.9° F), blood pressure is 110/65 mmHg, pulse is 80/min and respirations are 14/min. There is mild left lower quadrant tenderness without rebound or rigidity, and the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

537. A 23-year-old primigravid woman at 38 weeks gestation is admitted to the delivery room for management of labor. She has been in active labor for 4 hours, during which her cervical dilation has progressed from 3 cm to 8 cm and descent has progressed from the -1 to +1 station. Examination 6 hours later shows the same degree of dilation and descent. The fetal head is in the left occipitoanterior (LOA) position. An external tocometer reveals adequate contractions 3 minutes apart lasting 50 seconds each. Internal pelvic assessment reveals prominent ischial spines. Fetal heart monitoring shows a baseline of 140/min with frequent accelerations. Prenatal ultrasound at 37 weeks showed a fetus of average size. Which of the following is the most appropriate next step in management?

538. A 19-year-old primigravid woman at 32 weeks gestation comes to the physician's office because of w eight gain and mild generalized body swelling. She has no previous medical problems and her pregnancy has been otherwise uncomplicated. Her blood pressure is 150/90 mm Hg. Physical examination show s mild generalized edema; the remainder of her examination is unremarkable. A fetal heart tracing is reassuring. Laboratory studies show: Hematocrit: 48% Platelets: 230,000/mm3 Serum creatinine: 1.0 g/dl Alanine aminotransferase: 35 U/L Urinalysis: 2 +protein Amniotic fluid analysis show s immature fetal lungs. She lives close to the hospital and is compliant with medication follow-ups. Which of the following is the most appropriate next step in management?

539. 53-year-old obese, menopausal woman comes to the physician for a routine annual examination. Her last menstrual period was one year ago. Upon further questioning, she says that she sometimes experiences hot flashes of mild intensity. She is sexually active and denies vaginal dryness or dyspareunia. Her medical problems include mild hypertension managed with hydrochlorothiazide and a salt-reduced diet. Her obstetrical history is significant for an elective termination of pregnancy at 35 years of age because of an abnormal maternal serum alpha-fetoprotein. Physical examination is normal. Which of the following is a possible cause of the comparatively milder nature of the symptoms the patient is having compared to many other menopausal women with more severe symptoms?

540. A 39-year-old G5P5 woman delivered a 4.1-kg (9-lb) healthy male infant 20 minutes ago. She is now experiencing heavy vaginal bleeding, with the passage of large blood clots. She had an uncomplicated pregnancy, with a 15.9-kg (35-lb) weight gain. The patient had spontaneous onset of labor and spontaneous rupture of the membranes at 5 cm dilation. Labor lasted 3 hours, including 10 minutes of pushing. She did not have an episiotomy. The placenta delivered spontaneously 5 minutes after the infant, was normal in appearance, and was intact with a 3-vessel cord. The patient's previous 4 pregnancies and deliveries were normal. Her blood pressure is 110/60 mm Hg, pulse is 106/min, and respirations are 20/min. The uterine fundus is soft and at the level of the umbilicus. The patient's peri-pad is saturated with blood, and there are clots extruding from the vagina. Which of the following is the most likely cause of this patient's symptoms?

541. A nurse called to report a low grade temperature in a 20-year-old woman who delivered a healthy baby 12 hours earlier. She had a normal vaginal delivery, and the placenta was delivered spontaneously. She had shaking chills during and ten minutes following the delivery. She continues to have bloody vaginal discharge. Her temperature is 38.0° C (100.4° F), blood pressure is 120/80 mmHg, pulse is 76/min and respirations are 14/min. Pelvic examination shows bloody discharge along with small blood clots on the introitus and vaginal walls. Her uterus is firm and non-tender. Laboratory studies show a WBC of 11,000/mm3 with 78% neutrophils. Which of the following is the most appropriate next step in management?

542. A 51-year-old woman comes to your office for a routine health maintenance examination. She has no medical history but states that she has been having irregular menses and occasional hot flashes for the past eight months. Her husband has told her that she appears moody all the time. She has not had any surgeries in the past and currently takes no medications. She has a very stressful job and drinks two to three cups of coffee every morning. She does not smoke, but she does drink four to five twelve-ounce beers a day for the past 20 years to relieve her stress. She is a lacto-ovo vegetarian and walks two miles on a treadmill each day. Her temperature is 36.5° C (97.7° F), blood pressure is 120/70, heart rate is 84 beats/minute, and respirations are 12/minute. She is 5'4" and weighs 180 pounds (BMI is 30.9 kg/m2). Physical examination is unremarkable. You inform her that she is probably reaching menopause, and that she will be at an increased risk of developing osteoporosis. Which of the following is the most significant risk factor for the development of osteoporosis in this patient?

543. A 25-year-old woman comes to the physician with abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms intermittently in 7- to 10-day episodes. In retrospect, she is unable to identify any triggers for her symptoms. The patient has a history of postpartum depression but has no recent feelings of hopelessness or guilt Physical examination is normal. Complete blood count, serum chemistries, and thyroid-stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management of this patient?

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

545. A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (98.9F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 110/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50% Platelets: 200,000/mm3 Serum sodium: 130 mEq/L Serum potassium: 2.8 mEq/L Chloride: 86 mEq/L Bicarbonate: 30 mEq/L Blood urea nitrogen (BUN): 30 mEq/L Serum creatinine: 1.6 mg/dl Blood glucose: 98 mg/dl Which of the following is the most appropriate next step in management?

546. A 17-year-old female comes to your office for advice. She says that she is planning to have sexual intercourse with her boyfriend for the first time. However, she is worried about contracting a urinary tract infection because she has heard that there is a high incidence of UTI's in sexually-active females. Which of the following is the most appropriate advice to give this patient to decrease her chance of contracting a urinary tract infection?

547. A 19-year-old woman comes to the emergency department because of a 2-day history of fever, shaking chills and lower abdominal pain. She had an abortion at an outside clinic 3 days ago. Her temperature is 39.SC (103.7F), blood pressure is 100/65mmHg, pulse is 114/min and respirations are 26/min. Physical examination shows mild rigidity and guarding. Fundal height is at 12 weeks gestation, the adnexae are free and no mass is noted. Bimanual examination shows uterine tenderness with purulent, offensive vaginal discharge coming out of a dilated cervical os. Which of the following is the most appropriate sequence in management?

548. A 25-year-old woman presents to your office complaining of a seven-week history of amenorrhea. She also states that she has had nausea and vomiting for five weeks. She is sexually active. Her medical and obstetrical histories are unremarkable. Serum hCG level is elevated. Which of the following is the most important role of hCG in pregnancy?

549. 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?

550. Your patient delivers a 7-lb 0-oz male infant at term. On physical examination, the baby has normal-appearing male external genitalia. However, the scrotum is empty. No testes are palpable in the inguinal canals. At 6 months of age the boy’s testes still have not descended. A pelvic ultrasound shows the testes in the pelvis, and there appears to be a uterus present as well. The presence of a uterus in an otherwise phenotypically normal male is owing to which of the following?

551. A 25-year-old woman presents to your office for evaluation of primary infertility. She has regular periods every 28 days. She has done testing at home with an ovulation kit, which suggests she is ovulating. A hysterosalpingogram demonstrates patency of both fallopian tubes. A progesterone level drawn in the mid–luteal phase is lower than expected. A luteal phase defect is suspected to be the cause of this patient’s infertility. Which of the following studies performed in the second half of the menstrual cycle is helpful in making this diagnosis?

552. A 45-year-old woman who had two normal pregnancies 15 and 18 years ago presents with the complaint of amenorrhea for 7 months. She expresses the desire to become pregnant again. After exclusion of pregnancy, which of the following tests is next indicated in the evaluation of this patient’s amenorrhea?

553. A 22-year-old woman consults you for treatment of hirsutism. She is obese and has facial acne and hirsutism on her face and periareolar regions and a male escutcheon. Serum LH level is 35 mIU/mL and FSH is 9 mIU/mL. Androstenedione and testosterone levels are mildly elevated, but serum DHAS is normal. The patient does not wish to conceive at this time. Which of the following single agents is the most appropriate treatment of her condition?

554. An 18-year-old college student, who has recently become sexually active, is seen for severe primary dysmenorrhea. She does not want to get pregnant, and has failed to obtain resolution with heating pads and mild analgesics. Which of the following medications is most appropriate for this patient?

555. A 20-year-old female with Müllerian agenesis is undergoing laparoscopic appendectomy by a general surgeon. You are consulted intraoperatively because the surgeon sees several lesions in the pelvis suspicious for endometriosis. You should tell the surgeon which of the following?

556. A 19-year-old patient presents to your office with primary amenorrhea. She has normal breast and pubic hair development, but the uterus and vagina are absent. Diagnostic possibilities include which of the following?

557. A 27-year-old woman presents to your office complaining of mood swings, depression, irritability, and breast pain each month in the week prior to her menstrual period. She often calls in sick at work because she cannot function when she has the symptoms. Which of the following medications is the best option for treating the patient’s problem?

558. A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Which of the following classes of medication is a possible cause of her condition?

559. Which of the following pubertal events in girls is not estrogen dependent?

560. A 9-year-old girl has breast and pubic hair development. Evaluation demonstrates a pubertal response to a GnRH-stimulation test and a prominent increase in luteinizing hormone (LH) pulses during sleep. These findings are characteristic of patients with which of the following?

561. A 54-year-old Caucasian female is complaining of hot flashes, vaginal dryness and irritability. Her symptoms started about a year ago, and have been gradually getting worse. She has not had a menstrual period for 12 months. She currently smokes 1 pack of cigarettes daily and drinks a glass of wine occasionally. The cardiorespiratory examination is unremarkable. Inspection of her vagina reveals dryness and atrophy. She asks about the risks and benefits of combination hormone replacement therapy (HRT). Which of the following is NOT an appropriate statement to make regarding this treatment modality?

562. A 26-year-old woman presents for evaluation of infertility. She describes her menstrual cycles as irregular stating that they occur anywhere between 32 to 35 days. She has no galactorrhea. She eats a balanced diet and exercises regularly. She has no other medical problems. Her BMI is 22 Kg/m2. Physical examination is unremarkable. Which of the following is the most appropriate initial test to evaluate her infertility?

563. A 30-year-old woman, gravida 3, para 2, at 26 weeks gestation comes to the physician because of a decrease in fetal movements. She has felt few fetal kicks the past 20 hours. Her prenatal course, prenatal tests and fetal growth have been normal. She has chronic hypertension and is now taking methyldopa and labetalol. Her previous pregnancies were uncomplicated and both delivered vaginally. She does not use tobacco, alcohol or drugs. Fetal heart tones are heard by Doppler. Non-stress test is reactive. Which of the following is the most appropriate next step in management?

564. 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 4cm 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?

565. A 30-year-old female comes to the office complaining of vaginal discharge, dyspareunia and vulvar pruritus. She has a history of hypothyroidism and takes thyroid replacement therapy. She uses tobacco and alcohol every day. On examination, you notice a thin, grayish vaginal discharge and erythema and edema of the vulva and vaginal mucosa. The pH of the discharge is 6.0 and wet-mount examination reveals pear-shaped motile organisms. First line treatment is prescribed for both the patient and her partner. The patient must avoid which of the following during the treatment period?

566. A 16-year-old Caucasian female is brought to your office by her mother who is concerned that her daughter has not had menstrual bleedings yet. Her past medical history is significant for an episode of severe bilateral pneumonia that required hospitalization when she was seven years old. Physical examination reveals Tanner stage 3 breast development, but very little pubic and axillary hair. A left-sided inguinal mass is palpated. A blind vaginal pouch is noted on pelvic exam. A karyotype analysis showed 46 XY. Which of the following is the most appropriate next step in the management of this patient?

567. A 30-year-old female delivers a term male infant with signs of thyrotoxicosis. Prior to the pregnancy, she was surgically treated for Graves’ disease and was prescribed hormone replacement therapy in the form of levothyroxine 0.25 mg daily. Levothyroxine was maintained during pregnancy and thyroid hormone levels were monitored and maintained within the reference range. Which of the following is the most likely cause of the neonate's condition?

568. A 37-year-old woman presents for evaluation of infertility. She and her 39-year-old husband have not been able to conceive after 9 months of unprotected and frequent intercourse. She had one pregnancy with her husband when she was 31. She has 28-day regular menstrual cycles and enjoys frequent sexual intercourse. She has no other complaints. She denies any previous history of sexually transmitted diseases or abdominal surgery. She does not use tobacco, alcohol or drugs. She has been working as an aerobic teacher and teaches two 30 minute classes every day. Her blood pressure is 130/80 mmHg and her pulse is 84/min. Her BMI is 23 Kg/m2. Complete physical examination is unremarkable. Which of the following is most likely cause of her condition?

569. A 24-year-old woman comes to your office complaining of an 8-week history of amenorrhea. She is sexually active and uses OCPs for contraception. Her medical history is unremarkable. She does not have any particular complaints except moderate fatigue and a decline in mood. She denies headaches, visual disturbances, or any gastrointestinal symptoms. She denies cigarette smoking or any drug use, and drinks alcohol socially. Breast examination reveals a white, milky secretion upon expression of both nipples. A pelvic examination reveals a uterus of normal size. BMI is 28 kg/m2. Initial investigations reveal a negative serum beta-hCG level. According to these findings, which of the following is the most appropriate next step in the management of this patient?

570. 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 4cm 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?

571. A 23-year-old woman complains of breast pain two days after delivering her first child. The delivery was complicated by mild postpartum bleeding. On exam, both breasts are tense, warm, and tender to touch. Her blood pressure is 130/70 mmHg, heart rate is 100/min, and temperature is 994 0F (37,4 0C). What is the most likely diagnosis?

572. 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?

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

574. A 34-year-old obese female returns to the physician's office for a follow-up appointment at 16 weeks gestation. She was diagnosed with gestational diabetes at 12 weeks gestation and since then has been following dietary recommendations. She eats a balanced diabetic diet three times a day and avoids snacks. Her fasting blood sugars for the past two weeks have been in between 120 to 150 mg/dl. Her temperature is 37.0C (98.7F), blood pressure is 130/88 mmHg, pulse is 76/min and respirations are 14/min. Physical examination is unremarkable. Which of the following is the most appropriate therapy for this patient?

575. A 25-year-old female comes to the physician because of abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms seven to ten days before the start of each menstrual cycle. She has a past history of postpartum depression, but she denies any recent feelings of hopelessness or guilt. Physical examination shows no abnormalities. Complete blood count, serum chemistries and thyroid stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management?

576. A 23-year-old, gravida 2, para 1 woman at 30 weeks gestation comes to the ER after she noticed a sudden gush of clear fluid coming from her vagina. She has had no uterine contractions or vaginal bleeding. Her pregnancy has been uncomplicated; she has had consistent prenatal care. Vital signs are normal. Sterile speculum examination shows the cervix is minimally effaced and 2cm dilated; there is pooling of clear fluid in the vaginal fornix, and when pressure is applied to the fundus, clear fluid comes out of the cervix. Emergency ultrasound shows a fetus of average size in the vertex presentation and an Amniotic Fluid Index (AFI) of 15. Nonstress test shows a baseline of 120 bpm and frequent accelerations. Amniotic fluid analysis shows lecithin/sphingomyelin ratio of 1.0. Which of the following is the most appropriate next step in management?

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 37.2 C (98.9 F), blood pressure is 176/76, 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 3cm 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?

578. A 33-year-old woman is 12 weeks pregnant with her third pregnancy. Her prior two pregnancies were uncomplicated and resulted in two normal spontaneous vaginal deliveries. It has been 7 years since her last delivery, and 4 years ago she was diagnosed with chronic hypertension. She was managed on an ACE-inhibitor but discontinued all medication when she started trying to conceive 6 months ago. She is doing well during the pregnancy except for some mild nausea and rare vomiting. Her physical examination is within normal limits for a woman at 12 weeks’ gestation. Her current blood pressure is 100/60 mmHg. At which of the following blood pressures should antihypertensive therapy be initiated in this patient?

579. A 39-year-old woman, gravida 3, para 2, at 39 weeks’ gestation comes to the labor and delivery ward with regular contractions and gush of fluid 1 hour ago. On examination she is found to have rupture of membranes and is 4 cm dilated. She is admitted to labor and delivery. Her prenatal course was significant for a 36-week vaginal culture that was positive for Group B Streptococcus (GBS) that is sensitive to clindamycin. She also has gestational diabetes that is treated with diet. She has no other medical problems and has never had surgery. She takes no medications and is allergic to penicillin. After she is admitted to the labor and delivery ward, a penicillin infusion is erroneously started. Soon thereafter, the patient develops generalized pruritus and urticaria with angioedema and difficulty breathing. Which of the following is the most appropriate next step in the management of this patient?

580. An infertile couple presents to you for evaluation. A semen analysis from the husband is ordered. The sample of 2.5 cc contains 25 million sperm per mL; 65% of the sperm show normal morphology; 20% of the sperm show progressive forward mobility. You should tell the couple which of the following?

You suspect that your infertility patient has an inadequate luteal phase. She should undergo an endometrial biopsy on which day of her menstrual cycle?

You have recommended a postcoital test for your patient as part of her evaluation for infertility. She and her spouse should have sexual intercourse on which day of her menstrual cycle as part of postcoital testing?

583. You ask a patient to call your office during her next menstrual cycle to schedule a hysterosalpingogram as part of her infertility evaluation. Which day of the menstrual cycle is best for performing the hysterosalpingogram?

584. You have recommended that your infertility patient return to your office during her next menstrual cycle to have her serum progesterone level checked. Which is the best day of the menstrual cycle to check her progesterone level if you are trying to confirm ovulation?

585. Your patient is 43 years old and is concerned that she may be too close to menopause to get pregnant. You recommend that her gonadotropin levels be tested. Which is the best day of the menstrual cycle to check gonadotropin levels in this situation?

586. A 26-year-old G0P0 comes to your office with a chief complaint of being too hairy. She reports that her menses started at age 13 and have always been very irregular. She has menses every 2 to 6 months. She also complains of acne and is currently seeing a dermatologist for the skin condition. She denies any medical problems. Her only surgery was an appendectomy at age 8. Her height is 5ft 5 in., her weight is 180 lb, and her blood pressure is 100/60 mm Hg. On physical examination, there is sparse hair around the nipples, chin, and upper lip. No galactorrhea, thyromegaly, or temporal balding is noted. Pelvic examination is normal and there is no evidence of clitoromegaly. Which of the following is the most likely explanation for this patient’s problem?

587. Your patient is a 23-year-old woman with primary infertility. She is 5 ft 4 in tall and weighs 210 lb. She has had periods every 2 to 3 months since starting her period at age 12. She has a problem with acne and hair growth on her chin. Her mother had the same problem at her age and now has adult-onset diabetes. On physical examination of the patient, you notice a few coarse, dark hairs on her chin and around her nipples. She has a normal-appearing clitoris. Her ovaries and uterus are normal to palpation. Which of the following blood tests has no role in the evaluation of this patient?

588. A 28-year-old woman comes to your office for an annual visit. She has been in good health over the past year. She exercises regularly and watches her diet. She has hypothyroidism for which she takes thyroid hormone replacement. She has no other medical problems. She had an appendectomy at the age of 18 and has had no other surgeries. She takes no other medications and has no known drug allergies. Physical examination, including breast and pelvic exam, is normal. She has three children and does not wish to become pregnant again. She has tried the oral contraceptive pill and the intrauterine device (IUD), but stopped both of these methods because of side effects. She is now considering tubal ligation. Counseling of this patient should include the fact that if she does have a tubal ligation she will be at increased risk for which of the following conditions?

589. A 34-year-old woman comes to your office to establish primary care. While she has no current complaints and reports herself to be “fairly healthy,” she wishes to see a doctor regularly for preventive medicine. She does regular breast examinations on herself, has a good diet and exercise, and has no family history of malignancy or chronic disease. While all of her other habits are healthy, she reluctantly admits to smoking a pack of cigarettes a day. She had a “cervical smear” in her twenties, which she says was normal, and has never had a mammogram or ultrasound of her breasts. She reports being sexually active, and that she practices safe sex. Physical examination reveals a young woman in no apparent distress, with unremarkable vital signs. Her examination, including a breast and genitourinary exam, is normal. Which of the following is the most appropriate screening exam at this time?

590. A 29-year-old woman comes to the office for a periodic health maintenance examination. She has no complaints. Her past medical history is significant for irritable bowel syndrome. She has never had any surgery. She has been taking the oral contraceptive pill for the past 12 years, ever since she became sexually active. She has no known drug allergies. Physical examination, including pelvic examination, is unremarkable. By taking the oral contraceptive pill, this patient is decreasing her risk most significantly for which of the following?

591. A 51-year-old woman returns to clinic for a follow-up visit. You recently sent her for a routine mammogram, which shows a small, calcified mass that the radiologist labels as “probably benign finding—short-interval follow-up suggested.” The patient is extremely concerned because, although no one in her family has breast cancer, a close friend recently died of it. Breast examination reveals no abnormalities, and her physical examination is normal. Which of the following is the most appropriate course of action?

592. A 29-year-old woman, gravida 2, para 1, comes to the labor and delivery ward because of contractions. Her prenatal course was significant for a positive Group B Streptococcus (GBS) perineal culture at 35 weeks’ gestation. She has no medical problems. She had a cholecystectomy at the age of 17. She takes no medications and has no known drug allergies. She is found to be 5 cm dilated with contractions every 2 minutes. She is admitted to the labor and delivery unit in active labor and penicillin is started for GBS prophylaxis. Shortly after admission to labor and delivery the patient complains of warmth and tingling of her face. She notes feeling like her lips and tongue are swollen. Physical examination demonstrates normal vital signs but with generalized urticaria and angioedema. Her abdomen is gravid and there is scant bloody mucous around her genital area. Which of the following is the most likely diagnosis?

593. A 24-year-old woman has fever, right upper quadrant pain, and lower abdominal pain. She reports having multiple sexual partners and does not use condoms. She has no medical history, does not take any medications, and has no drug allergies. Her temperature is 38.9 C (102.0 F). Her lungs are clear to auscultation. Abdomen examination is notable for right upper quadrant tenderness. Pelvic examination reveals mucopurulent drainage and tenderness with cervical motion. She also has adnexal tenderness. Her leukocyte count is 14,000/mm3. Liver function tests are normal. Abdominal imaging is normal. Urine pregnancy test is negative. Which of the following is the appropriate management?

594. A 33-year-old woman comes to the clinic at 16 weeks’ gestation with no complaints. This is her second pregnancy. During the first pregnancy she delivered an 8.5 lb. infant. The patient reports hydramnios during that pregnancy. She has no prior medical history and is on no medications. On physical examination, she has a firm uterus. Which of the following is the appropriate management of this patient?

595. A 33-year-old woman comes to your office for a blood pressure check. She has had chronic hypertension for the past 4 years, for which she takes hydrochlorothiazide. Her blood pressure has been reasonably well controlled with this medication. She also uses the combined oral contraceptive pill (i.e., the pill containing an estrogen and a progestin). She has no other medical problems and has never had surgery. She is allergic to penicillin. Her physical examination is normal. This patient should be counseled that patients with chronic hypertension who are also using the combined oral contraceptive pill might be at increased risk of which of the following?

596. 19-year-old G1P0 African American woman who is at 30 weeks’ gestation is admitted to the hospital from the obstetrics clinic after being found to have an elevated blood pressure during a routine prenatal visit. She complains of a constant headache, intermittent blurred vision, and episodic nausea and vomiting for the last week. Before this week her pregnancy has been uncomplicated, and her prenatal visits have not revealed any health problems. Vital signs are: blood pressure 180/110 mm Hg, pulse 110/min, respirations 26/min. She is afebrile. Physical examination reveals a systolic ejection murmur and 1+ pitting edema bilaterally. Laboratory studies show: Liver Function Test: Albumin: 3.9g/dl Alkaline phosphatase: 230U/L ALT(SGPT): 133U/L AST(SGOT): 103U/L Bilirubin, unfractionated: 1.1mg/dl Total protein: 6.0g/dl Hematologic : Hematocrit: 29% Leukocytes: 8,200/mm3 Platelets: 8,900/mm3 PT: 12sec(normal: 11 to 15 sec) aPTT: 22sec(normal: 20-35sec) Urine dipstick: Specific gravity: 1.030 Hemoglobin: Trace Glucoose: 1+ Protein: 2+ Leukocyte esterase: Negative Nitrite: negative The patient is hospitalized and placed on bed rest. Her hypertension is controlled with hydralazine, and she is placed on a magnesium sulfate drip for seizure prophylaxis. Over the next 3 days, her liver enzyme levels continue to climb and her platelet count drops to 50,000/mm3. Which of the following is an additional medication that should be given at this time?

597. A 31-year-old woman comes to your office seeking advice about birth control. She had her third child 3 months ago and does not wish to get pregnant in the near future. Her medical history is significant for HIV infection with a CD4 count of 500 cells/mm3 and a viral load of 2000 copies/mL. She also has migraine headaches with an aura that she has had since the age of 14 years. She has never had surgery. She takes no medications and has no known drug allergies. She has a family history significant for breast, endometrial, and ovarian cancers. Her physical examination, including breast and pelvic examination, is normal. Which of the following conditions represents a contraindication to the combined oral contraceptive pill for this patient?

598. A 35-year-old woman comes to the clinic because of a left breast “thickness.” She noted this 5months ago and it has not receded. She has no family history of breast cancer. There is no drainage. She denies any pain. She has no other medical issues. She takes no birth control pills or any other medication. Examination shows a palpable mass in the left breast at 9 o’clock. A mammogram is nondiagnostic. Which of the following is the appropriate course of action?

599. A healthy 32-year-old woman vaginally delivers a healthy full-term baby boy. You are called to consult postpartum because the patient has difficulty with voiding. The delivery was the patient’s third child and was uncomplicated. However, by the end of her second day of hospitalization she is able to urinate only 25 cc at a time. Straight catheterization by the nurse reveals postvoid residuals of more than 300 cc. The patient denies any history of urinary tract infection, kidney stones, or prior voiding difficulties. She has no neurologic complaints. She has no significant past medical history. Surgical history is significant for a laparoscopic cholecystectomy 5 years ago. Her only medications are prenatal vitamins. She does not smoke or drink. On physical examination, she is in no distress but appears fatigued. She is afebrile and vital signs are normal. Heart and lung examination is within normal limits. Abdomen is appropriate for her recent delivery, soft and nontender. It is difficult to elicit any suprapubic distention. Rectal examination shows good sphincter tone. There are no gross neurologic deficits of the extremities. All of her laboratory studies are normal as well, and urinalysis does not show any leukocyte esterase, nitrites, or white blood cells. You prescribe bethanechol to help with her current urologic condition. As the prescribing physician, about which of the following side effects must you inform this patient?

600. A 52-year-old woman comes to clinic complaining of a persistent urinary tract infection. She tells you that she has had a burning, almost scalding sensation when she urinates. These symptoms have lasted months. Additionally, she has suffered from intermittent urinary incontinence for the last year, which has tended to correlate with the symptoms. Her primary care physician has treated her with trials of oral trimethoprim-sulfamethoxazole and levofloxacin, but she has had no improvement in her symptoms. She denies any fevers, flank pain, discharge, or recent sexual activity, though she notes that she is having severe hot flashes. Physical examination reveals a thin, friable vaginal mucosa with multiple small punctate hemorrhages. Which of the following is the most appropriate treatment?

601. A 36-year-old woman comes to your office because of back pain. She states that the pain started around the time of her cesarean delivery 8 weeks ago. The pain is located in the lower back and does not radiate. It improves with rest and worsens with prolonged standing. She cannot stand for more than 30 minutes without what she describes as debilitating pain. She has no significant past medical history. She had a cesarean delivery 8 weeks ago for arrest of dilation during labor. She had epidural anesthesia for labor and surgery. Otherwise she has never had surgery. She takes ibuprofen for the pain. She is allergic to sulfa drugs. Physical examination is within normal limits, including a normal neurologic examination. The patient is most interested in knowing what caused her to start having this back pain. Which of the following is the most appropriate response?

602. A 36-year-old woman comes to your office concerned that she might become pregnant after her partner’s condom broke during intercourse 2 days ago. She wasn’t sure what to do, but some friends of hers told her that her doctor could still give her the “morning-after” pill. Her past medical history is significant for occasional tension headaches that resolve with acetaminophen. She smokes ½ pack cigarettes a day. She has never had surgery, takes no medications, and is allergic to sulfa drugs. Her family history is significant for ovarian cancer. Physical examination is normal. Laborator evaluation demonstrates a positive urine HCG test. Which of the following represents an absolute contraindication to emergency contraception in this patient?

603. 65-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period was at age 50 and that she has had no bleeding since. She has no medical problems and takes no medications. She is not sexually active. Examination is unremarkable, including a normal pelvic examination. After informed consent is obtained, an endometrial biopsy is performed. The patient complains of discomfort during and after the procedure but feels well enough to go home. Later that night, with her abdominal pain worsening, the patient comes to the emergency department. An ultrasound is performed that shows a normal uterus and adnexae but a complex fluid collection posterior to the uterus. Which of the following is the most likely diagnosis?

604. A 23-year-old female comes to the physician because of a swelling in her vagina. She states that the swelling started about 3 days ago and has been growing larger since. The swelling is not painful, but it is uncomfortable when she jogs. She has asthma for which she uses an albuterol inhaler, but no other medical problems. Examination shows a cystic mass 4 cm in diameter near the hymen by the patient's left labia minora. The mass is nontender and there is no associated erythema. The mass is freely mobile. The rest of the pelvic examination is unremarkable. Which of the following is the most likely diagnosis?

605. A 37-year-old woman, gravida 3, para 2, comes to her physician for follow-up on her ectopic pregnancy. She was diagnosed with an ectopic pregnancy 7 days ago and given methotrexate. She now presents with abdominal pain that started this morning. Examination is significant for moderate left lower quadrant tenderness. Laboratory analysis shows that her beta-hCG value has doubled over the past week. Transvaginal ultrasound shows that the ectopic pregnancy is roughly the same size but there is an increased amount of fluid in the pelvis. Which of the following is the most appropriate next step in management?

606. A 26-year-old woman comes to the physician because of a lump in her vagina. The lump is nontender but is uncomfortable when she walks. She states that for the last 6 years this lump has appeared about once a year. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She has no other medical problems. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. The rest of the pelvic examination is unremarkable. Which of the following is the most appropriate next step in management?

607. You have just diagnosed a 21-year-old infertile woman with polycystic ovarian syndrome. The remainder of the infertility evaluation, including the patient’s hysterosalpingogram and her husband’s semen analysis, were normal. Her periods are very unpredictable, usually coming every 3 to 6 months. She would like your advice on the best way to conceive now that you have made a diagnosis. Which of the following treatment options is the most appropriate first step in treating this patient?

608. A patient in your practice calls you in a panic because her 14-yearold daughter has been bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency room. When you see the daughter in the emergency room, you note that she appears very pale and fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure remains stable, but her pulse increases to 100. While in the emergency room, you obtain a more detailed history. She denies any medical problems or prior surgeries and is not taking any medications. She reports that she has never been sexually active. On physical examinations, her abdomen is benign. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5ft 4in tall and weighs 95 lb. Which of the following blood tests is not indicated in the evaluation of this patient?

609. A 32-year-old morbidly obese diabetic woman presents to your office complaining of prolonged vaginal bleeding. She has never been pregnant. Her periods were regular, monthly, and light until 2 years ago. At that time, she started having periods every 3 to 6 months. Her last normal period was 5 months ago. She started having vaginal bleeding again 3 weeks ago, light at first. For the past week she has been bleeding heavily and passing large clots. On pelvic examination, the external genitalia is normal. The vagina is filled with large clots. A large clot is seen protruding through the cervix. The uterus is in the upper limit of normal size. The ovaries are normal to palpation. Her urine pregnancy test is negative. Which of the following is the most likely diagnosis?

610. One of your patients with polycystic ovarian syndrome presents to the emergency room complaining of prolonged, heavy vaginal bleeding. She is 26 years old and has never been pregnant. She was taking birth control pills to regulate her periods until 4 months ago. She stopped taking them because she and her spouse want to try to get pregnant. She thought she might be pregnant because she had not had a period since her last one on the birth control pills 4 months ago. She started having vaginal bleeding 8 days ago. She has been doubling up on superabsorbant sanitary napkins 5 to 6 times daily since the bleeding began. On arrival at the emergency room, the patient has a supine blood pressure of 102/64 mm Hg with a pulse of 96 beats per minute. Upon standing, the patient feels light-headed. Her standing blood pressure is 108/66 mm Hg with a pulse of 126 beats per minute. While you wait for lab work to come back, you order intravenous hydration. After 2 hours, the patient is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is 31%. She continues to have heavy bleeding. Which of the following is the best next step in the management of this patient?

611. A 29-year-old G0 comes to your OB/GYN office complaining of PMS. On taking a more detailed history, you learn that the patient suffers from emotional lability and depression for about 10 days prior to her menses. She reports that once she begins to bleed she feels back to normal. The patient also reports a long history of premenstrual fatigue, breast tenderness, and bloating. Her previous health-care provider placed her on oral contraceptives to treat her PMS 6 months ago. She reports that the pills have alleviated all her PMS symptoms except for the depression and emotional symptoms. Which of the following is the best next step in the treatment of this patient’s problem?

612. A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning hormone replacement therapy (HRT), but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She denies any medical problems and is not taking any medication except calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb. In counseling the patient regarding the risks and benefits of hormone replacement therapy, you should tell her that HRT (estrogen and progesterone) has been associated with which of the following?

613. A 56-year-old woman presents to your office for her routine wellwoman examination. She had a hysterectomy at age 44 for symptomatic uterine fibroids. She entered menopause at age 54 based on menopausal symptoms and an elevated FSH level. She started taking estrogen replacement therapy at that time for relief of her symptoms. She is fasting and would like to have her lipid panel checked while she is in the office today. You counsel the patient on the effects of estrogen therapy on her lipid panel. She should expect which of the following?

614. A 48-year-old woman consults with you regarding menopausal symptoms. Her periods have become less regular over the past 6 months. Her last period was 1 month ago. She started having hot flushes last year. They have been getting progressively more frequent. She has several hot flushes during the day, and she wakes up twice at night with them as well. She has done quite a lot of reading about perimenopause, menopause, and hormone replacement therapy. She is concerned about the risks of taking female hormones. She wants to know what she should expect in regard to her hot flushes if she does not take hormone replacement. You should tell her which of the following?

615. A 25-year-old woman, gravida 2, para 2 is 4days status post cesarean section and develops a temperature to 100.7 F (38.2 C). She had her cesarean section when she went into unstoppable preterm labor with a breech fetus. She had an uncomplicated postoperative course until this temperature elevation. Her pulse is 100/min, blood pressure is 110/70 mm Hg, and respirations are 16/min. There is discoloration and cyanosis around the incision. The area around the incision is completely numb. There is no uterine tenderness on bimanual exam. Which of the following is of the most concern in this patient?

616. A 32-year-old woman, gravida 2, para 2, comes to the physician for follow-up of an abnormal Pap test. One month ago, her Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy demonstrated acetowhite epithelium at 2 o'clock. A biopsy taken of this area demonstrated HGSIL. Endocervical curettage (ECC) was negative. The patient has no other medical problems, has never had cervical dysplasia, and takes no medications. Which of the following is the most appropriate next step in management?

617. A 31-year-old woman comes to the physician for follow-up after an abnormal Pap test and cervical biopsy. The patient's Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). This was followed by colposcopy and biopsy of the cervix. The biopsy specimen also demonstrated HGSIL. The patient was counseled to undergo a loop electrosurgical excision procedure (LEEP). Which of the following represents the potential long-term complications from this procedure?

618. A 27-year-old woman, gravida 2, para 2, comes to the physician to have her staples removed after an elective repeat cesarean delivery. Her pregnancy course was uncomplicated. She states that she is doing well except that since the delivery she has noticed some episodes of sadness and tearfulness. She is eating and sleeping normally and has no strange thoughts or thoughts of hurting herself or others. Physical examination is within normal limits for a patient who is status post cesarean delivery. Which of the following is the most likely diagnosis?

619. A 22-year-old primigravid woman comes to the labor and delivery ward at term with regular, painful contractions. Her prenatal course was unremarkable. She has a past medical history significant for mitral valve prolapse with regurgitation demonstrated on echocardiography. She takes no medications and has no allergies to medications. Examination shows that her cervix is 4 centimeters dilated and the fetus is in vertex presentation. The fetal heart rate is reassuring. Which of the following is the most appropriate management of this patient?

620. A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for induction of labor. The prenatal course was significant for a positive group B Streptococcus culture performed at 35 weeks. Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated Ringer's IV solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed. Prostaglandin (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In approximately 60 minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting every 1 minute with essentially no rest in between contractions. Which of the following was most likely the cause of the uterine hyperstimulation?

621. A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following?

622. A 16-year-old nulligravid woman comes to the emergency department because of heavy vaginal bleeding. She states that she normally has heavy periods every month but missed a period last month and this period has been unusually heavy with the passage of large clots. She has no medical problems, has no history of bleeding difficulties, and takes no medications. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 96/minute and respirations are 12/minute. Pelvic examination shows a moderate amount of blood in the vagina, a closed cervix, and a normal uterus and adnexae. Hematocrit is 30%. Urine hCG is negative. Which of the following is the most appropriate management?

623. A 12-year-old female comes to the physician because of a vaginal discharge. The discharge started about 2 months ago and is whitish in color. There is no odor. The patient has no complaints of itching, burning, or pain. The patient started breast development at 9 years of age and her pubertal development has proceeded normally to this point. She has not had her first menses and she is not sexually active. She has no medical problems. Examination is normal for a 12-year-old female. Microscopic examination of the discharge shows no evidence of pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely diagnosis?

624. A 34-year-old woman comes the physician because of lower abdominal cramping. The cramping started 2 days ago. Examination is unremarkable except for a pelvic examination that reveals a 10-week sized uterus. Urine hCG is positive, and pelvic ultrasound reveals a 10-week intrauterine pregnancy with a fetal heart rate of 160. The patient states that she is not sure whether to keep the pregnancy. Which of the following is the most appropriate next step in management?

625. A 50-year-old woman complains of leakage of urine. After genuine stress urinary incontinence, which of the following is the most common cause of urinary leakage?

626. A 65-year-old woman complains of leakage of urine. Which of the following is the most common cause of this condition in such patients?

627. A healthy 59-year-old woman with no history of urinary incontinence undergoes vaginal hysterectomy and anteroposterior repair for uterine prolapse, large cystocele, and rectocele. Two weeks postoperatively, she presents to your office with a new complaint of intermittent leakage of urine. What is the most likely cause of this complaint following her surgery?

628. A 53-year-old postmenopausal woman, G3P3, presents for evaluation of troublesome urinary leakage 6 weeks in duration. Which of the following is the most appropriate first step in this patient’s evaluation?

629. A postmenopausal woman is undergoing evaluation for fecal incontinence. She has no other diagnosed medical problems. She lives by herself and is self-sufficient, oriented, and an excellent historian. Physical examination is completely normal. Which of the following is the most likely cause of this patient’s condition?

You are discussing surgical options with a patient with symptomatic pelvic relaxation. Partial colpocleisis (Le Fort procedure) may be more appropriate than vaginal hysterectomy and anterior and posterior (A&P) repair for patients in which of the following circumstances?

631. A 65-year-old woman presents to your office for evaluation of genital prolapse. She has a history of chronic hypertension, well controlled with a calcium channel blocker. She has had three full-term spontaneous vaginal deliveries. The last baby weighed 9 lb and required forceps to deliver the head. She says she had a large tear in the vagina involving the rectum during the last delivery. She has a history of chronic constipation and often uses a laxative to help her have a bowel movement. She has smoked for more than 30 years and has a smoker’s cough. She entered menopause at age 52 but has never taken hormone replacement therapy. Which of the following factors is least important in the subsequent development of genital prolapse in this patient?

632. A 63-year-old woman is undergoing a total abdominal hysterectomy (TAH) for atypical endometrial hyperplasia. She mentioned to her doctor 2 weeks prior to the surgery that she has had problems with leakage of urine with straining and occasional episodes of urinary urgency. A urine culture at that visit is negative. She has had preoperative cystometrics done in the doctor’s office showing loss of urine during Valsalva maneuvers along with evidence of detrusor instability. The doctor has elected to do a retropubic bladder neck suspension following the TAH. A Marshall-Marchetti-Krantz procedure (MMK) is done to attach the bladder neck to the pubic symphysis. The patient does well after her surgery and is released from the hospital on postoperative day 3. Which of the following should her doctor advise her prior to her discharge?

633. A 30-year-old G3P3 is being evaluated for urinary urgency, urinary frequency, and dysuria. She also complains of pain with insertion when attempting intercourse. She frequently dribbles a few drops of urine after she finishes voiding. She has had three full-term spontaneous vaginal deliveries. Her last baby weighed more than 9 lb. She had multiple sutures placed in the vaginal area after delivery of that child. She also has a history of multiple urinary tract infections since she was a teenager. On pelvic examination, she has a 1-cm tender suburethral mass. With palpation of the mass, a small amount of blood-tinged pus is expressed from the urethra. Which of the following is the most likely cause of this patient’s problem?

634. A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?

635. A 27-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with a gush of fluid and regular contractions. Examination shows that she is grossly ruptured, contracting every 2 minutes, and that her cervix is dilated to 4 cm. The fetal heart rate tracing is in the 140s and reactive. She is admitted to labor and delivery, and over the following 4 hours she progresses to 9 cm dilation. Over the past hour, the fetal heart rate has increased from a baseline of 140 to a baseline of 160. Furthermore, moderate to severe variable decelerations are seen with each contraction. The fetal heart rate does not respond to scalp stimulation. The decision is made to proceed with cesarean delivery. Which of the following is the reason for the cesarean delivery and the preoperative diagnosis?

636. A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the labor and delivery ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony-forming units/milliliter of Group-B streptococci and asthma, for which she uses an albuterol inhaler. Examination shows that she is contracting every 2 minutes and her cervix is 5 centimeters dilated and 100% effaced. Which of the following medications should this patient be treated with during labor and delivery?

637. A 31-year-old primigravid woman comes to the physician for a prenatal visit. She is known to be HIV positive. She also has asthma, for which she uses an inhaler. She had a diagnostic laparoscopy at age 20 for pelvic pain and has had no other surgeries. She has no known drug allergies. Extensive counseling is given to the patient regarding vertical transmission of HIV to the fetus. It is recommended to her that she take antiretroviral therapy during the pregnancy to decrease the vertical transmission rate. It is also recommended to her that she have a scheduled cesarean delivery. After consideration of these options, the patient chooses not to take the antiretrovirals and opts for a vaginal delivery. Which of the following represents the approximate risk of vertical transmission (from the mother to the fetus) for this patient?

638. A 22-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward with a gush of fluid. Sterile speculum examination reveals a pool of fluid that is nitrazine positive and forms ferns when viewed under the microscope. The fetal heart rate is in the 150s and reactive. An ultrasound demonstrates that the fetus is in the breech position. A cesarean delivery is performed. During the operation, the physician, who has received no recent immunizations, is stuck with a needle that had been used on the patient. Which of the following is this physician at greatest risk of contracting?

639. A 43-year-old African American woman comes to the physician because of her concern regarding breast cancer. She has no complaints at present. In past years, she had noted bilateral breast tenderness prior to her menses, but this has since abated. She has no medical problems. She had two cesarean deliveries, but no other surgeries. She takes a low-dose oral contraceptive pill and has no known drug allergies. She does not smoke, and her family history is negative. Physical examination is normal. All mammograms (yearly since age 40) have been negative to date. She wants to know whether BRCA1 and BRCA2 screening would be appropriate for her. Which of the following is the correct response?

640. A 32-year-old woman comes to the hospital for an elective repeat cesarean delivery. Four years ago she had a primary cesarean delivery for a nonreassuring fetal heart rate tracing. Two years ago she chose to have an elective repeat cesarean delivery rather than attempt a vaginal birth after cesarean (VBAC). Her prenatal course was uncomplicated except that she has mitral valve prolapse. An echocardiograph demonstrated the mitral valve prolapse, but no other structural cardiac disease. Which of the following is the correct management of this patient?

641. A 38-year-old woman, gravida 4, para 4, comes to the physician 8 days after a cesarean delivery complaining of redness and pain at the leftmost aspect of her incision. Her cesarean delivery was performed secondary to a non-reassuring fetal heart rate tracing. She was feeling well after the operation until 4 days ago, when she developed pain and redness around her incision. Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 88/min, and respirations are 12/min. There is marked erythema and induration around the incision. At the left margin of the incision there is a fluctuant mass. Which of the following is most appropriate next step in management?

642. A 39-year-old woman, gravida 3, para 2, at term comes to the labor and delivery ward complaining of a gush of fluid. Examination shows her to be grossly ruptured, and ultrasound reveals that the fetus is in vertex presentation. The fetal heart rate is in the 120s and reactive. After a few hours, with no contractions present, oxytocin is started. Three hours later, the tocodynamometer shows the patient to be having contractions every minute and lasting for approximately 1 minute with almost no rest in between contractions. The fetal heart rate changes from 120s and reactive to a bradycardia to the 80s. Sterile vaginal examination shows that the cervix is 6 cm dilated. Which of the following is the most appropriate next step in management?

643. A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?

644. A 22-year-old primigravid woman at term comes to the labor and delivery ward because of painful contractions every 2 minutes. She has had no gush of fluid and no bleeding from the vagina. Her prenatal course was unremarkable. She takes no medications and has no allergies to medications. Examination shows that her cervix is 6 cm dilated and 100% effaced; the fetus is at 0 station. The fetal heart rate has a baseline in the 150s and is reactive. The patient desires an epidural for pain relief. Which of the following should be given orally shortly before the epidural is placed?

645. A 39-year-old woman, gravida 4, para 3, comes to the physician for a prenatal visit. Her last menstrual period was 8 weeks ago. She has had no abdominal pain or vaginal bleeding. She has no medical problems. Examination is unremarkable except for an 8-week sized, nontender uterus. Prenatal labs are sent. The rapid plasma reagin (RPR) test comes back as positive and a confirmatory microhemagglutination assay for antibodies to Treponema pallidum (MHA-TP) test also comes back as positive. Which of the following is the most appropriate pharmacotherapy?

646. A 67-year-old woman comes to the physician because of pain with urination and frequent urination. She has hypertension for which she takes a beta-blocker, but no other medical problems. She states that she is not sexually active. She does not smoke and drinks cranberry juice daily. Examination shows mild suprapubic tenderness and genital atrophy but is otherwise unremarkable. Urinalysis shows 50 to 100 leukocytes/high powered field (hpf) and 5 to 10 erythrocytes/hpf. Which of the following is the most likely cause of the infection?

647. A 39-year-old woman, gravida 2, para 1, at 30-weeks gestation comes to the physician for a prenatal visit. The patient's due date was determined by a 7-week ultrasound. Her prenatal course has been unremarkable. She has no complaints of contractions, loss of fluid, or bleeding from the vagina, and her baby is moving well. Examination demonstrates a fetal heart rate of 150 and a fundal height of 27 centimeters, which is the same measurement as that determined 4 weeks ago. This patient's fundal height measurement is most suggestive of which of the following?

648. A 33-year-old woman, gravida 3, para 3, comes to the physician for an annual examination. She has no complaints. Past medical history is significant for two episodes of Chlamydia and one episode of gonorrhea. Obstetric history is significant for three normal spontaneous vaginal deliveries with gestational diabetes during the last two pregnancies. She takes no medications. Family history is significant for paternal coronary artery disease. Physical examination is unremarkable. Which of the following interventions should this patient most likely have?

649. A 40-year-old woman comes to the physician for an annual examination. She has no complaints. She has menses every 28-30 days that last for 3 days. She has no intermenstrual bleeding. She has asthma, for which she uses an occasional inhaler. She had a tubal ligation 10 years ago. She has no known drug allergies. Examination is unremarkable, including a normal pelvic examination. One of her friends was recently diagnosed with endometrial cancer, and the patient wants to know when and if she needs to be screened for this. Which of the following is the most appropriate response?

650. A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past gynecologic history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable. Which of the following procedures or tests should most likely be performed on this patient?

651. A 21-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician because of a malodorous vaginal discharge. She states that she first noticed the discharge 2 days ago and since then it has become more profuse and malodorous. Her prenatal course has been unremarkable during this pregnancy. Her prior pregnancy was complicated by preterm labor and delivery at 31 weeks' gestation. Examination shows a grayish vaginal discharge. A strong amine odor is released when KOH is applied to a sample of the discharge. Examination of a normal saline ("wet") preparation reveals numerous "clue" cells. Which of the following is the most appropriate pharmacotherapy?

. A 23-year-old woman comes to the physician because she thinks that she may be pregnant. She missed her last two periods and feels "different." A urine pregnancy test is positive and an ultrasound reveals a 12-week fetus. The patient is very concerned because she received the measles-mumps-rubella (MMR) vaccine four months ago and was told to wait 3 months before attempting conception. The pregnancy is desired. The patient asks if she should have a termination of pregnancy because she was vaccinated shortly before becoming pregnant. Which of the following is the most appropriate response?

653. A 22-year-old woman comes to the physician because of a missed menstrual period. She has a complex past medical history. She has hypothyroidism, for which she takes thyroxine, she has an artificial heart valve, for which she takes Coumadin, and she recently started tetracycline for acne. She does not think that she is pregnant because she is currently on the oral contraceptive pill, but, if pregnant, she would keep the pregnancy. Physical examination, including pelvic examination, is unremarkable. Urine human chorionic gonadotropin (hCG) is positive. Which of the following medications should the patient continue to take during the pregnancy?

654. A 19-year-old nulligravid woman comes to the emergency department because of severe left lower quadrant pain. She has been noticing this pain intermittently for the past 3 days, but this afternoon it became persistent and severe and was accompanied by nausea and vomiting. Examination shows left lower quadrant tenderness and a tender left adnexal mass. Urine hCG is negative. Pelvic ultrasound shows a 7 cm left ovarian complex mass. Which of the following is the most appropriate next step in management?

655. A 26-year-old primigravid woman at 12 weeks' gestation comes to the physician because of pain and swelling in her right thigh. She first noted the onset of the pain 2 days ago, and since then it has grown worse. An ultrasound study performed on her lower-extremity venous system reveals evidence of a proximal thrombus in the right leg. She is started on low-molecular-weight heparin injections. Which of the following is an advantage of low-molecular-weight heparin compared with unfractionated heparin?

656. A 29-year-old female comes to the physician because of fevers and back pain. She is otherwise healthy with no significant past medical history. Examination is significant for a temperature of 38.3 C (101 F), moderate costovertebral angle tenderness, leukocytosis, and white blood cells and red blood cells in the urine. The patients is diagnosed with pyelonephritis and started on intravenous antibiotics. Over the next two days, she rapidly improves, and by hospital day 3, she is tolerating oral intake, voiding without difficulty, feeling no pain, and she has not had a fever for 48 hours. Which of the following is the most appropriate next step in management?

657. A 36-year-old woman, gravida 5, para 4, at 30 weeks' gestation comes to the physician for a prenatal visit. She feels the baby moving and has not had bleeding per vagina, contractions, or loss of fluid. The prenatal course has been uncomplicated thus far. The patient is interested in having a postpartum tubal ligation. She has many questions regarding the procedure, including whether there is a risk of failure. Which of the following represents the closest estimate for the likelihood of failure of a postpartum tubal ligation?

658. A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations?

659. A 19-year-old female comes to the physician because she has not had a menstrual period. She experienced normal breast development through puberty but has yet to have a period. She has no other complaints. She has no medical problems. Examination shows the patient to be tall with long arms and big hands. The breasts are normal-appearing except that the nipples are immature and the areolae are pale. Pelvic examination shows scant pubic hair with a blind-ended vaginal pouch. Which of the following is the most likely diagnosis?

660. A 53-year-old woman comes to the physician because of concerns regarding menopause. She has a period almost every month, but her cycle is lengthening. She is worried because her mother, her two older sisters, and practically all her aunts have osteoporosis. She does not want to be on estrogen because she is concerned about cancer and thrombosis. Physical examination is within normal limits. The patient is started on raloxifene. On this medication, which of the following is this patient most likely to develop?

661. A 47-year-old woman comes to the physician for an annual examination. One year ago, she was diagnosed with endometrial carcinoma and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. She was found to have grade I, stage I, disease at that time. Over the past year, she has developed severe hot flashes that occur throughout the day and night and are worsening. She is also concerned because her mother and several of her aunts have severe osteoporosis. She wonders whether she can take estrogen replacement therapy. Which of the following is the most appropriate response?

662. A 32-year-old woman, gravida 3, para 0, at 29 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. She had a prophylactic cerclage placed at 12 weeks' gestation because of her history of two consecutive 20-week losses. These spontaneous abortions were both characterized by painless cervical dilation, with the membranes found bulging into the vagina on examination. Ultrasound now demonstrates her cervix to be long and closed with no evidence of funneling. Which of the following is the most appropriate time to remove the cerclage from this patient?

663. A 55-year-old woman comes to the physician because of hot flashes. She first noted them about 9 months ago, and since then they have been worsening. She states that the flashes come on at various times throughout the day, but that they are especially intense at night. She had her last menstrual period approximately 5 months ago. Her medical history is significant for a pulmonary embolus at the age of 36 and severe depression. She takes fluoxetine for depression and has no allergies to medications but smokes one pack of cigarettes per day. Physical examination is unremarkable, including a normal pelvic examination. Which of the following is the most appropriate pharmacotherapy for this patient?

664. A 24-year-old woman comes to the physician for an initial prenatal visit. Her last menstrual period was 7 weeks ago and a home urine pregnancy test was positive. She has had no bleeding or abdominal pain. She does complain of increased fatigue lately and some mild nausea and vomiting. Examination is significant for both a systolic and a diastolic cardiac murmur. The uterus is 8 weeks' sized and nontender. Which of the following findings is most suggestive of structural heart disease in this woman?

665. A 42-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the physician for her first prenatal visit. She has no complaints. She has a history of Trichomonas infection, but no other medical problems. Examination is significant for a 10-week sized, nontender uterus. During the speculum examination, a Pap smear is performed and gonorrhea and Chlamydia screening tests are taken. The next day, the gonorrhea test returns as positive. Which of the following is the most appropriate pharmacotherapy?

666. A 54-year-old woman comes to the physician because of hot flashes. She states that her hot flashes have been steadily worsening over the past year since she had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for menometrorrhagia. Pathology from the surgery showed low grade endometrial hyperplasia. She has no medical problems and takes no medications. Her family history is unremarkable except for a strong family history of osteoporosis. She states that the hot flashes have become absolutely debilitating for her and she wants to take something that will give her the best chance of stopping them. Which of the following is the most appropriate pharmacotherapy?

A 22-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. She has had some nausea but no other complaints. She has had no bleeding per vagina or abdominal pain. She had an ovarian cystectomy at age 18 but no other medical or surgical problems. She takes no medications and has no known drug allergies. Examination is unremarkable except for an 8-week-sized non-tender uterus. The patient wants information on vitamin supplementation during pregnancy. Which of the following represents the correct amount of vitamin A supplementation this patient should take daily?

668. A 29-year-old woman comes to the emergency department because of abdominal distension and shortness of breath. Approximately 1 week ago, she underwent fertility treatment with ovulation induction and oocyte retrieval. She has a history of polycystic ovarian syndrome but no other medical problems. She had laparoscopy 1 year ago as part of a fertility evaluation. She has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 80/40 mm Hg, pulse is 130/min, and respirations are 28/min. Physical examination is remarkable for crackles at the lung bases bilaterally and a distended, nontender abdomen with a fluid wave. Ultrasound demonstrates bilaterally enlarged ovaries (each >10 cm) and free fluid in the abdomen. Urine hCG is negative. Which of the following is the most likely diagnosis?

669. A 24-year-old woman, gravida 3, para 2, comes to the physician for her first prenatal visit. Her last menstrual period was 8 weeks ago, and a home pregnancy test was positive. She states that this pregnancy, like her last two pregnancies, was unintended. She had been using condoms for birth control in all three instances. She had normal vaginal deliveries 2 and 4 years ago. Which of the following is the most likely reason for condom failure?

670. A 75-year-old woman comes to the physician because of abdominal distension. She states that she always feels bloated and that she gets full quickly when eating. She has hypertension, for which she takes an angiotensin converting enzyme (ACE) inhibitor, and no other medical problems. Examination shows abdominal distension and a positive fluid wave. Pelvic examination reveals a large, nontender right adnexal mass. Abdominal CT scan demonstrates masses on both ovaries, ascites, and omental caking. CA-125 level is significantly elevated. Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) are negative. Which of the following is the most likely diagnosis?

671. A 38-year-old woman, gravida 1, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has had no bleeding from the vagina or abdominal pain and no complaints. She has a long history of migraine headache and recently developed peptic ulcer disease (PUD). Examination shows a nontender 8-week sized uterus but is otherwise unremarkable. The patient is very concerned that her migraine headaches and peptic ulcer disease will make her pregnancy intolerable. Which of the following is the most appropriate response?

672. A 23-year-old primigravid woman at 29-weeks' gestation comes to the physician because of contractions. She states that they have been occurring every 3-5 minutes for the past few hours and that they are worsening in intensity. Examination reveals that the patient is afebrile and her abdomen is nontender. Her cervix is 3 cm dilated, and the fetus is in vertex position. The patient is started on IV magnesium sulfate and penicillin and given an intramuscular injection of betamethasone. Which of the following represents the most significant consequence of this patient's preterm labor?

673. A 25-year-old woman who is “about 5 months” pregnant with her first child presents for the first time to an obstetrician. She has had no prenatal care. When asked about her medical history, she states she sometimes takes medicine for “depression,” and she produces a prescription bottle with lithium tablets in it. She is otherwise healthy and her pregnancy has been uncomplicated to date. The fundus of her uterus is 22 cm from the pubic symphysis, fetal movement is felt, and fetal heart tones are present at 130/min. Which of the following tests should be advised given the patient’s lithium ingestion?

A 31-year-old African-American woman is diagnosed with uterine fibroids. Which of the following types of fibroids is most likely to interfere with conception and pregnancy?

675. A 20-year-old woman presents to her gynecologist complaining of several days of vaginal itching and increased vaginal secretions that have an unpleasant odor. She denies any recent fever, back pain, hematuria, or vaginal bleeding. She has been sexually active with multiple sexual partners and rarely uses protection. On examination she has a moderate amount of frothy green discharge. Amine “whiff” test of the discharge is negative, and the pH of the discharge is 6. Multiflagellated organisms are seen on microscopy. Which of the following is the most likely diagnosis?

676. A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2° C (98.9° F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 11 0/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 % Platelets: 200,000/mm3 Serum sodium: 130 mEq/L Serum potassium: 2.8 mEq/L Chloride: 86 mEq/L Bicarbonate: 30 mEq/L Blood urea nitrogen (BUN): 30 mg/dl Serum creatinine: 1.6 mg/dl Blood glucose: 98 mg/dl Which of the following is the most appropriate next step in management

677. 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 90/60mmHg, pulse is 120/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?

678. A 19-year-old nulligravid woman comes to the physician for a routine annual check-up. She complains of weight gain of approximately 10 lbs (4.5 kg) over the last year. She feels that this is related to her oral contraceptive pill use. She has no previous medical problems. She became sexually active at the age of 18. She has been sexually active with one partner for the past 2 months. She and her partner use condoms inconsistently, but use combination oral contraceptive pills regularly for contraception. Vital signs are normal. Her body mass index is 25 kg/m2. Physical examination shows no abnormalities. Which of the following is the most appropriate advice to give to this patient?

679. 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 154/98 mmHg. Physical examination shows 2+ pitting edema in both legs and hands. Deep tendon reflexes are normal. Fundoscopic examination shows no abnormalities. Fetal 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 24hour urine protein excretion is 1gm, which is new. Which of the following is the most likely diagnosis?

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

681. A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?

682. Mifepristone is an effective abortifacient if given within 72 hours of intercourse. Mifepristone contains which of the following?

683. A 45-year-old African-American woman who was diagnosed with PCOS in her early twenties presents to her gynecologist for her annual visit. One of her close friends has recently been diagnosed with ovarian cancer, so she is concerned about her own cancer risk. Menarche was at age 14 years, and she has yet to go through menopause. She has a healthy 19-yearold daughter. She has no family history of cancer. She does not smoke or drink and exercises regularly. Aside from a diagnosis of PCOS, she is otherwise in good health. Given her health history, which of the following statements is true?

684. 22-year-old G1 at 14 weeks gestation presents to your office with a history of recent exposure to her 3-year-old nephew who had a rubella viral infection. In which time period does maternal infection with rubella virus carry the greatest risk for congenital rubella syndrome in the fetus?

685. A pregnant woman is discovered to be an asymptomatic carrier of Neisseria gonorrhoeae. A year ago, she was treated with penicillin for a gonococcal infection and developed a severe allergic reaction. Which of the following is the treatment of choice at this time?

686. 22-year-old has just been diagnosed with toxoplasmosis. You try to determine what her risk factors were. The highest risk association is which of the following?

687. A 17-year-old woman at 22 weeks gestation presents to the emergency center with a 3-day history of nausea, vomiting, and abdominal pain. The pain started in the middle of the abdomen and is now located along her mid to upper right side. She is noted to have a temperature of 38.4C (101.1F). She denies any past medical problems or surgeries. How does pregnancy alter the diagnosis and treatment of the disease?

688. A 29-year-old G3P2 black woman in the thirty-third week of gestation is admitted to the emergency room because of acute abdominal pain that has been increasing during the past 24 hours. The pain is severe and is radiating from the epigastrium to the back. The patient has vomited a few times and has not eaten or had a bowel movement since the pain started. On examination, you observe an acutely ill patient lying on the bed with her knees drawn up. Her blood pressure is 100/70 mm Hg, her pulse is 110 beats per minute, and her temperature is 38.8C (101.8F). On palpation, the abdomen is somewhat distended and tender, mainly in the epigastric area, and the uterine fundus reaches 31 cm above the symphysis. Hypotonic bowel sounds are noted. Fetal monitoring reveals a normal pattern of fetal heart rate (FHR) without uterine contractions. On ultrasonography, the fetus is in vertex presentation and appropriate in size for gestational age; fetal breathing and trunk movements are noted, and the volume of amniotic fluid is normal. The placenta is located on the anterior uterine wall and no previa is seen. Laboratory values show mild leukocytosis (12,000 cells per mL); a hematocrit of 43; mildly elevated serum glutamicoxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), and bilirubin; and serum amylase of 180 U/dL. Urinalysis is normal. Which of the following is the most likely diagnosis?

689. An 18-year-old G1 has asymptomatic bacteriuria (ASB) at her first prenatal visit at 15 weeks gestation. Which of the following statements is true?

690. A 20-year-old female at 34 weeks of gestation develops a lower urinary tract infection. Which of the following is the best choice for treatment?

691. 27-year-old healthy woman comes to the office 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. Her husband is healthy and takes no medications. He has a normal semen analysis. She has regular 28-day menstrual cycles. The patient has mid-cycle pelvic pain and an egg white like consistency to her discharge mid-cycle. She has no pain during sexual intercourse. The patient does report having been hospitalized with a pelvic infection in her late teens, during which time she had pain with intercourse, discharge, and fever. Her sister was diagnosed with polycystic ovarian disease. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination shows no abnormalities. Which of the following is most likely to be abnormal in this patient?

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

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

694. A 30-year-old obese woman comes to the physician with a six-month history of oligomenorrhea. She has 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 21; none of which have shown any 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 indicated in the initial workup of this patient?

695. A 30-year-old class D diabetic is concerned about pregnancy. She can be assured that which of the following risks is the same for her as for the general population?

696. A 33-year-old woman at 10 weeks presents for her first prenatal examination. Routine labs are drawn and her hepatitis B surface antigen is positive. Liver function tests are normal and her hepatitis B core and surface antibody tests are negative. Which of the following is the best way to prevent neonatal infection?

Of a rash on her abdomen that is becoming increasingly pruritic. The rash started on her abdomen, and the patient notes that it is starting to spread downward to her thighs. The patient reports no previous history of any skin disorders or problems. She denies any malaise or fever. On physical examination, she is afebrile and her physician notes that her abdomen, and most notably her stretch marks, is covered with red papules and plaques. No excoriations or bullae are present. The patient’s face, arms, and legs are unaffected by the rash. Which of the following is this patient’s most likely diagnosis?

698. A 25-year-old G2P0 at 30 weeks gestation presents with the complaint of a new rash and itching on her abdomen over the last few weeks. She denies any constitutional symptoms or any new lotions, soaps, or detergents. On examination she is afebrile with a small, papular rash on her trunk and forearms. Excoriations from scratching are also noted. Which of the following is the recommended first-line treatment for this patient?

A 23-year-old G3P2002 presents for a routine obstetric (OB) visit at 34 weeks. She reports a history of genital herpes for 5 years. She reports that she has had only two outbreaks during the pregnancy, but is very concerned about the possibility of transmitting this infection to her baby. Which of the following statements is accurate regarding how this patient should be counseled?

700. A 28-year-old G1 presents to your office at 8 weeks gestation. She has a history of diabetes since the age of 14. She uses insulin and denies any complications related to her diabetes. Which of the following is the most common birth defect associated with diabetes?

701. A 32-year-old G1 at 10 weeks gestation presents for her routine OB visit. She is worried about her pregnancy because she has a history of insulin-requiring diabetes since the age of 18. Prior to becoming pregnant, her endocrinologist diagnosed her with microalbuminuria. She has had photo laser ablation of retinopathy in the past. Which diabetic complication is most likely to be worsened by pregnancy?

702. A 37-year-old G3P2 presents to your office for her first OB visit at 10 weeks gestation. She has a history of Graves disease and has been maintained on propylthiouracil (PTU) as treatment for her hyperthyroidism. She is currently euthyroid but asks you if her condition poses any problems for the pregnancy. Which of the following statements should be included in your counseling session with the patient?

703. A 40-year-old G3P2 obese patient at 37 weeks presents for her routine OB visit. She has gestational diabetes that is controlled with diet. She reports that her fasting and postprandial sugars have all been within the normal range. Her fetus has an estimated fetal weight of 6.5 lb by Leopold maneuvers. Which of the following is the best next step in her management?

704. A 36-year-old G1P0 at 35 weeks gestation presents to labor and delivery complaining of a several-day history of generalized malaise, anorexia, nausea, and emesis. She denies any headache or visual changes. Her fetal movement has been good, and she denies any regular uterine contractions, vaginal bleeding, or rupture of membranes. On physical examination, you notice that she is mildly jaundiced and appears to be a little confused. Her vital signs indicate a temperature of 37.7C (99.9F), pulse of 70 beats per minute, and blood pressure of 100/62 mm Hg. Blood is drawn and the following results are obtained: WBC = 25,000, Hct = 42.0, platelets = 51,000, SGOT/PT= 287/350, glucose = 43, creatinine = 2.0, fibrinogen = 135, PT/PTT = 16/50 s, serum ammonia level = 90 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones. Which of the following is the most likely diagnosis?

705. A 27-year-old G1P0 at 34 weeks gestation presents to your office complaining of a 2-day history of nausea and emesis. On physical examination, you notice that she is icteric sclera and skin. Her vital signs indicate a temperature of 37.2C (99F), pulse of 102 beats per minute, and blood pressure of 130/84 mm Hg. She is sent to labor and delivery for additional evaluation. In labor and delivery, the fetal heart rate is in the 160s with good variability, but nonreactive. Blood is drawn and the following results are obtained: WBC = 22,000, Hct = 40.0, platelets = 72,000, SGOT/PT = 334/386, glucose = 58, creatinine = 2.2, fibrinogen = 209, PT/PTT = 16/50 s, serum ammonia level = 65 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones. Which of the following is the recommended treatment for this patient?

706. A 32-year-old G1P0 reports to your office for a routine OB visit at 14 weeks gestational age. Labs drawn at her first prenatal visit 4 weeks ago reveal a platelet count of 60,000, a normal PT, PTT and bleeding time. All her other labs were within normal limits. During the present visit, the patient has a blood pressure of 120/70 mm Hg. Her urine dip reveals the presence of trace protein. The patient denies any complaints. The only medication she is currently taking is a prenatal vitamin. On taking a more in-depth history you learn that, prior to pregnancy, your patient had a history of occasional nose and gum bleeds, but no serious bleeding episodes. She has considered herself to be a person who just bruises easily. Which of the following is the most likely diagnosis?

707. A 23-year-old G1P0 reports to your office for a routine OB visit at 28 weeks gestational age. Labs drawn at her prenatal visit 2 weeks ago reveal a 1-hour glucose test of 128, hemoglobin of 10.8, and a platelet count of 80,000. All her other labs were within normal limits. During the present visit, the patient has a blood pressure of 120/70 mm Hg. Her urine dip is negative for protein, glucose, and blood. The patient denies any complaints. The only medication she is currently taking is a prenatal vitamin. She does report a history of epistaxis on occasion, but no other bleeding. Which of the following medical treatments should you recommend to treat the thrombocytopenia?

708. A 21-year-old G2P1 at 25 weeks gestation presents to the emergency room complaining of shortness of breath. She reports a history of asthma and states her peak expiratory flow rate (PEFR) with good control is usually around 400. During speaking the patient has to stop to catch her breath between words; her PEFR is 210. An arterial blood gas is drawn and oxygen therapy is initiated. She is afebrile and on physical examination expiratory wheezes are heard in all lung fields. Which of the following is the most appropriate next step in her management?

709. One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order?

710. A 20-year-old G1 patient delivers a live-born infant with cutaneous lesions, limb defects, cerebral cortical atrophy, and chorioretinitis. Her pregnancy was complicated by pneumonia at 18 weeks. What is the most likely causative agent?

711. A 34-year-old G2 at 36 weeks delivers a growth-restricted infant with cataracts, anemia, patent ductus arteriosus, and sensorineural deafness. She has a history of chronic hypertension, which was well controlled with methyldopa during pregnancy. She had a viral syndrome with rash in early pregnancy. What is the most likely causative agent?

712. A 25-year-old G3 at 39 weeks delivers a small-for-gestational-age infant with chorioretinitis, intracranial calcifications, jaundice, hepatosplenomegaly, and anemia. The infant displays poor feeding and tone in the nursery. The patient denies eating any raw or undercooked meat and does not have any cats living at home with her. She works as a nurse in the pediatric intensive care unit at the local hospital. What is the most likely causative agent?

713. A 23-year-old G1 with a history of a flulike illness, fever, myalgias, and lymphadenopathy during her early third trimester delivers a growth-restricted infant with seizures, intracranial calcifications, hepatosplenomegaly, jaundice, and anemia. What is the most likely causative agent?

714. A 32-year-old G5 delivers a stillborn fetus at 34 weeks. The placenta is noted to be much larger than normal. The fetus appeared hydropic and had petechiae over much of the skin. What is the most likely causative agent?

715. A 38-year-woman at 39 weeks delivers a 7-lb infant female without complications. At 2 weeks of life, the infant develops fulminant liver failure and dies. What is the most likely causative virus?

716. A 20-year-old woman who works as a kindergarten teacher presents for her routine visit at 32 weeks. Her fundal height measures 40 cm. An ultrasound reveals polyhydramnios, an appropriately grown fetus with ascites and scalp edema. The patient denies any recent illnesses, but some of the children at her school have been sick recently. What is the most likely cause of the fetal findings?

717. A 25-year-old female in her first pregnancy delivers a 6-lb male infant at 38 weeks. The infant develops fever, vesicular rash, poor feeding, and listlessness at 1 week of age. What is the most likely cause of the infant’s signs and symptoms?

718. A 22-year-old woman delivers a 7-lb male infant at 40 weeks without any complications. On day 3 of life, the infant develops respiratory distress, hypotension, tachycardia, listlessness, and oliguria. What is the most likely cause of the infant’s illness?

719. A 20-year-old G1 at 38 weeks gestation presents with regular painful contractions every 3 to 4 minutes lasting 60 seconds. On pelvic examination, she is 3 cm dilated and 90% effaced; an amniotomy is performed and clear fluid is noted. The patient receives epidural analgesia for pain management. The fetal heart rate tracing is reactive. One hour later on repeat examination, her cervix is 5 cm dilated and 100% effaced. Which of the following is the best next step in her management?

720. A 30-year-old G2P0 at 39 weeks is admitted in active labor with spontaneous rupture of membranes occurring 2 hours prior to admission. The patient noted clear fluid at the time. On examination, her cervix is 4 cm dilated and completely effaced. The fetal head is at 0 station and the fetal heart rate tracing is reactive. Two hours later on repeat examination her cervix is 5 cm dilated and the fetal head is at +1 station. Early decelerations are noted on the fetal heart rate tracing. Which of the following is the best next step in her labor management?

721. A 32-year-old G3P2 at 39 weeks gestation with an epidural has been pushing for 30 minutes with good descent. The presenting fetal head is left occiput anterior with less than 45o of rotation with a station of +3 of 5. The fetal heart rate has been in the 90s for the past 5 minutes and the delivery is expedited with forceps. Which of the following best describes the type of forceps delivery performed?

722. A 27-year-old G2P1 at 38 weeks gestation was admitted in active labor at 4 cm dilated; spontaneous rupture of membranes occurred prior to admission. She has had one prior uncomplicated vaginal delivery and denies any medical problems or past surgery. She reports an allergy to sulfa drugs. Currently, her vital signs are normal and the fetal heart rate tracing is reactive. Her prenatal record indicates that her Group B streptococcus (GBS) culture at 36 weeks was positive. What is the recommended antibiotic for prophylaxis during labor?

723. A 38-year-old G6P4 is brought to the hospital by ambulance for vaginal bleeding at 34 weeks. She undergoes an emergency cesarean delivery for fetal bradycardia under general anesthesia. In the recovery room 4 hours after her surgery, the patient develops respiratory distress and tachycardia. Lung examination reveals rhonchi and rales in the right lower lobe. Oxygen therapy is initiated and chest x-ray is ordered. Which of the following is most likely to have contributed to her condition?

724. A 23-year-old G1 at 38 weeks gestation presents in active labor at 6 cm dilated with ruptured membranes. On cervical examination the fetal nose, eyes, and lips can be palpated. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. The patient’s pelvis is adequate. Which of the following is the most appropriate management for this patient?

725. A 32-year-old G3P2 at 39 weeks gestation presented to the hospital with ruptured membranes and 4 cm dilated. She has a history of two prior vaginal deliveries, with her largest child weighing 3800 g at birth. Over the next 2 hours she progresses to 7 cm dilated. Two hours later, she remains 7 cm dilated. The estimated fetal weight by ultrasound is 3200 g. Which of the following labor abnormalities best describes this patient?

726. You are following a 38-year-old G2P1 at 39 weeks in labor. She has had one prior vaginal delivery of a 3800-g infant. One week ago, the estimated fetal weight was 3200 g by ultrasound. Over the past 3 hours her cervical examination remains unchanged at 6 cm. Fetal heart rate tracing is reactive. An intrauterine pressure catheter (IUPC) reveals two contractions in 10 minutes with amplitude of 40 mm Hg each. Which of the following is the best management for this patient?

727. A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, which of the following is an advantage of mediolateral episiotomy?

728. A 27-year-old woman (G3P2) comes to the delivery floor at 37 weeks gestation. She has had no prenatal care. She complains that, on bending down to pick up her 2-year-old child, she experienced sudden, severe back pain that now has persisted for 2 hours. Approximately 30 minutes ago she noted bright red blood coming from her vagina. By the time she arrives at the delivery floor, she is contracting strongly every 3 minutes; the uterus is quite firm even between contractions. By abdominal palpation, the fetus is vertex with the head deeply engaged. Fetal heart rate is 130 beats per minutes. The fundus is 38 cm above the symphysis. Blood for clotting is drawn, and a clot forms in 4 minutes. Clotting studies are sent to the laboratory. Which of the following actions can most likely wait until the patient is stabilized?

729. A 23-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are occurring every 4 to 8 minutes and each lasts approximately 1 minute. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 2 to 10 minutes. The nurse states that the contractions are mild to palpation. On examination the cervix is 2 cm dilated, 50% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. Which of the following stages of labor is this patient in?

730. A 19-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are very painful and occurring every 3 to 5 minutes. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 4 to 12 minutes. The nurse states that the contractions are mild to moderate to palpation. On examination the cervix is 1 cm dilated, 60% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. Which of the following is the most appropriate next step in the management of this patient?

731. A 38-year-old G3P2 at 40 weeks gestation presents to labor and delivery with gross rupture of membranes occurring 1 hour prior to arrival. The patient is having contraction every 3 to 4 minutes on the external tocometer, and each contraction lasts 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and no decelerations. The patient has a history of rapid vaginal deliveries, and her largest baby was 3200 g. On cervical examination she is 5 cm dilated and completely effaced, with the vertex at −2 station. The estimated fetal weight is 3300 g. The patient is in a lot of pain and requesting medication. Which of the following is the most appropriate method of pain control for this patient?

732. You are following a 22-year-old G2P1 at 39 weeks during her labor. She is given an epidural for pain management. Three hours after administrating the pain medication, the patient’s cervical examination is unchanged. Her contractions are now every 2 to 3 minutes, lasting 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and early decelerations. Which of the following is the best next step in management of this patient?

733. A 25-year-old G3P2 at 39 weeks is admitted in labor at 5 cm dilated. The fetal heart rate tracing is reactive. Two hours later, she is reexamined and her cervix is unchanged at 5 cm dilated. An IUPC is placed and the patient is noted to have 280 Montevideo units (MUV) by the IUPC. After an additional 2 hours of labor, the patient is noted to still be 5 cm dilated. The fetal heart rate tracing remains reactive. Which of the following is the best next step in the management of this labor?

734. A 29-year-old G2P1 at 40 weeks is in active labor. Her cervix is 5 cm dilated, completely effaced, and the vertex is at 0 station. She is on oxytocin to augment her labor and she has just received an epidural for pain management. The nurse calls you to the room because the fetal heart rate has been in the 70s for the past 3 minutes. The contraction pattern is noted to be every 3 minutes, each lasting 60 seconds, with return to normal tone in between contractions. The patient’s vital signs are blood pressure 90/40 mm Hg, pulse 105 beats per minute, respiratory rate 18 breaths per minute, and temperature 36.1C (97.6F). On repeat cervical examination, the vertex is well applied to the cervix and the patient remains 5 cm dilated and at 0 station, and no vaginal bleeding is noted. Which of the following is the most likely cause for the deceleration?

735. You are delivering a 26-year-old G3P2002 at 40 weeks. She has a history of two previous uncomplicated vaginal deliveries and has had no complications this pregnancy. After 15 minutes of pushing, the baby’s head delivers spontaneously, but then retracts back against the perineum. As you apply gentle downward traction to the head, the baby’s anterior shoulder fails to deliver. Which of the following is the best next step in the management of this patient?

736. You are delivering a 33-year-old G3P2 and encounter a shoulder dystocia. After performing the appropriate maneuvers, the baby finally delivers, and the pediatricians attending the delivery note that the right arm is hanging limply to the baby’s side with the forearm extended and internally rotated. Which of the following is the baby’s most likely diagnosis?

737. A 41-year-old G1P0 at 39 weeks, who has been completely dilated and pushing for 3 hours, has an epidural in place and remains undelivered. She is exhausted and crying and tells you that she can no longer push. Her temperature is 38.3C (101F). The fetal heart rate is in the 190s with decreased variability. The patient’s membranes have been ruptured for over 24 hours, and she has been receiving intravenous penicillin for a history of colonization with group B streptococcus bacteria. The patient’s cervix is completely dilated and effaced and the fetal head is in the direct OA position and is visible at the introitus between pushes. Extensive caput is noted, but the fetal bones are at the +3 station. Which of the following is the most appropriate next step in the management of this patient?

38. A 28-year-old G1 at 38 weeks had a normal progression of her labor. She has an epidural and has been pushing for 2 hours. The fetal head is direct occiput anterior at +3 station. The fetal heart rate tracing is 150 beats per minute with variable decelerations. With the patient’s last push the fetal heart rate had a prolonged deceleration to the 80s for 3 minutes. You recommend forceps to assist the delivery owing to the nonreassuring fetal heart rate tracing. Compared to the use of the vacuum extractor, forceps are associated with an increased risk of which of the following neonatal complications?

739. You performed a forceps-assisted vaginal delivery on a 20-year-old G1 at 40 weeks for maternal exhaustion. The patient had pushed for 3 hours with an epidural for pain management. A second-degree episiotomy was cut to facilitate delivery. Eight hours after delivery, you are called to see the patient because she is unable to void and complains of severe pain. On examination you note a large fluctuant purple mass inside the vagina. What is the best management for this patient?

740. A 20-year-old G1 at 41 weeks has been pushing for 21/2 hours. The fetal head is at the introitus and beginning to crown. It is necessary to cut an episiotomy. The tear extends through the sphincter of the rectum, but the rectal mucosa is intact. How should you classify this type of episiotomy?

741. A 16-year-old G1P0 at 38 weeks gestation comes to the labor and delivery suite for the second time during the same weekend that you are on call. She initially presented to labor and delivery at 2:00 PM Saturday afternoon complaining of regular uterine contractions. Her cervix was 1 cm dilated, 50% effaced with the vertex at −1 station, and she was sent home after walking for 2 hours in the hospital without any cervical change. It is now Sunday night at 8:00 PM, and the patient returns to labor and delivery with increasing pain. She is exhausted because she did not sleep the night before because her contractions kept waking her up. The patient is placed on the external fetal monitor. Her contractions are occurring every 2 to 3 minutes. You reexamine the patient and determine that her cervix is unchanged. Which of the following is the best next step in the management of this patient?

742. A 25-year-old G1P0 patient at 41 weeks presents to labor and delivery complaining of gross rupture of membranes and painful uterine contractions every 2 to 3 minutes. On digital examination, her cervix is 3 cm dilated and completely effaced with fetal feet palpable through the cervix. The estimated weight of the fetus is about 6 lb, and the fetal heart rate tracing is reactive. Which of the following is the best method to achieve delivery?

743. A 25-year-old G1 at 37 weeks presents to labor and delivery with gross rupture of membranes. The fluid is noted to be clear and the patient is noted to have regular painful contractions every 2 to 3 minutes lasting for 60 seconds each. The fetal heart rate tracing is reactive. On cervical examination she is noted to be 4 cm dilated, 90% effaced with the presenting part a −3 station. The presenting part is soft and felt to be the fetal buttock. A quick bedside ultrasound reveals a breech presentation with both hips flexed and knees extended. What type of breech presentation is described?

744. A 34-year-old G3P2 delivers a baby by spontaneous vaginal delivery. She had scant prenatal care and no ultrasound, so she is anxious to know the sex of the baby. At first glance you notice female genitalia, but on closer examination the genitalia are ambiguous. Which of the following is the best next step in the evaluation of this infant?

745. A 24-year-old primigravid woman, who is intent on breast-feeding, decides on a home delivery. Immediately after the birth of a 4.1-kg (9-lb) infant, the patient bleeds massively from extensive vaginal and cervical lacerations. She is brought to the nearest hospital in shock. Over 2 hours, 9 units of blood are transfused, and the patient’s blood pressure returns to a reasonable level. A hemoglobin value the next day is 7.5 g/dL, and 3 units of packed red blood cells are given. The most likely late sequela to consider in this woman is which of the following?

746. A 27-year-old G4P3 at 37 weeks presents to the hospital with heavy vaginal bleeding and painful uterine contractions. Quick bedside ultrasound reveals a fundal placenta. The patient’s vital signs are blood pressure 140/92 mm Hg, pulse 118 beats per minute, respiratory rate 20 breaths per minute, and temperature 37C (98.6F). The fetal heart rate tracing reveals tachycardia with decreased variability and a few late decelerations. An emergency cesarean section delivers a male infant with Apgar scores of 4 and 9. With delivery of the placenta, a large retroplacental clot is noted. The patient becomes hypotensive, and bleeding is noted from the wound edges and her IV catheter sites. She requires 12 units of packed red blood cells and fresh frozen plasma for resuscitation. After a short stay in the intensive care unit the patient recovers. When can long-term complications related to sequela of postpartum hemorrhage first be noted?

747. On postoperative day 3 after an uncomplicated repeat cesarean delivery, the patient develops a fever of 38.2C (100.8F). She has no complaints except for some fullness in her breasts. On examination she appears in no distress; lung and cardiac examinations are normal. Her breast examination reveals full, firm breasts bilaterally slightly tender with no erythema or masses. She is not breast-feeding. The abdomen is soft with firm, nontender fundus at the umbilicus. The lochia appears normal and is nonodorous. Urinalysis and white blood cell count are normal. Which of the following is a characteristic of the cause of her puerperal fever?

748. A 38-year-old G3P3 begins to breast-feed her 5-day-old infant. The baby latches on appropriately and begins to suckle. In the mother, which of the following is a response to suckling?

749. On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6C (99.8F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry reveals an oxygen saturation of 88% on room air and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis?

750. A 26-year-old G1P1 is now postoperative day (POD) 6 after a low transverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 390C (102.2F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with firm, nontender uterus below the umbilicus. On pelvic examination her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative. Which of the following statements is true regarding this patient’s condition?

751. A 24-year-old G1P1 presents for her routine postpartum visit 6 weeks after an uncomplicated vaginal delivery. She states that she is having problems sleeping and is feeling depressed over the past 2 to 3 weeks. She reveals that she cries on most days and feels anxious about taking care of her newborn son. She denies any weight loss or gain, but states she doesn’t feel like eating or doing any of her normal activities. She denies suicidal or homicidal ideation. Which of the following is true regarding this patient’s condition?

752. A 35-year-old G3P3 presents to your office 3 weeks after an uncomplicated vaginal delivery. She has been successfully breast-feeding. She complains of chills and a fever to 38.3C (101F) at home. She states that she feels like she has flu, but denies any sick contacts. She has no medical problems or prior surgeries. The patient denies any medicine allergies. On examination she has a low-grade temperature of 38C (100.4F) and generally appears in no distress. Head, ear, throat, lung, cardiac, abdominal, and pelvic examinations are within normal limits. A triangular area of erythema is located in the upper outer quadrant of the left breast. The area is tender to palpation. No masses are felt and no axillary lymphadenopathy is noted. Which of the following is the best option for treatment of this patient?